Note: This article first appeared in Transitioning Into Medicare and TRICARE For Life, a publication exclusive to MOAA Premium and Life members. Find more member-exclusive publications at this link, and check out member-exclusive discounts at this link.

There is a lot to know about using your TRICARE For Life (TFL) benefit. Here is a deeper dive into doctor’s appointments, filing claims, how other health insurance works with TFL and health care providers who accept Medicare Assignment, providers who are Medicare- approved and Medicare “opt-out” providers.

Doctor’s Appointments

You’ll need to bring two things:

• Your Medicare card, which indicates you have coverage.
• Your valid, up-to-date uniformed services ID card.

TFL does not have a special card like Medicare; your Medicare card, along with your valid uniformed services ID card, provides proof of your TFL eligibility and enrollment.

Filing Claims and Payment

Most providers bill Medicare directly for payment.

Under TFL, Medicare processes the primary claim and sends the Medicare payment directly to the provider. The secondary claim automatically crosses over to be processed by TFL using the paid Medicare claim as documentation.

TFL sends the patient’s Medicare copay directly to the provider. You will get a copy of the explanation of benefits (EOB) from both Medicare and TFL showing what each program has paid.

Other Health Insurance With TFL

Your Medicare claim crosses over to one other health insurance with TRICARE, by law, paying last. Other health insurance includes private insurance, the Federal Employees Health Benefits Program, and other employer-provided insurance plans. If you have insurance based on current employment, then your employer-based insurance pays first, followed by Medicare, and TFL picks up any remaining costs. If you have other coverage that is not based on current employment, Medicare pays first, followed by your other insurance and then TFL. When there is a break between Medicare and TFL, you will have to manually file claims with TFL.

To submit a claim for reimbursement, you must provide a copy of the Medicare EOB and your other insurer’s EOB, along with a TRICARE claim for reimbursement. You can download a claim form (DD Form 2642) at the TRICARE claims website.

If you have questions or concerns regarding TFL claims, contact Wisconsin Physicians Service (WPS), the processor for all TFL claims, at (866) 773-0404 or www.tricare4u.com.

Medicare-Approved vs. Medicare Assignment

When providers accept Medicare Assignment, they agree to accept the Medicare-approved amount as payment in full for any claim filed.

These providers must file claims with Medicare, which, in turn, files with TFL, leaving you with the least amount of out-of-pocket expenses (if any).

A Medicare-approved provider who does not accept Medicare Assignment still must file a claim with Medicare and cannot bill you for more than 115% of the Medicare maximum allowable charge (MMAC) — the fee Medicare sets as reasonable for a covered benefit. If you are asked to pay the provider up front, Medicare will reimburse you 80% of the MMAC. TFL then will pay you the balance, up to 115% of the MMAC.

When a provider opts out of Medicare completely, they do not file Medicare claims.

Medicare will not make payments for services received from an opt-out provider. TRICARE processes the claim as the second payer as long as the service is a covered benefit and the provider is TRICARE-authorized. As the second payer, TFL pays what it would normally if Medicare processed the claim (20% of the TRICARE allowable charge). You are responsible for the remainder.

If you have no choice for reasonable access to medical care but to use an opt-out provider, contact the WPS at (866) 773-0404 for further information.