Tricare Help

What should I do with my federal plan?

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Q. I am approaching age 65 and will then qualify for Medicare and Tricare for Life.  Additionally, as a retired government employee I also have Federal Blue Cross.  I understand how Medicare becomes primary and Tricare acts as a supplement,  but what part, if any, will Blue Cross play in my coverage?  My wife is 59 and will not be covered by Medicare for a number of years, so I will need to retain my Blue Cross to cover her.  As I see it, although I will be required to pay $110.50 per month Medicare Part B to keep my Tricare,  I will have no better coverage than I now do with Blue Cross and Tricare Standard, which cover nearly 100%.  I know I can suspend Blue Cross, but that isn’t an option until my wife is 65.  Do I have any other options?

You have the law in the matter pretty well nailed down.
 
When you get Medicare, and as you retire from the government, Medicare will be primary, your federal plan secondary, and Tricare (by law), will be last payer.
 
You’re right about the cost, which will end up with your having to pay the Part B premium and getting no real benefit from it, but that’s the law.
 
Because your BC/BS coverage is a result of your employment, not hers, it is likely not possible to suspend only your own coverage, leaving her as the sole beneficiary (unless OPM’s rules have changed).
 
I know of two possible options.  I retired from OCHAMPUS (the CHAMPUS Hq.) in 1991, and  I knew a couple of Air Force retirees who chose the very cheapest FEHBP plan they could find.  Tricare, as second payer, paid most of what the cheap-o FEHBP plan did not pay, so they had good coverage regardless.  But I don’t know whether the amount Tricare now pays as secondary is as good as it was back then.
 
The other alternative is to buy a Tricare supplement instead of the FEHBP for your wife.  That is sort of unpredictable because supplements never provide the coverage of a full-coverage stand-alone policy like the FEHBP BC/BC plan.  If you want to try, shop a dozen-or-so and read the fine print carefully.

If Tricare pays less than Medicare, how does it work with TFL?

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Q. I’ve read stories about Tricare and it seems less reliable than most commercial plans. It pays 5 percent less than Medicare does, so how will it help pay my Medicare claims under Tricare for Life?

Medicare and Tricare allow the same, or almost the same, amount for identical services because, by law, they must use the same, or almost the same, methods and databases to determine that amount.

Even when the amount allowed is the same, however, you are correct. Medicare pays 80 percent of the amount it approves or allows, whereas, for retirees, Tricare pays only 75 percent.
But Tricare’s allowance under Tricare for Life is seldom considered.

For Tricare for Life beneficiaries whose only health insurance is Medicare and Tricare Standard, and have no additional coverage from, say, a civilian job, Medicare is their primary health insurance, and Tricare Standard is secondary.

Tricare for Life beneficiaries must get all their civilian care from providers who will file a Medicare claim. On the vast majority of those claims, both Medicare and Tricare cover all the services on the initial Medicare claim. Tricare’s payment is determined by the amount Medicare pays, not by the amount Tricare allows.

When both programs cover every service on a claim, Medicare first pays 80 percent of the amount it allows on the charges after satisfaction of the Medicare deductible, if applicable, on that claim. Tricare pays the patient’s share — the Medicare deductible and copayment.

The patient owes the provider only what Medicare does not pay. When Tricare pays that amount, the Medicare claim and the provider’s bill are paid in full. The patient owes nothing more.
Therefore, on most TFL claims, Tricare’s allowable charge is not a factor.

Who pays first?

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Q. My daughter’s college infirmary says it’s written in their policy that all other insurance must pay first. That means she has to file claims with Tricare first. When she did, Tricare denied her claim and said the school has to pay first. I asked Tricare what to do. Although I’m her Tricare sponsor, they won’t talk to me because she is 19. What can we do?

By law, Tricare — and probably the school’s insurance under some other rule — must have your adult daughter’s written permission to talk with you. But it’s a good time for her to learn to handle her own insurance business, with your help.

First, within 90 days from the denial, your daughter should file a written appeal with Tricare. Instructions are on the Tricare Explanation of Benefits form, or she can call Tricare for help.
Then, she should write to the school’s insurance company about the problem of who must be first payer. Federal law says that Tricare is always last payer to all other coverage. The insurance company should know that already, or they can easily learn it by calling Tricare.

Once the school’s insurance company understands that it is first payer, she or the doctor should file a claim with that carrier. When it completes processing the claim and sends her an EOB, she should file with Tricare for the family deductible and catastrophic cap records, whether or not there is anything left to pay. Here’s how.

1. Complete a Tricare claim form, DD2642. Your daughter must sign it as the adult patient. You can download claim forms and get the claim filing address at www.tricare.mil/claims.
2. Attach a copy of the same itemized bill that was sent to the school’s insurance.
3. Attach a copy of that plan’s EOB showing its processing of those charges.

Make a habit of saving copies of all claim documents, including the appeal. If you do not, I guarantee that there will come a time when you will wish you had.

Cheating on Tricare forms isn’t worth it

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Q. You’re going to think I’m crazy, but I figure you’re probably a safe person to ask: The Tricare claim form asks if I have other health insurance, and I always report my other policy. But, if I didn’t report it, I could collect from both policies and offset some things that don’t get paid. So, please satisfy my curiosity. What are my chances of getting caught if I don’t report the other policy, and what would happen if I did?

Your question isn’t new and neither is my reply. It’s a legitimate question, and an important one. So, no, you aren’t crazy. Unless you do it, of course.

Deliberate failure to report your other health insurance on your claim form is illegal. Additionally, stating falsely that all information on the form is correct, when you know it is not, is illegal. That is not an auspicious beginning.

Your signature on the Tricare claim form affirms, “under penalty of perjury,” that the information on the form is true. If the information is untrue, it is a false sworn statement used to obtain something of value you are not legally entitled to. That being true, I don’t think the claim would be different from any other false claim against the government. It wouldn’t be special, or somehow different, because it involved Tricare. The prosecuting authority would probably call it fraud.
Some very elaborate and sophisticated insurance fraud schemes appear from time to time. And it goes without saying that you never hear about the successful ones. So, what are your chances of getting caught, and what would happen next? I don’t know your chances of getting caught. I’ve never seen any statistics on the subject. When I worked for Tricare, I wasn’t involved with the folks who investigated fraud. Minor offenses aren’t often reported in the newspapers.

Considering the millions of Tricare claims processed every year, and the fact that bad guys vastly outnumber good guys – the examiners and auditors – you would probably get away with it for a while; maybe for a long time. But once discovered, all of your claims would be audited, forever.
And, once caught, what would happen? I have to guess that it could be anything from a fine to a sudden lifestyle change. But, that would be up to a federal prosecutor and a court. If you decide to do it, and if you get caught, drop me a line from … wherever. It will be your turn to satisfy my curiosity.

Coverage during international travel

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Q. My husband and I have Tricare for Life. We plan a trip to Canada. Will Tricare for Life pay for emergency medical care we might need? Does it have a special plan for tourists? Do you know of any other plans?

Generally, only the Tricare Standard portion of Tricare for Life will cover you in Canada. I have heard that Medicare covers some limited emergency care in parts of Canada, but you’ll need to call Medicare for details. To the extent that is true, it would be a Tricare for Life benefit.

Before buying any “tourist” plans, read them carefully. If the plan does not agree to be primary payer, don’t buy it. Tricare will be unable to pay anything because of federal law requiring Tricare to always be last payer to any other insurance.

Tricare for Life is a U.S. government program, and U.S. law prevails in its operation, regardless of where the medical care is received.

If you can use Tricare only, be prepared for the likelihood that you will have to pay much of your Tricare $150 deductible when the claim is processed, along with a 25 percent Tricare cost share.

I believe the first commercial health insurance company to come up with an affordable, short-term Tricare supplement for travelers like you will make a killing.

Choosing an FEHB plan

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Q. My husband is retired from the U.S. Army and currently carries the FEHB Standard Blue Cross & Blue Shield and Tricare Standard.  The cost of the FEHB BCBS Standard has risen considerably; do you know which fee-for-service FEHB plan works best with Tricare Standard as a secondary insurance?  We were thinking about going with the BCBS Basic, which is almost half of what I am paying now for the BCBS Standard.

Regardless of what other health insurance (OHI) you have, Tricare is always second (last) payer, by law.  When Tricare Standard coordinates its benefits with their OHI, some beneficiaries have told me that it usually pays most, or sometimes all, of the OHI’s deductibles and copayments.  I have the impression, however, that much depends on the quality of the OHI.

Retirees I worked with at the CHAMPUS Headquarters (CHAMPUS was Tricare’s precursor until 1995) in the 1980s chose the cheapest FEHBP plan available because of the way Tricare coordinated benefits.

Folks working in the (now) Tricare Headquarters’ Coordination of Benefits (COB) section have told me that unless they have in hand a copy of the OHI claim, they can’t predict the amount Tricare will pay as second payer.  Coordination of benefits has become that complicated.

I have been writing Tricare Help since 1992, and I have responded to thousands of beneficiary inquiries about many things.  But, I have never heard of anybody collecting the data and doing the calculations necessary for a comparative analysis of the kind you suggest.

Not to be interpreted as advice — because I don’t know — but the BCBS Basic might be a nice conservative trial to see how well Tricare Standard serves as second payer to a less expensive plan than BCBS Standard.  If you are willing to gamble, you can always change back during Open Season the next year if it doesn’t work out well.

If you do it, you’ll have a story to tell me about it in 2011.  In turn, I will have something to report to the next person who asks the same question.

Is my wife covered by Medicare yet?

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Q. I retired from the Army in 2004, I’m now 57 and my wife just turned 60. When must my wife sign up for Medicare Part A or B?

The legal age for Medicare eligibility for most people is 65, unless they qualify for Social Security disability benefits before then. Social Security wants people to apply for Social Security and Medicare at least 90 days before the first day of the month when they will turn 65. At that time, your wife should apply for Social Security benefits, including Medicare parts A and B. To learn more, call Social Security at 1-800-772-1213.

You should also call the Defense Enrollment Eligibility Reporting Service (DEERS) Support Office at 1-800-538-9552 to ensure that you and your wife are properly registered in that database. Ask whether you and your wife are eligible for Tricare. As you are a uniformed service retiree, your wife should be eligible for Tricare Prime or Tricare Standard coverage now.

In the meantime, visit the Tricare web site and make a note of the contact information for your regional office. You can read overviews for Standard and Prime, as well. Tricare Standard is free; Tricare Prime costs $460 per year for a family of two people or more. Both plans can be used to supplement any other health insurance you have. Tricare Standard, however, is the recommended plan for people with other health insurance.  It will pay all, or most, of the deductible and copayment from your other health insurance.

Will Tricare and federal plan cancel out my copays?

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Q. I am trying to make a decision about health care and looking for some answers.  I am pregnant, and in order to see a civilian doctor I have to disenroll from Tricare Prime and enroll in Tricare Standard.  I am not happy with the military treatment facility OB care, as the doctors are never the same and each has their own opinion. I am also a federal employee and in my window to enroll for my own insurance.  The cost per month will be about $80 for myself, but there are copays and deductibles.

Will having two health insurances take care of the copays and deductibles, or will I still incur these out-of-pocket fees?

If you are enrolled in one of the plans available under the federal employees health benefits program, it will become your primary coverage.  If you are also enrolled in Tricare Standard, it will be second payer.

As second payer, Tricare Standard will probably pay most, perhaps even all, of the deductibles and copayments of the FEHBP plan.  There are no guarantees, but you should have very little, if any, out-of-pocket medical expenses.

You didn’t say, but I assume you are married and eligible for Tricare through your husband’s service.  He will have to register the baby in DEERS and enroll the baby in Prime or in Standard very soon after birth. Talk with the Tricare Adviser at your MTF about that soon, because I believe you personally will be locked out of Prime for one year.

If you are not married, and if your Tricare eligibility is a result of your father’s or your mother’s military service, your baby, as a grandchild, will not be eligible for Tricare at all.

If you do not know how to file a claim with Tricare as second payer, see my response to this previous question.

Switching Tricare from primary coverage to secondary

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Q. I recently married, and my husband is active-duty Army and will be deployed in December.  I went part-time with my job so I am not eligible for benefits right now, but I will go back to full time in January and will once again be eligible for benefits through that job.  Do I have to use that as my primary insurance, or can I keep Tricare as my primary insurance?

Federal law requires that Tricare must always be last payer to all other health insurance, medical plans such an HMO, or medical payments — such as you might receive as the result of an insurance settlement in an auto accident, slip-and-fall accident, and the like. The only exceptions under the law is if the other coverage is a bona fide, specially written Tricare supplemental policy, or if it is a welfare-related plan such as Medicaid (not Medicare).

During the time when your plan through employment is inactive, Tricare will be first payer — you will file claims with Tricare as your only coverage.  On the first day that your employer’s plan is reactivated, it must become your primary coverage.

When your other health insurance is in force and becomes first payer, you may use Tricare as your secondary coverage.  Tricare will pay much, if not all, of the OHI’s deductibles and copayments, which will greatly reduce your out-of-pocket health care costs.  And Tricare Standard, of course, is free. You can read more about filing claims with Tricare as a second payer here.

Tricare and FEHB: What are my options?

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Q. I am a retired naval officer who will be 60 in 2010.  I am also a retired federal employee who now uses the Federal Employee Health Benefits plan as primary health insurance.  I intend to continue with FEHB after age 60.  Its costs are reasonable now, about $75 per month plus medicines from an online pharmacy.

I am trying decide if signing up for Tricare for Life makes economic sense.  I am not counting on any significant payout from Social Security because of the dual compensation offset.  I am estimating about a 60% reduction there. I am not at all confident that Medicare will cover all my health costs.  Would Tricare for Life cover hospitalization as secondary to Medicare? What will TFL cost, and what will it cover after age 60?

When you ask about Tricare for Life, you are talking about five years from now, when you are old enough for Medicare — unless you qualify for Medicare disability benefits and become entitled to Medicare before you are 65.  A retiree must be entitled to Medicare and be enrolled in Parts A and B to be eligible for Tricare for Life.  It isn’t possible to predict what the program will be like in 2015 when you are 65 and become entitled to Medicare. In the meantime, you can read more about Tricare for Life online, and even download the handbook if you want to plan ahead.

You need to know about the plans you and your family will become eligible for when you are 60.  So, online, read about Tricare Standard, Tricare Extra, and Tricare Prime.  Also, become familiar with the Tricare Pharmacy Program.  All Tricare beneficiaries get the Pharmacy benefit.

While you are online, make a note of the contact information for your regional Tricare office.  Call and ask them to send you Handbooks for Tricare Standard or for Tricare Prime if you are interested in that program and if it is available in your residential area.  That is also the office to call if you need official Tricare information or help. You can also download the handbooks here: Standard, Prime.

Please note that Tricare Prime is not recommended for people who have other health insurance.  It is a useless expense, and coordination of benefits by Tricare Prime with other health insurance can be difficult.

When you are 60 years old and become entitled to receive retired pay, you, your wife, and any unmarried children under age 21 will become eligible for “ordinary” Tricare.  An unmarried child who is a full-time student at an accredited college, university, or trade school can remain eligible for Tricare until marriage, graduation, or his 23rd birthday.  Your reserve component will probably register you in DEERS, but you must apply on behalf of your family for them to be Tricare eligible.

For questions about Tricare eligibility, call the DEERS Support Office, toll-free, at 1-800-538-9552.  DEERS deals with eligibility issues only.  It cannot provide any information about the Tricare program or Tricare claims.

Tricare Standard is free.  Tricare Prime, if available, costs $230 per person per fiscal year, or $460 for an entire family of two or more people.

As you plan to retain your FEHBP plan, Tricare Standard would probably be your best choice of Tricare plans.  Tricare Standard is free, and it combines very easily with commercial health insurance such as your FEHBP plan, as second payer.  In most cases, Tricare Standard will pay the patient’s share (usually your FEHBP deductible and copayment) –  in part at least, but often completely, leaving you with little or no out-of-pocket medical care expense.

Tricare Standard or Prime will cover at least the same medical services as your FEHBP plan, and probably more.  It may not pay as much because the amounts Tricare may pay are linked by federal law to Medicare payments.  But, as you will have the FEHBP as your primary coverage, a smaller Tricare payment will not be significant, as it will be second (last ) payer and will need to pay only what the FEHBP plan did not pay.