Over the years I have often been asked to do I video and write a blog post on how Medicare works with Tricare for Life. I have hesitated to do so because TRICARE for Life is a government program. Insurance agents are not authorized to sell TRICARE for Life Insurance. I can only provide my opinion as licensed agent with over three decades of experience in financial services. I am not an agent of TRICARE for Life.
While I cannot help you directly with your TRICARE or ChampVA, I can help you to understand how TRICARE for Life works with Medicare, or ChampVA, and how to avoid a potentially serious mistake. That is what I am going to do here.
In recent years there is one insurance company that has decided to market directly to our military veterans. In marketing directly to veterans and their families, this insurance company has developed volumes of training material to help individual agents understand the products and the market.
Unfortunately, they are fighting an uphill battle. In some cases, it is simply a matter of agents not reading or watching the material that is provided to them. In other cases, it is a battle against greed. It’s a battle against those who are hungry for income and putting their commissions ahead of your healthcare.
This is a serious pet peeve of mine and recent interactions with other Medicare agents is what has motivated me most to write this post today. My parents had TRICARE for Life coverage. My father was career Navy. He and my mom have passed and are buried together at Arlington National Cemetery. Both of their end-of-life situations were very medically involved. In both cases, their end-of-life care was made much easier because they had TRICARE for Life and not a Medicare Advantage Plan.
Medigap Seminars Insurance Agency Reviews.
Understanding Medicare and Tricare
Medicare and Tricare are two separate health insurance programs that work together to provide comprehensive coverage for eligible individuals. Medicare is a federal health insurance program primarily for people aged 65 or older, certain younger individuals with disabilities, and those with End-Stage Renal Disease (ESRD). Tricare, on the other hand, is a health insurance program designed for active duty and retired military personnel and their families.
When you have both Medicare and Tricare, Medicare typically acts as the primary payer, meaning it pays first for Medicare-covered services. TRICARE pays as the secondary payer, covering any remaining costs that Medicare does not. This coordination ensures that you receive the maximum benefits from both programs. However, there may be some exceptions to this rule, so it’s essential to understand how Medicare and Tricare work together to avoid unexpected out-of-pocket costs and ensure seamless coverage.
How Does Medicare Work with TRICARE-for-Life?
What I am going to do here is to provide you with a short answer, then follow it up with a more detailed and important explanation.
If you have TRICARE for Life or ChampVA it is my opinion and the opinion of the insurance company to which I have alluded, that you keep your TRICARE or ChampVA, and keep Original Medicare. Medicare Part A is hospital insurance covering inpatient hospital care, skilled nursing care, and related services. Do not trade your Medicare in for a Medicare Advantage Plan, do not trade your TRICARE or ChampVA in for a Medicare supplement, and do not get a stand-alone Medicare Part D plan.
Medicare Part B is medical insurance, covering outpatient care, preventive services, and medical supplies. Beneficiaries must have Medicare Part B to qualify for TRICARE. I believe you cannot improve on your healthcare by messing with your TRICARE. If you replace your original Medicare with an Advantage plan you are actually reducing your insurance coverage and increasing your financial risk. Individuals must pay Medicare Part B premiums in addition to using TRICARE as a secondary insurance to Medicare. TRICARE for Life covers the Medicare deductible and any applicable coinsurance when both TRICARE and Medicare cover a service.
That’s the short answer. That’s my firm opinion.
Enrollment and Eligibility
To be eligible for Tricare for Life (TFL), you must have both Medicare Part A and Part B and meet specific eligibility criteria. TFL is an individual entitlement, meaning that while you may qualify for TFL, your family members who aren’t eligible for Medicare will continue to be covered under Tricare Prime or Tricare Select. Your TFL coverage automatically begins on the first day that you have both Medicare Parts A and B.
There are no enrollment forms or fees for TFL. However, to avoid any gaps in your Tricare coverage, it’s crucial to ensure that you are enrolled in both Medicare Part A and Medicare Part B at least two months before you turn 65. You can sign up for Medicare through the Social Security website or by contacting the Social Security Administration to set up an appointment. This proactive approach will help you maintain continuous coverage and avoid any disruptions in your healthcare benefits.
Tricare For Life is Like a Medicare Wraparound Coverage
For TRICARE for Life to be active, you must also have original Medicare. That is Medicare Part A (inpatient coverage) and Medicare Part B (outpatient coverage). Original Medicare becomes your Primary insurer and with Tricare being secondary, just like a Medicare supplement plan. TRICARE for Life is a form of Medicare supplement insurance that reduces out-of-pocket costs. Tricare for life is premium free. You earned it.
The part of this that is most important and the reason I made this video is that Original Medicare, that red, white and blue Medicare card is your primary insurance.
Why is it important that original Medicare remain your primary insurance? Because you get to keep the benefits of original Medicare.
There are two benefits of original Medicare that are critical to your healthcare.
First, with original Medicare being your primary insurance, you are not limited to any network. You can see any doctor or visit any medical facility in the country as long they accept original Medicare. That’s pretty much every doctor and every medical facility in the US. or US territory. There are very few exceptions.
Second, no insurance company can interfere with your care. Your medical decisions are between you and your doctor. The goal of both Medicare and TriCare is to cover everything that is medically necessary. Your doctor does not need to get prior approval from the insurance company. You do not need to get a referral from your doctor if you wish to see a specialist. No insurance company can stall or prevent your medical treatment based on their internal rules. All medical decisions are between you and your doctor.
When you have Original Medicare, TRICARE for Life and Medicare work hand in glove so that your annual maximum out-of-pocket financial risk is limited to near zero. TRICARE for Life provides Medicare wraparound coverage, coordinating benefits to reduce out-of-pocket costs. In fact, the only expense for inpatient or outpatient services would be if TRICARE approves a treatment that Medicare does not. I have never seen that, but I guess it’s possible. In that case TRICARE will cover the service with a small potential out-of-pocket from you. Please see your TRICARE benefit details online for specifics. I have a link to the government site below.
TRICARE benefits include covering copayments, deductibles, and prescription drugs, ensuring comprehensive coverage.
Do I Need Medicare Part D with Tricare for Life?
As I mentioned, TRICARE for life is like a Medicare supplement Plan on steroids. In addition to the standard Medicare supplement benefits, your TRICARE includes prescription drug coverage. You do not want to get a separate Medicare Part D plan. In fact, doing so can cause harm to your TRICARE, especially ChampVA.
By the way, did you know that the drug coverage you have through TRICARE is not subject to the expensive coverage gap that is a feature of Medicare Prescription drug coverage? You have no coverage gap, no donut hole like those with Part D have to deal with.
Costs and Fees
Tricare for Life does not charge any monthly premiums, but you are required to pay the Medicare Part B monthly premium, which is $174.70 in 2024. Medicare typically covers 80% of the out-of-pocket costs for covered services, while TFL pays the remaining 20% and the Part B annual deductible, which is $240 in 2024. If you visit a healthcare provider who does not accept Medicare, you will be responsible for paying 80% of the cost, and TFL will cover the remaining 20%.
TFL also includes prescription drug coverage, so you do not need to enroll in a separate Medicare Part D plan. However, if you choose to enroll in Medicare Part D, you will incur a monthly premium and must adhere to your Medicare Part D plan’s rules for obtaining prescriptions. This additional cost and complexity can be avoided by relying on the comprehensive prescription drug coverage provided by TFL.
Tricare For Life & International Coverage
One of the enhanced benefits I like about TRICARE is that it offers significant healthcare coverage overseas. Medicare only operates in the US and US territories. Some Medicare supplement plans offer limited emergency coverage if overseas. When you have TRICARE for life and are visiting or have moved overseas, TRICARE becomes your Primary Insurance for overseas healthcare. Very cool. TRICARE for Life also coordinates benefits with Medicare and other health insurance plans, particularly in relation to out-of-pocket costs.
Beware the Medicare Advantage Sales Pitch
So, what is it that motivated me to make this video and what is the issue with I have with some other Medicare agents or brokers?
Let’s start with the primary issue. Many Medicare focused insurance agents are struggling to make a living. Others simply do not put the time and effort into understanding their insurance products before selling them.
Insurance agents do not and cannot sell TriCare. On the other hand, Medicare Advantage Plans pay the highest commissions of any Medicare product. So, when a person with TRICARE is looking for help, instead of just telling them they are in a great plan some agents try to find a way to sell an Advantage Plan and make it look like you’re gaining in insurance coverage. You are not.
The only thing an insurance agent can do to improve your coverage is to offer you a dental plan. There is not much money in that.
So, what is the sales pitch? Well, they try to sell a Medicare Advantage plan based on what I refer to as Shiny objects. These are features of a plan that have nothing to do with your primary health needs. These can be dental benefits, gym membership, free uber to a doctor’s office, or even a give back of some of your Part B premium. All these shiny objects come with your having to give up an important part of your primary healthcare coverage. But that fact is entirely glossed over by the sales agent.
The pitch usually goes something like this; the agent will tell you to switch from original Medicare to a Medicare Advantage plan. Usually a zero premium plan that includes some dental coverage or gym membership. They will tell you that you can keep your TRICARE because it is still secondary coverage, but it’s to your advantage because you now have dental coverage.
Sounds good, right? Here is what is NOT being said.
When you trade in your original Medicare for a Medicare Advantage plan, you lose the two benefits of original Medicare I mentioned earlier.
First you can no longer see any medical provider in the US as long as they accept Medicare. You will now be limited to the Medicare Advantage plan network of providers. Seeing providers out of network can be cost prohibitive or simply not allowed by the Advantage Plan.
Second, instead of your healthcare decisions being between you and your doctors, it is now the insurance company who directs your healthcare. That is important. Your doctor will have to get permission from the insurance company for any procedure or treatment. The insurance company can deny the procedure or delay the procedure by up to two weeks. I have seen this done for urgently needed chemotherapy and even dialysis and organ transplants.
If you would like to know even more about the disadvantages of Medicare Advantage Plans, please see my article titled “Disadvantage of Medicare Advantage“.
The Inspector General Report on Medicare Advantage Plans
In another article I talk discuss the Inspector General Report, two reports actually. The inspector general for Health and Human Services did an original report on Medicare Advantage Plans published in 2018 that showed the insurance companies regularly deny service to the consumer as a tactic to increase profits. When you have a Medicare Advantage Plan, your doctor cannot perform a procedure without their permission. Except in emergencies, of course. For other procedures the insurance company can just say no and leave you to fight for your health insurance coverage.
The Inspector General then followed up that 2018 report with one published in 2022. In the latest study they found nothing has changed. The way that Medicare compensates Medicare Advantage Plans incentivizes them to deny coverage. That is not going to change. I go into detail why in the other video.
In addition, in 2021 the American Hospital Association representing 5,000 US Hospitals, wrote a scathing letter the Centers for Medicare & Medicaid Services (CMS) who manages Medicare, complaining that when doctors are forced to get prior approval for medical procedures, the delay in coverage is harming the patients. Often, these are treatments for aggressive cancer or the need to move from a hospital to rehabilitation after a stroke or an accident. The Medicare Advantage Plans are allowed to delay procedures up to 14-days and then can deny them as well.
The letter details the problem and the very real harm it causes patients.
I have linked all of this below.
Your TRICARE can pay some copays or deductibles left as your obligation after a Medicare Advantage plan has paid a claim. However, unlike when you have original Medicare and TRICARE, with an Advantage plan you will have to pay the claim and submit paperwork to TRICARE for reimbursement.
To be clear, when you have a Medicare Advantage Plan, anything that TRICARE would pay, you must pay first and then be reimburse. It is not automatically paid for like it is with Original Medicare.
As an important sidenote, retired veterans who have been switched from Original Medicare to a Medicare Advantage are a significant percentage of Medicare complaints. Once they use the Advantage plan and realize their benefits have been reduced from what they have, they often complain to Medicare that they have been duped.
Please go to https://www.tricare.mil/Publications and look for your TRICARE for Life handbook for more details on all that I have covered.
To recap, TRICARE for Life is designed to work hand in glove with Original Medicare. You cannot improve on that except to add dental coverage.
If you would like to look at some stand-alone Dental Plans, take a look at the plans in these two links. They are among my favorites.
Ameritas: https://myplan.ameritas.com/id/010S4605
Protector Plus: https://myplan.ameritas.com/ppd/id/010S4605
Anyway, if you trade in your original Medicare A & B for an Advantage Plan, you reduce your healthcare coverage and lose the greatest benefits of Medicare. In addition, anything that TRICARE would pay you, you will have to pay upfront and submit paperwork for reimbursement.
In my opinion, if you come across an agent that is trying to replace your original Medicare with a Medicare Advantage Plan, run away. They are not going to improve your healthcare over the TRICARE for Life you have.
Links mentioned in the video:
Medicare Advantage Denials of Care
FAQ Changing Medicare Plans Or Companies
Prescription Drug Coverage and Life Benefits
Understanding Prescription Drug Coverage
TRICARE for Life (TFL) offers robust prescription drug coverage, ensuring that beneficiaries have access to the medications they need without the hassle of high out-of-pocket costs. As a Medicare supplement program, TFL works seamlessly with Medicare Part D, allowing beneficiaries to fill prescriptions at participating pharmacies, including those within the TRICARE network.
With TFL, you can expect:
A comprehensive range of medications, including both brand-name and generic options.
Coverage for prescriptions needed for chronic conditions as well as acute illnesses.
A copayment structure designed to keep your out-of-pocket costs manageable.
Access to the TRICARE Pharmacy Program, which provides convenient and cost-effective options for obtaining your medications.
This integration ensures that you receive the medications you need without the financial burden often associated with prescription drug coverage.
How Life Benefits Integrate with Tricare for Life
TRICARE for Life (TFL) goes beyond just medical and prescription drug coverage by offering a suite of life benefits aimed at supporting your overall health and well-being. These benefits are designed to provide comprehensive care that addresses both physical and mental health needs.
Key life benefits include:
Access to wellness programs and services, such as fitness classes and health coaching, to help you maintain a healthy lifestyle.
Coverage for preventive care services, including routine check-ups and screenings, ensuring early detection and management of health issues.
Support for managing chronic conditions through disease management programs and case management services.
Access to mental health and substance abuse treatment services, providing essential support for mental well-being.
Coverage for hospice care and other end-of-life services, ensuring compassionate care during critical times.
By integrating these life benefits with its medical and prescription drug coverage, TFL offers a holistic approach to healthcare that supports your overall well-being, addressing the needs of your body, mind, and spirit.
Working with Medicare and Tricare
TRICARE for Life (TFL) is meticulously designed to complement Medicare, providing a seamless and comprehensive healthcare experience for its beneficiaries. Here’s how TFL works in conjunction with Medicare:
Primary Coverage: Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) serve as the primary coverage for TFL beneficiaries, covering a wide range of healthcare services.
Secondary Coverage: TFL acts as a Medicare supplement program, stepping in to cover costs that Medicare does not, such as copayments, coinsurance, and deductibles.
Coordination with Other Health Insurance: TFL coordinates benefits with other health insurance (OHI) plans, including employer-sponsored plans and Medicare Advantage plans, ensuring that beneficiaries receive the maximum coverage possible.
Medicare Advantage Plans: While TFL beneficiaries can choose to enroll in a Medicare Advantage plan, it’s crucial to understand how these plans interact with TFL. Medicare Advantage plans may offer additional benefits and services, but they also come with network restrictions and potential delays in care approval.
By working together, Medicare and TFL provide a comprehensive healthcare solution that meets the unique needs of military retirees and their families, ensuring that you receive the best possible care without unnecessary financial strain.
