1 / 21

TRICARE and Medicare Coverage for Dual-Eligible Beneficiaries

Pat_Xavi
Download Presentation

TRICARE and Medicare Coverage for Dual-Eligible Beneficiaries

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. TRICARE and Medicare Coverage for Dual-Eligible Beneficiaries Version 2 August 2006 Today’s presentation will discuss the TRICARE benefits available to beneficiaries who are eligible for both TRICARE and Medicare. Note to presenter: The following are suggested handouts for this briefing: TRICARE For Life Brochure Guiding the Claims Process Brochure (North, South, West) Pharmacy materials TRICARE Dental Program (TDP) and TRICARE Retiree Dental Program (TRDP) program materialsToday’s presentation will discuss the TRICARE benefits available to beneficiaries who are eligible for both TRICARE and Medicare. Note to presenter: The following are suggested handouts for this briefing: TRICARE For Life Brochure Guiding the Claims Process Brochure (North, South, West) Pharmacy materials TRICARE Dental Program (TDP) and TRICARE Retiree Dental Program (TRDP) program materials

    2. This slide shows the three TRICARE regions in the United States. As you may know, we are in the _______ Region. The regional contractors listed here are responsible for customer service in each TRICARE region. Your regional contractor is _________. TRICARE South Region—includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area), and Texas (excluding the El Paso area). TRICARE North Region—includes Connecticut, Delaware, the District of Columbia, Iowa (Rock Island Arsenal area), Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, North Carolina, Illinois, Indiana, Kentucky, Michigan, Missouri (St. Louis area), Ohio, Tennessee (Ft. Campbell area), and Wisconsin. TRICARE West Region—includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding Rock Island Arsenal), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner including El Paso), Utah, Washington, and Wyoming. This slide shows the three TRICARE regions in the United States. As you may know, we are in the _______ Region. The regional contractors listed here are responsible for customer service in each TRICARE region. Your regional contractor is _________. TRICARE South Region—includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area), and Texas (excluding the El Paso area). TRICARE North Region—includes Connecticut, Delaware, the District of Columbia, Iowa (Rock Island Arsenal area), Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, North Carolina, Illinois, Indiana, Kentucky, Michigan, Missouri (St. Louis area), Ohio, Tennessee (Ft. Campbell area), and Wisconsin. TRICARE West Region—includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding Rock Island Arsenal), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner including El Paso), Utah, Washington, and Wyoming.

    3. Dual-Eligible: Defined TRICARE beneficiaries who: Are entitled to Medicare Part A (hospitalization) Based on attaining age 65, disability or end-stage renal disease (ESRD) Must have Medicare Part B coverage (for outpatient care, such as doctor visits) to remain eligible for TRICARE Exception: Active duty family members Dual-eligible beneficiaries are defined as TRICARE beneficiaries who also are entitled to Medicare Part A based on attaining age 65, having a disability, or end-stage renal disease. In some cases, beneficiaries may qualify for “premium-free” Medicare Part A. To be eligible for premium-free Medicare Part A, an individual must be “insured” based on his/her own earnings or those of a spouse, parent, or child. To be insured, the worker must have a specific number of quarters of coverage; the number required is dependent upon whether the person is filing for Part A on the basis of age, disability, or end stage renal disease. Most dual-eligible beneficiaries must have Medicare Part B coverage to remain eligible for TRICARE. Active duty family members entitled to Medicare Part A are exempt from having Medicare Part B. (But when the sponsor retires, family members must have Medicare Part B coverage to remain eligible for TRICARE.) Individuals not eligible for premium-free Medicare Part A are not required to have Medicare Part B. Dual-eligible beneficiaries are defined as TRICARE beneficiaries who also are entitled to Medicare Part A based on attaining age 65, having a disability, or end-stage renal disease. In some cases, beneficiaries may qualify for “premium-free” Medicare Part A. To be eligible for premium-free Medicare Part A, an individual must be “insured” based on his/her own earnings or those of a spouse, parent, or child. To be insured, the worker must have a specific number of quarters of coverage; the number required is dependent upon whether the person is filing for Part A on the basis of age, disability, or end stage renal disease. Most dual-eligible beneficiaries must have Medicare Part B coverage to remain eligible for TRICARE. Active duty family members entitled to Medicare Part A are exempt from having Medicare Part B. (But when the sponsor retires, family members must have Medicare Part B coverage to remain eligible for TRICARE.) Individuals not eligible for premium-free Medicare Part A are not required to have Medicare Part B.

    4. Not Eligible for Premium-Free Part A Letter of Disallowance Visit ID card issuing facility Remain eligible for TRICARE Prime, Extra, and Standard Part B not required If married, you must file for Medicare Part A under earnings record of spouse age 62 or older. If you are not eligible for premium-free Medicare Part A, you should receive a “Letter of Disallowance” from the Social Security Administration (SSA). Take this notice to an ID card issuing facility and ask that your record be updated and a new ID card be issued. You remain eligible for TRICARE Prime, Extra, and Standard and do not need Medicare Part B. If you are married and your spouse is 62 or older, you must file for Medicare benefits under your spouse’s Social Security Number, only if you do not qualify under your own SSN. Example:  Retired sponsor is 60 and his/her spouse will be 65 in Sept. 2006.  The spouse is not eligible for premium-free Medicare Part A because he/she is not eligible for Social Security or Railroad Retirement Board Benefits (i.e., has not worked for ten years). However, he/she is eligible for Medicare Part B. In order to keep TRICARE coverage/benefits when the spouse turns age 65, he/she must file for Medicare Part A about three months before he/she turns age 65. The spouse should also file for Medicare Part B to avoid paying a premium surcharge for late enrollment. SSA will issue a Notice of Disallowance for Medicare Part A and Notice of Part B entitlement. When the sponsor turns 62, the spouse must file for Medicare Part A on the sponsors earnings record. If you are not eligible for premium-free Medicare Part A, you should receive a “Letter of Disallowance” from the Social Security Administration (SSA). Take this notice to an ID card issuing facility and ask that your record be updated and a new ID card be issued. You remain eligible for TRICARE Prime, Extra, and Standard and do not need Medicare Part B. If you are married and your spouse is 62 or older, you must file for Medicare benefits under your spouse’s Social Security Number, only if you do not qualify under your own SSN. Example:  Retired sponsor is 60 and his/her spouse will be 65 in Sept. 2006.  The spouse is not eligible for premium-free Medicare Part A because he/she is not eligible for Social Security or Railroad Retirement Board Benefits (i.e., has not worked for ten years). However, he/she is eligible for Medicare Part B. In order to keep TRICARE coverage/benefits when the spouse turns age 65, he/she must file for Medicare Part A about three months before he/she turns age 65. The spouse should also file for Medicare Part B to avoid paying a premium surcharge for late enrollment. SSA will issue a Notice of Disallowance for Medicare Part A and Notice of Part B entitlement. When the sponsor turns 62, the spouse must file for Medicare Part A on the sponsors earnings record.

    5. Medicare Part B (Age 65) DEERS letter: Benefits are changing 90 days before 65th birthday Social Security Administration (SSA) Provides an annual statement DON’T decline Medicare Part B If you decline: You WON’T be eligible for TRICARE Can enroll in Medicare Part B later, but a premium surcharge will apply (higher premiums) Ninety days before your 65th birthday, you will receive a letter from DEERS indicating that your TRICARE benefits are about to change. If you do not or have not received this letter, call 1-800-538-9552. You will have an initial enrollment period to get Medicare Part B coverage, which spans from 3 months before your birthday month to 3 months after your birthday month. We recommend that you sign up in the 3-month period before your birthday so that your coverage begins during your birth month. If you sign up after your birth month, you will have a break in your TRICARE coverage. If you miss the initial enrollment period, your next opportunity is the general enrollment period (Jan. 1-Mar. 31). Your coverage will begin in July and you may be responsible for a Medicare Part B premium surcharge. There will be a lapse in your TRICARE coverage until your Medicare Part B is effective. The Social Security Administration provides an annual Social Security Statement which provides an estimate of your Social Security benefits. Read all 4 pages very carefully. If you have earned enough credits to qualify for Medicare at age 65, there will be a statement that tells you to contact Social Security three months before your 65th birthday to enroll in Medicare. After you sign up for Medicare, you will receive a Medicare card indicating coverage for Part A and Part B. You will be given the option to decline Part B coverage. Remember in most cases, you must have Medicare Part B to remain eligible for TRICARE, so look at all your options before declining Part B coverage. If you decline Medicare Part B, you will not be eligible for TRICARE. Ninety days before your 65th birthday, you will receive a letter from DEERS indicating that your TRICARE benefits are about to change. If you do not or have not received this letter, call 1-800-538-9552. You will have an initial enrollment period to get Medicare Part B coverage, which spans from 3 months before your birthday month to 3 months after your birthday month. We recommend that you sign up in the 3-month period before your birthday so that your coverage begins during your birth month. If you sign up after your birth month, you will have a break in your TRICARE coverage. If you miss the initial enrollment period, your next opportunity is the general enrollment period (Jan. 1-Mar. 31). Your coverage will begin in July and you may be responsible for a Medicare Part B premium surcharge. There will be a lapse in your TRICARE coverage until your Medicare Part B is effective. The Social Security Administration provides an annual Social Security Statement which provides an estimate of your Social Security benefits. Read all 4 pages very carefully. If you have earned enough credits to qualify for Medicare at age 65, there will be a statement that tells you to contact Social Security three months before your 65th birthday to enroll in Medicare. After you sign up for Medicare, you will receive a Medicare card indicating coverage for Part A and Part B. You will be given the option to decline Part B coverage. Remember in most cases, you must have Medicare Part B to remain eligible for TRICARE, so look at all your options before declining Part B coverage. If you decline Medicare Part B, you will not be eligible for TRICARE.

    6. Medicare Part B (Under Age 65) Eligible due to disability or ESRD Medicare general enrollment period (Jan. 1 - Mar. 31) Benefits begin in July Automatic for persons with a disability After 24 months of Social Security benefits When active duty sponsor retires Can enroll in Medicare Part B any time before sponsor retires to avoid lapse in coverage 8-month window to purchase Medicare Part B to avoid premium surcharge (there could be a lapse in coverage) If you are entitled to Medicare Part A and need to enroll in Part B, you can do so during Medicare’s general enrollment period each year, Jan. 1-Mar. 31. When you do, your Medicare coverage begins in July. If you are under age 65, disabled, and have been entitled to Social Security disability or Railroad Retirement Board benefits for a period of 24 months, you will be enrolled automatically in Medicare Parts A and B, beginning with the 25th month of entitlement. If you are an active duty family member and your active duty sponsor is about to retire, you’ll need to enroll in Medicare Part B to remain eligible for TRICARE. Note to Presenter: emphasize that they should enroll before the sponsor retires so coverage is not lost. You can enroll in Medicare Part B anytime before your sponsor retires or you can enroll in Medicare Part B during an 8-month special enrollment period following his or her retirement date. The special enrollment period also applies to Medicare-eligible active duty family members covered through an employer group health plan based on current employment. The special enrollment period does not avoid loss of coverage. Beneficiaries entitled to Medicare Part A, but who do not have Medicare Part B, will lose TRICARE coverage upon retirement of their sponsor. If you are entitled to Medicare Part A and need to enroll in Part B, you can do so during Medicare’s general enrollment period each year, Jan. 1-Mar. 31. When you do, your Medicare coverage begins in July. If you are under age 65, disabled, and have been entitled to Social Security disability or Railroad Retirement Board benefits for a period of 24 months, you will be enrolled automatically in Medicare Parts A and B, beginning with the 25th month of entitlement. If you are an active duty family member and your active duty sponsor is about to retire, you’ll need to enroll in Medicare Part B to remain eligible for TRICARE. Note to Presenter: emphasize that they should enroll before the sponsor retires so coverage is not lost. You can enroll in Medicare Part B anytime before your sponsor retires or you can enroll in Medicare Part B during an 8-month special enrollment period following his or her retirement date. The special enrollment period also applies to Medicare-eligible active duty family members covered through an employer group health plan based on current employment. The special enrollment period does not avoid loss of coverage. Beneficiaries entitled to Medicare Part A, but who do not have Medicare Part B, will lose TRICARE coverage upon retirement of their sponsor.

    7. Take Action! Update DEERS with Medicare Eligibility Visit an ID card-issuing facility Find nearest at www.dmdc.osd.mil/rsl Call 1-800-538-9552 Mail proof of Medicare eligibility to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA 93955-6771 Permanent family member ID card at age 75 You can take your letter from Social Security, which includes your Medicare Part A and B effective dates, to a uniformed services ID card facility to have your Medicare status updated in DEERS. You do not have to wait to get your Medicare card to update DEERS with your Medicare eligibility. You may be issued a new uniformed services ID card when you update DEERS with your Medicare information. At age 75, eligible family members will receive a permanent uniformed services ID card—meaning it will no longer expire. Until the permanent ID card is received, family members will need to continue to have their ID card updated by the expiration date. You can take your letter from Social Security, which includes your Medicare Part A and B effective dates, to a uniformed services ID card facility to have your Medicare status updated in DEERS. You do not have to wait to get your Medicare card to update DEERS with your Medicare eligibility. You may be issued a new uniformed services ID card when you update DEERS with your Medicare information. At age 75, eligible family members will receive a permanent uniformed services ID card—meaning it will no longer expire. Until the permanent ID card is received, family members will need to continue to have their ID card updated by the expiration date.

    8. TRICARE Program Options TRICARE Prime Under age 65 Age 65 and over, but not eligible for premium-free Part A TRICARE For Life TRICARE Plus TRICARE Pharmacy Options TRICARE Dental Options Uniformed Services Family Health Plan We’ll discuss each of the programs in more detail. Please note that TRICARE Prime is available only to dual-eligible beneficiaries under age 65 or to those beneficiaries age 65 and over who do not qualify for premium-free Medicare Part A. We’ll discuss each of the programs in more detail. Please note that TRICARE Prime is available only to dual-eligible beneficiaries under age 65 or to those beneficiaries age 65 and over who do not qualify for premium-free Medicare Part A.

    9. TRICARE Prime for Dual-Eligibles TRICARE Prime enrollment fees waived for retired family members with Medicare Part B Most care received from primary care manager Administered by regional contractors If there are claims, then processed by Wisconsin Physicians Service (TFL branch) With TRICARE Prime, you’ll receive most care from an assigned primary care manager and he or she will provide referrals for specialty care. TRICARE Prime enrollment fees are waived for dual-eligible retired family members. If one family member with Medicare—$230 is waived If more than one family member with Medicare—$460 (whole amount) waived regardless of total number of dual-eligible family members. With TRICARE Prime there are no claims to file in most cases. However, if claims are paid, they are processed by Wisconsin Physicians Service—TFL branch (just like TFL claims). If interested, you’ll need to enroll with your regional contractor. North: Health Net Federal Services, Inc. South: Humana Military Healthcare Services, Inc. West: TriWest Healthcare Alliance With TRICARE Prime, you’ll receive most care from an assigned primary care manager and he or she will provide referrals for specialty care. TRICARE Prime enrollment fees are waived for dual-eligible retired family members. If one family member with Medicare—$230 is waived If more than one family member with Medicare—$460 (whole amount) waived regardless of total number of dual-eligible family members. With TRICARE Prime there are no claims to file in most cases. However, if claims are paid, they are processed by Wisconsin Physicians Service—TFL branch (just like TFL claims). If interested, you’ll need to enroll with your regional contractor. North: Health Net Federal Services, Inc. South: Humana Military Healthcare Services, Inc. West: TriWest Healthcare Alliance

    10. TRICARE For Life Available to all dual-eligible beneficiaries Care received from any Medicare provider MTF care on space-available basis only TRICARE second payer after Medicare (most services) Administered by Wisconsin Physicians Service (TFL branch) All dual-eligible beneficiaries are eligible to use TRICARE For Life—a program where TRICARE pays after Medicare, similar to a Medicare supplement. With TRICARE For Life, you can receive care from any Medicare provider—and usually Medicare providers are also TRICARE-authorized. Care also is available at military treatment facilities on a space-available basis only. There are no enrollment fees for TRICARE For Life. In most cases, when you get care, your provider will file the claim with Medicare. After Medicare pays its portion, Medicare forwards the claim automatically to TRICARE, and TRICARE pays the provider directly. Wisconsin Physicians Service (WPS) is the nationwide contractor for TRICARE For Life claims processing and customer service, so if you are using TRICARE For Life, you’ll contact WPS if you need assistance—not your regional contractor. All dual-eligible beneficiaries are eligible to use TRICARE For Life—a program where TRICARE pays after Medicare, similar to a Medicare supplement. With TRICARE For Life, you can receive care from any Medicare provider—and usually Medicare providers are also TRICARE-authorized. Care also is available at military treatment facilities on a space-available basis only. There are no enrollment fees for TRICARE For Life. In most cases, when you get care, your provider will file the claim with Medicare. After Medicare pays its portion, Medicare forwards the claim automatically to TRICARE, and TRICARE pays the provider directly. Wisconsin Physicians Service (WPS) is the nationwide contractor for TRICARE For Life claims processing and customer service, so if you are using TRICARE For Life, you’ll contact WPS if you need assistance—not your regional contractor.

    11. Medicare Card No TRICARE For Life card Just show this Medicare card along with your uniformed services ID card There is not a “TRICARE For Life” card. All you need to get care is a Medicare card along with your uniformed services ID card. Here’s a sample of what your Medicare card will look like. If you don’t have this or need another one, contact Medicare for assistance. There is not a “TRICARE For Life” card. All you need to get care is a Medicare card along with your uniformed services ID card. Here’s a sample of what your Medicare card will look like. If you don’t have this or need another one, contact Medicare for assistance.

    12. TRICARE For Life—How it Works You visit your Medicare provider Your provider files a claim with Medicare Medicare pays its portion and sends the remaining amount to TRICARE TRICARE pays remaining amount to your provider You get an explanation of benefits from Medicare and TRICARE When using TRICARE For Life in the United States, Guam, Puerto Rico, or the U.S. Virgin Islands, you should never have to file a paper claim. In most cases, the claims process is completely seamless to you. This is usually how it works: You visit any Medicare-certified provider and get care. You pay nothing at the time of service. Your provider files the claim with Medicare. Medicare pays its portion and then electronically forwards the claim to TRICARE (unless you have OHI, we’ll discuss this on slide 15). TRICARE pays the remaining amount directly to your provider. You receive an Explanation of Benefits (EOB) from Medicare and TRICARE.When using TRICARE For Life in the United States, Guam, Puerto Rico, or the U.S. Virgin Islands, you should never have to file a paper claim. In most cases, the claims process is completely seamless to you. This is usually how it works: You visit any Medicare-certified provider and get care. You pay nothing at the time of service. Your provider files the claim with Medicare. Medicare pays its portion and then electronically forwards the claim to TRICARE (unless you have OHI, we’ll discuss this on slide 15). TRICARE pays the remaining amount directly to your provider. You receive an Explanation of Benefits (EOB) from Medicare and TRICARE.

    13. Here’s a snapshot of your out-of-pocket costs when using TRICARE For Life. For a more detailed breakdown of costs associated with TFL, visit www.tricare.osd.mil/tfl/tflcostmatrix.html. Here’s a snapshot of your out-of-pocket costs when using TRICARE For Life. For a more detailed breakdown of costs associated with TFL, visit www.tricare.osd.mil/tfl/tflcostmatrix.html.

    14. Using TRICARE For Life Overseas Works the same in U.S. Territories as in the United States All other overseas locations: Must have Medicare Part B coverage even though Medicare coverage is not available Works like TRICARE Standard Visit any host nation provider Deductible: $150/individual or $300/family Cost-share: 25% after deductible is met File claims with overseas claims processor Wisconsin Physicians Service (overseas branch) In U.S. territories like Guam, Puerto Rico, and the U.S. Virgin Islands, Medicare coverage is available so TRICARE For Life works exactly the same in these locations as it does stateside. In all overseas locations, TRICARE For Life works like TRICARE Standard. However, you must still have Medicare Part B coverage, or you will lose eligibility for TRICARE all together. You will visit any TRICARE-authorized host nation provider and pay TRICARE Standard cost-shares after you’ve met an annual deductible. Essentially, if you are retired and living overseas, your health care will not change when you turn 65. You’ll continue to file claims exactly as you did before. Medicare does not provide coverage overseas. The only thing that’s different is that you’ll have to enroll in Medicare Part B. Since the contractor knows that Medicare cannot make any payments on such overseas claims, the contractor can process the claim without evidence of processing by Medicare. Note: WPS is also the overseas claims processor, but if you’re filing a TRICARE For Life overseas claim, you’ll use the overseas claims address for your overseas region not the TRICARE For Life claims address. Don’t be confused—just check the address in the TRICARE Beneficiary Handbook for your overseas area. In U.S. territories like Guam, Puerto Rico, and the U.S. Virgin Islands, Medicare coverage is available so TRICARE For Life works exactly the same in these locations as it does stateside. In all overseas locations, TRICARE For Life works like TRICARE Standard. However, you must still have Medicare Part B coverage, or you will lose eligibility for TRICARE all together. You will visit any TRICARE-authorized host nation provider and pay TRICARE Standard cost-shares after you’ve met an annual deductible. Essentially, if you are retired and living overseas, your health care will not change when you turn 65. You’ll continue to file claims exactly as you did before. Medicare does not provide coverage overseas. The only thing that’s different is that you’ll have to enroll in Medicare Part B. Since the contractor knows that Medicare cannot make any payments on such overseas claims, the contractor can process the claim without evidence of processing by Medicare. Note: WPS is also the overseas claims processor, but if you’re filing a TRICARE For Life overseas claim, you’ll use the overseas claims address for your overseas region not the TRICARE For Life claims address. Don’t be confused—just check the address in the TRICARE Beneficiary Handbook for your overseas area.

    15. Coordinating TRICARE For Life with Other Health Insurance (OHI) 1st Payer: Medicare 2nd Payer: OHI or Medicare supplement 3rd Payer: TRICARE 1st Payer: Employer-sponsored plan 2nd Payer: Medicare 3rd Payer: TRICARE If you have other health insurance which is not based on your current employment or that of a family member, for example a private Medicare supplement, Medicare is the primary payer, the OHI is secondary and TRICARE will become the third payer. In this situation, after Medicare pays its portion of the claim, Medicare forwards the claim to the other health insurer for processing and payment. If there is any remaining balance, you (the beneficiary) will need to file a paper claim with WPS and must include the EOB from Medicare and the OHI. Submit paper claims to: WPS-TRICARE For Life P.O. Box 7890 Madison, WI 53707-7897 Generally, if you have an employer (20+ employees) sponsored health plan based on current employment, that health plan is the primary or first payer for your health care claims, Medicare is second, and TRICARE is third. If there are under 20 employees Medicare is primary, OHI is second payer, and TRICARE is third payer. Medicaid is the only health coverage that pays after TRICARE. If you have other health insurance which is not based on your current employment or that of a family member, for example a private Medicare supplement, Medicare is the primary payer, the OHI is secondary and TRICARE will become the third payer. In this situation, after Medicare pays its portion of the claim, Medicare forwards the claim to the other health insurer for processing and payment. If there is any remaining balance, you (the beneficiary) will need to file a paper claim with WPS and must include the EOB from Medicare and the OHI. Submit paper claims to: WPS-TRICARE For Life P.O. Box 7890 Madison, WI 53707-7897 Generally, if you have an employer (20+ employees) sponsored health plan based on current employment, that health plan is the primary or first payer for your health care claims, Medicare is second, and TRICARE is third. If there are under 20 employees Medicare is primary, OHI is second payer, and TRICARE is third payer. Medicaid is the only health coverage that pays after TRICARE.

    16. TRICARE Plus Primary care enrollment option Available to beneficiaries not enrolled in TRICARE Prime or other HMO-like program Offered at some MTFs* Limited by MTF capacity Not transferable from one MTF to another * Check with your local MTF for program availability and details. TRICARE Plus is a primary care enrollment program that is offered at selected military treatment facilities. All beneficiaries eligible for MTF care (except those enrolled in TRICARE Prime, a civilian HMO, or Medicare HMO) can seek enrollment in TRICARE Plus if enrollment capacity exists. Note: TRICARE Plus is NOT transferable from MTF to MTF. Unlike Prime, TRICARE Plus is not portable and availability can change if MTF capacity decreases. Non-enrollment in TRICARE Plus does not affect TRICARE For Life benefits or other existing programs. If you don’t have Part B and the care is not available in the MTF you will be responsible for all the charges because you will not be covered by TRICARE.TRICARE Plus is a primary care enrollment program that is offered at selected military treatment facilities. All beneficiaries eligible for MTF care (except those enrolled in TRICARE Prime, a civilian HMO, or Medicare HMO) can seek enrollment in TRICARE Plus if enrollment capacity exists. Note: TRICARE Plus is NOT transferable from MTF to MTF. Unlike Prime, TRICARE Plus is not portable and availability can change if MTF capacity decreases. Non-enrollment in TRICARE Plus does not affect TRICARE For Life benefits or other existing programs. If you don’t have Part B and the care is not available in the MTF you will be responsible for all the charges because you will not be covered by TRICARE.

    17. TRICARE Pharmacy Program Robust pharmacy benefit Worldwide coverage Affordable Uniform formulary Four options for filling prescriptions TRICARE offers robust prescription drug coverage to all eligible beneficiaries, including those with dual-eligibility. TRICARE has a uniform formulary process that establishes three separate types of medications—or tiers: Tier 1: Formulary—Generic: Be aware that TRICARE policy requires the generic equivalent for any brand-name drug to be dispensed if available, unless your provider establishes medical necessity. Tier 2: Formulary—Brand Name Tier 3: Non-Formulary—Non-formulary medications can be dispensed, but at a higher cost. If your provider can establish medical necessity for a drug on the non-formulary list, you can obtain the prescription at the formulary cost. Costs for prescriptions are based on the category under which the drug falls—Tier 1, Tier 2, or Tier 3—and where the prescription is filled. We’ll discuss costs in just a moment. Find out what medications are considered formulary or non-formulary by visiting the Uniform Formulary Search Tool at www.tricareformularysearch.org/dod. Other pharmacy benefit information, including authorization requirements, quantity limits, frequently asked questions, and more, is available at www.tricare.osd.mil/pharmacy. As you may know, Medicare Part D now offers prescription drug coverage. There is no added value to purchasing Medicare Part D, and you are not required to do so to remain eligible for TRICARE’s robust pharmacy coverage. Please weigh your options carefully before purchasing Medicare Part D.TRICARE offers robust prescription drug coverage to all eligible beneficiaries, including those with dual-eligibility. TRICARE has a uniform formulary process that establishes three separate types of medications—or tiers: Tier 1: Formulary—Generic: Be aware that TRICARE policy requires the generic equivalent for any brand-name drug to be dispensed if available, unless your provider establishes medical necessity. Tier 2: Formulary—Brand Name Tier 3: Non-Formulary—Non-formulary medications can be dispensed, but at a higher cost. If your provider can establish medical necessity for a drug on the non-formulary list, you can obtain the prescription at the formulary cost. Costs for prescriptions are based on the category under which the drug falls—Tier 1, Tier 2, or Tier 3—and where the prescription is filled. We’ll discuss costs in just a moment. Find out what medications are considered formulary or non-formulary by visiting the Uniform Formulary Search Tool at www.tricareformularysearch.org/dod. Other pharmacy benefit information, including authorization requirements, quantity limits, frequently asked questions, and more, is available at www.tricare.osd.mil/pharmacy. As you may know, Medicare Part D now offers prescription drug coverage. There is no added value to purchasing Medicare Part D, and you are not required to do so to remain eligible for TRICARE’s robust pharmacy coverage. Please weigh your options carefully before purchasing Medicare Part D.

    18. Pharmacy Options and Costs You can have prescriptions filled at any MTF pharmacy at no cost to you. MTF pharmacies can accept a written prescription from any TRICARE-authorized provider, but be advised that the MTF may not stock every medication on the Uniform Formulary. If you did not get your prescription from a provider at the MTF, call first to see if your prescription is available. TRICARE offers a safe, convenient mail-order option that delivers prescriptions right to your mailbox. The program is administered by ESI (Express Scripts, Inc.), and it’s easy to register. After the MTF, the mail-order pharmacy is the least expensive option for you. Using the mail-order option is an excellent choice if you have regular medications for chronic conditions, such as high blood pressure, high cholesterol, or asthma. Contact ESI at 1-866-363-8667 or visit www.Express-Scripts.com/TRICARE for more details. Note: If you have OHI with a prescription drug plan, the mail order option normally is not available. There are more than 55,000 TRICARE network pharmacies across the United States, Guam, Puerto Rico, and the U.S. Virgin Islands, making it easy to have your prescription filled anywhere. Find a retail pharmacy near you by calling 1-866-363-8779 or visiting www.Express-Scripts.com/TRICARE. Please note that retail pharmacies are not located in all overseas locations. Lastly, you can have prescriptions filled at non-network pharmacies for a much higher cost. And, you’ll probably have to pay for the full amount then file a claim with TRICARE for reimbursement. We do not recommend having prescriptions filled at non-network pharmacies.You can have prescriptions filled at any MTF pharmacy at no cost to you. MTF pharmacies can accept a written prescription from any TRICARE-authorized provider, but be advised that the MTF may not stock every medication on the Uniform Formulary. If you did not get your prescription from a provider at the MTF, call first to see if your prescription is available. TRICARE offers a safe, convenient mail-order option that delivers prescriptions right to your mailbox. The program is administered by ESI (Express Scripts, Inc.), and it’s easy to register. After the MTF, the mail-order pharmacy is the least expensive option for you. Using the mail-order option is an excellent choice if you have regular medications for chronic conditions, such as high blood pressure, high cholesterol, or asthma. Contact ESI at 1-866-363-8667 or visit www.Express-Scripts.com/TRICARE for more details. Note: If you have OHI with a prescription drug plan, the mail order option normally is not available. There are more than 55,000 TRICARE network pharmacies across the United States, Guam, Puerto Rico, and the U.S. Virgin Islands, making it easy to have your prescription filled anywhere. Find a retail pharmacy near you by calling 1-866-363-8779 or visiting www.Express-Scripts.com/TRICARE. Please note that retail pharmacies are not located in all overseas locations. Lastly, you can have prescriptions filled at non-network pharmacies for a much higher cost. And, you’ll probably have to pay for the full amount then file a claim with TRICARE for reimbursement. We do not recommend having prescriptions filled at non-network pharmacies.

    19. TRICARE Dental Options The TRICARE Dental Program is available to eligible active duty family members and members of the National Guard and Reserve and/or their eligible family members. Benefits include: • Voluntary enrollment • Portable coverage worldwide • Single and family plans available • Low monthly premiums and cost-shares based on sponsor’s pay grade • Comprehensive coverage for most dental services; 100 percent coverage for preventive, diagnostic, and emergency services For more information, visit www.TRICAREdentalprogram.com or call 1-888-622-2256. The TRICARE Retiree Dental Program is available to retired service members and their eligible family members, including retired National Guard and Reserve members. Benefits include: • Voluntary enrollment • Portable coverage nationwide (not available overseas) • Single, two-party, and family plans available • Monthly premiums vary regionally by ZIP code; minimal deductibles and cost-shares • Comprehensive coverage for most dental services; visit any dentist within the TRDP service area For more information, visit www.trdp.org or call 1-888-838-8737.The TRICARE Dental Program is available to eligible active duty family members and members of the National Guard and Reserve and/or their eligible family members. Benefits include: • Voluntary enrollment • Portable coverage worldwide • Single and family plans available • Low monthly premiums and cost-shares based on sponsor’s pay grade • Comprehensive coverage for most dental services; 100 percent coverage for preventive, diagnostic, and emergency services For more information, visit www.TRICAREdentalprogram.com or call 1-888-622-2256. The TRICARE Retiree Dental Program is available to retired service members and their eligible family members, including retired National Guard and Reserve members. Benefits include: • Voluntary enrollment • Portable coverage nationwide (not available overseas) • Single, two-party, and family plans available • Monthly premiums vary regionally by ZIP code; minimal deductibles and cost-shares • Comprehensive coverage for most dental services; visit any dentist within the TRDP service area For more information, visit www.trdp.org or call 1-888-838-8737.

    20. US Family Health Plan TRICARE Prime option Available in six areas of the United States Eligible beneficiaries: Active duty family members Retirees and their eligible family members (including those age 65 and over) Cannot use other TRICARE options (including MTF and pharmacy benefits) listed in this briefing if enrolled The Uniformed Services Family Health Plan (USFHP) is an additional TRICARE Prime option available to active duty family members and retired service members and their eligible family members, including those age 65 and over, through networks of community-based hospitals and physicians in six areas of the country. Note: Although dual-eligible beneficiaries are not required to have Medicare Part B coverage to enroll in the USFHP, we strongly recommend that you get Part B when you are first eligible to avoid surcharges if you decide to enroll at a later date (10% for each 12-month period after your initial enrollment period). For instance, if you move from your USFHP location and its not offered in your new location, you will not be eligible for TRICARE without Medicare Part B. If you enroll in the USFHP, you are not eligible to use other TRICARE options/benefits including TRICARE pharmacy benefits discussed in today’s presentation. For additional information, visit www.usfamilyhealthplan.org. The Uniformed Services Family Health Plan (USFHP) is an additional TRICARE Prime option available to active duty family members and retired service members and their eligible family members, including those age 65 and over, through networks of community-based hospitals and physicians in six areas of the country. Note: Although dual-eligible beneficiaries are not required to have Medicare Part B coverage to enroll in the USFHP, we strongly recommend that you get Part B when you are first eligible to avoid surcharges if you decide to enroll at a later date (10% for each 12-month period after your initial enrollment period). For instance, if you move from your USFHP location and its not offered in your new location, you will not be eligible for TRICARE without Medicare Part B. If you enroll in the USFHP, you are not eligible to use other TRICARE options/benefits including TRICARE pharmacy benefits discussed in today’s presentation. For additional information, visit www.usfamilyhealthplan.org.

    21. In Conclusion… TRICARE and Medicare work together to provide affordable, comprehensive coverage for dual-eligible beneficiaries We are here to help—many resources available TRICARE regional contractors Wisconsin Physicians Service Pharmacy and dental contractors TRICARE Web site: www.tricare.osd.mil Questions? If you have any comments or additional feedback to this presentation or any other marketing and education materials, please visit www.tricare.mil/evaluations/feedback. If you have any comments or additional feedback to this presentation or any other marketing and education materials, please visit www.tricare.mil/evaluations/feedback.

More Related