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TRICARE for Life and TRICARE Plus

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Presentation on theme: "TRICARE for Life and TRICARE Plus"— Presentation transcript:

1 TRICARE for Life and TRICARE Plus
Presented by: Wendy Pritt TRIWEST Healthcare Alliance, Inc.

2 TRICARE Regional Contractors
North Region Health Net South Region Humana Military West Region TriWest 1-888-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 ( ), 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, LLC TRICARE Reserve Select Enrollment P.O. Box Surfside Beach, SC South Region: Humana Military Healthcare Services, Inc. P.O. Box Atlanta, GA West Region: TriWest Healthcare Alliance Corp. P.O. Box 42048 Phoenix, AZ 2

3 DEERS Medicare status Current Uniformed services ID card
DEERS automatically notifies beneficiaries within 90 days of 65th birthday about changing benefits How many of you have received this notification?

4 TRICARE for Life National Defense Authorization Act for FY 2001
Extended TRICARE eligibility Combines TRICARE Standard with Medicare Parts A & B Second payer to Medicare

5 TRICARE For Life Eligibility
All TRICARE beneficiaries entitled to Medicare, regardless of age or residence May receive Space A Military Treatment Facility (MTF) care Some beneficiaries may enroll in the Military Treatment Facilities “TRICARE Plus” program.

6 Medicare Eligibility Health insurance not a benefit like TRICARE
Ages 65 and older Under 65 with certain disabilities Any 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 Insurance Medicare Part B Medical Insurance Medicare Part C Medicare + Choice Plan Medicare Part D Medicare Prescription Drug Plan

8 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.

9 Medicare Part B Enrollment
Federal law mandates enrollment to remain TRICARE eligible Medical entitled Active Duty Service Members (ADSM)/Active Duty Family Members (ADFM) are not required to enroll until retirement These beneficiaries retain TRICARE eligibility Active 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 working Medicare Part B Monthly premium required for Medicare, no enrollment fee for TRICARE at that point 2010 Medicare Part B Premium Based on income May change each year

11 2010 Medicare Part B Premiums
Beneficiary Pays Beneficiary’s Yearly Income Beneficiary files individual tax return File 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 $353.60 Above $214,000 Above $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 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 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 Generally, 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 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 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 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

16 Medicare Advantage Plans
Health Plan options that are a part of: HMOs PPOs Fee-for-service Medicare Special Needs program Covered services and copayments are reimbursed by TRICARE

17 Medicare Prescription Drug Benefit – Medicare Part D
Covers brand name and generic drugs at participating pharmacies Enrollment window – every year between Nov 15 – Dec 31 TRICARE Pharmacy Program (may be better option for beneficiaries)

18 Pharmacy Options and Costs
Type of Pharmacy Formulary Non-Formulary (Tier 3) Generic (Tier 1) Brand Name (Tier 2) MTF (up to 90-day supply) $0 Not available Mail order $3 $9 $22* Network (up to 30-day supply) Non-network Prime: POS fees will apply TFL: $9 or 20%, whichever is more. Must meet deductible TFL: $22 or 20%, whichever is more. Must meet deductible You 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 overseas TRICARE is primary payer Except for U.S. overseas territories No location restrictions TRICARE Standard is a global benefit Beneficiaries file their own claims Submit claim (DD form 2642) to WPS No Medicare summary required

20 TRICARE For Life Claims Processing
Wisconsin Physician Services (WPS) Explanation 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 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.

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 -

24 Questions?

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