Military Health, Tricare programs - Army Times

Tricare help: Is gastric bypass surgery covered?

Q. CNN reported on a 600-pound man whose insurance denied him coverage for gastric bypass surgery, saying it was not medically necessary. Does Tricare consider surgery for overweight patients to be medically necessary? Does Tricare cover it?

A. Tricare covers several types of gastric surgery as medically necessary, but not for people who are simply “overweight.” You must be medically diagnosed as morbidly obese, or have at least one of several specific medical conditions associated with obesity.

If your weight is at least double the ideal for your body build, however, certain kinds of gastric surgery are covered. But that doesn’t mean you can simply get the service and file a claim. Each patient must meet all the other criteria required by Tricare policy.

Your doctor should write to Tricare explain your medical condition and explain exactly what surgical procedure he plans for you. He should ask for details about what is required for coverage and if the particular procedure he intends for you is covered by Tricare.

Remember that for Tricare to pay for medical care, it must be provided by a Tricare-authorized provider — one who has registered with Tricare and is authorized to be paid by Tricare for medical services.

Q. I’m a retired federal employee with my employee health insurance still in effect. I’ll get Medicare and Tricare for Life in December, but my wife is 58 and I have a son in college. Rather than the added cost of Part B, which my family can’t use, can I use my federal employee plan in place of Part B under Tricare for Life?

A. No. Tricare for Life consists of full benefits under Medicare Part A and Part B plus full benefits under Tricare Standard. In the law governing Tricare, there is no provision for any other health insurance to be used as a substitute for Medicare Part B.

Federal law requires retirees who become entitled to Medicare Part A to be enrolled in Medicare Part B at the same time their Medicare Part A is effective in order to retain Tricare eligibility and to be eligible for Tricare for Life.

If you are not enrolled in Part B on the day your Medicare Part A is effective, you’ll lose your Tricare eligibility. Your family’s eligibility will not be affected, however.

You can confirm this Tricare eligibility issue by calling the Defense Enrollment Eligibility Reporting System support office, toll-free, at 800-538-9552.

If you retain your federal employee plan for your family’s benefit, that plan, not Tricare, will be second payer to your Medicare coverage.

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Write to Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or tricarehelp@atpco.com. In e-mail, include the word “Tricare” in the subject line and do not attach files.