Q. My mother is now in a nursing home. Tricare for Life used to pay for home health care; will they pay for any part of her nursing home cost? If not, will they pay for her trips to the doctor and hospital, which are extra?
When your mother became a nursing home resident, she lost none of her Tricare for Life benefits. Tricare will continue to be second payer to Medicare for all covered services — doctor visits, drugs, hospital stays, surgery, laboratory, x-rays, etc., just as it was when she lived at home.
Tricare cannot pay for services that the nursing home provides equally for all residents, such as a secure and protected environment, room and board, general nursing services, help with the activities of daily living such as bathing, eating, dressing, personal hygiene, usually one physician visit per month, and the like. Such things are part of the services provided to all the residents and are covered by the monthly costs of nursing home care. Neither Medicare nor Tricare is allowed by federal law to pay for them. Those costs, unfortunately, are usually the most expensive part of nursing home care.
If your mother receives a medical service for which the nursing home makes an additional charge, you should ensure that the nursing home files a Medicare claim for that service whether or not it is payable by Medicare. If it is a service Medicare covers, Medicare will pay its share to the provider and automatically forward the claim to Tricare as second payer. Remember that Tricare Standard acts as a free Medicare supplement in such cases, so it will pay the balance on the Medicare claim. That is usually the Medicare deductible, if applicable, and the Medicare copayment.
Even if the nursing home knows Medicare will not pay for a particular service, however, they must still file a Medicare claim first. That is because, unlike a commercial Medicare supplement, Tricare often can pay for services that are not a Medicare benefit. Tricare often will pay for services that Medicare denies. For it to do that, however, a Medicare claim must be filed first. In such cases, Medicare will deny payment, but it will still forward the claim to Tricare for consideration and possible payment by Tricare Standard.
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