FALLS CHURCH, Virginia –
Are you a TRICARE beneficiary? Do you have other health care coverage in addition to your TRICARE plan? You may have employer-sponsored coverage or government health care plans. Or perhaps you have purchased additional coverage through private providers. Students may have health care coverage through their school. These additional plans are known as other health insurance, or OHI. If you have OHI, it’s important to know how you can use it with TRICARE.
“TRICARE beneficiaries with other health insurance should learn how it works in tandem with your TRICARE benefits,” said Shane Pham, TRICARE policy and program analyst at the Defense Health Agency. “Using your OHI and TRICARE correctly could save yourself time and money.”
Here are several facts about OHI you need to know.
Why is it important to report your OHI
If you’re adding, removing, or changing OHI, you need to tell TRICARE and all assigned providers to prevent future claims issues. Telling both TRICARE and your provider of any OHI updates before any scheduled appointment will help your claims process more quickly. It will also reduce the possibility of denials later. The more information you provide about your OHI, the more accurate and timely response to your claim.
Also, be sure you follow the rules of your OHI. If your OHI doesn’t pay on your claim because you didn’t follow their rules, TRICARE may not pay on your claim. If TRICARE receives your claim before your OHI processes it, TRICARE will deny it.
How to report your OHI
You can report your OHI using one of the options below:
Remember to keep your OHI information current. Doing this will help you make the most of your benefit.
How changes in your OHI might affect your enrollment
Gaining or losing OHI counts as a Qualifying Life Event (QLE). A QLE allows you to enroll in TRICARE Prime or TRICARE Select outside of TRICARE Open Season. This doesn’t apply to you if you’re an active duty service member (ADSM) or if you have TRICARE For Life. Keep in mind, you have 90 days after you lose or gain OHI to change your TRICARE health plan.
Which plan pays first
TRICARE and your OHI work together to coordinate your benefits for payment. By law, TRICARE pays after your OHI. If you have health coverage through an employer, private insurer, or school, your OHI is always your primary insurance. It pays any claims before TRICARE does. If TRICARE receives your claim before your OHI processes it, TRICARE will deny it. The only exceptions to this rule is if you have:
- TRICARE supplements
- State victims of crime compensation programs
- Other federal government programs identified by the Defense Health Agency
Also, if you’ve exhausted your OHI benefits, then TRICARE becomes the primary payer. In this case, you may need additional referrals or pre-authorization. And a TRICARE-authorized provider, either network or non-network, must be the one to provide services. ADSMs can’t use OHI as their primary insurance. If you’re on active duty, TRICARE is your only coverage.
OHI and Medicare
TRICARE pays after Medicare and your OHI for TRICARE-covered services. As noted in the TRICARE For Life Handbook, how Medicare coordinates with OHI depends on whether you have OHI based on current employment. But in either case, TRICARE pays last. Visit the Medicare website for more information on how Medicare works with other insurance.
OHI with pharmacy benefits
When you have OHI with pharmacy benefits, your OHI pays first and TRICARE pays second. You can avoid higher costs by getting your prescriptions filled at a TRICARE retail network pharmacy that’s also in your OHI network.
OHI and Unremarried former spouses
As an unremarried former spouse, you can lose your TRICARE eligibility if you purchase and are covered by an employer-sponsored health plan.
For more on TRICARE and OHI, review the information on the TRICARE website. You can also reach out to your TRICARE contractor with questions.
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