RE: Opting out of Medicare

[Guest guest]

Not sure how accurate...http://www.tricare.mil/mybenefit/ProfileFilter.do;jsessionid=HLTVFG6GKwF3bQ6rn9n1v0yFStpVcNP4sC40cJdpGsTk5gJLTh6n!-1126241923?puri=%2Fhome%2Foverview%2FPlans%2FForLife%2FProvidersWhoOptOutMedicare

TFL and Providers Who Opt Out of Medicare

When you see a provider who doesn't take Medicare and requires you to sign a private contract, you give up Medicare payment for services that otherwise would be covered by Medicare. TRICARE processes the claim as a second payer as long as the service is a benefit under TRICARE, and the provider is TRICARE-authorized. TRICARE pays what it would normally pay if Medicare processed the claim (20 percent of the TRICARE allowable charge). You are responsible for the remainder of the bill.

If you have no choice for reasonable access to medical care but to use an opt-out provider, TRICARE may recognize the hardship situation and grant a waiver to allow TRICARE to be primary payer on an individual case basis. To get a waiver, provide an explanation as to why care was not otherwise available from a Medicare participating provider.

Please contact the TFL contractor for detailed information about the opt-out waiver process.

Last Modified: September 18, 2007

This is from 2005, but...

http://www.aapsonline.org/medicare/tricare.htm

snip-snip

In general, here’s how we were told things to work:

For the most part, TRICARE reimbursement rates, known as CHAMPUS Maximum Allowable Charge (CMAC), are the same as Medicare. The most noted exceptions of OB/GYN and pediatrics, which don’t generally lend themselves to the over-65 Medicare population. So financially, accepting TRICARE is the same as accepting Medicare. Although legally TRICARE and Medicare may affect a physician’s practice differently.

A physician is allowed to accept TRICARE, but opt-out of Medicare. The reverse, however, is not the case; if a physician accepts Medicare, he must accept TRICARE. Institutions (hospitals) do not have this option. They must accept or reject both. See http://www.tricare.osd.mil/CFR/C6.PDF for balance billing regulations of Non-Participating (but Authorized) Providers.

Somewhere TRICARE policy specifies that a physician accepting Medicare, must also accept TRICARE. But, because TRICARE policy does not address the case of accepting TRICARE but opting-out of Medicare, this is allowed—as far as we can tell. We cannot offer definitive legal advice on this point.

A reasonable guess might be that Participating and Network Providers must accept Medicare, but an Authorized (only) Provider may opt-out of Medicare. That is to say, becoming a TRICARE Participating or Network Provider probably entails accepting Medicare.

Locke, MD

-----Original Message-----From: [mailto: ] On Behalf Of docboopsSent: Friday, January 11, 2008 5:30 PMTo: Subject: Opting out of MedicareDoes anyone know if opting out of Medicare also means that you cannot see Tricare Standard patients as well? There was brief mention of this in the Jan 08 FP Management article titled "Does Primary care Need Medicare?"

[Guest guest]

Tricare and Medicare, though both governmental, are managed by different

insurance entities and therefore opting out of one should not affect the other.

When I went through the credentialing process, there were two separate

applications and currently they pay me different reimbursements. Tricare Prime (their HMO) you are assigned patients as

their PCP. You get 100% of the negotiated rate. Tricare

standard (the old champus) is essentially the ppo version of Tricare

and Tricare pays 80% after the deductible. If the patient has Tricare for life (retiree tricare) and are not yet Medicare eligible, they

have a $12/copay and I believe this is under the same contract as the rest of Tricare. None of these should be linked to Medicare. But,

if someone has Tricare for life and they are Medicare

eligible, Medicare has to be billed first. If you opt out of Medicare, you

cannot bill the secondary and expect to get paid, so Tricare

won’t pay a dime even if you were seeing the patient prior to their 65th

birthday through Tricare for life. Even better, the

patient cannot refuse to go on Medicare and stay with Tricare

(Note: this switch also occurs when a patient becomes Medicare eligible through

disability so even though the patient is <65, they still may have Medicare

primary).

And now you know why I can’t

remember much of my childhood…

Opting out of Medicare

Does anyone know if opting out of Medicare also means that you cannot

see Tricare Standard patients as well? There was brief mention of this

in the Jan 08 FP Management article titled " Does Primary care Need

Medicare? "

[Guest guest]

By the

way, I did not read the article, but I will try and get to it this weekend. Who

knows, maybe I’m wrong…J

Opting out of Medicare

Does anyone know if opting out of Medicare also means that you cannot

see Tricare Standard patients as well? There was brief mention of this

in the Jan 08 FP Management article titled " Does Primary care Need

Medicare? "

[Guest guest]

Such emotional upheaval I get on the list serv

should i be

A blessed to know someone like Brady to ask this stuff of?

B disgusted that this stuff exists?

C worried about Brady that he DOES understand this stuff?

D guilty that , that Brady can't be any smarter than me ,how come i

don't know this stuff?

E fearful and guilty becasue I DO NOT CARE to know this ?

Opting out of Medicare

Does anyone know if opting out of Medicare also means that you cannot

see Tricare Standard patients as well? There was brief mention of this

in the Jan 08 FP Management article titled " Does Primary care Need

Medicare? "

[Guest guest]

Maybe F grateful that shares his

knowledge with us or G all of the above

Opting out of Medicare

Does anyone know if opting out of Medicare also means that you cannot

see Tricare Standard patients as well? There was brief mention of this

in the Jan 08 FP Management article titled " Does Primary care Need

Medicare? "

[Guest guest]

It's even more complex in Co. You can't be a Tricare Prime provider since the

contract is held by the Univ of Colo and Denver Health. So it is easy to stay

out of the way. I actually Take Tricare for Life, which is for " lifer retirees " .

Pays the same pitiful rate, but feel that those old vets, who do not go to the

VA, deserve soemthing for their service. Wrong headed?

________________________________

From: on behalf of F Strazzullo

Sent: Sat 1/12/2008 11:39 PM

To: ; ' Brady, MD '

Subject: RE: Opting out of Medicare

Maybe F grateful that shares his knowledge with us or G all of

the above

Opting out of Medicare

Does anyone know if opting out of Medicare also means that you cannot

see Tricare Standard patients as well? There was brief mention of this

in the Jan 08 FP Management article titled " Does Primary care Need

Medicare? "