Tricare Help

Transitioning to TFL while undergoing physical therapy

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Q. I am currently receiving physical therapy for two separate injuries, with the possibility of shoulder surgery if the PT does not work. I am currently under Tricare Prime and will transition to Medicare/TFL in August. My PT location and my primary care provider accept both Tricare and Medicare. What bureaucratic problems, if any, should I expect to encounter while undergoing care at this transition point?  I already draw Social Security and have received paperwork about enrollment in Part A and B.
This reply is based on the assumption that you successfully enrolled in Medicare Part A and Part B.  Medicare coverage for a person in your situation becomes effective on the first day of the month when you will have your 65th birthday.  Your continuing Tricare eligibility for the rest of your life is established by your enrollment in Medicare Part B.
You should expect no problems if your providers file the claims properly.
You will be 65 in August.  At 2400 hours on July 31 you will undergo an automatic transition in your Tricare coverage.  You will become entitled to Medicare, your Tricare Prime coverage be changed to Tricare Standard, and you will become eligible for Tricare for Life (TFL).  

Your letter reports that the providers in question are authorized Medicare and Tricare providers.  Thus, they can file both Medicare and Tricare claims and be paid for medical services rendered to Medicare and Tricare beneficiaries.
You wrote that you are enrolled in Tricare Prime.  Claims for all medical services you receive before 2400 hours on July 31, 2010, must be filed as Tricare Prime claims.
Claims for all medical services received on and after August 1, 2010, must be filed with Medicare, not with Tricare.
It’s that easy.  The rules for processing claims for TFL beneficiaries are established by federal law and regulation. 
Medicare will process those claims in exactly the same way as it would process any other Medicare claim, and pay its share directly to the provider of care.  Then, Medicare will automatically forward the Medicare claim and the resulting Medicare Summary Notice (Medicare’s name for its Explanation of Benefits — EOB) to the special claims processor for the Tricare portion of claims for TFL beneficiaries.
Tricare will review the Medicare claim and the accompanying Summary Notice.  For every service on the Medicare claim that is also covered by Tricare, Tricare Standard will pay the provider whatever Medicare did not pay.  Usually that will be your Medicare deductible and copayment.  In that way, the combined payments by Medicare and by Tricare will pay the Medicare claim and the provider’s bill for those services, in full.  You will have no out-of-pocket expense for those charges.  Note that on Medicare claims for services covered also by Tricare (as second payer), the Tricare deductible and copayment (cost share) are waived.
The vast majority of Medicare claims are for services that are covered by both Medicare and by Tricare.  Again, those claims will be paid in full by the combined Medicare and Tricare payments.
You have special circumstances, however, because of your Medicare claims for physical therapy.  Medicare has a legal limit on the amount it may pay for physical therapy during the Medicare benefit period.  When that limit is reached, Medicare must deny further physical therapy claims during that period.  When the claims are forwarded to Tricare, the Medicare Summary Notice will report that Medicare has begun to deny your physical therapy claims because you have reached the legal limit for that service.
Because, unlike Medicare, Tricare has no such legal limit on physical therapy services, the physical therapy charges which were denied by Medicare can be paid by Tricare, subject to certain rules.
I noted and highlighted above, that when services are covered (paid) by both Medicare and by Tricare, the Tricare deductible and cost share are waived.  When your Medicare benefit for physical therapy is exhausted, however, those charges can be paid only by Tricare.  That is, the claims for those charges now have become “Tricare-only” claims.  They are no longer covered by both Medicare and by Tricare because the Medicare benefit is exhausted.
When a TFL beneficiary has “Tricare-only” charges, all claims processing rules for Tricare Standard must be applied.  Because Medicare can pay nothing, the Tricare deductible and cost share must be applied when Tricare Standard processes those charges.  The charges will be processed as any ordinary Tricare Standard claim because you will have no Medicare coverage for those charges.  The Medicare benefit is exhausted.
Tricare will determine the amount it can allow for each of the physical therapy charges.  Then it must subtract any Tricare deductible that has not been satisfied by previous claims during that fiscal year.  Then Tricare must subtract your 25 percent cost share from the remainder and pay the provider whatever is left.
That may result in a very small amount being paid to the provider until your entire $150 Tricare deductible has been satisfied for that fiscal year.  Then, when the Tricare Standard deductible has been satisfied, Tricare will pay 75 percent of the amount it allows on each physical therapy claim for the remainder of that fiscal year.
The patient, not his health insurance, is always responsible for the costs of his medical care.  A beneficiary with health insurance depends on the insurance to pay a portion of those costs.  If his insurance does not pay, for whatever reason, the patient is responsible for paying the provider.