Tricare Help

Can wife keep same doctor under Tricare Prime changes?

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I am a retired reservist. My wife is currently on Tricare Prime and I am on Tricare for Life. We understand that Tricare Prime will cease in our area at the end of September. My wife has had some surgeries and hospitalizations in the past, and we’re trying to figure out the best course of action for her. One option is to transfer her to a primary care manager to a town about an hour away and sign Tricare’s travel waiver. She wants to keep seeing her local family physician (her current PCM) if possible, under regular Tricare coverage. Is that possible?

Unfortunately, you’re in a difficult position shared by many other Tricare Prime users who will be affected by the Defense Department’s plans to drastically reduce the geographic reach of Prime as of Oct. 1.

If Prime is eliminated in your immediate area, I don’t think it will be possible for your wife to continue to see her local PCM; she would have to find a PCM in an area that still offers Prime and agree to the waiver on travel time.

The other option, of course, is to go with Tricare Standard, which has some structural differences from Prime. Standard has no annual enrollment fee as Prime does, but Standard could carry higher out-of-pocket costs, particularly for beneficiaries who use a lot of health care. Standard has no PCMs and offers a wider variety of providers than Prime.

You can do a direct comparison of the cost and benefits of Prime and Standard here.

My doctor says Tricare won’t cover my pregnancy

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I recently married an active-duty soldier. I was six months pregnant at the time. He enrolled me in DEERS and and I was put on Tricare Standard. When I let my providers knew that I was married, I was told that Tricare Standard may not cover my pregnancy because it was pre-existing before I got on my husband’s insurance. Plus, the facility I go to now does not even accept Tricare, and I was told I may have to find another provider. What should I do?

Your providers are misinformed. Tricare places no restrictions or limitations on pre-existing conditions that are normally covered by Tricare. As of the moment you said, “I do,” you became a Tricare beneficiary in full standing. You should contact the managed-care contractor for the Tricare region in which you live for further guidance.

As far as whether your providers “accept” Tricare, that gets a bit more complicated, and depends largely on the specific relationship (or lack thereof) between your provider and Tricare.

Non-network providers are a routine aspect of Tricare Standard. Non-network providers, commonly referred to as Tricare Standard (Certified) Providers, do not have a contractual relationship with Tricare’s regional contractors, but they must be certified to provide care to Tricare beneficiaries. To be certified, the facility, doctor or other health care professional must meet the licensing and certification requirements of Tricare regulations and practices for their health care specialty or specialties. Once they are certified, they may or may not agree to “accept assignment” — in other words, accept the Tricare maximum allowable charge as payment in full for services. If they don’t agree, then they are considered authorized, non-participating providers. Providers can “accept assignment” on a claim-by-claim basis. Bu law, non-participating providers may not bill Tricare patients more than 115 percent of Tricare’s allowable charge for a particular service. Still that extra 15 percent could be a considerable amount of money.

Also, non-participating providers do not file claims on behalf of beneficiaries, as participating providers do. So if you have a non-participating provider, you’ll have to deal with all the claims paperwork yourself.

You and your husband may want to think about enrolling you in Tricare Prime as an alternative option. Tricare Standard is a good option for people who want the widest choice of providers, or who want to stick with a particular long-time provider who might not be in the Tricare network. But your out-of-pocket costs will be higher than under Prime, and again, you’ll have to deal with the paperwork. With Tricare Prime, your choice of providers is more limited, but your health care can be more convenient; under Prime, your care is usually coordinated at your local on-base military hospital or clinic through a primary care manager. And your provider files your claims paperwork.

The patient administration office at your local on-base hospital or clinic should be able to give you more information.

I’m on Tricare for Life, but my doctor won’t take Medicare

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I am going to get Medicare and Tricare for Life soon. The problem is that the doctor I have used for several years does not take Medicare. I don’t want to change doctors if I can help it. Is there anything I can do?

Medicare cannot pay for any services received from a health care provider who has opted out of the Medicare program. Although you can continue to use his services, you could not receive any payment from Medicare for his services.

You could file a Tricare claim. Tricare can calculate the amounts it would have paid if Medicare had paid the doctor’s claim. Tricare will pay you that amount only. At the most, that would be the amounts the Medicare copayment and Medicare deductibles would have been.

Unless you can persuade your doctor to become a Medicare provider, your dollar-wisest choice will probably be to change physicians.

If you will contact your Tricare Service Center, you can get a list of Medicare providers in your area. That will help if you decide to change physicians.

Doctor wants to see Tricare for Life card; where can I get one?

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Several times I’ve had doctor’s office give me a blank look when I tell them my health insurance is Tricare for Life. They say they’ve never heard of it, and they want to see a Proof of Insurance card. Where can I get such a card?

Under Tricare for Life, your primary insurance is Medicare. I know it seems awkward when you know you are a Tricare beneficiary, and your health insurance is called Tricare for Life. But look at it this way. Under TFL, Tricare acts as a free Medicare supplement.

Providers usually don’t care which Medicare supplement you have because they will look to you for payment of what Medicare does not pay. What you owe is your 20 percent Medicare copayment and maybe some Medicare deductible. Whether you have a supplement to pay it for you, or whether it comes out of your own pocket, you, the patient, are responsible.

So, when asked about your health insurance, just say you have Medicare. That’s the important word. If they ask about a Medicare supplement, then you can say you have Tricare.
TFL doesn’t have an identification or proof-of-insurance card because. Just show your Medicare card and your military ID card.

And, any time you go to a new provider of any health care service, whether it’s a doctor, or a hospital, or a physical therapist, or a medical supply and equipment vendor, or anything related to health care, always ask if the provider files Medicare claims, before you incur a debt.

If a provider does not, or cannot file Medicare claims, it is an indication that the provider is not an authorized Medicare provider. That doesn’t mean there is something wrong with the provider. It means, however, that neither Medicare nor Tricare will pay for any services you get from that provider.

How can TFL refuse to pay for a test doctor ordered?

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Q. I am a retired Air Force officer and have Medicare parts A and B and Tricare for Life. Recently my wife’s doctor ordered a set of lab tests that included a thyroid function test; neither Medicare nor TFL would pay for this test, leaving us to pay for that out of pocket (all other billed items were covered by one or both). How can Medicare and Tricare deny that tests ordered by a physician are “necessary”? And why was the $100 out-of-pocket payment we had to make not credited against our Individual/Family Deductible amounts?

You have the answer to your first question in your hands. Anytime a Medicare or a Tricare claim is denied, the reason for the denial is always reported on the Explanation of Benefits.

Every time Medicare or Tricare processes a claim, it sends the beneficiary and the participating provider a report of the details of all its actions when it processed the claim. That document is called an Explanation of Benefits, or EOB, for short.

The EOB reports the amount the provider billed, the amount the insurance plan approved or allowed (those terms mean the same thing), the amount the plan paid, and to whom it was paid.

If the claim, or a portion of the claim was denied (nothing was allowed or paid for that medical service), the EOB also contains a statement that tells you exactly the reason for the denial. If you have questions about the claim, including the denial, the EOB has a toll-free number you can call for a full explanation of the reason and, if possible, what you need to do so the claim becomes payable. Additionally, the EOB describes the things you must do to file an appeal. An appeal requires the plan to reconsider the way it processed the claim to ensure that all the rules for payment were considered correctly.

As I do not have a copy of the two EOBs, I have no way to know why the claims were denied. But since a test for thyroid function is a covered service under both Medicare and Tricare, the fact that the claims were denied makes me believe there was a error of some kind in the way you got the medical service or in the way the doctor filed the claim.

Was the doctor who ordered the tests a Medicare provider? A medicare provider is one that is enrolled with the Medicare program and us authorized to file Medicare claims for services provided to Medicare beneficiaries. If you have TFL and get care from a non-Medicare provider, neither Medicare nor Tricare may pay the claim.

Unless the EOB states that the amount Medicare or Tricare would have paid was credited to your deductible, the denial of the claim was not related to the deductible. It was denied for some other reason (which is reported on the EOB). The denial of a charge is unrelated to the deductible.

Doctor says she will stop taking Medicare – and Tricare

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Q. My wife is 60 and enrolled in Tricare Prime. Her doctor has recently notified her that she will soon stop seeing Medicare patients, and since the law requires that if she accepts Tricare she must also accept Medicare, she will also stop seeing her Tricare patients. One option is to find another doctor in the Prime network. My wife prefers to stay with her doctor, who offered the option of continuing to see her if we pay her out of pocket for her services. Can we switch to Tricare Standard, pay out of pocket, and file for reimbursement from Standard without invoking the link between Tricare and Medicare? Would the doctor be limited by Tricare billing/reimbursement limits? Or would we be denied Tricare reimbursement because the doctor wants nothing to do with Medicare?

I believe your wife’s doctor is confused about the requirements of law regarding Medicare and Tricare participation. I believe the law she is thinking of is the one that requires hospitals that accept Medicare patients to also accept Tricare patients. If we are talking about the same law, note that it applies only to hospitals. It does not apply to individual providers such as physicians. To the best of my knowledge, there is no requirement for Tricare Authorized Providers to accept Medicare patients.

There is a rule that physicians must be registered with Tricare as authorized providers. If you get medical care from a doctor who is not authorized by Tricare, Tricare cannot pay for his or her services.

It is very important for your wife’s doctor to write very soon to the Tricare Headquarters so she can get the correct information officially and learn exactly and officially where she stands. The address is Tricare Management Activity, 16401 E. Centretech Parkway. Aurora, CP 80011-9043. That office manages the Tricare Program worldwide. It is a federal agency and part of the Office of the Assistant Secretary of Defense for Health Affairs.

Just in case your doctor doesn’t want to write, then you should do it. Tell Tricare what your doctor believes and get an official answer.

Does my doctor have to accept TFL payments?

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Q. If a doctor accepts Medicare payments, does he also have to accept Tricare for Life payments?

If you are a Tricare for Life beneficiary, Medicare makes its payment directly to the provider of care. Then, it automatically forwards the claim to Tricare, which is your free Medicare supplement. Tricare processes the claim using Medicare’s EOB for information about what Medicare paid. For every medical service on the Medicare claim that is covered also by Tricare, Tricare pays directly to the provider whatever Medicare did not pay, up to the amount you owe. As that is an automatic action, the Medicare claim and the provider’s bill are paid in full. As the doctor is paid in full by the automatic combined Medicare plus Tricare payments, it is not necessary for him to “accept” Tricare. He still gets paid in full, and you owe nothing.

Your Tricare EOB will prove that the bill was paid in full. Save it as proof if there is ever a question.

When you’ve already paid Medicare’s copay

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Q. I had cataract surgery in both eyes. I have Tricare for Life, and the eyeglasses are covered under Medicare and Tricare. The eye care provider accepts Medicare and I had to pay the 20 percent copay. What happens when Tricare pays? Does the provider keep both payments? Who returns my copay?
As both Medicare and Tricare cover one set of eyeglasses following intraocular lens implant surgery, Tricare will pay the provider whatever Medicare did not pay.  It usually takes a couple of weeks for Tricare to pay the provider what Medicare did not pay. 
Contact the eyeglass provider for a refund.  Tricare will send both you and the eyeglasses provider an EOB as proof of payment.

My doctor says he doesn’t take TFL – can he do that?

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Q. I am retired Navy and my wife and I have Tricare for Life.  She was referred to a health care provider for shoulder problems, and the provider informed her they accept Medicare payments but not Tricare for Life payments.  Is this against federal law?

You have in mind a rule that applies only to institutional providers, such as hospitals.  That rule says that a hospital that accepts Medicare patients is required by law to accept Tricare patients also.

That rule does not apply to individual professional providers, such as physicians.

The way health insurance policies are set up, the patient is always responsible for whatever the primary plan does not pay.  That is usually the plan’s deductible and copayment, but it could include other things as well, such as a medical service the primary plan does not cover.

Many Medicare beneficiaries have a Medicare supplement.  There must be a hundred or more plans to choose from.  In the case of TFL, that choice is made for you — it is automatically Tricare Standard.  That was set up in 2001 when Congress created Tricare for Life.

The provider’s only interest is in receiving the full amount Medicare approves as payment for his services on the Medicare claim.  TFL is set up in a way so that happens.

If both Medicare and Tricare cover all the services on the Medicare claim, Tricare Standard will pay the provider whatever Medicare did not pay, up to the amount Medicare approved.  The Tricare deductible and cost share are waived on those claims.  The vast majority of claims filed under TFL are of that kind.

For information about the details of TFL operation, I suggest that you contact your Regional Tricare Service Center and request a free Tricare for Life Handbook, or download one for free, here.

Is my doctor taking advantage of Tricare?

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Q. My wife and I feel that our doctor is taking advantage of Tricare by scheduling us for unnecessary appointments and services. Is there an organization such as the Better Business Bureau for doctors that I should contact?

 Billing Tricare for excessive and unnecessary services is called abuse and is illegal. Tricare takes such matters very seriously.

I suggest you write a letter to the Tricare office that processes your claims. The address is on your explanation of benefits forms. In your letter, provide as many examples and other details as possible, including names and dates. If other providers are involved — as in a case of excessive laboratory tests —include their names, as well.

Also include copies of any pertinent documents relating to your complaint. Because of provisions of the Privacy Act, both you and your wife should sign the letter. Don’t forget to include a daytime phone number.

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