Personal Affairs -April 2019

Tricare for Life

Who is eligible?

TRICARE For Life is Medicare-wraparound coverage for TRICARE-eligible beneficiaries who have enrolled Medicare Part A and B.  
When you become eligible for and purchase Medicare, you become eligible for TRICARE for Life (TFL). The Social Security Administration is responsible for Medicare enrollment and should send you the necessary information 3-4 months prior to your 65th birthday. If you do not receive this information by one month prior to reaching age 65, you’ll want to contact your local Social Security Office.

While the Social Security retirement age is increasing, the Medicare eligible age remains 65regardless of when you are eligible for full Social Security retirement benefits. Once you enroll in Medicare, TFL automatically becomes the secondary payer to Medicare as long as you have a valid military ID card. Your military ID card expires on the first day of the month that you turn 65 so you will need to make sure it has been renewed in order to keep your TRICARE eligibility.

What does it cost?

There are no fees associated with TFL. Beneficiaries must pay the Medicare Part B premiums in order to stay enrolled in TFL. 

TFL works as the secondary to Medicare. Medicare pays 80% of covered-services, and TFL pays the remaining 20%. TFL also pays the Medicare deductible. Beneficiaries should not have any out of pocket costs for Medicare and TRICARE-covered services.

For services covered by TRICARE but not by Medicare, such as pharmacy services or overseas care, you may be required to pay any applicable TRICARE co-payments. In situations where Medicare coverage does not apply, TRICARE Standardbecomes primary payer and you will be responsible for the TRICARE Standard deductible and cost-shares.

For services covered by Medicare but not TRICARE, such as chiropractic care, Medicare pays 80 percent and you will be responsible for the remaining 20 percent. 

How does it work?

As a Medicare beneficiary, you visit a physician who accepts Medicare. The provider files the claim with Medicare and once the claim is processed by Medicare, it is automatically forwarded on to TFL for payment. TFL pays the remainder of the claim provided that the service is a Medicare and a TRICARE covered benefit. There are very few Medicare covered benefits that are not TFL covered benefits which would require you to pay the remainder of the claim instead of TFL (i.e. chiropractic care is a Medicare but not TRICARE benefit).

If you choose a provider who has opted-outof Medicare, meaning they do not accept Medicare patients and will not file with Medicare, TRICARE will process the claim as second payer as long as the service is a covered benefit and the provider is TRICARE authorized. As second payer, TFL pays what it would have paid if Medicare processed the claim as primary (meaning TFL pays 20% of the TRICARE allowable charge). You are responsible for the remaining 80% of the bill. 
 
The Medicare website provides a search tool to find a providerin your area. Should you have no option for reasonable access to medical care but to use an opt-outMedicare provider contact WPS at 1-866-773-0404 for details on the opt-out waiver process.

Traveling or Living Overseas and TFL 

TRICARE Overseas Program (TOP) TRICARE for Life is available to beneficiaries residing overseas. The Medicare Part B enrollment requirement applies regardless of whether you live in the United States or abroad. Because Medicare is primarily a U.S. based program, there is no Medicare coverage overseas with the exceptions listed below*.

In locations where Medicare coverage does not apply, TRICARE is the primary source of health benefits. TOP TFLprovides the same coverage and TOP Standardwith the same cost shares and deductibles. However, TRICARE pays billed charges overseas vs. maximum allowable charge. TOP Standard beneficiaries are responsible for paying annual deductibles and cost shares. You may be required to pay up front for care and then file claims with Wisconsin Physicians Service (WPS) – the TRICARE overseas claims processor

*Medicare is available 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, the territorial waters adjoining the land area of the United States). In these locations, TFL acts as the secondary payer after Medicare, just as with the stateside TFL program. 

Medicare/TFL and Other Health Insurance

When you have Other Health Insurance (OHI) that is not based on current employment (an FEHBP for example), then Medicare pays first, your OHI pays second, and you have to file any remaining balances yourself with TRICARE.

Generally speaking, TRICARE/Medicare-eligible beneficiaries (without other health insurance) find that Medicare as their primary insurance and TFL as their secondary insurance is adequate for their health care needs. It is often more cost-effective as well, because TFL doesn’t require any additional participation premiums outside the monthly Medicare Part B premium. There are very few Medicare-covered benefits that are not TFL-covered benefits which would require you to pay the remainder of the claim instead of TFL (for example, chiropractic care). The important question is whether or not you are required to pay for your employer-sponsored health coverage.

If you are not required to pay premiums for you and/or your spouse, then the only thing to consider is the fact that you are responsible for filing claims with TFL for any outstanding balances after both your OHI and Medicare have paid; however, there are probably very few instances where there would actually be an outstanding balance after both insurance plans have processed the claim.

If you are required to pay premiums for you and/or your spouse, then you will want to evaluate the cost-effectiveness of continuing enrollment in your OHI. Remember, you are already paying Medicare Part B premiums, and unlike your OHI, TFL doesn’t require additional participation premiums. If you decided to drop your OHI, you would be saving the cost of those premiums, and have Medicare as your primary payer and TFL as your secondary. You will not be responsible for filing your own claims with TFL as long as you seek care from providers that accept Medicare. The provider will file with Medicare and once the claim is processed by Medicare, it is automatically forwarded on to TFL for payment.

Keep in mind that TFL provides you with a pharmacy benefit at no cost (other than drug co-pays), whereas Medicare offers a separate pharmacy benefit (Medicare Part D) that requires a monthly premium on top of your Medicare Part B premium and generally higher drug co-pays. Medicare Part D is an optional benefit; but as far as TFL beneficiaries are concerned, there is generally no added benefit in enrolling in Medicare Part D.

Other items to consider are dental coverage, routine eye exams, and long term care; none of which are TFL or Medicare covered benefits. If your employer-sponsored health plan provides any of these services, you will want to take that into serious consideration in making your decision- especially if your OHI includes long term care.

TRICARE Pharmacy benefit

The pharmacy benefit under TFL is the same pharmacy benefit as TRICARE Prime and TRICARE Standard.

Can fill prescriptions three different ways: at a military treatment facility (MTF), at a local retail pharmacy, or through the mail-order pharmacy (TMOP)  

For current pharmacy costs, see this Tricare web page: https://tricare.mil/CoveredServices/Pharmacy/Costs  

To research currently covered medications, see the Tricare formulary list here: https://tricare.mil/CoveredServices/Pharmacy/Drugs