Presentation on theme: "TRICARE for Life and TRICARE Plus"— Presentation transcript:
1 TRICARE for Life and TRICARE Plus Presented by:Wendy PrittTRIWEST Healthcare Alliance, Inc.
2 TRICARE Regional Contractors North RegionHealth NetSouth RegionHumana MilitaryWest RegionTriWest1-888-TRIWEST ( )TRICARE is the name given to the Military Health System, it used to be called CHAMPUS but changed from CHAMPUS to TRICARE around There are three contractors in the United States who administer the TRICARE program, the North, South and West regions. I work for TriWest Healthcare Alliance who administers the TRICARE program in the West Region, the 21 states West of the Mississippi. The TRICARE program is the same regardless of where you choose to retire, its just a matter of which contractor you will contact for more information, enrollments and claims.Note: The addresses below are provided to the speaker for reference.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. Contact TriWest at TRIWEST ( ),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), West Virginia, and Wisconsin. Contact Health Net Federal Services at TRICARE ( ), s.com.TRICARE South Region—includes Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee (excluding the Ft. Campbell area), Louisiana, Arkansas, Texas (excluding the El Paso area), and Oklahoma. Contact Humana Military Healthcare Services at ,North Region:Health Net Federal Services, LLCTRICARE Reserve Select EnrollmentP.O. BoxSurfside Beach, SCSouth Region:Humana Military Healthcare Services, Inc.P.O. BoxAtlanta, GAWest Region:TriWest Healthcare Alliance Corp.P.O. Box 42048Phoenix, AZ2
3 DEERS Medicare status Current Uniformed services ID card DEERS automatically notifies beneficiaries within 90 days of 65th birthday about changing benefitsHow many of you have received this notification?
4 TRICARE for Life National Defense Authorization Act for FY 2001 Extended TRICARE eligibilityCombines TRICARE Standard with Medicare Parts A & BSecond payer to Medicare
5 TRICARE For Life Eligibility All TRICARE beneficiaries entitled to Medicare, regardless of age or residenceMay receive Space A Military Treatment Facility (MTF) careSome beneficiaries may enroll in the Military Treatment Facilities “TRICARE Plus” program.
6 Medicare Eligibility Health insurance not a benefit like TRICARE Ages 65 and olderUnder 65 with certain disabilitiesAny age with end-stage renal disease or amyotrophic sclerosis (ALS); most commonly known as Lou Gehring’s disease
7 Medicare Overview Medicare Part A Medicare Part B Medicare Part C Hospital InsuranceMedicare Part BMedical InsuranceMedicare Part CMedicare + Choice PlanMedicare Part DMedicare Prescription Drug Plan
8 Call 1-800-MEDICARE or visit www.medicare.gov Medicare CardShows your eligibility for Parts A & B and the effective dates of coverage.No TRICARE For Life cardJust show this Medicare card along with your uniformed services ID cardThere 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 visitif you need a new card.
9 Medicare Part B Enrollment Federal law mandates enrollment to remain TRICARE eligibleMedical entitled Active Duty Service Members (ADSM)/Active Duty Family Members (ADFM) are not required to enroll until retirementThese beneficiaries retain TRICARE eligibilityActive Duty Service Members (ADSM)/Active Duty Family Members (ADFM) must have Part B enrollment in effect on retirement date to avoid break in TRICARE coverage
10 TRICARE For Life Costs Medicare Part A Medicare Part B No fee if beneficiary paid Medicare taxes while workingMedicare Part BMonthly premium required for Medicare, no enrollment fee for TRICARE at that point2010 Medicare Part B PremiumBased on incomeMay change each year
11 2010 Medicare Part B Premiums Beneficiary PaysBeneficiary’s Yearly IncomeBeneficiary files individual tax returnFile joint tax return$96.40 if beneficiary has SSA withhold in 2009$ for all others$85,000 or below$170,000 or below$154.70$85,001–$107,000$170,001–$214,000$221.00$107,001–$160,000$214,001–$320,000$287.30$160,001–$214,000$320,001–$428,000$353.60Above $214,000Above $428,000
12 Medicare + TRICARE Standard = TFL Medicare Parts A and B along with TRICARE Standard as the second payer gives beneficiaries TRICARE For Life coverage
13 Coordinating TRICARE For Life with Other Health Insurance (OHI) Order of payment depends on whether or not you have employer-sponsored health insurance.Other HealthInsurance(not based on current employment)With Employer-SponsoredHealth Insurance(based on current employment)1st Payer: Medicare2nd Payer: OHI or Medicare supplement3rd Payer: TRICARE1st Payer: Employer- sponsored plan2nd Payer: Medicare3rd Payer: TRICAREIf 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 LifeP.O. Box 7890Madison, WIGenerally, if you have an employer (20+ employees) sponsored health plan based on current employment, that health plan is the primary or first payer for your health care claims, Medicare is second, and TRICARE is third.If there are under 20 employees Medicare is primary, OHI is second payer, and TRICARE is third payer.Medicaid is the only health coverage that pays after TRICARE.TRICARE For Life will always pay last.
14 TRICARE For Life—How it Works You visit your Medicare providerYour provider files a claim with MedicareMedicare pays its portion and sends the remaining amount to TRICARETRICARE pays remaining amount to your providerYou get an explanation of benefits from Medicare and TRICAREWhen using TRICARE For Life in the United States, Guam, Puerto Rico, or the U.S. Virgin Islands, you should never 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 talk about this in a moment.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
15 TRICARE For Life—What You Pay Type of ServiceWhat Medicare PaysWhat TRICARE PaysWhat You PayCovered by TRICARE and MedicareMedicare’s authorized amountRemaining amountNothingCovered by Medicare but not TRICAREMedicare deductible and cost-shareCovered by TRICARE but not MedicareTRICARE’s authorized amountTRICARE deductible and cost-shareNot covered by TRICARE or MedicareTotal amount chargedHere’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
16 Medicare Advantage Plans Health Plan options that are a part of:HMOsPPOsFee-for-serviceMedicare Special Needs programCovered services and copayments are reimbursed by TRICARE
17 Medicare Prescription Drug Benefit – Medicare Part D Covers brand name and generic drugs at participating pharmaciesEnrollment window – every year between Nov 15 – Dec 31TRICARE Pharmacy Program (may be better option for beneficiaries)
18 Pharmacy Options and Costs Type of PharmacyFormularyNon-Formulary(Tier 3)Generic(Tier 1)Brand Name(Tier 2)MTF(up to 90-day supply)$0Not availableMail order$3$9$22*Network(up to 30-day supply)Non-networkPrime: POS fees will applyTFL: $9 or 20%, whichever is more. Must meet deductibleTFL: $22 or 20%, whichever is more. Must meet deductibleYou can have prescriptions filled at any MTF pharmacy at no cost to you. MTF pharmacies can accept a written prescription from any TRICARE-authorized provider, but be advised that the MTF may not stock every medication on the Uniform Formulary. If you did not get your prescription from a provider at the MTF, call first to see if your prescription is available.TRICARE offers a safe, convenient mail-order option that delivers prescriptions right to your mailbox. The program is administered by ESI (Express Scripts, Inc.), and it’s easy to register. After the MTF, the mail-order pharmacy is the least expensive option for you. Using the mail-order option is an excellent choice if you have regular medications for chronic conditions, such as high blood pressure, high cholesterol, or asthma. Contact ESI at or visit for more details.Note: If you have OHI with a prescription drug plan, the mail order option normally is not available.There are more than 55,000 TRICARE network pharmacies across the United States, Guam, Puerto Rico, and the U.S. Virgin Islands, making it easy to have your prescription filled anywhere. Find a retail pharmacy near you by calling or visiting Please note that retail pharmacies are not located in all overseas locations.Lastly, you can have prescriptions filled at non-network pharmacies for a much higher cost. And, you’ll probably have to pay for the full amount then file a claim with TRICARE for reimbursement. We do not recommend having prescriptions filled at non-network pharmacies.*Non-formulary drugs are available at the formulary cost if medical necessity is established. Visit for information.
19 TRICARE for Life (TFL) Overseas No Medicare coverage overseasTRICARE is primary payerExcept for U.S. overseas territoriesNo location restrictionsTRICARE Standard is a global benefitBeneficiaries file their own claimsSubmit claim (DD form 2642) to WPSNo Medicare summary required
20 TRICARE For Life Claims Processing Wisconsin Physician Services (WPS)TRICARE4u.comExplanation of Benefits (EOB)
21 TRICARE for Life (TFL) Explanation of Benefit (EOB) Detailed summary of claims for all medical care processed that month
22 TRICARE Plus Primary care enrollment option Available to beneficiaries not enrolled in TRICARE Prime or other HMO-like programOffered at some MTFs*Limited by MTF capacityNot 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.
23 Additional Information TRICARE For Life (TFL) -Defense Manpower Data Center (DMDC) Support Office - (800)ID Cards -Social Security Administration (SSA) -TRICARE Fact Sheets -Centers for Medicare and Medicaid Services -