Tricare --> was RE: Opting out of Medicare

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More info...

http://www.tricare.mil/Factsheets/viewfactsheet.cfm?id=294

How TFL Works with Providers who Opt-Out of Medicare

W hen 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.

Locke, MD

From: [mailto: ] On Behalf Of Locke's in ColoradoSent: Friday, January 11, 2008 6:13 PMTo: Subject: RE: Opting out of Medicare

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?"