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Tricare Help: Clearing confusion on policy tweak

Feb. 21, 2014 - 12:26PM   |  

Q. Iím rated 100 percent disabled by the Veterans Affairs Department (80 percent medical and 20 percent unemployability) and also receive military retirement pay and Social Security disability. Iíve heard that when I turn 65 (soon), I must sign up for Medicare and Tricare and pay the Medicare Part B premiums. Iíve also been told VA no longer covers all health conditions, only those connected to service, and that if I want paid health coverage in the future, I must use Medicare and Tricare and my VA 100 percent disability rating will be reduced to 80 percent. Can that be right?

A. You seem to be misconstruing the admittedly convoluted details of a recent Tricare policy change that affects Tricare for Life beneficiaries who are also eligible for VA care.

As of last Oct. 1, some ó repeat, some ó veterans who are eligible for health care through both VA and Tricare for Life face higher outpatient costs if they seek care in VA facilities for medical conditions not rated as service-connected.

VA does not actively seek to bring Tricare beneficiaries into its health care orbit, but VA is a Tricare network provider and will care for Tricare beneficiaries if capacity exists. VA overwhelmingly focuses on medical conditions connected to military service; however, in some cases, to provide continuity of care, VA also gives veterans the option to receive routine care for nonservice-connected conditions.

In recent years, a typical veteran in the above situation would be billed certain co-pays by VA, and then he would submit those co-pays for reimbursement through his second-payer TFL benefit. Tricare has now determined that such reimbursements are improper because of the statutory relationship among VA, Medicare and Tricare.

Under TFL, Tricare covers health care costs only after Medicare has paid its share; by law, Tricare must be last payer to all other health insurance except in very limited and specific circumstances.

But while VA facilities are Tricare-authorized, they are not Medicare-certified ó which means VA canít bill Medicare for any care related to nonservice-connected conditions. Such bills would pass directly to Tricare, as last payer. But by law, TFL can cover no more than 20 percent of the Tricare-allowable charge on such claims.

So beneficiaries in the scenario described above should be responsible for the 80 percent of the charge that Medicare wonít pay because VA is not Medicare-certified, and that Tricare canít pay because it can cover only 20 percent of the allowable charge.

The change that took effect Oct. 1 is an end-state realization by Tricare officials that Tricare had been erroneously covering the entire cost in such situations.

Confusion has spread because certain veterans using VA health care are exempt from any co-pays for any care. One such category is veterans who have disability ratings of 50 percent or higher for service-connected conditions. Since they are exempt from all co-pays, the entire situation described above has no effect on them.

In fact, the the Tricare for Life contractor has identified only about 12,000 TFL retirees ó out of a total TFL beneficiary population of about 2 million ó who over the past year or so have received VA care for nonservice-connected conditions but are not exempt from VA co-pays for such care, and thus may now face higher out-of-pocket costs.

If you havenít received such a letter, you should not be affected by any of this.

Once you turn 65, you would have to sign up for Medicare Parts A and B and pay the Part B monthly premiums in order to retain eligibility for Tricare for Life as backup secondary coverage to your VA health care benefits, if you want such backup coverage. But your access to VA health care will not be affected.

Write to Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or http://tricarehelp@militarytimes.com/. In email, include the word ďTricareĒ in the subject line and do not attach files. Get Tricare advice any time at http://blogs.militarytimes.com/tricarehelp.

Answers by RallyPoint

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