FALLS CHURCH, Virginia –
Are you curious about how Medicare and TRICARE For Life (TFL) work together? Medicare pays first and TRICARE pays second, unless you have other health insurance (OHI).
Either way, it’s good to know what costs are involved when you have both Medicare and TRICARE.
“A good understanding of how Medicare and TRICARE work together is really important,” said Anne Breslin, TFL program manager at the Defense Health Agency. “We encourage all TRICARE For Life beneficiaries to know their benefits. No one likes surprises, especially when it comes to unanticipated out-of-pocket costs.”
Generally, your costs will depend on whether the care you receive is covered by both Medicare and TRICARE, or only by one of them or neither. If Medicare and TRICARE cover the service, you’ll have no out-of-pocket expenses.
Let’s start with the basics.
Q: Is Medicare and TRICARE coverage the same?
A: Medicare and TRICARE work together to minimize your out-of-pocket expenses. But, there are differences between Medicare and TRICARE coverage policies. You’ll have some out-of-pocket costs when only Medicare or only TRICARE covers the care you receive. One important difference is that Medicare only covers services in the U.S. and U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). So, if you live overseas, or obtain health care services while traveling overseas, TRICARE will be the only payer.
To learn what health care services TFL does and doesn’t cover, go to the TRICARE Covered Services page. For Medicare services, visit the Medicare website.
Q: Does TFL have enrollment fees?
A: No. TFL coverage is automatic without enrollment forms to complete or fees to pay. Once a retiree — or their eligible dependent— is entitled to Medicare Part A and has Medicare Part B, TFL automatically covers them.
Q: Do I have to pay premiums?
A: There are no premiums for TFL, but you must pay a monthly premium for Medicare Part B. Your Medicare Part B premium is based on your income. Your premium amount can change from year to year. If you’re receiving monthly Social Security retirement or disability payments, your Medicare premium is automatically deducted from those payments. If you aren’t receiving either of these payments, you’ll receive a bill every three months for your Medicare Part B premium. Be sure to pay these bills promptly. Failure to pay your Part B premiums will result in the loss of Medicare Part B and TFL. You pay for Medicare Part A through payroll taxes while you’re working.
Q: What about a TFL deductible?
A: You only have to pay the TRICARE deductible and cost-shares for services you receive if Medicare doesn’t cover them. To find out what your deductible and cost-share may be, use the TRICARE Compare Costs Tool or the TRICARE For Life Cost Matrix.
Q: When will I have a copayment or cost-share?
A: As described in the TRICARE For Life Handbook, there are four scenarios to consider when anticipating what your out-of-pocket costs will be:
- Medical services covered by Medicare and TRICARE
When you see a Medicare participating or Medicare non-participating provider, you have no out-of-pocket costs for services covered by both Medicare and TFL. Most health care services fall into this category. After Medicare pays its portion of the claim, TRICARE pays the remaining amount, and you pay nothing.
- Medical services covered by Medicare, but not by TRICARE
When you get care that’s covered by Medicare only, Medicare processes the claim as the primary payer and pays the Medicare-allowed amount. TRICARE pays nothing. You’re responsible for the Medicare deductible and cost-share and any remaining billed charges.
- Medical services covered by TRICARE, but not by Medicare
When you get care that’s covered only by TRICARE, TRICARE processes the claim as the primary payer and pays the TRICARE-allowable amount. You’re responsible for the applicable TRICARE deductible, cost-shares, and any remaining billed charges.
- Medical services not covered by Medicare or TRICARE
When you get care that isn’t covered by Medicare or TRICARE, neither makes a payment on the claim. You’re responsible for the entire bill, which may be more than the Medicare-allowed amount or TRICARE-allowable amount.
Refer to the TRICARE For Life Cost Matrix for a breakdown of costs for certain Medicare and TRICARE covered services.
Q: Who pays what if I have other health insurance?
A: If you have OHI through your or a family member’s current employer, generally:
- OHI pays first
- Medicare pays second
- TRICARE pays last
If you have OHI that isn’t based on your or a family member’s current employment, such as a private plan you purchased yourself:
- Medicare pays first
- OHI pays second
- TRICARE pays last
Q: Will I have to pay for my vaccinations and immunizations?
A: No. Medicare and TRICARE cover COVID-19 vaccines and boosters, shingles, pneumonia, flu, and other vaccines and immunizations. Check to ensure your provider accepts Medicare.
Q: What will my pharmacy costs be?
A: TRICARE offers comprehensive prescription drug coverage, which is the same regardless of your TRICARE health plan (TRICARE Prime, TRICARE Select, or TFL). The only exception is with the US Family Health Plan; this has a separate prescription drug plan for its enrollees. For details about your pharmacy options and costs, go to the TRICARE Pharmacy Program page. You don’t need to purchase a Medicare Part D prescription drug plan.
Check out the TRICARE For Life Handbook for additional resources and contact information. You can also listen to the “Get to Know TRICARE” podcast for short episodes about TFL eligibility, getting care, Medicare providers, filing claims, and more.
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