All Tricare beneficiaries are automatically eligible for, and are automatically enrolled in, the free Tricare Pharmacy Program and are eligible for its complete benefits. It is recognized as one of the best pharmacy plans available. They do not need any pharmacy insurance other than the Tricare Pharmacy Program.

You can find detailed information about the Tricare Pharmacy Program online. If you want it, additional printed information is available from the Tricare worldwide pharmacy benefit administrator, Express Scripts Inc. The toll-free number is 877-363-1393.

Health Affairs does not recommend that Tricare beneficiaries enroll in the Medicare Part D Pharmacy Program. The only Tricare beneficiaries who are likely to derive any significant advantage from Medicare Part D are the few whose incomes are below the federal poverty level and who qualify for financial aid to pay their Medicare Part B monthly premiums.

Because you have other health insurance (Medicare Part D), you are not eligible to use TMOP. That is because of the way Tricare is required by law to coordinate its benefits with Express Scripts Inc. which, for TMOP services, is not only the plan’s administrator, but also the provider of the drugs under TMOP.

When you enrolled in Medicare Part D, you had several commercial pharmacy plans to choose among, depending on where you live. Each plan has its own rules for using its benefits. You must follow that plan’s rules for all your pharmacy services and use it first, before you may use your free Tricare pharmacy plan.

You may find that your commercial plan under Medicare Part D will not pay for certain drugs. Although Tricare has special rules for dispensing certain drugs, if your doctor can document the medical necessity of that particular drug in your particular case, Tricare will make it available for you without penalties.

If your Part D pharmacy plan charges you a co-payment or a deductible for your prescription services, you may file a claim with the Tricare Pharmacy Program for partial reimbursement of those expenses.

If you have to pay a premium for the Part D pharmacy plan, however, you may not file a claim with Tricare for the premium payment. Tricare will reimburse you only for your co-payment and deductible on the cost of the drugs, but not for any cost of the insurance plan.

You will probably need help to learn how to file a claim with Tricare as second payer for your prescription drugs. I suggest you call Express Scripts for that help. If you use the Tricare Pharmacy Program exclusively, there are no claims to file.

You may also want to discuss with Express Scripts your need, or the advisability, of continuing to be enrolled in Medicare Part D. Call Medicare if you choose to withdraw from your Medicare Part D enrollment. It is easy to do, and there is no penalty.

You are right that federal law doesn’t let Tricare pay for hearing aids, just like it can’t pay for glasses, either. But it’s not quite as bad as you might think.

There is a program called RACHAP (Retiree At Cost Hearing Aid Program) that allows retirees only (not their family members) to buy hearing aids at the government’s cost. It is not related to Tricare in any way.

I haven’t had any dealings with them or talked with anybody who has. In fact, I’d appreciate it if you tell me what happens when you contact them and whether it works to your satisfaction. Good hearing aids are expensive, so even with the government’s discount, you are going to have some pocket-book pain.

No, at midnight of the day you married you automatically lost all the Tricare eligibility you had from your father’s service.

You can confirm that by calling the DEERS Support Office, toll-free, at 1-800-538-9552. You or your father must notify DEERS of your marriage.

I sympathize with your problem, but I don’t have good news for you.

Tricare is not allowed to provide coverage for any kind of technical assistance with conception, including artificial insemination, even with your husband as sperm donor.

I have not heard of any exceptions being made, but you might want to write to the Tricare Headquarters, Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043, to inquire.  Explain your situation and include a daytime phone number. Please don’t get your hopes up.

Tricare is currently forbidden by federal law and regulation to pay for chiropractic care or acupuncture. I am aware that there are people with strong feelings about the effectiveness of both of those treatment modalities, both for and against, and both have been the subject of considerable public dispute and debate.

Tricare is not a health insurance policy or an insurance company.  It is a federal health benefits program created and governed by federal law, which determines who is eligible and when, which medical services Tricare may cover and which are excluded, the amounts it may pay for each medical service and the manner of payment, the portion of the costs of care that are the beneficiary’s responsibility to pay, and the like. Only Congress can change it.

If you believe your hair loss is a result of your military service, you may want to file a claim with the Department of Veterans Affairs.

Medicare and Tricare allow the same, or almost the same, amount for identical services because, by law, they must use the same, or almost the same, methods and databases to determine that amount.

Even when the amount allowed is the same, however, you are correct. Medicare pays 80 percent of the amount it approves or allows, whereas, for retirees, Tricare pays only 75 percent.
But Tricare’s allowance under Tricare for Life is seldom considered.

For Tricare for Life beneficiaries whose only health insurance is Medicare and Tricare Standard, and have no additional coverage from, say, a civilian job, Medicare is their primary health insurance, and Tricare Standard is secondary.

Tricare for Life beneficiaries must get all their civilian care from providers who will file a Medicare claim. On the vast majority of those claims, both Medicare and Tricare cover all the services on the initial Medicare claim. Tricare’s payment is determined by the amount Medicare pays, not by the amount Tricare allows.

When both programs cover every service on a claim, Medicare first pays 80 percent of the amount it allows on the charges after satisfaction of the Medicare deductible, if applicable, on that claim. Tricare pays the patient’s share — the Medicare deductible and copayment.

The patient owes the provider only what Medicare does not pay. When Tricare pays that amount, the Medicare claim and the provider’s bill are paid in full. The patient owes nothing more.
Therefore, on most TFL claims, Tricare’s allowable charge is not a factor.

But now, as soon as I get Tricare for Life, I will become ineligible for Tricare Prime and be switched to Tricare Standard against my will. Not only will I have the additional expense of Medicare Part B, but under Tricare Standard, we will start incurring deductibles and cost shares that we don’t have under Tricare Prime. Is there any way we can keep Prime when we get Tricare for Life?

Your loss of Tricare Prime eligibility and automatic transfer to Tricare Standard  can’t be avoided — it’s part of the legal requirements for Tricare for Life.

Under Tricare for Life, Tricare Standard acts as a free Medicare supplement. You cannot choose to keep Tricare Prime.

Reading between the lines in your letter, however, leads me to believe you expect your transition to Tricare for Life and Tricare Standard to affect other members of your family. Not so.

Your transition to Tricare for Life and transfer from Prime to Standard will have no effect on your family’s Tricare Prime enrollment. You will be the only one affected.

Your daughter may continue under Tricare Prime until she loses Tricare eligibility at age 21 (age 23 if she is a full-time college student), or until she marries, whichever comes first.

Your wife may continue under Tricare Prime until she becomes entitled to Medicare and Tricare for Life at age 65. At that time, she’ll lose her Tricare Prime eligibility and transfer to Tricare Standard under the Tricare for Life program, just as you were.

You are correct. The doctor may not charge you more than 15 percent over the amount Tricare allowed. If he sees Medicare patients, he is aware that the Limiting Charge law applies to Medicare claims; he needs to learn that it applies to Tricare claims also.

You should send a report to the Tricare office that processed your claim. The address is on the Tricare Explanation of Benefits form. Include a copy of the EOB and any “balance due” notices from the doctor. If the doctor persists, report him again.

It is unfortunate that the law will not allow Tricare to do more than write to the doctor and explain the federal law. Beyond that, all it can do is threaten to discontinue his status as a Tricare-authorized provider and threaten to cancel his ability to participate in other federal programs such as Medicare.

The doctor may be unaware of what his billing clerk is doing. You might consider writing or talking with him about it.

Didn’t you write that if a provider accepts and bills Medicare, federal law requires him to also accept and bill Tricare? What are the facts?

That law applies only to institutional providers, such as hospitals. Individual providers, such as physicians, psychologists, private physical therapists and the like, are not bound by that law.

If the physician has severed his relationship with Tricare and is no longer a Tricare-authorized provider, Tricare cannot pay for any of his services regardless of who files the claim.

If he remains a Tricare-authorized provider but no longer participates in Tricare on the claims, you may use his services and file the claims yourself. In that case, he is no longer required to accept the amount Tricare allows as full payment for his services.

However, there is a law that limits the amount you may be charged for his services. It is a provision of the law governing Medicare called the Limiting Charge. In 1983, Congress made that law apply to Tricare as well as to Medicare.

The Limiting Charge allows a nonparticipating physician to charge a Medicare or a Tricare beneficiary up to, but not more than, 15 percent over the amount Tricare allows on a claim. Tricare will pay its usual amount directly to you. You will be responsible for paying the physician the amount Tricare allowed on the claim plus an additional 15 percent more than the amount allowed.

Your out-of-pocket expense for using such a physician, then, is your usual 25 percent cost share plus the 15 percent surcharge.

You might want to tell the office manager that Medicare and Tricare are required by law to use the same methodology and most of the same databases to calculate the amounts they allow on claims.
The amounts allowed by the two programs seldom differ by more than a few dollars. Tricare often allows slightly more than Medicare because of its younger, healthier beneficiary population.

Your friend is mistaken, but that particular mistake is one I haven’t heard before.

During each fiscal year, Tricare maintains a running total of all the deductible and cost share amounts your family has had to pay out of pocket (or that was paid by your Tricare supplement, if applicable).

As a retiree family, your Catastrophic Cap amount is $3,000, as you have assumed.

When your family members, combined, have paid $3,000 in deductibles and cost shares during a given fiscal year, Tricare will begin to pay 100 percent of the amount it allows on each claim. That is, you will not be charged any more cost shares or deductibles for the remainder of that fiscal year.

The government’s fiscal year runs from Oct. 1 of one year through Sept. 30 of the next year. At midnight on Sept. 30 every year, the amount accumulated in your family’s catastrophic cap account returns to zero and the accumulation of deductibles and cost shares your family pays begins anew.

Tricare eligibility is established by federal law for designated categories of persons.  Tricare, however, does not have the authority to make individual eligibility determinations.  Only the uniformed services have the authority to determine whether a given individual meets the legal criteria for Tricare eligibility, to register an eligible person in the Defense Enrollment Eligibility Reporting System (DEERS) computer database, and to issue an appropriate uniformed service identification card.

Following your divorce from your military sponsor, you will be in a category referred to as a former spouse.  In order to remain eligible for Tricare following your divorce, you will have to meet the eligibility criteria federal law requires for persons in that category.  According to the information in your letter, above, I do not believe you would meet those criteria.  I believe you will lose all rights to Tricare and to any medical care provided at government expense at midnight of the day the divorce is final.

For official confirmation of my statement and for official information and answers to all questions regarding Tricare eligibility, I urge you to contact DEERS, by calling its toll-free number, 1-800-538-9552, to discuss your personal and individual circumstances.  Before you call, perhaps you would find it helpful to make a list of all your questions so you forget none of them and are prepared to make notes about your conversation with DEERS.

DEERS is a federal agency under the auspices of the US Department of Defense.  DEERS is not related in any way to any program under the Social Security Administration, such as Medicare.

For official information concerning your rights to coverage by any Medicare program or plan, you should call the Social Security Administration, toll-free, at 1-800-772-1213.

The Tricare program called Tricare for Life consists of full coverage by Medicare Part A and Part B plus full coverage by Tricare Standard.  To be eligible for Tricare for Life, you must be enrolled in Medicare Part A, and Medicare Part B, and Tricare Standard.  The loss of either Medicare eligibility or of Tricare eligibility will cancel your eligibility for Tricare for Life.

The gentleman’s new wife will become legally eligible for Tricare at the moment the officiating person pronounces them married. To use Tricare, however, the husband must enroll her through his uniformed service so she can be registered in DEERS and be issued a military identification card.

For instructions on registering his new wife, the service member should call the Defense Enrollment Eligibility Reporting System (DEERS), toll-free, at 800-538-9552.

If the lady is entitled to Medicare and is enrolled in Medicare Part B, he should tell DEERS so special instructions can be issued.

If the marriage ends in divorce, her Tricare eligibility will end at midnight of the day the divorce is final. If the marriage ends by the husband’s death, however, her Tricare eligibility will continue for the rest of her life unless she remarries. If she were to remarry, her Tricare eligibility under this husband’s sponsorship would end immediately. It can never be restored.

Yes, certain stomach surgical procedures for weight loss are covered by Tricare for certain beneficiaries.

For the procedure to be covered for a particular patient, however, she must meet specific guidelines concerning her weight and associated medical conditions.  Those guidelines are established by the federal regulation that governs Tricare. Federal regulations have the force and effect of law.

I suggest that your wife’s surgeon write to her Tricare Service Center. He or she should ask for a statement of exactly what is required by regulation for the surgery to be covered by Tricare for any particular patient.

The surgeon will have to decide whether your wife meets those medical criteria and whether the procedure he/she proposes is one of those authorized by regulation.  If the regulation’s medical requirements are not met, the procedure cannot be covered. Thus the surgeon will know in advance whether to proceed with the proposed surgical intervention.

Meeting the regulatory requirements does not constitute preapproval and guarantee of coverage. It merely establishes the conditions under which coverage is possible.

Please note that, among the requirements for coverage, the physician must be a Tricare-authorized provider. That is, the physician must be registered with Tricare and be authorized to receive payment from Tricare for medical services rendered to its beneficiaries.

The registration process is simple, and the physician incurs no obligation with Tricare by becoming a Tricare-authorized provider. All health insurance plans require some form of physician registration and certification for the protection of both the patient and the insurer.

Your fiancé is mistaken about Tricare’s payment for your past medical care. Your Tricare benefits will apply only to medical care you receive on and after the date you become eligible for Tricare.

I don’t understand your statement that your fiancé is able to use Tricare at this time.  Reservists and Guards normally do not become eligible for Tricare until their 60th birthday.  A new law may change that before the end of 2010 and make some of them eligible earlier, but that law is not in effect yet.

For official information regarding Tricare eligibility such as who is eligible and when eligibility begins, please call the Defense Enrollment Eligibility Reporting System, known as DEERS, toll-free, at 1-800-538-9552.  DEERS is a federal agency under the Defense Department.  It maintains a registy of all persons who are, or who may become, eligible for military benefits, including Tricare.

You need to call the Defense Enrollment Eligibility Reporting System (DEERS), toll-free, at 1-800-538-9552, to make sure your Dad properly enrolled you in Tricare, and you (because you are over 17 and an adult for Tricare legal purposes) have kept your military ID card and DEERS registration up-to-date.

If you are unmarried, Tricare eligibility will usually continue (by law) until  midnight on the day before your 21st birthday.  However, for as long as you are enrolled as a full-time student in good standing at an accredited university, your Tricare eligibility can be continued until midnight of the day before your 23rd birthday.  Eligibility beyond age 21 is not automatic.  You must make special arrangements.  Ask DEERS for help.

So, first, call DEERS.  If DEERS does not report that you are eligible for Tricare, ask what you need to do to re-establish your Tricare eligibility.  While talking with DEERS, make sure all your other information is correct and up-to-date.  Check the expiration date of your ID card.  If it is within 90 days or so of expiring, ask DEERS how to renew it.

To use Tricare, your DEERS record and ID card both must be up-to-date.  DEERS will help you with instructions for anything you need to do.  Talk with DEERS about extending your eligibility after age 21.  Get them to explain the matter of your full-time student status.  Such as, if you drop out of school for a semester to have the baby, you will not be covered by Tricare during that time because you will not be a full-time student.  Make sure you talk with DEERS about that situation and understand it thoroughly.

At any time when DEERS reports that you are eligible for Tricare, you are entitled to full Tricare benefits, including all maternity care.  If DEERS says you are not eligible at any time, Tricare cannot pay for any medical care you get when DEERS does not say you are eligible.

You are eligible for Tricare because of your father’s military service.  That benefit, however, does not extend to his grandchildren.  The fact that you, the mother, are Tricare-eligible, does not make your baby eligible.

If the baby’s father is an active duty service member, or a military retiree, the baby can be made eligible, even if you are not married to him.  Ask DEERS about it if that’s the case.

Be sure that you know what Tricare plan you are covered by. If you are enrolled in Tricare Standard, you may get care under Tricare anyplace in the world.  If you are enrolled in Tricare Prime, you may use only certain doctors and hospitals.  They are most likely only in the area where your father lives.

You have to make some decisions about where you will get all your maternity care and which Tricare plan to be enrolled in.  If Tricare Prime is available where you live, you can have your Prime membership transferred, if that is the area where you will get your medical care.

You cannot easily get your prenatal care in one Prime service area and deliver in a different Prime service area.  You can get your prenatal care in Prime area A and deliver in Prime area B only if you time it right and get your membership transferred in time.  That is hard to do when you are in labor.  Especially on a weekend or at 2 a.m. on Tuesday.  Don’t count on being able to do it.

If you are enrolled in Tricare Prime, I suggest that you call your Tricare Prime Service Center and have a long talk with them to make sure you understand Tricare Prime’s rules about which providers you may use.  You can incur a lot of unnecessary expense if you do not follow Prime’s rules exactly.

Also, changing doctors in mid-pregnancy may be a problem.  It isn’t easy to find a doctor who will accept you as a new maternity patient after your first trimester.

I’m sure your Dad or Mom will want to be involved, and Dad will want to help you to resolve all your Tricare issues.  Tricare, however, is not allowed to talk with him about your medical care unless you send Tricare a signed and dated letter with which you authorize them to talk with Dad and Mom (by name) or whomever you wish to authorize.  Otherwise, Tricare cannot talk with another person about you.  That is Privacy Act stuff.  There is no getting around that law, not even for your Tricare sponsor.

If you have thought of having an abortion, Tricare is not allowed by federal law to cover it unless your life would be in danger if the pregnancy were to continue.  That is a pretty powerful restriction and hard to prove.

You have a lot of things to learn and arrangements to make, and not a lot of time to do it,  especially the decision about your maternity care doctor.

By law, Tricare — and probably the school’s insurance under some other rule — must have your adult daughter’s written permission to talk with you. But it’s a good time for her to learn to handle her own insurance business, with your help.

First, within 90 days from the denial, your daughter should file a written appeal with Tricare. Instructions are on the Tricare Explanation of Benefits form, or she can call Tricare for help.
Then, she should write to the school’s insurance company about the problem of who must be first payer. Federal law says that Tricare is always last payer to all other coverage. The insurance company should know that already, or they can easily learn it by calling Tricare.

Once the school’s insurance company understands that it is first payer, she or the doctor should file a claim with that carrier. When it completes processing the claim and sends her an EOB, she should file with Tricare for the family deductible and catastrophic cap records, whether or not there is anything left to pay. Here’s how.

1. Complete a Tricare claim form, DD2642. Your daughter must sign it as the adult patient. You can download claim forms and get the claim filing address at www.tricare.mil/claims.
2. Attach a copy of the same itemized bill that was sent to the school’s insurance.
3. Attach a copy of that plan’s EOB showing its processing of those charges.

Make a habit of saving copies of all claim documents, including the appeal. If you do not, I guarantee that there will come a time when you will wish you had.

Both you and your wife became legally eligible for Tricare when you became entitled to receive retired pay on your 60th birthday.  For your wife to use Tricare, you had to apply on her behalf so she could get a military ID card and be registered in DEERS.

From what you report, it sounds as if she is eligible for Tricare. But to be sure, you should call DEERS, toll-free, at 1-800-538-9552.  Make sure her record is up-to-date and she is reported as Tricare-eligible.

If she is, her military ID card is the only proof of insurance she needs.  On the back of her card, it refers to civilian medical care.  “YES” in that area shows she is eligible for civilian care at government expense (Tricare.)

When your wife gets Medicare at age 65, and is enrolled in Part B, she will get Tricare for Life just as you did, if her DEERS record and ID card are kept up-to-date.

You need to teach her how to stay up-to-date in case you predecease her.  Your death would have no effect on her eligibility unless she were to remarry.  In that case, she would lose all her eligibility under your sponsorship.  It cannot be restored even if her second marriage were to end by death or divorce.

I contacted Health Affairs regarding your inquiry.  Here is the reply I received:

Yes, this is a legitimate survey that is conducted by a contracted company to do such surveys.  These surveys are managed by HPA&E in Fall Church, Va.  It is always the individual’s choice as to whether to participate or not.  However, feedback (good or bad) regarding the Tricare  programs is indeed welcomed, and these surveys are the mechanisms that are used for this feedback, which we use to identify areas that we may be able to improve, or determine that what Tricare provides is meeting the needs of our folks.

So it’s a legitamite letter, and a chance for you to provide some feedback on the service you receive. But, as Health Affairs states, participating is strictly up to you.

I can tell you that dependent parents are not eligible for Tricare. You can confirm that by calling the DEERS Support Office, toll-free, at 1-800-538-9552.

But there is a possibility that the commanding officer of your military treatment facility may grant permission for your parents to receive medical care there.  Dependent parents’ use of a MTF is not a right under the law — it is a privilege that may be granted by the MTF’s commanding officer, subject to the availability of space, personnel, and the MTF’s technical ability to provide needed care.  Even if permission is granted, it can be terminated at any time.

Do two things.  First, call DEERS to confirm whether your parents can be made eligible for Tricare.  That is so you can be absolutely certain whether they have any rights to medical care at government expense as your dependents. Second, make an appointment to speak with your MTF’s executive officer or the officer in charge of patient administration.  Present your case, explaining your parent’s financial situation and/or any special needs that might contribute to a successful request.  You wrote that they are dependent on you.  Explain why that is.  Ask whether approval can be granted for them to use any of the MTF’s facilities, including the pharmacy.

If the XO denies permission, ask for permission to speak with the hospital’s commanding officer about the matter.  The CO’s decision is governed by law, regulation, and his special knowledge and experience regarding the capacity of his MTF, and the needs of the military personnel and families under his care.  It will be final.

The CO is responsible for the health care of the entire military facility.  By law, however, active-duty military personnel always come first.  In the competition for MTF space, the spouse and children of active duty members and who also are enrolled in Tricare Prime are second.  Everybody else is last.

On your 60th birthday, you, your wife, and any unmarried children under 21 (under 23 if an unmarried, full-time college student) will become eligible for Tricare.

If you enroll in one of the plans under the Federal Employees Health Benefits Program, Tricare will automatically be second payer to that plan.  Usually it will pay all, or most, of the FEHBP plan’s deductibles and copayments.  Whether you keep an FEHBP plan is entirely up to you;  Tricare doesn’t care.

I recommend against choosing Tricare Prime if you retain the FEHBP coverage.  Standard is the best way to go when you have other health insurance.  That’s because it is free, and with Standard, it’s much easier to coordinate benefits between the two plans.

If you leave the FEHBP plan, be sure to suspend membership — do not cancel.  If you cancel you can never get it back.  If you suspend, you can get it back any year during Open Season.  Talk with the Office of Personnel Management to make sure you understand thoroughly before you decide.

Prime is not available everywhere.  Check with your Tricare Service Center to find out if Prime is available where you live.  Prime is your best bet if that will be your only coverage.  If it’s not, the best coverage is to retain the FEHBP.

As an alternative, consider a bona fide Tricare Supplement — a specially written plan designed to be a Tricare supplement.  Study the fine print carefully before deciding which supplement to buy.  What you will get for your money is what is written in the fine print, not in the ads or sales pitches.

But don’t be seduced by a few bucks.  Tricare Standard plus an FEHBP plan, even the least expensive one, provides much better coverage than Tricare plus a supplement.

Remember to check with DEERS (call 1-800-538-9552, toll-free) to confirm that you and your family have been made eligible for Tricare on your 60th birthday.  Registration is supposed to be automatic, but people make mistakes.

To file a claim with Tricare as second payer to any other health insurance  (OHI) plan, you do in fact have one year.  Please do the following:

1. Complete a Tricare Claim Form DD2642 for each patient and each provider.
2. Attach clear, legible copies of exactly the same itemized bills that were sent to the OHI.  An itemized bill lists each medical service you received plus the price for each service.  A “balance due” bill without itemization of services cannot be used.
3. Attach a copy of the OHI’s Explanation of Benefits reporting its processing of each of the charges on the itemized bill.
4. Send the package to the proper Tricare claims processor.

I strongly recommend that you make copies of each of the documents filed with Tricare, including Tricare’s EOB when it processes the charges.  Always keep files on each claim you submit.

Tricare claims must be filed within one year of the date of the medical care.  If it is a hospital claim, the filing deadline is one year from the date of discharge from the hospital.

Note that a hospital bill is for the services provided by the hospital itself.  That is, for room and board, general nursing services, the use of hospital equipment, supplies, employees, and the like.  It does not include bills for doctor services you received while in the hospital.  The doctors will bill separately.

If a claim for any service is denied, the Tricare EOB will report $0.00 in the column entitled Amount Allowed.  The reason for the denial is always reported on the Tricare EOB.  That reason is what must be fixed for the claim to be reconsidered for payment.

If the reason for denial makes any mention of eligibility or DEERS, call the DEERS Support Office, toll-free, at 1-800-538-9552 for help.

If the reason for the denial is not something that can be fixed by a quick phone call, I recommend filing an appeal within 90 days of the date of the EOB showing the denial.

An appeal must be in writing, it must state the specific matter in dispute, it must be accompanied by a copy of the Tricare EOB that reports the denial, and it must be signed by the adult patient, or the legal guardian of a minor or incompetent patient.  A husband may not sign for the wife or vice versa.  The signature thing is all Privacy Act stuff.

If you have questions or need help with filing claims, call your Tricare Service Center. And you are going to need official help from Express Scripts with the pharmacy issues.   The toll-free number is 1-877-363-1303.

A few years ago, the Social Security law was indeed amended to make eligibility to receive Social Security payments depend on the beneficiary’s year of birth.  The age for entitlement for Medicare, however, remained unchanged at 65.

Medicare will bill the beneficiary every 90 days for the Medicare Part B premium until he or she reaches the statutory age to receive Social Security payments.  From that time on, the Part B premium will be deducted from the monthly benefit check.

Since Tricare for Life began in 2001, federal law requires all except active duty family members and Tricare beneficiaries enrolled in the US Family Health Plan to be enrolled in both Medicare Part A and Part B on the effective date of their Medicare coverage. Failure to be enrolled in Part B on that date causes the loss of Tricare eligibility until Part B enrollment is in force.

Your question isn’t new and neither is my reply. It’s a legitimate question, and an important one. So, no, you aren’t crazy. Unless you do it, of course.

Deliberate failure to report your other health insurance on your claim form is illegal. Additionally, stating falsely that all information on the form is correct, when you know it is not, is illegal. That is not an auspicious beginning.

Your signature on the Tricare claim form affirms, “under penalty of perjury,” that the information on the form is true. If the information is untrue, it is a false sworn statement used to obtain something of value you are not legally entitled to. That being true, I don’t think the claim would be different from any other false claim against the government. It wouldn’t be special, or somehow different, because it involved Tricare. The prosecuting authority would probably call it fraud.
Some very elaborate and sophisticated insurance fraud schemes appear from time to time. And it goes without saying that you never hear about the successful ones. So, what are your chances of getting caught, and what would happen next? I don’t know your chances of getting caught. I’ve never seen any statistics on the subject. When I worked for Tricare, I wasn’t involved with the folks who investigated fraud. Minor offenses aren’t often reported in the newspapers.

Considering the millions of Tricare claims processed every year, and the fact that bad guys vastly outnumber good guys – the examiners and auditors – you would probably get away with it for a while; maybe for a long time. But once discovered, all of your claims would be audited, forever.
And, once caught, what would happen? I have to guess that it could be anything from a fine to a sudden lifestyle change. But, that would be up to a federal prosecutor and a court. If you decide to do it, and if you get caught, drop me a line from … wherever. It will be your turn to satisfy my curiosity.

Your decision regarding military survivor benefits for your wife will have no effect on her Tricare or Tricare For Life coverage.  Neither will your death have any effect — unless she were to remarry.

If your wife were to remarry, she would immediately and permanently lose all Tricare eligibility received as a result of your service.  If her second marriage were to end by divorce or death, her Tricare benefits under your sponsorship can never be restored.

To confirm those facts officially, please call the DEERS Support Office, toll-free, at 1-800-538-9552.

DEERS is the place to call for answers to all Tricare eligibility questions, for help with resolving eligibility issues or problems, and for help to enroll a new spouse or child in Tricare.

DEERS cannot provide any information about the Tricare program, its benefits, or its claims.  For that information, you must call your Tricare Service Center or search for the information in the official Tricare web site.

Tricare beneficiaries should contact DEERS at least once each year to confirm that all information in their DEERS record is correct and up-to-date.  Any status changes — such as an address change, or changes in family members such as a newborn child, a child turning 21, a child who marries, or a family member who dies — should be reported to DEERS promptly.

I checked with Health Affairs, and they told me that the only service covered for TMJ problems is oral surgery under certain specific conditions.  Health Affairs advises that you or the provider should contact your Regional Tricare Service Center for advice and for information about the procedures that must be followed prior to any surgery.

My opinion is that it might be best if your provider made the call to Tricare in case there are technical or medical questions that he can address best.

Don’t go forward on any treatment procedure without contacting Tricare first.

Tricare Standard and Tricare Prime have different payment agreements with health care providers.

A provider is at complete liberty to provide care to Tricare Standard or Tricare Prime beneficiaries, or both, or neither, totally ad lib.  It is the provider’s choice.

To understand the differences in payment methods, you can read more about Standard and Prime on the Tricare web site.

My question is, if he dies — say, a month after marriage — would I still be eligible for Tricare benefits?

Your fiance should contact the Defense Enrollment Eligibility Reporting System, better known as DEERS, for instructions to enroll you in Tricare.  That can be done only through the uniformed services.  DEERS is the official Defense Department agency that will provide the help he will need to do that. The toll-free number for DEERS is 1-800-538-9552.

You will become legally entitled to Tricare the moment your husband kisses the bride.  If he were to die in the next minute, your Tricare eligibility will still be in effect.  It is the fact of your legal marriage that creates your Tricare eligibility, immediately.  To use Tricare, of course, there will be administrative details to accomplish.  Call DEERS for help.

You didn’t mention your age.  If you are, or if you become, entitled to Medicare, federal law requires you to be enrolled both in Medicare Part A and Medicare Part B to qualify for Tricare eligibility.

For the rest of your life, you will be responsible for checking your registration in DEERS to keep it up-to-date, and to promptly advise DEERS of any changes in your status, such as an address change.

Similarly, you will be responsible for keeping your military identification card up-to-date.  At least 90 days before your card expires you will need to contact DEERS for help with renewing it.

Every time a Tricare claim is processed, the claims processing computer automatically contacts the DEERS computer to ensure that the patient on the Tricare claim was eligible for Tricare on the date she received the medical care.  At that time, also, Tricare confirms the beneficiary’s eligibility generally by comparing the information on the claim form with the information in the beneficiary’s DEERS record.  Thus, you see the need to keep it up to date.  Discrepancies can cause claims to be denied until they are corrected.

If you are, or if you become, entitled to Medicare and are enrolled in Part B, you will be eligible for the Tricare program named Tricare for Life, also called TFL for short.  TFL is a Tricare plan created by Congress in 2001.  It allows a Tricare beneficiary who has Medicare to use Tricare Standard as second payer to her Medicare A and B coverage.  In the vast majority of claims, the combined payments by the two federal benefit programs will pay your medical bills in full.

I suggest you visit the official Tricare web site now.  Here you can locate your Regional Tricare Office (make a permanent record of the contact information — that will be your primary source for official Tricare help and information), see  an overview of the Tricare plans, and — if you are entitled to Medicare now, or will become entitled soon, and are enrolled in Part B — look at the information about TFL and download a Tricare for Life Handbook.

If you are not near Medicare entitlement age (65), your choices for coverage will be Tricare Standard or Tricare Prime.

Prime is not available in all areas, so if you are interested in that plan, call your Regional Office again to ask if Prime is available for persons in your residential area.  Tricare Prime costs the least in out-of-pocket expenses, but it also has certain inconveniences for members who travel frequently.

Under Prime, you must use only certain providers in your local area who are under contract with Tricare to provide care at discounted rates.  Prime membership also allows you priority access to your nearby military treatment facility where you can get free medical care including hospitalization.

When you become eligible for Tricare, it is for life, unless, as a widow, you remarry.  If you remarry, you will lose all military benefits from this husband.  They can never be restored, even if the next marriage ends in death or divorce.

All Tricare beneficiaries without exception are automatically eligible for and are enrolled in the Tricare Pharmacy Program.  It is one of the very best prescription drug programs in the nation.  It needs no help from any other pharmacy insurance plan. You can get a 90-day supply of a drug for the same price as you pay for a 30-day-or-less supply when purchased locally.

Because you are not legally married to the baby’s father, you are not eligible for Tricare for any of your maternity care.

If you were married, you would be covered from the date of the marriage.  You can confirm that by asking DEERS. Its toll-free telephone number is 1-800-538-9552.  Everything you tell DEERS is completely confidential, and the information DEERS will give you is official.

I urge you to call DEERS now and talk with them about your eligibility question, especially as concerns the baby’s Tricare eligibility from the moment he is born.  You need official information and help.

Because the father is on active duty, federal law makes the baby eligible for Tricare from the moment he is born.  But, the father must do some things to get the baby signed up in Tricare because you and he are not married.  The baby cannot use Tricare until he is properly signed up for the program.  Talk with DEERS about that also.

Tell the father to go to the Legal Office (JAG Office) at his base and to talk with one of the Legal Officers (a military lawyer) about his baby’s Tricare coverage.  He will need help to do the things that are necessary for the baby to get Tricare benefits for his medical care.  That legal help will be free.

Tell the father about DEERS and give him the DEERS phone number.  He should also talk with DEERS about the baby’s Tricare eligibility.  Both you and the father need to know about those things so Tricare can help pay for any medical care the baby needs from birth, and for as long as the father is on active duty.

Tricare eligibility is established by federal law for designated categories of persons.  Tricare does not have the authority to make individual eligibility determinations.  Only the uniformed services have the authority to determine whether a particular person meets the legal conditions to be eligible for Tricare, to register an eligible person in DEERS, and to issue an appropriate identification card.

No one can predict what the future may bring, but you can include me on your list of “everyone” who says the Tricare Prime enrollment fee and coverage will not be be changed in fiscal 2010.

Any changes would have gone into effect on October 1, 2009, at the beginning of the government’s fiscal 2010.  If an increase were intended, or significant benefit changes were planned, however, they would not be a secret or a surprise.  The information would have been widely publicized months ago.

Changes in the number of Tricare Prime providers, however, are subject to constant potential change nationwide.  That is because a Tricare Prime provider is one who chooses to provide medical services to Tricare Prime beneficiaries at discounted rates.  Tricare has no control over whether a provider chooses to do that.

Remember that Tricare is not a health insurance policy or company.  It is a federal health benefits program created by Congress by Public Law 89-614 in 1966.  All Tricare operations are governed by federal law and regulation.  It has no secrets.

You might be right, but I haven’t seen your friend’s Tricare Explanation of Benefits form. An EOB is the statement you get from a health insurance plan that explains how it processed each of the charges on the claim.

If Tricare denied payment for all or part of the claim, the reason for the denial is reported on the Tricare EOB.

I think it may be more likely that your friend’s Tricare claim was denied because it resulted from a work injury. But there’s a way to find out, and perhaps to get payment.

Tell your friend he has 90 days to file an appeal of the denial. The appeal must be in writing and state the specific matter in dispute. It must be signed by the adult patient and include a copy of the EOB that reports the denied charges. He should send it to the address on the EOB.

If he has questions, advise him to call his Tricare Service center. He can get that number by calling the Defense Enrollment Eligibility Reporting System office toll-free at (800) 538-9552.

Generally, only the Tricare Standard portion of Tricare for Life will cover you in Canada. I have heard that Medicare covers some limited emergency care in parts of Canada, but you’ll need to call Medicare for details. To the extent that is true, it would be a Tricare for Life benefit.

Before buying any “tourist” plans, read them carefully. If the plan does not agree to be primary payer, don’t buy it. Tricare will be unable to pay anything because of federal law requiring Tricare to always be last payer to any other insurance.

Tricare for Life is a U.S. government program, and U.S. law prevails in its operation, regardless of where the medical care is received.

If you can use Tricare only, be prepared for the likelihood that you will have to pay much of your Tricare $150 deductible when the claim is processed, along with a 25 percent Tricare cost share.

I believe the first commercial health insurance company to come up with an affordable, short-term Tricare supplement for travelers like you will make a killing.

I thought that if a provider accepts and bills Medicare, federal law requires him to also accept and bill Tricare. What are the facts?

That law applies only to institutional providers, such as hospitals. Individual providers, such as physicians, psychologists, private physical therapists and the like, are not bound by that law.
If the physician has severed his relationship with Tricare and is no longer a Tricare-authorized provider, Tricare cannot pay for any of his services regardless of who files the claim.

If he remains a Tricare-authorized provider but no longer participates in Tricare on the claims, you may use his services and file the claims yourself. In that case, he is no longer required to accept the amount Tricare allows as full payment for his services.

However, there is a law that limits the amount you may be charged for his services. It is a provision of the law governing Medicare called the Limiting Charge. In 1983, Congress made that law apply to Tricare as well as to Medicare.

The Limiting Charge allows a nonparticipating physician to charge a Medicare or a Tricare beneficiary up to, but not more than, 15 percent over the amount Tricare allows on a claim. Tricare will pay its usual amount directly to you. You will be responsible for paying the physician the amount Tricare allowed on the claim plus an additional 15 percent more than the amount allowed.

Your out-of-pocket expense for using such a physician, then, is your usual 25 percent cost share plus the 15 percent surcharge.

You might want to tell the office manager that Medicare and Tricare are required by law to use the same methodology and most of the same databases to calculate the amounts they allow on claims.
The amounts allowed by the two programs seldom differ by more than a few dollars. Tricare often allows slightly more than Medicare because of its younger, healthier beneficiary population.

Tricare may pay for medically necessary and appropriate medical and surgical services to treat injuries and diseases of the eye.  It may cover one routine eye examination to measure the eyes for glasses for active duty family members only.

Tricare may not pay for eyeglasses or contact lenses except for two or three specific and uncommon eye conditions, and for one pair of spectacles or lenses following intraocular lens implant surgery.

Contact your Tricare Service Center for more information regarding coverage for spectacles or lenses if you believe you might qualify.

Tricare may not pay for vision training or eye exercises of any kind.

TFL consists of full coverage under Medicare Parts A and B plus full coverage under Tricare Standard.  The TFL beneficiary has two, full-coverage, stand-alone health insurance plans.  The Tricare portion is free. Medicare is the primary plan. The beneficiary must seek all his medical care from Medicare providers who will file a Medicare claim for the services he provides.

When Medicare completes all its processing of the claim and pays its share to the provider, it will automatically forward the claim to Tricare as second payer.  In the vast majority of claims, Tricare will pay whatever Medicare did not pay for every medical service that is covered by both Medicare and Tricare.  When both Medicare and Tricare cover a service, Tricare acts as a free Medicare supplement.  The Tricare deductible and cost share are waived, and the combined Medicare plus Tricare payments will pay the Medicare claim, and the provider’s bill, in full.  The patient will pay nothing.  The vast majority of TFL claims will be of that kind.

In response to your question, if Medicare denies payment on a portion of the claim — if it cannot pay for one or more of the services the patient received — the first thing to do is to file an appeal with Medicare.  You will find instructions with the documents Medicare sent to you when it reported the charge was denied.

After all the appeal actions have been taken and resolved for or against your claim, Medicare will forward the claim to Tricare as usual, including the charges for the items Medicare did not pay and the report of the appeal actions.

If the particular item that was denied is for a service that is covered by Tricare, Tricare will process the claim for that particular item as the only insurance coverage for that item.  In that case, all Tricare claims processing rules will apply including the Tricare deductible and cost share.  That is, the claim for the service not covered by Medicare will be processed as if the patient did not have Medicare coverage — as if Tricare is his only health insurance.  It will be processed in exactly the same way as your Tricare claims were processed before you became eligible for Medicare.

If the item is not covered by Tricare or Medicare, the patient must pay the entire charge for that item out of his own pocket.

My question is, should I be doing something now? If not, when? Should I wait until my wife retires?

If you are entitled to receive retired pay, you are eligible for Tricare in your own right. But being an active-duty dependent is a better situation than having Tricare under your own Social Security number.

You have a smaller cost share, 20 percent instead of a regular retiree’s 25 percent, and your catastrophic cap is only $1,000, instead of $3,000 as it is for most retirees.  It seems that you are in very good shape for your health care coverage.

When your wife retires, you and she should continue to keep your Tricare eligibility under only one of your SSNs.  That keeps you with only one family catastrophic cap account, which is good.

I don’t think that you need to do anything until you get Medicare when you are 65.  Between now and then, call DEERS at least once a year to make sure your registration is correct and up-to-date, and promptly report to DEERS any change in your status, such as an address change so your record is up-to-date at all times.  The DEERS toll-free number is 1-800-538-9552.

I’m disadvantaged because I don’t know what benefits are provided under various plans available through the Federal Employees Health Benefits Program (FEHBP).  I am aware that Mail Handlers is one of the better plans available for federal employees, but I don’t know how Mail Handlers Value differs from Mail Handlers Standard.  I must leave that analysis and its applicability to your needs to you alone.

Let me talk briefly about what I do know.

I can tell you that Tricare Standard is a full service, stand-alone plan that, when it was created in 1966, was modeled after the FEHBP’s High Option Blue Cross and Blue Shield Plan.  That plan was considered to be one of the best available in the nation at the time.  Because of its generous and broad coverage, it was the most expensive plan available to federal employees.  It is no longer available, perhaps for that reason.

Over the years, many beneficiaries have had Tricare Standard as their only health insurance.  It’s greatest deficiency as one’s only coverage is its $150 deductible and 25 percent copayment (cost share).  Tricare has always recommended a good Tricare supplement, when possible, for those enrolled only in Tricare Standard.

In my experience, and having corresponded with several thousand Tricare beneficiaries, I believe that when Tricare Standard is combined with a good Tricare supplement — or much better, with a good primary plan such as any of the FEHBP plans — beneficiaries find that most of their health care costs are paid in full or almost in full. The latter would be my choice for coverage.

That is particularly true because all Tricare beneficiaries are automatically eligible for, and are enrolled in, the free Tricare Pharmacy Program, which is one of the best prescription drug plans available. A Tricare beneficiary does not need any other pharmacy insurance.

Note:  The Tricare Pharmacy Program has a new, combined information center at 1-877-363-1303, toll-free.

By federal law, Tricare is always last payer to all other health insurance plans.  Whatever commercial plan you choose under the FEHBP, Tricare will serve as second payer, and it will usually pay most, often all, of what the primary FEHBP plan does not pay.

The FEHBP doesn’t offer any “junk” plans.  Although they differ in the kinds and amounts of coverage, all the FEHBP plans are solid, legitimate plans. Tricare Standard is a good choice as your second payer for any plan under the FEHBP.

Thus, your decision must be based on your reading of the fine print in your two Mail Handlers plans, to decide which of the two provides more adequately for you and your family.  With Tricare Standard as second payer, only the details of the two Mail Handlers plans and their application to your particular family needs to concern you

Tricare Prime, on the other hand, is in my opinion the plan of first choice as an individual’s or a family’s only coverage. But I do not recommend Tricare Prime for any beneficiary who has other health insurance.  Tricare Prime functions as a Health Maintenance Organization, or HMO — a plan under which the beneficiary must receive all his care from providers who are under contract with the plan, and he usually pays a fixed fee which is the same for each doctor visit.

Because you may use only plan providers, an HMO limits your choice of physicians to those on a list of certain providers in one specific geographic locality.  Because of those requirements under Tricare Prime, it is not a good choice to be second payer to any other health insurance.  It has a potential for too many problems when benefits are coordinated between the two plans.  That invites errors and, especially, misunderstandings.

Regardless of what other health insurance (OHI) you have, Tricare is always second (last) payer, by law.  When Tricare Standard coordinates its benefits with their OHI, some beneficiaries have told me that it usually pays most, or sometimes all, of the OHI’s deductibles and copayments.  I have the impression, however, that much depends on the quality of the OHI.

Retirees I worked with at the CHAMPUS Headquarters (CHAMPUS was Tricare’s precursor until 1995) in the 1980s chose the cheapest FEHBP plan available because of the way Tricare coordinated benefits.

Folks working in the (now) Tricare Headquarters’ Coordination of Benefits (COB) section have told me that unless they have in hand a copy of the OHI claim, they can’t predict the amount Tricare will pay as second payer.  Coordination of benefits has become that complicated.

I have been writing Tricare Help since 1992, and I have responded to thousands of beneficiary inquiries about many things.  But, I have never heard of anybody collecting the data and doing the calculations necessary for a comparative analysis of the kind you suggest.

Not to be interpreted as advice — because I don’t know — but the BCBS Basic might be a nice conservative trial to see how well Tricare Standard serves as second payer to a less expensive plan than BCBS Standard.  If you are willing to gamble, you can always change back during Open Season the next year if it doesn’t work out well.

If you do it, you’ll have a story to tell me about it in 2011.  In turn, I will have something to report to the next person who asks the same question.

Your question primarily concerns Tricare eligibility.  Although it may seem strange, Tricare has no authority in the matter of Tricare eligibility.  Only the services have the authority to make individual determinations about Tricare eligibility.

Before you do anything else, call the Defense Enrollment Eligibility Reporting System (DEERS), to determine whether you and your family are eligible for Tricare — what you are eligible for, and when.  DEERS is an official computerized database of all DoD beneficiaries and the benefits to which each is entitled by law.  DEERS’ toll-free number is 1-800-538-9552.  Put that number in your Rolodex.  You will very likely need it again.

Ask DEERS any questions you might have regarding eligibility.  Find out what you must do to enroll in Tricare — to become registered in DEERS as eligible for the program.

There will be things regarding the Tricare Program itself, such as benefits and claims, that DEERS will be unable to answer.  DEERS deals only with eligibility issues.  I suggest you make a checklist before calling so you don’t forget anything, and keep notes of what you are told.

Then, after you have resolved all your questions with DEERS, get back to me so we can discuss any other questions.

I could pay him that amount, but I don’t think he is entitled to it. I explained to them that I had paid the amount Tricare allowed plus an additional 15 percent. That is what you have explained in your column. I showed them the Tricare Explanation of Benefits so they could see it themselves. They told me this rule applies only to Medicare patients, not to me. Is that right?

The only information I have is what you report in your question. Based on that information, it appears you have paid correctly.

The 15 percent rule is a provision of Medicare law called the Limiting Charge. It says that a nonparticipating provider may charge a Medicare beneficiary up to, but not more than, 15 percent over the amount Medicare approved on the claim.

Congress passed a law applying the Medicare Limiting Charge to Tricare claims beginning Oct. 1, 1993.

But you will never be able to persuade your doctor’s office that you and I are right, and they are wrong. Here’s what you need to do: Write a letter to your Tricare claims processing office at the same address where you submit claims. Explain the situation to them. Attach a copy of the EOB for that claim and copies of the bills you have received.

Tricare will contact the doctor’s office on your behalf and explain the law to them. In most cases, that will resolve the issue. If it doesn’t and the doctor’s office has really dug in its heels, send me another e-mail.

If Tricare pays a claim in error, federal law requires it to recoup the money. It will ask the payee on the claim to refund the erroneous payment.

If the provider participated in Tricare on the claim and received payment directly from Tricare, the provider would be asked to refund the payment. If the provider did not participate on the claim, payment would have gone to the adult patient or the custodial parent of a minor child, who would be responsible for repaying Tricare.

When Tricare determines that a claim has been paid in error and requests a refund, it is because the claim was denied. Whoever is asked to return the payment — the adult patient on the claim, the custodial parent if the patient was a minor, or the participating provider — may, and should, file an appeal of the denied claim.

Tricare has only one concern and one responsibility: the return of the full amount of a payment made in error.

My family and I will get Tricare later this year when I am 60. Will my daughter’s subsequent surgeries be covered by Tricare, or will coverage be denied or limited because the scar is a pre-existing condition?

Tricare is not an insurance company; it is a federal health benefits program, similar in that respect to Medicare. Unlike many commercial health insurance plans, Tricare has no restrictions or limitations on the coverage of pre-existing conditions.

A potential problem, easily overcome, could be with the continuity of care if you want the later surgeries performed by the same surgeon who did the previous operations.

For Tricare to cover the surgery, the surgeon must be or become a Tricare-authorized provider. That is, he must apply to Tricare and submit the information required to establish that he is a properly trained and licensed physician in the state where he practices.

When Tricare approves his application, he will be authorized to receive payment for services rendered to Tricare beneficiaries. All insurance plans and companies require some form of provider authorization.

Apart from certain medical emergencies, Tricare may not pay for any services received from an unauthorized provider.

Will Tricare refuse to insure her because of her pre-existing medical conditions? Or, if Tricare will cover her, will it be limited in some way — especially if her cancer returns?

As soon as you are married, contact the Pass and ID Card Section at any uniformed service facility so your wife can apply for all the benefits to which she will be entitled, including Tricare. If there is no facility nearby, call the Defense Enrollment Eligibility Reporting System support office, toll-free, at (800) 538-9552, for instructions and advice about the best way for her to apply. Only the military services can register her in DEERS so she can use Tricare.

Tricare has no exclusions or limitations on coverage for pre-existing medical conditions. From her first day of eligibility, your wife’s Tricare coverage will be exactly the same as that of all other Tricare beneficiaries.

I am concerned, however, about your wife’s coverage by your Tricare supplement. Tricare is not a health insurance company or policy. It’s a federal health benefits program governed by federal law and regulation. Tricare supplements, however, are offered by commercial insurance companies. They’re not part of Tricare, and Tricare has no control over them. Each has its own rules.

I know little about Tricare supplements. Tricare Help is seldom asked about them, and my comments are limited to “read the fine print,” which is always good advice about any contract.
Most commercial health insurance policies have limitations on the coverage they provide for pre-existing medical conditions. Policies they write as supplements for primary plans, such as Medicare or Tricare, most likely will have similar provisions. The important details are in the fine print.

For example, a commercial insurer might exclude any coverage for cancer from your wife’s Tricare supplemental policy. Or it might limit its cancer exclusion to breast cancer because of her personal and family history of the disease.

A fairly common exclusion is that a new beneficiary must go for several months, sometimes a year or more, without needing treatment for a pre-existing condition in order for it to be covered. When that time has passed, and if the beneficiary has not needed medical care for the pre-existing condition, it will be covered as if it were not pre-existing.

That can be bad news for beneficiaries with chronic conditions such as diabetes or arthritis. How bad the news is could depend on the way the policy defines a “need” for medical care for the condition.

It might not balk at a diabetic’s routine needs for insulin, blood testing and related supplies, but if the beneficiary has had an acute diabetic episode requiring emergency care or hospitalization, she might be disqualified for coverage.

These are only illustrations of the kinds of restrictions commercial policies can put on their coverage of pre-existing conditions. Different policies may have different restrictions.
Check the fine print on your existing Tricare supplement and, perhaps, several others, to learn exactly how each supplement handles coverage of pre-existing conditions.

There is an unpleasant reality I must mention: If you were to die, your wife’s Tricare eligibility would not be affected. Unless she remarried, she would be eligible for Tricare for the rest of her life.

If the marriage ended in divorce, however, she would lose Tricare eligibility immediately.
If your wife were to cancel her present health insurance policy, and if your marriage were to end in divorce, she would find herself uninsured by Tricare and, because of her medical history, she probably would be uninsurable by any commercial insurer except at great cost.

Please note that if your wife is a federal employee, she can suspend — rather than cancel — her federal employees health insurance plan. That way, she could reinstate the coverage during open season in any year.

A provider is any person or organization that provides services to another person or organization. Your phone company, for example, is a provider of telephone services.
There are many kinds of providers of health services. In addition to physicians and hospitals, they include self-employed nurse practitioners, physical and occupational therapists, nurses in private practice, clinical psychologists, medical supply and equipment vendors, and the like.
This discussion is limited to physicians. The participation rules apply to all Tricare-authorized providers.

For the safety of their beneficiaries and to prevent (or at least discourage) fraud, all health insurance companies require some form of provider registration or certification. Before they pay claims on behalf of beneficiaries, insurance companies must be certain that providers are fully qualified, licensed physicians in good standing in the states where they practice.

Tricare is no different. To become Tricare-authorized providers, physicians or other providers of health services must apply to Tricare, submit information to confirm their qualifications and be approved. They then can receive payment from Tricare for covered medical services provided to Tricare beneficiaries.

Except in certain medical emergencies, Tricare will not pay for any service a beneficiary receives from an unauthorized provider.

On every Tricare claim, an authorized provider can choose whether to participate. Tricare will allow, and pay, the same amount regardless of whether the provider participates. However, the beneficiary will be responsible for paying more when the provider does not participate.

If providers choose to participate on a claim, they will sign the participation agreement on the claim forms and file the claims on behalf of the beneficiaries. They agree to accept the amount Tricare allows on that claim as full payment for those services.

Tricare will pay its share directly to the participating providers. When the beneficiaries pay their part of the claim, the participating providers’ bills for the covered services will be paid in full.
A beneficiary is not responsible for paying more than the amount allowed for covered services on a participating claim, regardless of the amount billed.

If a provider chooses not to participate on a claim, Tricare will send its payment to the beneficiary, who is responsible for paying the nonparticipating provider as much as, but not more than, 15 percent over the amount allowed on the claim. Tricare will pay nothing toward that 15 percent surcharge.

It’s important to note the difference between the amount Tricare allows on a claim and the amount it pays. On most claims, that difference is the beneficiary’s deductible, if applicable, and cost share. If Tricare denies a charge, however, the amount the beneficiary is expected to pay may be more than those items.

When a Tricare claim, or a portion of a claim, is denied — it will say “$0.00” in the “Amount Allowed” column on the explanation of benefits — the beneficiary should file a written appeal within 90 days. The EOB always reports the reason a charge was denied. An appeal may change, or even remove, the amount a beneficiary is required to pay on denied charges.

Appeal instructions are on the back of every EOB. You cannot appeal by telephone. For further information about appeals, call your Tricare Service Center.

The federal law that limits the amount a Tricare beneficiary may be charged for covered services on a nonparticipating claim is a provision of Medicare law called the Limiting Charge. Physicians who see Medicare patients know about that law. Congress extended the law to include Tricare claims in 1993.

Regardless of whether a provider participates on a claim, if he demands payment in excess of the amount permitted by law, you should notify the Tricare claims processor immediately by mail. Include a copy of the original Tricare EOB and copies of the bills or letters that cite the balance due.

According to your letter, Tricare has already done for your wife all the things it is supposed to do. It has paid all of the claims for her medical care. If your wife has paid her cost shares and any deductibles on the claims, according to the Explanation of Benefits forms she has received from Tricare, she has no providers demanding payment. Her bills were paid in full.

Your question now concerns legal matters, and I am not a lawyer. While I can tell you what a law says, or you can read the law yourself; I am not qualified to interpret a law or to say how it applies to a given individual or situation.

This reply is based on what I learned when I worked for the Pentagon’s Office of Health Affairs and things I have read after that. You should take no action or make any decisions based on what I tell you — seek guidance from your lawyer. If he has questions, he can write to the Office of General Counsel, Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.
According to your letter, because the other driver caused the accident, he was responsible for paying for the resulting damages, including your wife’s medical bills. His insurance company became a third party in the case; on his behalf, it became liable for paying at least part of the costs of restoring your wife to the condition she was in before the accident — what lawyers refer to as “making her whole.” Whether it does is a legal matter and out of my purview.

Federal law requires Tricare to try to recover, from a liable third party, the reasonable costs of the medical care Tricare paid for.

That is a matter between Tricare and the insurance company; your wife is not involved in Tricare’s recovery efforts. Even if Tricare is unable to recover the full amount, your wife will not be held liable to pay any remaining amount.

In my experience, the amount due to Tricare under federal law will be withheld from the insurance settlement before any funds are released to your wife. Presumably, part of the settlement has never been hers alone. The amount remaining after Tricare recovers its part will be hers to keep.

Because of her previous marriage, your fiancée was indeed eligible to retain her Tricare eligibility after the divorce from her former husband. Her Tricare eligibility, however, was carried in the Defense Enrollment Eligibility Reporting System under her own Social Security number, not that of her former sponsor.

Handled properly with DEERS, that eligibility will end at midnight of the day before she marries you. She will become eligible for Tricare under your sponsorship and Social Security number one second later on the day she marries you.

For your bride to use Tricare, you will have to apply for a new ID card for her and ensure she is properly registered in DEERS. Contact the DEERS Support Office at (800) 538-9552.

The only problem I foresee might be with proper crediting of any Tricare deductible that has been withheld on her claims in the current fiscal year under her Social Security number.

For information on transferring deductible credits from one Social Security number to another for the same person, call or write to the Tricare Service Center for the Tricare region where you will live after the marriage.

I have no way to gain access to your Tricare claims, so I couldn’t do more than speculate about the reason for the balance due.  But, I can tell you how to get the information.

Write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.  Explain the problem in detail. Because your wife was the adult patient, she must sign the letter (Privacy Act stuff).  Include her full name and her Social Security number, your full name and SSN, home address, a daytime phone number for her, the name and address of the emergency room, and the date(s) of medical care.

Every time a health insurance plan processes a claim, it issues to the patient a full report of each action it took on each of the medical service charges submitted.  On a hospital claim, there may be dozens, even hundreds, of them. Most plans call their report an Explanation of Benefits, or EOB.  Medicare calls its report a Summary Notice.

Include with your letter to Tricare Management Activity a legible copy of each EOB and Summary Notice your wife received from Medicare and Tricare for all the charges related to her emergency room care.  It is important that each charge submitted to Medicare should be reported on both the Medicare Summary Notice and the Tricare EOB.  That is so TMA, in its search for an unpaid $153, can trace each charge to determine the way it was processed.

The legal age for Medicare eligibility for most people is 65, unless they qualify for Social Security disability benefits before then. Social Security wants people to apply for Social Security and Medicare at least 90 days before the first day of the month when they will turn 65. At that time, your wife should apply for Social Security benefits, including Medicare parts A and B. To learn more, call Social Security at 1-800-772-1213.

You should also call the Defense Enrollment Eligibility Reporting Service (DEERS) Support Office at 1-800-538-9552 to ensure that you and your wife are properly registered in that database. Ask whether you and your wife are eligible for Tricare. As you are a uniformed service retiree, your wife should be eligible for Tricare Prime or Tricare Standard coverage now.

In the meantime, visit the Tricare web site and make a note of the contact information for your regional office. You can read overviews for Standard and Prime, as well. Tricare Standard is free; Tricare Prime costs $460 per year for a family of two people or more. Both plans can be used to supplement any other health insurance you have. Tricare Standard, however, is the recommended plan for people with other health insurance.  It will pay all, or most, of the deductible and copayment from your other health insurance.

Those who wrote the law and regulation governing Tricare eligibility, fortunately, had the foresight to consider situations like your son’s. A uniformed service member’s child born out of wedlock may be declared eligible for Tricare if paternity is judicially determined. The child’s eligibility presumably begins at the moment of birth. But to the best of my knowledge, that does not confer any Tricare eligibility on the mother, not even for her maternity care.

Tricare Help has no official affiliation with the Defense Department, however. For official answers about eligibility, you must contact the the Defense Enrollment Eligibility Reporting System (DEERS) at 1-800-538-9552. DEERS is a federal agency under auspices of the Defense Department. All matters discussed with DEERS are protected by the federal Privacy Act of 1974. It maintains a computerized database of all Defense Department beneficiaries and the military benefits to which each is entitled by law.

Tricare itself does not have the authority to make individual eligibility determinations. Only the uniformed services have the authority to determine whether a given individual meets the legal criteria for Tricare eligibility, to register an eligible person in DEERS, and to issue a uniformed service identification card. DEERS will help you resolve the matter of the child’s Tricare eligibility. They can tell you what to do and whom to contact.