(Updated March 2023)
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More Resources: Medicare and TRICARE for Life
Who Is Eligible?
Retirees and their spouses individually lose their TRICARE benefit on the last day of the month prior to their 65th birth month. Unless covered by their own (or their spouse’s) employer health care plan, they must enroll in Medicare or face premium penalties for late enrollment. Medicare enrollment entitles a military retiree and their spouses (and surviving spouses) access to TRICARE For Life (TFL). This article details the process of transitioning into Medicare and TFL.
Enrollment in Medicare -- either Original Medicare Parts A and B or a Medicare Advantage Plan (Part C) -- entitles retirees and spouses to TFL. TFL acts as a Medicare supplement, picking up the annual deductible and 20% copays. It also acts as your pharmacy plan, negating the need for Medicare Part D.
TRICARE (via the Defense Manpower Data Center) sends out a notice to beneficiaries five months in advance of their 65th birthday which explains the requirement to sign up for Medicare and when to do so.
If you are receiving Social Security benefits at least four months prior to turning 65, you will be automatically enrolled in Medicare. Medicare will send you a welcome package three months prior and a reminder letter one month before your Medicare coverage starts.
Your military ID card expires on the first day of the month that you turn 65, so you will need to make sure it has been renewed to keep your TRICARE eligibility. ID card renewal (https://idco.dmdc.osd.mil/idco/) presents a good opportunity to confirm TFL enrollment. Don’t schedule an ID appointment until you’ve received your Medicare insurance card in the mail. Show the ID clerk your Medicare insurance card and they can confirm TFL enrollment through DEERS. Another way to confirm TFL enrollment is through your DMDC milConnect account (https://milconnect.dmdc.osd.mil/milconnect/).
What Does It Cost?
Medicare Part A (Hospitalization) is free for almost every military retiree and their spouse. Medicare Part B (medical insurance) premiums are tiered by income (2023 Medicare Part B premium costs). There are no fees associated with TFL. Beneficiaries remain eligible for TFL as long as they are enrolled in Part B or a Medicare Advantage plan.
For all Medicare/TFL covered medical services, the only expenses incurred during the year are Part B premiums and pharmacy co-pays.
When Medicare doesn’t cover a medical procedure, TFL becomes the primary payer.
For services covered by Medicare but not TRICARE, such as chiropractic care, Medicare pays 80%, and you will be responsible for the remaining 20%.
How Does It Work?
As a Medicare beneficiary, when you visit a physician who accepts Medicare, the provider files the claim with Medicare and once the claim is processed by Medicare, it is automatically forwarded on to TFL for payment. Wisconsin Physicians Service (WPS) is contracted to provide customer service and claims processing for TFL covered Medicare deductibles/copays in the U.S. and U.S. Territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands). TFL pays the remainder of the claim provided that the service is a Medicare and a TRICARE covered benefit.
There are very few Medicare-covered benefits that are not TFL-covered benefits, which would require you to pay the remainder of the claim instead of TFL (i.e., chiropractic care is a Medicare but not TRICARE benefit).
If you choose a provider who has opted out of Medicare, meaning they do not accept Medicare patients and will not file with Medicare, TRICARE will process the claim as second payer if the service is a covered benefit and the provider is TRICARE-authorized. As second payer, TFL pays what it would have paid if Medicare processed the claim as primary (meaning TFL pays 20% of the TRICARE allowable charge). You are responsible for the remaining 80% of the bill.
The Medicare website provides a search tool to find a Medicare provider in your area. Should you have no option for reasonable access to medical care but to use an opt-out Medicare provider contact WPS at 1-866-773-0404 for further details.
Types of Service and Payment Procedures
- Services covered by TRICARE and Medicare: Medicare pays authorized amount, TRICARE pays remaining amount, you pay nothing.
- Services covered by Medicare only: Medicare pays Medicare-authorized amount, TRICARE pays nothing, you pay Medicare deductible and cost share.
- Services covered by TRICARE only: Medicare pays nothing, TRICARE pays TRICARE allowable amount, you pay TRICARE deductible and cost share.
- Services not covered by TRICARE or Medicare: Medicare and TRICARE pay nothing, you pay billed charges, which may exceed the Medicare or TRICARE allowable amount.
Traveling or Living Overseas and TFL
When enrolled in Medicare/TFL and travelling or living overseas, the TRICARE Overseas Program (TOP) becomes your primary medical coverage as Medicare does not cover medical expenses outside of the U.S. or its territories*. TFL is available to beneficiaries residing or traveling overseas. The Medicare Part B enrollment requirement applies regardless of whether you live in the U.S. or abroad.
In locations where Medicare coverage does not apply, TRICARE is the primary source of health benefits. International SOS is the TOP contractor responsible for customer service for the TRICARE/Medicare population who reside or receive care overseas. The catastrophic cap is still $3,000. However, you are responsible for the applicable TRICARE deductible, cost shares, and remaining billed charges.
Outside the U.S. and U.S. territories, there may be no limit to the amount that a nonparticipating, non-network overseas provider may bill. You are responsible for paying any amount that exceeds the TRICARE-allowable charge, in addition to your deductible and cost shares. You may be required to pay up front for care and then file claims with the TRICARE overseas claims processor.
*Medicare is available in U.S. territories (Guam, Puerto Rico, the U.S. Virgin Islands, American Samoa, the Northern Mariana Islands, and for purposes of services rendered onboard ship, the territorial waters adjoining the land area of the United States). In these locations, TFL acts as the secondary payer after Medicare, just as with the stateside TFL program.
Medicare/TFL and Other Health Insurance
When you have Other Health Insurance (OHI) that is not based on current employment, then Medicare pays first, your OHI pays second, and you may file any remaining balances yourself with TRICARE. OHI based on employment (assume employer provided), that health plan pays first, Medicare pays second, and TRICARE pays last.
Generally speaking, TRICARE/Medicare-eligible beneficiaries (without other health insurance) find that Medicare as their primary insurance and TFL as their secondary insurance is more than adequate for their health care needs.
Keep in mind that TFL provides you with a pharmacy benefit at no cost (other than drug copays), whereas Medicare offers a separate pharmacy benefit (Medicare Part D) that requires a monthly premium on top of your Medicare Part B premium. Medicare Part D is an optional benefit; but as far as TFL beneficiaries are concerned, there is generally no added benefit in enrolling in Medicare Part D.
TRICARE Pharmacy benefit
The pharmacy benefit under TFL is the same pharmacy benefit as TRICARE Prime and TRICARE Select.
You can fill prescriptions three different ways: at a military treatment facility (MTF), at a local retail pharmacy, or through the mail-order pharmacy.
For current pharmacy costs, and information on other TRICARE costs, see this TRICARE webpage: https://tricare.mil/Costs/Compare
To research currently covered medications, see the Tricare formulary list here: https://tricare.mil/CoveredServices/Pharmacy/Drugs
Who Is Eligible?
Medicare is a health insurance program for:
- People age 65 or older,
- People under age 65 with certain disabilities
- People with end-stage renal disease (ESRD)
Although the age for full Social Security payments has increased, the age for Medicare entitlement has not changed; it continues to be age 65.
If you are in receipt of Social Security benefits at least 4 months before turning 65, you will be automatically enrolled in Medicare Part A and Part B starting the first day of the month you turn 65.
If you have not filed for Social Security, you must take action to enroll or Part A and Part B. The Medicare Initial Enrollment Period spans the seven-months that begins three months prior to 3 months after your 65th birth month. Failure to enroll (without the exception of having employer provided health insurance) incurs a 10% penalty each year.
What Does It Cost?
Medicare Part A comes at no cost to most retirees and their spouses. Medicare Part B has monthly premiums based on income.
For detailed cost information on Medicare programs, go to this Medicare webpage: https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html
How Does It Work?
If enrolled prior to your 65th birth month, your Medicare/TFL coverage begins on the first day of the month that you turn 65. If you delay enrollment to your birth month or the three months after your birth month, your coverage doesn’t begin until the next month.
If you miss the initial enrollment period, you cannot enroll in Medicare until the open enrollment period (Jan. 1 until March 31); coverage will not begin until July 1, and you will be charged a permanent penalty.