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Does Your Patient Have Medicare?

No, my patient does not have Medicare coverage.

If your patient has TRICARE coverage but no Medicare entitlement then TRICARE4u.com is not the correct website for you. There are three prime contractors based on your geographic location. Please choose your location below and contact them with any questions you have regarding your patient.

TRICARE Prime Region Websites

 

 

 

Yes, my patient has Medicare coverage.

You are in the right place. TRICARE For Life (TFL) is Medicare-wraparound coverage for TRICARE beneficiaries who have Medicare Part A and Medicare Part B, regardless of age or place of residence.

TFL provides comprehensive health care coverage. Beneficiaries have the freedom to seek care from any Medicare-participating or Medicare-nonparticipating provider, or military hospital or clinic on a space-available basis. Medicare-participating providers please file your claims with Medicare. After paying its portion, Medicare automatically forwards the claim to TRICARE for processing (unless there is other health insurance [OHI]). TRICARE pays after Medicare and OHI for TRICARE-covered health care services.

TRICARE For Life (TFL) is a benefit available to retired U.S. Military and their families. It encompasses the processing of all TRICARE claims for services rendered within the 50 United States and the District of Columbia, as well as Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa and the Northern Mariana Islands, to individuals who have dual eligibility under both TRICARE and Medicare. Medicare and TFL work together to minimize the beneficiaries’ out-of-pocket expenses.

There are instances when some health care costs may not be covered by Medicare and/or TFL. See the chart below which breaks down what the TRICARE For Life beneficiary should pay based on how the service is covered (please note that the chart below is the general rule and there are exceptions).

 

Coverage for Services

 How the service is covered

What the beneficiary pays

By both Medicare and TRICARE For Life    
 

*Medicare pays first

*TRICARE For Life pays the remaining balance

*The beneficiary pays nothing

By TRICARE For Life but not Medicare    
 

*TRICARE For Life pays first

*Medicare pays nothing

*The beneficiary pays the TRICARE For Life fiscal year deductible and cost shares

By Medicare but not TRICARE For Life    
 

* Medicare pays first

*TRICARE For Life pays nothing

*The beneficiary pays the Medicare deductible and coinsurance

Not covered by Medicare or TRICARE For Life    
 

* Medicare pays nothing

*TRICARE For Life pays nothing

*The beneficiary pays the entire bill

 

To determine if Medicare covers a specific service, visit www.medicare.gov or call 1-800-633-4227. To determine if TFL covers the service, visit the Defense Health Agency (DHA) site.

Coordinating TRICARE For Life with Other Health Insurance besides Medicare

How Medicare coordinates with Other Health Insurance (OHI) depends on whether or not the OHI is based on current employment. In either case, TRICARE For Life (TFL) is the last payer. If the beneficiary has OHI that is not based on their or their family member’s current employment, Medicare pays first, the OHI pays second, and TFL pays last.

What is covered?

TRICARE For Life and Medicare cover proven, medically necessary, and appropriate care. TFL has special rules and limitations for certain types of care, and some types of care are not covered at all. TFL policies are very specific about which services are covered and which are not.

For more information on what specific services are covered please click here.

Medicare also has limits on the amount of care it covers and, in some cases TFL may cover these health care services after Medicare benefits run out. To determine if Medicare covers a specific service visit www.medicare.gov or call 1-800-633-4227.

Exclusions

Some common examples of services that are excluded from TFL coverage are acupuncture, assisted living facility care, chiropractic care, custodial care, elevators or chair lifts, exercise equipment or programs, long term care, nursing homes, and weight loss products. The full list of policy exclusions can be found here.

Click here to find out if a specific procedure code is on the No Government Pay Procedure Code List. If the code is on this list it is a procedure that the Defense Health Agency has determined to never cover.

I need more information

The Defense Health Agency is your official source for TRICARE information. They have many resources available in the provider section of their site for you to utilize.