Do we still need Tricare Prime Plus under Tricare for Life?
January 25th, 2012 | TriCare Help | Posted by Military Times
My wife and I just qualified for Medicare and Tricare for Life. We were both enrolled in Tricare Prime. We are also enrolled in Tricare Prime Plus at a military treatment facility. Do we need to continue paying the annual enrollment fee to use Tricare Prime Plus?
If a person is enrolled in Tricare Prime when they become eligible for Medicare and Tricare for Life, his or her Prime enrollment is terminated. On the effective date of Medicare coverage, it is automatically changed to Tricare Standard, which becomes a free supplement to Medicare. The person is no longer eligible for Tricare Prime. He no longer has priority access to free care at a military hospital, and any Tricare Prime enrollment fees paid in advance are lost; they cannot be refunded.
Can girlfriend give birth in military hospital?
December 2nd, 2011 | TriCare Help | Posted by Military Times
I’m an active-duty soldier and my girlfriend and I are getting ready to have a baby. She doesn’t have health care at the moment. I know the baby can be covered as my dependent, but my question is, can she have the baby in a military hospital?
Whether your girlfriend can give birth at a military hospital does not fall under Tricare’s authority. Only your military hospital can decide. Contact the hospital’s Patient Administration Office for an official answer.
Of course, the problem is instantly resolved if you get married. She would be covered under Tricare.
The baby will be covered after birth either way, however. Call the DEERS Support Office, toll free, at 1-800-538-9552, to discuss that matter.
Can I still go to military doctors once I’m on Tricare for Life?
November 11th, 2011 | TriCare Help | Posted by Military Times
I will get Medicare and Tricare for Life on Dec. 1. I live near an Air Force base and have been getting most of my health care from specialists there. I know that under Tricare for Life, I need to get my care from Medicare providers, which is fine, but can they still refer me to the military doctors if necessary?
When most Tricare beneficiaries turn 65, get Medicare and are enrolled in Part B, those who were formerly enrolled in Tricare Prime are automatically transferred from Prime to Tricare Standard, which, along with Medicare, makes up your Tricare for Life coverage. If you are no longer enrolled in Prime, your access to free medical care at your local military treatment facility will likely be curtailed.
Retirees and their family members have priority access to military hospital care as a result of being enrolled in Tricare Prime. Once you are switched from Prime to Standard, you do not have the same priority access.
As there are individual differences among MTFs, however, the facility near your home may still have space and personnel available to allow non-Prime enrollees to access their services. You will need to ask the patient administration office if you can continue to use their facilities, including their pharmacies.
Can sister be covered under my husband’s Tricare?
September 23rd, 2011 | TriCare Help | Posted by Military Times
I have a sister who is going to be moving in with me. She is on Social Security disability and Medicare. My husband is retired Navy. Can he add her to his Tricare as a dependant?
Tricare eligibility is established by federal law for certain categories of people. Brothers, sisters, parents or other family members do not meet the legal requirements for Tricare eligibility.
If you live near a uniformed service facility with a hospital or clinic, it is possible that your husband can arrange for your sister to get some, or even all, of her medical care and pharmacy services there. He should contact the Patient Administration Office or the Executive Officer at the facility for more information about that.
For your sister to have access to any military benefits, there are some administrative actions your husband would have to take to establish her as his legal dependent. His Personnel Office can help make those arrangements, including her registration in DEERS.
For confirmation of my reply, above, and for official answers to any and all questions about Tricare eligibility, please call the Defense Enrollment Eligibility Reporting System Support Office at 1-800-538-9552. DEERS deals with eligibility issues only.
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.
Son is an airman; can I get Tricare?
August 19th, 2011 | TriCare Help | Posted by Military Times
My son is in the Air Force, stationed at Hickam Air Force Base, Hawaii. He applied to have me as a secondary dependent (I am his mother) and it was approved in June. I went to MacDill Air Force Base, Fla., a few weeks ago to get my military ID and to find out about medical care. They told me I couldn’t see a doctor there, but if I saw a civilian doctor and he ordered tests, they could do them on base. I’m sure there is some way for me to get some medical care. Can I join Tricare? Can I go to another military medical facility?
By law, a service member’s parents are not eligible for Tricare. That is true even if the parent is totally dependent on the service member. You can get official confirmation of the above by calling the Defense Enrollment Eligibility Reporting System at 1-800-538-9552.
Dependent parents may be authorized medical services, at varying levels of care, at a military hospital. Depending on the situation at the particular hospital, a parent may get total care there, limited services or no services. The parent has no legal right to care at the military hospital. If granted, it is a matter of courtesy only.
Apparently, that was your experience in that, although you cannot see a military doctor at your hospital, it can provide certain laboratory services for you when ordered by your civilian physician.
The primary consideration for whether a dependent parent can get care is usually the availability of space, personnel, and/or the technical capacity of that hospital to provide the care the parent needs.
The primary mission of military hospitals, by law, is to provide care for active duty military personnel. That must always be the hospital’s primary concern.
The decision to grant or deny a dependent parent’s access to care at the military hospital rests entirely with its Commanding Officer. That decision is based on his or her professional opinion, after consideration of the hospital’s primary mission.
You may want to approach the hospital’s Patient Administration Office or Executive Officer about your concerns.
Unhappy with care at base hospital; can Tricare help?
August 1st, 2011 | TriCare Help | Posted by Military Times
Q. My wife has issues with sleeplessness, weight gain and possible hormone imbalance issues. She’s been seen at our local base hospital a dozen times by both women’s clinic doctors and family practice doctors. The docs continue to bounce here back and forth with no resolution of the problem and will not send her off base for another opinion or possibly to see a specialist who works with female hormone problems. How can we get a Tricare referral? We’re almost to the point of paying for off base care out of pocket if necessary, but it’s hard to believe Tricare wouldn’t cover this problem.
Tricare is unrelated to military health services. It has no authority to require or even recommend that the military refer a patient to civilian care or specialists.
If you and your wife have a complaint about care she received at the military hospital, go through the chain of command at that hospital first. If unsuccessful, then ask for guidance about the next step for filing a complaint.
You may want to ask for advice from the Tricare Headquarters. That address is Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. TMA does not have an e-mail address or telephone number suitable for public contact.
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.
How does Tricare work with my auto insurance after an accident?
April 15th, 2011 | TriCare Help | Posted by Military Times
Q. I am the spouse of an active-duty soldier. I got in an auto accident in January and had minor neck injuries, and I was treated at the military clinic on post. I filled out my paperwork with my auto insurance company for my claim. I was told that Tricare will send them the medical bills. Will Tricare send medical bills to the auto insurance company even though I received treatment from a military clinic on post? If so, how does that work?
If you were a civilian who was injured in an auto accident, the civilian doctors and/or hospital would seek payment for the costs of your medical care from whatever other party was responsible. Usually that would be an insurance company — your insurance, that of the other driver, or both. I’m not an attorney, but I believe that is called third party liability. That is, (1) you; (2) the other driver; and (3) the insurance company.
There is a federal law called the Medical Care Recovery Act that requires the government to do the same thing when one of its beneficiaries requires medical care and a third party is responsible for payment. The government (the military hospital, or Tricare, if you got civilian care) will seek recovery of the costs of your care from a third party (usually an insurance company) in exactly the same way.
Remember, although you pay nothing for your care at a military hospital, there is a cost involved. The care is not free. Ultimately, it is paid for by the taxpayer.
The recovery law isn’t limited to auto accidents. Every medical procedure has a code number that identifies it and makes automated claims processing possible. Certain code numbers indicate care for a medical condition involving a traumatic injury of some kind. The name of the procedure and its code number are part of your Tricare claim.
If your claim includes one of those procedure codes, Tricare will require you to submit a Third Party Liability Form. That information will allow Tricare to determine whether there is a possibility that a third party may be responsible for payment. Then, Tricare will collect the reasonable costs of your care from that party.
In Tricare’s collection activities, you will not be involved in any way. You are not responsible regardless of whether Tricare recovers or does not recover. You will never hear another word about the matter from Tricare. Your responsibility ended when you submitted the Third Party Liability Form.
Can I switch kids to Tricare Prime against ex-wife’s wishes?
March 10th, 2011 | TriCare Help | Posted by Military Times
Q. I am active duty and recently divorced. Our separation agreement states that I am to provide health insurance for my minor children. I am also to pay 80 percent of out-of-pocket expenses. The children live with their mother in a Tricare Prime eligible location. At the time of divorce they were enrolled in Tricare standard, and my ex-wife has been seeking treatment for them at non-network providers even though there are other options, leaving me with extreme medical bills. I would like to switch the children to Tricare Prime, since it is available. Neither my separation agreement or divorce decree mandate that the children must remain on Tricare standard, all it says is that I am to provide health insurance. Can I switch the children to Tricare Prime, even against my ex-wife’s wishes? Also she refuses to provide me with any current medical updates on the children, just receipts. Can I legally contact the physicians treating my children for medical updates once they are treated in a military facility? I would like to see my children get the best care possible and feel that being enrolled in Prime, and treated at a nearby military facility would be in their best interest.
By federal law, your children will be eligible for Tricare until they marry or turn 21 years old. They are automatically eligible for Tricare Standard, or you can enroll them in Tricare Prime if they live in an area where Prime is available. For them to use Tricare, however, you must register them with your uniformed service. Because your wife is no longer eligible for Tricare, each child must have his/her own uniformed service identification card which only your service can issue. I suggest that you talk with your Personnel Section as soon as possible.
In order for Tricare to pay any part of their medical care, they must see a Tricare-authorized provider. An authorized provider is one who is registered with Tricare and is authorized to be paid by Tricare for medical services rendered to a Tricare Beneficiary. To use Tricare Prime, they must go to a physician that is registered as a Tricare Prime provider.
If they get care from an unauthorized provider, Tricare cannot pay for it.
There is nothing Tricare can do to make your former wife use a proper physician. That is something your lawyer will have to take care of on your behalf. It may take a court order to make her cooperate.
Whether you can switch your children to Prime depends on whom has legal custody of the children. That is something else you must discuss with your lawyer. The same holds true for your getting any information about the children’s medical care or Tricare claims. Tricare cannot release that information to you unless you have, or share, legal custody of the children. That is because of the Privacy act. Again, talk with your lawyer.
If your lawyer needs to know anything about the laws that govern Tricare, please ask him to write a letter with his questions to the Tricare Headquarters. That address is Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. He must include with his letter the full name of each child, your full name, and your Social Security number.