Military Health, Tricare programs - Army Times

Tricare Help: Rules on Tricare as last payer

Q My employer provides a free health insurance plan with a $3,000 deductible. I never have that much medical expense, so I doubt the plan will ever pay anything. If that policy does not pay anything first, how do I file claims so Tricare pays last, as required by law?

AWhen a Tricare beneficiary has other health insurance, figuring out how much Tricare will pay is complicated. You can’t do it yourself.

Here is the general rule: Tricare will pay the difference between the amount the other health insurance pays and the patient’s legal obligation to pay for the services on the claim. However, Tricare will never pay more than it would have paid if the patient did not have the other insurance.

Your high-deductible plan will not actually pay anything until you have paid $3,000 out of pocket. On each claim, that plan will calculate the amount it would have paid and subtract it from the $3,000. Then the other health insurance will send you an explanation of benefits reporting those actions.

After you receive that plan’s EOB, you must submit a Tricare Claim Form DD 2642 with copies of the bills that were submitted to the other plan and a copy of its EOB. Tricare will determine the amount allowable on the charges, note that the other insurance paid nothing toward that amount, subtract any Tricare deductible not previously satisfied and pay 75 percent of the remainder.

Call your Regional Tricare Service Center for help with filing.

Q If President Barack Obama succeeds in creating a universal health care plan, how would it affect Tricare and Tricare for Life?

A The smallest details regarding beneficiaries and benefits would first have to be worked out, accepted by Congress and voted into law. There have been no discussions in Congress of a national health care plan, so it’s only speculation.

But if the matter does become one of public debate, you’ll have ample opportunity to give your personal input to your elected representatives in Washington.

Write to James E. Hamby Jr. at Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or tricarehelp@atpco.com.