Social Security says retirement is at 66; Tricare says 65. Which is it?
May 14th, 2010 | TriCare Help | Posted by Military Times
Q. According to Social Security, if you were born between 1943 and 1955, full retirement age is 66. But doesn’t Tricare say that by time we reach age 65 we have to go to Tricare for Life and have medicare Part D? How can this happen when we can’t get it until age 66? Didn’t Tricare adjust the age as did Social Security?
Medicare and Tricare were created by, and continue to be governed by, different and unrelated federal laws.
Initially, one became entitled to receive monthly Social Security benefit payments and Medicare at age 65. Several years ago, Congress changed that law. Now, the age for entitlement to receive monthly benefit payments depends on one’s year of birth.
Congress did not change the age for Medicare entitlement. A Social Security beneficiary still becomes eligible for Medicare benefits at age 65.
The law I refer to is the one that created and governs Social Security and Medicare. It is not related to Tricare.
If a person applies for Medicare in a timely manner, he or she will become entitled to Medicare on the first day of the month of his 65th birthday. If he was born on the first day of that month, his Medicare entitlement will begin on the first day of the previous month. That is true regardless of when he becomes eligible to receive monthly Social Security benefit payments.
Thus, if a Tricare beneficiary is properly enrolled in Medicare Part A and Part B, and if his DEERS registration is properly updated to show those enrollments, DEERS will report his eligibility for Tricare for Life effective on the same date as his Medicare entitlement is effective.
Medicare will bill the beneficiary every 90 days for his Medicare Part B monthly premium. If he fails to pay, his Part B enrollment, and his Tricare eligibility, will be terminated until payment is made. That can cause administrative hassles and delays to fix it and to restore his TFL eligibility. Tricare may not pay retroactively the costs of medical care received while his Tricare eligibility is suspended.
When the Social Security beneficiary becomes old enough to receive monthly benefit payments, the Part B premium will be deducted as an allotment to pay his Part B monthly premium.
The law governing Medicare does not require enrollment in a Medicare Pharmacy Plan, known as Medicare Part D. Neither does Tricare require Medicare Part D enrollment.
In fact, Health Affairs is on public record for saying that the only Tricare beneficiaries likely to receive a financial advantage by enrolling in Medicare Part D are those whose incomes are below the federal poverty line, and who qualify to receive financial aid to pay their Medicare Part B monthly premium. In other words, do not enroll in Medicare Part D. You do not need it.
Note that the carriers of some Medicare Advantage Plans require Part D enrollment, but that is not related to any requirement by Tricare.
Every Tricare beneficiary is automatically eligible for, and is automatically enrolled in, the free Tricare Pharmacy Program. It is probably one of the very best prescription drug plans in the country. It needs no help.
Why most beneficiaries have no need for Medicare Part D
March 29th, 2010 | TriCare Help | Posted by Military Times
Q. I’m in the process of signing up for Medicare. I know that I have to enroll in Part A and Part B to become eligible for Tricare for Life. My sister says her Medicare plan required her to sign up for Medicare Part D, the Medicare pharmacy plan. She has no military connections. Does that apply to me as well?
Unless you were to enroll in a Medicare Advantage plan that has Part D as a requirement, as in your sister’s case, you have no obligation to enroll in Medicare Part D, the pharmacy plan. To the contrary, as I mentioned above, it is not recommended.
Under Tricare for Life, you will have full coverage with Medicare Part A and Part B plus full coverage by Tricare Standard. All Tricare beneficiaries are eligible for the free Tricare Pharmacy Plan; it is probably the best pharmacy plan in the country. It needs no help to meet all your pharmacy needs.
For more information about the Tricare Pharmacy Plan, you can read about it online or call Express Scripts Inc. toll free at (866) 363-8779. I also suggest that you download a free Tricare for Life Handbook.
What happens to my pharmacy benefit when I get TFL?
March 26th, 2010 | TriCare Help | Posted by Military Times
Q. I will get Medicare and Tricare for Life on July 1. It’s bad enough that we’ll have to start paying a lot more for our health insurance, but the loss of Tricare Prime and its pharmacy benefit when we get transferred to Medicare seems unfair. Is there any way my wife, at least, can keep her Tricare Prime insurance and its pharmacy plan?
Only you, not your wife, will get Medicare when you are 65. Only you will be affected by the loss of Tricare Prime eligibility at that time.
Your Tricare Prime coverage will be changed to Tricare Standard when you get Medicare and become eligible for Tricare for Life. Your wife’s Tricare Prime coverage, however, can continue unchanged until she gets Medicare, probably not until she is 65.
You seem confused also about requirements concerning Medicare Part D, the drug-insurance plan. Neither Medicare nor Tricare require enrollment in Medicare Part D. The Pentagon’s Office of Health Affairs does not recommend Part D for most Tricare for Life beneficiaries because most will not gain any financial advantage from that plan unless their income is below the federal poverty line and they qualify for financial aid to pay their Medicare Part B monthly premiums.
But even if you did enroll in Part D, it would affect only you. Your wife could not be affected because she will not be entitled to Medicare.
Your and your wife’s coverage under the Tricare Pharmacy Program will continue unchanged: yours because you will be enrolled in Tricare Standard, and your wife’s because she will continue to be enrolled in Tricare Prime. All Tricare beneficiaries are eligible.
When a spouse has other insurance
March 19th, 2010 | TriCare Help | Posted by Military Times
Q. I’m a retired reservist with Tricare For Life. My wife has her own civilian health insurance, as well as Tricare Standard, since I am her sponsor. How does coordination of benefits work for medical care and prescriptions? For example, her drug plan has a higher copay for some drugs than Tricare has. Can she use Tricare to get the lower co-pay, or does she pay the higher co-pay and file a claim with tricare to get the difference? And can my wife and I use the Tricare mail order drug plan?
As required by federal law, Tricare is always last payer to all other health insurance, medical plans such as an HMO, or medical payments such as one might receive for medical bills resulting from an auto accident, slip-and-fall injury, or the like. The beneficiary must file first with all other plans. When the other health insurance (OHI) has paid its maximum and issued the beneficiary an Explanation of Benefits, a Tricare claim may be filed.
The only exceptions to the rule making Tricare last payer are if the OHI is a bona fide, specially written Tricare supplement, or if the OHI is a welfare-related plan such as Medicaid (not Medicare), Indian Health Service, and the like.
Your wife must use her OHI first for all medical and pharmacy services. For medical care, to file with Tricare as second payer, she must do the following:
1. Complete an official Tricare Claim Form DD2642.
2. Attach copies of exactly the same bills (the same sheets of paper) that were sent to the OHI.
3. Attach a copy of the OHI’s Explanation of Benefits that reports details of its processing of each of those charges.
4. Make copies of all the documents for your records.
5. Send Tricare’s copy of the package to the proper Tricare claims processing contractor for your Tricare Region.
Your wife must use her commercial plan’s pharmacy benefit first.
To be reimbursed a portion of the OHI’s pharmacy deductibles and copayments, contact Express Scripts, toll-free, at 1-877-363-1303, for instructions.
Please note that because of the way federal law requires pharmacy benefits to be coordinated, Tricare beneficiaries who have OHI are not eligible to use the Tricare Mail Order Pharmacy Plan.
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.
How does Tricare work with Medicare Part D?
February 6th, 2010 | TriCare Help | Posted by Military Times
Q. I am retired military, age 65. I know Tricare pays last, but do you have to fill prescriptions with Medicare first and then submit to Tricare for any expenses not covered? Or can I use the Tricare mail order prescription service as my preferred prescription service?
All Tricare beneficiaries are automatically eligible for, and are automatically enrolled in, the free Tricare Pharmacy Program and are eligible for its complete benefits. It is recognized as one of the best pharmacy plans available. They do not need any pharmacy insurance other than the Tricare Pharmacy Program.
You can find detailed information about the Tricare Pharmacy Program online. If you want it, additional printed information is available from the Tricare worldwide pharmacy benefit administrator, Express Scripts Inc. The toll-free number is 877-363-1303.
Health Affairs does not recommend that Tricare beneficiaries enroll in the Medicare Part D Pharmacy Program. The only Tricare beneficiaries who are likely to derive any significant advantage from Medicare Part D are the few whose incomes are below the federal poverty level and who qualify for financial aid to pay their Medicare Part B monthly premiums.
Because you have other health insurance (Medicare Part D), you are not eligible to use TMOP. That is because of the way Tricare is required by law to coordinate its benefits with Express Scripts Inc. which, for TMOP services, is not only the plan’s administrator, but also the provider of the drugs under TMOP.
When you enrolled in Medicare Part D, you had several commercial pharmacy plans to choose among, depending on where you live. Each plan has its own rules for using its benefits. You must follow that plan’s rules for all your pharmacy services and use it first, before you may use your free Tricare pharmacy plan.
You may find that your commercial plan under Medicare Part D will not pay for certain drugs. Although Tricare has special rules for dispensing certain drugs, if your doctor can document the medical necessity of that particular drug in your particular case, Tricare will make it available for you without penalties.
If your Part D pharmacy plan charges you a co-payment or a deductible for your prescription services, you may file a claim with the Tricare Pharmacy Program for partial reimbursement of those expenses.
If you have to pay a premium for the Part D pharmacy plan, however, you may not file a claim with Tricare for the premium payment. Tricare will reimburse you only for your co-payment and deductible on the cost of the drugs, but not for any cost of the insurance plan.
You will probably need help to learn how to file a claim with Tricare as second payer for your prescription drugs. I suggest you call Express Scripts for that help. If you use the Tricare Pharmacy Program exclusively, there are no claims to file.
You may also want to discuss with Express Scripts your need, or the advisability, of continuing to be enrolled in Medicare Part D. Call Medicare if you choose to withdraw from your Medicare Part D enrollment. It is easy to do, and there is no penalty.
Can I file claims for back copays?
January 1st, 2010 | TriCare Help | Posted by Military Times
Q. My wife and I have our recently obtained our DEERs cards and I found out we have been in the system since I retired from the reserves a couple of years ago. I have never used any of my military retiree benefits. While getting our ID cards recently at the nearest military facility, we visited the Tricare counter. According to the person there, I should be able to make a claim with Tricare for a year’s worth of back copays for doctor’s visits and medications — charges remaining after my my civilian employer’s health plan paid the bills. Are you familiar with this one year look-back?
To file a claim with Tricare as second payer to any other health insurance (OHI) plan, you do in fact have one year. Please do the following:
- Complete a Tricare Claim Form DD2642 for each patient and each provider.
- Attach clear, legible copies of exactly the same itemized bills that were sent to the OHI. An itemized bill lists each medical service you received plus the price for each service. A “balance due” bill without itemization of services cannot be used.
- Attach a copy of the OHI’s Explanation of Benefits reporting its processing of each of the charges on the itemized bill.
- Send the package to the proper Tricare claims processor.
I strongly recommend that you make copies of each of the documents filed with Tricare, including Tricare’s EOB when it processes the charges. Always keep files on each claim you submit.
Tricare claims must be filed within one year of the date of the medical care. If it is a hospital claim, the filing deadline is one year from the date of discharge from the hospital.
Note that a hospital bill is for the services provided by the hospital itself. That is, for room and board, general nursing services, the use of hospital equipment, supplies, employees, and the like. It does not include bills for doctor services you received while in the hospital. The doctors will bill separately.
If a claim for any service is denied, the Tricare EOB will report $0.00 in the column entitled Amount Allowed. The reason for the denial is always reported on the Tricare EOB. That reason is what must be fixed for the claim to be reconsidered for payment.
If the reason for denial makes any mention of eligibility or DEERS, call the DEERS Support Office, toll-free, at 1-800-538-9552 for help.
If the reason for the denial is not something that can be fixed by a quick phone call, I recommend filing an appeal within 90 days of the date of the EOB showing the denial.
An appeal must be in writing, it must state the specific matter in dispute, it must be accompanied by a copy of the Tricare EOB that reports the denial, and it must be signed by the adult patient, or the legal guardian of a minor or incompetent patient. A husband may not sign for the wife or vice versa. The signature thing is all Privacy Act stuff.
If you have questions or need help with filing claims, call your Tricare Service Center. And you are going to need official help from Express Scripts with the pharmacy issues. The toll-free number is 1-877-363-1303.
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.
How will my service-connected disability affect my coverage?
October 27th, 2009 | TriCare Help | Posted by Military Times
Q. I currently have Medicare Parts A and B, and Tricare for Life. After a two-year fight with the VA, they now say my hearing loss and tinnitus is service connected. My DAV rep thinks I will get either 20% or 30%, depending on the hearing test the VA is giving me. Once I get the service connected disability, will this change any of my health coverage?
Because you have TFL, Medicare is your primary coverage and half of the TFL Program. Your TFL benefits begin when a Medicare provider files a Medicare claim for the services he provides to you. Because the Medicare claim must be filed first, you need to ask Medicare about any effects of your VA rating on your Medicare coverage.
My guess is that Medicare will have the same rule as Tricare about the rating, but only Medicare can tell you about that officially.
The VA rating you mention should have no effect on your or your family’s Tricare coverage. Tricare Help’s reply is always unofficial, however. To get official information, call Tricare.
Tricare Standard is the other half of your TFL coverage. By law, it is second (last) payer. When Medicare finishes processing a claim for a TFL beneficiary, it will pay its share to the provider. Then it will automatically forward the claim to the special Tricare claims processor for TFL. On the vast majority of your claims, Tricare will pay whatever Medicare did not pay for every medical service that is covered by both Medicare and Tricare. As a TFL beneficiary, you will seldom have any out-of-pocket expenses for your medical care. The major exception is the small copayments (cost shares) for your prescription drugs; all Tricare beneficiaries automatically qualify for benefits under the Tricare Pharmacy Program. It’s the best pharmacy plan I know of. That’s why TFL beneficiaries do not need to enroll in the Medicare Part D Pharmacy Plan. For TFL beneficiaries, Medicare Part D is not necessary, and it can cause a lot of hassles for little in return because you have to file two claims to get full reimbursement for your prescription drugs.
A very few VA medical centers have a special arrangement with Tricare that allows them to file a Tricare claim for those charges, but most of them do not. If you get a bill from the VA, call your Tricare Service Center to ask whether you may file a Tricare claim.
How will my daughter be covered while studying abroad?
October 17th, 2009 | TriCare Help | Posted by Military Times
Q. I’m a retired soldier and my daughter is covered under Tricare Prime as a dependent. She will be studying abroad in Bath, England, next semester. Will she be covered? What additional insurance will I need to provide her?
Tricare Prime is not available overseas for retirees or their family members. Your daughter will have to rely on Tricare Standard, which requires a $150 deductible per fiscal year and a 25 percent cost share. Local providers may require up-front payment of fees at time of service. You can read more about Tricare Standard and the Tricare Pharmacy Program online.
Unless she is eligible for a commercial health insurance policy that will cover her as primary payer to Tricare outside the U.S., you may want to consider buying a Tricare supplement through one of the military associations. Most supplements pay, at least, the patient’s Tricare deductible and cost share. Compare several plans, and make sure you read the fine print carefully before buying. Be certain it states in the body of the policy itself that it is a specially written plan, designed to be a Tricare supplement, and that it covers Tricare claims for medical care received outside the U.S.
There will be some problems with the Tricare Pharmacy Program due to international laws concerning mailing of prescription drugs outside the U.S. If there is a U.S. Consulate in Bath, it is possible that she can arrange to have drugs sent to that address. To get official clarification about that matter and advice about filing prescription claims, call Express Scripts Inc. at 1-866-363-8779.
I strongly suggest that you contact the Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, Co 80011-9043, to discuss your daughter’s plans officially with Tricare Management. Among other things, if your daughter is 18 or older, you will need to file with Tricare a statement, signed and dated by your daughter, authorizing Tricare to deal with you concerning matters of her medical care and Tricare claims. This is a Privacy Act concern if she is, or will be, 18 or older. That way, you can help her with claims and/or medical care should the need arise.