Switching to Tricare and shopping for supplements
January 31st, 2011 | TriCare Help | Posted by Military Times
Q. I am retired from the Army but have never used Tricare. I use health care provided by my employer, but in 18 months I will retire and my health coverage will stop. I will be 58 when I retire. Do you recommend a supplement? What do I do and how far in advance should I start converting to Tricare.
About 30 days before your last day of coverage by your other health insurance (OHI), write to the Tricare Headquarters to advise that you are going to cancel your OHI. The address is Tricare Management Actvity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. Include your full name, Social Security number, and the full names of any family members who are covered by that plan.
Include with your letter an official statement written by your other plan on its official stationery which states your last date of coverage by that plan. You will need to advise any health care providers as well so they will file appropriately with Tricare.
To use Tricare, your DEERS record must be kept up-to-date and report that you are eligible for Tricare. Please call the DEERS Support Office, toll-free, at 1-800-538-9552 to ensure that your DEERS record is correct and up-to-date so you will have no lapse in coverage. It is most likely that your Tricare coverage is in effect now, provided you have kept your DEERS record and military ID card up-to-date.
Those with no health insurance other than Tricare are well-advised to purchase a good Tricare supplement. Most of the military associations sell a Tricare supplement. They vary, however, in their price, what they cover, and their rules for doing it.
I suggest that you request a copy of the policy from several plans and read the fine print carefully. Make sure you buy the plan that best meets your needs and that it is a bona fide Tricare supplement. A bona fide Tricare supplement describes itself as a Tricare supplement in writing in the plan itself. In the policy, look at such things as its policy concerning coverage for pre-existing conditions; how long you must be hospitalized before the plan begins to pay; whether it has limits on the amount it will pay during a coverage period. Do not allow price to be the most important factor in your decision.
How does Tricare coordinate with FEHB, Medicaid?
January 10th, 2011 | TriCare Help | Posted by Military Times
Q. I am a federal employee and a mobilized reservist on active duty, so I have my FEHB – AETNA as well as Tricare. I recently found out that my son, who has Cerebral Palsy, is covered by Medicaid. He had major surgery after I was mobilized. How are the benefits coordinated?
By law, Tricare is always last payer to all other health insurance, medical plans such as HMOs, or medical payments such as you might receive from an auto accident, slip-and-fall injury and the like.
The only exceptions to that rule are in the case when the other coverage is a bona fide, specially written Tricare supplement, or a welfare-related plan such as Medicaid (not Medicare), Indian Health Service, and the like.
In your son’s case, the order of filing will depend on his coverage. If he has Aetna, those claims must be filed first. Then you can file with Tricare (which will probably pay all, or most, of Aetna’s deductibles and copayments), and finally claims can be filed with Medicaid.
We didn’t declare other health insurance; now Tricare wants money. Where do we turn?
December 7th, 2010 | TriCare Help | Posted by Military Times
Q. Through my wife’s job we have another health insurance, Blue Cross Blue Shield, but we have never used it. I am retired from the Navy and have Tricare Prime. We were recently notified by Tricare that they were denying payment and requiring reimbursement from providers, which they have passed on to us. How many years back can Tricare demand reimbursement for? We were unaware that we had to declare this unused insurance plan. How should we proceed?
Your problem is that, by federal law, Tricare is always last payer to all other health insurance policies, medical plans such as a Health Maintenance Organization (HMO, such as Kaiser Permanente), or medical payments such as you might receive for auto accident medical expenses, dog bite, slip-and-fall, and the like. If you have another health insurance plan in addition to Tricare, you must use it first.
You must file each claim with the other coverage first. After it has paid its maximum and issued you an EOB, you may file a Tricare claim for whatever the other coverage left unpaid. The unpaid portion will usually be what is often called the “patient’s share.” It usually consists of the other plan’s copayment and, when applicable, the other plan’s deductible.
That law has two exceptions: First, if the other coverage is a bona fide, specially written, Tricare supplement, you must file first with your Tricare plan. The other exception is if the other coverage is a welfare-related plan such as Medicaid (not Medicare), Indian Health Service, or the like. In those cases, you must file first with your Tricare plan.
I believe you have a problem with federal law, but I’m not a lawyer, so take anything I tell you with a grain of salt Only lawyers can give legal advice. I think yours is a simple mistake, not a “hanging offense.” But, I believe you are going to owe Tricare some money.
My guess is that what you owe will be some of the difference between the amount Tricare actually paid and the amount Tricare would have paid if you had filed the claim with your wife’s insurance plan first, as the law requires.
In answer to your question, I don’t know how far Tricare can go back in recouping the amount it paid in excess. For that information, you need official help: Write to the Tricare Headquarters. The address is Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. TMA is a federal agency under the auspices of the Office of the Assistant Secretary of Defense for Health Affairs. Everything you tell them is confidential except for need-to-know stuff required for the investigation.
For starters, tell TMA about the problem just as you did with me. As the military sponsor, tell TMA your full name and SSN as they appear on your military ID card, and report the name of each member of your family who is enrolled in Tricare. You can call the DEERS Support Office toll-free, at 1-800-538-9552, for information about your family’s DEERS registration.
Then tell TMA your wife’s full name and SSN as they appear on her employer’s policy, the name and address of the insurance company, the name of the plan, and the date when your family was enrolled in it.
I am sure that TMA will have other questions. They may refer you to your Regional Tricare Contractor to resolve the matter. Don’t panic; just answer the questions. If you think you need a lawyer, use one who is familiar with the practice of federal administrative law. Yours is a federal issue. I don’t believe the state is involved in any way.
How will employer’s plan, TFL work for wife?
November 24th, 2010 | TriCare Help | Posted by Military Times
Q. I am a retired sailor and a federal employee. We have my employer’s health insurance, with Tricare as second payer. My wife is two years older than I am and will be eligible for Medicare this year. How will Medicare, Tricare and my employer’s plan work together for her? What will be the effect on my coverage?
A. At least 90 days before the first day of the month before she turns 65, your wife must apply for Medicare. Because she has Tricare, she is required by federal law to enroll in both Medicare Part A and Part B.
Once she does, she must seek all her care from Medicare providers. Medicare cannot pay for care she receives from a provider who is not authorized to file Medicare claims.
While you are still working for the government, your employer’s plan will remain her primary coverage. She must file first with that plan, just as she does now.
Medicare will be her secondary insurance. And Tricare, by law, is always the last payer. After your federal employees plan and Medicare have processed a claim, she should file a claim with Tricare.
Changes to your wife’s coverage will have no effect on your coverage. You will pass through the same transition when you get Medicare at age 65.
When I get TFL, what happens to my wife’s coverage?
November 5th, 2010 | TriCare Help | Posted by Military Times
Q. When I am 65, my federal employee plan will convert to Medicare and Tricare for Life. My wife is only 58 and can’t get Medicare yet. Will Tricare be her only insurance?
Your employee plan will not convert to Medicare. Medicare is a separate plan and you must enroll in Part A and Part B at least 90 days before the month when you turn 65.
Both you and your wife will continue to be covered under your federal employees plan, and her Tricare coverage also will continue unchanged.
Your Medicare Parts A and B coverage will become effective on the first day of the month of your 65th birthday. It will be in addition to your federal employees insurance.
If you are no longer working for the government, Medicare will be your primary insurance coverage and the federal employee plan will be secondary. If you are still employed, your employee plan will be primary and Medicare will be secondary.
In either case, Tricare Standard will be your third plan, and you will have to file those claims yourself.
Tricare can help defray costs of a more expensive plan
September 22nd, 2010 | TriCare Help | Posted by Military Times
Q. I have a health insurance policy at work, but its prescription plan’s copayment is much higher than Tricare’s. Is there any way we can use Tricare for our prescriptions instead of my company insurance?
Unfortunately, no. Federal law requires Tricare always to be last payer. That means if you have other health insurance with a pharmacy benefit, you must use it first. However, you can file claims with Tricare for reimbursement of a portion of your other plan’s copayment.
With some commercial plans, the pharmacy benefit is optional. Contact your other health insurance to determine whether that’s the case with your policy. If you can drop the other plan’s pharmacy benefit, you can use the Tricare Pharmacy Program as first payer for your prescription services.
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.
For secondary insurance: Prime or Standard?
August 25th, 2010 | TriCare Help | Posted by Military Times
Q. I have Blue Cross and I also am eligible for Tricare. Is there any benefit to me getting Tricare Prime versus Tricare Standard as my secondary insurance?
No, to the contrary. Tricare Prime functions as a Health Maintenance Organization. HMOs have restrictive rules that require you to use only their physicians and facilities, and to use them first.
Having an HMO (such as Tricare Prime) as second payer to your other health insurance (OHI) can make coordination of benefits more difficult and increases the chance of errors and misunderstandings.
I believe you will be better off using Tricare Standard, which is free, as second payer to your OHI.
Here’s how to do it:
1. Complete an official Tricare Claim Form DD2642.
2. Attach a copy of exactly the same itemized bills as were sent to your OHI.
3. Attach a copy of the OHI’s EOB that reports details of its processing of those same charges.
4. Send the packet to the Tricare claims processor for your residential area.
The official Tricare website has a section dedicated to claims filing, where you will find claim forms to download, filing instructions, points of contact, and claims filing addresses.
How much will Tricare pay as secondary insurance?
August 11th, 2010 | TriCare Help | Posted by Military Times
Q. I am a reserve component retiree who will turn 60 soon and get Tricare. I have a health insurance policy from my second career, which will be my primary coverage. Please tell me how much Tricare Standard will pay in that situation.
It isn’t possible to state the dollar amount Tricare Standard would pay from so little information, so I’m thinking that’s not your question. I’m guessing you want to know what percentage, out of what the other health insurance leaves unpaid, Tricare Standard will pay.
However, I can’t answer that either. As second payer to other health insurance, Tricare doesn’t pay a set percentage. And because Tricare Standard is a government program, its payment rules are set by federal law and regulation. That could cause its payments to be different from what a commercial secondary plan might pay in the same situation.
Generally speaking, though, Tricare Standard will pay the difference between the amount of the patient’s legal obligation to pay and the amount actually paid by the other health insurance. In no case, however, will Tricare Standard pay more than it would have paid if there were no other health insurance.
The calculations a secondary insurer performs to determine the amount it is supposed to pay is called coordination of benefits.
The section at the Tricare Management Activity that is in charge of directing coordination of benefits has said that it isn’t possible to accurately determine the amount Tricare Standard will pay on a given claim without a copy of the original claim and the other plan’s explanation of benefits — the detailed report a health insurance plan provides to the beneficiary that shows all the pertinent information about the way the claim was processed.
That said, it’s probably safe to say that most of the time, Tricare Standard will pay most of what remains of your legal debt after the other health insurance has paid its maximum.
The right way to deal with a problem with Express Scripts
July 15th, 2010 | TriCare Help | Posted by Military Times
Q. Why is Express Scripts such a frustrating outfit to do business with? They have not responded to two greivance letters. In particular, I do not believe that they have paid out one single dollar for paper-processed claims for reimbursement that I have filed on behalf of my mother. They just recycle the paperwork back to you and they don’t care.
Your communication problems may have to do with the Privacy Act. By federal law, Tricare, Express Scripts, etc. cannot discuss your mother’s claims with a third party (you) without her written consent.
As that is only a guess, however, please send a detailed report of your mother’s problem to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, Co 80011-9043. Both you and your mother should sign the letter. That way, you can be included in the communications loop. If your mother is unable to sign the letter, please include a statement to that effect.
Include copies of all correspondence and other pertinent documents and a telephone number where you can be reached during the day. Be sure to include your mother’s full name, her military sponsor’s full name, and his Social Security number.
The more information you provide, the more effectively you can be helped. As an example, your letter, above, provided no information I could have used to suggest things you might do to resolve the problem. Surely Express Scripts reported its reasons for not paying the claims. Or perhaps, they didn’t, and said they couldn’t discuss the problem with you because of the Privacy Act. I don’t know, of course.
TMA, above, is a federal agency and the worldwide Tricare Headquarters. That office has the authority to order copies of all your mother’s claims documents and analyze them to get to the root of the problem.
If your mother is enrolled in Medicare Part D Pharmacy Plan (which she does not need unless her income is below the federal poverty line), her problem may be related to the coordination of benefits between two pharmacy benefit plans. Such claims must be filed in a certain order and contain certain documents to be processed and paid smoothly.
Without Part D, all your mother’s prescription services can be handled locally by an Express Scripts network pharmacy, or by mail order where she can get a 90-day supply of her medicines at the same price she pays for a 30-day supply purchased locally. Find information about that on Tricare’s website.