Posted on Dec 8, 2024
Tricare for Life and Medicare, what does one gain or lose if one signs up for Medicare part C?
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I've been informed that accepting Medicare part D will affect one's Tricare Prescriptions, but what about Part C??? With what is offered by various Medicare supplement providers is the part C supplement worth purchasing?
Posted 14 d ago
Responses: 5
When using Medicare or Medicare Advantage (M/MA) with TRICARE For Life (TFL), M/MA pays first and TFL pays second. There are three situations you could encounter – both cover the procedure, M/MA covers but TRICARE doesn’t (MYTN), or M/MA doesn’t but TRICARE does (NMTY).
• Both – M/MA pays and TFL picks up the rest (see note below).
• MYTN – Medicare pays 80%, TFL pays 0%, and you pay according to your plan (remaining deductible, copay, etc.)
• MNTY – Medicare pays 0%, TRICARE covers the cost, and you have a TFL co-pay (typically 20%* for most TRICARE in-network doctors) and any remaining TFL deductible ($3,000 for 2024).
Note: If you’re seeing a Medicare authorized doctor that doesn’t accept the Medicare assignment amount, the doctor can charge up to the ‘limiting charge’ for the procedure (set by Medicare, but the max will not exceed 15% over the Medicare-allowed amount). If you have TFL, they will cover that 15%.
The biggest impacts with a Medicare Advantage plan you will have are:
• Additional costs or benefits with a Medicare Advantage plan
This is the key factor you'll be weighing to see if the Part C plan is worth purchasing. Some Medicare Advantage plans will reimburse a portion/all of your Part B premiums. Some will expand coverage and include dental and eye care as well (TFL doesn’t cover either unless medically necessary). Some will give non-medical benefits such as transportation allowances, fitness memberships, etc.
On the other side of the comparison is if there is any additional costs involved. Some plans will offer some significant benefits, but will charge you a Part C premium that is in addition to the Part B premium you will still pay.
• Many Medicare Advantage plans restrict the doctors you can see.
All the doctors in the plan must be "Medicare participating", but not all Medicare participating doctors are in the plan's network (i.e., "all squares are rectangles, but not all rectangles are squares"). That means your choice using a Medicare Advantage plan will usually be limited compared to Medicare (not always, but it's very common).
• TFL works seamlessly with Medicare - not so much with Medicare Advantage (but...)
With Medicare, TFL is seamlessly integrated into the reimbursement. The doctor bills Medicare, Medicare pays their 80%, the remaining portion of the bill is sent to TFL, and TFL pays the physicians directly. No involvement needed by you.
With a Medicare Advantage plan, TFL acts as a secondary insurance, which means there isn't a seamless coordination between the two - Medicare won't send the remaining bill to TRICARE so you may have to submit the bill to TFL to be reimbursed. However, many doctor's offices will handle two insurances for their patients. They will bill your Medicare Advantage plan and submit the remainder to TFL when it comes back. If your doctor's office does that, then it will still be seamless for you. If they don't then it falls back on you to submit for reimbursement.
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* https://www.cms.gov/medicare/physician-fee-schedule/search/overview
* TFL cost share (2024 as 2025 hasn’t been posted yet) - https://tricare.mil/Costs/HealthPlanCosts/TFL/Retiree_Rates
• Both – M/MA pays and TFL picks up the rest (see note below).
• MYTN – Medicare pays 80%, TFL pays 0%, and you pay according to your plan (remaining deductible, copay, etc.)
• MNTY – Medicare pays 0%, TRICARE covers the cost, and you have a TFL co-pay (typically 20%* for most TRICARE in-network doctors) and any remaining TFL deductible ($3,000 for 2024).
Note: If you’re seeing a Medicare authorized doctor that doesn’t accept the Medicare assignment amount, the doctor can charge up to the ‘limiting charge’ for the procedure (set by Medicare, but the max will not exceed 15% over the Medicare-allowed amount). If you have TFL, they will cover that 15%.
The biggest impacts with a Medicare Advantage plan you will have are:
• Additional costs or benefits with a Medicare Advantage plan
This is the key factor you'll be weighing to see if the Part C plan is worth purchasing. Some Medicare Advantage plans will reimburse a portion/all of your Part B premiums. Some will expand coverage and include dental and eye care as well (TFL doesn’t cover either unless medically necessary). Some will give non-medical benefits such as transportation allowances, fitness memberships, etc.
On the other side of the comparison is if there is any additional costs involved. Some plans will offer some significant benefits, but will charge you a Part C premium that is in addition to the Part B premium you will still pay.
• Many Medicare Advantage plans restrict the doctors you can see.
All the doctors in the plan must be "Medicare participating", but not all Medicare participating doctors are in the plan's network (i.e., "all squares are rectangles, but not all rectangles are squares"). That means your choice using a Medicare Advantage plan will usually be limited compared to Medicare (not always, but it's very common).
• TFL works seamlessly with Medicare - not so much with Medicare Advantage (but...)
With Medicare, TFL is seamlessly integrated into the reimbursement. The doctor bills Medicare, Medicare pays their 80%, the remaining portion of the bill is sent to TFL, and TFL pays the physicians directly. No involvement needed by you.
With a Medicare Advantage plan, TFL acts as a secondary insurance, which means there isn't a seamless coordination between the two - Medicare won't send the remaining bill to TRICARE so you may have to submit the bill to TFL to be reimbursed. However, many doctor's offices will handle two insurances for their patients. They will bill your Medicare Advantage plan and submit the remainder to TFL when it comes back. If your doctor's office does that, then it will still be seamless for you. If they don't then it falls back on you to submit for reimbursement.
--------------------------
* https://www.cms.gov/medicare/physician-fee-schedule/search/overview
* TFL cost share (2024 as 2025 hasn’t been posted yet) - https://tricare.mil/Costs/HealthPlanCosts/TFL/Retiree_Rates
PFS Look-Up Tool Overview | CMS
PFS Look-up Tool OverviewWhat's the PFS Look-Up Tool?The PFS Look-Up Tool gives Medicare payment information on more than 10,000 services, including:PricingAssociated relative value units (RVUs)Payment policiesThe tool doesn’t display Medicare Administrative Contractor (MAC) priced codes or Medicare Part B non-payable codes.
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COL Randall C.
SGM Mikel Dawson - Yes and no. It really depends on what the Part C plan does. By law, it must offer the same or better coverage than standard Medicare. Some of the "better than Medicare" options that some Medicare Advantage plans offer are:
• Part B reimbursement. You still have to pay your Part B premiums ($185/month standard cost for 2025) if you have a Part C plan. Some of the Part C plans will reimburse a portion of your premiums (best I've seen is up to $150/month).
• Dental/Vision coverage. Many will have coverage rolled into the plan so you won't have to obtain separate insurance.
• Drug coverage. Not really an issue for those with TRICARE or TFL as you have drug coverage already, but for those that don't, it's another 'advantage' with many plan.
• Additional benefits such as transportation allowances, fitness club memberships, etc.
Of course, if you have the above in the Advantage plan, then there usually will be some sort of trade-off such as a higher annual deductible, increased co-pay, etc.
If your existing doctors are in network with the Part C plan and will process it as second payer without any involvement from you, it might be exactly what you're looking for. If not, are the 'advantages' worth it if there is an increased administrative burden such as having to request the TFL reimbursement yourself?
Again, it will be situationally dependant, and many don't bother because they hate doing the gain/loss comparison and/or like the flexibility of using original Medicare without limitations (other than seeing only those that accept it).
• Part B reimbursement. You still have to pay your Part B premiums ($185/month standard cost for 2025) if you have a Part C plan. Some of the Part C plans will reimburse a portion of your premiums (best I've seen is up to $150/month).
• Dental/Vision coverage. Many will have coverage rolled into the plan so you won't have to obtain separate insurance.
• Drug coverage. Not really an issue for those with TRICARE or TFL as you have drug coverage already, but for those that don't, it's another 'advantage' with many plan.
• Additional benefits such as transportation allowances, fitness club memberships, etc.
Of course, if you have the above in the Advantage plan, then there usually will be some sort of trade-off such as a higher annual deductible, increased co-pay, etc.
If your existing doctors are in network with the Part C plan and will process it as second payer without any involvement from you, it might be exactly what you're looking for. If not, are the 'advantages' worth it if there is an increased administrative burden such as having to request the TFL reimbursement yourself?
Again, it will be situationally dependant, and many don't bother because they hate doing the gain/loss comparison and/or like the flexibility of using original Medicare without limitations (other than seeing only those that accept it).
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If you can get a part C lower than the eye and dental, cheaper than FEDVIP might be worth a look.
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SSG Dave Johnston
I do have the FEDVIP Vision Dental, it helps cover what VA and Tricare have trouble with... I perform, portraying characters from the 1880's, finding period correct eyewear is a bite in the schwartz, and most optometrist's shops don't carry the style of eyewear needed... Seeing an actor wearing 'Photogray Ray-Ban Aviators' while portraying a 18180's cowboy just doesn't have the feel of authenticity, right?
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Part C has a lot of advantages, including zero premiums AND reduction in Medicare premium cost, incentives for targets (fitness, immunizations, check-ups, etc), network of both Primary and Referral specialists and many more that don’t come with “just” Medicare. Do your research before you turn 65 in order to get the most benefit available.
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