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Using TRICARE and Medicare

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1 Using TRICARE and Medicare
Today’s presentation will discuss the TRICARE benefits available to beneficiaries who are eligible for both TRICARE and Medicare. Presenter Tips: Review slides before briefing Print out briefing with notes prior to presentation Ensure “slide show” setting The following are suggested handouts for this briefing: TRICARE and Medicare Turning 65 fact sheet Your TRICARE Resources fact sheet October 2011

2 TRICARE Regions West Region North Region TriWest Healthcare Alliance
North Region Health Net Federal Services, Inc. 1-877-TRICARE This slide shows the three TRICARE regions in the United States. As you may know, we are in the _______ Region. The regional contractors listed here are responsible for customer service in each TRICARE region. Your regional contractor is _________. TRICARE South Region—includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area), and Texas (excluding the El Paso area). TRICARE North Region—includes Connecticut, Delaware, the District of Columbia, Iowa (Rock Island Arsenal area), Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, North Carolina, Illinois, Indiana, Kentucky, Michigan, Missouri (St. Louis area), Ohio, Tennessee (Ft. Campbell area), and Wisconsin. TRICARE West Region—includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding Rock Island Arsenal), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner including El Paso), Utah, Washington, and Wyoming. South Region Humana Military Healthcare Services, Inc.

3 Using TRICARE and Medicare
TRICARE beneficiaries who: Are entitled to Medicare Part A (hospitalization) Based on attaining age 65, disability or end-stage renal disease (ESRD) Must have Medicare Part B coverage (for outpatient care, such as doctor visits) to remain eligible for TRICARE Exception: Active duty service members, active duty family members, beneficiaries who have purchased TRICARE Reserve Select or TRICARE Retired Reserve, and those enrolled in the US Family Health Plan TRICARE beneficiaries who are entitled to Medicare Part A (hospitalization) based on attaining age 65, disability or end-stage renal disease (ESRD) must have Medicare Part B coverage, for outpatient care, to remain eligible for TRICARE. Exception: Active duty service members, active duty family members, beneficiaries who have purchased TRICARE Reserve Select or TRICARE Retired Reserve, and those enrolled in the US Family Health Plan. Individuals not eligible for premium-free Medicare Part A are not required to have Medicare Part B.

4 Not Eligible for Premium-Free Part A
“Notice of Award” or “Notice of Disapproved Claim” Visit an ID card-issuing facility Remain eligible for TRICARE Prime, Extra, and Standard Part B not required If married, you must file for Medicare Part A under earnings record of spouse age 62 or older. If you sign up for Medicare and are not eligible for premium-free Part A under your or your spouse’s (including divorced or deceased spouse’s) Social Security number (SSN), you receive a “Notice of Award” or “Notice of Disapproved Claim” from the Social Security Administration (SSA). To keep your TRICARE coverage, take the “Notice of Award” or “Notice of Disapproved Claim” to a uniformed services identification (ID) card-issuing facility to have your DEERS record updated and receive a new ID card. This allows you to keep your eligibility for TRICARE Prime or TRICARE Standard and TRICARE Extra after you turn 65. To ensure that your TRICARE coverage continues without a break, contact Wisconsin Physicians Service (WPS/TFL) after you update your DEERS record. If you are not eligible for premium-free Medicare Part A under your own SSN when you turn 65, you must file for benefits under your spouse’s (including divorced or deceased spouse’s) SSN if he or she is 62 or older. If your spouse (or divorced spouse) is not yet 62, you must file for benefits under his or her SSN when he or she turns 62. If you will be eligible under your spouse’s SSN in the future, you should sign up for Medicare Part B during your initial premium enrollment period to avoid paying monthly Part B surcharges for late enrollment. Even if you are not eligible for premium-free Medicare Part A, you are eligible for Part B at age 65. See “Medicare Entitlement Based on Age” in this section for more information.

5 Medicare Part B (Age 65) DEERS letter: Benefits are changing
90 days before 65th birthday Social Security Administration (SSA) Provides an annual statement DON’T decline Medicare Part B If you decline: You may not be eligible for TRICARE Can enroll in Medicare Part B later, but a premium surcharge may apply (higher premiums) Ninety days before your 65th birthday, you will receive a letter from DEERS indicating that your TRICARE benefits are about to change. If you do not receive this letter, call You will have an initial enrollment period to get Medicare Part B coverage, which spans from 3 months before your birthday month to 3 months after your birthday month. We recommend that you sign up in the 3-month period before your birthday so that your coverage begins during your birth month. If you sign up after your birth month, you will have a break in your TRICARE coverage. If you miss the initial enrollment period, your next opportunity is the general enrollment period (Jan. 1-Mar. 31). Your coverage will begin in July and you may be responsible for a Medicare Part B premium surcharge. There may be a lapse in your TRICARE coverage until your Medicare Part B is effective. The SSA provides an annual Social Security Statement which provides an estimate of your Social Security benefits. Read this very carefully. If you have earned enough credits to qualify for Medicare at age 65, there will be a statement that tells you to contact Social Security three months before your 65th birthday to enroll in Medicare. After you sign up for Medicare, you will receive a Medicare card indicating coverage for Part A and Part B. You will be given the option to decline Part B coverage. Remember in most cases, you must have Medicare Part B to remain eligible for TRICARE, so look at all your options before declining Part B coverage. If you decline Medicare Part B, you may not be eligible for TRICARE. Contact SSA or Medicare for more information: 1-800-MEDICARE 

6 Medicare Part B (Under Age 65)
Eligible due to disability or End-stage renal disease Medicare general enrollment period (Jan. 1 - Mar. 31) Benefits begin in July Automatic for persons with a disability After 24 months of Social Security benefits When active duty sponsor retires Can enroll in Medicare Part B any time before sponsor retires to avoid lapse in coverage 8-month window to purchase Medicare Part B to avoid premium surcharge (there could be a lapse in coverage) If you are under age 65, and are disabled or have ESRD, and have been entitled to Social Security disability or Railroad Retirement Board benefits for a period of 24 months, you will be enrolled automatically in Medicare Parts A and B, beginning with the 25th month of entitlement. If you are an active duty family member and your active duty sponsor is about to retire, you’ll need to enroll in Medicare Part B to remain eligible for TRICARE. Note to Presenter: emphasize that they should enroll before the sponsor retires so coverage is not lost. You can enroll in Medicare Part B anytime before your sponsor retires or you can enroll in Medicare Part B during an 8-month special enrollment period following his or her retirement date. The special enrollment period also applies to Medicare-eligible active duty family members covered through an employer group health plan based on current employment. The special enrollment period does not avoid loss of coverage. Beneficiaries entitled to Medicare Part A, but who do not have Medicare Part B, may lose TRICARE coverage upon retirement of their sponsor. Contact SSA or Medicare for more information: 1-800-MEDICARE 

7 Take Action! Update DEERS with Medicare Eligibility
Visit an ID card-issuing facility Find nearest at Call Mail proof of Medicare eligibility to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA Permanent family member ID card at age 75 For more information: You can take your letter from Social Security, which includes your Medicare Part A and B effective dates, to a uniformed services ID card facility to have your Medicare status updated in DEERS. You do not have to wait to get your Medicare card to update DEERS with your Medicare eligibility. You may be issued a new uniformed services ID card when you update DEERS with your Medicare information. At age 75, eligible family members will receive a permanent uniformed services ID card—meaning it will no longer expire. Until the permanent ID card is received, family members will need to continue to have their ID card updated by the expiration date. For more information, visit

8 TRICARE Program Options
TRICARE Prime Under age 65 Age 65 and over, but not eligible for premium-free Part A TRICARE For Life TRICARE Plus TRICARE Pharmacy Options TRICARE Dental Options Uniformed Services Family Health Plan We’ll discuss each of the programs in more detail. Please note that TRICARE Prime is available only to beneficiaries under age 65 or to those beneficiaries age 65 and over who do not qualify for premium-free Medicare Part A.

9 TRICARE Prime for Medicare-Eligibles
TRICARE Prime enrollment fees waived for retired family members with Medicare Part B Most care received from primary care manager Administered by regional contractors If there are claims, then processed by Wisconsin Physicians Service (TFL branch) With TRICARE Prime, you’ll receive most care from an assigned primary care manager and he or she will provide referrals for specialty care. TRICARE Prime enrollment fees are waived for Medicare-eligible retired family members. If one family member with Medicare—$230 is waived If more than one family member with Medicare—$460 (whole amount) waived regardless of total number of Medicare-eligible family members. With TRICARE Prime there are no claims to file in most cases. However, if claims are paid, they are processed by Wisconsin Physicians Service—TFL branch. If interested, you’ll need to enroll with your regional contractor. North: Health Net Federal Services, Inc. South: Humana Military Healthcare Services, Inc. West: TriWest Healthcare Alliance For more information about TRICARE Prime: North  South  West 

10 Contact Wisconsin Physicians Service-TFL
TRICARE For Life Available to all Medicare-eligible TRICARE beneficiaries Care received from any Medicare provider MTF care on space-available basis only TRICARE is the last payer after Medicare (and other health insurance, if applicable) Administered by Wisconsin Physicians Service (TFL branch) All Medicare-eligible TRICARE beneficiaries are eligible to use TRICARE For Life—a program where TRICARE serves as Medicare-wraparound coverage. With TRICARE For Life, you can receive care from any Medicare provider—and usually Medicare providers are also TRICARE-authorized. Care also is available at military treatment facilities on a space-available basis only. There are no enrollment fees for TRICARE For Life. In most cases, when you get care, your provider will file the claim with Medicare. After Medicare pays its portion, Medicare forwards the claim automatically to TRICARE, and TRICARE pays the provider directly. Wisconsin Physicians Service (WPS) is the contractor for TRICARE For Life claims processing and customer service, so if you are using TRICARE For Life, you’ll contact WPS if you need assistance—not your regional contractor. Contact Wisconsin Physicians Service-TFL

11 Call 1-800-MEDICARE or visit
Medicare Card Shows your eligibility for Parts A & B and the effective dates of coverage. No TRICARE For Life card Just show this Medicare card along with your uniformed services ID card There is not a “TRICARE For Life” card. All you need to get care is a Medicare card along with your uniformed services ID card. Here’s a sample of what your Medicare card will look like. If you don’t have this or need another one, contact Medicare for assistance. Call MEDICARE or visit if you need a new card.

12 TRICARE For Life—How it Works
You visit your Medicare provider Your provider files a claim with Medicare Medicare pays its portion and sends the remaining amount to TRICARE TRICARE pays remaining amount to your provider You get an explanation of benefits from Medicare and TRICARE When using TRICARE For Life in the United States, Guam, Puerto Rico, or the U.S. Virgin Islands, you shouldn’t have to file a paper claim. In most cases, the claims process is completely seamless to you. This is usually how it works: You visit any Medicare-certified provider and get care. You pay nothing at the time of service. Your provider files the claim with Medicare. Medicare pays its portion and then electronically forwards the claim to TRICARE (unless you have OHI, we’ll discuss this on slide 15). TRICARE pays the remaining amount directly to your provider. You receive an Explanation of Benefits (EOB) from Medicare and TRICARE. Contact Wisconsin Physicians Service-TFL

13 TRICARE For Life—What You Pay
Type of Service What Medicare Pays What TRICARE Pays What You Pay Covered by TRICARE and Medicare Medicare’s authorized amount Remaining amount Nothing Covered by Medicare but not TRICARE Medicare deductible and cost-share Covered by TRICARE but not Medicare TRICARE’s authorized amount TRICARE deductible and cost-share Not covered by TRICARE or Medicare Total amount charged Here’s a snapshot of your out-of-pocket costs when using TRICARE For Life. For a more detailed breakdown of costs associated with TFL, visit

14 Using TRICARE For Life Overseas
Works the same in U.S. Territories as in the United States All other overseas locations: Must have Medicare Part B coverage even though Medicare coverage is not available Works like TRICARE Standard Visit any host nation provider Deductible: $150/individual or $300/family Cost-share: 25% after deductible is met File claims with overseas claims processor International SOS Assistance, Inc. For information, visit In U.S. territories like Guam, Puerto Rico, and the U.S. Virgin Islands, Medicare coverage is available so TRICARE For Life works exactly the same in these locations as it does stateside. In all other overseas locations, TRICARE For Life works like TRICARE Standard. However, you must still have Medicare Part B coverage, or you may lose eligibility for TRICARE all together. You will visit any TRICARE-authorized host nation provider and pay TRICARE Standard cost-shares after you’ve met an annual deductible. Essentially, if you are retired and living overseas, your health care will not change when you turn 65. You’ll continue to file claims exactly as you did before. Medicare does not provide coverage overseas. The only thing that’s different is that you’ll have to enroll in Medicare Part B. Since the contractor knows that Medicare cannot make any payments on overseas claims, the contractor can process the claim without evidence of processing by Medicare. File claims with International SOS Assistance, Inc., overseas claims processor. For information, visit

15 Coordinating TRICARE For Life with Other Health Insurance (OHI)
Order of payment depends on whether or not you have employer-sponsored health insurance. Other Health Insurance (not based on current employment) With Employer-Sponsored Health Insurance (based on current employment) 1st Payer: Medicare 2nd Payer: OHI or Medicare supplement 3rd Payer: TRICARE 1st Payer: Employer- sponsored plan 2nd Payer: Medicare 3rd Payer: TRICARE OHI is any non-TRICARE health insurance that is not considered a supplement. This insurance is acquired through an employer, entitlement program (including Medicare), or other source. TRICARE is the last payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs or plans as identified by the TRICARE Management Activity. If you have other health insurance which is not based on your current employment or that of a family member, for example a private Medicare supplement, Medicare is the primary payer, the OHI is secondary and TRICARE will become the third payer. In this situation, after Medicare pays its portion of the claim, Medicare forwards the claim to the other health insurer for processing and payment. If there is any remaining balance, you (the beneficiary) will need to file a paper claim with WPS and must include the EOB from Medicare and the OHI. Submit paper claims to: WPS-TRICARE For Life P.O. Box 7890 Madison, WI TRICARE For Life will always pay last.

16 TRICARE Plus Primary care enrollment option
Available to beneficiaries not enrolled in TRICARE Prime or other HMO-like program Offered at some MTFs* Limited by MTF capacity Not transferable from one MTF to another * Check with your local MTF for program availability and details. TRICARE Plus is a primary care enrollment program that is offered at selected military treatment facilities. All beneficiaries eligible for MTF care (except those enrolled in TRICARE Prime, a civilian HMO, or Medicare HMO) can seek enrollment in TRICARE Plus if enrollment capacity exists. Note: TRICARE Plus is NOT transferable from MTF to MTF. Unlike Prime, TRICARE Plus is not portable and availability can change if MTF capacity decreases. Non-enrollment in TRICARE Plus does not affect TRICARE For Life benefits or other existing programs. If you don’t have Part B and the care is not available in the MTF you will be responsible for all the charges because you will not be covered by TRICARE.

17 TRICARE Pharmacy Program
Robust pharmacy benefit Worldwide coverage Affordable Uniform formulary Four options for filling prescriptions TRICARE offers robust prescription drug coverage to all eligible beneficiaries, including those with Medicare-eligibility. TRICARE has a uniform formulary process that establishes three separate types of medications—or tiers: Tier 1: Formulary—Generic: Be aware that TRICARE policy requires the generic equivalent for any brand-name drug to be dispensed if available, unless your provider establishes medical necessity. Tier 2: Formulary—Brand Name Tier 3: Non-Formulary—Non-formulary medications can be dispensed, but at a higher cost. If your provider can establish medical necessity for a drug on the non-formulary list, you can obtain the prescription at the formulary cost. Costs for prescriptions are based on the category under which the drug falls—Tier 1, Tier 2, or Tier 3—and where the prescription is filled. We’ll discuss costs in just a moment. Pharmacy benefit information, including authorization requirements, quantity limits, frequently asked questions, and more, is available at or As you may know, Medicare Part D now offers prescription drug coverage. There is no added value to purchasing Medicare Part D, and you are not required to do so to remain eligible for TRICARE’s robust pharmacy coverage. Please weigh your options carefully before purchasing Medicare Part D. Medicare Part D prescription drug coverage? - NOT required

18 Pharmacy Options and Costs
You may use the TRICARE pharmacy benefit unless you are enrolled in the US Family Health Plan. To have a prescription filled, you will need the prescription, a valid uniformed services ID card, and up-to-date information in DEERS. Note: Pharmacies are legally permitted to copy military and dependent ID cards to verify TRICARE eligibility. You will normally receive a generic drug rather than a brand-name drug. Your doctor or other provider must prove medical necessity for you to receive a brand-name medication if a generic version is available. Non-formulary drugs are not available to active duty service members without medical-necessity approval. If the ADSM receives approval, the copayment is $0. Pharmacy costs depend on the pharmacy option you choose, whether the drug is generic or brand name, and whether it’s listed in the TRICARE formulary, which is the list of drugs covered by TRICARE. There is no copayment when you fill a prescription at an MTF pharmacy. If you have recurring prescriptions, such as allergy or blood pressure medicine, you can use TRICARE Pharmacy Home Delivery to order up to a 90-day supply by phone, online, or by mail. TRICARE Pharmacy Home Delivery copayments are $0 for generic formulary drugs, $9 for brand-name formulary drugs, and $25 for non-formulary drugs. If you need a prescription filled immediately, your best option is to find one of TRICARE’s 60,000-plus retail network pharmacies. To find a retail network pharmacy, visit the Express Scripts Web site provided at the bottom of the screen. The most expensive option is a non-network retail pharmacy. Express Scripts, Inc. Web site: Phone number:

19 TRICARE Dental Options
TRICARE Dental Program TRICARE Retiree Dental Program Active duty family members National Guard/Reserve members and eligible family members Transitional survivors (first 3 years after sponsor’s death) Retired service members and eligible family members Medal of Honor recipients and family members Survivors United Concordia Companies, Inc. Delta Dental of California The TRICARE Dental Program is available to eligible active duty family members, members of the National Guard and Reserve and/or their eligible family members and transitional survivors. Benefits include: • Voluntary enrollment and portable coverage worldwide • Single and family plans available • Low monthly premiums and cost-shares based on sponsor’s pay grade • Comprehensive coverage for most dental services; 100 percent coverage for preventive, diagnostic, and emergency services For more information, visit or call The TRICARE Retiree Dental Program is available to retired service members and their eligible family members, including retired National Guard and Reserve members, as well as survivors. Benefits include: • Voluntary enrollment and portable coverage nationwide • Single, two-party, and family plans available • Monthly premiums vary regionally by ZIP code; minimal deductibles and cost-shares • Comprehensive coverage for most dental services; visit any dentist within the TRDP service area For more information, visit or call Overseas dental program options include the TRICARE Dental Program and the Enhanced-Overseas TRICARE Retiree Dental Program. For more information, please visit the Web sites provided. Overseas Dental Options: TRICARE Dental Program Enhanced-Overseas TRICARE Retiree Dental Program

20 Visit for more information.
US Family Health Plan TRICARE Prime option Available in six areas of the United States Eligible beneficiaries: Active duty family members Retirees and their eligible family members (including those age 65 and over) Cannot use other TRICARE options (including MTF and pharmacy benefits) listed in this briefing if enrolled The Uniformed Services Family Health Plan (USFHP) is an additional TRICARE Prime option available to active duty family members and retired service members and their eligible family members, including those age 65 and over, through networks of community-based hospitals and physicians in six areas of the country. Note: Although Medicare-eligible beneficiaries are not required to have Medicare Part B coverage to enroll in the USFHP, we strongly recommend that you get Part B when you are first eligible to avoid surcharges if you decide to enroll at a later date (10% for each 12-month period after your initial enrollment period). For instance, if you move from your USFHP location and its not offered in your new location, you will not be eligible for TRICARE without Medicare Part B. If you enroll in the USFHP, you are not eligible to use other TRICARE options/benefits including TRICARE pharmacy benefits discussed in today’s presentation. For additional information, visit Visit for more information.

21 Comments or feedback?
In Conclusion… TRICARE and Medicare work together to provide affordable, comprehensive coverage for Medicare-eligible beneficiaries We are here to help—many resources available TRICARE Web site: TRICARE regional contractors Wisconsin Physicians Service Pharmacy and dental contractors Overseas contractor Questions? PP4342BET09112W If you have any comments or additional feedback to this presentation or any other marketing and education materials, please visit Comments or feedback?

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