AMRA TRICARE Supplement Frequently Asked Questions

Transcription

1 A M R A T R I C A R E S U P P L E M E N T P L A N AMRA TRICARE Supplement Frequently Asked Questions MZ H

2 Frequently Asked Questions Q. Who is eligible for enrollment in the TRICARE Supplement Plan? A. Employees who are eligible for enrollment in the TRICARE Supplement Plan cannot be eligible for Medicare and include the following: Military retirees entitled to retired pay and their spouses/surviving spouses who are ineligible for Medicare. Retired Reservists and National Guardsmen between the ages of 60 and 65 with 20 years of creditable service and their spouses/surviving spouses who are ineligible for Medicare. Retired Reservists and National Guardsmen under age 60 and enrolled in TRICARE Retired Reserves (TRR) and their spouses/surviving spouses who are ineligible for Medicare. Military retirees and their spouses/surviving spouses who reside outside the U.S. or its territories (must enroll in Medicare if eligible for Medicare). Military retirees and their spouses/surviving spouses age 65 or older but ineligible for Medicare (and received a Statement of Disallowance from Social Security Administration). Q. Under what circumstance would a member, age 65 or older, be eligible for the TRICARE Supplement? A. There are two circumstances that would allow continuing eligibilty for members who are 65 or older: 1. The TRICARE beneficiaries who live/work outside the U.S or its territories. They must be eligible for Medicare Part A and enrolled in Medicare Part B, and TRICARE must have the information on file with the Defense Enrollment Eligibility Reporting Systems (DEERS). You may contact DEERS at: (in the continental United States) Fax address changes to: Write to: DEERS Support Office 400 Gigling Road Seaside, CA Beneficiaries who are ineligible for Medicare. These members must have received a Statement of Disallowance from the Social Security Administration. Q. Up to what age are Dependents eligible? A. Eligibility for an unmarried dependent child ends at age 21 (23 if a full-time student). Dependents over the maximum age are eligible to continue coverage if they meet one of the following criteria: MZ H0000A 1. An unmarried child who is mentally or physically handicapped and incapable of earning his/her own living and is primarily dependent on you for support and maintenance, or 2. An unmarried adult-age dependent under age 26 who is enrolled in the TRICARE Young Adult (TYA) Program. 2 P.O. Box 2510, Rockville, Maryland Fax:

3 Q. Are incapacitated dependents eligible for coverage? A. An incapacitated dependent is eligible for coverage during an open enrollment period providing he/she continues TRICARE eligibility. The dependent incapacitated child of a new member is eligible if application is made within the specified eligibility period of the member. Q. Are pre-existing conditions covered under the Supplement? A. Yes. There is no waiting period for coverage. Any medical conditions that exist prior to the effective date are covered immediately. The incapacitated dependent child of a new member is eligible if application is made within the specified eligibility period of the member. Q. How does my current company sponsored health plan work with TRICARE Standard, Extra or Prime? A. It can be confusing when there is coordination of benefits between other insurance and TRICARE. As the secondary payor TRICARE's payment will be the lower of: 1) The amount remaining after the primary coverage has paid its benefits. 2) The amount TRICARE would have paid as primary payer. As a result, you may be left with out-of-pocket expenses. Q. How does the Supplement coordinate with TRICARE? A. There is no confusion with coordination of benefits between TRICARE and the TRICARE Supplement Plan. TRICARE is the primary payer and the TRICARE Supplement pays secondary. After TRICARE has paid, the TRICARE Explanation of Benefits (EOB) should be submitted to ASI for secondary consideration. Q. Does the TRICARE Supplement Plan reimburse the TRICARE Deductible? A. The TRICARE Supplement Plan reimburses 100% or the TRICARE Outpatient Deductible of $150 individual (maximum $300 per family). Q. Does the TRICARE Supplement have a Plan Deductible? A. Yes, the TRICARE Supplement Plan has a deductible of $100 per individual (maximum $200 per family). P.O. Box 2510, Rockville, Maryland Fax:

4 Frequently Asked Questions (cont.) Q. Will the TRICARE Outpatient Deductible be applied to the Supplement Plan deductible? A. The covered portion of the TRICARE Outpatient Deductible will be applied to the supplement plan deductible. Q. How do I find a provider? A. Since TRICARE is your primary health benefit provider, all providers must be TRICARE-authorized. You may either see a network or non-network provider. To find a network provider in your region, search the online provider directory on the TRICARE web site. To find a non-network provider search the yellow pages, AMA DoctorFinder, ask a friend or ask the provider. Q. Does the TRICARE Supplement Plan pay the providers balance billed amount? A. TRICARE participating or network providers cannot bill for the balance between TRICARE's allowed amount and their billed charges. Therefore, neither you nor the TRICARE Supplement Plan will be responsible for such an amount. According to the Department of Defense (DoD) Nonparticipating or non-network providers may only bill you for 115% above the TRICARE Allowable charge. This is considered the Legal Limit. Your TRI- CARE Supplement Plan will pay 100% of the applicable Excess Charges up to the Legal Limit. Q. How does the TRICARE Supplement coordinate with TRICARE Standard/Extra? A. TRICARE Standard and Extra are interchangeable. You have flexibility and freedom of choice when visiting a doctor under TRICARE Standard or Extra. TRICARE pays 75% of the TRICARE Standard allowed amount or 80% of the TRICARE Extra negotiated rate, after your deductible has been met. The TRICARE Supplement Plan pays 100% of your TRICARE Standard Outpatient Deductible, your 25% Standard or 20% Extra cost share after the plan deductible has been met plus 100% of the applicable Excess Charges up to the TRICARE Legal limit for non-participating/non-network providers. Q. How does the TRICARE Supplement coordinate with TRICARE Prime? A. TRICARE Prime is similar to an HMO plan. It requires a referral to see any doctor other than your primary care physician (PCM). As long as you use the military facilities under TRICARE Prime, you have no out of pocket expenses. When you use civilian doctors in the TRICARE Prime network of providers, you are responsible for copayments. The Supplement will reimburse the eligible TRICARE Prime copayments. 4 P.O. Box 2510, Rockville, Maryland Fax:

5 If you see an out-of-network doctor without a referral, you are using the Point of Service (POS) option under TRICARE Prime. Under the POS option, you may have large out of pocket expenses. You will be responsible for the POS deductible of $300 per individual (maximum $600 per family) plus 50% of the TRICARE allowed amount after TRICARE pays 50% plus applicable Excess Charges. The TRICARE Supplement Plan pays 50% of the POS deductible ($150 individual (maximum $300 per family), your 50% cost share after the plan deductible has been met plus 100% of the applicable Excess Charges up to the TRICARE Legal Limit. Q. Are all services covered under the TRICARE Supplement Plan? A. No. For a listing of exclusions and limitations, please see a copy of the TRICARE Supplement Plan brochure, member handbook or Certificate of Insurance. Q. If I currently have TRICARE Prime, and would like to take the Supplement, can I change from Prime to the Standard/Extra option? A. Yes. The TRICARE Supplement Plan works with both TRICARE Standard/Extra and TRICARE Prime. Q. How are prescription drugs covered under the TRICARE Supplement Plan? A. There are more than 60,000 TRICARE retail network pharmacies available in the United States, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands. You have the option of getting your prescriptions filled at a military pharmacy, a retail network pharmacy, a nonnetwork pharmacy or TRICARE Mail Order pharmacy. The TRICARE Supplement Plan reimburses your copayment or cost shares regardless of where the prescription is filled. If your prescription is filled at a nonnetwork pharmacy you must file your claim first with TRICARE and submit the TRICARE EOB to ASI for reimbursement. Q. How are claims filed with the Supplement? A. Since TRICARE is primary, claims must be filed first with them. TRICARE will send you and your provider (if a participating/network provider) a copy of your TRICARE EOB. You or your provider must submit your claim to ASI. If the provider submits your claim, you should not also submit the claim. If your provider does not submit your claim, you are required to submit the claim. ASI, however, makes it easy for you to submit claims. You simply write your Member ID number on the EOB and copy of provider's bill if available. Also, write "Pay Provider" if you would like the benefits paid directly to your provider, otherwise the benefits will be paid to you. Claims may be mailed or faxed to: ASI, P.O. Box 2510, Rockville, MD Fax: or P.O. Box 2510, Rockville, Maryland Fax:

6 Frequently Asked Questions (cont.) Q. Do most providers submit claims to ASI? A. Approximately, 90% of providers do submit claims to ASI for TRICARE Supplemental reimbursement. You should always ask your provider to file your supplemental claims for you. Q. What happens when I reach age 65? A. Your TRICARE Supplement enrollment ends at age 65 or when you become eligible for Medicare. When that happens your TRICARE coverage changes to TRICARE for Life which is secondary to Medicare. If you are ineligible for Medicare and received a Statement of Disallowance from Social Security Administration or reside outside the United States or its territories and enrolled in Medicare Part B you must notify your employer or ASI so that your TRICARE Supplement Plan Coverage may be continued. Q. Will ASI notify us before the TRICARE Supplement Plan ends? A. Yes, 60 days prior to your 65th birthday, you will be sent notification that your coverage will end. If your date of birth is on the first of the month, coverage ends the first of the month prior. If your date of birth is on the second to the last day of the month, coverage ends the first day of your birthday month. Q. Can my spouse and dependents continue TRICARE Supplement coverage if I am ineligible to continue? A. Yes, your spouse and dependents may continue enrollment in the plan. First, check with your employer if they will continue payroll deduction. If not, your spouse and dependents may continue TRICARE Supplement coverage directly with ASI. Q. How can I pay my premiums to enroll? A. Your employer will deduct the premiums from your paycheck on a pre-tax basis and submit such premiums to ASI monthly. Q. Can my employer share the cost of my monthly premiums? A. Due to federal legislation, your employer cannot share the cost of your premiums for the TRICARE Supplement Plan. 6 P.O. Box 2510, Rockville, Maryland Fax:

7 Q. Can I continue the TRICARE Supplement upon termination of employment? A. Yes, the TRICARE Supplement Plan is portable. As long as you are under age 65 and still eligible for TRI- CARE, you can take the supplement with you when you leave employment. You will be billed directly for the full premium cost. Your cost will not increase due to age. This is a key feature of this group supplement because individual TRICARE Supplement premiums increase as you advance from one age bracket to the next. Q. Is the time limits on portability the same as COBRA? A. No. COBRA time limits are 18-, 29- or 36-month maximum coverage period while on portability you will be covered for as long as you choose to or under age 65, whichever comes first, providing your monthly premiums are paid. Q. Will my premium change if I enroll on portability? A. Your monthly premium amount will remain the same but will be paid on a post tax basis. Q. How long can I continue enrollment in the TRICARE Supplement while on portability? A. Unlike COBRA which is available for a short period of time, portability is available to you for as long as you choose to continue or until you attain age 65, whichever comes first, providing your premiums are paid. Your monthly cost while on COBRA will be 2% more than portability since COBRA requires an administration fee of 2% of your premium amount. Q. What options do I have to make premium payments while on portability? A. You have the following options to make premium payments: Monthly by electronic fund transfer (EFT) from your checking account. Quarterly Semiannual Annually P.O. Box 2510, Rockville, Maryland Fax:

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