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TRICARE For Life and Medicare

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.

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8 Replies to “TRICARE For Life and Medicare”

  1. Hi, there. I”m finding the Medicare plans to be extremely confusing. I’m a veteran, but not retired from the military, so I do not qualify for TriCare. I did, however, enroll in VA Health Care Services, and substituted VA prescriptions for Medicare Part D, which is allowed. I did not enroll in Medicare Part B because I am on fixed income. I have SSRI and VADC, and that’s it. It has to cover all my expenses, so I’m very frugal about what I purchase.
    The changes in Medicare seem to be endless, and the stories about people NOT being admitted to a hospital, which is covered by Medicare Part A, have been going on since the 1990s. If Part A isn’t invoked, then Part B is void, EVEN AFTER FIVE DAYS, and you leave the hospital with an enormous financial burden. Apparently, hospitals just don’t want to be bothered with Medicare, period.
    Right now, I have only Medicare Part A, which is basically worthless, and I do know how the VA’s copay plan works. I live 15 minutes from a VA health care center and I don’t travel anywhere, except locally.
    My funds are very limited for any kind of insurance, including Part B. Since I can’t get a supplemental plan that the VA could bill without Part B, I really think I’d be better off self-insured, but I need to know what would work better, considering that my funds are limited.
    Is Part A+B plus a Part C policy better, which may be too expensive? Or if I chose Medigap, does that mean canceling Part A? I need something that I can present to the VA for what is termed ‘critical care’.
    This is very confusing, as you can imagine. My auto insurance policy is less confusing. I’m covered for every possible occurrence, including being smashed into by uninsured/underinsured drivers. So why are my auto and homeowners policies so much more clear than Medicare’s muddled policies?
    Thanks for your feedback.

    1. Hi Sara,

      I understand that this process can be incredibly confusing. With the VA, you will need to call them to find out exactly what you need to have to present to them in the situation of critical care. Most of our clients with VA benefits have Medicare Parts A & B and a lower cost Medicare supplement that allows them to go outside of the VA if they need to. If you’re trying to budget for Medicare Parts A & B and a Medicare supplement, then you can still find ways to have a very low cost premium each month.

      Medicare Part C plans are Medicare Advantage plans, also called Medicare replacement plans. However, you are required to have both Medicare Part A and Part B in place to have a Medicare Advantage plan.

      I think that in order to better understand your situation, it would be best if you gave us a call at (866) 894-3258. GoMedigap is an independent agency, therefore our agents are completely unbiased and only provide the best recommendations for your unique and specific situation. One of our agents will be happy to listen and provide expert advice to ensure you have the best coverage possible at the lowest rate.

      Again, our number is (866) 894-3258. I hope you have a great day, and we look forward to speaking with you soon!

    1. Hi there,

      TRICARE For Life does not cover the cost of Silver Sneakers. However, there may be a good option for you.

      Because TRICARE For Life also includes Part D coverage, and you can only have one Part D drug plan at a time, many TRICARE For Life beneficiaries will also enroll in a zero premium Medicare Advantage Plan without Part D called a MA only plan, to get additional benefits like Silver Sneakers.

    1. Mr. Heier,

      If you have Medicare and TRICARE For Life, the only time you will pay deductibles, coinsurance or copayments is when your care is covered by one but not the other.

      Here’s a bit of a break down:

      If the service is covered by both Medicare and TRICARE, then you pay nothing.
      If the service is covered by TRICARE, but not Medicare, then you must pay the TRICARE deductible and cost shares.
      If the service is covered by Medicare, but not TRICARE, then you pay the Medicare deductible and coinsurance.

      Here’s some additional information, if you’re interested: https://tricare.mil/Costs/HealthPlanCosts/TFL

      Please let me know if you have any additional questions.

    1. Hi Mr. Ziesmer,

      Thank you very much for your service. Here’s some helpful information from the TRICARE website.

      “TRICARE is a health program for:
      1. Uniformed Service members and their families,
      2. National Guard/Reserve members and their families,
      3. Survivors,
      4. Former spouses,
      5. Medal of Honor recipients and their families, and
      6. Others registered in the Defense Enrollment Eligibility Reporting System.

      Your benefits and plans will vary depending on your beneficiary category.”

      To find the right TRICARE plan for you, please visit this page: https://tricare.mil/Plans

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