Tricare Management Activity Fact Sheet
 

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From: Waspscpo@aol.com [mailto:Waspscpo@aol.com]
Sent: Sunday, July 03, 2005 6:17 AM
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Subject: Tricare Management Activity Fact Sheet

 



 Updated July 1, 2005 
TRICARE For LifeTRICARE and Medicare Part A and B 

When TRICARE beneficiaries become entitled to Medicare Part A and B on the basis of age, disability or end-stage renal disease they are eligible for TRICARE for Life.  TRICARE For Life (TFL) is TRICARE’s Medicare-wraparound coverage available worldwide to TRICARE beneficiaries that are also entitled to Medicare. 

If a beneficiary entitled to Medicare Part A declines Medicare Part B coverage, he/she will lose TRICARE coverage (with the exception of active duty family members). 

Eligibility
TFL is available to all TRICARE and Medicare dual-eligible Uniformed Services beneficiaries, regardless of age including retired members of the National Guard and Reserve who are in receipt of retired pay, family members, widows/widowers and certain former spouses.

Uniformed Services beneficiaries entitled to Medicare Part A are required by law to have Medicare Part B coverage to retain their TRICARE benefits with one exception.  Active duty family members entitled to Medicare Part A are not required to have Medicare Part B coverage.  When the active duty service member retires, family members must have Medicare Part B coverage to avoid loss of TRICARE benefits.   Dependent parents and parents-in-law are not eligible for TFL.   

Cost to Beneficiaries
There are no enrollment fees for TFL. 

 Medicare Part B
The Department of Defense (DoD) strongly encourages beneficiaries to purchase Medicare Part B when they are first eligible.  Although a beneficiary may delay Medicare Part B sign up for up to eight months in certain circumstances, the beneficiary will not be covered by TRICARE until Part B coverage begins. 

Beneficiaries who do not sign up for Medicare Part B when first eligible will pay a 10 percent surcharge for each 12 month period that they delayed signing up. Beneficiaries should confirm that their Medicare status is current in the Defense Eligibility and Enrollment Reporting System (DEERS). 

Beneficiaries may go to the TRICARE DEERS information page to see a full list of contact options. Beneficiaries may sign up for Medicare Part B during their initial enrollment period, which begins three months before the month a beneficiary turns 65 and ends three months after the month the beneficiary turns 65.  NOTE:  Although the eligibility age for full Social Security benefits is changing, the eligibility age to get Medicare is not changing. 

If a beneficiary does not sign up for Medicare Part B when first eligible, he or she can sign up for Part B during the general enrollment period that occurs January 1 through March 31 of each year.  When a beneficiary enrolls in Part B during the general enrollment period, Part B and TFL coverage begin July 1 of that year. 

Employer Group Health Plan Coverage
Beneficiaries with group health plan coverage based on their current employment or that of a family member are not required by Medicare to sign up for Part B.  They may sign up for Medicare Part B without paying the surcharge for late enrollment anytime while they are still covered by an employer group health plan or they may delay sign up for up to eight months after employment or health plan coverage ends, whichever comes first. 

Although Medicare does not require beneficiaries with group health coverage to sign up for Part B, TRICARE coverage will not begin until Medicare Part B coverage begins. Beneficiaries may check with the Social Security Administration online at www.ssa.gov, call toll-free at (800) 772-1213 or visit Medicare online at www.medicare.gov for information about Medicare Part B. 

How TFL Works with Medicare
For services received from a provider that accepts Medicare, the provider first files claims with Medicare.  Medicare pays its portion and electronically forwards the claim to the TFL claims processor.  TFL sends its payment for the remaining beneficiary liability directly to the provider.  Beneficiaries receive a Medicare summary notice from Medicare and a TFL explanation of benefits (EOB) from the TFL contractor indicating the amounts paid.        

For Medicare and TRICARE covered services, Medicare pays first and the remaining beneficiary liability may be paid by TFL.        

For services covered by TRICARE but not by Medicare, such as care received overseas, TFL pays first and Medicare pays nothing.  Beneficiaries are responsible for the TRICARE fiscal year deductible and cost shares. §       For services covered by Medicare but not by TRICARE, such as chiropractic services, Medicare is the first payer and TFL pays nothing.  Beneficiaries are responsible for Medicare deductibles and coinsurance. §      

For services not covered by Medicare or TRICARE, such as cosmetic surgery, Medicare and TRICARE pay nothing.  The beneficiary is responsible for the entire bill. 

How TFL Works With Medicare and Other Health Insurance (OHI)
Beneficiaries with OHI, such as a Medicare supplement or employer-sponsored medical coverage, may use TFL.  By law, TRICARE pays claims only after all OHIs have paid. Typically, after Medicare processes a claim—either approving or denying it—the claim is automatically forwarded to the beneficiary’s OHI. 

Once the OHI processes the claim, the beneficiary needs to file a paper claim with TRICARE for any out-of-pocket expenses.  TRICARE may reimburse the beneficiary if the services provided are covered by TRICARE.  Paper claims must be submitted to the TFL contractor using a CHAMPUS claim form (DD Form 2642) along with a copy of the provider’s itemized bill, the Medicare summary notice and EOBs from all OHIs. 

TFL claims must be filed within one year from the date the care is received.  Beneficiaries may receive assistance with claims filing procedures from the TFL contractor, a local Beneficiary Counseling and Assistance Coordinator or from the TRICARE Web site at www.tricare.osd.mil/claims/default.htm. 

Canceling OHI
Beneficiaries must contact their OHI administrator if they wish to cancel their OHI.  After canceling OHI, beneficiaries MUST mail a copy of the termination notice to Wisconsin Physician Services (WPS), the TFL contractor, at:  WPS TFL
P.O. Box 7890
Madison, WI 53707-7890 

TRICARE Overseas Program (TOP) TFLEligible beneficiaries living overseas may use TOP TFL as long as they are entitled to Medicare Part A and Part B.  TOP TFL coverage is the same as stateside TRICARE Standard.  Medicare does not typically provide health care coverage overseas; therefore TOP TFL will be the primary payer and the beneficiary will be responsible for the fiscal year deductible and cost shares. 

However, Medicare does pay for health care services received in U.S territories (Guam, Puerto Rico, the U.S. Virgin Islands, American Samoa, the Northern Mariana Islands and, for purposes of services rendered onboard ship, in the territorial waters adjoining the land areas of the United States).  In these locations, TOP TFL acts as the second payer after Medicare, just as with the stateside TFL program. 

When a beneficiary receives medical care from a provider that accepts Medicare in one of the U.S. territories, their provider may file the claim with Medicare; if so, no action is required by the beneficiary.  Medicare then processes the claim and forwards the claim to TRICARE for payment of the remaining amount.  TRICARE automatically sends payment to the beneficiary’s provider. 

The beneficiary will receive a Medicare summary notice from Medicare and an EOB from the TFL contractor indicating the amounts Medicare and TRICARE paid. When seeking reimbursement for care received in locations not covered by Medicare, beneficiaries must file their own claim(s). 

Paper claims are submitted to the TRICARE Overseas claims processor using a DD Form 2642, along with a copy of the provider’s itemized bill and any EOBs from all OHIs; no Medicare summary notice is required.  Beneficiaries are responsible for the TRICARE Standard deductible and cost shares.  The TOP TFL claims filing address is: 

TRICARE Overseas
P.O. Box 7985
Madison, WI 53707-7985  

Beneficiaries may receive assistance with claims filing procedures from the TRICARE Overseas claims processor, a local TRICARE Service Center or Beneficiary Counseling and Assistance Coordinator or from the TRICARE Web site at www.tricare.osd.mil/claims/default.htm 

Services In Military Treatment Facilities
TFL beneficiaries may receive care in military treatment facilities on a space-available basis.   For More Information: For more information, beneficiaries may contact the TFL contractor, WPS/TFL, by telephone at 1-866-773-0404, or by mail at:   WPS TFL
P.O. Box 7890
Madison, WI 53707-7890 

Beneficiaries may visit the TRICARE Web site at www.tricare.osd.mil/tfl or the TFL contractor Web site at www.tricare4u.com.  
See also: www.tricare.osd.mil/Factsheets/index.cfm
Fact sheet on Eligibility and DEERS. http://www.tricare.osd.mil/Factsheets/viewfactsheet.cfm?id=299
Fact sheet on    the TRICARE Pharmacy Program.   
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Contributed,
YNCS Don Harribine, USN(ret)