TRICARE For Life (TFL) is Medicare-wraparound coverage for TRICARE beneficiaries who have Medicare Part A and Medicare Part B, regardless of age or where you live. Let’s dive into TRICARE for Life and Medicare so you can understand what kind of coverage you will receive.
With TFL, you can visit:
- Medicare participating providers
- Medicare non-participating providers
- Military hospitals and clinics (only on a space-available basis)
Here’s how it works… You may visit any authorized provider (listed above). Your provider then files your claim(s) with Medicare. Medicare pays its portion and sends the claim to the TRICARE For Life claims processor. If you have other health insurance (OHI), Medicare will forward the claim to your OHI and you are responsible for filing a claim with TRICARE if there is any remaining balance after your OHI pays. TRICARE the pays the provider directly after Medicare and OHI for TRICARE-covered services.
Understanding TRICARE For Life and Medicare
The Department of Defense manages TFL. Medicare is managed by the Centers for Medicare & Medicaid Services (CMS). The two agencies work together to coordinate your benefits.
You must have both Medicare Part A and Part B to qualify for TFL.
How Does TRICARE For Life Work With Medicare?
Medicare and TRICARE cover many medical services. For those services, you have no costs. There are other times when a service is only covered by Medicare or TRICARE, or when a service isn’t covered by either. In those cases, you are responsible for deductibles and cost-shares.
Care Covered by Medicare and TRICARE
When you see a Medicare provider (participating or non-participating) for medically necessary care covered by Medicare and TRICARE, you have no out-of-pocket costs. As the first payer, Medicare determines if the care provided was medically necessary. TFL follows Medicare’s determination.
If Medicare determines…
- Care is medically necessary: Medicare pays its portion of the claim first. Then, TRICARE pays the remaining amount if the care is a TRICARE-covered service.
- Care is not medically necessary: Neither Medicare nor TRICARE pays. You are responsible for the whole bill, but can appeal the decision. If Medicare reconsiders and decides to cover the service, TFL will reprocess the claim, too.
- Care is medically necessary, but you have used up your Medicare benefits: TRICARE is the primary payer. If TRICARE covers the service, you are responsible for the TFL deductible and cost-share.
Opt-Out and Veterans Affairs Providers
Please note that some providers opt out of Medicare. That means they cannot bill Medicare and can charge any amount for your care. When you see an opt-out provider, Medicare pays nothing and TRICARE is the second payer, unless you have OHI.
TRICARE pays up to 20% of the amount allowed by TRICARE for that service, and you are responsible for the rest of the bill.
This rule also applies to any care you get from a U.S. Department of Veterans Affairs (VA) provider from an injury or illness that is not connected to your military service. For more information about VA care and costs, visit www.va.gov/healthbenefits/apply/veterans.asp.
Care Covered by Medicare but Not by TRICARE
When you get care that is only covered by Medicare, like chiropractic care, Medicare processes the claim and pays its portion. TRICARE pays nothing. You are responsible for the Medicare deductible and cost-shares.
Care Covered by TRICARE but Not by Medicare
When you get care that only TRICARE covers, like TRICARE-covered services received overseas, Medicare pays nothing. You must pay the TFL deductible, cost-shares and rest of the bill. Be aware that overseas nonparticipating non-network providers can charge any amount for your care. You are responsible for any amount over the TRICARE-allowable charge in addition to your deductible and cost-shares.
Your provider normally files claims with Medicare first. For overseas care, be prepared to pay up front and file a claim to get money back.
Care for Services Not Covered by Medicare or TRICARE
When neither Medicare or TRICARE cover the care, neither pays the claim. You pay the entire bill. For example, this is the case with most cosmetic surgeries.
How Does TRICARE For Life Work with Other Health Insurance?
Like Medicare, OHI normally processes and pays claims before TFL. The order in which Medicare and OHI process claims depends on whether your OHI is based on current employment or not. Payment of your claim also depends on whether or not you’re outside the U.S. when you get care. Your OHI and TFL may pay for care overseas, but Medicare doesn’t cover care outside the U.S., U.S. territories (American Samoa, Guam, the Northern Marina Islands, Puerto Rico and the U.S. Virgin Islands) or aboard ships outside U.S. territorial waters.