Choromom

Thanks, Wife... I really think this is going to be doable...it's just that after so many years of Tricare Prime Remote, and needing only an authorization in place, knowing that I'm going to have some expenses makes me want to pin things down. I know I will have my deductable. $150. Then, I'm not sure on the hospital if I will have 25% of what Tricare pays, or the $25 outpatient cost. I'm assuming I will have 25% of the doctor's allowed Tricare. My surgeon has an incredible staff, very knowledgable. Just hard to get through to them by phone...they do a lot of these surgeries! It would be nice to have just one place to go to find all of the answers! My caseworker at Tricare is so good to call me right back, but she wasn't quite sure about some of the charges for the hospital and anesthetist. You can be sure that if and when I learn anything concrete, I will let folks know what my answers were! I appreciate your post. Thank you.

Aculberg! I'm going to Salt Lake Regional and Drs Cottam and Richards, too! And, yes, it is more than a little difficult to connect with the office! The gal that usually does all of the coordinating stuff is on maternity leave until July. Have you seen them at all yet? Do you have a preference as to which surgeon? I've done my initial consult, psych eval, nutritionist, and exercise consults, and had an esophageal scope because of GERD. Just need to get the last few paper hoops done, and the last couple of phone calls connect with the office. (Both docs are taking vacation in June, too, so that complicates it a little more!) Keep in touch!

Is your Tricare Prime, Prime Remote, Standard, Extra? That will make a difference. I am trying to find out what Standard pays...couldn't get it cleared before hubby retired the end of May, and I need to know what I'm going to have to cover. Both the hospital and doctor are contract providers, which I'm told means that they will accept Tricare's payment. But as Standard, I now have a copay and deductable. My contact lady at Triwest told me that the doctors gets paid about $1000. No wonder no one wants to accept it!

I was able to get authorization without the 6 month diet thing by being able to show that I had tried and failed with other plans...for as far back as 25 years. My current dilemma is that hubby retired last weekend, so I'm now on Standard, instead of Prime. Both MD and hospital are Tricare contract, so I'm told they will accept what Tricare pays, but now I have my deductable and co-pay. I think it's going to work anyway, but I would certainly like to have an idea of how much Tricare (Triwest) actually pays, so that I know what my cost share will be? Anyone have any ideas?

OogaBooga, I think Tricare is supplementing Medicare for you, because any time there is another insurance, Tricare is automatically secondary. So, Medicare would pay first, and then Tricare will cover what is left of the allowable charges, which, if your providers accept, will mean you will not have further expenses. I just copied this from the Tricare.mil site concerning coverage: Gastric Bypass TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions: Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints Is 200 percent or more over ideal weight for height and bone structure Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown) TRICARE does not cover: Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction Biliopancreatic bypass, gastric bubble or balloon for the treatment of morbid obesity Last Modified: March 24, 2008 Having posted this, we all need to realize that there are differences between Tricare Prime, Prime Remote, Tricare Standard, and Tricare for Life, and your accessability to a military medical facility. And, anytime there is another health insurance in place, Tricare is secondary. If the first insurance doesn't cover gastric surgery, Tricare needs a letter of denial from the first insurance before they will cover anything. So, as we compare experiences, we need to be aware of which Tricare coverage is being discussed, and what other circumstances effect the individual situation. I have been paper-pushing and hoop-jumping since January, when I learned that Tricare would cover lap band, because my husband retires this Saturday. He started a civilian job in February, when he went on terminal leave. The civilian job has insurance that does not cover gastric surgery. Letter of denial has not yet been processed (see previous post about timeframe for Tricare approval) - Tricare coverage changes on Saturday - civilian insurance is in the process of doubling monthly premiums, so we are changing to a private Tricare supplement. This will probably mean that I will have to wait until after the first of July to get authorization, so that Tricare, and the supplement, will cover the costs. IF the letter gets processed, and IF I can see what our expenses would be with a different Tricare, and IF it is manageable, I'll push for surgery in June. Everything is done except the pre-op. Surgeon and hospital accept Tricare, and both have already done some pre-op exams and testing for me. Tricare has told me I qualify (how does one react to that information---'Congratulations! You are officially overweight enough that you need surgical help!') and that it is just a matter of getting the DEERS and Other Health Insurance issues resolved.

Kitty, I have to agree with Fdiljn concerning Tricare. I have an actual person working on my authorization. I have her name and her direct phone number, and every time I've called her, I've heard back from her within a couple of hours! Tricare can be hard to deal with at times, but I have been a military wife for 37 years, and it is better now than it has ever been. Tricare HAS to have an authorization processed - either approved or denied, within five business days. I've worked in doctor's offices, and have had coverage from private insurances, and do not know of a SINGLE other insurance that makes that kind of effort. The biggest drawback with Tricare is that they pay less than other insurances! So, if you want to know why private insurance or other group insurances are so expensive...there's one of the reasons. Every state has an insurance board that sets acceptable pricing for procedures in that state. Tricare, and other federal insurance programs, like Medicare, pay at the low end of that scale. Doctors and hospitals always charge at the high end, and above, if they can. Many Tricare employees are military; either a dependent or a retired member. They KNOW what we are dealing with. I have always been treated with utmost respect and courtesy. I'm sorry if you have not.