Anyone on Tricare Standard?

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CinD
CinD Member Posts: 163
edited September 2016 in Employment, Insurance, and Other Financial Issues

Hello all, I am wondering if someone out there is able to answer some questions on Tricare Standard. I have been on Tricare Prime for years, and it was wonderful during my cancer treatment.  We may be moving to an area where they do not accept Tricare Prime, so I would have to go on Standard.  The whole thought scares me because I don't want to give up Prime. With a history of breast cancer, I know I have to be more careful with insurance just in case.

Is anyone on Tricare Standard?  Were you covered during your cancer treatment?  Did they pay most of the bills ... surgery, chemo, etc? I have been trying to navigate the Tricare site, but it doesn't give enough information. I am hoping someone with firsthand experience will be able to give me the facts.  I see I would have a yearly cap of $3000 and assume with cancer treatment it doesn't take too long to get to that cap. If/when you reached it, was there any problem with them picking up all of the bills thereafter?

Any information you can give me will be greatly appreciated!

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  • Obxflygirl1
    Obxflygirl1 Member Posts: 377
    edited September 2014

    I am on Tricare Standard and it has been wonderful.  No co pays and I hardly ever get a bill for more than $25 after insurance payment. But I haven't had chemo, etc. so not sure how it works for that if needed. 

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  • shycat
    shycat Member Posts: 76
    edited September 2014

    We were also on Tricare Prime until last year when they decreased the geographic coverage areas and we were no longer eligible.  So starting 10/1/2013, we were on Tricare Standard and a bit concerned about how that would work out.  In January, I was diagnosed with IBC and burned through that $3000 catastrophic cap very quickly.  So far Tricare has been billed over $200,000 for my care, and paid their contracted (greatly reduced) share promptly.  My only issue is with our stupid hospital chain -- they hope I don't understand what "Patient Responsibility: $0" means and try to bill me for the remaining balance.  For example, over $20,000 for bilateral mastectomy, Tricare paid about $4000, and the hospital billed me for the remaining $16,000.  <grumble snarl spit>  I have to call and point out (again) that the EOB clearly states "Patient Responsibility: $0".   I had a similar experience under Tricare Prime so it's a problem at the hospital billing side, not Tricare itself.  Now if I can just get that stupid hospital chain to refund an overpayment that I made based on their estimate of what I would owe for my chemo port implant (and an incorrect Tricare Prime billing from 2013).  I hate dealing with this carp.

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  • CinD
    CinD Member Posts: 163
    edited September 2014

    Thank you for sharing your experiences Obxflygirl1 and shycat.  I appreciate both of you taking the time to respond.  Shycat, I'm sorry you've had billing problems, something you don't need on top of all of the treatment you endured. 

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  • CinD
    CinD Member Posts: 163
    edited September 2014

    If we make the move, I think I'll look into supplement insurance.  I see ASI has reasonable policies. It appears as if you must wait six months for pre-existing condition coverage to kick in, but at least they don't seem to rule out pre-existing conditions.  Does anyone have experience with the supplemental policies?

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  • Olaf
    Olaf Member Posts: 159
    edited November 2014

    I have Tricare Standard. They are denying me for a nipple sparing mastectomy. They are stating that skin sparing and nipple sparing are not viable treatments. Standard, means you do not have to be preapproved. This is the first I have had problems with Standard. And it all stems from their terminology and antiquated thinking.

    I don't think you will have a problem.

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited November 2014

    olaf - Tricare Prime paid for a skin/nipple sparing for me back in 2010 - not sure why Tricare would disallow this surgery as not viable, unless they are specifically linking it to the diagnosis and size of your DCIS.  In essence, saying it is not viable for you as an individual patient, rather than not a viable surgery for anyone.

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  • Olaf
    Olaf Member Posts: 159
    edited November 2014

    specialk, Tricare stated that they didn't cover skin and nipple sparing mastectomy because it is considered subcutaneous. In other words, breast tissue is left behind so therefore it is not considered a viable cancer therapy.

    My diagnosis was stage 0 , tumor was .4 cm and located peripherally at @ 6cm away from nac. So I was a good candidate for NSM. Any help you can offer, I am all ears.

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited November 2014

    olaf - trust me when I tell you that I did not have any more breast tissue left behind than any other type of MX.  My nipple tissue was cored and pathology separately done, my mass was 2cm IDC well away from the nipple (I was originally a lumpectomy candidate, self-elected BMX), and it was known that I was Her2+ prior to surgery - so I know that my surgeon did a very thorough job at removing all tissue possible.  There was absolutely no push-back from Tricare on having this type of surgery, and mastectomy, let alone bi-lateral, was not a requirement based on my diagnosis.  I am wondering if you can get a peer-to-peer review with your surgeon and Tricare, or if your surgeon's office is correctly coding your request for approval.

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  • Olaf
    Olaf Member Posts: 159
    edited November 2014

    specialk, I read my surgeon's report and it stated all breast tissue was removed and the tissue under the NAC was sent separately to pathology. When I filed my appeal, it was all underlined along with studies of m, a letter from my doctor along with a study. They came back to me with the same garbage of it being subcutaneous citing their policy of not covering such. Subcutaneous was a procedure doctors used 30 years ago but no longer. But for some reason tricare refuses to change their terminology. I have to now file an appeal for a hearing. I feel like they didn't even put any consideration into everything I sent them. They basically just turned around and said nope it's still subcutaneous. Everything you submitted doesn't coincide with what we believe.

    I have spent hours coming up with more studies. I first tried calling tricare months ago when I got the denial. One worker had to pass me off to another. They were no help as all they kept saying, it was denied and send your appeal.

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  • VAT
    VAT Member Posts: 11
    edited January 2015

    Olaf,

    Wondering if you got anywhere with your appeal. I am Tricare Standard and was just denied nipple sparing mastectomy and reconstruction

    . Been given the same antiquated garbage and told to send an appeal. Have you had any luck? This process is holding up my surgery!

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  • Olaf
    Olaf Member Posts: 159
    edited January 2015

    VAT, what timing! I received my Appeal Hearing letter on Friday and it just said I would be granted a hearing and will be notified. A Captain from TRICARE called me today. Nothing new. He got an earful about how antiquated TRICARE is and some anguish and tears from me. I am sure he was so happy to hang up.

    Are you in Virginia? So your doctor went the route of pre authorization even though you are standard?

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  • Olaf
    Olaf Member Posts: 159
    edited January 2015

    VAT, I have been at this since August!

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  • MagicalBean
    MagicalBean Member Posts: 362
    edited January 2015

    I have Tricare standard and I love it, but it is secondary to Medicare. Between the two, I haven't had a bill in over 2 years.

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  • Olaf
    Olaf Member Posts: 159
    edited January 2015

    MagicalBean, yes TRICARE can be very good unless you want to have a NSM or a SSM. They believe the only standard of care is a radical mastectomy or lumpectomy. Some have been lucky to fly under the radar. In this case they are way behind the times.

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  • VAT
    VAT Member Posts: 11
    edited January 2015

    Yes, I am in Va. My breast surgeon and plastic surgeon both went preapproval route to be on the safe side, but did not expect a problem. I do not have a cancer diagnosis at this time. I have a family history and genetic defect that puts me in the high risk category. I am a perfect candidate for NSM since my surgery is prophylactic. My surgery was scheduled for this Friday. I still haven't even received the denial from Tricare, but my surgeon called me yesterday after she called Tricare on my behalf and got nowhere. Only will approve complete mastectomy. Even denied reconstructions!

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  • Olaf
    Olaf Member Posts: 159
    edited January 2015

    VAT, I am going to PM you.

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  • VAT
    VAT Member Posts: 11
    edited January 2015

    Olaf,

    Sounds good

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  • Olaf
    Olaf Member Posts: 159
    edited February 2015

    Valerie,

    I am having trouble PMing you. It says I have filled my quota of PMs. Ring in if you see this.

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  • VAT
    VAT Member Posts: 11
    edited February 2015

    Marybeth, maybe I need to clear out some posts. I will try and do that now. Val

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  • melissaelena
    melissaelena Member Posts: 2
    edited June 2015

    Olaf: just sent you a pm on this topic!

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  • Moderators
    Moderators Member Posts: 25,912
    edited June 2015

    Dear melissaelena, Welcome to the community. We hope that you get some information on this topic. Keep posting and let us know how we can help. The Mods

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  • CAREGIVERS
    CAREGIVERS Member Posts: 1
    edited September 2016


    Tricare is becoming more regressive in terms of granting a patient's access to cancer care. Retired Tricare Prime /beneficiaries that live within 60 miles of a Military Hospital are now being required to go to said military hospital for cancer care (Tricare: Military Facility "Right of First Refusal"). This can become a problem for cancer patients. Thereby creating delays in care and limiting access to the major centers for cancer care. Imagine being required to see a specialist for cancer care without the supporting research and medical staff professionals to accomplish best clinical outcomes. The University of North Carolina and Duke University hospitals have been designated by Tricare as Centers of Excellence (COEs) for cancer and transplant Patients. These organizations have the protocols for treating cancer. Tricare has said that these organizations have the certified methods for treating cancer... yet to gain access to this care a military doctor has to give his approval. To receive the proper diagnosis such diagnosis has to come from a military doctor. How sad.

    Military hospitals are the new VA Hospital killing fields. Veterans should receive the same options as any other citizen. Remember without the Veteran none of us would have health care.

    Please read more about the Military Hospital Right of First Refusal. Sounds like they are dealing with property and not human beings.

    GOD Bless

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