Military Health, Tricare programs - Army Times

Tricare Help: No worries about filing with Medicare

Q. When I get Tricare for Life with Medicare Part A and Part B, how can I tell which Medicare part to file my claims with? I read what Medicare has to say about what each part covers, but it still seems confusing.

A. Filing claims under Tricare for Life, fortunately, is not the patient’s problem. All Tricare for Life benefits begin when a Medicare claim is filed.

Beneficiaries must seek all their civilian medical care from providers who are enrolled with Medicare and who are authorized to file Medicare claims. The patient is not responsible for filing claims; the provider is.

Most individual providers, such as physicians, psychologists and private physical therapists, will file Medicare Part B claims. Their itemized bills will describe the services the doctor provided, and you will be asked to send your payment to the doctor. Those are the kinds of services covered by Medicare Part B.

Hospitals and similar institutional providers file claims under Medicare Part A. An itemized hospital bill will show things the hospital provided, such as your room and board, special diets, and use of the hospital’s laboratory, X-ray facilities and other equipment — all things the hospital itself provided to you. You won’t see the names of any people on the hospital’s bill.

Q. I understand that the Tricare catastrophic cap for retirees is $3,000. How can I find out the amount in my cap account? Is the cap the total amount Tricare will pay in a month? If not, how long is the period?

A. The catastrophic cap is not the amount Tricare will pay; rather, it’s the maximum amount a family must pay as deductibles and cost shares during a given fiscal year. Usually, that will be the maximum amount of that family’s out-of-pocket medical care costs in each fiscal year.

Every time a Tricare claim is processed, certain amounts are withheld from Tricare’s payment. Those amounts are the family’s Tricare deductible and the patient’s cost share — which, for retirees and their family members, is 25 percent of the amount allowed on each claim. The Tricare deductible is $150 per family member with a maximum of $300 per family.

Tricare maintains a running tally of deductibles and cost shares that a family pays during the fiscal year, which runs from Oct. 1 to Sept. 30. For retirees, when that total reaches $3,000, Tricare will stop withholding deductibles and cost shares on claims.

For the remainder of that fiscal year, Tricare will pay 100 percent of the amount it allows on each claim for that family.

The current amount in your family’s catastrophic cap account is reported on each Tricare explanation of benefits. You can also call your Tricare Service Center to find out the amount.