Tricare Help

Is Tricare a prompt payer?

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Q. I just turned 65 and subscribed to Medicare and Tricare for Life. I understand that Tricare Standard is second payer to Medicare, and that the same bills have to be sent to Tricare, along with a copy of Medicare’s explanation of benefits showing how it processed those charges.

My problem is with the timeliness of the Tricare for Life payments.  I learned that Medicare issues its EOBs only every 90 days. I’m not sure my doctors will be willing to wait for payment if it takes 90 days just for me to get the Medicare EOB before I can even file a claim with Tricare for it to pay the balance on the bill. Is there any way I can get around the 90-day delay?

You will have few concerns about the timeliness of payments to your Medicare providers under Tricare for Life.

You won’t have to wait 90 days for Medicare’s EOB before you can submit a claim to Tricare. In fact, you won’t have to submit claims to Tricare; Medicare will do it for you. The claim is forwarded to Tricare with the push of a button, electronically, as soon as Medicare finishes processing the claim.

By the way, Medicare calls its EOB a summary notice. It’s just a different name for the same document.
In most cases, Tricare pays its share to the Medicare provider quickly. Some providers report that they’ve received Tricare’s check for the balance due on the claim before they received Medicare’s payment of the principal amount.

There is something else you didn’t mention, which might not have occurred to you: Tricare for Life beneficiaries must seek all their care from Medicare providers.

A doctor or other provider who sees Medicare patients files Medicare claims often — one for every Medicare patient he sees. The provider knows how long it takes Medicare to process most claims. And Medicare sends its payments directly to the provider as soon as processing is done. It doesn’t have to wait for Tricare’s payment to “catch up” with it first. In most cases, the provider quickly receives from Medicare up to 80 percent of what is due for the services he provided.

What the provider is waiting for is the amount of the patient’s share of the claim — the amount Tricare will pay. Usually, this is the Medicare deductible, if applicable, and the patient’s 20 percent co-payment.
Medicare providers who see Tricare for Life beneficiaries know from experience how quickly Tricare Standard pays its share of the claim, and most have no complaints.

Can I just stick with VA care?

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Q. I retired from the Army with 50 percent disability and the VA handles all of my medical care and medication at no cost.  Do I even need to enroll in Tricare?  Do I need to apply for Medicare at age 65 or can I simply stay with the VA system?  

 Your VA disability rating is totally unrelated to your Tricare eligibility.  The VA and Tricare are unrelated programs.  The VA may file claims with Tricare only for services that you receive from one of the few VA medical centers that is registered with Tricare as an authorized provider.
 
I believe that you became eligible for Tricare automatically if you became entitled to retired, retainer, or equivalent pay when you retired from the Army.  You can confirm your Tricare eligibility by calling the DEERS Support Office, toll-free, at 1-800-538-9552. 
 
If you have a family, your wife and unmarried children under 21, or under age 23 if the child is a full-time college or accredited trade school student, also became eligible at the same time.  You must enroll them in Tricare for them to use the program.
 
Medicare and Tricare also are unrelated programs that were created by, and are governed by, different federal laws.  You must call the Social Security Administration for information concerning your Medicare eligibility at age 65.  All questions concerning Medicare should be directed to Social Security or Medicare.  Medicare cannot officially answer any questions concerning Tricare.
 
If you become legally entitled to Medicare Part A without cost at any age or for any reason, the federal law that governs Tricare requires you to enroll immediately in Medicare Part B.  Failure to be enrolled in Medicare Part B when your Part A entitlement becomes effective will result in the immediate loss of your Tricare eligibility including your free Tricare Pharmacy Program and your becoming ineligible for the Tricare plan called Tricare for Life, or TFL.  Your Tricare eligibility cannot be restored until and unless you are enrolled in Medicare Part B.  For official confirmation of this rule, please contact the DEERS Support Office, above.
 
You may be inadequately informed about your health care guarantees under the VA system.  As I understand the law, a 50 percent disability rating guarantees you free medical care only for your service-connected conditions.  Your other health care needs could be denied or require payment on your part.  There is no guarantee that you can continue under the VA system for your other medical care.  I strongly recommend that you contact the VA to discuss these things with that office.
 
You should also contact the Social Security Administration to discuss the consequences of failure to enroll in Medicare at least 90 days before the month when you will be 65 years old.
 
Important note:  Social Security and/or Medicare will provide information under Medicare law about when you must enroll in Medicare Part B.  They will provide information that, while true, does not take into account the special circumstances of Tricare beneficiaries. 
 
The law that governs Tricare has a different requirement concerning when you must enroll in Part B.  You must conform to requirements of the Tricare law or lose your Tricare eligibility when you become legally entitled to Medicare Part A.  That is, Tricare law requires that all Tricare beneficiaries (except active duty family members and USFHP members) must enroll in Medicare Part B at that time.  For most people, that will be on the first day of the month of their 65th birthday.
 
When you become entitled to Medicare and are enrolled in Medicare Part B, you will become eligible for Tricare for Life, or TFL.  Medicare will become your primary health insurance and Tricare Standard will act as a free Medicare supplement for the rest of your life.  The vast majority of your Medicare claims and medical bills will be paid in full by their combined payments (Medicare plus Tricare Standard) under TFL.  Your only premium costs for TFL will be the monthly premium for Medicare Part B.
 
I believe you have no such guarantees under the VA system if you do not have a 100 percent, permanent and total, service-connected disability.  Most likely it will also be necessary for you to live within a reasonable commuting distance from a functioning VA medical center.  You can use Tricare and Tricare for Life nationwide.  Without your having a 100 percent disability, the VA will not provide medical services for your family members. Tricare will.  Check these things with the VA.

What happens when I change providers?

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Q. When I change providers, do I need to contact Tricare? 
 
If you are enrolled in Tricare Standard, you may use any Tricare-authorized provider without notifying Tricare.  If you use an unauthorized provider, however, Tricare must deny your claim and pay nothing.  That is a requirement of federal law.
 
If you are enrolled in Tricare Prime, you may use Tricare Prime providers only.  In that case, I recommend that you contact your Tricare Prime contractor for guidance prior to making any changes in providers.
 
If you are enrolled in Tricare for Life, you must seek all your civilian care from Medicare providers only.  It is not necessary to notify Tricare if you change providers.

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.

Can disabled adult daughter get TFL?

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Q. I am retired from the Air Force and would like to get my 37-year-old daughter on Tricare for Life.  She was diagnosed with fibromialgia about 10 years ago and had to go on full disability two years ago.  She had to sell her home and move in with us.  She has never been married and Social Security disability is her only source of income.  She has Medicare parts A, B and D and a supplemental policy.  I want to get her on TFL so I won’t have to pay for Part D and the supplemental policy.  How can I do this? 
 
I’m sorry to learn of your daughter’s disability, but it’s good to know, at least, that she qualifies for Social Security disability benefits and Medicare.
 
Unless her disability was discovered before she was 21 years old, I doubt that your daughter will be found to be eligible for Tricare.  For official information about Tricare eligibility, you should contact the DEERS Support Office, toll-free, at 1-800-538-9552. Though she will likely not be found eligible, DEERS will discuss with you what federal law may allow in her case.  If it is possible that she is eligible for Tricare, DEERS will provide instructions and any help needed to enroll her in the program.

Tricare eligibility is established by federal law and regulation.  Tricare, however, does not have the authority to make individual eligibility determinations.  Only the uniformed services have the authority to determine whether a particular person meets the legal criteria for Tricare eligibility, to register an eligible person in DEERS, and to issue a uniformed service identification card which can be used as proof of Tricare eligibility.

If she has not done so already, it might be of benefit for her to contact your state’s Social Services office to learn whether there may be additional benefits available, including Medicaid.

Covered by Standard and federal plan – what happens when I turn 65?

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Q. This September I will be 65 years old and eligible for Medicare. I am retired from the Navy, and have Tricare Standard for myself and my family. I am also retired from federal service, and I am enrolled in the Government-wide Service Benefit Plan (BlueCross BlueShield) for government retirees. This is my primary health insurance. My wife will not be eligible for Medicare for another seven years.

What should I do about my health insurance needs when I turn 65 and go on Medicare? I know I will have Tricare for Life, and I realize I need to get Part B of Medicare. Am I correct to assume that my wife and child (20 years old) will still be eligible for Tricare Standard, and I will have TLF and Medicare? What should I do about my government retiree plan?
 
In your case, unfortunately, your transition from “ordinary” Tricare to TFL will be expensive for you.  Here’s why.
 
Your transition to TFL will have no effect of any kind on your family’s eligibility for “ordinary” Tricare Standard.  And, they will continue to need other health insurance – the federal employees plan (FEP) — in addition to Tricare, just as they do now.  Your family’s coverage will not change in any way.
 
Your FEP premium is at the family rate — two or more family members.  That will not change, because you will still have the FEP plan.
 
You cannot leave the FEP plan.  You, the former employee and sponsor, must also be enrolled in the FEP in order for your family to have FEP coverage.  You will have to pay the FEP monthly premium at the family rate just as you do today for two or more family members.  

Now about your TFL.  You know that federal law requires you to be enrolled in Medicare Part B when your free Medicare Part A becomes effective.  That means you will have to pay a monthly premium for Medicare Part B in addition to the FEP premium. 
 
Your own personal costs for health insurance will increase by the amount of the Part B premium.  Your first payment will be due on August 1.  You will pay for Part B one month in advance.  For the remainder of this fiscal year, which ends on September 30, it’s around $100.  You can arrange for the premium to be taken from your OPM pension.
 
For your family, the FEP will be primary and Tricare will act as a free supplement (second payer) for it, just like today.  Nothing will change for them.
 
For you, Medicare will become primary on Sept. 1, the FEP will be secondary, and Tricare, by law, is always last. Your Medicare coverage, Part A and Part B, will be effective on Sept. 1.  You will get a Medicare ID card in August that shows Sept. 1 as the date for your Part A and Part B to become effective. 
 
Social Security wants people to apply for benefits at least 90 days prior to the effective date of their coverage. You must apply for Part B at that time according to the law that governs Tricare.  That is a different law from the one that governs Medicare.
 
As of Sept. 1, you must seek all your civilian medical services from Medicare providers.  That is, providers that will file Medicare claims for their services.  Do not use any provider who cannot, or will not, file Medicare claims for your bills.  If you do, Medicare will deny payment on the claim.
 
When the provider asks about your secondary insurance or Medicare supplement, tell them it is your FEP plan.  Show them your FEP ID card.  After Medicare pays a claim, it will automatically forward the claim to the FEP as second payer.
 
FEP will be primary and Tricare will be your second payer for all medical care you receive until midnight on Aug. 31.  

When Medicare and the FEP are both done with a claim, and both have sent you EOBs, it’s time to file a Tricare claim, even if there is nothing left to pay.  You should always file a Tricare claim as third payer in order to get family credit on your Tricare Catastrophic Cap
 
Call your Tricare Service Center for help with filing the Tricare claim the first two or three times until you learn how to do it yourself.  Your FEB will not forward the claim to Tricare.  You must file it.

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.

How Tricare for Life covers nursing home care

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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.

Shop carefully when you need supplemental insurance

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Q. I am retiring next month at age 62 and will be on my employer’s insurance until I am 65.  But my 19-year-old son will be off of my employer’s insurance in September.  He will be a full-time student and Tricare will be his main insurance.  If Tricare pays 75 percent to 80 percent, where can I get  supplement insurance for him for the other 20 percent?  Our sponsor will be on Medicare with Tricare for Life.
 
Most of the officer and enlisted retiree associations sell a specially written Tricare supplement.  A genuine Tricare supplement is a specially written plan designed especially to be a Tricare supplement and to be last payer after Tricare pays its maximum.  It must say in the fine print that it is a Tricare supplement.
 
Contact several vendors and ask for a copy of their policy.  Study each policy carefully to make sure you understand it. 
 
What you get for your money is spelled out in the fine print of the policy itself.  Ignore the ads and sales pitches.  They are not the insurance policy, and can sometimes give a wrong impression about how good the policy is. 
 
Read the fine print to learn whether the policy has a deductible, how it covers pre-existing conditions, things it does not cover, or for which it has limits and/or restrictions on coverage.  See how many days you have to be in the hospital before the policy begins to pay.  Read about coverage for drug and alcohol abuse.  Make sure it pays your Tricare deductible and cost shares from day one for any illness or accident.  See if it will pay what Tricare does not pay if the doctor does not participate in Tricare on the claims.  A doctor who participates agrees to accept the amount Tricare allows as his full payment.  If a provider does not participate in Tricare, you will have to pay up to 15 percent over what Tricare allows in addition to your 25 percent cost share.  Will the supplement pay that 15 percent surcharge?
 
Buy only a policy whose fine print description best meets your needs.  Don’t shop for price alone.  You usually get what you pay for.

Using Tricare for Life with FEHBP

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Q. I’m federal employee with government health insurance plus Tricare Standard. I’ll soon turn 65 and get Medicare, but I must keep my FEHB plan because my wife is only 57. In what order must I file claims? Do I file first with Tricare for Life and then with my FEHB plan? Also, Medicare says I do not have to enroll in Part B for as long as I continue to work. Tricare told me I must enroll in Part B as soon as I become eligible for Medicare. Who is right?

As far as the order of filing claims, remember one simple rule: By law, Tricare is always last payer to all other health insurance.

Your only issue, then, is whether to file first with Medicare or with your FEHB plan. Medicare’s rules say that depends on whether you continue to work for the employer who sponsors the other plan. So, for as long as you work for that employer, the FEHB plan is primary, Medicare is second, and Tricare is last. When you retire, Medicare becomes primary, the FEHB plan second, and Tricare last, as always.
As for enrolling Medicare Part B, because you are a Tricare beneficiary who is retired from the military, the rule under Tricare law takes precedence over the Medicare rule.

Tricare law requires any retiree, retiree family member, or survivor who becomes entitled to Medicare to be enrolled in Part B on the effective date of Medicare coverage. Failure to do that causes the immediate loss of all your Tricare eligibility. Note that this would have no effect on your wife’s Tricare eligibility.

Just remember to apply for Medicare Part A and Part B at least 90 days before the month of your 65th birthday.