Module 8:
Medicare and TRICARE
Module Objectives
After this module, you should be able to:
• State what TRICARE For Life (TFL) is and who
is eligible
• Identify how active duty service affects
Medicare Part B enrollment
• Discuss the interaction between TFL and Other
Health Insurance
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TRICARE for Life
• TRICARE for Life (TFL) combines TRICARE Standard coverage
with Medicare Part A and B to provide wrap-around medical
coverage to dual-eligible (Medicare-TRICARE) beneficiaries
worldwide
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TFL Eligibility
• TFL is for TRICARE • TFL benefits start on the
beneficiaries entitled to first day that Medicare
premium-free Medicare Part A and Part B are
Part A and who purchased effective
Medicare Part B, regardless
of their age or place of • Medicare-TRICARE
residence beneficiaries under age
65:
• The Defense Manpower Data May enroll in TRICARE
Center automatically notifies Prime if available in their
TRICARE beneficiaries within local area; Prime
120 days prior to their 65th enrollment fees are
birthday of the requirement to waived for beneficiaries
enroll in Medicare B when entitled who have Medicare Part B
to Medicare Part B based on age Alternatively, beneficiaries
under age 65 who have
Medicare Part A and Part
B may also use TFL
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Medicare Basics
Medicare is a health insurance program. Eligibility is based on:
• Age
People age 65 or older
• Disability
People under age 65 with certain disabilities
• Disease
People (of any age) with end-stage renal disease (ESRD) or
People (of any age) with amyotrophic lateral sclerosis (ALS),
(commonly Lou Gehrig’s disease)
People of Lincoln County, Montana who have an asbestos-related
disease
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Medicare Part A and Part B
Medicare Part A Medicare Part B
• Hospital insurance • Medical Insurance
• Funded through payroll • Helps cover medically-
taxes, helps cover inpatient necessary services like
care in hospitals, skilled doctor’s services, outpatient
nursing facilities, hospice care, home health services,
care, and home health care some preventive health
services, and other medical
• If a beneficiary has paid services
into Medicare for 40
quarters, they will be entitled • Medicare Part B premiums
to premium-free Medicare are based on an individual’s
Part A at age 65 reported income
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Medicare (continued)
Medicare Part A Medicare Part B
• If eligible for premium-free Part A, • Beneficiaries should
beneficiaries will receive a “Notice enroll in Medicare Part B
of Award”, the official letter from when first eligible at age
the Social Security Administration 65 to avoid paying higher
(SSA) advising the beneficiary of Medicare premiums
his/her entitlement to premium-free
Part A and enrollment in Part B
(or enrollment in Part B only)
• If not eligible for premium-free
Part A based on their work history,
beneficiaries should contact SSA
to find out if they may qualify under
their spouse’s social security
number
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Medicare Part B Requirement
• Under Federal law, TRICARE beneficiaries entitled to
premium-free Medicare Part A must have Medicare Part B
to remain TRICARE eligible
• Beneficiaries lose their TRICARE benefits and claims are
denied if they do not have Part B, disenroll from Part B, or
stop paying their Part B premiums
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Medicare Part B Requirement
(Exceptions)
• Medicare-entitled ADSMs and ADFMs are not required to
have Part B in order to keep TRICARE coverage
• ADSMs/ADFMs who are entitled to premium-free Medicare
Part A remain eligible for TRICARE Prime and/or TRICARE
Standard programs without enrolling in Medicare Part B, until
the sponsor is retired (either medical or regular retirement)
• Medicare Part B MUST be in effect on the active duty
sponsor’s retirement date to avoid a break in TRICARE
coverage
• If the beneficiary enrolls in Medicare Part B after the
retirement date, there may be a break in TRICARE coverage
until Medicare Part B takes effect
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Medicare & TRICARE Application #1
Captain Williams is a combat-wounded ADSM receiving Social Security disability
benefits. He received notice that his Medicare Part A and Part B effective dates
were May 2010.
He disenrolled from Part B because he is on active duty. His Service component
notified him that his medical retirement date was December 2010.
He decided to enroll in Part B, while still on active duty, with his Part B effective
October 2010. Although he declined his Part B when he was first eligible, he
enrolled prior to his retirement date, ensuring his TRICARE eligibility continued
without break in coverage.
While on Active Duty Upon Retirement
Part A effective May 2010 Part A effective May 2010
Part B effective October 2010 Part B effective October 2010
May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
10 10 10 10 10 10 10 10 11 11 11 11 11 11 11
TRICARE Eligibility Continues Without A Break in Coverage
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Medicare & TRICARE Application #2
Captain Williams is a combat-wounded ADSM receiving Social Security disability
benefits. He received notice that his Medicare Part A and Part B effective dates are May
2010.
He disenrolled from Part B because he was still on active duty. His Service component
notified him that his medical retirement date was December 2010.
Later, Captain Williams decided to enroll in Part B in June 2011. Based on Medicare
guidelines, his Part B was effective on July 2011. He had a break in TRICARE
coverage.
While on Active Duty After Retirement
Part A effective May 2010 Part A effective May 2010
No Part B Part B effective July 2011
May 1- November 10 December 2010 – June 2011 July 2011
TRICARE eligibility No TRICARE Coverage Part B and TRICARE
continues without Coverage Begin
Coverage
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Medicare Payer Table
Services covered Services covered Services covered Services not
by Medicare and by Medicare,not by TRICARE, not covered by either
TRICARE by TRICARE by Medicare Medicare or
TRICARE
Medicare Medicare pays Medicare pays Medicare Medicare
first first does not pay does not pay
TRICARE TRICARE pays TRICARE TRICARE TRICARE
last, normally does not pay pays second does not pay
paying the actual
out-of pocket
costs incurred by
the beneficiary
Beneficiary No out-of-pocket Pays for any Pays for any Pays cost shares
expenses remaining cost remaining cost or deductibles
shares or shares or
deductibles deductibles
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Working TFL Beneficiaries
Age 65 & Older
• Medicare-eligible beneficiaries who continue to work beyond
age 65 must have Medicare Part B to remain TRICARE-eligible,
regardless of group health plan coverage based on their current
employment
• Beneficiaries may enroll in Medicare Part B before they retire or
lose group health plan coverage to ensure TRICARE coverage
under TFL
• Unless they have Medicare Part B, TRICARE cannot be second
payer
• TFL coverage begins on the same day as the Medicare Part A
and Medicare Part B effective dates
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Using TFL While Overseas
• TFL is available to dual-eligible beneficiaries residing overseas,
provided they have Medicare Part A and Part B
• Medicare provides coverage in U.S. territories (Puerto Rico, Guam,
U.S. Virgin Islands, American Samoa, and Northern Mariana Islands.)
• TFL beneficiaries should be prepared to pay out-of-pocket and file
their own claims for reimbursement
• Claims are submitted to the overseas claims processing contractor,
along with a copy of the provider’s itemized bill
• For beneficiaries residing overseas, TRICARE is the primary payer
(as long as there is no other health insurance) and no Medicare
summary notice is required
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TFL Claims Processing
• When a beneficiary has TFL and Medicare:
Medicare pays its portion for Medicare-covered services
Medicare then automatically forwards the claim to TRICARE for
processing
• The TFL claims processor handles all claims for TFL beneficiaries,
including those ADSMs/ADFMs enrolled in TRICARE Prime who
have Medicare Part A and/or Medicare Part B
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TFL Claims Processing
(continued)
• Beneficiaries receive a monthly TFL explanation of benefits (EOB)
detailing the claims processed, rather than separate EOBs for
each service associated with a claim
• TFL beneficiaries can choose to receive their EOBs electronically
by registering to receive e-mail alerts at www.TRICARE4u.com
• The e-mail alert provides a link to the web site so that beneficiaries
can view and/or print the TFL EOB
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TFL Pharmacy
• The TRICARE pharmacy benefit does not change under TFL
Beneficiaries do not need to enroll in the Medicare Part D
prescription drug plan to keep the TRICARE pharmacy benefit
• For nearly all TFL beneficiaries, there is no benefit in enrolling in
Medicare Part D
• If a beneficiary chooses to enroll in Medicare Part D, he/she will
not incur a penalty for late enrollment, as eligibility for the TRICARE
pharmacy benefit is considered creditable drug coverage
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TFL Application #1
True or False?
Mrs. White, a uniformed service retiree, has Medicare Part A and
Part B, OHI, and TFL.
TFL will be the primary payer for her claims.
Answer: False. TFL will be the last payer.
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TFL Application #2
True or False?
Mr. Smith is a uniformed service retiree, who is still employed
full-time at age 67. He has Medicare Part A, but does not have
Medicare Part B.
He is eligible for TFL.
Answer: False. He is not eligible for TFL coverage until his
Medical Part B is in effect. Beneficiaries must have Medicare
Part B to remain TRICARE eligible, even if they are employed.
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TFL Application #3
True of False?
Sergeant Jones was an active duty service member receiving social
security disability benefits. Before her retirement, she enrolled in
Medicare Part B.
She is eligible for TFL.
Answer: True. She is eligible for TFL benefits because she has
TRICARE and Medicare Part B.
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TFL Application #4
True or False?
Mr. Green is a retired uniformed service member who lives outside
of the United States. He is entitled to Medicare Part A and enrolled
in Medicare Part B.
He is eligible for TFL.
Answer: True. He is eligible for TFL, regardless of whether he lives
in the U.S. or overseas
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Congratulations! You Have Completed
Module 8: Medicare and TRICARE
You should now be able to:
• State what TRICARE For Life (TFL) is and who
is eligible for it
• Identify how active duty service affects
Medicare Part B enrollment
• Discuss the interaction between TFL and Other
Health Insurance
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