Tricare Help

Social Security says retirement is at 66; Tricare says 65. Which is it?

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Q. According to Social Security, if you were born between 1943 and 1955, full retirement age is 66.  But doesn’t Tricare say that by time we reach age 65 we have to go to Tricare for Life and have medicare Part D?  How can this happen when we can’t get it until age 66?  Didn’t Tricare adjust the age as did Social Security?
 
Medicare and Tricare were created by, and continue to be governed by, different and unrelated federal laws.
 
Initially, one became entitled to receive monthly Social Security benefit payments and Medicare at age 65.  Several years ago, Congress changed that law.  Now, the age for entitlement to receive monthly benefit payments depends on one’s year of birth.
 
Congress did not change the age for Medicare entitlement.  A Social Security beneficiary still becomes eligible for Medicare benefits at age 65.
 
The law I refer to is the one that created and governs Social Security and Medicare.  It is not related to Tricare.  

If a person applies for Medicare in a timely manner, he or she will become entitled to Medicare on the first day of the month of his 65th birthday.  If he was born on the first day of that month, his Medicare entitlement will begin on the first day of the previous month.  That is true regardless of when he becomes eligible to receive monthly Social Security benefit payments.
 
Thus, if a Tricare beneficiary is properly enrolled in Medicare Part A and Part B, and if his DEERS registration is properly updated to show those enrollments, DEERS will report his eligibility for Tricare for Life effective on the same date as his Medicare entitlement is effective.
 
Medicare will bill the beneficiary every 90 days for his Medicare Part B monthly premium.  If he fails to pay, his Part B enrollment, and his Tricare eligibility, will be terminated until payment is made.  That can cause administrative hassles and delays to fix it and to restore his TFL eligibility.  Tricare may not pay retroactively the costs of medical care received while his Tricare eligibility is suspended.
 
When the Social Security beneficiary becomes old enough to receive monthly benefit payments, the Part B premium will be deducted as an allotment to pay his Part B monthly premium.
 
The law governing Medicare does not require enrollment in a Medicare Pharmacy Plan, known as Medicare Part D.  Neither does Tricare require Medicare Part D enrollment. 
 
In fact, Health Affairs is on public record for saying that the only Tricare beneficiaries likely to receive a financial advantage by enrolling in Medicare Part D are those whose incomes are below the federal poverty line, and who qualify to receive financial aid to pay their Medicare Part B monthly premium.  In other words, do not enroll in Medicare Part D.  You do not need it.
 
Note that the carriers of some Medicare Advantage Plans require Part D enrollment, but that is not related to any requirement by Tricare.
 
Every Tricare beneficiary is automatically eligible for, and is automatically enrolled in, the free Tricare Pharmacy Program.  It is probably one of the very best prescription drug plans in the country.  It needs no help.

I just turned 65 – why did my premiums triple?

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Q. My wife and I paid $115 per quarter for Tricare Prime. Then I got Medicare, which costs $289.40 per quarter just for me, while my Prime cost was cut in half. Our insurance premiums are now three times what they were before I turned 65. What’s going on?

Your situation is common, and so is your confusion. Hundreds of retirees and their families are similarly affected each year, and my mail clearly shows that many are unaware of what will happen when they get Medicare.

You became entitled to Medicare when you were 65. You are enrolled in “Original Medicare,” consisting of Part A, which is free, and Part B, which has a monthly premium you must pay.

Retirees and their family members who become entitled to Medicare are required by law to be enrolled in Part B at the moment their Part A coverage takes effect. If they are not, they lose Tricare eligibility until their Part B enrollment takes effect. Active-duty members nearing retirement who have a family member covered only by Medicare Part A should pay particular attention to that legal requirement.

When Congress created CHAMPUS, the forerunner of Tricare, in 1966, families of active-duty service members, retirees, their family members, survivors and a few others were eligible for limited civilian health care at government expense for the first time.

Before CHAMPUS, they were dependent on the military medical system for their health care. If they were unable to get care at a military hospital, they had to pay out of pocket for civilian care or use a commercial health insurance policy that they purchased or received through their employer.

Congress did not intend CHAMPUS to be a lifetime benefit. It was meant to be a bridge in health care support between the young age of most military retirees and Medicare entitlement at age 65. The law that created CHAMPUS, therefore, had a provision that all CHAMPUS beneficiaries lost their eligibility at age 65 if they were entitled to Medicare.

CHAMPUS was modernized and renamed Tricare in 1995, but it is still governed by the same 1966 law, as amended.

Effective Oct. 1, 2001, all Tricare beneficiaries can keep Tricare after turning 65, provided they are enrolled in both Part A and Part B of Medicare. That act by Congress created the benefit now called Tricare for Life.

This consists of full coverage by Part A and Part B of Medicare plus full coverage by Tricare Standard. Retirees or their family members cannot have Tricare for Life without being enrolled in Part B.

Before the 2001 change that created Tricare for Life, you would’ve lost Tricare eligibility, including your pharmacy benefit, when you turned 65 and got Medicare. Part A would have been free, but you would have had to pay a premium for Part B, just as you do now.
Retired Tricare for Life members are not eligible for Tricare Prime, so your coverage was changed to Tricare Standard. Your cost for Tricare Prime was reduced to $230 a year for your wife alone; her Tricare coverage was not affected by any of the changes in your situation.

Medicare has become your primary coverage. Tricare Standard has become second payer to your Medicare coverage. You must seek all your medical care from Medicare providers first. They will file a Medicare claim for their services. When Medicare pays the provider, if appropriate, it will forward the claim to Tricare for consideration of all amounts not paid by Medicare.

When both Medicare and Tricare cover a medical service, Tricare Standard acts as a free Medicare supplement and pays the balance on the Medicare claim. The combined payments by Medicare and Tricare pay the Medicare provider’s bill in full. As a Tricare for Life member, you will seldom have any out-of-pocket medical care expenses, except your cost shares under the Tricare Pharmacy Program.

Using Tricare and Medicare after eye surgery

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Q. I have Tricare for Life and I need surgery for cataracts. I know Medicare and Tricare will pay for the surgery, but what about my new glasses? Medicare will pay part of their cost, but will Tricare pay a share, too? My wife also needs new glasses — how much will Tricare pay for her glasses if she is too young for Medicare?

Medicare will help pay for one pair of glasses after cataract surgery and the implantation of an approved artificial lens. Tricare will most likely pay your Medicare deductible, if applicable on the claim, and your Medicare co-payment, as it usually does for other covered services.

It isn’t necessary for your wife to be eligible for Medicare to use the limited Tricare coverage for eyeglasses and contact lenses. Tricare would help pay for one pair of glasses or lenses if she had an intraocular lens replacement, as in your case. Apart from that, Tricare may not pay for glasses or contact lenses except in the case of certain specific, and uncommon, eye conditions. Common refractive errors, such as near- or farsightedness, are not among those conditions.

Can I get coverage for pregnant granddaughter?

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Q. Does Tricare cover expenses of pregnancy and childbirth for a dependent child? My wife and I are legal guardians of our granddaughter, who just turned eighteen, attends high school and is two months pregnant. Health insurance through my civilian employer has covered my granddaughter’s childhood health expenses, but pregnancy expenses, other than my wife’s, are excluded in the policy. The ID card facility informs me that my documentation is sufficient to enroll her in DEERS, but I hesitate to go through the bother if Tricare has similar exclusions. 
 
Tricare eligibility is established by federal law for designated categories of persons.  Tricare has no authority to make eligibility determinations.  By law, only the services may determine whether a particular individual meets the legal criteria for Tricare eligibility, to register an eligible person in DEERS, and to issue an appropriate uniformed service identification card.
 
If you believe your granddaughter might be eligible for Tricare, it is not difficult to enroll her in the program. 
 
Tricare has no limitations or exclusions for pre-existing conditions, and the entire maternity episode is covered from prenatal care through postnatal care.
 
Please note that your grandaughter’s baby probably will not be covered.  You will want to discuss that with DEERS  and any other health insurance.
 
Tricare Standard is the recommended plan for beneficiaries having other health insurance (OHI).  Standard is free, and it will act as a supplement to the OHI, usually paying the things – such as the patient’s deductible and copayments – that the OHI does not pay.
 
By federal law, Tricare is required to always be last payer to all other health insurance.  That is, beneficiaries with OHI must use that plan’s benefits first — file claims with the OHI first.  When the OHI has paid its maximum, the beneficiary may file a Tricare claim for any unpaid balance.  
 
The first thing to do is to determine whether your granddaughter is eligible for Tricare.  Grandchildren are not usually eligible, but there are exceptions depending on the circumstances.
 
To begin the process, please call the DEERS Support Office, toll-free, at 1-800-538-9552.  DEERS is a federal agency under the auspices of the Office of the Assistant Secretary of Defense for Health Affairs.  All matters discussed with DEERS are confidential and protected by the Privacy Act.
 
DEERS is the official source for all information relating to Tricare eligibility including information, advice, and assistance with establishing program eligibility.
 
I suggest you talk with DEERS also about your entire family’s Tricare eligibility.  All eligible family members must be properly registered in DEERS and be issued uniformed service identification cards in order to use the program.  DEERS will explain the entire process to you and provide step-by-step guidance as needed at no cost.  It can all be done by mail.
 
Go to the official Tricare website  to review benefit information for Tricare Standard, Tricare Extra, and Tricare Prime.  If you or your wife are nearing age 65 and Medicare entitlement, see also the plan called Tricare for Life.  Make a permanent record, too, of contact information for your Regional Tricare Service Center.
 
For Medicare-eligible beneficiaries who are enrolled in both Medicare Part A and Part B, Tricare Standard will act as a free Medicare supplement, usually paying whatever Medicare does not pay.  That will pay the balance on the Medicare claim and the provider’s bill in full. 
 
It will also pay 75 percent of the amount it allows for Tricare-covered services that are not covered by Medicare (after satisfaction of the $150 fiscal year Tricare deductible).
 
Prime is not available in all areas, and your Regional Service Center can tell you whether it is available for persons living in your ZIP code.  Tricare Extra is a special benefit category automatically associated with Tricare Standard and does not require special enrollment by persons enrolled in Tricare Standard.
 
You can also find information online about other Tricare benefits such as the Tricare Pharmacy Program, mental health care, and dental coverage.

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.

Does getting VA care negate Tricare eligibility?

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Q. If a military retiree of over 20 years’ service is enrolled/treated at a VA hospital, does that make him/her and spouse ineligible for Tricare for Life?  Also, has there been a change in the new medical bill signed by President Obama? 

Tricare and VA benefits are unrelated programs governed by totally different federal laws.  If a person is otherwise eligible for Tricare, using VA benefits will not negate his Tricare eligibility except that he may not file Tricare claims for any costs incurred by getting care with the VA. 
 
The only exception to that rule is in the case of the very few VA Medical Centers that have special status as Tricare-authorized providers.  Your VA center administration can advise you if your center is one of them.
 
Until DoD legal experts have properly evaluated the new health care law, it is not possible to say what, if any, effects there will be for Tricare.  Any changes to Tricare will be widely publicized far in advance of their effective date.  None are expected except the possibility of extending the upper age limits of Tricare eligibility of certain children in certain circumstances.

What happens to my pharmacy benefit when I get TFL?

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Q. I will get Medicare and Tricare for Life on July 1. It’s bad enough that we’ll have to start paying a lot more for our health insurance, but the loss of Tricare Prime and its pharmacy benefit when we get transferred to Medicare seems unfair. Is there any way my wife, at least, can keep her Tricare Prime insurance and its pharmacy plan?

Only you, not your wife, will get Medicare when you are 65. Only you will be affected by the loss of Tricare Prime eligibility at that time.

Your Tricare Prime coverage will be changed to Tricare Standard when you get Medicare and become eligible for Tricare for Life. Your wife’s Tricare Prime coverage, however, can continue unchanged until she gets Medicare, probably not until she is 65.

You seem confused also about requirements concerning Medicare Part D, the drug-insurance plan. Neither Medicare nor Tricare require enrollment in Medicare Part D. The Pentagon’s Office of Health Affairs does not recommend Part D for most Tricare for Life beneficiaries because most will not gain any financial advantage from that plan unless their income is below the federal poverty line and they qualify for financial aid to pay their Medicare Part B monthly premiums.

But even if you did enroll in Part D, it would affect only you. Your wife could not be affected because she will not be entitled to Medicare.

Your and your wife’s coverage under the Tricare Pharmacy Program will continue unchanged: yours because you will be enrolled in Tricare Standard, and your wife’s because she will continue to be enrolled in Tricare Prime. All Tricare beneficiaries are eligible.

Mixed messages on Medicare rules

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Q. I got Tricare when I turned 60, and now I’m signing up for Medicare and Tricare for Life. Medicare told me that because I’m still working and have health insurance from my job, I don’t have to sign up for Part B until I retire. Then, the Navy told me that is true, but that I cannot get Tricare for Life until I sign up for Part B. The only coverage I will have will be my employer’s plan and Medicare Part A.

I’m confused by the mixed messages. Who is right, Medicare or the Navy?

You’re going to love this: Both are right. You’re dealing with two different laws concerning Part B enrollment — and you must choose between them.

The Medicare law says that if beneficiaries have a creditable health insurance policy through employment, they can delay enrolling in Part B without penalty for as long as they work for the employer who sponsors the insurance.

A creditable health insurance policy is one whose benefits Medicare agrees are at least as good as what Medicare provides.

Some people choose that way if they feel their employer’s plan meets their needs, because they can avoid having to pay Part B’s monthly premium. But they must understand that when a retiree, or a retiree family member, gets Medicare, Tricare law requires immediate Part B enrollment in order to retain Tricare eligibility.

Without Tricare eligibility, they can’t have Tricare for Life. They have only Part A and their employer’s insurance plan, as you were told.

To be eligible for Tricare for Life, Medicare beneficiaries must be enrolled in Medicare Part B. That way, they will have their employer’s plan as their primary coverage, Medicare Parts A and B as secondary and Tricare, which is always last, as required by law.

Only you can decide what is best for you.

If you’re married, your loss of Tricare eligibility (if you decide not to enroll in Part B yet) will not affect your spouse’s Tricare eligibility in any way.

Medicare should advise the Defense Enrollment Eligibility Reporting System automatically as soon as you are enrolled in Part B. Sometimes that doesn’t happen, though, and you must do it yourself. Your DEERS record must show Part B enrollment for you to use Tricare for Life. Contact DEERS toll-free at (800) 538-9552 for information and instructions.

What about the expiration date on my ID card?

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Q. In answering questions about proof of insurance, you have said to look on the back of the retired ID card about eligibility for civilian medical care and look for the word “yes”.  However, one of the next entries is an expiration date that seems to coincide with the day before you turn 65.  What do we tell doctors’ offices about the expiration date?

Tricare has no authority or responsibility in matters pertaining to the issue or correction of military identification cards.  Only the services have that authority.  Timely renewing of your ID card and keeping your DEERS record current in a timely manner, however, is your responsibility.
 
With regard to using Tricare, the only proof of insurance your provider needs is your currently valid military ID card.
 
If your ID card reports that you are eligible on the date you receive the medical care, your doctor need have no concerns about eligibility.  

 Now, let’s talk about why the card-issuing office chose that date for your card to expire.  It has to do with your Medicare eligibility and its effect on your Tricare eligibility.
 
If they apply in a timely manner, the vast majority of Americans become entitled to Medicare on the first day of the month of their 65th birthday.  If the person was born on the first day of the month, their Medicare entitlement becomes effective on the first day of the previous month.
 
When your ID card was issued, the issuing office assumed you will become eligible for Medicare on the first day of the month of your 65th birthday. 
 
I haven’t read service regulations concerning the matter, but I believe it is SOP.  Every ID card I’ve seen follows that procedure.  That is, ID cards show Tricare eligibility ending on the last day of the month preceding the first day of the month of the bearer’s 65th birthday.
 
With three exceptions, any Tricare beneficiary who becomes entitled to Medicare Part A, at any age or for any reason, is required by federal law, to be enrolled in Medicare Part B on the date his Medicare Part A becomes effective. 
 
The three exceptions are: (1) an active duty family member; (2) a person enrolled in the US Family Health Plan; or, (3) an active duty uniformed service member.  The legal requirement for Part B enrollment does not apply to them.  (Active duty members’ Tricare Prime enrollment [#3, above] is a special category which is exempt from everything discussed here.)
 
Medicare has a different law about when you must enroll in Part B.  But you must obey the Tricare law, reported above, about Part B enrollment.
 
Every month, DEERS runs through the list of Tricare beneficiaries who are going to be 65 in the next month.  Each of them must have in his DEERS record one of two reports:  (1) an official report from Medicare that the person is not eligible for Medicare; or, (2) a report from Medicare that the person is enrolled in Medicare Part B.  If a beneficiary does not, DEERS automatically terminates his Tricare eligibility.  That is required by federal law.
 
Medicare is supposed to notify DEERS automatically when the Tricare beneficiary is enrolled in Part B.  If, for any reason, the beneficiary’s DEERS record does not report your Medicare Part B is in effect as required by law, or if it doesn’t report that you are not eligible for Medicare, DEERS must automatically terminate your Tricare eligibility. 
 
To restore or preserve Tricare eligibility, the beneficiary is responsible for any action needed to correct his DEERS record to report that he has Medicare Part B in effect.  A person who loses Tricare eligibility because his DEERS record does not report Part B enrollment should ask DEERS for help about how to fix it.  Mostly it will involve enrolling in Part B and telling Social Security that you have an emergency and need to have Part B go into effect immediately.
 
Automatic weapons can fail.  So can Medicare’s action to notify DEERS of the beneficiary’s Part B enrollment.  I recommend calling DEERS, toll-free, at 1-800-538-9552, a week or so before the effective date of your Medicare coverage to ensure your DEERS record has been updated automatically and that it reports that you are enrolled in Part B.  The DEERS update also should report Tricare for Life eligibility.  If any of it was not done, ask DEERS how to fix it.

How TFL works outside the U.S.

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Q. If I decide to live outside of the United States (i.e. Philippines) upon retirement at age 65,  I understand that I will still need to pay the Medicare Part B to be covered under Tricare For Life.  Then, when I visit the medical facility over there, my claims would be processed just like I had Tricare Standard (since Medicare does not cover claims outside the U.S.) with the deductible having to be met and the co-pay also. Is that correct?  

 You are correct, unfortunately.  The only time you will have full TFL coverage (Medicare plus Tricare) is when you visit the U.S. or a U.S. possession.
 
People have tried for many years without success to get Congress to change the law.  I hear that the proposal never even makes it out of committee.