Tricare and/or private health insurance for retirees

[pgg]

A question for the group.

I've been mulling this over for a while because of some recent annoyance with my civilian-land insurance plan. Today's United Health CEO news jogged my memory and I figure I might as well reach some conclusions and make a decision. I feel a little bit silly as a doctor 20+ years out of school but confused by health insurance. 🙂 I would appreciate input.


I'm retired from active duty, and eligible for Tricare. We're enrolled in Tricare Select. Just my wife and I.

I also get insurance (United Health) through my private practice group. About $580 comes out of my monthly draw to pay for it. The group pays the other 3/4 of the premium. I'm a partner, which means in the grand scheme of things, I'm paying for the other 3/4 of the premium also. (Sort of - if I opted out, I'd save $580/month, and that 3/4 would go into the group's general account, for which I'd receive some bit of at a later time when the books are zeroed.)

Kids are in their 20s. Two are on the United plan with us, but will come off late in 2025. Youngest daughter is finishing grad school and will get a job with benefits (I hope). Middle son will turn 26, and will get his own policy.

Between my PP income and Navy retirement, I'm making $7-800K/year so the United premiums are not a huge burden, but I hate paying money for something I don't need ... and I especially hate paying money for something that doesn't actually deliver the benefit I thought I was paying for:

Recently United Health denied coverage for a medically-indicated but not urgent surgery for my wife (reduction mammoplasty). Apparently that specific CPT code is specifically excluded by the particular plan our group has. I think one secretary thought it was lumped in with other "medically-necessary" but actually "kinda elective" procedures like bariatric surgery. An appeal from the surgeon's billing office with additional documentation was denied. Beyond being annoyed, I mostly just shrugged because the office said Tricare Select covers it and she'll get it done anyway in a few months.

All this has led me to ask myself why we would want to pay for United once we have no need of a family plan. Tricare premiums are dirt cheap. So cheap, that they might as well be free. In 20+ years on active duty, Tricare never said no to us about a claim. I know they reimburse terribly, so there exist practices which don't accept Tricare or limit their number of Tricare patients. Access to non-emergent and specialty care could conceivably be an issue with only Tricare, but it appears that acceptance of Tricare is not a significant problem locally. We aren't in a military town and I'm going to guess very few people around here have Tricare.

My wife and I are about 50, and healthy. I take no meds. She's on a HTN med and a statin, and honestly is on the edge of not needing them at all.

So, to get to the point. My questions for the group:

What is the real-world value to having the non-Tricare insurance? Is it worth paying ~$7-8K/year for it?

If you're retired and still working full time, what do you do and why? Tricare only? Tricare plus an employer / PP group plan? Just the employer/group plan?


Thank you for educating and advising me.

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[MTGas2B]

🍿
Interesting, my debate, hold out for FEHB at 62 or just roll on to Tricare at 60.

 

[RE-Tired]

I retired at 61(mil ret at 45) and used Tricare till Medicare; spouse is younger and still using tricare. Spouse went through major reconstructive surgery, multiple surgeries with billing near 300k -Tricare covered all and we met catastrophic cap which is pretty low compared to a lot of insurers; this is esentially all we had to pay. Only problem we have had is we had to shop around for primary care as you said they are poor payers and many practices will not take. So our experience has been good. All of the specialists she has seen take Tricare. Clearly the money spent on Private insurance will not affect your lifestyle, but in general private insurance is becoming a gauntlet. My daughters private ins thru her job has separate deductibles for every additional procedure (eg $2500 for bx then another $2500 for lumpectomy for an FA) so despite high premiums for a young person she had to pay large sums out of pocket. Uggh!

 

[armytrainingsir]

Fun fact. TRICARE is always secondary. And if you have United Healthcare and uhc won’t cover surgery, neither will Tricare. Even if TRICARE alone would cover it.


As far as finding a primary care, doctor, doesn’t really matter anymore. The good ones are all going direct primary care or concierge. The handful of independent guys left are left because they don’t take low payers like TRICARE. Corporate primary care doesn’t care about you at all. It exists just as a referral generator, dominated nurse practitioners.

Thankfully, you can still find good specialty care within academic or corporate organizations. In my experience they all take tricare.

Personally, I would take that 7 to $8000 and find an affordable concierge or direct primary care practice and spend it there. That way, tricare still remains primary payer for everything else. Even better, as a partner, you should figure out how to make the group pay for it, ha ha.

 

[pgg]

Fun fact. TRICARE is always secondary. And if you have United Healthcare and uhc won’t cover surgery, neither will Tricare. Even if TRICARE alone would cover it.

Interesting.

The surgeon's billing office thinks Tricare will cover it. I called to the Tricare claims office just now and specifically asked them if Tricare (as secondary) would cover that CPT code which was declined by primary insurance, and they said maybe (hedging that all cases are evaluated individually) but that it needs pre-authorization and has to be with an in-network surgeon. The claims person said that in general, Tricare sometimes covers things declined by primary insurance.

What a ridiculous process.

The downside to dropping United entirely, is that the "Tricare Young Adult" premiums actually cost more than our share of the United family premium. Our daughter could probably get reasonably priced coverage through her university for her final semester, but my son's employer doesn't provide health insurance so I'd rather keep him on ours as long as possible. (He's a musician who teaches to pay the bills. They say poverty and hunger is the root of all great art, but I'd rather he not actually starve while trying to get there. 🙂)

I guess the worst case scenario is we drop United late 2025 and then only have Tricare, and the surgery gets delayed a bit. Or we just negotiate a cash payment for the surgery which might actually end up being the simplest and cheapest thing.

As far as finding a primary care, doctor, doesn’t really matter anymore. The good ones are all going direct primary care or concierge. The handful of independent guys left are left because they don’t take low payers like TRICARE. Corporate primary care doesn’t care about you at all. It exists just as a referral generator, dominated nurse practitioners.

That's kind of what I figured. Even with my fancy private health insurance, I always get seen by some NP with many weeks of waiting time.

At this point, it feels like the main purpose of having health insurance is to avoid bankruptcy if someone gets cancer or seriously injured. Or obstetric care, which we're well past now. 🙂 Routine primary care and prescriptions and optometry and dental might as well just be cash out of pocket, with catastrophic insurance to backstop it all.

 

[RE-Tired]

RE: Fun fact. TRICARE is always secondary.

No this is not correct; it is only secondary if you have other main insurance; my spouse had no insurance through job and was and is fully covered by Tricare and will be till she qualifies for Medicare.
Some areas have Tricare prime which after very small premium there is no out of pocket. This is what we had till we moved to an area where it was not offered. Tricare prime could have changed though- was last on that 6 years ago.
Now I have Medicare with Tricare as a secondary (Tricare for Life)

 

[armytrainingsir]

RE: Fun fact. TRICARE is always secondary.

No this is not correct; it is only secondary if you have other main insurance; my spouse had no insurance through job and was and is fully covered by Tricare and will be till she qualifies for Medicare.
Some areas have Tricare prime which after very small premium there is no out of pocket. This is what we had till we moved to an area where it was not offered. Tricare prime could have changed though- was last on that 6 years ago.
Now I have Medicare with Tricare as a secondary (Tricare for Life)

Of course it’s not secondary if you don’t have other insurance.

This discussion is whether OP should dump his OHI.

Using Other Health Insurance | TRICARE

tricare.mil

 

[Helpful Troll]

Take UHC and tricare for now so both children continue coverage. If approved for spouse surgery via tricare early next year then great.

If surgery is denied by tricare as secondary coverage, you will be eligible to change your UHC plan with any qualifying life event. Your daughters graduation and insurance coverage via new employment in May or June is a qualifying event to change your UHC coverage.

If your UHC options include employee plus one, drop the family plan and insure you and your son until he's 30--- or hopefully sooner. If your only option is UHC family, when the qualifying event to change coverage based on new coverage for your daughter, you can also drop your spouse coverage.

Had to play these games with coverage as my children got jobs...