Updated: July 9, 2004
TRICARE For Life and Dual Eligibility
When TRICARE beneficiaries (other than eligible active duty family members) become entitled to Medicare Part A, on the basis of age or disability/end-stage renal disease and purchase Medicare Part B, they do not experience a break in TRICARE coverage. TRICARE For Life (TFL) pays secondary to Medicare.
Eligibility:
TFL is available for all dual TRICARE-Medicare eligible uniformed services retirees, including retired members of the Reserve Component who are in receipt of retired pay, Medicare-eligible family members, Medicare-eligible widows/widowers, certain former spouses, and beneficiaries under age 65 who are also entitled to Medicare Part A because of a disability or chronic renal disease. Dependent parents and parents-in-law are not eligible for TRICARE benefits – except TRICARE Senior Pharmacy benefits – and they may continue to receive services within a military treatment facility on a space-available basis. In order to be eligible for TRICARE Senior Pharmacy benefits, they must be entitled to Medicare Part A, and if they turned age 65 on or after April 1, 2001, be enrolled in Medicare Part B.
Cost to Beneficiaries:
There are no enrollment fees for TFL. Beneficiaries, other than active duty family members, are required to purchase Medicare Part B and must pay the appropriate Medicare Part B monthly premiums. Beneficiaries may check with the Social Security Administration online at www.ssa.gov, call toll-free at (800) 772-1213 or visit Medicare online at www.medicare.gov for more information about enrolling in Medicare Part B and monthly premiums that apply.
Benefits:
- For services payable by both Medicare and TFL, Medicare pays first, any other health insurance pays second, and the remaining beneficiary liability may be paid by TFL.
- For services received from a civilian provider, the provider first files claims with Medicare. Medicare pays its portion and electronically forwards the claim to TFL for processing. TFL sends its payment for the remaining beneficiary liability directly to the provider, and beneficiaries receive a Medicare summary notice (from Medicare) and a TFL explanation of benefits (EOB) that indicates the amount paid to the provider. The claims processing linkage between Medicare and TFL is now available for the under age 65 dual-eligible population. All TFL claims for dual-eligible beneficiaries under age 65, as well as age 65 and over, will go to a new, centralized claims processor. The new contractor, Wisconsin Physicians Service (WPS), has agreements with each Medicare carrier allowing Medicare to submit claims directly to WPS TFL or, before transition, to the regional TFL claims processor. (The regional phase-in dates for the WPS TFL contract are listed below.) The beneficiary's Social Security Number must be in the Defense Enrollment Eligibility Reporting System (DEERS) for the electronic claims process to work.
- For services payable by TFL, but not Medicare, such as overseas care, TFL pays the same as for TRICARE Standard beneficiaries. Beneficiaries are responsible for the TRICARE Standard fiscal year deductible and cost shares.
- For services payable by Medicare, but not TFL, such as chiropractic services, Medicare pays as usual, however, TFL makes no payment. Beneficiaries are responsible for Medicare coinsurance and deductibles.
- For services not payable by Medicare or TRICARE, beneficiaries are responsible for the entire bill.
Medicare Part B and Eligibility Based on Age:
Through the Defense Manpower Data Center's (DMDC's) Defense Enrollment Eligibility Reporting System (DEERS) beneficiaries are notified within 90 days before their 65th birthday that their medical benefits are about to change. DMDC asks beneficiaries to contact the nearest Social Security Administration office or Medicare regarding their eligibility for Medicare. Beneficiaries must elect to enroll in Medicare Part B in order to be eligible for TFL. Once a beneficiary is enrolled in Medicare Part B, TFL pays secondary to Medicare beginning on the first day of the month the beneficiary turns 65. If a beneficiary's 65th birthday is on the 1st day of the month, eligibility for Medicare and TFL begins on the 1st day of the previous month. Beneficiaries may visit the Social Security Administration online at www.ssa.gov or call toll free at (800) 772-1213 (TTY/TDD [800] 325-0778) for more information on enrolling in Medicare Part B.
Beneficiaries who are age 65 and older and who have Medicare Part A only may enroll in Medicare Part B during the general enrollment period, which runs from January 1 to March 31 every year. Medicare Part B coverage begins on July 1 of the year in which they enroll.
One of the provisions of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 allows uniformed services beneficiaries who would be eligible for TFL but are not enrolled in Medicare Part B to enroll without premium surcharge during a special enrollment period through December 31, 2004. Beneficiaries who are entitled to Medicare Part A but are not enrolled in Medicare Part B will be automatically enrolled in Medicare Part B without a premium surcharge during a special enrollment period that will continue through December 31, 2004. In early fall 2004, these beneficiaries will receive a form in the mail, giving them the option of selecting any month in 2004 as their Medicare Part B entitlement date, or refusing Part B altogether.
The law also provides for the elimination of Medicare Part B premium surcharges for those who enrolled between 2001 through 2004 and were required to pay a premium surcharge because they did not enroll when first eligible. Beneficiaries whose current Medicare Part B entitlement began between January 2001 and December 2004 and who are paying a premium surcharge (more than $66.60 a month) for Medicare Part B, will have their Part B premium reduced to the 2004 rate of $66.60 beginning January 2004, or if later, their Part B entitlement date. In early fall 2004, these beneficiaries will receive a refund for any excess premium surcharges they paid beginning in January 2004.
Beneficiaries who enrolled in Medicare Part B between January and March of 2004 (the Medicare General Enrollment Period) will have the option to retain their July 2004 entitlement date or change their entitlement date to any other month within 2004.
Medicare Part B and Eligibility Based on Disability or Chronic Renal Disease:
Beneficiaries entitled to Medicare Part A because of a disability or chronic renal disease MUST enroll in Medicare Part B to be eligible for TRICARE For Life (if other than active duty family members). They may enroll during the general enrollment period that occurs January 1 through March 31 of each year. Part B coverage begins the following July.
One of the provisions of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 allows uniformed services beneficiaries who would be eligible for TFL but are not enrolled in Medicare Part B to enroll without premium surcharge during a special enrollment period through December 31, 2004. Beneficiaries who are entitled to Medicare Part A but are not enrolled in Medicare Part B will be automatically enrolled in Medicare Part B without a premium surcharge during a special enrollment period that will continue through December 31, 2004 In early fall 2004, these beneficiaries will receive a form in the mail, giving them the option of selecting any month in 2004 as their Medicare Part B entitlement date, or refusing Part B altogether.
The law also provides for the elimination of Medicare Part B premium surcharges for those who enrolled between 2001 through 2004 and were required to pay a premium surcharge because they did not enroll when first eligible. Beneficiaries whose current Medicare Part B entitlement began between January 2001 and December 2004 and who are paying a premium surcharge (more than $66.60 a month) for Medicare Part B, will have their Part B premium reduced to the 2004 rate of $66.60 beginning January 2004, or if later, their Part B entitlement date. In early fall 2004, these beneficiaries will receive a refund for any excess premium surcharges they paid beginning in January 2004.
Beneficiaries who enrolled in Medicare Part B between January and March of 2004 (the Medicare General Enrollment Period) will have the option to retain their July 2004 entitlement date or change their entitlement date to any other month within 2004.
Dual-eligible beneficiaries under age 65 enrolled in Medicare Part B (other than active duty family members) keep their TRICARE Prime eligibility and are not required to pay TRICARE Prime enrollment fees.
(Active duty family members, regardless of age, do not have to enroll in Medicare Part B to remain eligible for TRICARE. A special enrollment period is available for active duty family members whose sponsor retires. They may enroll in Part B at any time before the active duty sponsor retires or during the eight-month period that begins the month the active duty sponsor retires.)
TRICARE For Life Overseas:
Eligible beneficiaries living overseas may use TFL as long as they are enrolled in Medicare Part B. Since Medicare does not typically provide health care coverage overseas, TRICARE provides the same TRICARE Standard benefits available to retirees under age 65, and beneficiaries are responsible for the TRICARE Standard cost shares and deductibles.
Services in Military Treatment Facilities
Beneficiaries using TFL may continue to receive care in military treatment facilities on a space-available basis. Under the program TRICARE Plus, they may be allowed to enroll in a military treatment facility for primary care. TRICARE Plus is based on local availability.
TRICARE For Life and Other Health Insurance (OHI):
Beneficiaries with other health insurance (OHI), such as a Medicare supplement or employer-sponsored medical coverage, may use TFL. However, by law, TFL will pay a claim only after all OHIs have paid.
TFL works differently with other coverages depending on whether a service is payable by Medicare. Most of the time, after Medicare processes the claim, it is automatically forwarded by Medicare to the beneficiary's OHI. After the OHI processes the claim, the beneficiary needs to file a paper claim with WPS TFL or the regional TFL claims processor. TFL may reimburse any remaining beneficiary liability for TRICARE covered services.
If a beneficiary receives a service that is not covered by Medicare, such as a prescription medication, TFL follows TRICARE's other health insurance rules in determining what portion to pay. The beneficiary may need to file a claim with WPS TFL or, before transition, the regional TFL claims processor after the other coverage pays its portion. TRICARE pays either the amount it would have paid as the primary plan or any remaining beneficiary liability after all OHI has paid, whichever is less.
Paper claims must be submitted to WPS TFL or the regional TFL claims processor using a DD Form 2642 (CHAMPUS claim form), along with a copy of the provider's itemized bill, the Medicare summary notice, and EOBs from all OHIs. TFL claims must be filed within one year from the date the care is received. Beneficiaries may receive assistance with claims filing procedures from WPS TFL or the regional TFL claims processor, from a local beneficiary counseling and assistance coordinator, a TRICARE service center, or from the TRICARE Web site at www.tricare.osd.mil/claims/default.htm
Canceling OHI:
Beneficiaries must contact their OHI administrator to cancel their OHI. After canceling OHI, beneficiaries MUST contact the WPS TFL or the regional TFL claims processor to notify TFL of the OHI cancellation.
For More Information:
TFL claims processing is currently in a state of transition. The outgoing regional claims processor will continue to process claims for services beneficiaries receive until WPS TFL is implemented in the region. For information about current claims processors and to find out what region you are in, go to: http://www.tricare.osd.mil/main/chart.html
WPS TFL is being phased-in as follows:
| Region 11: | April 1, 2004 |
| Regions 2/5: | June 1, 2004 |
| Regions 9/10/12: | July 1, 2004 |
| Regions 3/4: | August 1, 2004 |
| Region 1: | September 1, 2004 |
| Regions 7/8 (Central): | October 1, 2004 |
| Region 6: | November 1, 2004 |
Once implemented in a region, beneficiaries may call WPS TFL (866) 773-0404, or TDD (866) 773-0405. For basic TFL information, they may contact WPS TFL or the TRICARE Information Service at (888) DOD-LIFE, (888) 363-5433. Beneficiaries may visit the TRICARE Web site at www.tricare.osd.mil/tfl or the WPS Web site at www.tricare4u.com for more information about TFL.
Fact sheets on eligibility, TRICARE Plus and DEERS are available at www.tricare.osd.mil/Factsheets/index.cfm. 