I am a new insurance agent trying to help some military clients. What benefits for long-term care do they have through Tricare?
Tricare covers skilled nursing care, home health care and hospice care, but unfortunately it generally does not cover long-term care (also known as custodial care) for patients with degenerative conditions such as Alzheimer’s. Exceptions or partial exceptions to the “no coverage” guidance may be discussed with the managed-care contractors for the various Tricare regions, but my understanding is that such exceptions are fairly rare.
One potential option for service members and military retirees is the Federal Long Term Care Insurance Program. About 20 million people are eligible to apply for FLTCIP, including all active-duty and National Guard members activated for more than 30 days, retired uniformed service members, and members of the Selected Reserve.
My wife has been diagnosed with Alzheimer’s disease. I can no longer take care of her; there are only two of us in the household, and we are both 80 years old. I had to put her in an Alzheimer’s home where she would be safe. My cost is $2,500 a month. Is there any way that Tricare can help me? We both have Tricare for Life.
Tricare will cover skilled nursing care, home health care and hospice care, but unfortunately it generally does not cover long-term care (also known as custodial care) for patients with degenerative conditions such as Alzheimer’s. Exceptions or partial exceptions to the “no coverage” guidance should be discussed with the managed-care contractor for the Tricare region where you live.
You may want to look into long-term care insurance through commercial insurance programs or through the Federal Long Term Care Insurance Program. About 20 million people are eligible to apply for FLTCIP, including all active-duty and National Guard members activated for more than 30 days, retired uniformed service members, and members of the Selected Reserve.
FLTCIP eligibility and enrollment requirements are complex, and not everyone who applies for this insurance will be approved for it. You can get full details at the program’s website.
I retired from the Army in 1975 and I have Tricare for Life. My wife of 52 years passed away in 2010 and now I am thinking of getting remarried. I am concerned about how to protect my children’s inheritance if my new wife has to go to a nursing home for a long period of time. What benefits does Tricare offer?
Like Medicare, Tricare makes no provisions for long-term care such as in a nursing home.
While there is no upper age limit for active medical care designed to make a patient “well” and able to live more or less independently, Tricare cannot cover long-term care in a protected and secure environment with assistance with the activities of daily living, such as eating, dressing and bathing. That is called custodial care. Both Tricare and Medicare are specifically forbidden by federal law to cover that kind of care.
As a result, you must look to the private sector for such benefits.
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.
Q. I am a retired reservist who will be eligible for Tricare when I turn 60. I am also a current federal employee covered by the FEHBP. Do I need to purchase a separate long term care insurance policy or will my FEHBP, Tricare and eventually Medicare cover those expenses? What about my spouse?
When people talk about “long term care,” they often have in mind a nursing home type of environment where people go to live when they can no longer care for themselves.
It is a place where you can live, and be watched over and protected. Your meals will be provided and, if you are unable to “do” for yourself, you will be helped to eat, dress, bathe, attend to personal hygiene, and the like. In insurance and medical vernacular, such care is usually referred to as “custodial care.”
It is very expensive to live in a place where you have have nurses and aides of several kinds, and probably a doctor on call 24/7 to care for you and meet your needs with the “activities of daily living.” (That is a technical term used in the law.)
The federal laws that created both Medicare and Tricare make no provision to help pay for such living arrangements. In fact, both programs are specifically prohibited by law to pay for “custodial care.”
Other than specific long term care policies, I know of no commercial health insurance policy, such as your FEHBP plan, that will pay for it.
Only you can decide whether you and your wife need such insurance. But, you cannot count on Medicare and Tricare (Tricare for Life), or your FEHBP plan, to help pay for it. Those programs will continue to pay for your medical care, including hospitalization, and your pharmacy needs, just as they do now, but they cannot pay for the costs of being cared for in such a facility.
The insurance for that kind of “long term care” is expensive, and the older you are when you buy the policy, the more it costs.