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FOLLOW UP ANSWERS TO RETIREE QUESTIONS

At our retirees’ breakfast, on Friday October 12, we had a representative from Tri-Care give a briefing on "Tri-Care for Life". At that meeting several questions were raised at that time, in which the representative could not answer. Listed below are the answers to those questions, as forwarded by the representative and answers to some of the questions asked during today's briefing. Please let me know if I can assist you in any way.

Ed O'Dell

Dover Tricare Service Center Manager

How do I submit a claim?

* The doctor submits the Medicare claim as usual. If the patient does not have Other Health Insurance (i.e. a Medicare Supplement) the claim automatically goes on to Tri-Care For Life (TFL) for payment and gets an EOB. Medicare knows individual is TFL that this claim goes on to TFL as the second payer because DoD has provided Medicare a data tape of all TFL eligibles.

* If the patient does not have Other Health Insurance (OHI), and the doctor accepted Medicare assignment, the check goes to the doctor. If the doctor does not accept Medicare assignment, the check goes to the patient.

* If the person has OHI, Medicare pays first and his Supplement pays OHI second. There probably won't be a balance, but if there is the patient must send a claim to TRICARE along with a copy of the EOBs from Medicare and OHI showing what the balance is. Patients can download a claim form (DD 2642) from our website (sierramilitary.com) or pick one up at the nearest Military Treatment Facility or Tricare Service Center. Claim forms should be mailed to: TFL Region 1, Box 7051, Camden, SC 29020.

* Note: Even if the patient has OHI, he/she will still receive an EOB from TFL-this EOB will state how much Medicare paid and how much TFL would have paid if you did not have OHI.

* The doctor will submit Medicare claims just as he does now. He writes the diagnosis and procedure codes on the form just as he does now. Because TFL is the secondary payer to Medicare, the doctor follows all the Medicare rules for submitting.

What is in and what is out of the USA for OCONUS Tricare Coverage?

* The 50 states are considered within and everything else outside.

What is the deductible for care received outside of the USA?

* Because Medicare does not cover any services outside of the USA, the beneficiary pays the deductibles for Tricare Standard ($150/person $300 family) plus the usual 20% cost share for covered services. Note: If the service is not a TRICARE covered benefit within the US, it's not covered outside.

What are ANG Pharmacy benefits?

* Reservists and ANG retirees can start using the pharmacy benefits as soon as they retire from the military. They do not need to wait until they are 65 to use the pharmacy benefits, only to use Tricare For Life. The pharmacy benefit includes MTF pharmacy, the National Mail Order Pharmacy, and both TRICARE Network and non-Network pharmacies (of course non-Network costs are much higher than at Tricare Network pharmacies). A directory of Tricare Network doctors, facilities, and pharmacies can be found at our web site, sierramilitary.com.

Additional Information:

Here is a little more information you or your folks might find helpful.

FEHB is the only Medicare "Supplement" I'm aware of that allows beneficiaries to suspend coverage so they can try Tricare for Life.

Federal Employees Health Benefits Program (FEHB) - Conversion Between FEHB and TRICARE or Medicare/Medicaid and Certain State Sponsored Health Plans

The Office of Personnel Management has issued an interim rule (see notes below) to allow TRICARE-eligible FEHB Program annuitants and former spouses to suspend their FEHB enrollments, and then return to the FEHB Program during the Open Season, or return to FEHB coverage immediately if they involuntarily lose TRICARE coverage. The intent of this rule is to allow TRICARE-eligible beneficiaries to avoid the expense of continuing to pay FEHB Program premiums while they are using TRICARE coverage, without endangering their ability to return to the FEHB Program in the future. Effective October 1, 2001, the National Defense Authorization Act for 2001 will reinstate TRICARE coverage for Medicare-eligible uniformed services retirees, their survivors and eligible dependents. TRICARE coverage will be advantageous to many Medicare-eligible military system beneficiaries who now are covered under the FEHB Program as Federal civilian retirees, family members, or former spouses.

Under previous FEHB regulations, an annuitant or former spouse who canceled his or her FEHB coverage to use TRICARE coverage would not be allowed to return to FEHB coverage. Therefore, OPM has issued these interim regulations, with a request for comments, to allow these FEHB participants to suspend, rather than cancel, their FEHB coverage when they begin TRICARE coverage. Under this rule, they are allowed to return to FEHB coverage immediately if they involuntarily lose TRICARE coverage or, if not, during the next annual FEHB Open Season.

We also amended our regulations to clarify a similar situation involving FEHB-covered annuitants and former spouses. The regulations allow an individual who drops FEHB coverage when he or she enrolls in a Medicare-sponsored plan, or in Medicaid or a similar State-sponsored program of medical assistance for the needy, to return to FEHB coverage during the annual Open Season or immediately upon being involuntarily disenrolled from the non-FEHB coverage.