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Tricare Help: If surgery isn't covered, complications from procedure may not be either

May. 21, 2014 - 04:20PM   |  

Q. I’m an active-duty family member. Tricare paid for my lap band for weight reduction, but I had many issues with it and finally had to have it removed for medical reasons. Tricare paid for the removal. If I was to have another surgery, it would be to get a duodenal switch, and I’d have to pay for it myself because Tricare doesn’t cover that. But how does Tricare work if I have medical complications related to a noncovered service?

A. Yours is a deceptively simple question with a comparatively complicated answer.

Tricare will cover otherwise covered services and supplies required in the treatment of complications (known as “unfortunate sequelae”) resulting from noncovered services only if the noncovered service was approved by and performed at a military hospital or clinic, and only if the military treatment facility is unable to provide the necessary treatment of the complications.

This policy stems from a 2011 rule change. The background: In an effort to support the general medical proficiency of its health care professionals, MTFs often perform medical procedures that may not be covered under Tricare. Unexpected complications from these procedures may result and, in those instances where the MTFs are unable to provide the appropriate level of care necessary for the proper treatment of these complications, the MTF commander must refer the beneficiary for treatment outside the MTF.

Under previous regulations, Tricare could not cover treatment of the complications resulting from noncovered procedures. When beneficiaries required treatment outside an MTF for these complications arising from noncovered procedures, they were fully responsible for payment.

The 2011 change addressed this situation by allowing Tricare to cover treatment for complications resulting from noncovered treatment, but only if the original noncovered treatment was provided in an MTF and authorized by the MTF commander.

Under all other circumstances, treatment of complications arising from noncovered services are not covered by Tricare.

Q. My wife is on active duty. We added her to my private insurance coverage this year and have been using my coverage. Will Tricare, as the secondary insurer, cover the co-pays for her other coverage. If so, where do we send copies of our co-payments?

A. Active-duty service members cannot use other health insurance. They are required to have Tricare Prime and coordinate their care through military treatment facilities. You can see that clearly stated on this Web page detailing how, and when, Tricare works with OHI: www.tricare.mil/GettingCare/OHI.aspx.

From a military readiness perspective, the services are quite finicky about ensuring they retain health care visibility and authority over active-duty personnel. If your active-duty wife receives health care outside the military sphere under your health plan, she risks running afoul of her chain of command.

Write to tricarehelp@militarytimes.com. Include the word “Tricare” in the subject line and do not attach files.

Answers by RallyPoint

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