Paul Sanchez
Medicaid and TRICARE are both health insurance programs, but they serve different purposes and populations. Medicaid is a federal and state program that provides health coverage for people with low incomes and assets. TRICARE, on the other hand, is a health care program specifically for military personnel, including active-duty service members, retirees, and their families. When it comes to determining which insurance is primary, it depends on several factors, including the individual's specific situation and the nature of their coverage. In general, if an individual has TRICARE and another form of health insurance, TRICARE typically pays after the other insurance, except in certain cases, such as when the individual is on active duty or receiving services from a military hospital or federal healthcare provider.
| Characteristics | Values |
|---|---|
| If on active duty | Tricare pays first for Medicare-covered services, and Medicare pays second |
| If not on active duty | Medicare pays first for Medicare-covered services, and Tricare pays second |
| If receiving items or services from a military hospital, clinic, or federal health care provider | Tricare pays |
| If receiving drugs through an Indian health facility | Medicare pays first, and Tricare pays second |
| If losing other health insurance (OHI) | Tricare becomes the primary payer |
| If having Tricare for Life | Tricare becomes the second payer |
| If having OHI | Tricare requires coordination of benefits with OHI coverage |
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What You'll Learn
Active duty status
If you are an active-duty service member with health insurance other than Tricare, this is referred to as "other health insurance" or OHI. In this case, you must obtain approval from Health Net Federal Service, LLC (HNFS) for all services. Medicaid is one of the exceptions to this rule, where Tricare is primary.
OHI can be provided by an employer, association, private insurer, or school health care coverage for students. By law, Tricare pays after all other health insurance has been processed, except for other federal government programs identified by the Director of the Defense Health Agency (for example, the Indian Health Service). This means that your OHI must be used before Tricare and your claim must first be processed by your OHI provider. If Tricare pays first and then discovers you have OHI, they will take back any payments made and will only reprocess your claim after your OHI provider has done so.
It is important to keep your Tricare contractors, doctors, and other healthcare providers updated on your OHI information. They can coordinate your benefits and help ensure your claims are paid promptly. If your OHI plan does not cover the entire cost, you can file a claim with Tricare. However, Tricare does not always pay your OHI copayment or the balance left over after the OHI payment, and the Tricare payment calculation is based on the provider's status.
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TRICARE as primary payer
TRICARE is a health care programme for service members and their families. If you are an active-duty service member, TRICARE is your primary payer, and you cannot use other health insurance as your primary insurance. This means that TRICARE pays first for Medicare-covered services or items, and Medicare pays second. If you are not on active duty, Medicare pays first, and TRICARE may pay second.
If you have any health insurance other than TRICARE, this is called "other health insurance" (OHI). By law, TRICARE pays after all other health insurance, except for other federal government programmes identified by the Director of the Defense Health Agency. This means that your OHI processes your claim first, and then you or your doctor file your claim with TRICARE. If TRICARE gets your claim before your OHI processes it, they will deny it. If your OHI does not cover the entire cost, you can file a claim with TRICARE. If your OHI denies a claim for failure to follow their rules, TRICARE may also deny your claim.
If you decide to get care from a civilian provider, you must comply with Service regulations. This includes providing all medical records to your current primary care manager. Unauthorized care may affect your fitness for duty status. You can still get all your medical care (including mental health and dental care) at no cost to you through TRICARE. If you have questions about how using OHI may affect you, talk to your Service Personnel.
If you lose your other health insurance, TRICARE becomes your primary payer. If you have TRICARE for Life, TRICARE becomes the second payer. You must inform your doctor and contractor by completing and returning a form. Failure to tell your doctor or contractor may result in TRICARE denying your claims.
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Medicare-covered services
Medicare is a health insurance program provided by the federal government. There are two main ways to get Medicare coverage: Original Medicare and Medicare Advantage. Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). It covers inpatient hospital care, doctors' services and tests, and preventive services. You pay for services and items as you get them and Medicare pays part of the cost.
Medicare Part A covers inpatient hospital stays, including costs, benefit periods, and lifetime reserve days. It also covers skilled nursing facility (SNF) care after a hospital stay if certain conditions are met. Medicare Part B covers a range of outpatient rehabilitation services, medically necessary durable medical equipment (DME) for home use, and preventive services to help detect and manage health conditions early.
Medicare also covers outpatient hospital services, ambulance services, and prescription drugs. Costs and coverage for outpatient hospital services depend on the type of care received. Ambulance services, including emergency and certain non-emergency transport, are covered by Medicare. Medicare Part D offers prescription drug coverage, with plans covering a variety of brand-name and generic drugs.
Medicare Advantage (Part C) plans offer all the benefits of Original Medicare (Part A and Part B) with additional benefits like dental, vision, hearing, and prescription drug coverage. Chronic Special Needs Plans (C-SNPs) are designed for people living with qualifying chronic conditions, while Dual Special Needs Plans (D-SNPs) are for those eligible for both Medicare and Medicaid coverage.
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Military hospitals
Walter Reed National Military Medical Center (WRNMMC)
Commonly referred to as Bethesda Naval Hospital or simply Walter Reed, this medical centre is located in Bethesda, Maryland, near the National Institutes of Health headquarters. WRNMMC is one of the most renowned military medical facilities in the Washington, D.C., metro region and the nation as a whole. It has a long history of serving multiple US presidents throughout the twentieth century.
Brooke Army Medical Center (BAMC)
Situated on Fort Sam Houston in San Antonio, Texas, BAMC is the largest military hospital in the United States. It boasts a substantial 425-bed patient capacity and is recognised as the Department of Defense's largest Level 1 Trauma Centre. The medical centre comprises ten distinct organisations centred around the Army's largest in-patient hospital and includes local treatment clinics. BAMC employs a diverse workforce of approximately 8,000 individuals, including soldiers, sailors, contractors, airmen, and civilians, who provide medical services to injured service members and the general public.
Captain James A. Lovell Federal Health Care Centre
This military hospital is named after Captain James A. Lovell and is dedicated to providing comprehensive healthcare services to military personnel and their families.
Carl R. Darnall Army Medical Centre
The Carl R. Darnall Army Medical Centre is another prominent military hospital within the United States, offering specialised medical services to military personnel and their dependents.
Dwight D. Eisenhower Army Medical Centre
Named after President Dwight D. Eisenhower, this medical centre is committed to serving the healthcare needs of military service members and their families.
In terms of insurance coverage, TRICARE is the primary insurance for active-duty service members. If an individual has TRICARE and another insurance plan, TRICARE typically pays after the other insurance, except in specific cases. TRICARE pays first for Medicare-covered services if the individual is on active duty, while Medicare pays second. However, if the person is not on active duty, Medicare pays first, and TRICARE may pay second. TRICARE For Life (TFL) is available to Medicare-eligible uniformed services retirees aged 65 and older, their eligible family members, survivors, and certain former spouses.
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TRICARE For Life
TFL is only for those with Medicare who are TRICARE-eligible. Coverage does not extend to family members. If you have other health insurance, such as a Medicare supplement or an employer-sponsored health plan, you can use TFL as long as you have both Medicare Parts A and B. TRICARE becomes the second payer if you have TRICARE for Life. You must inform your doctor and contractor by completing and returning a form. Failure to do so may result in TRICARE denying your claims.
In most cases, your provider files your claims with Medicare. 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'll have no out-of-pocket costs for services that both Medicare and TRICARE cover. You’ll have out-of-pocket costs for care that isn’t covered by Medicare and/or TRICARE.
When using TRICARE For Life in all overseas locations, TRICARE is the primary payer, and you're responsible for paying TRICARE's annual deductible and cost shares. If you live overseas, you must have Part B to remain eligible for TRICARE even though Medicare doesn't provide coverage overseas.
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Frequently asked questions
Any health insurance plan other than Tricare is considered "other health insurance" or OHI. This includes employer-sponsored coverage, government health care plans, or private insurance.
Tricare is the second payer after all other health insurance plans, except in the case of Federal Government Programs identified by the Director, Defense Health Agency. Therefore, if you have Medicaid in addition to Tricare, Medicaid is the primary payer, and Tricare is the second payer.
If Tricare pays first and then discovers you have other health insurance, Tricare will take back any payments made. They will only reprocess the claim after your other health insurance processes it.
Losing or gaining other health insurance is considered a qualifying life event (QLE). You must update your OHI information and inform your doctor and contractor. Failure to do so may result in Tricare denying your claims.
Yes, active-duty service members can use other health insurance under certain circumstances and when complying with DoD and Service regulations. However, there is no coordination of benefits with Tricare, and you are responsible for all costs.
