MARCH 21, 2025 – As you age, it’s important to think about your future health needs. If you’re eligible for Medicare at age 65, TRICARE has you covered if you take the appropriate steps. Once you actively have Medicare Part A and Part B, you’re automatically enrolled in TRICARE For Life. TFL coverage allows you to get the care you need while minimizing out-of-pocket expenses.
“TFL is what we call ‘wraparound’ coverage to Medicare for TRICARE-eligible retirees,” said Anne Breslin, TFL program manager, TRICARE Health Plan, at the Defense Health Agency. “Understanding your coverage is key to maximizing benefits and minimizing healthcare costs as you age.”
Here’s what you need to know about TFL.
Signing up for Medicare
You need both Medicare Part A and Part B to get TFL coverage. You’re eligible for Medicare Part A and Part B if you’re:
- Aged 65 or older
- Under age 65 with certain disabilities
- Any age with end-stage renal disease
You must apply for Medicare benefits. As mentioned in the TRICARE For Life Handbook, your initial Medicare enrollment period is a seven-month window. Remember to sign up for Medicare as early as possible. You should sign up for Medicare at least two months before the month you turn 65. This will ensure you don’t experience a gap in coverage.
How to get TFL
Getting TFL coverage is easy–you’ll transition automatically if you:
- Are TRICARE-eligible
- Have Medicare Part A and Part B
You don’t need to fill out any forms, and you don’t pay premiums for TFL coverage.
How Medicare works with TRICARE
Medicare and TRICARE work together to cover your healthcare costs. If both Medicare and TRICARE cover a service:
- Medicare pays the Medicare-allowed amount.
- TRICARE pays the remaining amount.
- You pay nothing.
If you receive a service covered only by Medicare:
- Medicare pays the Medicare-allowed amount.
- TRICARE pays nothing.
- You pay the Medicare deductible and cost-share.
Similarly, if you receive a service covered by TRICARE only:
- Medicare pays nothing.
- TRICARE pays the TRICARE-allowable amount.
- You pay the TRICARE deductible and cost-share.
If the service you receive isn’t covered by either Medicare or TRICARE:
- Medicare pays nothing.
- TRICARE pays nothing.
- You pay any billed charges.
If you have other health insurance based on employment, they pay in the following order:
- OHI
- Medicare
- TRICARE
If your OHI isn’t based on employment, they pay in the following order:
- Medicare
- OHI
- TRICARE
Choosing your provider
To get the most out of your TFL coverage, you should know the difference between Medicare provider types. These include:
- Medicare-participating providers agree to accept the Medicare-allowed amount as payment in full.
- Medicare non-participating providers don’t accept the Medicare-allowed amount as payment in full. They may charge up to 15% above the Medicare-allowed amount, which is then covered by TRICARE.
- Opt-out providers opt out of Medicare and enter private contracts with their patients. Since they opt out, Medicare can’t pay for any healthcare services you receive. TRICARE pays the amount it would’ve paid if Medicare processed the claim. You’re responsible for paying the remaining charges. In this case, you must visit TRICARE-authorized providers and facilities. Otherwise, you may have significant out-of-pocket expenses.
Using TFL overseas
Since Medicare only covers care in the U.S. and U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands), there are some key differences you should know. If you get care while living or traveling overseas:
- You must have Part B to remain eligible for TRICARE, even though Medicare doesn’t provide coverage overseas.
- TRICARE becomes your primary payer.
- You pay TRICARE’s annual deductible and cost shares.
- You can visit any TRICARE-authorized provider for care.
- Be prepared to pay up front and file a claim within three years of the provided service.
Note that if you’re in the Philippines, you must visit a Philippine Preferred Provider Network or certified providers.
Understanding Medicare Advantage Plans
Although you only need Medicare Part A and Part B to get TFL, you can choose to purchase a Medicare Advantage plan instead. Medicare Advantage plans:
- Are also known as Medicare Part C
- Are offered by private companies that contract with Medicare
- Include services you receive with Medicare Part A and Part B
- Usually include Medicare Part D (pharmacy coverage) and additional benefits
Medicare Advantage plans have additional requirements:
- You may pay a plan premium each month on top of your Medicare Part B premium.
- Generally, you need to use doctors and hospitals within the plan’s network to get the most coverage. This doesn’t apply to emergency services.
- You may have to pay copayments at the time of service. You may need to file your own claim for TRICARE to reimburse copayments for TRICARE-covered services.
Keep in mind, if you have TFL, you still have TRICARE Pharmacy Program benefits at no additional cost. So, you don’t need Medicare Part D to cover your prescription drugs. With Medicare Part D, you may also pay a monthly premium, and you’ll need to follow the plan’s rules for filling prescriptions.
Remember: Coverage rules can change. Always check the official Medicare and TRICARE websites to get the latest information about your coverage. Unlock your health by staying informed to get the best care and lower costs.
Courtesy Story
Defense Health Agency