Tricare Help

When Tricare Standard becomes your primary coverage

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Q. I am 62 years old and have been retired from the Navy for 21 years. I have worked at my current job for 18 years and have been covered by my employer’s insurance, with Tricare as my secondary insurance. Now, due to health complications, I have had to cut back on my work hours, and I no longer have my employer’s insurance. Will Tricare Standard take over as my primary insurer? If so, what do I need to do? How much will it cost? How can I get my prescriptions filled? I don’t live near a military base.

You probably already know that you must keep your DEERS registration and your military ID card up to date in order to have Tricare coverage. You can update your DEERS record by calling the DEERS Support Office, toll-free, at 1-800-538-9552. That office will also provide any guidance you need to update your ID card.

It may be, however, that you need some information about how to handle the effects of the loss of coverage by your employer’s health insurance plan. You will be told in advance when your coverage under that plan will end.

You must get an official letter from that insurance company that reports the last date that you will have coverage under that plan. That is, a report of the last date that plan will pay for your medical care. Call DEERS and ask to whom you should send a copy of that letter, together with a brief explanation of the reason the policy will be canceled — whom should you notify and when.

If you have made proper notification, DEERS and Tricare will know the last date of your other coverage. Tricare Standard will automatically become your only health insurance effective on the following day.

When Tricare Standard is your only coverage, you will become responsible for paying the $150 yearly Tricare deductible and your 25 percent cost share of the amount allowed on each Tricare claim. Otherwise, Tricare Standard is free; it has no monthly premium. All Tricare beneficiaries are automatically eligible for the Tricare Pharmacy Program at no cost other than the small copayments for drugs.

A month or two before you lose your employer’s plan, you may want to begin to research the coverage offered by one of the several Tricare supplement plans. Most of the retiree associations offer such a plan.

Write to several associations and request a copy of their Tricare supplemental policy. In that way, you can compare several to find the plan that best meets your needs. Check carefully the policy’s coverage of pre-existing conditions.

I suggest, also, that you contact the Social Security Administration to research possible coverage under the Social Security Disability Program.

If you qualify for that program, you will become eligible for Medicare after receiving disability benefits for 24 consecutive months. Otherwise, you will have to wait until you are 65 to qualify for Medicare and Tricare for Life.

How does my catastrophic cap work?

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Q. I understand that when I reach the catastrophic cap of $3,000, Tricare will pay my medical bills in full for a year. How will I know when I reach that capped amount?

The catastrophic cap doesn’t work quite that way.

Tricare maintains a running total record of all deductible and cost share amounts a family pays during a given fiscal year. That total is reported on each Tricare explanation of benefits for every family member.
When the total reaches $3,000, Tricare will pay 100 percent of the amount it allows on every family member’s claims for the remainder of that fiscal year.

That is, for the remainder of that fiscal year, Tricare will not withhold any deductibles or cost shares from the amount it allows on each family members’ claims. It will pay in full the amount it allows, not the amount of the bill.

But it will apply this rule only to claims received through Sept. 30 of that year.

The fiscal year runs from Oct. 1 through Sept. 30. At midnight on Sept. 30 each year, the amount in the family’s catastrophic cap account reverts to zero, and the amount in the cap account begins to accumulate again with the first claim for services received in the new fiscal year.

Will Tricare cover my kids and their special nutritional needs?

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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.

Standard, Prime: Weighing the options

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Q. I am retired from the military and the civil service and am 70 years old.  When I became 65, I suspended my civilian health insurance (Blue Cross), enrolled in Medicare Part B and am now covered by Medicare Parts A and B and Tricare for Life.  My wife is 58 and is working for the state  as a teacher and is provided a health care plan (without charge)  and has  Tricare Standard.  She is allowed to see any doctor of her choosing.  When she retires in June 2011, she will have the option of continuing her state Blue Cross plan, but it will no longer be free.  Is there a Tricare plan that she can qualify for that will allow her to continue to see the doctor of her choosing? 

Tricare is not an insurance policy or insurance company.  It is a federal health benefits plan similar to Medicare in that respect.
 
All insurers require providers to apply to become certified by the plan by proving they are properly trained, educated, and licensed to provide certain medical services.  Tricare is no exception.
 
Under Tricare, your wife’s ability to use any physician of her choice depends on the provider.  She may use any provider who has applied with Tricare, been accepted and, thus, has become a Tricare-authorized provider.  Tricare may not pay for the services of any unauthorized provider except in certain bona fide medical emergencies.
 
There will be two possible Tricare plans for your wife:  Tricare Standard and Tricare Prime.  Prime is not available everywhere.  You will have to ask your Regional Tricare Service Center whether Prime is available in your area.
 
Tricare Standard is a fee-for-service plan.  You receive medical care, get a bill, and file a Tricare claim for reimbursement of a portion of the cost.  After satisfaction of the $150 Tricare fiscal year deductible, Tricare Standard pays 75 or 80 percent of the amount it allows on each claim.  The copayment (cost share - the patient’s share) for active-duty family members is 20 percent of the amount Tricare allows; for all others it is 25 percent of the amount allowed.
 
On each Tricare Standard claim filed, the provider has the option to participate or not to participate in Tricare on that claim.  If the provider agrees to participate, he will file the claim on the patient’s behalf.  He will sign a legally binding agreement to accept the amount Tricare allows on that claim as his full payment for the services on that claim.  Tricare will pay its share directly to the provider and send an EOB to the provider and to the patient which describes in detail all its actions on those charges.  After Tricare has paid its share of the amount allowed, the patient is responsible for paying the provider the difference between the amount actually paid by Tricare and the amount Tricare allowed on those charges.  When the patient has done that, the claim and the provider’s bill will have been paid in full.  The patient is not responsible for any amount greater than the amount Tricare allowed on the claim. 
 
If the provider chooses not to participate on a claim, a portion of the law governing Medicare applies also to Tricare Standard claims.  It is called the Limiting Charge provision.  All Medicare providers know of the law, but many are not aware that it applies also to Tricare beneficiaries claims.  It limits the amount the patient may be charged to 15 percent more than the amount Tricare allows on that particular non-participating claim.  Tricare can pay no part of that 15 percent surcharge.  The patient is responsible for that amount in addition to any deductible required and the co-payment (20 or 25 percent of the amount allowed).
 
Tricare Standard can be used worldwide and is free.  A Tricare supplement is strongly recommended for Tricare Standard members in order to pay the deductible and co-payments (called cost shares) and the surcharge on non-participating claims.  Read the fine print carefully before buying any Tricare supplement.  Make sure you are buying what you think you are buying, and that it meets your anticipated needs.
 
Tricare Prime functions as a Health Maintenance Organization (HMO).  As noted, it is not available in all areas.  Certain providers contract voluntarily with Tricare to provide services to Prime members at reduced rates. They have independently negotiated with Tricare and agreed to those amounts.  The patient may use only those (Prime) providers.  The providers will file the claims on the patient’s behalf and will receive their payment directly from Tricare.  The patient is required to pay the provider a fixed amount for each office visit or other medical service.  Tricare pays the remainder of the fee directly to the provider.  The member may use only Prime providers in their residential area.  To use a Prime provider in another area, such as when traveling, special preauthorization from the Prime administrative office is required except in bona fide emergency situations. Prime costs $230 per person, $460 maximum per family, per year.

Will Tricare cover ER visit in Canada?

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Q. While on a visit to Canada, I injured my knee and was taken to an emergency room.  The total cost was over $800.  It’s my understanding that Medicare does not cover these expenses.  Is there any coverage under Tricare? 

Medicare can provide coverage for medical care received outside the U.S. and its possessions only in certain limited situations.
 
I suggest that you contact Medicare to explain the details of the events resulting in your Canadian medical care.  Medicare will tell you whether it can provide any coverage and how to file a Medicare claim in that event.  If Medicare can provide coverage, the claim will be processed as any other TFL claim — that is, with Medicare as primary payer and Tricare Standard, automatically, as second payer.
 
As a Tricare for Life beneficiary, you have coverage by two full service, stand-alone, health insurance policies, Medicare and Tricare Standard.  If you receive a medical service that is not covered by Medicare, such as your Canadian care, you have Tricare Standard as fall-back coverage.
 
If Medicare is unable to pay anything toward your care in this case, Tricare will be your only coverage.  In that case, the Tricare claim will be subject to all of Tricare’s claims processing rules including the application of the Tricare deductible and cost share.  Let me explain the consequences in that event.
 
Under TFL, when a medical service is covered by both Medicare and Tricare, the Tricare deductible and cost share are waived.  In those cases, the combined payments by both plans (Medicare plus Tricare) will pay the Medicare claim and the provider’s bill in full.
 
All medical services on the vast majority of a TFL beneficiary’s Medicare claims are covered by both Medicare and Tricare.  Because Tricare’s deductible is waived on those claims, it is possible that the beneficiary has paid very little toward satisfying the $150 fiscal year Tricare deductible.
 
When Medicare does not pay on a medical service, Tricare becomes the beneficiary’s only health insurance for that particular medical service.  Thus, when the Tricare-only claim is processed, any amount of the Tricare deductible not previously paid must be applied to that claim. 
 
Depending on the beneficiary’s previous claims history during that fiscal year, the deductible amount remaining unpaid could be large.  It must be subtracted from the amount Tricare allows on that item, then the beneficiary’s 25 percent cost share must be subtracted from the amount remaining.  Those actions can considerably reduce the amount Tricare pays on the claim.  That rule is required by federal law.
 
If you find that Medicare can be of no help in paying your foreign medical bill, please call Wisconsin Physicians Service, the Tricare claims contractor for TFL.  The toll-free number is 1-866-773-0404.  That office will provide instructions for filing a Tricare Standard claim for your care. 
 
So there are no surprises when the claim is paid, WPS also can tell you how much of the amount allowed on the claim must be subtracted and credited to your Fiscal Year 2010 Tricare deductible.

Why does my doctor keep billing me?

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Q. My doctor charged $268. Tricare allowed $192.50 and sent me a check for 75 percent, or $144.38. I paid the doctor $192.50 plus the 15 percent surcharge, for a total of $221.38. Now the doctor is demanding another $46.62, making the total the amount of his original bill, and says he’ll turn my account over to a collection agency if I don’t pay. It’s my understanding that federal law doesn’t allow him to do that. What should I do?

You are correct. The doctor may not charge you more than 15 percent over the amount Tricare allowed. If he sees Medicare patients, he is aware that the Limiting Charge law applies to Medicare claims; he needs to learn that it applies to Tricare claims also.

You should send a report to the Tricare office that processed your claim. The address is on the Tricare Explanation of Benefits form. Include a copy of the EOB and any “balance due” notices from the doctor. If the doctor persists, report him again.

It is unfortunate that the law will not allow Tricare to do more than write to the doctor and explain the federal law. Beyond that, all it can do is threaten to discontinue his status as a Tricare-authorized provider and threaten to cancel his ability to participate in other federal programs such as Medicare.

The doctor may be unaware of what his billing clerk is doing. You might consider writing or talking with him about it.

Who is required to accept Tricare?

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Q.  Our doctor joined a group practice. Although he continues to see Medicare patients, the office manager said the practice does not belong to Tricare, and we have to pay full price for our medical care and file with Tricare ourselves.

Didn’t you write that if a provider accepts and bills Medicare, federal law requires him to also accept and bill Tricare? What are the facts?

That law applies only to institutional providers, such as hospitals. Individual providers, such as physicians, psychologists, private physical therapists and the like, are not bound by that law.

If the physician has severed his relationship with Tricare and is no longer a Tricare-authorized provider, Tricare cannot pay for any of his services regardless of who files the claim.

If he remains a Tricare-authorized provider but no longer participates in Tricare on the claims, you may use his services and file the claims yourself. In that case, he is no longer required to accept the amount Tricare allows as full payment for his services.

However, there is a law that limits the amount you may be charged for his services. It is a provision of the law governing Medicare called the Limiting Charge. In 1983, Congress made that law apply to Tricare as well as to Medicare.

The Limiting Charge allows a nonparticipating physician to charge a Medicare or a Tricare beneficiary up to, but not more than, 15 percent over the amount Tricare allows on a claim. Tricare will pay its usual amount directly to you. You will be responsible for paying the physician the amount Tricare allowed on the claim plus an additional 15 percent more than the amount allowed.

Your out-of-pocket expense for using such a physician, then, is your usual 25 percent cost share plus the 15 percent surcharge.

You might want to tell the office manager that Medicare and Tricare are required by law to use the same methodology and most of the same databases to calculate the amounts they allow on claims.
The amounts allowed by the two programs seldom differ by more than a few dollars. Tricare often allows slightly more than Medicare because of its younger, healthier beneficiary population.