How do we decide between Tricare Prime and FEHBP?
September 8th, 2011 | TriCare Help | Posted by Military Times
My husband is retiring from the military and now is eligible for the Federal Employee Health Benefits Program through his new job. He has minimal health issues, but I have a history of cancer and other problems. Should we enroll in FEHBP or use Tricare Prime? The premiums alone for FEHBP equal or exceed Tricare’s yearly $3,000 catastrophic cap. If we had both, could the FEHBP deductibles, copayments and premiums count toward Tricare’s catastrophic cap?
I cannot tell you exactly what you “ought” to do regarding your health insurance coverage; nobody can make that decision except you and your husband. But I can give you as much information as possible about Tricare to help you make that decision.
Tricare Prime functions as a Health Maintenance Organization (HMO). Tricare Prime providers (called network providers) are under contract with Tricare to provide the services mandated by law and regulation to beneficiaries enrolled in Prime.
They have privately negotiated with Tricare the fees they will charge for each of their services, but that’s between Tricare and the provider only. All the patient must be concerned about is the flat rate of $12 he or she must pay per office visit, or the flat rate of $11 per day for hospital stays.
Prime is not available everywhere. It is usually found within a 40- 50-mile radius of a military treatment facility. Tricare beneficiaries enrolled in Prime have priority access, right after active-duty family members, to free care at the MTF.
As with commercial HMOs, you must seek all care, except bona fide medical emergency care, from providers in your local network.
If you take a trip, clear it first with Tricare Prime, because on the road, “routine” care will not be covered inexpensively. There are considerable penalties ($300 deductible, 50 percent cost share) on claims for unauthorized care by non-network providers.
People have exactly the same problems with commercial HMOs under the FEHBP. Personally, I like HMO care except for the limited choice of providers, and the inconvenience if one travels. They are most like military sick call. The big ones have everything — labs, etc. under one roof, plus centralized record-keeping, central appointments, and the like. Big civilian HMOs may even own their own hospital. And their low cost is a big factor.
Like many things in life, it’s a trade-off. Study assiduously; know before you buy. You can download a free Tricare Prime handbook here.
FEHBP deductibles and cost shares do not count for your Tricare catastrophic cap, however. Only Tricare’s deductibles and cost shares count.
Will my injuries from an old accident be covered?
February 10th, 2011 | TriCare Help | Posted by Military Times
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.
My doctor says he doesn’t take TFL – can he do that?
June 22nd, 2010 | TriCare Help | Posted by Military Times
Q. I am retired Navy and my wife and I have Tricare for Life. She was referred to a health care provider for shoulder problems, and the provider informed her they accept Medicare payments but not Tricare for Life payments. Is this against federal law?
You have in mind a rule that applies only to institutional providers, such as hospitals. That rule says that a hospital that accepts Medicare patients is required by law to accept Tricare patients also.
That rule does not apply to individual professional providers, such as physicians.
The way health insurance policies are set up, the patient is always responsible for whatever the primary plan does not pay. That is usually the plan’s deductible and copayment, but it could include other things as well, such as a medical service the primary plan does not cover.
Many Medicare beneficiaries have a Medicare supplement. There must be a hundred or more plans to choose from. In the case of TFL, that choice is made for you — it is automatically Tricare Standard. That was set up in 2001 when Congress created Tricare for Life.
The provider’s only interest is in receiving the full amount Medicare approves as payment for his services on the Medicare claim. TFL is set up in a way so that happens.
If both Medicare and Tricare cover all the services on the Medicare claim, Tricare Standard will pay the provider whatever Medicare did not pay, up to the amount Medicare approved. The Tricare deductible and cost share are waived on those claims. The vast majority of claims filed under TFL are of that kind.
For information about the details of TFL operation, I suggest that you contact your Regional Tricare Service Center and request a free Tricare for Life Handbook, or download one for free, here.
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.
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.
If we marry and my husband dies, will I be eligible?
December 4th, 2009 | TriCare Help | Posted by Military Times
Q. My fiance is 84, a retired Navy man, and he’s just been diagnosed with pancreatic cancer. He would like me to marry him so I can be covered by Tricare after his death.
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.
Wanted: A guide to filing Tricare Standard claims
October 24th, 2009 | TriCare Help | Posted by Military Times
Q. My first wife died three years ago, and I remarried in July 2009. My new wife registered in DEERS, and now we both use Tricare Standard, with MOAA MediPlus as supplemental health insurance. My first wife used to handle the bills, so I did not keep track myself. Now, I have been getting bills, and EOBs, but so far — over the past three years — have not submitted any claims, as I don’t know how to go about it. Is there a procedure or pamphlet I can get that explains how I should proceed?
Health Affairs maintains an official Tricare web site at www.tricare.mil. It is designed especially to be of service to Tricare beneficiaries.
Go to the site and complete a profile, following instructions at the site. You should find all you need there. Be sure to make a permanent, easily accessible record of contact information for your Tricare Service Center (your Regional Tricare Office). You will need to talk with them from time to time. Then contact that office on its toll-free number to ask your questions and to order a free Tricare Standard Handbook, or download one from the site.
I’m deploying – how can I make sure my wife gets care?
October 16th, 2009 | TriCare Help | Posted by Military Times
Q. I’m on active duty, and this is my first deployment since I got married. I don’t think I will need medical care, but my wife is on disability and requires medicine every week. What is the best plan for us?
All your personal medical care will be provided free by your service. Your personnel section will take care of that for you.
You need official advice and information concerning registering your wife and any children in DEERS and getting military ID cards for your family.
Call the DEERS Support Office, toll-free, at 1-800-538-9552, for all your questions about eligibility for military benefits, including getting your wife enrolled in Tricare.
Then, go to the official Tricare web site and review the eight options for Tricare information. Write down the contact information for the Tricare regional office for the area where your wife will live while you are deployed. Call that office, tell them your situation and ask them to send your wife a Tricare Prime Handbook. (You can also download one here.) Then, read up on the Tricare Pharmacy Program, Tricare Prime, and Tricare Standard.
In the Patient Affairs Office at every military treatment facility you will find a person called a Health Benefits Advisor or Tricare Advisor whose job is to help resolve Tricare problems or answer questions you or your wife might have. That person works for the treatment facility, not for Tricare. If you have a complaint about that person, talk with the hospital’s adjutant about it, not with Tricare.
Make sure your wife knows how, if necessary, to file Tricare claims, use the Point of Service option under Prime, resolve claims problems and file appeals.
She needs to know to call DEERS for any and all questions regarding eligibility for any military benefit, how to contact Tricare — and how to reach me, for usually quick, but unofficial help, at tricarehelp@atpco.com
You mentioned your wife’s disability and special medication needs. Her medicine will be free at the hospital pharmacy. The nationwide phone number for the non-military treatment facility Tricare Pharmacy Program Administrator, Express Scripts, Inc, is 1-866-363-8779.
If your wife is eligible, or will soon become eligible, for Medicare due to her disability, ask her to contact me.
Spouses are the real backbone of all the services and the most important morale element of all. Encourage your wife to socialize with the other wives — there’s nobody tougher, and all will be glad to help.
Can I still get care at military treatment facilities?
September 11th, 2009 | TriCare Help | Posted by Military Times
Q. I will soon be transitioned to Tricare for Life. With the fact that my primary insurance will be Medicare and secondary will be Tricare Standard, will I be eligible to use a local military treatment facility? I live in San Antonio and we have some of the finest military hospitals and clinics in the world within 15 miles of my home and I have received fantastic service from them.
When you become entitled to Medicare, enroll in Part B, and your DEERS record is updated, you will be eligible for Tricare for Life (TFL). By law, you will lose your Tricare Prime eligibility, but the rest of your family will not be affected in any way by your transition to Tricare for Life.
With your loss of Tricare Prime, you will no longer have the priority access to military treatment facility (or MTF for short) care you and your family have now. Theirs will continue under Tricare Prime, but your primary health insurance will be Medicare. You must seek all your civilian medical care from Medicare providers.
It’s not too early to begin searching for one. When you call for an initial appointment, ask whether the doctor is accepting new Medicare patients. Many do not, so that’s why you may need some lead time, unless you are sure you can get MTF care.
The Medicare provider will file a Medicare claim for the services he provides to you. Medicare will process the claim, pay its share directly to the doctor, and automatically forward the claim to Tricare Standard as second payer. Tricare also will send its payment directly to the doctor. You will learn more about how it all works when you get your Tricare for Life Handbook (see below).
Now, let’s talk about your continued ability to get free care at MTFs.
Tricare has nothing to do with military regulations concerning MTF management or decisions about a retiree’s access to MTF care. You need to call the Patient Administration Office at each of the MTFs near your home. Discuss with them your situation about Medicare entitlement, Tricare for Life, and your loss of Tricare Prime eligibility. Each MTF’s Commanding Officer has sole authority to determine whether you can continue to get care at the facility. The situation may differ from one MTF to another and is dependent on the availability of space, personnel, and the facility’s technical capacity to provide the kinds of care you need.
For more information about Tricare for Life, call your Regional Tricare Office, Humana Military Healthcare Services, toll-free, at 1-800-444-5445, and ask them to send you a free Tricare for Life Handbook. You can also download one here.
And be sure to study Tricare’s official web site, which will help you use the program more efficiently. The overview is the best place to start.