Military Health, Tricare programs - Military Times

Tricare Help: Reservists: Learn your benefits

Q. I receive retired reserve pay and just got Medicare and Tricare for Life. My wife is only 61, so she is not eligible for Medicare. Can she be covered by Tricare yet, or does she have to wait until she gets Medicare?

A. Both you and your wife became eligible for Tricare on your 60th birthday. This is a common misconception about this and many reservists miss out on benefits as a result.

Before doing anything else, please call the Defense Manpower Data Center Support Office at (800) 538-9552 for help in getting your wife enrolled in Tricare. Both you and your wife should learn more about your benefits. Start by contacting your Tricare Service Center to request free handbooks for Tricare Standard, Tricare Prime and Tricare for Life.

Then, spend some time on www.tricare.mil, the Tricare Web site. You can subscribe to receive Tricare news releases and fact sheets by e-mail.

Study your Medicare handbook, too, to learn about that program. Medicare and Tricare are unrelated programs and have different rules.

Q. My doctor ordered a medical test that Tricare says was not medically necessary. How can an administrative decision override a doctor’s professional judgment?

A. Such decisions involve review of the circumstances by Tricare’s professional medical review team, or by independent consultants employed by Tricare.

One function of the appeals process is to require Tricare to manually review all details of a claim. On this claim, it is necessary to distinguish what is medically desirable from that which is medically necessary for proper treatment of this particular patient’s condition.

The fact that a physician may recommend or order a particular medical service does not, of itself, make the service medically necessary, appropriate or a Tricare benefit. It depends on the particular needs of the particular patient.

Write to James E. Hamby Jr. at Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or tricarehelp@atpco.com. In e-mail, include the word “Tricare” in the subject line and do not attach files.