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.
You don’t need sponsor’s permission to get care for eligible child
October 7th, 2010 | TriCare Help | Posted by Military Times
Q. My daughter and son-in-law — he is medical retired from the Army – recently separated. He left her no means to take care of herself or their 5-year-old son, so she moved to another state to her father’s house. My daughter needs to get their son immunized for school, and she has other medical needs, but her husband says he cannot change their primary-care facility from where he is, and unless he comes to the state where she lives and personally goes in with their child to a facility at a local base, it cannot be done. Is this true?
The father seems confused about his family’s use of Tricare. The child’s Tricare coverage (and your’s daughter’s as well, if they are still legally married) is still in force nationwide. Tricare benefits are provided directly to family members by federal law. They flow directly to the beneficiary. The service member’s help, permission, or cooperation are not required for family members to use Tricare.
Your grandson’s and his mother’s eligibility for Tricare depends on the father’s status with the uniformed services at this time. If the father was discharged, and if the service has no further obligation to him, it is likely that his family has no more rights to military medical benefits. Conversely, if he was medically retired, with a right to retired pay or something equivalent, his family may retain full military medical care rights.
For official information about Tricare eligibility, the appropriate place to call is the Defense Enrollment Eligibility Reporting System (DEERS). Your daughter should call the DEERS Support Office, toll-free, at 1-800-538-9552. She will need to tell the DEERS office her husband’s full name and Social Security number, her own full name, and that of the child. The DEERS office will be able to tell her the Tricare eligibility status for herself and all children. DEERS also can tell her how to get and use those benefits at her new address.
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.
Mother may become dependent, but cannot get Tricare
April 2nd, 2010 | TriCare Help | Posted by Military Times
Q. I am a retired Marine. How can I enroll my mother as my dependent? I have been supporting her.
To register your mother as your dependent, talk with your Personnel Section. But please note that, even if your mother becomes your dependent, she will not become eligible for Tricare. Federal law forbids it.
You may be able to arrange for her to get free medical care at your military hospital. Talk with the hospital’s Executive Officer or the Officer-in-Charge of Patient Administration about that.
For official confirmation that your mother cannot become eligible for Tricare as your dependent, call the DEERS Support Office, toll-free, at 1-800-538-9552.
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.
Will Tricare cover new orthopedic surgeries?
February 11th, 2010 | TriCare Help | Posted by Military Times
Q. I broke my leg a little over a year ago and have had two reconstructive surgeries that have since proven to be a complete waste of time. My leg is still in pieces. This horrible care was provided through my employer’s insurance.
Last month I married a soldier, and I am now trying to be seen at one of the best hospitals around, hoping that Tricare will approve my claim to be referred to a good orthopedic surgeon. I’ve been told that Tricare will most likely deny my claim because I have been previously treated by my employer’s insurance provider. Is that true?
Although no one can guarantee your unrestricted or unlimited access to the surgeon of your choice, I’m certain that your request for a particular provider will be given fair consideration. Tricare has no limits or restrictions on medically necessary and appropriate coverage for pre-existing conditions.
Please keep in mind that our country is at war, and there are a very large number of orthopedic and reconstructive surgeons with extensive experience in the rebuilding of shattered limbs. Many of them are employed at military medical facilities. Your care, however, is not limited to military medical facilities.
Can my parents get coverage?
January 4th, 2010 | TriCare Help | Posted by Military Times
Q. My parents had to move in with my wife and me, which I think makes them my dependents now. I’m active duty and my parents are in their late 60s and early 70s. Is there a way to get them covered by my Tricare?
I can tell you that dependent parents are not eligible for Tricare. You can confirm that by calling the DEERS Support Office, toll-free, at 1-800-538-9552.
But there is a possibility that the commanding officer of your military treatment facility may grant permission for your parents to receive medical care there. Dependent parents’ use of a MTF is not a right under the law — it is a privilege that may be granted by the MTF’s commanding officer, subject to the availability of space, personnel, and the MTF’s technical ability to provide needed care. Even if permission is granted, it can be terminated at any time.
Do two things. First, call DEERS to confirm whether your parents can be made eligible for Tricare. That is so you can be absolutely certain whether they have any rights to medical care at government expense as your dependents. Second, make an appointment to speak with your MTF’s executive officer or the officer in charge of patient administration. Present your case, explaining your parent’s financial situation and/or any special needs that might contribute to a successful request. You wrote that they are dependent on you. Explain why that is. Ask whether approval can be granted for them to use any of the MTF’s facilities, including the pharmacy.
If the XO denies permission, ask for permission to speak with the hospital’s commanding officer about the matter. The CO’s decision is governed by law, regulation, and his special knowledge and experience regarding the capacity of his MTF, and the needs of the military personnel and families under his care. It will be final.
The CO is responsible for the health care of the entire military facility. By law, however, active-duty military personnel always come first. In the competition for MTF space, the spouse and children of active duty members and who also are enrolled in Tricare Prime are second. Everybody else is last.