mom's coverage pulled! ins trying to re-coup their money. Tri Care

[Successor TTEE]

Here's the scenario in a nutshell regarding Mom (81), who lives in AL. While accompanying a friend to a naval base for a doctors appt, she talked to one of the staff, who advised her that she should be eligible for Tri-Care insurance through the military. My dad had been in the navy, active and reserve, almost 20ys. he had a great civilian job / great benefits the entire time they were married. Jump ahead 4 decades, mom and dad divorced after 45 ys of marriage. Mom has medicare, and she had a med-sup as well at the time she was given this advice. So, she called my dad, asked him to forward his separation papers, etc. so the people on base can take a further look. They reviewed the paperwork, and, sure enough, approved her for tri-care and issued her coverage. She cancelled her med-sup, and had enjoyed about 5 years of tricare benefits, all the while encouraging my dad to take advantage of tri-care benefits, instead of paying for a med-sup and just dealing with the VA. So, he finally looked into it in 2007. It was when my dad applied for benefits and submitted his paperwork on his end that he got a call from Tricare saying that not only was he not eligible, but they immediately pulled my mom from the system and terminated her coverage. (She was on a cruise at the time. We just kept our fingers crossed that she wouldn’t have a medical emergency before she found this out.) The explanation that they gave to my dad on the telephone is that he left the navy just prior to retiring with full benefits. They also told him they intended to recover all the money paid for my mom’s benefit (12K ballpark). Mom received a letter, this time stating that she’s ineligible due to the fact that they are divorced. They also told her (although I don’t know if that was in writing, or during a phone call) they are not going to pursue re-couping their costs. Phew! we thought the saga was over.

Well, a month ago, they changed their minds again. Much written correspondence and collection letters sent to her as well as to her medical providers - anyone who had been paid by Tri-Care for treating mom for the past 5 ys. .... from the dentist, optometrist, to her quintuple bipass. Now, she has the doctors calling her. She doesn't want to lose her doctors and is considering making monthly payments (either to Tricare, or the providers - I'm not sure which). I feel that she should fight this tooth and nail because a) it was because of Tri-care that she cancelled her insurance. b) Tricare had issued the coverage to her - she didn't force them, or falsify documents. c) because even though an error may have been made, the error wasn't hers. (there was no mistake in dad's papers, apparently just in reading the papers correctly.) d) they are obligated to pay for benefits while coverage was in force. (aren’t they?) Anyway, all of this sounds illegal to me. I have urged her to get a lawyer. and hopefully she will. In the meantime, if any of you would weigh in with your impression of the matter, I'd sure appreciate it. thanks.

[vestagrayanna]

Truly wish I had more knowledge of this, but I don't. I can only speak to the fact that government payers, Medicare, Medicaid, Tricare etc etc etc do have right of recovery for (I thought) up to six years, at least against other payers (ie a commercial payer was primary, but government paid). Your post mentions they are seeking five. Doesn't surprise me. I think this is absurd and virtually criminal, but my thoughts don't count in this situation. I suggest that you find a knowledgeable attorney and I hope you can find redress.

[vestagrayanna]

I'm thinking there was information in the post I overlooked, even though I still say I am not terribly knowledgeable in government plans. But, was the insurance cancelled by your mom the medi - gap plan and thus Tricare the assumed / presumed secondary payer? Your Mom has / had Medicare? If I now understand that correctly, Medicare should pay prime regardless of Tricare. I'm certainly not a government plan expert, nor even halfway knowlegeable, really. But, Tricare is always a payer of last resort. Always, always. By what is in your post, I think Medicare should pay prime. I also don't know off hand the rules for Medicare / Tricare COB, but I do think they COB. Dept. of Health and Human Services maintains a website and PDF booklet of Medicare COB rules. I suggest perhaps trying that as well.

I understand that Tricare now says she was not eligible, yet the the sums you mention seem extremely high for Medicare out of pockets if Medicare was paying first. So, help me, what am I not understanding? Was Medicare paying prime and are the dollars you mention her actual out of pocket costs after Medicare? Or, am I missing something and there is no payer paying at all?

[Successor TTEE]

vestagrayanna, thanks so much for your response. Yes, they were the secondary coverage after medicare. The high dollar amount is due a quintuple bipass she had May, 2007, followed by another month's stay in a re-hab facility. Mom did and still does have medicare, and has since replaced the tricare with another med-sup, like she had before all of this started.
Thanks, sandy

[vestagrayanna]

You know, I am again saddened that I cannot help. If this were commercial / private health insurance, I could help step-by-step how to appeal--perhaps win, perhaps lose, but we could give it a shot. However, when questioning our government, likely useless. However, I am still bothered by the high out of pockets even given your explanations. You mention the 5 year recoupment period, however, I would like to further clarify if Medicare was prime for that entire 5 years? Medicare approved providers must waive any balances other than Medicare out of pockets. It is those out of pockets that TriCare or a medi-gap plan would cover. IE, these are secondary payer responsibility. So, from that, I assume that the entire 12K you menition is Medicare out of pocket dollars. You also mention that the inpatient admissions and care your mom received could have been quite lengthy. In that case, it is possible to accumulate that much Medicare out of pocket, but I would want to track it down. I would ask if she ran out of her 100 inpatient Medicare days. If she didn't, I still question 12K out of pocket if Medicare were prime that entire 5 years. As far as getting TriCare to relent in any way, even if they were at fault for the cancellation of the medi-gap plan, I have not a clue or input. But, I do question the large out of pockets given your Mom's Medicare prime payer status. Medicare out of pockets can certainly accumulate depending upon A and / or B coverage (answering that would also help), but still, even in a 5 year time frame, 12K is a lot unless she exceeded some unusual norms like the 100 day IP limit. To the best of my knowledge (again, not much in this area), there is a relatively high per diem out of pocket once 100days at one admission is exceeded. Then, once discharged, there needs to be 60 days (I think 60) without IP admission to reset the 100 day Medicare limit. That is why I ask about the 100 days. Are you confused? I am!

In a nutshell, you state the 12K came from the May 2007 bypass, but are you sure those out of pockets passed to your Mom are accurate? The simple size of those out of pockets still gives me pause.

PS, sandy, other than an attorney as I've mentioned, there are very good websites maintained by CMMS, DOL, Medicare that are monstrous, but patience could pay off if you wish to research them. (Another ps, cmms and medicare do have separete websites with differing info. (ie, they ain't the same, according to your local hillbilly)

[Successor TTEE]

vestagrayanna, thanks once again! I'm can't speak with certainty to the points in question (part A or B, breakdown of charges, time frame, etc). So, I will print out our dialog and mail it to Mom. When she answers these, I can post again with the info. I'll also find out specifically the time frame from which they're trying to collect. About the 100 days, seems like hospital and re-hab lasted appr 6 wks or so - can't recall at the moment. Since then, she has been receiving on-going physical therapy. First weeks, a therapist came to the house. Now, she gets it at a senior wellness center. Not in-patient, but could it be that the continuing therapy may play a role in the high dollars? (all speculation, of course, until I hear back from mom). Also, I don't know what CMMS or DOL are. Can you clue me in? I do appreciate being able to talk with you about this. Thank you so much! Sandy

[vestagrayanna]

Sandy. I apologize. CMMS = Centers for Medicare and Medicaid Services. DOL = Department of Labor, meaning the United States DOL. Also, I am curious why TriCare determined both of your folks were not eligible. I do thlink you need to determine which coverages your mom had and at what time. Who is covering the physical therapy? I assume Medicare. Again, I don't see that therapy contributing (much) to that larege out of pocket. I'm sorry again, Sandy, but I cannot pin point the problem. How old is your Mom? I keep going back to the fact that if your Mom had Medicare for that 5 years, or even the majority of that 5 years, $12K is a LOT out of pocket. I also wonder about the TriCare eligibility. I suggest you try to find someone in your area that is an expert in government plans if you can. I will try to help if I can, but again, this is not my area.

[Successor TTEE]

Hello again! here's the latest. mom called me today after she got my letter asking for info. She corrected some things. Tri-Care is trying to collect $5000 (approx) - not 12K as she first thought. Also, no dental care was ever in the tri-care coverage. $1700 of the $5K is scrips. Mom is 81. Yesterday, she went to the Naval base with all the paperwork and correspondence. The man who processed her into the system in 2004 wasn't working, but she spoke with other personnel. It puzzled her that when they looked her up in the system, it showed that she owed just a small balance. They said that it could be that the providers have already paid the money back. (I think that's doubtful - don't know what's going on there.) still doesn't change her situation, in that she still will be in debt for the $5000. Whether it's to Tri-Care or the care providers is of no consequence. While she was at the base, an employee slipped her a note that said "contact your congressman". Then another gentleman who was also involved in looking over the mess said, "there's really nothing we can do for you here. But, if I were you, I would contact my congressman." So, she hopped in her car to pay her congressman (Jo Bonner) a visit. He was in Washington, but his office got the ball rolling, and she now has a case worker who is looking into the matter. She's already feeling a sense of relief now that she has an ally.
Mom is sending me copies of all her documents, including my dad's papers - (he passed away a year ago), so l can take a look. Then, I can see the dates of service for my dad. Should be interesting. that's about all I have for now. I'll keep you posted. Thanks for your interest. (p.s. sorry - forgot to ask her about part A or B medicare)