Dependant without TRICARE Access

Dependant Scenarios

These scenarios reflect the changes to the Primary and Secondary Insurer > > Note: For any Emergencies, call 9-1-1 or report to the nearest Emergency facility. If you are a TRICARE beneficiary, contact 1-800-TRICARE (1-800-874-2273) ASAP to let them know you are in the ER. If you are not currently a TRICARE beneficiary, provide the ER with your Canada Life/MSH International information, but advise them that direct billing may not be possible.

• Scenario #1 - Awaiting TRICARE Access
  Mrs F has just arrived in Washington, D.C. with her children and Reg Force spouse. She will eventually have TRICARE access, but has not completed the DEERs enrollment process yet, so has not yet received base access. She feels she may have a urinary tract infection and wants to be assessed. 
  
  Suggested:
  Without TRICARE benefits, Mrs F has her comprehensive coverage through the Public Service Health Care Plan (PSHCP), which is administered in the US by MSH International. However, TRICARE benefits are effective on the COS date on the posting message; dependants can retroactively file claims with TRICARE as well:

  1. She should book an appointment at a local clinic (i.e., walk-in or local clinic).
  2. Clinician assesses and prescribes an antibiotic medication.
  3. Mrs F pays out of pocket for clinic services before leaving the clinic, keeping all invoices and receipts.
  4. Mrs F goes to a local pharmacy to get her prescription filled, pays out of pocket, and keeps a copy of the prescription and receipt. 
  5. Mrs F submits a claim for clinic access and prescriptions to MSH International using the MSH International portal, OR if she manages, in the meantime, to get access to TRICARE, she can claim manually through TRICARE as well.  
  6. If MSH International returns an Explanation of Benefits (EOB) with an R70 amount (an amount that may account for the higher cost of medical care in the USA), dependents can usually claim these amounts through CFSU(CS) or CDLS(W), which will be reimbursed as per Military Foreign Service Instructions (MFSI). If she chose to claim retroactively through Tricare at a later date, she would claim any co-pays/cost-shares through MSH International next. 
• Scenario #2 - No TRICARE Access
  Ms P has accompanied her spouse to New York City on a United Nations Posting, will not have access to US Military Medical Treatment Facilities (MTFs) during her posting, so has no TRICARE access. She is 16 weeks pregnant and is concerned about how to pay for childbirth when the time comes. 
  
  Suggested:
  Without TRICARE benefits, Ms P is dependent on her Comprehensive coverage through the Public Service Health Care Plan (PSHCP), which is administered in the US by MSH International:

  1. Ms P should locate a clinician for her perinatal care. If possible, she should coordinate direct billing (electronically, via fax/email, otherwise) to MSH Int. through the clinic manager (who may need to contact MSH Int. for assistance).  If clinic is unable to bill MSH Int directly (which may be an issue with MSH International for the time being), Ms P can pay and claim later via the MSH International portal. 
  2. Before delivery, Ms P should attempt to get a predetermination from the provider on how much the delivery will cost (including admission to the hospital as required). Childbirth in the US is expensive, and if unable to bill MSH International directly, she may be advised to request an advance, through her spouse, from CFSU(CS) or CDLS(W) to pay for the delivery. CDLS(W) advances $70,000.00 USD to Ms P’s spouse.
  3. Healthy baby delivered. The hospital provides a bill for $65,000.00 USD, which Ms P pays using the advance received from CDLS(W).
  4. Ms P then submits a claim using the MSH International portal to be reimbursed for the $65,000.00 USD.
  5. MSH International reimburses Ms P $60,000.00 USD for the costs of her delivery. The Explanation of Benefits (EOB) states an R70 amount of $5,000.00 USD. 
  6. Ms P, through her spouse, pays the remaining balance of the advance to CDLS(W). 
• Scenario #3 - TRICARE & MTF Access - Outpatient Care
  Mr Q accompanied his spouse to Colorado Springs. He has a dependant ID card, access to the base and has registered at the MTF. He wants to see a clinician regarding his shoulder pain. He books an appointment with a primary care clinician. 
  
  Suggested:
  With MTF access and TRICARE benefits, TRICARE is the Primary Insurer for Mr Q; the PSHCP, administered in the US by MHS International, is the Secondary Insurer. 

  1. Mr Q is assessed at the clinic by a primary care clinician.
  2. Clinician prescribes a medication for pain relief.
  3. Mr Q leaves the doctor's office and goes to the MTF Pharmacy to retrieve his medication.
  4. Mr Q returns home. There should be no bills for any care/medications received. 
• Scenario #4 - TRICARE & MTF Access - Specialist Referral on Base
  Mr Q is still having shoulder pain and some functional loss of renge of motion. He returns to his clinician regarding his ongoing shoulder pain and an xray reveals a should defect. His clinician refers him to an Orthopedic Surgeon in the MTF for a consult. 
  
  Suggested: 
  With MTF access and TRICARE benefits, TRICARE is the Primary Insurer for Mr QQ and the PSHCP, administered in the US by MSH International, is the Secondary Insurer. 

  1. Mr Q waits 72 hours for the referral to be approved by the Referrals Manager on base.
  2. The referral is approved, so Mr Q books an appointment with Dr T, Base Othopedic Surgeon. 
  3. Mr Q attends the appointment and opts for surgery. Surgery date at the MTF is booked.
  4. Operation goes well. Mr Q goes home the same day (no hospital admission). LCol Q drives Mr Q home. There should be no bills for any care/medication received, as TRICARE should cover all aspects of this care. 
• Scenario #5 - TRICARE & MTF Access - Off Base Referral
  Mrs H is posted to Tacoma, WA, with her Reg Force spouse. She thinks that she may have some issues with anxiety and coping with stress, so books an appointment with her primary care clinician, Dr L, at the base MTF.  Dr L is concerned as well.  Mrs H agrees to be seen by a Social Worker, but there are limited Social Work services on base at this time. So, Dr L refers her to a civilian Social Worker who is in the TRICARE network off-base.
  
  Suggested:
  With MTF access and TRICARE benefits, TRICARE is the Primary Insurer for Mr Q and the PSHCP, administered in the US by MSH Int., is the Secondary Insurer. 

  1. Mrs H wait the 72hrs for the referral to be approved by the Referrals Manager on base.
  2. The referral is approved, so Mrs H books an appointment with the off-base civilian Social Worker.
  3. Mrs H tells the Social Work clinic that TRICARE is to be billed directly (as the clinic is registered on the TRICARE Network, direct billing to TRICARE should not be an issue). 
  4. Mrs H does not have an Other Health Insurer (OHI) - TRICARE does not recognize MSH Int as an OHI, so Mrs H will not need to disclose this.
  5. Mrs H is seen by the Social Worker. Additionally, Mrs H goes on to have 10 more sessions until her treatment is considered complete.
  6. Mrs H receives a bill in the mail for each therapy session. Each therapy session costs $110 dollars, of which TRICARE pays $80.00 USD, leaving Mrs H with a $30.00 USD co-pay.
  7. Mrs H pays the $30.00 USD Co-Pay to TRICARE, keeping all invoices/receipts.
  8. Mrs H submits a claim for the co-pay to MSH Int. and receives the equivalent of $30.00 USD from them. 
  9. If there is an R70 amount on the EOB from MSH Int., Mrs H can claim that through CFSU(CS) claims section. 
• Scenario #6 - TRICARE & MTF Access - Admission at Civilian Hospital (Childbirth)
  Mrs B has accompanied her spouse to Kansas and is 16 weeks pregnant. She was referred off base for her perinatal care and sees an Obs/Gyn physician who is registered on the TRICARE Network. TRICARE, up until this point, has paid for all of her care up to the point of delivery, as all of her appointments have been considered Outpatient Services.  Mrs B is scheduled for a C-Section at a civilian hospital and knows that she will be required to be admitted to the hospital (Inpatient Services). 
  
  Suggested:
  Kansas is NOT a Reciprocal Health Care Agreement (RHCA) State (only California, Georgia, Hawaii, Maryland, North Carolina, Texas, Virginia, Washington, and the District of Columbia are). In these locations TRICARE will generally NOT cover the costs of a dependent’s admission to a civilian MTF.  With MTF access and TRICARE benefits, TRICARE is the Primary Insurer for Mrs B for all Outpatient Services (no admission to hospital required). However, be advised, TRICARE will not pay for admission to civilian hospitals for dependants. 

  1. As this requires an admission to hospital, TRICARE will not cover costs and the hospital billing department should be told this as their default may be to try and bill TRICARE.  They still may, but Tricare will most likely decline to pay, and you will receive a bill in the mail for the admission from the hospital.
  2. Prior to delivery, Mrs B should attempt to get a predetermination from the provider on how much the delivery will cost (including admission to hospital as required).  Childbirth in the US is expensive, and if unable to bill MSH Int. directly, she may be advised to request an advance, through her spouse, from CDLS(W) to pay for the delivery. CDLS(W) advances $70,000.00 USD to Mrs B’s spouse. 
  3. Healthy baby delivered.  The hospital provides a bill for $65,000.00 USD, which Tricare will decline.  Mrs B pays the hospital using the advance received from CDLS(W).
  4. Mrs B then submits a claim using the MSH Int. portal to be reimbursed the $65,000 USD.
  5. MSH International reimburses Mrs B $60,000.00 USD for the costs of her delivery.  The EOB states an R70 amount of $5,000.00 USD.
  6. Mrs B claims the R70 amount through MFSI funds by submitting a claim to CDLS(W) Med Admin.  Med Admin deducts the R70 amount from the advance balance.
  7. Mrs B, through her spouse, pays the remaining amount of the advance back to CDLS(W).
• Scenario #7 - TRICARE & No MTF Access - Off Base Outpatient Care
  Mr T accompanied his spouse to Tyndall, FL. As dependants are not seen at the base MTF, Mr T receives all his care from civilian resources. Mr T thinks that he injured his hip while running and would like it to be assessed at his doctor’s office, which is registered on the TRICARE Network.
  
  Suggested:
  Without MTF access but still in receipt of TRICARE benefits, TRICARE is the Primary Insurer for Mr T for all Outpatient Services.  The PSHCP, administered in the US by MSH Int., is the Secondary Insurer.

  1. Mr T books an appointment with his civilian doctor, Dr Z, who is preferably registered with the TRICARE Network.  He has removed his previous OHI information from the clinic and has told them that TRICARE is the Primary Insurer.
  2. Mr T attends his appointment. 
  3. Mr T receives a bill in the mail for his appointment, which cost $300 USD, of which TRICARE pays $280.00 USD, leaving Mr T with a $20.00 USD co-pay. 
  4. Mr T pays the $20.00 USD Co-Pay to the provider, keeping all invoices/receipts.
  5. Mr T submits a claim for the co-pay to MSH Int. and receives the equivalent of $20.00 USD from them. 
  6. If there is an R70 amount on the EOB from MSH International, Mr T can claim that through CFSU(CS). 
• Scenario #8 - TRICARE & MTF Access - Admission to MTF (RHCA State)
  Mrs C has accompanied her spouse to Norfolk, VA and is 16 weeks pregnant. She receives perinatal care on base and is expected to deliver her baby at the base hospital. 
  
  Suggested: 
  Virginia is a Reciprocal Health Care Agreement (RHCA) State (along with California, Georgia, Hawaii, Maryland, North Carolina, Texas, Virginia, Washington, and the District of Columbia). In these locations, and these locations only, TRICARE will cover the costs of a dependent’s admission to a military MTF.  With MTF access and TRICARE benefits, TRICARE is the Primary Insurer for Mrs C for all Outpatient Services (no admission to hospital required) and Inpatient Services (hospital admission). 

  1. Mrs C delivers a healthy baby at the base MTF and is admitted for 3 days.
  2. Mrs C and baby return home on the 4th day.
  3. TRICARE pays the costs. Mrs C receives a bill from the hospital for $65 USD for “subsistence fees”. TRICARE does not cover subsistence fees (i.e., meals), so Mrs C pays these.
  4. Mrs C then submits a claim using the MSH Int. portal to be reimbursed the $65 USD.
  5. MSH International reimburses Mrs C $65 USD.  If MSH int. does not reimburse these fees, then Mrs C can submit a claim for subsistence fees reimbursement thorough CDLS(W) Med Admin.
• Scenario #9 - TRICARE & MTF Access - Admission to MTF (Non-RHCA State)
  Mr E has accompanied his spouse to Colorado Springs and is being seen at the MTF for knee problems. He receives physio and other care on base, but has now decided on knee replacement surgery at the base hospital, which will be accompanied by an admission for approximately 3 days.
  
  Suggested:
  Colorado is NOT an RHCA State (only California, Georgia, Hawaii, Maryland, North Carolina, Texas, Virginia, Washington, and the District of Columbia are). In these locations, TRICARE will generally NOT cover the costs of a dependent’s admission to a military MTF, but the costs may be much cheaper than at a civilian facility.  With MTF access and TRICARE benefits, TRICARE is the Primary Insurer for Mr E for all Outpatient Services (i.e., physio - no admission to hospital required) and MSH International is the Secondary Insurer. However, for all Inpatient Services (hospital admission, including the surgery as it is the reason for admission), you will most likely require the PSHCP to cover the costs.

  1. Mr E will not need to pay for any pre-surgical care, as this should be considered Outpatient Services and is covered by TRICARE. He should not receive any bills for these services.
  2. Mr E should discuss surgery with the MTF (Benefits Counsellor, or Health Benefits Advisor) and confirm that an admission to the MTF for surgery will not be covered by TRICARE.  He should get a predetermination of the costs and request an advance from CFSU(CS) if required (ie the MTF won’t bill MSH International directly.
  3. Mr E undergoes successful surgery at the base MTF and is admitted for 3 days.
  4. Mr E returns home on the 4^th day. He received a bill from the Hospital as TRICARE refused to cover the costs of his admission. Mr E pays the bill.
  5. Mr E then submits a claim using the MSH International portal to be reimbursed for the costs of surgery and admission to the hospital.
  6. MSH International reimburses Mr E the entire amount.
  7. Mr E reimburses the CAF for any advanced funds, if required.