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TRICARE and Medicare

How TRICARE Works with Medicare
07/27/2022
  • Medicare with Melissa

This is such an important topic and there is much to cover. Before we dive in, there are some things to know about TRICARE and Medicare.

  • TRICARE is not Medicare
  • TRICARE for Life (TFL) is not the same as TRICARE
  • VA coverage (veterans’ coverage) is not the same as TRICARE

 Ok, now that we’ve covered our grounds, its also important to note that often the term TRICARE is used loosely when referring to TRICARE for life.

The easy way to remember the difference between the two is that TFL (TRICARE for life) is only available to those that are also eligible for Medicare Part A and Part B.

What is Tricare for life?

TFL is supplemental insurance policy that helps cover some of the costs that Original Medicare doesn’t cover. It is available to military retirees and their families who are enrolled in both Medicare Part A and Medicare Part B.

TRICARE for Life is a great way to get additional coverage if you are enrolled in Original Medicare. It can help you reduce your overall healthcare costs, and it can give you peace of mind knowing that you have coverage for routine and emergency services.

If you are retired from the military, or if you are a family member of a retiree, be sure to ask about TRICARE for Life the next time you are shopping for supplemental insurance policies.

Tricare for Life and Medicare. How does it work?

TRICARE for Life coverage allows you to see any provider that participates and doesn’t participate in Medicare. You can also seek services from the military hospital or clinic, if room permits.

Medicare is primary and TFL is secondary. After Medicare has paid its share, TRICARE for Life will kick in and cover most of the remaining costs. This includes things like hospital stays, doctor’s visits, prescription drugs, and more. The exception is if you have other insurance. Your other health insurance could pay second and then TFL pays remainder.

Whether you see a participating or non-participating Medicare provider, you will have zero out-of-pocket costs for services that are covered by both Medicare and TFL (most will fall into this bucket).

There may be times when some healthcare costs are not covered by Medicare or TFL and you may have to pay some Medicare deductibles and coinsurance out-of-pocket.

See the Medicare and Tricare benefit chart below.

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Medicare Advantage and Tricare for Life

TFL policy holders have the option to enroll in additional insurance. Some find that Tricare for life coverage is sufficient. Others choose to enroll in a Medicare Advantage Plan to gain access to additional benefits, like:

•        Money back in social security check (Part B buyback)

•        Gym Membership discounts

•        Grocery Cards

•        Money towards OTC items and much more.

Medicare Supplement and Tricare for Life

We commonly get asked,” Do you need a Medicare supplement if you have Tricare for life”? That depends on your needs and budget. Generally, we do not recommend being enrolled in a Medicare Supplement and TFL plan (you’d be paying for something that you’re not getting much from).

Instead, we suggest securing additional coverage for dental, vision, and hearing. Our team also offer hospital and cancer cash plans.

Is Tricare for life a Medicare Supplement?

Although Tricare for life is supplemental insurance that will help cover some of your out-of-pocket cost, it is not a Medicare Supplement Plan. There are no plan designations like, Plan F, Plan G or Plan N and you do not pay a monthly premium for TFL.

If I have TFL, should I cancel my Medicare supplement?

Before cancelling your Medicare Supplement, you should always take into consideration your needs, wants, budget and lifestyle. Talking with a licensed broker at Senior HealthCare Solutions can help make it easier by talking through your situation. In most cases, you may not need both. Call 866-633-4427 today.

Healthcare Services covered by Medicare and TFL

Medicare is the primary payer and makes the decision on approval or denial of claims. If Medicare determines the service(S) performed is not medically necessary, they may deny the claim. If Medicare denies the claim, TFL will not pay either. You can always appeal Medicare claims decision and if Medicare reconsiders and provides coverage TFL also reconsiders payment of the claim.

If you receive services that are covered by both Medicare and TFL, but Medicare does not pay because you have exhausted your benefit, TFL becomes the primary payer and you’re responsible for your TFL deductible and cost sharing. (Ex: Medicare limits the days of coverage for SNF, skilled nursing facility.)

If a health care service is normally covered by both Medicare and TFL, but you get the service from a provider who has opted out of Medicare, the provider can’t bill Medicare and Medicare pays nothing.

When you see an opt-out provider, TFL processes the claim as the second payer, unless you have other health insurance. TFL pays the amount it would have paid if Medicare had processed the claim (normally TFL pays 20% of the TRICARE-allowable charge) and you’re responsible for the remainder of the billed charges.

Medical Services Covered by Tricare but NOT by Medicare

When you have services performed that is covered only by TFL (for example, TRICARE-covered services received overseas), TRICARE processes the claim as the primary payer. You’re responsible for the applicable TFL deductible, cost-shares, and remaining billed charges.

Outside the U.S. and U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the

U.S. Virgin Islands), there may be no limit to the amount that nonparticipating non-network providers may bill. You’re responsible for paying any amount that exceeds the TRICARE-allowable charge, in addition to your deductible and cost-shares. Learn more at https://www.tricare.mil/overseas.

TFL claims are normally filed with Medicare first; however, when a health care service is not covered by Medicare, your provider may file the claim directly with Wisconsin Physicians Service (WPS)—Military and Veterans Health, unless you have OTHER HEALTH INSURANCE (OHI).

Medical Services NOT covered by Medicare or TRICARE

When you get care that is not covered by Medicare or TFL (for example, most cosmetic surgery), neither makes a payment on the claim. You’re responsible for the entire bill. To learn more, visit https://www.medicare.gov/ or https://www.tricare.mil/coveredservices or contact WPS.

Coordinating TRICARE For Life with Other Health Insurance

How Medicare coordinates with OTHER HEALTH INSURANCE depends on whether or not the OTHER HEALTH INSURANCE is based on current employment. In either case, TFL pays last.

OTHER HEALTH INSURANCE Not Based on Current Employment

If you have OTHER HEALTH INSURANCE that is not based on your or a family member’s current employment, Medicare pays first, your OTHER HEALTH INSURANCE pays second, and TFL pays last.

OTHER HEALTH INSURANCE Based on Current Employment

Generally, if you have an employer-sponsored health plan based on current employment, that health plan pays first, Medicare pays second, and TFL pays last.

If there are fewer than 20 employees in the employer-sponsored plan, Medicare pays first, your OTHER HEALTH INSURANCE pays second, and TFL pays last.

When your OTHER HEALTH INSURANCE processes the claim after Medicare, you need to submit a claim to WPS for any remaining balance. Note: TRICARE pays after most insurance plans with the exception of Medicaid, TRICARE supplements and the Indian Health Service.

How TRICARE For Life Works Overseas

TRICARE is the only payer overseas. Medicare provides coverage in the U.S. and U.S. territories. Medicare also covers health care services received aboard ships in U.S. territorial waters.

In these locations, TFL works exactly as it does in the U.S. unless you have other health insurance, TFL is the second payer after Medicare for most health care services. Your provider files the claim with Medicare first. Medicare pays its portion and automatically forwards the claim to WPS.

Medicare does not provide coverage outside the U.S., U.S. territories, or aboard ships outside U.S. territorial waters. Therefore, TFL is your primary payer for health care received in all other overseas locations, unless you have other health insurance.

Be prepared to pay upfront for services and submit a claim to the TRICARE Overseas Program (TOP) claims processor.

Tricare for Life Frequently Asked Questions

Who is eligible for Tricare for life coverage?

Tricare-eligible beneficiaries that also have both Medicare Part A and Medicare Part B can access Tricare for life.

How much does Tricare cost?

If you are eligible for TFL, you pay $0 enrollment fees. You are required to continue paying your Medicare Part B premium. If you have other health insurance, you will keep paying that premium too.

Does TFL pay for the Medicare Part B premium and deductible?

No, TFL does not pay the Part B premium. The Medicare Part B monthly premium is your responsibility. TFL covers the Medicare Part B deductible as long as the health care service is covered by both Medicare and TRICARE.

Is Medicare and Tricare for life enough coverage?

You should always evaluate your health insurance needs, lifestyle and budge. For most, Medicare and TFL can be enough coverage. Others choose to add on other insurance such as a Medicare Supplement, Medicare Advantage Plan or even stand-alone dental, vision, and hearing plans.

I have TRICARE Prime and am eligible for Medicare. Can I keep TRICARE Prime?

Once you become entitled to premium-free Medicare Part A because you’re age 65, you’re eligible for TFL when you also have Medicare Part B.

You’re no longer eligible for enrollment in TRICARE Prime, unless you have an active-duty sponsor. You may continue to seek care at a military hospital or clinic if space is available but will likely need to seek care from civilian Medicare providers. Contact Medicare for assistance with finding Medicare providers.

Do military retirees have to pay for Medicare

Regardless of age or military status, if you are eligible for and have qualified for Medicare Part A and Part B, you will have to pay your Part B premium.

Your income level will determine your Part B premium amount.

If you need help paying your Part B premium, you can apply for extra help with the state Medicaid office.

Is Tricare Medicare?

Tricare is not the same as Medicare. You can be eligible for one but not the other. If you are eligible for both, you are automatically qualified for TFL (Tricare for life coverage).

Is a referral or TRICARE pre-authorization required for health care services?

A referral or TRICARE pre-authorization is not required under TFL when Medicare is the primary payer. However, when TFL becomes the primary payer, TRICARE pre-authorization requirements apply.

What is a Medicare Participating Provider?

Medicare participating providers agree to accept the Medicare allowed amount as payment in full.

What are Medicare Non-participating Providers?

Medicare non-participating providers do not accept the Medicare allowed amount as payment in full. They may charge up to 15% above the Medicare allowed amount, a cost that is covered by TFL.

Meet Melissa MacCalla

Medicare is not simple and can be hard, frustrating, and downright confusing for most. I love when I get someone on the phone and I am given the opportunity to explain the difference in plans to them and have Medicare make sense. I enjoy talking to clients year after year, hearing about their families growing or them asking about mine.

-Melissa

Oh my gosh!! I was so confused about the Medicare Supplement process. I am turning 65 soon and am retired and have always had insurance thru my former employer. I didn’t know a thing about going on Medicare and was struggling to sort it all out.

A friend of mine recommended contacting Senior HealthCare Solutions, so I did. Melissa was FANTASTIC!! She was professional, responsive, caring and friendly. She explained the steps I needed to take, gathered my information, helped me choose good plans for MY specific needs and took care of my applications over the phone. 1-2-3, eesy-peesy and I was done!! And it didn’t cost me a DIME!!! WOW!!! I HIGHLY recommend Senior Healthcare Solutions for anyone who’s overwhelmed with making the right choices with Medicare Supplemental Insurance and Rx coverage. It’ll take a load off your mind!

Janice W.

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