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co-pays

Military Authority Member
Al Bancroft August 22nd, 2012

I am still working and my primary care is Amerihealth, secondary is Medicare and finally Tricare for life. Why won't Tricare for life pay my co-pay?


Replies

Military Authority Member
Jason Van Steenwyk August 27th, 2012

Hello, Al, and thanks for writing.

You have stumbled into the arcane and confusing world of "coordination of benefits."

Things can get pretty technical, and I don't know your situation. But in a nutshell, if you have OHI (or "other health coverage," Tricare for Life only picks up what the other two programs... Amerihealth and Medicare... don't cover. And then TRICARE only picks up what they would have paid if you had had only TRICARE. TRICARE doesn't automatically cover something it doesn't otherwise cover just because you have other health coverage.

It's a complicated field. Here's the simplest thing I could find online, actually from a HUMANA document. To wit:

"Federal law requires that TRICARE be the last
payer after other health plans, except for
Medicaid, TRICARE supplements, the Indian
Health Service, and other programs or plans as
identified by the TRICARE Management
Activity.
When you have double coverage, your OHI
pays its benefits in full as the first payer. After
your OHI pays, TRICARE will pay what is left
up to the amount TRICARE would have paid
had there been no OHI. There is no change in
the TRICARE allowable charge (the maximum
amount TRICARE will pay for medical and
other services) when TRICARE is the
secondary payer. TRICARE will only pay for
TRICAREcovered services, and all TRICARE
policies and procedures must still be followed."

Source: http://www.humana-military.com/library/pdf/coordinating-with-medicare-ohi.pdf

So apply these rules to your situation. If all three of these plans require a copay for the specific service you get, you can expect a copay. Whatever you would have paid under TRICARE anyway would be your copay, unless OHI specifically covers it first.

Hope that helps, and thanks for reading Military Authority!


Jason Van Steenwyk

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