Will fiancee’s grandson be covered if we get married?
January 6th, 2012 | TriCare Help | Posted by Military Times
I am currently in a relationship and would like to get married. My fiancee has legal custody of her grandson. Once we are married, will this child be eligible for care under my Tricare? Also, will any of my fiancee’s pre-existing conditions be covered, such as diabetes?
By federal law, unless you were to legally adopt the grandson, I don’t believe his Tricare eligibility is possible. To confirm that, however, and to explore what other possibilities might exist, call the DEERS Support Office at 1-800-538-9552.
Tricare has no restrictions on its coverage of pre-existing conditions.
Already pregnant and just getting Tricare; is my care covered?
February 17th, 2011 | TriCare Help | Posted by Military Times
Q. My husband is a 4th-year medical student under the Health Professions Scholarship Program. He receives health insurance through his med school, and I pay out of pocket for private insurance. In June, when he graduates and starts his residency in the Army, we are finally eligible for Tricare. However, we just found out we are expecting our first child, due around July. Will Tricare pay for the final medical care as well as labor and delivery, or will it be considered a pre-existing condition?
Tricare has no limitations or restrictions of any kind regarding pre-existing conditions. Thus, all your maternity care will be covered from your very first day of Tricare eligibility.
Contact the DEERS Support Office to learn the official date for the beginning of your Tricare eligibility. That toll-free number is 1-800-538-9552. DEERS also will help resolve any problems that could arise concerning your enrollment in the Program.
DEERS deals with eligibility issues only. DEERS cannot tell you anything about the Tricare program, its rules, its benefits, its claims, or its payments.
Please note that, although coverage is retroactive to your first day of legal eligibility, checks cannot be issued until your husband contacts his Personnel Section to officially register you with DEERS and with his uniformed service so you can be issued a uniformed service identification card.
That is administrative stuff having to do only with your use of Tricare, not with your eligibility for coverage. Once you are properly enrolled, any payments due since your first day of eligibility will be made retroactively.
Will my injuries from an old accident be covered?
February 10th, 2011 | TriCare Help | Posted by Military Times
Tricare works with other insurance and covers pre-existing conditions
September 13th, 2010 | TriCare Help | Posted by Military Times
Q. My job doesn’t offer health insurance, so I bought my own policy. Now they say they will not cover my pre-existing conditions. Does Tricare cover pre-existing conditions? Do I still have to file a claim with my commercial plan first even if I know they will not pay?
Tricare has no restrictions or limitations on payments for pre-existing conditions that are otherwise covered by Tricare.
You must file a claim with your commercial plan first, even if you know it will deny the claim. After it has processed the claim and sent you an Explanation of Benefits (EOB), you may file a Tricare claim.
File the Tricare claim just as you would if the other plan had paid part of the bill. Don’t forget to send Tricare copies of the bill you sent to the other plan and of the EOB reporting its actions on those charges. If you have questions about filing the Tricare claim, call your Tricare Service Center.
Transitioning to TFL while undergoing physical therapy
July 21st, 2010 | TriCare Help | Posted by Military Times
Q. I am currently receiving physical therapy for two separate injuries, with the possibility of shoulder surgery if the PT does not work. I am currently under Tricare Prime and will transition to Medicare/TFL in August. My PT location and my primary care provider accept both Tricare and Medicare. What bureaucratic problems, if any, should I expect to encounter while undergoing care at this transition point? I already draw Social Security and have received paperwork about enrollment in Part A and B.
This reply is based on the assumption that you successfully enrolled in Medicare Part A and Part B. Medicare coverage for a person in your situation becomes effective on the first day of the month when you will have your 65th birthday. Your continuing Tricare eligibility for the rest of your life is established by your enrollment in Medicare Part B.
You should expect no problems if your providers file the claims properly.
You will be 65 in August. At 2400 hours on July 31 you will undergo an automatic transition in your Tricare coverage. You will become entitled to Medicare, your Tricare Prime coverage be changed to Tricare Standard, and you will become eligible for Tricare for Life (TFL).
Your letter reports that the providers in question are authorized Medicare and Tricare providers. Thus, they can file both Medicare and Tricare claims and be paid for medical services rendered to Medicare and Tricare beneficiaries.
You wrote that you are enrolled in Tricare Prime. Claims for all medical services you receive before 2400 hours on July 31, 2010, must be filed as Tricare Prime claims.
Claims for all medical services received on and after August 1, 2010, must be filed with Medicare, not with Tricare.
It’s that easy. The rules for processing claims for TFL beneficiaries are established by federal law and regulation.
Medicare will process those claims in exactly the same way as it would process any other Medicare claim, and pay its share directly to the provider of care. Then, Medicare will automatically forward the Medicare claim and the resulting Medicare Summary Notice (Medicare’s name for its Explanation of Benefits — EOB) to the special claims processor for the Tricare portion of claims for TFL beneficiaries.
Tricare will review the Medicare claim and the accompanying Summary Notice. For every service on the Medicare claim that is also covered by Tricare, Tricare Standard will pay the provider whatever Medicare did not pay. Usually that will be your Medicare deductible and copayment. In that way, the combined payments by Medicare and by Tricare will pay the Medicare claim and the provider’s bill for those services, in full. You will have no out-of-pocket expense for those charges. Note that on Medicare claims for services covered also by Tricare (as second payer), the Tricare deductible and copayment (cost share) are waived.
The vast majority of Medicare claims are for services that are covered by both Medicare and by Tricare. Again, those claims will be paid in full by the combined Medicare and Tricare payments.
You have special circumstances, however, because of your Medicare claims for physical therapy. Medicare has a legal limit on the amount it may pay for physical therapy during the Medicare benefit period. When that limit is reached, Medicare must deny further physical therapy claims during that period. When the claims are forwarded to Tricare, the Medicare Summary Notice will report that Medicare has begun to deny your physical therapy claims because you have reached the legal limit for that service.
Because, unlike Medicare, Tricare has no such legal limit on physical therapy services, the physical therapy charges which were denied by Medicare can be paid by Tricare, subject to certain rules.
I noted and highlighted above, that when services are covered (paid) by both Medicare and by Tricare, the Tricare deductible and cost share are waived. When your Medicare benefit for physical therapy is exhausted, however, those charges can be paid only by Tricare. That is, the claims for those charges now have become “Tricare-only” claims. They are no longer covered by both Medicare and by Tricare because the Medicare benefit is exhausted.
When a TFL beneficiary has “Tricare-only” charges, all claims processing rules for Tricare Standard must be applied. Because Medicare can pay nothing, the Tricare deductible and cost share must be applied when Tricare Standard processes those charges. The charges will be processed as any ordinary Tricare Standard claim because you will have no Medicare coverage for those charges. The Medicare benefit is exhausted.
Tricare will determine the amount it can allow for each of the physical therapy charges. Then it must subtract any Tricare deductible that has not been satisfied by previous claims during that fiscal year. Then Tricare must subtract your 25 percent cost share from the remainder and pay the provider whatever is left.
That may result in a very small amount being paid to the provider until your entire $150 Tricare deductible has been satisfied for that fiscal year. Then, when the Tricare Standard deductible has been satisfied, Tricare will pay 75 percent of the amount it allows on each physical therapy claim for the remainder of that fiscal year.
The patient, not his health insurance, is always responsible for the costs of his medical care. A beneficiary with health insurance depends on the insurance to pay a portion of those costs. If his insurance does not pay, for whatever reason, the patient is responsible for paying the provider.
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.
Will surgeries on pre-existing scar be covered?
November 8th, 2009 | TriCare Help | Posted by Military Times
Q. My young daughter was burned two years ago. She has had surgery two times for scar revision as she has grown, and will need at least two more operations as she gets older.
My family and I will get Tricare later this year when I am 60. Will my daughter’s subsequent surgeries be covered by Tricare, or will coverage be denied or limited because the scar is a pre-existing condition?
Tricare is not an insurance company; it is a federal health benefits program, similar in that respect to Medicare. Unlike many commercial health insurance plans, Tricare has no restrictions or limitations on the coverage of pre-existing conditions.
A potential problem, easily overcome, could be with the continuity of care if you want the later surgeries performed by the same surgeon who did the previous operations.
For Tricare to cover the surgery, the surgeon must be or become a Tricare-authorized provider. That is, he must apply to Tricare and submit the information required to establish that he is a properly trained and licensed physician in the state where he practices.
When Tricare approves his application, he will be authorized to receive payment for services rendered to Tricare beneficiaries. All insurance plans and companies require some form of provider authorization.
Apart from certain medical emergencies, Tricare may not pay for any services received from an unauthorized provider.
Could my new wife be turned away for pre-existing conditions?
November 7th, 2009 | TriCare Help | Posted by Military Times
Q. I’m a retired sailor. My lady friend and I plan to be married next month. She has had a health insurance policy through her job for almost 20 years, but its price keeps going up. We hope to cancel that policy and put her under my Tricare insurance and supplement, if that is possible. The problem is that she is diabetic, has bad arthritis, and has lost one breast to cancer, which runs in her family.
Will Tricare refuse to insure her because of her pre-existing medical conditions? Or, if Tricare will cover her, will it be limited in some way — especially if her cancer returns?
As soon as you are married, contact the Pass and ID Card Section at any uniformed service facility so your wife can apply for all the benefits to which she will be entitled, including Tricare. If there is no facility nearby, call the Defense Enrollment Eligibility Reporting System support office, toll-free, at (800) 538-9552, for instructions and advice about the best way for her to apply. Only the military services can register her in DEERS so she can use Tricare.
Tricare has no exclusions or limitations on coverage for pre-existing medical conditions. From her first day of eligibility, your wife’s Tricare coverage will be exactly the same as that of all other Tricare beneficiaries.
I am concerned, however, about your wife’s coverage by your Tricare supplement. Tricare is not a health insurance company or policy. It’s a federal health benefits program governed by federal law and regulation. Tricare supplements, however, are offered by commercial insurance companies. They’re not part of Tricare, and Tricare has no control over them. Each has its own rules.
I know little about Tricare supplements. Tricare Help is seldom asked about them, and my comments are limited to “read the fine print,” which is always good advice about any contract.
Most commercial health insurance policies have limitations on the coverage they provide for pre-existing medical conditions. Policies they write as supplements for primary plans, such as Medicare or Tricare, most likely will have similar provisions. The important details are in the fine print.
For example, a commercial insurer might exclude any coverage for cancer from your wife’s Tricare supplemental policy. Or it might limit its cancer exclusion to breast cancer because of her personal and family history of the disease.
A fairly common exclusion is that a new beneficiary must go for several months, sometimes a year or more, without needing treatment for a pre-existing condition in order for it to be covered. When that time has passed, and if the beneficiary has not needed medical care for the pre-existing condition, it will be covered as if it were not pre-existing.
That can be bad news for beneficiaries with chronic conditions such as diabetes or arthritis. How bad the news is could depend on the way the policy defines a “need” for medical care for the condition.
It might not balk at a diabetic’s routine needs for insulin, blood testing and related supplies, but if the beneficiary has had an acute diabetic episode requiring emergency care or hospitalization, she might be disqualified for coverage.
These are only illustrations of the kinds of restrictions commercial policies can put on their coverage of pre-existing conditions. Different policies may have different restrictions.
Check the fine print on your existing Tricare supplement and, perhaps, several others, to learn exactly how each supplement handles coverage of pre-existing conditions.
There is an unpleasant reality I must mention: If you were to die, your wife’s Tricare eligibility would not be affected. Unless she remarried, she would be eligible for Tricare for the rest of her life.
If the marriage ended in divorce, however, she would lose Tricare eligibility immediately.
If your wife were to cancel her present health insurance policy, and if your marriage were to end in divorce, she would find herself uninsured by Tricare and, because of her medical history, she probably would be uninsurable by any commercial insurer except at great cost.
Please note that if your wife is a federal employee, she can suspend — rather than cancel — her federal employees health insurance plan. That way, she could reinstate the coverage during open season in any year.