Tricare Help

If spouse gets surgery just after divorce is finalized, will I have to pay for it?

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I am finalizing a divorce and just waiting for the judge to sign off on the final decree. My ex-wife has a surgery scheduled – already approved by Tricare – that may fall after the divorce has been finalized. Will Tricare still cover this surgery even if it falls after the official date we are divorced, and if it is not covered, can I be charged for the operation?

If you have at least 20 years of active duty, have been married for at least 20 years, and the marriage and your service overlapped by at least 20 years, your spouse can remain eligible for Tricare after the divorce indefinitely, as long as she does not remarry. If you don’t meet the requirements of this “20/20/20″ rule, your spouse will lose her Tricare coverage on the day your divorce becomes final. Tricare has approved the operation based on the fact that your spouse is your legal dependent, or was at that time. If the operation occurs after the divorce becomes final, you almost certainly would be charged for it once Tricare denies the claim for payment.

Will I get billed for civilian surgery?

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I am retired Army and have Tricare Prime as only insurance. The local military treatment facility does not do hip replacement surgery. They referred me to a civilian surgeon about 40 miles away. How much of the surgery costs will Tricare cover? And what if I get a bill — do I send it somewhere, or wait for an EOB?

Tricare generally covers any surgery that is medically necessary, even if performed by civilian physicians in civilian facilities — on one condition: that the physician is, or is willing to become, a Tricare-authorized provider. In cases like yours, Tricare may provide coverage only if you use a civilian physician who is authorized by Tricare to attend its beneficiaries. Since your military hospital made this referral, I would hope they know this and referred you to a physician who is, in fact, a Tricare-authorized health care provider.

I can’t tell you with certainty what charges, if any, may not be covered by Tricare. But you should not directly receive a bill; in the vasy majority of cases, Tricare-authorized providers will file the medical claims with Tricare, and you will subsequently receive an Explanation of Benefits detailing what was paid. At that point, if anything was left unpaid that you believe should have been covered, you need to contact the managed-care contractor for your region.

Tricare has a clearly defined process for appealing unpaid charges. I would also suggest circling back to your military hospital and revisiting with the patient administration office, and/or the physician/official who referred you to the hospital, to discuss the matter. Again, the most important consideration is whether the facility you were referred to and the physician who performed the surgery are Tricare-authorized.

Is travel covered for out-of-state surgery?

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My daughter has a complicated medical condition, and her local doctors are not willing to do a medically necessary surgery. They want her to travel to another state to have the procedure done. She will have to arrive three days prior to surgery for tests and procedures. She will be hospitalized for one month after the surgery. Will Tricare Prime cover the surgery? Will it also cover our trip there and a hotel for us to stay at?

Tricare generally covers all medically necessary procedures, even in referral situations like yours. For family members like your daughter, Tricare Prime will reimburse “reasonable travel expenses” for non-emergency specialty care, but this benefit is limited to specialty referrals when no other specialist (i.e., military treatment facility, network or non-network specialists) is available within 100 miles (one way) of the primary care manager’s office.

Reasonable travel expenses include actual costs incurred while traveling, such as meals, gas, tolls, parking and tickets for public transportation.

You will need to save all receipts to be reimbursed.

In some cases, a non-medical attendant (NMA) may also be authorized for travel reimbursement. The NMA can be a parent, spouse, another family member age 21 years or older, or a legal guardian. The referring health care provider must verify in writing that an NMA is medically necessary and appropriate to travel with the patient. When approved, the NMA is authorized reimbursement of actual travel expenses, unless the NMA is an active-duty service member; in that case, a TDY per diem is paid rather than reimbursement of actual expenses.

In addition to travel costs, lodging costs also may be reimbursed up to the government per diem rate for the location where the care is provided. This includes overnight stays both before and after an outpatient visit, procedure or an admission when the need is appropriately documented by a medical authority. Itemized lodging receipts are required. Reimbursement of lodging costs for approved non-medical attendants are also authorized, but there may be limits in the length of time you may be reimbursed for. In other words, if you intend to stay in a hotel near your daughter for the entire month of her recovery, you may not be able to get reimbursed for your entire month’s expenses.

To get specific information on what you need to do to prepare and arrange for your daughter’s out-of-state care, you should talk to her Tricare Prime primary care manager or contact the managed-care contractor for the Tricare region in which you live.

Will Tricare cover treatment for mesothelioma?

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After a 30-year Navy career, I have been diagnosed with mesothelioma. I will require surgery and follow up at a distant hospital. We will have to pay for lodging for my surgical recovery and subsequent radiation. Will Tricare Standard cover any of this, or am I on my own?

Tricare generally covers all medically necessary procedures for qualified beneficiaries, including those related to treatment for mesothelioma.
You should be aware that mesothelioma is a condition that may entitle individuals to premium-free Medicare Part A even if they are under age 65, the normal Medicare eligibility age. If you are eligible for Medicare because of your mesothelioma, you can enroll in Medicare Part B and qualify for Tricare for Life, even if you are under age 65.

In addition, assuming you can provide documentation that your condition is a result of your military service, another option for you would be Veterans Affairs Department health care.

Your first move should be to contact the managed-health care contractor for the Tricare region where you live. They can give you more information and guidance.

If surgery is covered, why did the hospital send a bill?

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My father is retired Air Force and just recently had retinal re-attachment surgery. He has Medicare as well as Tricare for Life, so I don’t understand why he received a bill from the hospital for over $300. Does Tricare not cover the surgery?

Ordinarily there should be no unpaid balance under Tricare for Life; the combination of payments by Medicare (primary coverage) plus those by Tricare should have paid the Medicare claim and all providers’ bills in full.

The balance most likely results from an error in the way the Medicare claim was filed or processed.
Your father will need to research the matter by comparing the itemized bills for the balance with the explanations of benefits from Medicare and Tricare. He can find contact information for help on the Tricare website.

How can I make sure my surgery is covered?

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I’m married to an active-duty airman. I have an ovarian cyst that must be removed ASAP. Does Tricare cover this kind of surgery?

Tricare does cover medically necessary care, including surgery, for your condition. If you live near a military hospital, make an appointment to be seen by military physicians. If you do not live near a military facility, you must find a civilian physician who is, or who is willing to become, a Tricare-authorized provider, to provide the care you need.

Tricare may provide coverage only if you use a military hospital, or a civilian physician who is authorized by Tricare to attend its beneficiaries.

Getting a divorce and just got huge surgery bill – aren’t I still covered?

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I’m a Navy wife going through a divorce and I recently had to get my appendix taken out. I thought I was still covered until the divorce was final, but I just got an $11,000 bill for the surgery. When I reached my husband, he said he took me off his Tricare. Can he do that? And what can I do about this bill?

Your husband does not have the legal authority to cancel your Tricare eligibility. Tricare benefits flow directly to the beneficiary; the military sponsor has no control over it. You will be eligible for Tricare until midnight of the day your divorce is final.

Also, Tricare will not allow him any access to information about your Tricare claims or medical care. You are protected by the Privacy Act.

The provider of your medical care should file a Tricare claim for his bill. If he will not do that, you should do it yourself. You can find detailed instructions at www.tricare.mil/claims. Remember that the only thing that matters is that you were covered at the time the service was rendered; after your divorce is final, you still have a year from the date the service was rendered to file claims.

If doctor orders it, must Tricare cover it?

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My doctor says I need laser surgery on my eyes, but he does not do that kind of procedure and recommends a different doctor. Mine is a Tricare doctor, so, if he orders it, will it be covered by Tricare?

Several factors must be considered:

    • First, is the surgical procedure itself covered by Tricare? For example, the laser procedure to improve visual acuity called Lasik is not covered by Tricare. Conversely, there are other laser-involved procedures, such as some to treat retinal detachment, that may be covered.
    • Second, in order to be covered, a medical or surgical service must be medically necessary and appropriate for the particular patient’s diagnosis, symptoms, or history. Before payment, Tricare would need to ascertain those facts in your particular case. A Tricare-authorized physician recommending or ordering a particular medical or surgical service does not, of itself, make the service medically necessary, appropriate, or covered by Tricare. Your Tricare doctor might recommend something that Tricare is not allowed to cover in your particular case.
    • Third, although the referring physician may be Tricare-authorized, his referral does not make the specialist a Tricare-authorized provider. Tricare may not pay for the services of any provider who is not registered with Tricare as an authorized provider — regardless of any recommendations or referrals.

I suggest that you contact your Regional Tricare Office for more, and official, information.

Will Standard cover my cataract surgery?

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I am supposed to have cataract surgery in May. My husband is my Tricare sponsor. I am 62 and not eligible for Medicare yet, but I have a supplemental policy. Will Tricare Standard pay for my surgery?

When medically necessary and appropriate for the particular Tricare beneficiary, the costs of surgery to remove and replace the eye’s natural lens is covered by Tricare, as is one pair of spectacles following the surgery if medically necessary in the particular case.

The fact that the procedure is an authorized benefit does not guarantee Tricare’s payment in a given case. That can be determined only after the service is performed and Tricare claims are filed.

Note that Tricare may cover the procedure only when performed by a Tricare-authorized provider. An authorized provider is one that is registered with Tricare and is approved to be paid by Tricare for covered medical services provided to Tricare beneficiaries. Tricare may not pay for any health-related services received from an unauthorized provider.

Is plastic surgery after weight loss covered?

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I am full time Guard on Title 10 orders. While I was gone, my wife lost 135 pounds. I am very proud of her and this accomplishment. The problem is, because of all this weight she has lost, she a lot of excess skin, and this makes her very self-conscious. She would like to have plastic surgery to remove this if this possible. Does Tricare offer any coverage for this?

I understand your wife’s problem.  The remedy she seeks, unfortunately, is cosmetic surgery performed for psychological reasons, in order to improve her appearance.
 
By federal regulation, it is not covered by Tricare.
 
For an official response about this matter, please write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.  For Privacy Act purposes, as the adult patient, your wife must sign the inquiry.