treatment of pregnancy or well-child care. Additionally, all services and supplies (including inpatient institutional costs) related to a non-covered condition or treatment, or provided by an unauthorized provider, are excluded. Pre-existing Conditions. There are no pre-existing condition limitations for enrollment in TRICARE Prime or Select. Catastrophic Cap. The purpose of a catastrophic cap is to limit the out–of–pocket costs incurred by TRICARE participants during a fiscal year. The cap includes TRICARE Prime enrollment fees, deductibles, inpatient care, outpatient care, and prescription cost shares and co-pays. See the “TRICARE Cost Table” for current caps. The specific rules governing the costs that are included/excluded from the cap are complicated. Additional information can be obtained from your local Medical Treatment Facility or at www.tricare.mil . 3–2. ACTIVE DUTY MEMBERS AND DEPENDENTS. Active duty members must enroll in one of the TRICARE Prime options depending on where they live. Dependents of active duty members may also enroll in TRICARE Prime without paying an annual enrollment fee. Dependents of active duty personnel who do not enroll in TRICARE Prime may choose to participate in TRICARE Select. 3–3. RETIREES AND DEPENDENTS. In order to participate in a TRICARE program, retirees and their dependents must enroll in either the Prime or Select option. Retirees and their dependents living more than 40 miles from a military treatment facility are not eligible to participate in TRICARE Prime. However, they may apply and be allowed to participate in the program if they agree to waive their “drive time” standards to receive primary and speciality care under the Prime option. 3–4. TRICARE FOR LIFE (TFL) . The objective of the TRICARE For Life program is to offer secondary coverage to TRICARE eligible beneficiaries who have both Medicare Part A and B. It does not affect retirees under age 65 (with the exception of those who are Medicare eligible due to disability).
Enrollment. Enrollment in the program is automatic. There are no TRICARE For Life enrollment costs or fees. However to guarantee continued TFL eligibility, retirees must: a. Ensure that their status and the status of their family members is current in DEERS (see paragraph 3–7); b. Enroll in Medicare Part A and B (see Chapter 12 for more information); and, c. Ensure that their Military ID card is current. Payment. The TFL program functions as a supplement to Medicare. TFL allows Medicare to make the initial coverage determination for health care benefits and TFL serves as a secondary payer to Medicare. Basic payment guidelines are discussed below. See the “Medicare/TFL Cost Share Table” for additional payment information. a. For medical services or supplies that are covered by both Medicare and TFL, Medicare will pay first and TFL will pay the Medicare cost share and the Medicare deductible. b. For services and supplies that are covered by Medicare but not TFL (i.e., chiropractic services), Medicare will pay its normal amount and TFL will pay nothing. In this case you are responsible for the Medicare deductible and cost share. c. For services and supplies that are covered by TFL but not Medicare (i.e., overseas care, skilled nursing coverage over 100 days), Medicare will pay nothing. TFL will become the primary payer and you are responsible for the applicable TRICARE deductible and cost shares. d. For services and supplies not covered by TFL or Medicare, you are responsible for the entire cost. e. If you have other private insurance and the service or supply is covered under Medicare and TFL, Medicare pays first, the private insurance will pay second, and TFL will pay last. A TFL supplement will pay after TFL.
CHAPTER 3: TRICARE
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