News | Dec. 22, 2021

TRICARE For Life: Choosing Your Provider Option

By TRICARE Communications

Do you have medical coverage under the TRICARE For Life (TFL) program? Will you soon be eligible for TFL? If so, it’s important to become familiar with your choices of Medicare providers, whatever your needs may be. There are two main categories of Medicare providers: participating and non-participating. A third category is opt-out providers, which are your most expensive option. If you wish to make the best choice for your coverage, it’s important that you learn the differences between each provider type.

Medicare Participating Providers
As described in the TRICARE For Life Handbook, Medicare participating providers accept the Medicare-allowed amount as payment in full. They’ll also file claims with Medicare for care you receive. After Medicare pays its portion, it will forward the claim to Wisconsin Physicians Service (WPS), which is the TFL contractor. WPS is responsible for processing and paying TRICARE’s portion of claims for TRICARE beneficiaries, who also have Medicare. When the care you receive is a benefit of Medicare and TRICARE, you’ll have no out-of-pocket costs.

To find a Medicare provider near you, you can:  Medicare Non-participating Providers
You may choose to see a Medicare non-participating provider. These providers don’t accept the Medicare-allowed amount as payment in full. They may also charge up to 15% above the Medicare-allowed amount for your health care services.  
 
“This shouldn’t be a concern for you because TRICARE covers that additional 15%,” said Anne Breslin, the TFL program manager at the Defense Health Agency. “No matter whether you see Medicare participating provider or a Medicare non-participating provider, your costs will be the same.”
 
Opt-Out Providers
You can also get care from providers who opt out of the Medicare program. Opt-out providers aren’t held to the Medicare or TRICARE-allowed amounts. So, you could have significant out-of-pocket costs if you get care from these providers. Before you choose this option, you should know all the costs for which you’ll be responsible.
 
Opt-out providers don’t take part in Medicare, so they can’t bill Medicare. Medicare also can’t pay for health care services you get from them. When you see an opt-out provider, TRICARE will only pay up to 20% of the TRICARE-allowable amount. You’ll be responsible for billed charges, minus the amount paid by TRICARE.
 
Department of Veterans Affairs Providers
Are you eligible for both TFL and benefits through the Department of Veterans Affairs (VA)? Like opt-out providers, VA providers can’t bill Medicare, nor can Medicare pay for health care services that you get from a VA provider. As described in the TRICARE For Life Handbook, if you see a VA provider for non-service connected care, you’ll have significant out-of-pocket costs. TRICARE can only pay up to 20% of the TRICARE-allowable amount. So, care at a VA facility may leave you responsible for the rest of the costs. What you pay depends on whether or not the care you receive is for a service-connected illness or injury. You’ll pay nothing when you get non-service connected care from Medicare providers and the care you receive is a benefit of Medicare and TRICARE.
 
If you choose to seek care from a VA provider, you can confirm your coverage details with the TFL contractor. They’ll let you know what TRICARE will cover.
 
Getting Care at Military Hospitals and Clinics
You can get care at any military hospital or clinic if space is available. You may also be able to use TRICARE Plus, as described in the TRICARE and Medicare: Turning Age 65 Brochure. This program allows certain beneficiaries to enroll at a military hospital or clinic and have priority access to primary care.
 
Overseas Providers
If you have TFL and live overseas, you may generally use any civilian provider and get care at military hospitals and clinics if space is available. But be prepared to pay up front for services and submit a claim. You’ll need to send your claims to the TRICARE Overseas Program claims processer, International SOS Government Services, Inc. While overseas, TRICARE is the primary payer unless you have other health insurance.
 
Keep in mind, you may have significant costs for your health care if you get care from VA or opt-out providers. Be sure to ask your provider if they’re participating, non-participating, or opt-out. Or, look them up on the Medicare website. To learn more about TFL, go to the TRICARE For Life page. And check out TFL episodes from the “Getting to Know TRICARE” podcast. 
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