When a spouse has other insurance
March 19th, 2010 | TriCare Help | Posted by Military Times
Q. I’m a retired reservist with Tricare For Life. My wife has her own civilian health insurance, as well as Tricare Standard, since I am her sponsor. How does coordination of benefits work for medical care and prescriptions? For example, her drug plan has a higher copay for some drugs than Tricare has. Can she use Tricare to get the lower co-pay, or does she pay the higher co-pay and file a claim with tricare to get the difference? And can my wife and I use the Tricare mail order drug plan?
As required by federal law, Tricare is always last payer to all other health insurance, medical plans such as an HMO, or medical payments such as one might receive for medical bills resulting from an auto accident, slip-and-fall injury, or the like. The beneficiary must file first with all other plans. When the other health insurance (OHI) has paid its maximum and issued the beneficiary an Explanation of Benefits, a Tricare claim may be filed.
The only exceptions to the rule making Tricare last payer are if the OHI is a bona fide, specially written Tricare supplement, or if the OHI is a welfare-related plan such as Medicaid (not Medicare), Indian Health Service, and the like.
Your wife must use her OHI first for all medical and pharmacy services. For medical care, to file with Tricare as second payer, she must do the following:
1. Complete an official Tricare Claim Form DD2642.
2. Attach copies of exactly the same bills (the same sheets of paper) that were sent to the OHI.
3. Attach a copy of the OHI’s Explanation of Benefits that reports details of its processing of each of those charges.
4. Make copies of all the documents for your records.
5. Send Tricare’s copy of the package to the proper Tricare claims processing contractor for your Tricare Region.
Your wife must use her commercial plan’s pharmacy benefit first.
To be reimbursed a portion of the OHI’s pharmacy deductibles and copayments, contact Express Scripts, toll-free, at 1-877-363-1303, for instructions.
Please note that because of the way federal law requires pharmacy benefits to be coordinated, Tricare beneficiaries who have OHI are not eligible to use the Tricare Mail Order Pharmacy Plan.
How TFL works outside the U.S.
March 18th, 2010 | TriCare Help | Posted by Military Times
Q. If I decide to live outside of the United States (i.e. Philippines) upon retirement at age 65, I understand that I will still need to pay the Medicare Part B to be covered under Tricare For Life. Then, when I visit the medical facility over there, my claims would be processed just like I had Tricare Standard (since Medicare does not cover claims outside the U.S.) with the deductible having to be met and the co-pay also. Is that correct?
You are correct, unfortunately. The only time you will have full TFL coverage (Medicare plus Tricare) is when you visit the U.S. or a U.S. possession.
People have tried for many years without success to get Congress to change the law. I hear that the proposal never even makes it out of committee.
When one spouse gets TFL before the other
March 12th, 2010 | TriCare Help | Posted by Military Times
Q. My wife is three years older than me. As long as we are still on Tricare Prime, this poses no problems. However, she will reach 65 and become eligible for Medicare before I will. What steps will we need to take to get her Tricare for Life before me? If it makes a differrence, we live near a military medical facility.
Tricare couples are very seldom exactly the same age, and it doesn’t matter which of the two is the elder.
At least 90 days before the month when she will be 65, your wife should contact the Social Security Administration to apply for Medicare Part A and Part B. Medicare will review her application, and if it finds she is eligible, it will send her a Notice of Award and a Medicare ID card a few weeks before she is 65.
Social Security is supposed to automatically notify DEERS when your wife is enrolled in Medicare Part B so it can make the transition to Tricare for Life (TFL) in her DEERS record. Federal law requires her to be enrolled in both Medicare Part A and Part B to keep her Tricare eligibility and have TFL. She should not enroll in the Medicare Pharmacy Program (Part D of Medicare) because she has the free Tricare Pharmacy Program.
When she gets the Medicare ID card, she should call DEERS, toll-free, at 1-800-538-9552 to make sure it has updated her record to show Part B enrollment and TFL eligibility.
DEERS will automatically change her Tricare Prime to Tricare Standard, and she will become eligible for Tricare for Life on the first day of the month when she is 65. She may no longer use Tricare Prime. She must get all her civilian medical care from Medicare providers because Medicare will become her primary coverage and Tricare Standard will automatically become her secondary coverage and free Medicare supplement for the vast majority of her Medicare claims.
I recommend that she start looking for a Medicare provider who will accept her as a new patient at the same time as she applies for Medicare.
You will go through the same process three years later when you turn 65 and get Medicare.
The Medicare provider will file a Medicare claim each time she sees him. Medicare will pay its share to the provider and automatically forward the claim to Tricare as second payer. On the vast majority of her claims, Tricare will pay the balance on her Medicare claim for every service that is also covered by Tricare. Those two payments — Medicare’s and Tricare’s — will pay the provider’s bill in full.
The only times she will have any out-of-pocket costs for medical care is if she get a medical service that is not covered by both Medicare and by Tricare. That will not be very often. Some TFL beneficiaries go more than a year without any such claims.
For her last enrollment period in Tricare Prime, your wife should arrange to pay her Prime enrollment fee on a month-to-month basis. That is so she doesn’t pay in advance for Tricare Prime she will no longer be able to use once her Medicare begins. That may mean she will no longer be able to use the military medical facility. She will have to ask.
She will no longer have to pay $230 per year for Tricare Prime, but she will have to begin paying the monthly premium for Medicare Part B. Medicare will bill her every 90 days for the premium until she is old enough for Social Security checks. Then the premium will come out of her check as an allotment to Medicare.
In the meantime, she should go to the official Tricare web site and read up on Tricare for Life. She can also download a TFL Handbook, which will be very useful.
Will I still be covered if I get married?
March 11th, 2010 | TriCare Help | Posted by Military Times
Q. My father is active-duty Army, and I have been covered by Tricare ever since I can remember. I am 19 and a full-time student, so I am still covered. I am thinking about getting married, but I want to know if Tricare will still cover me if I do. If I don’t, how long will Tricare cover me if I remain a student?
If you marry, your Tricare eligibility will end at midnight of the day of your marriage. You must notify DEERS (see below) when you marry.
If you do not marry, your Tricare eligibility will end at midnight of the day before your 21st birthday, unless you are a full-time student at an accredited college, university, or trade school.
During any period after age 21 when you are enrolled as a full-time student, your Tricare coverage will continue until you marry, graduate, or until midnight of the day before your 23rd birthday.
For official clarification and confirmation of these rules, please call the DEERS Support Office, toll-free, at 1-800-538-9552.
Will Tricare cover ER visit in Canada?
March 9th, 2010 | TriCare Help | Posted by Military Times
Q. While on a visit to Canada, I injured my knee and was taken to an emergency room. The total cost was over $800. It’s my understanding that Medicare does not cover these expenses. Is there any coverage under Tricare?
Medicare can provide coverage for medical care received outside the U.S. and its possessions only in certain limited situations.
I suggest that you contact Medicare to explain the details of the events resulting in your Canadian medical care. Medicare will tell you whether it can provide any coverage and how to file a Medicare claim in that event. If Medicare can provide coverage, the claim will be processed as any other TFL claim — that is, with Medicare as primary payer and Tricare Standard, automatically, as second payer.
As a Tricare for Life beneficiary, you have coverage by two full service, stand-alone, health insurance policies, Medicare and Tricare Standard. If you receive a medical service that is not covered by Medicare, such as your Canadian care, you have Tricare Standard as fall-back coverage.
If Medicare is unable to pay anything toward your care in this case, Tricare will be your only coverage. In that case, the Tricare claim will be subject to all of Tricare’s claims processing rules including the application of the Tricare deductible and cost share. Let me explain the consequences in that event.
Under TFL, when a medical service is covered by both Medicare and Tricare, the Tricare deductible and cost share are waived. In those cases, the combined payments by both plans (Medicare plus Tricare) will pay the Medicare claim and the provider’s bill in full.
All medical services on the vast majority of a TFL beneficiary’s Medicare claims are covered by both Medicare and Tricare. Because Tricare’s deductible is waived on those claims, it is possible that the beneficiary has paid very little toward satisfying the $150 fiscal year Tricare deductible.
When Medicare does not pay on a medical service, Tricare becomes the beneficiary’s only health insurance for that particular medical service. Thus, when the Tricare-only claim is processed, any amount of the Tricare deductible not previously paid must be applied to that claim.
Depending on the beneficiary’s previous claims history during that fiscal year, the deductible amount remaining unpaid could be large. It must be subtracted from the amount Tricare allows on that item, then the beneficiary’s 25 percent cost share must be subtracted from the amount remaining. Those actions can considerably reduce the amount Tricare pays on the claim. That rule is required by federal law.
If you find that Medicare can be of no help in paying your foreign medical bill, please call Wisconsin Physicians Service, the Tricare claims contractor for TFL. The toll-free number is 1-866-773-0404. That office will provide instructions for filing a Tricare Standard claim for your care.
So there are no surprises when the claim is paid, WPS also can tell you how much of the amount allowed on the claim must be subtracted and credited to your Fiscal Year 2010 Tricare deductible.
Is long term care covered?
March 5th, 2010 | TriCare Help | Posted by Military Times
Q. I am a retired reservist who will be eligible for Tricare when I turn 60. I am also a current federal employee covered by the FEHBP. Do I need to purchase a separate long term care insurance policy or will my FEHBP, Tricare and eventually Medicare cover those expenses? What about my spouse?
When people talk about “long term care,” they often have in mind a nursing home type of environment where people go to live when they can no longer care for themselves.
It is a place where you can live, and be watched over and protected. Your meals will be provided and, if you are unable to “do” for yourself, you will be helped to eat, dress, bathe, attend to personal hygiene, and the like. In insurance and medical vernacular, such care is usually referred to as “custodial care.”
It is very expensive to live in a place where you have have nurses and aides of several kinds, and probably a doctor on call 24/7 to care for you and meet your needs with the “activities of daily living.” (That is a technical term used in the law.)
The federal laws that created both Medicare and Tricare make no provision to help pay for such living arrangements. In fact, both programs are specifically prohibited by law to pay for “custodial care.”
Other than specific long term care policies, I know of no commercial health insurance policy, such as your FEHBP plan, that will pay for it.
Only you can decide whether you and your wife need such insurance. But, you cannot count on Medicare and Tricare (Tricare for Life), or your FEHBP plan, to help pay for it. Those programs will continue to pay for your medical care, including hospitalization, and your pharmacy needs, just as they do now, but they cannot pay for the costs of being cared for in such a facility.
The insurance for that kind of “long term care” is expensive, and the older you are when you buy the policy, the more it costs.
Trouble getting surgery hospitalization covered
March 4th, 2010 | TriCare Help | Posted by Military Times
Q. My child needs dental surgery, and the procedure must be performed in a hospital. Tricare won’t cover the hospital portion – why? The dental insurance and Tricare are each saying the other needs to pay.
Your didn’t say how you learned that Tricare will not cover the hospital portion of your child’s dental care. Depending on whom you asked and the reasons you gave about why hospitalization will be needed, it is possible that you were misinformed.
If certain medical criteria are met, hospitalization for certain dental or oral surgery procedures can be covered for certain patients. Those rules are established by the federal regulation that governs Tricare.
If hospitalization is medically necessary and appropriate for the particular surgery your child needs, or if his medical condition is such that hospitalization is required for his safety, it can be covered by Tricare. That is a decision Tricare’s medical advisors will make based on medical information they receive from his physician and/or oral surgeon.
If Tricare has given you an official statement that the hospitalization will not be covered, I suggest you write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. Ask that office to reconsider its decision. A request for reconsideration is an appeal of an official decision. It requires Tricare to review the entire case to ensure that all the rules were followed correctly.
Include the name, address, and phone number of the oral surgeon. He, or your child’s physician, will need to explain exactly what is the surgical procedure to be done and the reason it must be done in a hospital rather than on an outpatient basis in the oral surgeon’s office or clinic. Tricare may want to speak with him about the case.
In your letter, you must state the specific matter that is dispute, and include copies of all correspondence you have had with the Dental Plan and with Tricare. Include the child’s full name, date of birth, your full name, and your Social Security number. Be sure to include a phone number where you can be reached during the day in case Tricare needs more information from you.
If all the business was transacted by telephone, please tell Tricare exactly whom (exactly which offices) you talked with and when. Include names of those you spoke with, if possible.
What’s the story on supplements?
March 3rd, 2010 | TriCare Help | Posted by Military Times
Q. You have mentioned Tricare supplements before. Is there a supplement available for Tricare Prime and Tricare for Life? If so, what company offers this coverage?
Most of the retired military associations sell Tricare supplements. They vary in price and in the specific kinds of coverage they provide. Check out several of them before you buy.
Note that the coverage you will get for your money is spelled out in detail in the fine print in the policy itself, not in the ads or the sales pitches. Make sure you read the policy fine print. That’s where your money goes.
Supplements vary in price and the kinds of coverage they provide. Some supplements have a deductible; others may have restrictions or limitations on the way they cover pre-existing conditions.
A supplement for Tricare Prime is much more complicated than one for Tricare Standard because Prime has more complicated rules. Look to see whether the supplement covers the 15 percent surcharge on claims by non-participating Tricare Standard providers. Those are just a few of the things to watch out for.
You mentioned Tricare for Life (TFL). Do you know that if a Tricare beneficiary has Medicare, he must be enrolled in both Part A and Part B to keep his Tricare eligibility and be eligible for TFL?
Also, a beneficiary who is eligible for TFL is not eligible for Tricare Prime. TFL consists of a combination of Medicare Parts A and B plus Tricare Standard. He cannot be enrolled in Tricare Prime.
Most people don’t buy a supplement when they get TFL. That’s because, on the vast majority of their Medicare claims, Tricare Standard acts as a free Medicare supplement on every claim when all the medical services on the Medicare claim are covered by both Medicare and Tricare.
On those claims, when both Medicare and Tricare cover all the medical services, the combination of Medicare plus Tricare payments pay the Medicare claim and the provider’s bill in full. The Tricare deductible and cost share are waived on TFL claims when both Medicare and Tricare pay on a charge.
The loss of Tricare Prime eligibility applies only to the TFL member. Other family members who do not have TFL (Medicare plus Tricare Standard) are still eligible for Tricare Prime.
You do not need a Medicare supplement. That’s what Tricare Standard does, and its free.
The only time a Tricare supplement will have anything to pay is if you get a medical service that is not covered by Medicare — a medical service that is covered by Tricare only. Under TFL, only Tricare will pay on the particular charge if Medicare cannot pay for something. On those Tricare-only charges, all Tricare processing rules apply including the Tricare deductible and cost share.
Are psychologist visits covered?
March 2nd, 2010 | TriCare Help | Posted by Military Times
Q. My daughter currently sees a psychologist a few times a month. Her dad is being deployed in June and is switching insurance. Will Tricare pay any part of these visits?
Tricare has a mental health benefit. Several things will be necessary, however, for your daughter to use the program for her care.
First, assuming his call to active duty is for a period exceeding 30 days, her father has to register his entire immediate family in the Defense Enrollment Eligibility Reporting System (DEERS) for any of you to use Tricare. He should contact his military personnel office as soon as possible for help in doing that.
Refer all questions about Tricare eligibility to the DEERS Support Office by calling 1-800-538-9552, toll-free.
Second, if he or she has not already done so, the therapist must contact Tricare to be registered with the program as a Tricare Authorized Provider for Tricare to pay for any of his or her services. By law, Tricare may not pay for the services of any provider who is not registered with the program as an authorized provider. The psychologist should contact your Tricare Service Center to learn how to request a Provider Certification Packet in order to apply.
Please go to the official Tricare Web site at www.tricare.mil on the Internet. Enter the site, and find a row of blue buttons near the top of the page. Click on Mental Health and Behavior for information about that coverage. I suggest you advise your daughter’s therapist about that information also.
You can learn more about Tricare’s mental health benefit online, as well as your Tricare coverage in general. The better you understand your coverage, the better Tricare will serve you.
Make sure you also know how to contact your regional Tricare Service Office. Make a permanent record of that information. You will need it from time to time.
Will Prime pay to reverse sterilization procedure?
February 15th, 2010 | TriCare Help | Posted by Military Times
Q. I have Tricare Prime, and I want to get my tubes untied so my husband and I can have a baby. Will Tricare pay for this?
No. Although Tricare may help with payment of the costs of surgical sterilization, it is not allowed to help pay for the reversal of a surgical sterilization procedure.