If you are a service member and retire from service, you may be eligible for continued care through a program known as TRICARE for Life. TRICARE for Life is a supplementary medical insurance program available specifically for military retirees. The question many people have is whether Medicare combined with TRICARE for Life enough insurance. To answer this question, it is important to understand what Medicare and TRICARE for Life offers as well as how they work together.
The Short Answer Is Yes… But
The simple answer to this question is yes, Medicare and TRICARE for Life is enough insurance but they must be combined correctly. One thing to keep in mind is to take advantage of TRICARE for Life you must pay Medicare part B premiums.
What is Medicare?
Medicare is the federal health insurance program available to Americans who are 65 years of age or older. It is also made available to those who have been diagnosed with certain chronic ailments. In total, Medicare has four separate parts which all serve different purposes.
Medicare Part A covers inpatient hospitalization costs. In most cases, it is free to every retiree and people who were already automatically enrolled in Medicaid when they turned 65. Medicare part a covers inpatient care, hospice care services, and home healthcare services. While it covers most things, it does not cover everything in these categories. For example, frequent or lengthy hospitalizations may not be entirely covered. Similar to traditional health insurance, there are also co-pays and deductibles which must be met.
Medicare Part B covers a majority of costs dealing with physician fees and lab fees. Generally, it will pay 80% of all costs of the services which means you are responsible for 20%. Most people are automatically enrolled in Medicare Part B when they turn 65 at a rate of just under $100 per month. The annual deductible is $140 per year.
Medicare Part C allows beneficiaries to access their Medicaid benefits through a private managed care plan. This is often referred to as Medicare advantage. The benefit of these plans is they are extremely customizable which allows you to buy plans tailored to your individual circumstances. Since you can select your own plan, the premiums and deductibles will vary.
The final portion of Medicare is Part D. This is the part which covers prescription drugs. There will be a monthly premium as well as deductibles and co-pays. Over time, Part D will provide substantial protection against the high cost of prescription drugs but can be frustrating because the deductibles and co-pays can be complicated.
What is TRICARE for Life?
TRICARE for Life is designed to complement Medicare Part A and Part B. The goal of this program is to activate where Medicare leaves off. For example, it covers acute medical services not covered under Medicare Part A or Part B. Compared to Medicare it offers substantial coverage for things like hospitalization deductibles and co-pays as well as a percentage of coinsurance for doctor visits, durable medical equipment, and emergency room visits not generally covered by Medicare Part B.
If you have TRICARE for Life, you will pay nothing out of pocket for a majority of hospitalizations lasting less than 150 days.
According to MilitaryAuthority.com
“The general rule is that if Medicare covers most of it, TRICARE for Life covers the rest of it.”
What You Pay
To participate in the TRICARE for Life you do not need to pay any enrollment fees but you do have to pay for Medicare Part B. As with regular insurance, Medicare Part B requires monthly premium payments. The payments are based on your income so they will vary from person to person.
How the Process Works When You Go to a Health Care Provider
The process always follows the same basic steps but there are a few specific differences based on the type of procedure and how much of your Medicare benefits remain. Generally, your provider will file your claim with Medicare and/or TRICARE for Life depending on your situation.
If Care is Medically Necessary
If the care is covered by Medicare and TRICARE and is medically necessary, then Medicare will pay its portion of the claim first. TRICARE for Life will then pay any remaining amount. In this situation, you will almost never have to pay for any of the medical expenses.
If Care is Medically Necessary but You Have Used All Your Medicare Benefits
This situation is similar to the first with a key exception, you do not have any Medicare benefits remaining. This makes TRICARE the primary payer. Assuming this is a TRICXARE covered expense, you will still be responsible for the Tricare for Life deductible and any associated cost-share.
If Care is Not Medically Necessary
If you are getting treatment that is not considered medically necessary, then neither Medicare or TRICARE will pay for the bill because they are not responsible for it. You will be responsible for the entire amount but do have an opportunity to appeal any payment denial if you believe it was made on the basis of medical necessity. If you appeal the decision and Medicare decides it was medically necessary and covers a portion of the bill, then TRICARE will cover the rest as they will always make the same determination as Medicare. Typically, you don’t need to appeal to both entities, only Medicare. TRICARE will following any determination Medicare makes.
Pharmacy/Prescription Drug Coverage Questions
There are several different ways you can address pharmacy and prescription drug cost concerns. The most important factor to remember is if you are enrolled in any TRICARE health plan then you have already been automatically enrolled in a pharmacy program.
TRICARE has two different pharmacy programs so it is important to make sure you know which one you were enrolled in. The first is the TRICARE Pharmacy Program. This is plan provides prescription drug coverage at retail pharmacies. The second program is the TRICARE Maintenance Medications Program. This program allows you to get refills through the TRICARE Pharmacy Home Delivery services or use a military pharmacy.
IMPORTANT NOTE: To be enrolled in the TRICARE Maintenance Medications Program you must also be enrolled in the TRICARE Pharmacy Program.
Do you Need Medicare Supplement Plans or Medicare Advantage?
Very rarely does anyone need an additional Medicare Supplement Plan or Medicare Advantage. TRICARE for Life essentially acts a supplement plan so an additional plan would be redundant and increase your monthly premiums. Plus, you are already paying for Medicare Part B to activate your TRICARE for Life policy.
What if You Have Other Health Insurance (OHI)?
Generally, other health insurance (OHI) functions similarly to Medicare. OHI will process the claim and then TRICARE for Life will be a secondary provider. This is a popular option for people living outside of the U.S. as Medicare will not offer coverage overseas. It is also popular for people who need other health insurance because they do not have Medicare.
What if Your Provider Has Opted Out of Medicare?
It is important to remember some medical providers have opted out of Medicare. This means Medicare will not be billed and you will be charged any amount for your care since there are no negotiated rates. TRICARE will pay up to 20% of the amount allowed by TRICARE for that service and you will be responsible for the rest. If you have OHI, it will be billed first and TRICARE will be billed second.
What About Dental Care?
Medicare does not provide coverage for most dental care but TRICARE does offer two supplemental dental programs. The first is TRICARE Retiree Dental Program (TRDP). This program is available for retired service member and eligible family members. Some survivors and Medal of Honor recipients may obtain this coverage as well. The second program is TRICARE Dental Program (TDP). This program is like TRDP but for active duty service members.
How Does TRICARE Work Overseas?
The most important fact to remember is for TRICARE for Life to work overseas, you must have Medicare Part A and Part B even though they will not provide any overseas coverage. TFL is the only payer for your TRICARE services unless you have OHI. In most cases, TRICARE for Life will provide the same coverage overseas as they will in the United States. This includes the same deductible and cost-shares.
Excluding emergency care, you will normally need to get authorization before receiving care. You will often need to pay up front when submitting claims to the processing address for the area you received care from.
Is Medicare and TRICARE for Life Enough Insurance?
For most people, Medicare and TRICARE for Life is enough insurance. Keep in mind, you are not only receiving Medicare but also paying for Part B to keep your TRICARE for Life insurance active. If additional coverage is needed for prescription drugs or dental benefits, TRICARE offers several add-on plans to choose from. The two situations you may need additional coverage is if you are not retired/eligible for Medicare yet and if you are living overseas. In these situations, other health insurance will likely be necessary and used in conjunction with TRICARE for Life.