Forward Observer — TRICARE For Life Users Face Potentially Higher Costs When Using the VA

LVMAC Poster Art 2005In an August 14,  2013 News Release, TRICARE announced that its TRICARE For Life (TFL) beneficiaries may incur higher costs for treatment when using a VA healthcare facility effective October 1 – if the condition for which they are being treated is not related to their service-connected disability.

It states that after October 1, 2013, “as part of the intake process at VA facilities … TFL beneficiaries will be asked if they’re using their VA or TFL benefit or if they have other health insurance (OHI).  When electing to use their TFL benefit at the VA, they will also be informed they must pay the remained bill after TRICARE pays its portion of the TRICARE-allowable charge. They may be asked to sign a form indicating they understand their responsibility.”

What does this really mean?  The Military Officers Association of America (MOAA) in an August 16 blog site article best explains:

Effective October 1, 2013 TRICARE will only reimburse the VA 20% of the allowable charge vice the past practice of paying 80% for non-service connected care received in the VA for TRICARE for Life (TFL) beneficiaries rated at less than 50% disabled.  While this is not a new law, it has not been enforced.  [Editor’s Comment: To be clear, this does not affect veterans not enrolled in Medicare, such as TRICARE Prime or TRICARE Standard/Extra beneficiaries.]

 

The rationale that supports this change follows:

–  Although VA Facilities are TRICARE-authorized, they are not Medicare-certified.
–  Medicare, by statute, cannot reimburse for care provided by a Government facility.
–  Simply put, the VA can’t bill Medicare and Medicare can’t reimburse the VA for care (what the VA calls the Medicare subvention issue).
–  Since the VA can’t be Medicare-certified, it presents (becomes in the system) as an opt-out (non-) Medicare provider.
–  Therefore, TRICARE reimburses the VA what it would have paid if Medicare had been primary – which is 20%, leaving you with a bill for the remaining 80%. (It’s a twist in the law: when you seek care from a non-Medicare   provider, TRICARE can pay only up to 20 percent of the TRICARE allowable charge). 

In other words,

  • if the condition for which you are being treated is not rated as service-connected
  • and you do not have a 50% or higher service-connected disability rating (a situation where the VA is totally responsible for your healthcare, service or non-service connected, at your option, not theirs),
  • use a community healthcare facility (a Medicare-certified provider) instead to prevent being billed for the balance of 80% — especially if you are not using private insurance to make up the difference. 

Strange, isn’t it?  You’re completely covered if you use a non-VA facility when using TRICARE For Life, but maybe not if you use one of the Federal Government’s own facilities, the VHA.  Is it good legislation?  Is it smart?  It is certainly not patient-centric and it potentially leaves an unnecessary taint on the quality of Veterans Health Administration service.

For more information, see http://www.tricare.mil/tfl and http://www.moaablogs.org/healthcare/2013/08/beware-non-service-connected-vatfl-healthcare-users/  or call the TFL support contractor Wisconsin Physicians Service (WPS) at 1-866-773-0404.

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RJH

27 August 2013
Updated: 30 August 2013

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