Tricare For Life: Primary Insurance And You

TRICARE is a health insurance program for military members and their families. It is important to understand how TRICARE works with other health insurance plans, especially when it comes to being the primary or secondary payer. By law, TRICARE pays after all other health insurance plans, with some exceptions, such as state victims of crime compensation programs and other federal government programs. When it comes to TRICARE For Life (TFL), which is Medicare-wraparound coverage for those who are TRICARE-eligible and have Medicare Part A and B, the dynamics of primary and secondary payers change depending on whether the beneficiary is in the US or overseas.

Active duty service members with other health insurance

Active-duty service members and their families are eligible for TRICARE. However, TRICARE is not the primary payer for active-duty service members with other health insurance (OHI). If you have OHI, you are responsible for all costs, and TRICARE won't be the second payer, meaning there is no coordination of benefits with your OHI and TRICARE.

Your OHI may have some exclusions for military duty status, and it may not pay for your care or may recoup claims for services received while on active duty or line-of-duty status. Therefore, you must disclose your military status to your OHI to avoid claim denials or recoupments. Failure to disclose this information could lead to administrative or judicial consequences.

If you have TRICARE For Life (TFL) and OHI, you can use TFL as long as you have both Medicare Parts A and B. If you have employer-sponsored insurance with your current employer, your employer will file your health claims, and the OHI pays first, followed by Medicare. If your OHI is not based on your or a family member's current employment, you must file a claim with the TFL contractor. In this case, Medicare pays first, followed by the OHI.

If you lose your OHI, TRICARE becomes your primary payer. If you have TRICARE For Life, TRICARE becomes the second payer.

Medicare and TRICARE for Life

Medicare is a federal entitlement programme that provides health insurance for people under 65 with certain disabilities, end-stage renal disease, or Lou Gehrig's disease. Managed by the Centers for Medicare and Medicaid Services, it offers Original Medicare or Medicare Advantage Plans (Part C).

TRICARE For Life (TFL) is Medicare-wraparound coverage for those who are TRICARE-eligible and have Medicare Part A and B, regardless of age or place of residence. TFL is automatic for those with Medicare Part A and B, with coverage starting the first day that Medicare Part A and B are in effect. There are no enrolment fees, but you must pay Medicare Part B premiums.

Medicare is the primary payer for TRICARE beneficiaries, and TRICARE pays second to Medicare. If you have other health insurance, TRICARE pays last. When using TRICARE For Life overseas, TRICARE becomes the primary payer, and you are responsible for paying TRICARE's annual deductible and cost shares.

If you are under 65 and entitled to Medicare Part A, you don't have to disenroll from TRICARE Prime or the US Family Health Plan. Your TRICARE Prime individual enrollment fee will be waived. If you have TRICARE Prime or TRICARE For Life, your claims won't be processed through the regional contractor. Instead, providers file claims with Medicare first, then Medicare forwards the claims to the TRICARE For Life contractor for processing and payment of the TRICARE portion of the claim.

If you have Medicare Part A and become entitled to Medicare at age 65, you are automatically covered by TRICARE For Life and are not eligible to enrol in other TRICARE health plans.

Other Federal Government Programs

The official website of the US Office of Personnel Management (OPM) provides information on health and other insurance programs, including the Federal Employees Health Benefits Program (FEHB) and the Federal Employees Dental and Vision Insurance Program. The FEHB Program offers the widest selection of health plans in the country to federal employees, retirees, and their survivors. It includes Consumer-Driven and High Deductible plans, Fee-for-Service (FFS) plans, Preferred Provider Organizations (PPO), and Health Maintenance Organizations (HMO).

The Postal Service Health Benefits Program is a new program that will provide health insurance to eligible Postal Service employees, annuitants, and their eligible family members starting in 2025.

The Federal Government also runs the Medicare program for the elderly and disabled, with Part A covering hospital care and Part B covering medical services. Additionally, Medicaid is a federal-state partnership that provides public funding for healthcare for low-income children and adults. The State Children's Health Insurance Program (SCHIP) is another federal initiative that provides funds for states to offer coverage to uninsured children.

Claims and payments

If you have any health insurance other than Tricare, it is considered "other health insurance" (OHI). This includes Medicare or an employer-sponsored health insurance plan. By law, Tricare pays after all other health insurance plans have paid, except for:

• State Victims of Crime Compensation Programs
• Other Federal Government Programs identified by the Director, Defense Health Agency (e.g. Indian Health Service)

This means that your OHI processes your claim first, and then you or your doctor files your claim with Tricare. If Tricare pays first and then discovers that you had another health insurance plan, they will take back any payments made and will only reprocess your claim after your other health insurance has paid.

If you have Tricare For Life and another health insurance plan, your provider will file your claims with Medicare first. Medicare pays its portion first and sends the claim to the Tricare For Life claims processor. Tricare For Life then pays the provider directly for Tricare-covered services. Generally, you will have no out-of-pocket costs for services that both Medicare and Tricare cover. However, you will have out-of-pocket costs for care that isn't covered by either Medicare or Tricare.

If you have employer-sponsored insurance with your current employer, your employer will file your health claims, and the process is as follows:

• The other health insurance pays first.
• Medicare pays second.

If you have other health insurance that isn't based on your or a family member's current employment, you must file a claim with the Tricare For Life contractor. Submit a paper claim to WPS along with the following:

• Your provider's itemized bill
• The Medicare Summary Notice
• The explanation of benefits from all other health insurances

Your claim must be filed within one year of the date of care.

TRICARE and other health insurance

TRICARE is a health insurance option for those in the military. If you have any health insurance other than TRICARE, it is known as "other health insurance" (OHI). This could be Medicare or an employer-sponsored health insurance programme. TRICARE supplements do not qualify as OHI.

By law, TRICARE pays after all other health insurance has paid, except for State Victims of Crime Compensation Programs and Other Federal Government Programs identified by the Director, Defense Health Agency (e.g. Indian Health Service). This means that your OHI processes your claim first, and then you or your doctor files your claim with TRICARE. If TRICARE pays first and then discovers you had other health insurance, they will take back any payments made and will only pay again once your other insurance has paid.

If you have Medicare, this is considered OHI, and Medicare pays first, followed by TRICARE For Life (TFL). TFL is Medicare-wraparound coverage if you are TRICARE-eligible and have Medicare Part A and B, regardless of age or place of residence. Coverage is only for those with Medicare and who are TRICARE-eligible, and does not extend to family members. TFL coverage is automatic if you have Medicare Part A and B, and coverage starts the first day that Medicare Part A and B are in effect. You must pay Medicare Part B premiums.

If you have other health insurance, such as a Medicare supplement or an employer-sponsored health plan, you can use TRICARE For Life as long as you have both Medicare Parts A and B. If your insurance is employer-sponsored, your employer files your health claims, and the process is as follows:

• The other health insurance pays first.
• Medicare pays second.

If your insurance is not based on your current employment or that of a family member, the process is as follows:

• Medicare pays first.
• The OHI pays second.
• You must file a claim with the TFL contractor. Submit a paper claim to WPS along with a copy of the provider's itemized bill, the Medicare Summary Notice, and the explanation of benefits from all other health insurances.
• Your claim must be filed within one year of the date of care.

If you are an active-duty service member, you cannot use other health insurance as your primary insurance. TRICARE is the primary payer, and coordination of benefits with other insurance carriers does not occur. If you have other health insurance (OHI), you require approval from Health Net Federal Service, LLC (HNFS) for all services. All other beneficiaries with OHI (excluding Medicare) only require prior authorization for applied behaviour analysis services.

The OHI must be used before TRICARE. Health coverage through an employer, association, private insurer, school health care coverage for students, or Medicare is always primary to TRICARE. The exceptions to this rule are Medicaid, State Victims of Crime Compensation Programs, Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA), the Maternal and Child Program, the Indian Health Service, and plans specifically designated as TRICARE supplements.

Frequently asked questions