FALLS CHURCH, Va. –
If you have
TRICARE For Life, you’ll get health care from
Medicare providers. Here’s what you need to know about finding different types of Medicare providers.
“You can lower your health care costs when you see Medicare participating providers who accept the Medicare-approved amount as full payment,” said Anne Breslin, TRICARE For Life Program Manager at the Defense Health Agency. “Always prepare to show your Medicare card along with your Military ID card at any medical appointment.”
How do I find the right provider?
TFL is
Medicare-wraparound coverage for TRICARE beneficiaries who have
Medicare Part A and
Medicare Part B. You can see three types of
providers. This is described in the
TRICARE For Life Handbook.
- Medicare participating providers. They accept the Medicare-approved amount as full payment. Seeing these providers will result in the lowest costs.
- Medicare nonparticipating providers. They don’t accept the Medicare amount as full payment. They can charge up to 15% more than Medicare allows. TRICARE covers this extra cost.
- Opt-out providers. They don’t work with Medicare at all. You’ll pay much more when you see these providers. Medicare won’t pay anything. TRICARE only pays what it normally would. This is about 20% of the TRICARE-allowable charge. You pay the rest.
How do Medicare and TRICARE pay?
Medicare is generally your primary payer. Are you seeing a Medicare participating or Medicare nonparticipating provider? If so, then you have no out-of-pocket costs for services covered by both Medicare and TFL. Most health care services fall into this category. Medicare pays its portion of the claim, TRICARE pays the remaining amount, and you pay nothing.
Sometimes, TRICARE is your primary insurance. In this case, you must see TRICARE-authorized providers. This occurs when:
- Medicare doesn’t cover the service.
- You’re in overseas locations.
Can I get Department of Defense care?
You can get care at
military hospitals and clinics if space is available.
How does Department of Veterans Affairs care work?
VA providers can’t bill Medicare. If you see a VA provider for care that isn’t related to a service-connected condition, you’ll pay about 80% of the bill. TRICARE only pays up to 20%. Want to see a VA provider? Call the TFL contractor,
WPS Military and Veterans Health, at 866-773-0404 to check your coverage before you go.
What about care overseas?
Do you live overseas? You can usually see any civilian provider. You’ll need to pay up front and file your own claim. In the
Philippines, you must see certified providers.
For emergencies overseas, try military hospitals first. If none are available, go to the nearest emergency care facility. Call the TRICARE Overseas regional call center within 24 hours if you’re admitted.
How do I get emergency and urgent care?
When getting emergency or urgent care, always show your Medicare card along with your Military ID card.
Do you need emergency care? Emergency care means care for an illness or injury that threatens your life, limb, sight, or safety. If you reasonably believe you have an emergency, always call 911 or your international emergency number. Or, go to the nearest emergency room.
Do you need urgent care? Urgent care treats conditions that need attention within 24 hours but aren’t life-threatening. Examples include sprains or rising fevers.
Are virtual health care visits covered?
You can get
virtual health care via phone or video appointments. Medicare covers these visits when your provider accepts Medicare. TRICARE pays first if Medicare doesn’t cover the
virtual health service.
Is mental health care covered?
Medicare covers visits with these
mental health providers:
- Psychiatrists and other doctors
- Clinical psychologists
- Clinical social workers
- Clinical nurse specialists
- Nurse practitioners
- Physician assistants
What about services that need pre-authorization?
Some services need
pre-authorization before you get care. These include:
- Dental care for medical conditions
- Home health care
- Hospice care
- Organ transplants
- Some prescription drugs
Contact WPS if you have questions about pre-authorization requirements.
Remember! Seeing Medicare participating providers gives you the lowest out-of-pocket costs.
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