Tricare Help: I have Tricare for Life; why am I being billed for a deductible? - Military Health, Tricare programs - Military Times

Tricare Help: I have Tricare for Life; why am I being billed for a deductible?

Answering your questions on Tricare.

Q. I have Tricare for Life. I got an Explanation of Benefits from Tricare reporting that a deductible had been withheld, and I had to pay the doctor that amount. I never had a TFL deductible before. Is that correct?

This reply assumes that you have no health insurance other than TFL. TFL consists of full coverage by Medicare parts A and B, which is primary, plus full coverage by Tricare Standard, the second payer. Usually you pay nothing on TFL claims because both Medicare and Tricare cover the services. But when an item is covered by Tricare and not Medicare, you can end up owing money.

When only Tricare covers a particular item, it is treated as a separate, Tricare-only claim, and federal law requires the Tricare deductible and cost share to be applied when that charge is processed. Tricare will determine the amount it can allow for that item, then subtracts any of your annual $150 Tricare deductible not satisfied on previous Tricare claims. Next, it subtracts your 25 percent cost share from the remainder. You are then responsible for paying what Tricare does not, up to the amount Tricare allowed for that particular item. I suspect that is what happened on your claim.

Those actions should be explained in detail on your Tricare Explanation of Benefits. If you will replicate all the arithmetic steps shown on the EOB, paying close attention to the identity of each line item, you will understand how Tricare uses each line item in its calculations.

Q. My wife is older than me. We are both enrolled in Tricare Prime. Can she get Medicare and Tricare for Life when she is 65, or does she have to wait until I am 65? How will that affect our Tricare Prime enrollment?

If your wife becomes entitled to Medicare at age 65 and enrolls in Medicare Part B, her Tricare Prime should be automatically changed to Tricare Standard by the Defense Enrollment Eligibility Reporting System, and she will become eligible for Tricare for Life at that time. Your Tricare Prime enrollment will not be affected.

You will make the same transition when you turn 65 and become entitled to Medicare.

Call the Social Security Administration for clarification of its rules in any case where there is confusion about this matter.

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