Tricare for Life and SilverSneakers: The Coverage Relationship
Tricare for Life (TFL) provides comprehensive healthcare coverage for military retirees and their families who are also enrolled in Medicare Parts A and B. In this arrangement, Medicare acts as the primary payer and TFL serves as the secondary, or "wrap-around," coverage. Because TFL functions as supplemental insurance, it primarily covers the out-of-pocket costs—like deductibles and copayments—for services that are covered by both Medicare and Tricare.
SilverSneakers, on the other hand, is a supplemental fitness benefit that neither Original Medicare nor Tricare covers directly. These types of wellness programs fall outside the scope of both programs' standard, medically necessary services. This is a crucial distinction that helps explain why beneficiaries cannot simply expect TFL to pay for a SilverSneakers membership.
How to Get SilverSneakers with Tricare for Life
Since TFL does not include SilverSneakers, eligible seniors must get the benefit through a different insurance product. The most common way to do this is by enrolling in a Medicare Advantage (Part C) plan.
- Maintain TFL and Enroll in a Medicare Advantage (MA) Plan: Beneficiaries can have TFL and a Medicare Advantage plan simultaneously. By enrolling in an MA plan that includes SilverSneakers, you can get the gym membership as an extra benefit.
- Understand Billing Procedures: If you enroll in a Medicare Advantage plan, the billing process with TFL becomes more complex. For services covered by the MA plan, it will pay first according to its network rules and cost-sharing. You will then likely need to file a claim with the TFL contractor for reimbursement of any out-of-pocket costs. This is different from the seamless, automatic coordination between Original Medicare and TFL.
- Choose a Plan Carefully: Not all Medicare Advantage plans offer SilverSneakers. When shopping for an MA plan, it is essential to check if it includes the benefit. Additionally, if the MA plan has a drug benefit (Part D), it can interfere with your existing TFL pharmacy coverage, so you must enroll in an MA plan without prescription drug coverage.
Comparison: TFL + Original Medicare vs. TFL + Medicare Advantage
| Feature | TFL with Original Medicare | TFL with Medicare Advantage (MA) | TFL with MA and SilverSneakers |
|---|---|---|---|
| Primary Coverage | Original Medicare (Parts A & B) | Medicare Advantage Plan | Medicare Advantage Plan |
| Secondary Coverage | Tricare for Life | Tricare for Life | Tricare for Life |
| Coordination of Benefits | Seamless and automatic. Claims are sent from Medicare to TFL. | Requires manual claim filing with Tricare for reimbursement. | Requires manual claim filing with Tricare for reimbursement. |
| Provider Choice | Any Medicare-authorized provider. | Limited to the MA plan's network of doctors and hospitals. | Limited to the MA plan's network of doctors and hospitals. |
| Fitness Benefits | None included. | Varies by plan; may include SilverSneakers or similar programs. | Includes the SilverSneakers fitness program benefit. |
| Extra Benefits (Dental/Vision) | None included. | Often included, but vary by plan. | Often included, but vary by plan. |
| Pharmacy Coverage | TRICARE Pharmacy Program. | Must select an MA plan without a drug component (MA-only) to avoid complications with TFL's pharmacy benefit. | Must select an MA plan without a drug component (MA-only) to avoid complications with TFL's pharmacy benefit. |
| Out-of-Pocket Costs | Typically very low for most covered services. | Can vary significantly depending on the plan's cost-sharing structure. | Can vary significantly depending on the plan's cost-sharing structure. |
Steps to Access SilverSneakers as a TFL Beneficiary
- Assess Your Needs: Determine if the benefits of a Medicare Advantage plan, such as SilverSneakers and other supplemental coverage, outweigh the potential complexities of network restrictions and manual claim filing. For some, sticking with the straightforward TFL and Original Medicare combination is preferable.
- Shop for a Medicare Advantage Plan: Use resources like the Medicare Plan Finder to search for MA plans in your area. Look specifically for plans that list SilverSneakers as a benefit.
- Choose an MA-Only Plan: If you want to keep your Tricare pharmacy coverage, ensure you enroll in a Medicare Advantage plan that does not include prescription drug coverage (Part D).
- Confirm Eligibility: Before enrolling, check your eligibility with both the prospective plan and SilverSneakers directly to confirm you qualify.
- Understand the Process: Be prepared for a different claims process. For medical services, your MA plan will be the primary payer, and you will need to manage reimbursement from TFL for covered expenses.
Conclusion
While Tricare for Life does not cover SilverSneakers for seniors, it is still possible for beneficiaries to receive the benefit by enrolling in a qualifying Medicare Advantage plan. This approach allows retirees to get extra coverage for fitness programs and other perks. However, it requires careful consideration of the potential changes to billing and provider networks. By weighing the pros and cons, TFL beneficiaries can make an informed decision to find the best health and wellness plan for their needs.
