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A change to Tricare Policy and win for Disabled Retirees
Recently, a known veteran advocate fought for four (4) years to win
a Department of Veterans Affairs claim (awarded 90% IU - effective 100%)
and three (3) years to win a Social Security Disability claim
(awarded 100% disability backdated to July 2006).
The Social Security Administration properly backdated Medicare Part A coverage
 to January 2009, and Part B coverage to November 2010. The disabled veteran
had paid the premiums and had been covered under Tricare Prime health
insurance for himself and family since 2006, and could have gone to the
Veterans Health Administration Regional Hospital; however, the facility is 160 miles
one way.
In April 2010, the veteran suffered from a service-connected problem and visited
his Tricare Prime Primary Care Manager. The physician ordered a hip x-ray at
the next door hospital. When the x-rays came back negative, the physician
referred the veteran to an orthopedic surgeon in the Tricare Prime network.
After examining the veteran,the physician order a MRI on the lower back.
The resulting diagnosis was sciatica due to a further degredation of the s
ervice-connected injury to the lumbarsacral spine. Tricare Prime paid the claims in
May 2010.
In June 2011, the Tricare Prime subcontractor recouped $376 for its prior payment
to the hospital based on the Medicare Part A backdate,and the failure of the veteran
to obtain Part B coverage. The hospital billed the veteran $2,672. The veteran fought back.

A Change to Tricare Policy - A Win for Disabled Retirees
Based on facts, the veteran contended he did not have Medicare on the date of service,
had paid the premiums for Tricare Prime, therefore had a contract for healthcare insurance
with Tricare. Additionally, Tricare Prime never refunded or offered to refund the premiums,
informed the veteran of the recoupment nor offered the veteran an appeal, and told the
veteran no refund was due because the veteran was covered through
September 30, 2011. Finally, the veteran charged that Tricare Prime had misinterpreted
the law, taking away coverage when the intent of the law was to assist those having no
coverage, and that the recoupment violated the Patient Protection and Affordable Care
Act (PPACA)Sections 2712 - Prohibitions on Recissions and Section 2719 -
Appeals Process in terminating the disabled veteran.
The result is in the highlighted paragraph.
TRICARE For Life is TRICARE's Medicare-wraparound coverage
WHAT IS TRICARE FOR LIFE?
TRICARE For Life (TFL) is TRICARE's
Medicare-wraparound coverage available to all
Medicare-eligible TRICARE beneficiaries,
regardless of age or place of residence; provided
they have Medicare Part A and Part B. There is no
paperwork associated with TFL-beneficiaries
automatically gain coverage when they meet
the requirements,
With TFL, Medicare becomes your primary
insurance, and TRICARE acts as your secondary
payer, which minimizes your out-of-pocket
expenses. TRJCARE benefits include covering
Medicare's coinsurance and deductible.
'Wisconsin Physicians Service (\VPS) is the
contractor that administers the TFL program and
should be your primary contact for TRICARErelated
customer service needs in the United States
or U.S. territories (Arnerican Samoa, Guam. the
Northern Mariana Islands, Puerto Rico, and the
U.S. Virgin islands). If you are overseas, contact
your TRICARE Overseas Program (TOP)
Regional Call Center with TFL questions.
You may contact your regional contractor for
help with prior authorizations.
WHAT IS MEDICARE?
Medicare is health insurance for people age 65
or older, as well as for people of any age because
of disability, end-stage renal disease (ESRD),
amyotrophic lateral sclerosis (ALS), or
mesothelioma. Medicare is administered by the
Centers for Medicare & Medicaid Services (CMS).
BASIS FOR MEDICARE ENTITLEMENT
Age 65 or older: The Social Security
Administration determines your entitlement
to Medicare Part A based on your work history
or your spouse's work history. You are entitled to
premium-free Medicare Part A at age 65 if you
have 40 quarters, or 10 years, of Social Securitycovered
employment.
If you are not entitled to premium-free Medicare
Part A when you turn 65 under your own Social
Security number (SSN), you must file for benefits
under your spouse's (including divorced or
deceased spouses) SSN if he or she is 62 or older.
If your spouse is not yet 62, you should enroll in
Medicare Part B at age 65 to avoid paying an
enrollment surcharge for late enrollment. You
should then file for Part A benefits under your
spouse's record when he or she turns 62.
This fact sheet is not all-inclusive. For additional information. please visit 11'1,Vl'.'.JL'iLI,!LLJrP.
November 2011
PDF processed with CutePDF evaluation edition www.CutePDF.com
Disability: You are entitled to Medicare Part A
and Medicare Part B beginning the 25th month of
receiving Social Security disability payments. CMS
will notify you of your Medicare entitlement
start date.
ESRD: If you are eligible for premium-free
Medicare Part A due to ESRD, you can enroll
in Medicare Part B by visiting your local
Social Security office or by calling the SSA at
1-800-772-1213. TTY users should call
1-800-325-0778.
ALS: If you have ALS (also called Lou Gehrig's
diseases; you autcmatically get P-at=t-A~andPart-B
the month your disability benefits begin.
Mesothelioma: If you have been diagnosed with
an asbestos-related disease and lived in Lincoln
County. Montana, for a total of at least six months
during a period ending 10 years or more before
the diagnosis, you are eligible for Medicare. Your
Medicare coverage will be effective the month
after you sign up.
IF I HAVE TRICARE, DO I NEED MEDICARE?
TRICARE beneficiaries entitled to premium-free
Medicare Part A must have Medicare Part A
and Medicare Part B coverage to remain
TRICARE-eligible. You are ineligible for
TRICARE benefits for any period of time that
you have Medicare Part A but not Part B, with
the following exceptions:
----- - Active duty service members (ADSl\tls) and
active duty family members (ADFMs): If you
are an ADSM or ADFM entitled to premium-free
Medicare Part A, you do not need Medicare Part B
to keep your TRICARE benefits. ADSMs and
ADFMs may enroll in Medicare Part B during the
special enrollment period-which is any time you
or your sponsor is on active duty or within the first
eight months following your sponsor's retirement
date-or following the loss of TRICARE,
whichever occurs first. The surcharge for late
enrollment does not apply when you enroll in
Part B during a special enrollment period.
However, if you wait to enroll until after your
sponsor has retired, you will have a break in
TRICARE coverage until Part B takes effect.
If you do not enroll in Part B during the special
enrollment period, you may enroll during the
general enrollment period (Lanuary l=Marcli 31
each year). Your Part B coverage will be effective
July 1 of the year you enroll and you will pay an
additional 10 percent for each 12-month period
th~atyou were eligible to enroll bl.lt did not. T~e
Department of Defense (DoD) strongly encourages
you to enroll in Medicare Part B prior to your
sponsor's retirement date to avoid a break in
. TRICARE coverage and late-enrollment
surcharges. Note: ADSMs and ADFMs with
ESRD do not have a special enrollment period,
and should enroll when first eligible.
US Family Health Plan (USFHP), TRICARE
Reserve Select (TRS), or TRICARE Retired
Reserve (TRR) enrollees: If you are enrolled in
the USFHP, TRS, or TRR and are eligible for
premium-free Medicare Part A, you do not need
Medicare Part B to keep your current USFHP,
TRS, or TRR benefits. However, if you do not
enroll in Part B when first eligible, you may be
required to pay the 10 percent Medicare surcharge
for each 12-month period you were eligible to
enroll in Part 13, but did n.9J:.DoD ~[ol}g]y
recommends that you enroll in Medicare Part B
when you are first eligible. Note: If you disenroll
from USFHP or move to a non-USFHP area, you
will not be eligible for other TRICARE programs
if you do not have Part B. USFHP enrollees with
ESRD will be responsible for the full cost of
ESRD-re1ated expenses if they do not enroll in
Medicare Part B.
Retroactive Disability Determination: If you
are a retiree or retiree family member and were
awarded disability based on an appeal with a
Medicare Part B effective date of October 2009
or later, you are not required to retroactively enroll
in Medicare Part B back to your Part A effective
date. You remain TRICARE-eligible for the
retroactive period when you had Part A only.
HOW TRICARE FOR LIFEWORKS WITH
MEDICARE IN THE UNITED STATES AND
U.S. TERRITORIES
Covered by TRICARE and Medicare:
When you see a participating or nonparticipating
Medicare provider, you have 110 out-of-pocket costs
for services covered by both Medicare and TFL.
Most health care services fall into this category.
After Medicare pays its portion of the claim,
TRICARE pays the remaining amount and you
pay nothing. As the primary payer, Medicare
approves health care services for payment.
Covered Medicare but not TRICARE:
When v., ou receive care that is covered bv.Medicare
only (e.g., chiropractic care), Medicare processes
the claim as the primary payer. TFL makes no
payment, regardless of any action Medicare takes.
You are responsible for the Medicare deductible
and cost-shares.
Covered bv. l'RICARE:\Vhen v,ou receive care
that is covered only by TEL (e.g., care received
overseas), TRICARE processes the claim as the
primary payer. You are responsible for the
applicable TFL deductible and cost-shares.
TFL claims are normally filed with Medicare
first; however, when a health care service is not
covered by Medicare, the claim may be filed
directlv with WPS/TFL. unless you have other -' '-
health insurance (OHT). If you are overseas,
contact your TOP Regional Call Center with
TEL questions.
Not Covered TRICARE or Medicare:
IfMedicare does not pay because it determines
that the care is not medically necessary, TRICARE
also does not pay. You may appeal Medicare's
decision. If Medicare reconsiders and provides
coverage, TRICARE also reconsiders coverage.
If a health care service is covered by both Medicare
and TFL, but Medicare does not pay because you
have used up your Medicare benefit, TRICARE
becomes the primary payer. In this case, you
are responsible for your TRICARE deductible
and cost-shares.
Covered by ORI: If you have OBI, Medicare
forwards your claim to your OHI. You must then
send a paper claim to the appropriate TEL
claims-filing address. For claims-filing addresses,
see "Claims Addresses" on the following page.
If you have employer group health plan coverage
based on current employment, the employer
group pays first, Medicare pays second, and
TRICARE pays last.

Nothing Billed charges
If a health care service is normally covered by
both Medicare and TRICARE, but you receive
the service from a provider who has opted out of
Medicare, the provider cannot bill Medicare, and,
therefore, Medicare will pay nothing. Unless you
have OHI, TRICARE will process the claim as the
second payer, and pay the amount it would have
paid if Medicare had processed the claim (normally
20 percent of the TRICARE-allowable charge).
You will be responsible for the remainder of the
billed charges. Opt-out providers establish
private contracts with patients and, under a private
contract, there are no limits on what the provider
can charge for health care services.
TRICARE FOR LIFE OVERSEAS
Medicare does not provide coverage outside of
the United States and U.S. territories (American
Samoa, Guam, the Northern Mariana Islands,
CLAIMS ADDRESSES
Puerto Rico, and the U.S. Virgin Islands).
Therefore, TRICARE is your primary payer
for health care received overseas (except U.S.
territories), unless you have OHI. Overseas,
TFL provides the same coverage as TRICARE
Standard and has the same cost-shares and
deductibles for beneficiaries who live or travel
overseas. When seeking care from a host nation
provider,' you should be prepared to pay up front
for services and submit a claim to the overseas
claims processor. Additionally, submit claims for
care received overseas directly to the overseas
claims processing address for the region where
you received care.
* III Puerto Rico and the Philippines. TRICARE may
only reimburse for services received from approved
providers. Contact the TOP Regional Call Center in
your area for more information.
TI,'L claims in the United States WPS TRICARE For Life
and U.S. territories PO. Box 7890
Madison, \VI 53707-7890
Eurasia-Africa TRICARE Overseas Program
(Africa, Europe, and the Middle East) no. Box 8976
Madison, WI 53708-8976
Latin America and Canada TRICARE Overseas Program
(Canada, the Caribbean Basin, Central no. Box 7985
and South America, Puerto Rico, and Madison, WI 53707-7985
the u.s. Virgin Islands) - - - --
Pacific TRICARE Overseas Program
(Asia, Guam, India, Japan, Korea, PO. Box 7985
New Zealand, and lVestern Pacific Madison, WI 53707-7985
remote countries)
4
FOR INFORMATION AND ASSISTANCE
TRICARE For Life Customer Service
(United States and U.S. territories)
Wisconsin Physicians Service (WPS)
1-866-773-0404
1-866-773-0405 (TOO/TTY)
Medicare
i-800-MEDICARE
(1-800-633-4227)
'fY.\NV~(JIl.E:'di~9T~-,-9-QV
Social Security Administration
1-800-772-1213
1-800- 325-0778 (TOO/TTY)
W\fY..y!-s~~gov
Y!YI/.YL?~<;lJJQ.v!forr:;LQO (overseas)
II
Defense Enrollment Eligibility
Reporting System (DEERS)-
Update Information
Phone: 1-800-538-9552
Fax: 1-831-655-8317
TRICARE Web Site
wwwtricare.mii
TRICARE Claims Web Site
V\)\fI}w.tricare. rn iVela irns
US Family Health Plan
1-800-74-USFH P (1-800-748-7347)
'fY.-.YYYY_,.USLD...h'lSm.o
wwwtricare.IIJil/deers

TRICARE North Region TRICARE South Region TRICARE West Region
Health Net Federal Services, LLC Humana Military Healthcare TriWest Healthcare Alliance
1-877-TRICARE (1-877-874-2273) Services, Inc. 1-888-TRIWEST (1-888-874-9378)
www.hnfs.ccm 1-800-444-5445
vvvvvv.humana-militSlfv.com
TRICARE Overseas Program (TOP)
Regional Call Center-
Eurasia-Africa 1
+44-20-8762-8384 (overseas)
1-877-678-1207 (stateside)
tricarelon@internationalsos.com
TOP Regional Call Center-
Latin America and Canada'
+1-215-942-8393 (overseas)
1-877-451-8659 (stateside)
tricareohl@internationaisos.com
www.triwest.ccm
TOP Regional Call Centers-
Pacific'
Singapore:
+65-6339-2676 (overseas)
1-877-678-1208 (stateside)
s:n.tricare@internationaisos.com
Sydney:
+61-2-9273-2710 (overseas)
1-877-678-1209 (stateside)
sydtricare@it"}temationaiso;;.<;:otI}
An important Note about TRICARE Program Information
At the time of printing. this information is current. It is important to remember
 that TRICARE policies and benefits are governed by public law and
federal regulations. Changes to TRICARE programs are continually made as
public law and/orfederal regulations are amended. Military treatment
facility guidelines and policies may be different than those outlined ill this
product. For the most recent information, contact your TRICARE regional
contractor, TRICARE Service Center, or local military treatment facility.
"TRICARE" is a registered Trademark of the TRICARE Management Activity.
All rights reserved.