Frequently Asked Questions

Benefits (17)

1. What is the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)?

   The TDEFIC is a single, nationwide contract for claims processing, customer service and administrative services for individuals who are dually eligible for TRICARE and Medicare, regardless of whether they are over or under age 65. This contract has been awarded to Wisconsin Physicians Service (WPS) of Madison, Wisconsin. Over a five-month period, beginning June 1, 2004, TDEFIC will complete phase-in across the country, by region, replacing the current practice of managed care support contractors providing these services. Transition will begin with Region 11 on June 1, 2004. Regions 9, 10 and 12 will transition July 1, 2004. Region 6 will transition November 1, 2004. As part of its new responsibilities, WPS will notify beneficiaries of process changes, the appropriate address for filing paper claims and phone numbers for reaching customer service representatives.

2. I am a dual-eligible beneficiary. Will my status be reflected in DEERS?

   Yes, your dual-eligibility status can be reflected in DEERS. However, for DEERS to show your dual-eligibility status, you must take your Medicare card, showing your Medicare Parts A and B effective dates, to the nearest ID card facility (you can locate the nearest one online here), or call the Defense Manpower Data Center Support Office (DSO) at 1-800-538-9552 for more information.

3. Is there a limit on how many doctor visits I can make?

   No, there is no limit. However, TRICARE must deem ALL services "medically necessary" and must be referred by your PCM if enrolled in TRICARE Prime.

4. Do TRICARE benefits stop for the Reserve component (RC) member and family members when released from active duty?

   Yes. However, RC members ordered to active duty for 31 consecutive days or more and their family members are eligible for the Continued Healthcare Benefits Program similar to TRICARE Standard upon release from active duty or when no longer eligible for healthcare under the Military Healthcare System (MHS). RC members ordered to active duty in support of a contingency operation for 31 days or more are eligible for Transitional Healthcare under TRICARE upon release from active duty. Continued Healthcare Benefits Program: RC members, who served on active duty for 31 days or more and are not eligible for the transitional healthcare benefit, may enroll in the Continued Healthcare Benefits Program (CHCBP) upon release from active duty. This program provides healthcare benefits similar to TRICARE Standard for up to 18 months to RC members and their family when released from active duty or those who are no longer eligible for healthcare under the Military Medical Healthcare System. Eligible members must enroll in the CHCBP within 60 days after release from active duty or loss of eligibility for military healthcare. The member is responsible for quarterly premiums from $933 per individual to $1966 per family. For more information about CHCBP, call toll free: 1-800-444-5445, visit www.humana-military.com, or write to Humana Military Healthcare Services Inc., Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201. Transitional Healthcare Benefits: RC members ordered to active duty for 31 days or more in support of a contingency operation are entitled to transitional healthcare benefits upon release from active duty. RC members separated with less than 6 years of cumulative active federal service (indicated on the member’s DD214) are eligible for 60 days of transitional healthcare. Those members with 6 or more years of cumulative active federal service are eligible for 120 days of transitional healthcare. Family members are also eligible for transitional healthcare for either 60 days or 120 days depending on the total cumulative years of active federal service of the sponsor/service member. Upon termination of the transitional healthcare benefit period, the member may enroll himself/herself and eligible family members in the CHCBP described above. For more information about transitional health care benefits, contact TriWest at 1-888-874-9378.

5. I am enrolled in TRICARE Prime Remote (TPR). What if my physician wants payment upfront?

   Non-participating providers may require payment up front, before, or at the time of health care delivery. If so, you (ADSM) have a true out-of-pocket cost. If the care is a covered benefit and was authorized, you will be reimbursed for actual costs once a claim is filed.

6. What is the basic difference between TRICARE Standard and TRICARE Extra?

   You do not need to enroll or pay an annual fee for TRICARE Standard or Extra, however you do need to satisfy an annual deductible for outpatient care before government cost sharing starts. When you use network providers you exercise the TRICARE Extra option. Using any TRICARE authorized provider not in the network is the TRICARE Standard option. You may choose these options on a visit by visit basis. Under TRICARE Standard you will pay cost-shares five percent higher than under TRICARE Extra. When you use TRICARE Standard, you generally will have to file paper claim forms.

7. Which TRICARE option is the best choice for me if I do not live close to a military treatment facility (MTF)?

   If you are eligible for TRICARE Prime, it would be the most cost-efficient option for you. If there is not an MTF in your area, contact your regional contractor to inquire about civilian TRICARE Prime providers. If there is not a TRICARE Prime provider in your area, you can still reduce your out-of-pocket expenses by using a civilian network provider with TRICARE Extra. If such a provider is not available in your area, you will have the option of using TRICARE Standard. The TRICARE Service Center (TSC) in your region has lists of both TRICARE Prime and TRICARE Extra providers.

8. If I am enrolled in TRICARE Plus at MTF "A" can I be seen at MTF "B" on a priority basis?

   No. TRICARE Plus is not transferable to other MTFs. You will be considered for care at other MTFs on a "space-available" basis. For more information call the nearest Military Treatment Facility to learn more about the TRICARE Plus program.

9. As a dual-eligible, whom can I contact to ensure my provider is a TRICARE-authorized provider?

   You can ask the provider's office directly or contact your regional contractor since they may have information on your particular provider. Remember, as a dual-eligible, you can use any Medicare-authorized provider for your health care needs and TRICARE will pay for appropriate, covered services.

10. I'm on active duty and stationed away from a military installation. How do I obtain health care and what do I pay for it?

    TRICARE Prime Remote (TPR) is a program that provides active duty service members in the United States with a specialized version of TRICARE Prime while they are assigned to duty stations in areas not served by the traditional military healthcare system. You must verify your eligibility for the TPR program. Eligibility can be verified through the TRICARE Web site or by calling TriWest at 1-888-TRIWEST (874-9378). If you are eligible, enroll immediately. This will provide you with primary care access in your area without the need for pre-authorization. Specialty care will need to be coordinated with your regional Health Care Finder (HCF) for pre-approval by the Military Medical Support Office (MMSO). Active duty service members pay nothing for approved health care delivered by authorized civilian providers. For primary care, no authorization is required when you obtain care from your PCM. For specialty care, your PCM or doctor must make the referral and you must have an authorization from the HCF. This includes hospitalizations, ambulatory surgery, and other visits to specialists.

11. I am a dual-eligible benficiary under the age of 65 and a family member of an active duty family member. Must I purchase Medicare Part B in order to use the TRICARE benefit?

    No. Family members of an active duty service member are not required to purchase Medicare Part B to participate in the TRICARE benefit However, when your sponsor retirees you will be required to purchase Medicare Part B in order to use the TRICARE benefit.

12. How do I switch from TRICARE Extra to TRICARE Standard and vice-versa? Can I do this at any time?

    You may use Extra or Standard on a visit by visit basis. To use TRICARE Extra you must use a TRICARE network provider. The advantage of utilizing TRICARE Extra is lower cost shares. Consult TriWest at 1-888-874-9378 for more information.

13. Under TRICARE Extra, do I have to pay for health care at an MTF?

    There aren't any out-of-pocket costs for covered services. The MTF can bill you for non-covered services if you have other health insurance. You will be seen on a space-available-basis only. Consult the MTF in your area for more information.

14. Which providers may I use with TRICARE Standard?

    You are free to choose any doctor or healthcare provider who is TRICARE authorized. TRICARE authorized providers are specifically listed as being authorized to provide benefits under TRICARE. Regional TRICARE contractors must certify a provider's authorized status before making payment. Use the TriWest Provider Directory to find an authorized provider, or call TriWest at 1-888-TRIWEST (874-9378).

15. Are there pre-existing condition clauses with TRICARE Extra?

    TRICARE has no pre-existing condition limitations.

16. Does the point-of-service option apply to TRICARE Extra?

    No, the point-of-service option does not apply to TRICARE Extra.

17. Will I be able to contact someone when I have questions about dual-eligibility and associated issues?

    Yes. No matter what time zone you live in stateside, you will be able to speak real time with the TRICARE Dual-Eligible Fiscal Intermediary Contract (TDEFIC) contractor service staff during normal business hours for your time zone. Live operator services typically end at 5 p.m. The TDEFIC contractor will provide automated services around the clock.