Module 9: Medicare and TRICARE

2 Module Objectives After this module, you should be able to: Describe the TRICARE for Life benefit Explain how TRICARE and Medicare work together List the Medicare enrollment periods Discuss coordination between TRICARE, Medicare and Other Health Insurance

3 TRICARE for Life  TRICARE for Life (TFL) combines TRICARE Standard coverage with Medicare Part A and B to provide wrap-around medical coverage to dual-eligible (Medicare-TRICARE) beneficiaries worldwide  Under TFL, TRICARE is second payer to Medicare  For services covered by Medicare and TRICARE, TRICARE pays the beneficiary’s cost shares and deductibles  If a services is covered only by Medicare or only by TRICARE, the beneficiary is responsible for the cost shares and deductible

4 TRICARE for Life Eligibility TFL is for TRICARE beneficiaries entitled to premium-free Medicare Part A and who have Medicare Part B, regardless of their age or place of residence While some beneficiaries are not required to have Part B to remain TRICARE eligible, in order to use TFL, beneficiaries must have Medicare Part A and Part B

5 Seeking Care TFL beneficiaries may seek care from Medicare participating, non- participating or “opt-out providers” TFL beneficiaries may receive care on a space available basis in military treatment facilities (MTFs)  TFL beneficiaries may enroll in TRICARE Plus, a primary care enrollment program available at some MTFs (see the TRICARE Options module for more information on TRICARE Plus) TFL beneficiaries who seek care at VA facilities will have greater out-of-pocket expenses than if they obtained care outside the VA. This is because the VA cannot bill Medicare

6 Coverage  Under TFL, TRICARE is second payer to Medicare  For services covered by Medicare and TRICARE, TRICARE pays the beneficiary’s cost shares and deductibles  If a services is covered only by Medicare or only by TRICARE, the beneficiary is responsible for the cost shares and deductible

7 Coordination of Benefits Once Medicare pays its portion for Medicare-covered services, Medicare then automatically forwards the claim to TRICARE for processing If a beneficiary has other heath insurance (OHI), his or her claim does not automatically cross over to TRICARE  The beneficiary must then file a claim with TRICARE once they receive the Medicare Summary Notice and the OHI’s explanation of benefits (EOB)

8 Medicare Basics Medicare is a health insurance program for the following: People age 65 or older People under age 65 with certain disabilities People (of any age) with end-stage renal disease or amyotrophic lateral sclerosis (commonly known as Lou Gehring’s disease) People with Mesothelioma due to asbestos exposure in Troy and Libby, Montana Medicare Overview: Medicare Part A Hospital Insurance Medicare Part B Medical Insurance Medicare Part C Medicare Advantage Plan Medicare Part D Prescription Drug Coverage Inpatient hospital care Inpatient rehab Skilled nursing facility care (not custodial or long-term care) Helps cover physician services and outpatient hospital care Provides all medically necessary Medicare covered services Offers some extra benefits Available through private insurance companies approved by the Centers for Medicare and Medicaid Services

9 Medicare Part B Enrollment Initial Enrollment Period: The seven-month period that begins three months before the month the beneficiary is first eligible for Medicare Part A and Part B General Enrollment Period for Part B: If an individual didn’t sign up for Medicare Part B when they first became eligible, they may be able to sign up during this period (January 1–March 31 of each year) Special Enrollment Period: For individuals who delay enrolling in Medicare Part B because they have group health plan coverage based on their or their spouse’s current employment or have an active duty sponsor

10 Medicare Part B Initial Enrollment Period If a beneficiary receives Social Security or Railroad Retirement Board (RRB) retirement benefits before age 65, enrollment in Medicare Part B starts automatically the first day of the month they turn age 65; or the month prior if their birthday falls on the first of the month  TFL benefits start the first date that Medicare Part A and Part B are effective If the beneficiary is under age 65 and disabled, they automatically get Part A and Part B in the 25 month of receiving disability benefit (Social Security Disability Insurance (SSDI) benefits or Disability from the RRB  TFL benefits start on the first date that Medicare Part A and Part B are effective

11 Medicare Part B General Enrollment Period Beneficiaries who disenroll from Medicare Part B when first eligible can re-enroll in Part B during the Medicare General Enrollment Period (GEP) The GEP runs from January 1 through March 31 of every year; Medicare Part B coverage begins July 1 of that year The cost of Medicare Part B will go up 10 percent for each 12-month period the beneficiary was eligible to enroll in Part B, but chose not to

12 Medicare Part B Special Enrollment Period The Special Enrollment Period (SEP) is for beneficiaries who waited to enroll in Medicare Part B because either they or their spouses were working and they had group health plan coverage or their sponsor was on active duty status During the SEP, beneficiaries can enroll in Medicare Part B:  Any time they are covered by employee group health plan coverage based on current employment  During the eight month period that begins the month following the month that employment ends or the employee group health plan coverage ends, whichever comes first

13 Medicare Part B Special Enrollment Period (continued) Beneficiaries who enroll in Medicare Part B during the SEP have Part B coverage beginning the month following enrollment To avoid a break in TRICARE coverage, beneficiaries should enroll in Medicare Part B prior to the end of employment or group health plan coverage, whichever comes first or during the initial enrollment period If the beneficiary does not enroll in Medicare Part B during the Special Enrollment period, they have to wait until the General Enrollment Period to enroll Thus, they may have a break in TRICARE coverage and may have to pay the 10 percent Medicare premium surcharge for each 12 month period they could have enrolled in Part B, but did not enroll

14 Coordination of Medicare, TRICARE, and OHI The following chart details who makes payment for medical services when the beneficiary has Medicare, TRICARE, and OHI: *NOTE: Table assumes that the beneficiary’s OHI is a retiree policy/not based on current employment. Services covered by Medicare, TRICARE and OHI Services covered by Medicare and OHI, but not by TRICARE Services covered by TRICARE and OHI, but not by Medicare Services covered by OHI, but not Medicare or TRICARE Medicare Pays firstPays first and beneficiary pays for any cost share or deductibles Does not pay Other Health Insurance (OHI)* Pays secondPays second and beneficiary pays for any cost shares or deductibles Pays firstPays and the beneficiary is responsible for any cost shares or deductibles TRICARE Pays last, normally paying the actual out- of-pocket costs incurred by the beneficiary Does not payPays second and the beneficiary is responsible for cost shares and deductibles Does not pay

15 Congratulations! You’ve Completed Module 9: Medicare and TRICARE You should now be able to: Describe the TRICARE for Life benefit Explain how TRICARE and Medicare work together List the Medicare enrollment periods Discuss coordination between TRICARE, Medicare and Other Health Insurance