Mom’s soon-to-be ex threatening to take away her Tricare
August 12th, 2011 | TriCare Help | Posted by Military Times
My 62-year old mother is in the process of divorcing her husband, who’s retired from the Navy. She is currently covered under his Tricare. They have been married 14 years, only 18 month of which while he was on active duty, so we realize she will not be eligible for Tricare on her own after the divorce. Divorce proceedings may take months, however, and he is threatening to “make a phone call” now and have her dropped from his plan before the divorce is final. Can he do this?
In short, no. Under the law that created Tricare, the benefit flows directly to the beneficiary, not “through” the military sponsor. The sponsor cannot control the beneficiary’s eligibility for Tricare or use of the program. Neither does the sponsor have a legal right to any information about an adult beneficiary’s Tricare claims or medical care without the beneficiary’s written permission. That information is protected by the federal Privacy Act of 1974.
You are correct that your mother’s Tricare eligibility will end when the divorce is final. Tricare will not cover the costs of any medical service she receives after midnight on the day the divorce is final. She and/or her providers, however, may continue to file Tricare claims for medical services received before that time and date. The filing deadline for those claims is one year from the date of the care.
I strongly recommend that you call the DEERS Support Office for official information regarding this matter and confirmation of the information above.The toll-free number is 1-800-538-9552. DEERS can provide official information and guidance about any matter pertaining to Tricare eligibility only. It can’t help with matters concerning Tricare benefits, claims, or payments. Please contact your Regional Tricare Service Center for that information.
Bear in mind that I am not an attorney; while I can tell you what a law or regulation says, I am not qualified to tell you how it applies to a particular person or situation. Only a qualified attorney or official agency can do that.
How does having other insurance affect my Tricare coverage?
July 25th, 2011 | TriCare Help | Posted by Military Times
I am a military spouse, and I work as a nurse, so I have Tricare as well as my employer’s insurance. My employer and the Tricare Outpatient Clinic I visit told me that Tricare would be my secondary insurance, but neither explained what that means. I continued to see my Tricare provider and they referred me to outside doctors when their own staffing was low at the military treatment facility. Triwest is now asking all providers they had previously authorized to pay them back, and sending me notices that I owe for services they authorized with these providers. They claim they did not know I had another insurance when I had previously filled out papers at the Tricare clinic when I started coverage under my employer’s plan. How does having another insurance affects my benefits through Triwest?
When a Tricare beneficiary has other health insurance, federal law requires that Tricare must always be the last payer. That means all claims for civilian medical care must be filed first with the OHI. When the OHI has paid its maximum and has issued the beneficiary an Explanation of Benefits (the report you get from an insurer showing all of its actions in paying your claim), you may file a Tricare claim.
The Tricare claim must consist of (1) a properly completed Tricare Claim Form DD2642; (2) copies of exactly the same itemized medical bills as were sent to the OHI; and, (3) a copy of the OHI’s EOB showing the way it processed (paid or denied) each of the charges on the medical bills. You must send the completed package to the Tricare claims processor for your state or ZIP code.
(You can download official claim forms and look up the filing address here.)
As last payer, Tricare will pay all, or most, of whatever the OHI did not pay for the medical services on the bills.
You didn’t mention if you have Tricare Standard or Tricare Prime. Tricare Standard is free; Tricare Prime costs $230 per year for one person, or a maximum of $460 for a family of two or more people.
Your mention of using a military treatment facility leads me to think you have Tricare Prime. Unlike Tricare Standard, Tricare Prime functions like a Health Maintenance Organization (HMO). You may use only the health care providers that are enrolled in Tricare Prime’s Provider Network unless you are referred to other providers by Tricare Prime. According to your letter, that was the case with your medical care.
As you report, Tricare is requesting that you refund its payments made in error. According to the information in your letter, Tricare paid in error because you failed to report that you had OHI, and did not file first with the OHI as required by law. No, the cops are not going to come knocking on your door.
But, you do have some problems with having to return payments made in error by Tricare. Pursuant to that, you need more help than Tricare Help can give you.
Please write to the Tricare Headquarters about this matter. The address is Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.
With your letter, please explain the problem in detail, include your full name as it appears on your military ID card, your husband’s name and his Social Security number, and a telephone number where you can be reached during the day. Include copies of any correspondence, bills, EOBs, and the like, that pertain to the problem. The more information you can provide, the more efficiently Tricare can serve you.
Where can I get help with EOBs?
April 18th, 2011 | TriCare Help | Posted by Military Times
Q. I sometimes find it hard to understand Tricare’s explanation of benefits forms. Where can I get help?
Each Tricare contractor maintains a website — find yours on the Tricare website — with a link to information for the beneficiary. That link will provide full explanations of EOBs issued by that Tricare Regional Center and will answer any questions you may have about the way your claim was processed.
Many of the problems experienced by Tricare beneficiaries result from not understanding the program’s rules — your rights and your responsibilities, especially in the matter of claims filing. Very often, problems result from simple clerical errors when claims are filed. Other problems can result from failure to provide additional information when requested.
I strongly recommend that beneficiaries spend some time studying the information provided online. The better you understand Tricare, the better it will serve you.
How will employer’s plan, TFL work for wife?
November 24th, 2010 | TriCare Help | Posted by Military Times
Q. I am a retired sailor and a federal employee. We have my employer’s health insurance, with Tricare as second payer. My wife is two years older than I am and will be eligible for Medicare this year. How will Medicare, Tricare and my employer’s plan work together for her? What will be the effect on my coverage?
A. At least 90 days before the first day of the month before she turns 65, your wife must apply for Medicare. Because she has Tricare, she is required by federal law to enroll in both Medicare Part A and Part B.
Once she does, she must seek all her care from Medicare providers. Medicare cannot pay for care she receives from a provider who is not authorized to file Medicare claims.
While you are still working for the government, your employer’s plan will remain her primary coverage. She must file first with that plan, just as she does now.
Medicare will be her secondary insurance. And Tricare, by law, is always the last payer. After your federal employees plan and Medicare have processed a claim, she should file a claim with Tricare.
Changes to your wife’s coverage will have no effect on your coverage. You will pass through the same transition when you get Medicare at age 65.
Will my granddaughter be covered overseas?
November 16th, 2010 | TriCare Help | Posted by Military Times
Q. I would like to take my daughter and granddaughter to Korea. I want to know if my granddaughter will be covered in Korea. Her dad is in the Army and she is in Tricare under him.
Please call the DEERS Support Office, toll-free, at 1-800-538-9552, to ensure that your granddaughter’s DEERS record is correct, up-to-date, and won’t expire before she returns home.
If she is enrolled in Tricare Standard — not Tricare Prime — she has coverage worldwide. Tricare Prime does not provide coverage overseas.
I suggest that you call your Regional Tricare Service Center to discuss the matter with that office.
If she receives foreign medical care, it is important that you save all medical documentation — copies of bills, receipts, prescriptions, doctor’s statements, clinical notes, and the like. You will need that information to file Tricare claims after she returns home. You do not have to provide translations or currency conversions. Tricare will do that.
Note that foreign providers are not likely to recognize U.S. health insurance of any kind. Most will expect payment “up front” when services are rendered.
If you or any member of your party is a Medicare beneficiary, please be aware that Medicare, by law, cannot pay for any foreign medical care. Medicare benefits are lost the moment a beneficiary departs US waters or air space.
Tricare works with other insurance and covers pre-existing conditions
September 13th, 2010 | TriCare Help | Posted by Military Times
Q. My job doesn’t offer health insurance, so I bought my own policy. Now they say they will not cover my pre-existing conditions. Does Tricare cover pre-existing conditions? Do I still have to file a claim with my commercial plan first even if I know they will not pay?
Tricare has no restrictions or limitations on payments for pre-existing conditions that are otherwise covered by Tricare.
You must file a claim with your commercial plan first, even if you know it will deny the claim. After it has processed the claim and sent you an Explanation of Benefits (EOB), you may file a Tricare claim.
File the Tricare claim just as you would if the other plan had paid part of the bill. Don’t forget to send Tricare copies of the bill you sent to the other plan and of the EOB reporting its actions on those charges. If you have questions about filing the Tricare claim, call your Tricare Service Center.
A phone call works instead of an appeal – sometimes
August 16th, 2010 | TriCare Help | Posted by Military Times
Q. You always recommend that beneficiaries file an appeal with Tricare any time a claim is denied. I have used Tricare for more than 10 years and have had payment denied a few times. Every time, I was able to resolve the problem with a phone call to Tricare. I have never filed an appeal, and I believe what you recommend is a waste of time for me and the government.
You’re right, a claim problem often can be resolved with a phone call, and that’s a much more efficient way of resolving an issue — when it is possible. The problem is that it doesn’t always work, and a simple phone call will not protect your rights to your benefits under the claim. That’s a reason for the formal appeals process established by law and regulation.
When there’s a problem with a claim, including a denial of payment for a charge, you have 90 days to file an appeal or otherwise resolve the issue. It sounds like a long time, but it passes quickly.
What may appear on the surface to be something easily resolved can be the result of something much more complicated. In the meantime, while you’re waiting for Tricare to resolve the issue as a result of your phone call, the time for filing an appeal is running out.
It’s also possible for human error to cause the record of your phone call to get lost, or the person with whom you spoke could leave the job, or simply may not be very efficient. The point is, if the 90 days run out without resolution, you could lose your rights to benefits for the claim.
Perhaps we can combine safety and efficiency by first filing an appeal of the denial of the claim to protect your rights. Then you can make the phone call and try to resolve the problem that way.
The right way to deal with a problem with Express Scripts
July 15th, 2010 | TriCare Help | Posted by Military Times
Q. Why is Express Scripts such a frustrating outfit to do business with? They have not responded to two greivance letters. In particular, I do not believe that they have paid out one single dollar for paper-processed claims for reimbursement that I have filed on behalf of my mother. They just recycle the paperwork back to you and they don’t care.
Your communication problems may have to do with the Privacy Act. By federal law, Tricare, Express Scripts, etc. cannot discuss your mother’s claims with a third party (you) without her written consent.
As that is only a guess, however, please send a detailed report of your mother’s problem to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, Co 80011-9043. Both you and your mother should sign the letter. That way, you can be included in the communications loop. If your mother is unable to sign the letter, please include a statement to that effect.
Include copies of all correspondence and other pertinent documents and a telephone number where you can be reached during the day. Be sure to include your mother’s full name, her military sponsor’s full name, and his Social Security number.
The more information you provide, the more effectively you can be helped. As an example, your letter, above, provided no information I could have used to suggest things you might do to resolve the problem. Surely Express Scripts reported its reasons for not paying the claims. Or perhaps, they didn’t, and said they couldn’t discuss the problem with you because of the Privacy Act. I don’t know, of course.
TMA, above, is a federal agency and the worldwide Tricare Headquarters. That office has the authority to order copies of all your mother’s claims documents and analyze them to get to the root of the problem.
If your mother is enrolled in Medicare Part D Pharmacy Plan (which she does not need unless her income is below the federal poverty line), her problem may be related to the coordination of benefits between two pharmacy benefit plans. Such claims must be filed in a certain order and contain certain documents to be processed and paid smoothly.
Without Part D, all your mother’s prescription services can be handled locally by an Express Scripts network pharmacy, or by mail order where she can get a 90-day supply of her medicines at the same price she pays for a 30-day supply purchased locally. Find information about that on Tricare’s website.
Covered by Standard and federal plan – what happens when I turn 65?
June 28th, 2010 | TriCare Help | Posted by Military Times
Q. This September I will be 65 years old and eligible for Medicare. I am retired from the Navy, and have Tricare Standard for myself and my family. I am also retired from federal service, and I am enrolled in the Government-wide Service Benefit Plan (BlueCross BlueShield) for government retirees. This is my primary health insurance. My wife will not be eligible for Medicare for another seven years.
What should I do about my health insurance needs when I turn 65 and go on Medicare? I know I will have Tricare for Life, and I realize I need to get Part B of Medicare. Am I correct to assume that my wife and child (20 years old) will still be eligible for Tricare Standard, and I will have TLF and Medicare? What should I do about my government retiree plan?
In your case, unfortunately, your transition from “ordinary” Tricare to TFL will be expensive for you. Here’s why.
Your transition to TFL will have no effect of any kind on your family’s eligibility for “ordinary” Tricare Standard. And, they will continue to need other health insurance – the federal employees plan (FEP) — in addition to Tricare, just as they do now. Your family’s coverage will not change in any way.
Your FEP premium is at the family rate — two or more family members. That will not change, because you will still have the FEP plan.
You cannot leave the FEP plan. You, the former employee and sponsor, must also be enrolled in the FEP in order for your family to have FEP coverage. You will have to pay the FEP monthly premium at the family rate just as you do today for two or more family members.
Now about your TFL. You know that federal law requires you to be enrolled in Medicare Part B when your free Medicare Part A becomes effective. That means you will have to pay a monthly premium for Medicare Part B in addition to the FEP premium.
Your own personal costs for health insurance will increase by the amount of the Part B premium. Your first payment will be due on August 1. You will pay for Part B one month in advance. For the remainder of this fiscal year, which ends on September 30, it’s around $100. You can arrange for the premium to be taken from your OPM pension.
For your family, the FEP will be primary and Tricare will act as a free supplement (second payer) for it, just like today. Nothing will change for them.
For you, Medicare will become primary on Sept. 1, the FEP will be secondary, and Tricare, by law, is always last. Your Medicare coverage, Part A and Part B, will be effective on Sept. 1. You will get a Medicare ID card in August that shows Sept. 1 as the date for your Part A and Part B to become effective.
Social Security wants people to apply for benefits at least 90 days prior to the effective date of their coverage. You must apply for Part B at that time according to the law that governs Tricare. That is a different law from the one that governs Medicare.
As of Sept. 1, you must seek all your civilian medical services from Medicare providers. That is, providers that will file Medicare claims for their services. Do not use any provider who cannot, or will not, file Medicare claims for your bills. If you do, Medicare will deny payment on the claim.
When the provider asks about your secondary insurance or Medicare supplement, tell them it is your FEP plan. Show them your FEP ID card. After Medicare pays a claim, it will automatically forward the claim to the FEP as second payer.
FEP will be primary and Tricare will be your second payer for all medical care you receive until midnight on Aug. 31.
When Medicare and the FEP are both done with a claim, and both have sent you EOBs, it’s time to file a Tricare claim, even if there is nothing left to pay. You should always file a Tricare claim as third payer in order to get family credit on your Tricare Catastrophic Cap.
Call your Tricare Service Center for help with filing the Tricare claim the first two or three times until you learn how to do it yourself. Your FEB will not forward the claim to Tricare. You must file it.
Will Tricare cover my kids and their special nutritional needs?
June 24th, 2010 | TriCare Help | Posted by Military Times
Q. My fiancé is an active-duty soldier and we are getting married this summer. I have two kids from a previous marriage, and in the divorce it states I must keep major medical insurance for them. Will Tricare cover my kids when my fiancé and I get married?
Also, my kids are also on a prescription milk replacement because they are allergic to milk and soy. Will Tricare cover it? It’s about $1,200 a month otherwise.
As soon as you are married, your husband should go to his Personnel Section to apply for military benefits, including Tricare, for his new family.
Stepchildren are covered by Tricare under certain conditions. I don’t know your family situation now, or what you have planned, so please call the Defense Enrollment Eligibility Reporting System to resolve all eligibility issues. The toll-free number for the DEERS Support Office is 1-800-538-9552. Be sure to take notes.
Tricare qualifies as a full-service health benefits plan, so it will meet your court requirements. You will probably want to enroll in Tricare Prime as soon as you and the children are settled in your home near a military hospital.
There are a number of excellent resources on Tricare’s official website. To start with, from the list of covered services, you can see that Tricare definitely qualifies as a major medical plan. Next, make a record of contact information for your regional Tricare office. Then read up on Tricare Standard and Tricare Prime.
If you know and follow the rules exactly, you will seldom have a problem. Tricare’s only reason for existing is to help with the payment of medical bills, but federal law specifies how you go about it. If you violate a rule, you may find yourself having to pay the medical bill yourself. Some errors can’t be fixed.
To begin with, you must always use an authorized provider. That is one who is registered with Tricare and has an official Tricare provider number. If you use an unauthorized provider, Tricare cannot pay for the services.
The web site has a section written especially for providers. If a doctor wants to know about becoming a Tricare-authorized provider, he will find all he wants to know at that site. You can tell him where to find that information.
Some authorized providers will participate in Tricare on a Standard claim. If he does, he will file the claim for you and will agree to accept the amount Tricare allows as his full payment for the medical services on that claim. You will have to pay only your Tricare deductible ($150 per fiscal year) and your copayment (called your cost share) which is 20 percent of the amount Tricare allows on that claim.
If the authorized provider does not agree to participate on a claim, he may charge you up to, but not more than, 15 percent over the amount Tricare allows. You must pay that out-of-pocket in addition to the deductible and 20 percent cost share. That can get expensive, which is why Prime is so much better.
Prime is not available everywhere, but it is always available near a military treatment facility and it is the recommended plan for active-duty families. You may have to enroll in Standard until you are situated in a Prime medical service area.
Under Prime, you will get all, or almost all, of your care from your MTF at no cost. Or you will pay a flat rate of $12 per visit if you go to a civilian doctor who is registered with Prime. You can download a free Prime handbook here.
Regarding the milk substitute: With your first claim for it, you should include a detailed statement from the children’s doctor for Tricare’s medical review board. He must describe the medical necessity for the substitute and the medical reasons he ordered that particular brand of milk substitute. By law, nutritional materials must have their medical necessity documented and justified by the physician.
It is possible that the claim will be denied. If that happens, don’t get mad. Tricare is following the federal rules. You should read the reason for the denial reported on Tricare’s Explanation of Benefits (EOB). That is the report you will get each time you file a Tricare claim. It is a very important document because it explains everything Tricare did with the charges on that claim. The reason for denial is what has to be “fixed” for the claim to be paid. You have 90 days to file an appeal of the denial.
An appeal has to be in writing, state the specific matter in dispute, and include a copy of the EOB reporting the denial. Send it to the Tricare claims processing office that issued the EOB. Your appeal must be an attempt to resolve the reason the original claim was denied.