(TRICARE) ON CHANGING YOUR PROVIDER

From MOAA

TRICARE For Life (TFL) beneficiaries are strongly encouraged to find out what type of Medicare provider they have prior to making an appointment with their health care professional. If you don't, you may wind up paying more than you think.

Medicare currently has three types of providers:

  • opt-out providers;
  • participating providers; and
  • nonparticipating providers.

Opt-out providers have chosen to not see Medicare patients and cannot submit claims to the Medicare program. They are considered nonauthorized and nonparticipating. If you use a nonauthorized provider, you will be responsible for the full bill, including the portion TRICARE would have paid.

Participating providers are Medicare-authorized providers who agree to accept the Medicare-allowable charge as payment in full, and who agree to file claims. A nonparticipating provider does not agree to accept the allowable charge as payment in full, and may or may not file claims.

To find out what type of health care provider you have, call Medicare toll-free at 1-800-633-4227.

Beginning June 5, 2006, a small number of TFL beneficiaries who were treated by providers who “opted-out” saw their claims denied by both Medicare and TRICARE.

This was incorrect.

The TFL claims processor will automatically reprocess those claims that were improperly denied. No action by the beneficiary is necessary. TRICARE will continue to pay claims at the TRICARE Standard rate for any Medicare-eligible beneficiary who is treated by a provider who has opted-out of Medicare only until September 30, 2006.

After that date, a TFL or Dual Eligible beneficiary who seeks care from a provider who has opted out of Medicare will be responsible for the entire bill.

Overview: TRICARE For Life (TFL) restores TRICARE coverage for all Medicare-eligible retired uniformed services beneficiaries who are enrolled in Medicare Part B. It was passed by Congress as part of the FY 2001 National Defense Authorization Act (P.L. 106-398) and became Public Law Oct. 30, 2000, and TFL took effect Oct. 1, 2001.

Coverage: Eligible beneficiaries will receive all Medicare-covered benefits under Medicare in addition to all TRICARE covered benefits. For most beneficiaries who use a Medicare provider, Medicare will be first payer for all Medicare-covered services and TRICARE Standard (formerly CHAMPUS) will be second payer.

Cost: TFL has no annual premium and pays all Medicare copayments and deductibles. However, eligible beneficiaries must pay the monthly premium for Medicare Part B ($88.50 a person in 2006) and any applicable TRICARE copayments for services covered by TRICARE but not Medicare, such as pharmacy services. In situations where Medicare coverage does not apply, TRICARE will become first payer, and beneficiaries will be responsible for the standard TRICARE deductible ($150 a person and $300 a family) and 25-percent copayments and not to exceed the annual $3,000 catastrophic cap for a family a year for TRICARE covered services.

Pharmacy Benefit: The DOD “triple option” pharmacy benefit called TRICARE Senior Pharmacy (TSRx) began April 1, 2001. For information about this benefit, see the TSRx information below.

Funding: TFL is set in permanent law, just like Social Security, Medicare, and military retired pay. As such, annual action by Congress to reauthorize TFL is not required. Public Law 106-398 established a DOD Medicare Eligible Health Care Trust Fund, effective Oct. 1, 2002. For those beneficiaries who are currently retired, the fund will be resourced with annual mandatory contributions from DOD and the U.S. Treasury. Active Duty beneficiaries' future TFL benefits will be paid for by funds set aside through an annual accrual fund similar to that of the current retiree system.

Administration: DOD and their TRICARE Managed Care Support Contractors are responsible for the administration of TFL. To contact the regional TRICARE For Life in your area, refer to the contact information table.

TRICARE website.