Tricare And Mapd Plans

[Travis Price]

So this is what I am trying to find out, In the past this is what I thought and was taught

However, what some are saying here is they are not losing anything from T4L only getting extra from MA but still can use T4L outside of MA network

So I still don't know if I was taught correct or have I been wasting opportunities to enhance people T4L all this time

Using TRICARE For Life with Other Health Insurance | TRICARE

TFL pays after Medicare and after any other insurance. When you're using a provider that isn't in network for MA, TFL pays after the other health insurance.

In short, T4L will only pay 20% of allowable charges.

So, in theory:

Let's say you go to the doctor with an MA plan that's out of network and the co-insurance is 50%. You'd pay zero with Medicare and T4L and 30% with Medicare advantage.

If the copay is less than 20%, then TFL covers the rest AFTER you meet the $300 deductible.

So, you kind of screw the person up.. they start getting less and less from TFL after MA.

The benefits are rarely that good. The "free" dental/vision/hearing coverage, a few hundred dollars for otc/gym Membership vs essentially a free plan G for life?

The best interest of client is to leave them alone, imo.

 

[DonP]

Yes and no. For the most part, I would leave T4L's alone. However, when working for Humana, there have been some T4L folks that were adamant I sign them up for a policy. They knew the ins and outs better than anyone in the call center.

Like others have said (and sorry, a lot of what I'm saying is rehashed from earlier posts in this thread, especially runnerdude and wln417), they HAVE to stay within the MA plan's network for T4L to pick up the copay they would otherwise pay on an MA with no T4L. That much is for certain.

The part that isn't detailed as clearly as it should be when talking about this with carriers, I think, is what happens if they receive care outside of the network? What would happen is that T4L wouldn't pick up, as it won't pay more than the primary insurance. If there is no primary insurance, then there is no T4L coverage, unless the care is received at a military or federal healthcare provider.

I think a lot of agents brush over that, especially when the wording used is "If Medicare doesn't cover it, Tricare still kicks in." That's not really the case and I think that gives the beneficiary the implication that they can still go to the provider of their choice if not explained correctly.

The only things that Medicare doesn't cover that T4L does besides care in a military or federal facility would be Rx's, overseas care, and I think chiropractic services. It's very limited.

To sum it up, it's safe for T4L beneficiaries who see a limited amount of providers that are in network and understand the ramifications of going out of network. If they are looking at a MAPD, they need to know it will become a paperwork situation with their Rx coverage. For some that only take Tier 1's, they don't care because they prefer to go to the local Walgreen's or CVS and don't have a copay anyway. If any Tier 3-5's are involved, then it isn't in their best interest at all I would say to go to an MAPD.

I grilled a very knowledgeable Regional director yesterday on this very subject.Overall yes they need to want to use the dr’s in network BUT he said Tricare will pick up most out of network charges BUT he very possibly could have some out of pocket . So i think unless the Tricare person is comfortable with the network AND wants the extra benefits he should just stay with Tricare .

 

[TRG1225]

Using TRICARE For Life with Other Health Insurance | TRICARE

TFL pays after Medicare and after any other insurance. When you're using a provider that isn't in network for MA, TFL pays after the other health insurance.

In short, T4L will only pay 20% of allowable charges.

So, in theory:

Let's say you go to the doctor with an MA plan that's out of network and the co-insurance is 50%. You'd pay zero with Medicare and T4L and 30% with Medicare advantage.

If the copay is less than 20%, then TFL covers the rest AFTER you meet the $300 deductible.

So, you kind of screw the person up.. they start getting less and less from TFL after MA.

The benefits are rarely that good. The "free" dental/vision/hearing coverage, a few hundred dollars for otc/gym Membership vs essentially a free plan G for life?

The best interest of client is to leave them alone, imo.

Great point, I forgot to separate the PPO's from the HMO's in my post...but there's also a caveat to it with PPO's: The provider has to be willing to make the claim. If the provider isn't willing to make the claim, then, as I understand it, the beneficiary is back to paying 100% of the OOP costs.Since Tricare is only going to pay second...and if no one paid first, then SOL.

 

[TRG1225]

I grilled a very knowledgeable Regional director yesterday on this very subject.Overall yes they need to want to use the dr’s in network BUT he said Tricare will pick up most out of network charges BUT he very possibly could have some out of pocket . So i think unless the Tricare person is comfortable with the network AND wants the extra benefits he should just stay with Tricare .

That's mostly the total picture...one thing I learned while working at Anthem: sometimes providers won't send a claim to an OON carrier. It's kind of ridiculous in my opinion, but it happened more than what you would think. If the provider won't send a claim to the carrier, then T4L ain't payin' anything.

 

[somarco]

Situation 1 - If the provider has opted out of Medicare the claim will not be filed by the provider, and, neither Mcare nor the MA carrier will pay anything.

Situation 2 - If the provider participates in Medicare, is non-par with the PPO MA provider but files the claim, the carrier will pay something but there may be an outstanding balance due if the provider does not accept the amount as paid in full.

Situation 3 - If the provider participates in Medicare, is non-par with the HMO MA provider but files the claim, the carrier will pay nothing unless the claim qualifies as an emergency.

Situation 4 - If the provider participates in Medicare, is par with the PPO MA provider and files the claim, the carrier will pay their contractual liability.

If you guys are going to mess around with T4L you might want to familiarize yourself with this.
https://www.tricare.mil/~/media/Files/TRICARE/Publications/Handbooks/TFL_HBK.pdf

Page 3 T4L is a Medicare wrap around . . . you really should understand what this means unless you want to step on a land mine or two

Here is another summary.
TRICARE For Life | TRICARE

Maybe the carrier reps know what they are talking about but I am always suspicious of relying on them for advice.

And this . . . while I have clients who use the VA (many have service related disabilities) AFAIK I don't have any T4L clients. Mine are mostly champva

 

[Insbiz101]

I grilled a very knowledgeable Regional director yesterday on this very subject.Overall yes they need to want to use the dr’s in network BUT he said Tricare will pick up most out of network charges BUT he very possibly could have some out of pocket . So i think unless the Tricare person is comfortable with the network AND wants the extra benefits he should just stay with Tricare .

Don’t you love how the very knowledgeable RDs never use definitives in describing how the plan “may” work with T4L. “Usually” they’ll need to use network doctors and claims “should” be paid “most” of the time but their “could” “possibly” be some out of pocket expenses.

Whereas, with MCR + T4L... your covered. End of story. Thank you for your service, you’ve earned it. On to the next prospect

 

[somarco]

very knowledgeable Regional director

Oxymoron.

Very knowledgeable and RD are mutually exclusive terms.