Is Tricare a prompt payer?
August 9th, 2010 | TriCare Help | Posted by Military Times
Q. I just turned 65 and subscribed to Medicare and Tricare for Life. I understand that Tricare Standard is second payer to Medicare, and that the same bills have to be sent to Tricare, along with a copy of Medicare’s explanation of benefits showing how it processed those charges.
My problem is with the timeliness of the Tricare for Life payments. I learned that Medicare issues its EOBs only every 90 days. I’m not sure my doctors will be willing to wait for payment if it takes 90 days just for me to get the Medicare EOB before I can even file a claim with Tricare for it to pay the balance on the bill. Is there any way I can get around the 90-day delay?
You will have few concerns about the timeliness of payments to your Medicare providers under Tricare for Life.
You won’t have to wait 90 days for Medicare’s EOB before you can submit a claim to Tricare. In fact, you won’t have to submit claims to Tricare; Medicare will do it for you. The claim is forwarded to Tricare with the push of a button, electronically, as soon as Medicare finishes processing the claim.
By the way, Medicare calls its EOB a summary notice. It’s just a different name for the same document.
In most cases, Tricare pays its share to the Medicare provider quickly. Some providers report that they’ve received Tricare’s check for the balance due on the claim before they received Medicare’s payment of the principal amount.
There is something else you didn’t mention, which might not have occurred to you: Tricare for Life beneficiaries must seek all their care from Medicare providers.
A doctor or other provider who sees Medicare patients files Medicare claims often — one for every Medicare patient he sees. The provider knows how long it takes Medicare to process most claims. And Medicare sends its payments directly to the provider as soon as processing is done. It doesn’t have to wait for Tricare’s payment to “catch up” with it first. In most cases, the provider quickly receives from Medicare up to 80 percent of what is due for the services he provided.
What the provider is waiting for is the amount of the patient’s share of the claim — the amount Tricare will pay. Usually, this is the Medicare deductible, if applicable, and the patient’s 20 percent co-payment.
Medicare providers who see Tricare for Life beneficiaries know from experience how quickly Tricare Standard pays its share of the claim, and most have no complaints.
What happens when I change providers?
July 30th, 2010 | TriCare Help | Posted by Military Times
Q. When I change providers, do I need to contact Tricare?
If you are enrolled in Tricare Standard, you may use any Tricare-authorized provider without notifying Tricare. If you use an unauthorized provider, however, Tricare must deny your claim and pay nothing. That is a requirement of federal law.
If you are enrolled in Tricare Prime, you may use Tricare Prime providers only. In that case, I recommend that you contact your Tricare Prime contractor for guidance prior to making any changes in providers.
If you are enrolled in Tricare for Life, you must seek all your civilian care from Medicare providers only. It is not necessary to notify Tricare if you change providers.
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.
Turning 60, ready to retire. Where do I start with Tricare?
April 15th, 2010 | TriCare Help | Posted by Military Times
Q. I am turning 60 this December. I spent 26 years in the Naval Reserves, 16 as a drilling reservist and 10 active duty. I have applied for my retirement, but I have no clue what to do regarding Tricare. I am not married. Can you steer me in the right direction?
Your Personnel Section was responsible for filing the paperwork necessary to enroll you in all your retired benefits including receipt of retired pay and Tricare.
If you have any unmarried children under 21, or under 23 and a full-time college student, they may become eligible for Tricare on your 60th birthday even if you were never married to the mother.
If that could be an issue, call the DEERS Support Office, toll-free, at 1-800-538-9552. DEERS is an official DoD agency, so everything you tell them is completely confidential and protected by the Privacy Act. DEERS deals only with eligibility issues and what is allowed by law.
You should visit the Tricare web site and make a permanent record of contact information for your Regional Tricare Office. You’ll need to study and understand Tricare Standard and Tricare Prime. Those are your coverage options until you get Medicare at age 65. Then, you will qualify for Tricare for Life.
Prime may not be available where you live so, if you want to enroll in it, call your Tricare Office to ask if it is available. If it isn’t, you will be eligible automatically for Tricare Standard. Ask for a free Handbook for whichever Tricare plan you choose — Standard or Prime. Or you can download them right here: Standard, Prime
Tricare is not a health insurance policy or an insurance company. What we now call Tricare was created by federal law as a health benefits program in 1966. All of its operations — eligibility, covered medical services, payments, etc. — are governed by federal law and regulation.
By law, since 1966, Tricare exists for one reason only. It was created to help pay the costs of civilian medical care for its beneficiaries. Federal law and regulation say, in detail, how it does that.
All health insurance companies and similar government programs require health care providers to be registered with them before they will pay for the provider’s services. You must get all your care from Tricare-authorized providers. If you get care from an unauthorized provider, Tricare cannot pay for it.
The Tricare web site has an entire section dedicated to providers. It tells them everything they need to know about what it means to be a Tricare-authorized provider. If your favorite doctor is not an authorized provider, tell him that registration with Tricare is just like his registration with Blue Cross Blue Shield, Aetna, or any other health insurance plan. Refer him to the web site for official information.
If you have other health insurance (OHI), you must use the OHI first. Federal law requires Tricare to always be last payer to all other health insurance except a genuine, bona fide, specially written Tricare supplement and welfare-related plans such as Medicaid (not Medicare).
After the OHI has paid its maximum, you can file with Tricare as second payer. Tricare will pay most, often all, of what the commercial plan (the OHI) did not pay, such as your deductibles and copayments. Write to me later, and I’ll tell you how to do it.
If you have OHI and plan to keep it, I recommend Tricare Standard, not Tricare Prime. Prime’s rules make it hard to coordinate its benefits with OHI. It makes for misunderstandings and, sometimes, errors.
Standard, Prime: Weighing the options
April 1st, 2010 | TriCare Help | Posted by Military Times
Q. I am retired from the military and the civil service and am 70 years old. When I became 65, I suspended my civilian health insurance (Blue Cross), enrolled in Medicare Part B and am now covered by Medicare Parts A and B and Tricare for Life. My wife is 58 and is working for the state as a teacher and is provided a health care plan (without charge) and has Tricare Standard. She is allowed to see any doctor of her choosing. When she retires in June 2011, she will have the option of continuing her state Blue Cross plan, but it will no longer be free. Is there a Tricare plan that she can qualify for that will allow her to continue to see the doctor of her choosing?
Tricare is not an insurance policy or insurance company. It is a federal health benefits plan similar to Medicare in that respect.
All insurers require providers to apply to become certified by the plan by proving they are properly trained, educated, and licensed to provide certain medical services. Tricare is no exception.
Under Tricare, your wife’s ability to use any physician of her choice depends on the provider. She may use any provider who has applied with Tricare, been accepted and, thus, has become a Tricare-authorized provider. Tricare may not pay for the services of any unauthorized provider except in certain bona fide medical emergencies.
There will be two possible Tricare plans for your wife: Tricare Standard and Tricare Prime. Prime is not available everywhere. You will have to ask your Regional Tricare Service Center whether Prime is available in your area.
Tricare Standard is a fee-for-service plan. You receive medical care, get a bill, and file a Tricare claim for reimbursement of a portion of the cost. After satisfaction of the $150 Tricare fiscal year deductible, Tricare Standard pays 75 or 80 percent of the amount it allows on each claim. The copayment (cost share - the patient’s share) for active-duty family members is 20 percent of the amount Tricare allows; for all others it is 25 percent of the amount allowed.
On each Tricare Standard claim filed, the provider has the option to participate or not to participate in Tricare on that claim. If the provider agrees to participate, he will file the claim on the patient’s behalf. He will sign a legally binding agreement to accept the amount Tricare allows on that claim as his full payment for the services on that claim. Tricare will pay its share directly to the provider and send an EOB to the provider and to the patient which describes in detail all its actions on those charges. After Tricare has paid its share of the amount allowed, the patient is responsible for paying the provider the difference between the amount actually paid by Tricare and the amount Tricare allowed on those charges. When the patient has done that, the claim and the provider’s bill will have been paid in full. The patient is not responsible for any amount greater than the amount Tricare allowed on the claim.
If the provider chooses not to participate on a claim, a portion of the law governing Medicare applies also to Tricare Standard claims. It is called the Limiting Charge provision. All Medicare providers know of the law, but many are not aware that it applies also to Tricare beneficiaries claims. It limits the amount the patient may be charged to 15 percent more than the amount Tricare allows on that particular non-participating claim. Tricare can pay no part of that 15 percent surcharge. The patient is responsible for that amount in addition to any deductible required and the co-payment (20 or 25 percent of the amount allowed).
Tricare Standard can be used worldwide and is free. A Tricare supplement is strongly recommended for Tricare Standard members in order to pay the deductible and co-payments (called cost shares) and the surcharge on non-participating claims. Read the fine print carefully before buying any Tricare supplement. Make sure you are buying what you think you are buying, and that it meets your anticipated needs.
Tricare Prime functions as a Health Maintenance Organization (HMO). As noted, it is not available in all areas. Certain providers contract voluntarily with Tricare to provide services to Prime members at reduced rates. They have independently negotiated with Tricare and agreed to those amounts. The patient may use only those (Prime) providers. The providers will file the claims on the patient’s behalf and will receive their payment directly from Tricare. The patient is required to pay the provider a fixed amount for each office visit or other medical service. Tricare pays the remainder of the fee directly to the provider. The member may use only Prime providers in their residential area. To use a Prime provider in another area, such as when traveling, special preauthorization from the Prime administrative office is required except in bona fide emergency situations. Prime costs $230 per person, $460 maximum per family, per year.
When one spouse gets TFL before the other
March 12th, 2010 | TriCare Help | Posted by Military Times
Q. My wife is three years older than me. As long as we are still on Tricare Prime, this poses no problems. However, she will reach 65 and become eligible for Medicare before I will. What steps will we need to take to get her Tricare for Life before me? If it makes a differrence, we live near a military medical facility.
Tricare couples are very seldom exactly the same age, and it doesn’t matter which of the two is the elder.
At least 90 days before the month when she will be 65, your wife should contact the Social Security Administration to apply for Medicare Part A and Part B. Medicare will review her application, and if it finds she is eligible, it will send her a Notice of Award and a Medicare ID card a few weeks before she is 65.
Social Security is supposed to automatically notify DEERS when your wife is enrolled in Medicare Part B so it can make the transition to Tricare for Life (TFL) in her DEERS record. Federal law requires her to be enrolled in both Medicare Part A and Part B to keep her Tricare eligibility and have TFL. She should not enroll in the Medicare Pharmacy Program (Part D of Medicare) because she has the free Tricare Pharmacy Program.
When she gets the Medicare ID card, she should call DEERS, toll-free, at 1-800-538-9552 to make sure it has updated her record to show Part B enrollment and TFL eligibility.
DEERS will automatically change her Tricare Prime to Tricare Standard, and she will become eligible for Tricare for Life on the first day of the month when she is 65. She may no longer use Tricare Prime. She must get all her civilian medical care from Medicare providers because Medicare will become her primary coverage and Tricare Standard will automatically become her secondary coverage and free Medicare supplement for the vast majority of her Medicare claims.
I recommend that she start looking for a Medicare provider who will accept her as a new patient at the same time as she applies for Medicare.
You will go through the same process three years later when you turn 65 and get Medicare.
The Medicare provider will file a Medicare claim each time she sees him. Medicare will pay its share to the provider and automatically forward the claim to Tricare as second payer. On the vast majority of her claims, Tricare will pay the balance on her Medicare claim for every service that is also covered by Tricare. Those two payments — Medicare’s and Tricare’s — will pay the provider’s bill in full.
The only times she will have any out-of-pocket costs for medical care is if she get a medical service that is not covered by both Medicare and by Tricare. That will not be very often. Some TFL beneficiaries go more than a year without any such claims.
For her last enrollment period in Tricare Prime, your wife should arrange to pay her Prime enrollment fee on a month-to-month basis. That is so she doesn’t pay in advance for Tricare Prime she will no longer be able to use once her Medicare begins. That may mean she will no longer be able to use the military medical facility. She will have to ask.
She will no longer have to pay $230 per year for Tricare Prime, but she will have to begin paying the monthly premium for Medicare Part B. Medicare will bill her every 90 days for the premium until she is old enough for Social Security checks. Then the premium will come out of her check as an allotment to Medicare.
In the meantime, she should go to the official Tricare web site and read up on Tricare for Life. She can also download a TFL Handbook, which will be very useful.
Who is required to accept Tricare?
January 22nd, 2010 | TriCare Help | Posted by Military Times
Q. Our doctor joined a group practice. Although he continues to see Medicare patients, the office manager said the practice does not belong to Tricare, and we have to pay full price for our medical care and file with Tricare ourselves.
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.
Why do some doctors take Standard but not Prime?
December 11th, 2009 | TriCare Help | Posted by Military Times
Q. Why do doctors out of the network accept Tricare Standard, and not Tricare Prime?
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.
Will my Prime premiums change?
December 2nd, 2009 | TriCare Help | Posted by Military Times
Q. I’m a retired Navy CPO, and we currently pay roughly $420 a year for our Tricare insurance. Everyone is saying our coverage won’t change, and the list of providers may decrease, but my question is: Will my premiums change? I can’t seem to find any answers.
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.