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Simplifying Your Retirement Healthcare
Transitioning into retirement brings changes, including adjustments to healthcare coverage. For military retirees and their eligible family members, understanding how TRICARE interacts with Medicare is crucial. TRICARE For Life (TFL) is a significant health benefit designed specifically for this group, provided they are enrolled in Medicare Part A and Part B. TFL functions as “Medicare-wraparound” coverage, meaning it works alongside Medicare to coordinate benefits and minimize healthcare expenses. For healthcare services covered by both programs, TFL often reduces the beneficiary’s out-of-pocket costs substantially, sometimes to zero.
This guide aims to demystify TRICARE For Life. It breaks down the essential components of Medicare Part A and Part B, defines TFL and its eligibility criteria, explains how benefits are coordinated, details the scope of covered services (including medical care, prescriptions, durable medical equipment, and mental health support), outlines how to use the benefit in the United States and overseas, clarifies potential costs, and discusses access to military treatment facilities.
The concept of “wraparound” coverage is central to understanding TFL. It signifies that TFL is designed to fill the gaps often left by Medicare, such as deductibles and coinsurance. Grasping this relationship helps clarify why TFL beneficiaries frequently experience minimal out-of-pocket expenses for services covered under both Medicare and TRICARE. TFL is not a standalone health plan like TRICARE Prime or Select; rather, it is a supplement specifically engineered to complement Medicare coverage.
Understanding the Foundation: Medicare Part A and Part B
To fully comprehend how TRICARE For Life operates, it is essential first to understand its foundation: Original Medicare, specifically Part A and Part B. TFL is designed to work in tandem with these two parts of Medicare.
Medicare Part A (Hospital Insurance)
Definition & Purpose: Medicare Part A primarily covers inpatient care services. This includes stays in hospitals, care in skilled nursing facilities (SNF) following a qualifying hospital admission (not long-term or custodial care), hospice care, and certain home health care services. Its focus is largely on facility-based medical needs.
Eligibility & Cost: For most individuals, Medicare Part A is premium-free. This typically applies if the person or their spouse worked and paid Medicare taxes for at least 10 years (equivalent to 40 quarters). Having Medicare Part A entitlement is a prerequisite for TFL eligibility. If an individual does not qualify for premium-free Part A, they may have the option to purchase it. Delaying enrollment beyond the initial eligibility period could result in a late enrollment penalty, leading to higher monthly premiums.
Medicare Part B (Medical Insurance)
Definition & Purpose: Medicare Part B covers a broad range of medically necessary services and supplies. This includes services from doctors and other healthcare providers, outpatient care, durable medical equipment (DME) like wheelchairs and walkers, home health care, and numerous preventive services such as screenings and vaccinations. Part B primarily covers services received outside of an inpatient hospital setting.
Eligibility & Cost: While enrollment in Part B is optional for the general Medicare population, it is mandatory for TRICARE For Life eligibility. Beneficiaries must enroll in Part B and pay the monthly premiums to maintain their TFL coverage. The Part B premium amount is typically deducted from Social Security retirement or disability benefits and is based on the beneficiary’s reported income from previous tax years; higher incomes result in higher premiums. Failure to enroll in Part B during the initial eligibility period, without qualifying for a Special Enrollment Period (e.g., due to coverage under an employer group health plan based on current employment), can lead to a permanent late enrollment penalty, increasing the monthly premium for as long as the beneficiary has Part B.
The distinction between Part A and Part B costs is significant for retirees planning their transition to TFL. While TFL itself carries no enrollment fee, the mandatory Medicare Part B premium represents an unavoidable monthly expense necessary to maintain TFL eligibility. This prevents the misconception that TFL is entirely without cost and allows retirees to budget appropriately. Furthermore, the potential for late enrollment penalties for Part B (and Part A, if purchased) highlights the critical importance of timely Medicare enrollment. Delaying enrollment not only postpones the activation of TFL coverage but can also result in permanently higher Medicare premiums, posing a considerable financial risk.
For comprehensive details directly from Medicare, beneficiaries can visit the official Medicare website.
Understanding TRICARE For Life (TFL)
TRICARE For Life (TFL) is specifically defined as Medicare-wraparound coverage available to TRICARE-eligible beneficiaries who are entitled to Medicare Part A and enrolled in Medicare Part B. It is not a health plan that requires active enrollment; instead, coverage begins automatically on the first day a beneficiary has both Medicare Part A and Part B in effect.
The primary purpose of TFL is to work in coordination with Medicare to minimize the beneficiary’s out-of-pocket medical expenses. It achieves this by covering Medicare’s deductibles and coinsurance amounts for healthcare services that are covered by both Medicare and TRICARE. This ensures that military retirees and their eligible family members can maintain robust healthcare coverage after becoming eligible for Medicare.
It is important to understand that TFL operates differently from other TRICARE plans like TRICARE Prime or TRICARE Select. TFL is not a standalone plan but rather a benefit that complements Medicare. Family members who are not eligible for Medicare (e.g., spouses under 65 without qualifying disabilities) remain enrolled in their existing TRICARE Prime or TRICARE Select plans.
The transition to TFL signifies a notable shift in how healthcare is accessed and paid for, especially within the United States. Before TFL eligibility, beneficiaries typically interact primarily with the TRICARE system (using TRICARE networks, obtaining referrals under TRICARE Prime, etc.). However, once TFL is active in the U.S., the healthcare model becomes Medicare-centric. The primary point of interaction shifts to Medicare; beneficiaries seek care from providers who accept Medicare, and Medicare processes and pays claims first. Recognizing this fundamental operational change is crucial for beneficiaries to navigate the healthcare system effectively under TFL.
The official TRICARE website provides detailed information on TFL: tricare.mil/tfl.
Are You Eligible for TFL? Key Requirements
Eligibility for TRICARE For Life hinges on meeting two fundamental criteria simultaneously: maintaining TRICARE eligibility and being enrolled in both Medicare Part A and Part B.
TRICARE Eligibility
The individual must first be eligible for TRICARE benefits. This generally includes military retirees (including those on the Temporary or Permanent Disability Retirement List), their eligible spouses, unremarried former spouses meeting specific criteria, and survivors. Eligibility is determined by the sponsor’s uniformed service and must be accurately reflected in the Defense Enrollment Eligibility Reporting System (DEERS). Keeping DEERS information current is essential for maintaining TRICARE eligibility. Dependent parents and parents-in-law are generally not eligible for TFL.
Medicare Part A & Part B Enrollment
The beneficiary must be entitled to Medicare Part A (which is typically premium-free based on work history) AND actively enrolled in Medicare Part B (which requires payment of monthly premiums). This requirement applies regardless of the beneficiary’s age (including those under 65 who qualify for Medicare due to disability or End-Stage Renal Disease) and regardless of where they live, including overseas locations.
Once both these conditions are met, TFL coverage begins automatically on the first day that Medicare Part A and Part B are both effective. There are no separate TFL enrollment forms to fill out or enrollment fees to pay.
The Critical Role of Medicare Part B
Maintaining enrollment in Medicare Part B is absolutely essential for retaining TRICARE For Life coverage. Beneficiaries (excluding active duty service members and their families covered under other TRICARE plans) who become eligible for Medicare Part A must enroll in and continuously pay premiums for Medicare Part B to keep any TRICARE coverage, including TFL and the TRICARE Pharmacy Program. Choosing to drop Medicare Part B will result in the loss of TFL and potentially all TRICARE benefits.
The timing of Medicare enrollment is critical to ensure continuous health coverage. Beneficiaries approaching age 65 should enroll in Medicare Part A and Part B during their Initial Enrollment Period (IEP), which begins three months before their 65th birthday month, includes their birthday month, and ends three months after. To avoid any gap in TRICARE coverage, enrollment should be completed at least two months before turning 65. Those who miss their IEP can enroll during the Medicare General Enrollment Period (January 1 to March 31 each year), but coverage will not start until July 1, potentially creating a coverage gap and likely incurring the Part B late enrollment penalty.
A significant policy detail often causes confusion for beneficiaries living or traveling outside the United States: even though Medicare generally does not provide coverage overseas, beneficiaries eligible for TFL must still enroll in and pay monthly premiums for Medicare Part B to remain eligible for TRICARE/TFL. This requirement stems from federal law and links TRICARE eligibility directly to Medicare Part B enrollment for retirees, irrespective of geographic location. Paying for a service (Medicare Part B) that cannot be readily used locally overseas is essentially the cost of maintaining access to TRICARE benefits abroad.
Eligibility for TFL is therefore not merely about achieving retiree status; it requires proactive action (enrolling in Medicare Part B) and ongoing maintenance (paying Part B premiums). The “automatic” nature of TFL activation only occurs after the beneficiary successfully completes the necessary Medicare enrollment steps. Failure to act promptly can lead to gaps in health coverage and permanent financial penalties through increased Medicare premiums.
For specific details on Medicare eligibility and enrollment, visit the TRICARE page for Medicare-eligible beneficiaries.
How TFL and Medicare Coordinate Your Benefits (In the U.S. and U.S. Territories)
Within the United States and its territories (specifically American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands), TRICARE For Life and Medicare work together seamlessly to process healthcare claims.
Payer Order
For healthcare services covered by Medicare that are received in the U.S. or U.S. territories, Medicare acts as the primary payer. The healthcare provider submits the claim directly to Medicare first. Medicare processes the claim and pays its portion based on the Medicare-approved amount for the service.
Following Medicare’s payment, Medicare automatically forwards the claim details electronically to the TRICARE For Life claims processor (currently WPS Military and Veterans Health for claims in the U.S. and territories). This automatic “crossover” process means beneficiaries usually do not need to file claims themselves. TFL then processes the claim as the secondary payer and pays the remaining amount directly to the provider for services that are also covered by TRICARE. This streamlined, automated claim forwarding from Medicare to TFL is a significant convenience, minimizing paperwork for beneficiaries for most healthcare encounters within the U.S.
Your Out-of-Pocket Costs
The coordination between Medicare and TFL significantly impacts the beneficiary’s out-of-pocket expenses. The amount owed depends on whether the service is covered by Medicare, TRICARE, both, or neither.
TFL and Medicare Cost Sharing in the U.S.
| Type of Service | Medicare Pays | TRICARE (TFL) Pays | You Pay |
|---|---|---|---|
| Covered by BOTH Medicare & TRICARE | Medicare-approved amount | Remaining amount (deductible/coinsurance) | $0 (Generally) |
| Covered by Medicare ONLY | Medicare-approved amount | Nothing | Medicare deductible and cost-share/coinsurance |
| Covered by TRICARE ONLY | Nothing | TRICARE-allowable amount | TRICARE deductible and cost-share |
| Covered by NEITHER Medicare nor TRICARE | Nothing | Nothing | All billed charges (may exceed allowed amounts) |
Covered by Both: This scenario highlights the primary advantage of TFL. For services covered by both programs, TFL typically covers the Medicare Part A hospital deductible and copayments, as well as the Medicare Part B annual deductible and the 20% coinsurance. This results in the beneficiary paying nothing out-of-pocket for these services.
Covered by Medicare Only: If a service is covered by Medicare but not by TRICARE, TFL pays nothing. The beneficiary is responsible for the standard Medicare deductible and coinsurance amounts.
Covered by TRICARE Only: For services that TRICARE covers but Medicare does not (examples include care received overseas or inpatient hospital stays exceeding Medicare’s limits), Medicare pays nothing. TRICARE becomes the primary payer, and the beneficiary is responsible for the annual TRICARE deductible and applicable TRICARE cost-shares or copayments. This means that even with TFL, beneficiaries might encounter some out-of-pocket costs when accessing services outside Medicare’s coverage scope.
Covered by Neither: If a service is not covered by either Medicare or TRICARE, the beneficiary is responsible for the entire billed amount. Providers may bill more than the Medicare or TRICARE-allowable charge in these cases.
Beneficiaries must remain aware that TFL only “wraps around” Medicare for services that are also covered under TRICARE rules. It’s essential to verify coverage under both programs for specific treatments or procedures to avoid unexpected costs, as TFL does not automatically cover everything Medicare covers, nor does Medicare cover everything TRICARE covers.
Provider Types and Impact
The type of Medicare provider chosen can affect costs. Medicare providers can be “participating” (accept Medicare’s approved amount as full payment), “non-participating” (accept Medicare but can charge up to 15% above the approved amount, known as the “limiting charge”), or “opt-out” (do not accept Medicare at all and contract privately with patients).
TFL offers protection against the limiting charge; if a beneficiary sees a non-participating provider, Medicare pays its share, and TFL covers both the standard coinsurance and the additional limiting charge, resulting in $0 out-of-pocket for the beneficiary for dually covered services. However, if a beneficiary sees an opt-out provider, Medicare pays nothing. TFL will then pay only the amount it would have paid if Medicare had processed the claim (typically 20% of the TRICARE-allowable charge after the TRICARE deductible is met). The beneficiary is responsible for the remainder of the provider’s bill, which can be substantial. Therefore, seeing Medicare participating or non-participating providers is generally the most cost-effective approach.
For detailed cost information, refer to the official TRICARE For Life costs page and the downloadable TRICARE For Life Cost Matrix.
Scope of Coverage: What Healthcare Services Are Included?
TRICARE For Life, working in conjunction with Medicare Parts A and B, provides comprehensive healthcare coverage for eligible beneficiaries. The scope includes a wide range of medical services, durable medical equipment, and mental health care.
General Medical Care
Inpatient Care: TFL covers inpatient hospital stays, primarily paid first by Medicare Part A. TFL typically covers the Medicare Part A deductible and any applicable copayments for stays covered by both programs. For very long hospital stays that exceed Medicare’s coverage limits (e.g., beyond 150 days), TFL may provide coverage as the primary payer, subject to TRICARE’s rules, deductible, and cost-shares.
Outpatient Care: Services received outside of an inpatient hospital setting, such as visits to primary care doctors and specialists, laboratory tests, X-rays, outpatient surgeries, and preventive screenings, are primarily covered by Medicare Part B. For services covered by both Medicare and TRICARE, TFL generally covers the Medicare Part B annual deductible and the 20% coinsurance, resulting in no out-of-pocket cost for the beneficiary.
Durable Medical Equipment (DME)
Definition: DME refers to reusable medical equipment prescribed by a physician for use in the home. Examples include wheelchairs, walkers, hospital beds, oxygen equipment, glucose monitors, infusion pumps, and blood testing strips. The equipment must be able to withstand repeated use, serve a medical purpose, and generally not be useful to someone without an illness or injury.
Coverage in the U.S.: For TFL beneficiaries in the U.S. and territories, DME is primarily covered under Medicare Part B. Beneficiaries must follow Medicare’s rules for obtaining DME, which includes getting a prescription from a Medicare-enrolled provider and using a supplier that participates in Medicare. Using Medicare-enrolled suppliers is crucial for proper claim processing and cost coverage. Medicare Part B typically pays 80% of the Medicare-approved amount for covered DME after the Part B deductible is met, and TFL covers the remaining 20% coinsurance for items covered by both programs.
TRICARE DME Rules: TRICARE covers DME when it is medically necessary and appropriate to improve, restore, or maintain function or prevent deterioration. The TRICARE regional contractor decides whether DME will be rented or purchased based on cost-effectiveness and appropriateness. TRICARE may also cover medically necessary customizations, attachments (like a wheelchair lift for a car), repairs to beneficiary-owned equipment, and replacements under specific circumstances (e.g., change in condition, irreparable damage, FDA recall). Certain items are excluded, such as equipment with deluxe or luxury features, non-medical items (humidifiers, exercise bikes), duplicate items solely for backup (unless part of a fail-safe life-support system), and equipment available from an MTF.
For more details on DME coverage, visit tricare.mil/CoveredServices/IsItCovered/DurableMedicalEquipment.
The requirement to adhere to Medicare rules and utilize Medicare-enrolled suppliers for DME within the U.S. underscores the Medicare-centric nature of TFL stateside. Beneficiaries cannot simply choose any supplier; they must ensure the supplier works with Medicare to guarantee correct claim processing and TFL’s coverage of the coinsurance.
Mental Health Services
Coverage: TFL provides comprehensive coverage for medically and psychologically necessary mental health and substance use disorder (SUD) services. Covered treatments include outpatient services like psychotherapy (individual, family, group therapy) and medication management; intensive outpatient programs (IOP); partial hospitalization programs (PHP); acute inpatient psychiatric care; and psychiatric residential treatment centers (PRTCs) for children and adolescents. Telemental health services, allowing remote access to care via secure video or phone, are also covered.
Coordination with Medicare (in the U.S.): Similar to other medical services, Medicare is the primary payer for covered mental health services received in the U.S. TFL acts as the secondary payer, covering the Medicare deductible and coinsurance for services covered by both programs.
Access and Authorization: Access to outpatient mental health care is generally streamlined for TFL beneficiaries in the U.S. A referral or pre-authorization from TRICARE is typically not required for outpatient mental health services (like therapy or counseling, excluding psychoanalysis) when Medicare is the primary payer. However, TRICARE pre-authorization is required for certain higher levels of care, including non-emergency inpatient mental health admissions (for SUD and mental health), PHP, and IOP. Authorization is also needed from TRICARE if Medicare benefits for a particular service become exhausted. Emergency mental health care does not require pre-authorization, but the TRICARE contractor should be notified within a specified timeframe for continued inpatient stays. This tiered approach simplifies access for initial outpatient care while ensuring TRICARE oversight for more intensive and costly treatments.
For comprehensive information on mental health coverage, visit tricare.mil/mentalhealth.
Understanding Your Prescription Drug Coverage
Prescription drug coverage is a vital component of healthcare for retirees. TRICARE For Life beneficiaries have robust pharmacy benefits provided through the TRICARE Pharmacy Program.
Primary Coverage via TRICARE Pharmacy Program
Beneficiaries with TFL automatically retain their prescription drug coverage through the established TRICARE Pharmacy Program. This program is managed by TRICARE’s pharmacy contractor, currently Express Scripts.
Medicare Part D Interaction
Medicare Part D is the part of Medicare that provides prescription drug coverage through private insurance plans approved by Medicare. However, for individuals covered by TFL, enrollment in a Medicare Part D plan is generally not necessary or advantageous.
The TRICARE Pharmacy Program is considered “creditable coverage” by Medicare. This means that the coverage provided by TRICARE is, on average, at least as good as standard Medicare Part D coverage. Because TRICARE provides creditable coverage, TFL beneficiaries will not face a late enrollment penalty if they decide to enroll in a Medicare Part D plan later on. This protects beneficiaries and offers flexibility should their financial situation change, such as qualifying for Medicare’s “Extra Help” program.
For the vast majority of TFL beneficiaries, adding Medicare Part D offers “almost NO advantage”. Enrolling in Part D would mean paying an additional monthly premium for coverage that often overlaps with, and may be less comprehensive than, the existing TRICARE benefit. The primary exception is for beneficiaries with limited income and resources who may qualify for Medicare’s “Extra Help” program, which assists with Part D premiums and cost-sharing. Individuals in this situation should carefully compare their potential costs under a Part D plan with Extra Help versus the standard TRICARE Pharmacy Program costs.
If a TFL beneficiary does choose to enroll in a Medicare Part D plan, Medicare Part D becomes the primary payer for their prescriptions, and TRICARE will pay second. The beneficiary must then follow their specific Part D plan’s rules regarding formularies (list of covered drugs) and pharmacy networks.
TRICARE Pharmacy Options and Costs (Without Part D)
For TFL beneficiaries relying solely on the TRICARE Pharmacy Program, several options are available for filling prescriptions:
Military Treatment Facility (MTF) Pharmacies: Beneficiaries can fill prescriptions at MTF pharmacies, usually at no cost ($0 copay) for up to a 90-day supply of most medications available on the MTF formulary. Availability of specific drugs may vary by facility.
TRICARE Pharmacy Home Delivery (Express Scripts): This mail-order option allows beneficiaries to receive up to a 90-day supply of maintenance medications (drugs taken regularly for chronic conditions) delivered to their home. Home delivery is typically the most cost-effective option after MTFs, with lower copayments than retail network pharmacies. Copayments vary depending on whether the drug is generic, brand-name formulary, or non-formulary. Current costs can be checked online at tricare.mil/pharmacycosts.
TRICARE Retail Network Pharmacies: Beneficiaries can use pharmacies within the TRICARE retail network for up to a 30-day supply of medication. Copayments at network pharmacies are higher than those for home delivery. A network pharmacy locator tool is available at militaryrx.express-scripts.com/find-pharmacy.
Non-Network Pharmacies: Filling prescriptions at pharmacies outside the TRICARE network is the most expensive option. Beneficiaries must pay the full price upfront and then file a claim with Express Scripts for partial reimbursement (up to the TRICARE-allowable amount minus the applicable deductible and cost-share). This option is generally used only when network pharmacies or home delivery are not accessible.
TRICARE Formulary
The TRICARE Pharmacy Program utilizes a formulary, which is a list of covered medications. Drugs on the formulary are categorized into tiers: generic formulary, brand-name formulary, and non-formulary drugs. These tiers determine the beneficiary’s copayment amount, with generic drugs typically having the lowest cost. Some medications may require pre-authorization from Express Scripts before they can be filled. Beneficiaries can check if their medication is covered and view its tier status using the TRICARE Formulary Search Tool.
Medicare Part B Requirement for Pharmacy Benefits
It is crucial to remember that maintaining enrollment in Medicare Part B is generally required to use the TRICARE Pharmacy Program benefits (Home Delivery, Retail Network, Non-Network). Beneficiaries without Part B (unless they meet specific exceptions) are restricted to using only MTF pharmacies for their prescriptions. This underscores the importance of Part B enrollment for accessing the full range of TRICARE benefits, extending beyond just medical care to include comprehensive pharmacy coverage.
For official information on the pharmacy benefit, visit tricare.mil/pharmacy and the page specific to Medicare-eligible beneficiaries tricare.mil/CoveredServices/Pharmacy/Eligibility/Medicare.
Using Your TFL Benefit: Practical Steps
Navigating healthcare under TRICARE For Life involves a few practical steps regarding finding providers, showing proof of coverage, and understanding the billing process.
Finding Providers (in the U.S.)
A key feature of TFL when used with Original Medicare in the U.S. is the freedom of provider choice. TFL beneficiaries are not restricted to a specific TRICARE network. They can receive care from any civilian provider who accepts Medicare. Beneficiaries should confirm if a provider accepts Medicare assignment (meaning they accept the Medicare-approved amount as full payment). Medicare offers an online tool to help locate participating providers and suppliers: medicare.gov/care-compare/.
Showing Proof of Coverage
There is no specific TRICARE For Life enrollment card. When seeking care from civilian providers, beneficiaries must present both their Medicare card and their Uniformed Services ID card (the standard military retiree ID card). Both cards are necessary for the provider to verify eligibility and bill correctly – first to Medicare, then allowing for the automatic crossover to TFL. The absence of a dedicated TFL card can occasionally cause confusion for provider office staff unfamiliar with the program. Beneficiaries may sometimes need to explain that Medicare is primary and that TFL information is linked via their military ID/DoD Benefits Number, ensuring claims are processed correctly through Medicare first.
How Billing Works (in the U.S.)
For services received from Medicare-participating providers in the U.S., the billing process is typically seamless and requires little action from the beneficiary:
- Provider Bills Medicare: The healthcare provider submits the claim directly to Medicare.
- Medicare Pays & Forwards: Medicare processes the claim, pays its share of the Medicare-approved amount, and automatically forwards the claim information and remaining balance details to the TFL claims contractor (WPS Military and Veterans Health).
- TFL Pays: WPS processes the claim as the secondary payer and pays the provider the remaining amount for services covered by TRICARE (typically covering the Medicare deductible and coinsurance).
- Explanation of Benefits (EOB): The beneficiary will receive separate statements from both Medicare (called a Medicare Summary Notice or MSN) and TRICARE (a TFL EOB) detailing what each program paid.
When You Might Need to File a Claim
While the automated process covers most situations in the U.S., beneficiaries may occasionally need to file a claim manually with TFL:
Provider Type: If receiving care from a Medicare non-participating provider who does not file with TFL, or from a Medicare opt-out provider.
Other Health Insurance (OHI): If TFL is paying third after Medicare and an OHI plan that is not based on current employment (e.g., a retiree plan or Medicare Supplement).
Overseas Care: Claims for care received outside the U.S. and its territories almost always require manual filing (see below).
How to File: If manual filing is necessary for U.S. claims, the beneficiary should obtain a claim form (DD Form 2642), attach the provider’s itemized bill, the Medicare Summary Notice (MSN), and the Explanation of Benefits (EOB) from any OHI, and submit the package to the TFL contractor (WPS Military and Veterans Health, P.O. Box 7890, Madison, WI 53707-7890). It is important to adhere to filing deadlines: claims must be filed within one year of the date of service for care received in the U.S. and U.S. territories.
For official information on claims filing, visit tricare.mil/PatientResources/Claims.
TFL Coverage Outside the United States
The way TRICARE For Life operates changes significantly when beneficiaries receive healthcare outside the United States and its territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, U.S. Virgin Islands).
Fundamental Shift: TRICARE Becomes Primary Payer
The most crucial difference is that Medicare generally provides no coverage for healthcare services received in foreign countries. Consequently, when a TFL beneficiary seeks care overseas (outside U.S. territories), TRICARE (TFL) functions as the primary payer, assuming there is no Other Health Insurance (OHI) involved.
Beneficiary Cost Responsibilities Overseas
Because TRICARE is the primary payer overseas, the financial responsibility shifts. Beneficiaries are responsible for paying TRICARE’s annual deductible and applicable cost-shares or copayments for covered services, similar to how TRICARE Select Overseas functions. The near-zero out-of-pocket cost often experienced in the U.S. for dually covered services does not apply overseas. Beneficiaries should anticipate costs consistent with TRICARE Select retiree rates (Group A or B depending on sponsor’s initial enlistment/appointment date). These costs can be reviewed using the TRICARE Compare Costs Tool. This change requires beneficiaries living or traveling abroad to budget for potential deductibles and cost-shares that they might not encounter stateside.
Finding Providers Overseas
TFL beneficiaries overseas can generally seek care from any TRICARE-authorized civilian provider. It is advisable to use the TRICARE Overseas provider directory or contact the TRICARE Overseas Program contractor (currently International SOS) for assistance in locating providers. The provider search tool can be accessed online at tricare-overseas.com/beneficiaries/provider-search. Note that specific network requirements apply in the Philippines, where beneficiaries must generally use providers in the Philippine Preferred Provider Network or other certified providers.
Getting Care and Filing Claims Overseas
The process for receiving and paying for care overseas differs significantly from the U.S. system:
Payment: Beneficiaries often need to pay the healthcare provider upfront for the full cost of services at the time care is received.
Claim Submission: To get reimbursed, the beneficiary must manually file a claim with the TRICARE Overseas Program claims processor (International SOS). The claim package must include a completed claim form, the provider’s detailed itemized bill (including diagnosis), and proof of payment. If OHI is involved, the OHI’s EOB must also be included. This manual process places a greater administrative burden on the beneficiary compared to the automated system in the U.S. and requires careful record-keeping.
Filing Deadline: Claims for overseas care must be filed within three years of the date of service.
For information on filing overseas claims, visit tricare-overseas.com/beneficiaries/claims.
Crucial Reminder: Medicare Part B Still Required
It cannot be stressed enough: even when living or traveling overseas where Medicare provides no coverage, TFL beneficiaries must maintain their enrollment in Medicare Part B and continue paying the monthly premiums to remain eligible for TRICARE For Life. Failure to do so will result in the loss of all TRICARE coverage.
For official guidance on using TFL overseas, visit tricare.mil/Plans/HealthPlans/TFL/TFL_O.
Accessing Care at Military Treatment Facilities (MTFs)
Military retirees and their eligible family members with TRICARE For Life retain the option to seek care at military hospitals and clinics (MTFs), both within the United States and in overseas locations where MTFs are present.
However, access to care at MTFs for TFL beneficiaries is strictly on a space-available basis. MTFs must prioritize providing care to active duty service members and their enrolled family members. This means that appointment availability for TFL beneficiaries, particularly for routine or specialty care, may be limited and cannot be guaranteed. Consequently, TFL beneficiaries should not rely on MTFs as their primary or sole source of healthcare. Understanding how to navigate the civilian provider network (using Medicare providers in the U.S.) is essential for ensuring consistent access to care.
When care is successfully accessed at an MTF, it typically involves minimal or no out-of-pocket cost for most services. However, certain charges, such as subsistence fees for inpatient stays, may apply. Prescriptions filled at MTF pharmacies are generally provided at no cost to the beneficiary.
How TFL Works with Other Health Insurance (OHI)
It is possible for TRICARE For Life beneficiaries to have additional health insurance coverage alongside TFL and Medicare. This Other Health Insurance (OHI) could include employer-sponsored group health plans (from current employment of the beneficiary or a spouse), retiree health plans, or private Medicare supplement (Medigap) policies. Having OHI does not affect TFL eligibility, as long as the beneficiary maintains enrollment in both Medicare Part A and Part B. Note that TRICARE supplement plans are not considered OHI for the purposes of coordinating benefits.
Payment Coordination Rules with OHI
When OHI is present, the order in which the insurance plans pay depends on the nature of the OHI:
OHI Based on Current Employment: If the OHI is a group health plan based on the current employment of the beneficiary or their spouse, that employer plan pays first. Medicare pays second, and TRICARE For Life pays last. In these situations, the provider or employer typically handles the claim filing process.
OHI NOT Based on Current Employment: If the OHI is not based on current employment (such as a retiree plan, an individual plan, or a Medicare Supplement/Medigap policy), the payment order is: Medicare pays first, the OHI pays second, and TRICARE For Life pays third or last.
When TFL pays third, the claims process often becomes more complex. The automatic crossover from Medicare to TFL may not occur. The beneficiary may need to manually file a claim with TFL (WPS for U.S. claims) after both Medicare and the OHI have processed the claim. This manual submission must include the Medicare Summary Notice (MSN) and the Explanation of Benefits (EOB) from the OHI plan. This adds an administrative step for the beneficiary compared to having only Medicare and TFL.
Considering Medicare Advantage (Part C) Plans?
While Original Medicare (Part A and Part B) is the standard foundation for TRICARE For Life, some beneficiaries may consider enrolling in a Medicare Advantage (MA) plan, also known as Medicare Part C. It’s important to understand how choosing an MA plan impacts the TFL experience.
Medicare Advantage (MA / Part C) Overview
Medicare Advantage plans are an alternative way to receive Medicare benefits, offered by private insurance companies that contract with Medicare. These plans are required to cover all services that Original Medicare (Part A and Part B) covers, but they may have different rules, costs, and restrictions. MA plans often bundle Medicare Part D prescription drug coverage and may offer extra benefits not covered by Original Medicare, such as routine vision, hearing, or dental care. Most MA plans operate using provider networks (like HMOs or PPOs), meaning beneficiaries generally must use doctors and hospitals within the plan’s network to receive full coverage for non-emergency services. MA plans may also charge their own monthly premium in addition to the standard Medicare Part B premium.
Using MA Plans with TFL
TRICARE For Life beneficiaries can enroll in a Medicare Advantage plan; doing so does not cause them to lose their TFL eligibility. However, choosing an MA plan significantly changes how TFL works and the overall healthcare experience.
Impact and Considerations of Combining MA and TFL
Network Restrictions: Unlike the freedom to see any Medicare provider under Original Medicare + TFL, beneficiaries enrolled in an MA plan are typically required to use the plan’s network providers for non-emergency care. Seeking care outside the network may result in higher costs or no coverage, depending on the plan type.
Cost Sharing: Beneficiaries will likely have copayments or coinsurance dictated by the MA plan when they receive services.
TFL Reimbursement Process: The seamless, automatic coordination between Medicare and TFL does not occur with MA plans. TFL may still help cover the beneficiary’s cost-sharing (copayments) under the MA plan for services that are also covered by TRICARE. However, this requires the beneficiary to pay the MA plan copay upfront and then manually file a paper claim with the TFL contractor (WPS) for reimbursement. This claim must include documentation from the MA plan (their Explanation of Benefits). This manual reimbursement process introduces significant administrative effort compared to the automatic secondary payment under Original Medicare + TFL.
Pharmacy Coverage: Even if enrolled in an MA plan that includes prescription drug coverage (MA-PD), the TFL beneficiary still retains their full TRICARE Pharmacy Program benefit. They effectively have two separate pharmacy coverages and can choose which one to use for a given prescription. Using the MA plan’s drug benefit requires following that plan’s specific formulary, network pharmacy rules, and cost-sharing structure.
Choosing a Medicare Advantage plan fundamentally alters the TFL experience. The simplicity of automatic secondary coverage and broad provider choice associated with Original Medicare + TFL is replaced by a system involving network limitations and manual claims filing to potentially get TFL to cover MA plan cost-sharing. The primary value TFL adds when combined with an MA plan is the potential for copay reimbursement (requiring beneficiary action) and the continued availability of the separate, often robust, TRICARE Pharmacy Program. Beneficiaries should carefully weigh whether the potential extra benefits or lower premiums of an MA plan outweigh the loss of simplicity and provider freedom offered by the standard Original Medicare and TFL combination.
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