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Reimbursement

Defense Health Agency (DHA) (http://www.tricare.mil/) is the source for all reimbursement rates for the TRICARE program. The information below will assist with determining TRICARE payment or Allowable Charge rates for TRICARE covered benefits determined by the TRICARE Policy and Reimbursement Manuals. The maximum amount that TRICARE can pay a provider for a procedure or service is known as the TRICARE allowable charge. The TRICARE allowable charge is tied by law to Medicare's allowable charge whenever practical and may vary based on the prevailing rate in a given location.

TRICARE For Life

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. Claims should be filed to Medicare first as the primary insurance.

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).

 

 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 calendar 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 visit http://www.tricare.mil/CoveredServices/IsItCovered.aspx

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: http://www.tricare.mil/CoveredServices/IsItCovered/Exclusions.aspx

See also https://www.tricare.mil/Costs for the TFL Cost Matrix.

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 rates and reimbursement information. They have many resources available in the provider section of their site for you to utilize.