Are you a U.S. military veteran in Ecuador? (From here on, I’ll simply refer to you as “veterans” or “vets.”) Over the past week or so, I’ve chatted online with several fellow vets who were unaware that former military who are TRICARE-eligible can use their TRICARE insurance right here in Ecuador!
Also, for those of you with service-connected disabilities (as awarded by the U.S. Veterans Association, or “VA”), there will soon be local treatment options for you, too!
There are three programs I’d like to cover: TRICARE Overseas, TRICARE for Life, and the VA Foreign Medical Program (FMP). This is more of an awareness article than anything else, so if you need more information than I can provide here, please contact either TRICARE Overseas or, for the FMP, contact the VA.
TRICARE
Five years ago I had to have emergency life-saving surgery. That was followed up by eight days in a semi-intensive-care status, being regularly seen by a dozen different specialists, taking a lot of medication, and receiving all of my nutrition via a tube in my neck. Total cost: A little over $10,000.
I certainly wasn’t in a financial position to absorb that cost, but I did remember having seen something about an “overseas” option for TRICARE, which is the health insurance provider, contracted by the U.S. Government to provide coverage for anyone who is TRICARE-eligible. For expat purposes, this would typically be retired military members and/or their eligible family members. So after a quick search, I discovered that TRICARE Overseas absolutely did exist, and that if I filed a claim, they would indeed reimburse me for a large portion of any qualifying medical bills.
General Information
The first thing you need to know is that you or any TRICARE-eligible family member can only use TRICARE Overseas (TOS) if you are under 65. (For over-65, see the section on TRICARE for Life.) For TOS, there is a small monthly premium for the whole family, or an even smaller premium for single vets. Fortunately for us, you use the exact same website to file your claims, whether you’re filing a claim for TOS or TRICARE for Life (TFL). The reason for this will become clear when we get to the TFL section.
Coverage
Of course, as with any insurance plan, all claimed amounts must be for the same sorts of care and services that TRICARE customarily pays for in the U.S. Neither TRICARE Overseas nor TRICARE for Life will guarantee payment up-front, so you must pay for the claim through some other means (like, out-of-pocket), and then file a claim afterwards for reimbursement. Reimbursement generally starts at about 75 percent of the claimed amount, and there are small annual deductibles involved. If you submit multiple claims, you’ll gradually begin to get closer to your annual “catastrophic cap,” at which point the percentage of reimbursement begins to creep up. If you have a sufficient number of claims, I believe you could eventually receive close to 100 percent of a given claim.
Note: Unless you find a very good facilitator who can find just the right person in the office that issues Ecuadorian visas, you generally cannot use TRICARE to fulfill the insurance requirements associated with obtaining a visa or cédula. I’m only aware of one case where TRICARE was accepted for that purpose, and according to the facilitator, it was a fluke.
Other Health Insurance (OHI)
Do you have another private insurer here in Ecuador or in the U.S.? If so, when you file a claim, there is a space to list all the information required on the claim form, and you also have to show what the OHI paid toward the current claim. If they paid nothing (say, because it was for a pre-existing condition), then TOS would become the primary payer. But by law, OHI must pay first, then TRICARE will usually cover all or part of the amount that OHI declined to pay.
As for IESS, that’s not actually considered “insurance.” There are medical benefits involved, but I spoke to a claims representative at TOS once, explained to him in detail how IESS was simply part of the Ecuadorian Social Security system, that it does include a health care system, but that there are were no claims forms, no specific fees to pay for medical treatment, no claim system to speak of, and no reimbursements for outside care or meds, etc. It took him all of five seconds to tell me that they would not consider IESS as Other Health Insurance, and that I should not fill out that portion of the claim form or make any reference to IESS.
Eligibility Requirements
To use your TOS or TFL, you must be TRICARE-Eligible, and your family members must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS) in order to use TRICARE. If you retired from the military, you and your family members should already be in DEERS, and you shouldn’t have to re-enroll anyone unless you get married or remarry.
If you marry a foreign-born national, to-date I’ve personally found it impossible to get them into DEERS or otherwise qualified to use my TRICARE. One thing that’s required is a Social Security Number (SSN), and they don’t just hand those out to foreign-born spouses unless they live in the U.S. and have been working there for a while. I won’t go into deep detail on this aspect because there may have been some changes since the last time I tried. But I did try a couple of times, and I was told that they had to have a SSN. If any of you find out differently, please let the rest of us know!
One thing you do not need with either TOS or TFL is to be assigned to a Primary Care Manager (PCM), nor do you need referrals from a general practitioner (GP) to see the provider or specialist of your choice. Just make sure it’s a real doctor! To a large extent, TOS has put those of us who live abroad on the “honor system” – but not without caveats. Filing a claim is relatively simple, but there are some quirky things they don’t tell you about the first time you file. I’ll cover some of those after I go over TRICARE for Life, because, for our purposes, the process is identical.
One cool bonus about TRICARE Overseas is that it’s not only for use overseas; if you’re back in the U.S. for some reason, TOS is still your insurer, and you can use it for any otherwise TRICARE-authorized medical care or prescriptions. You simply have to be based overseas and have that as your home address.
Apart from what I include below, the way you file claims with TRICARE for Life and TRICARE Overseas are virtually identical, and you use the exact same site and login.
As I mentioned above, there is a small monthly premium for TRICARE Overseas. But for TRICARE for Life, there is no premium involved; as long as you’re already in DEERS, your enrollment in TFL is automatic once you turn 65.
The “gotcha!” is that you can’t use TFL unless you currently have and are maintaining Medicare Parts A and B. Many expats living here have either declined to sign up for Part B, or they’ve since canceled it. It is a chunk of change, to be sure, but if you cancel it or wait too long to sign up, they essentially penalize you, and you will be charged more for Part B than you if you’d signed up for it when first eligible. I believe my Medicare Part B is between $150 – 160 per month. But if I were to be hospitalized and/or have surgery just one time in a given year, then the Part B fee would easily pay for itself. For something truly catastrophic, it becomes even more valuable. Again, like TFL, you have to pay your local medical bill first, then submit a claim for reimbursement.
The Other Health Insurance (OHI) mentioned above applies with TFL, too, and if you have OHI, they are the primary payer when you’re living abroad. But if you go back to the U.S., things are a little different with TFL. Mainly, Medicare is who you would be dealing with, and they would be the primary payer for any claims within the boundaries of the U.S. Then, after Medicare pays their share, TRICARE for Life kicks in and covers most or all of the remaining balance. But since Medicare doesn’t pay for anything outside of the U.S., TFL becomes the default primary payer, and you don’t even need to think about Medicare if you’re filing a claim from Ecuador.
And that’s about it for TFL and TOS, with the exception of getting into the claims process. First you’ll need to go to the Tricare Overseas site and create a logon. To register or log in to the TRICARE Overseas site, please click here.
Filing Claims with TRICARE for Life and TRICARE Overseas
The very first thing you’ll want to do after successfully creating a logon is to set up your Direct Deposit! If you don’t, and you submit a claim that gets approved, they’re going to try to send a check to Ecuador, and we already know that that doesn’t work! So set up your direct deposit with a U.S. bank immediately, before filing a single claim. In fact, you may want to wait the 10 – 12 days it takes for your Direct Deposit to be approved before filing any claims. If you forget to set up your Direct Deposit and they do cut a check for you, you can still go in later, set up the Direct Deposit, and once it’s approved, TRICARE can cancel payment on the check and send the money to your bank, but there will be a delay of about two extra weeks to get your money.
The next thing you’ll want to do if you’re ready to file a claim is to click on the specific link for that, and follow the prompts to download the claim form. You can fill it out online, or you can print it out and fill it out by hand. I personally recommend filling it out online and saving it where you can find it to proceed with the filing process. Just tell your printer-dialogue box to “Print to PDF,” and it will save the document as a PDF in the folder you specify. I highly recommend creating a separate computer folder to house each individual claim and all associated paperwork.
Time Frame for Filing Claims
Both TFL and TOS will allow you to submit claims that are up to three years old! Of course you may not have the necessary paperwork if you’ve waited that long, but if you save everything, you might be able to pull it off. But trust me – it’s best if you file your claims as soon as you get the facturas together, because the longer you wait, the more difficult and confusing it can be. Paperwork can get separated, or missing paperwork can become difficult (or impossible) to obtain.
Requirements & Other Quirks Associated with Filing Claims
There are a lot of things they don’t tell you before you file your first claim. If you don’t follow these guidelines, they’ll just keep kicking it back to you until you’ve given them everything they want. The following may not be a complete list, nor is it intended to be. I’m simply sharing my experiences with you, and yours may vary. But here are some things I know they want with each claim:
- If you’re filing a claim that’s associated with a hospital stay, you’ll need to go to the administrative department a few days or a week after you’re released from the hospital and ask them for a full and complete copy of your “epicrisis,” to include any detailed doctors notes and his/her fees. An epicrisis is a clinical summary of a hospitalization, or of a detailed outpatient visit that’s more involved than a routine doctor’s appointment, e.g., you may need a nerve-block that requires a short visit to an operating room. The epcrisis will be in Spanish, of course, but that’s fine – TRICARE has their own translators.
- If you’ve just been to see a doctor, you need to work with that doctor and/or their secretary to obtain a proper factura, which is simply a detailed receipt. Here are the things TRICARE looks for on a factura:
- The date(s) of service, name, address, and phone number of the provider, along with their professional title to indicate what type of doctor they are, e.g., gastroenterólogo or medicina general. If any of those items are missing, just write them legibly on the same factura, or include any missing information on a separate sheet as part of your claim-submission package.
Now, I’ve submitted facturas that had all the correct information on them, and about half of the time they kick the claim back because they don’t recognize the address as an address, or they can’t find the phone number, etc. You usually find out about any perceived problems with your claim when you receive an email, telling you that the website has a new message for you. To read your messages, you need to log in, read the message, and then you submit any additional information requested. I think that the next one I do, I’m just going to go ahead and type up the doctors’ names, addresses, phone numbers, and specialties in English, then submit that information with the rest of the package.
For yourself, you mainly need - The actual reason for the visit. More often than not, they will usually write “consulta médica” (medical consult). You have to tell them that that’s not sufficient information for your insurance, and that you need the actual reason for your visit included on the factura, e.g., twisted ankle, gallbladder attack, chest pains, etc. They can also put the international diagnostic code on it, which is always helpful, but not absolutely necessary. All you really need is just a few words stating the reason for the doctor’s visit has always worked for me. Sometimes the doctor will write the reason on the factura, or sometimes the doctor will have the secretary do it. However you get it, you do need it!
- The amount they charged, and the amount you paid.
- If your bill is more than a few hundred dollars, TRICARE wants to know how you paid for it! This is due to fears about unscrupulous members who either file bogus claims, or those who might potentially be involved in money-laundering schemes. So what you need to do is withdraw the money from an ATM, then keep all the ATM slips to show that the money you spent came out of your account (and that you’re not in cahoots with some local hospital to rip off TRICARE). Or if you use a debit or credit card to pay the bill, you could probably use a printed statement from your account. When I had the $10,000 balance at Hospital Monte Sinaí, I actually had to borrow the money first, then put it in my bank account; immediately after the deposit, I had to get a bank check that was drawn on my account and made out to the hospital, a copy of which I sent along with my claim.
- If you have separate receipts for the hospital and the doctor, or for the doctor and any additional exams you paid for (such as X-rays, a CT scan, etc.), those should normally be submitted as separate claims. If the two claims are inextricably connected, you can sometimes get away with combining more than one reimbursement request in a single claim. I can’t really give you a good example here, but the help line for Tricare Overseas is usually pretty “helpful,” and because their mission is relatively limited compared to the rest of TRICARE, phone calls typically get answered quickly. I use my Magic Jack and call the US help humber, but there’s also an international number. If you look for the “Contact Us” link on the website, it will ask you to select your overseas country for the correct phone number to call.
- If your bill is more than a few hundred dollars, TRICARE wants to know how you paid for it! This is due to fears about unscrupulous members who either file bogus claims, or those who might potentially be involved in money-laundering schemes. So what you need to do is withdraw the money from an ATM, then keep all the ATM slips to show that the money you spent came out of your account (and that you’re not in cahoots with some local hospital to rip off TRICARE). Or if you use a debit or credit card to pay the bill, you could probably use a printed statement from your account. When I had the $10,000 balance at Hospital Monte Sinaí, I actually had to borrow the money first, then put it in my bank account; immediately after the deposit, I had to get a bank check that was drawn on my account and made out to the hospital, a copy of which I sent along with my claim.
- TRICARE wants your entire claim submission all in a single PDF document, and all documents must be in black-and-white or gray-scale. Here’s how I put my packages together:
- I use my scanner to scan all documents, save them in JPG format, and then pull them into MS Word, starting with the claim form, and then adding each additional item in order of relative importance.
- If any of the objects you put in your document are in color, you can go to the “Format” menu, choose “Picture Color,” and then select one of the grayscale options. (Just make sure the option you choose leaves the item legible.)
- Once I have all my documents and supporting paperwork imported into MS Word, I choose Word’s “File / Export” function, which will render the file into a PDF. That’s the version you want to upload to Tricare, which is pretty simple – just follow the prompts in the website, and you can upload the document directly to them.
- I use my scanner to scan all documents, save them in JPG format, and then pull them into MS Word, starting with the claim form, and then adding each additional item in order of relative importance.
- Once your claim is uploaded, keep an eye on your email, and also check the claims portal website periodically for messages, requesting clarification or additional information. But if they do ask for more information, only send what has been requested – they do not want you to upload the entire claim package again.
- The site says they have up to 90 days to process and reimburse a claim. I’ve personally found that the simpler the claim (like a single doctor’s appointment) gets reimbursed relatively quickly, whereas the claim for more extensive medical services and hospitalization can take the full 90 days. If you find that you’re getting close to the processing-time limit and they haven’t deposited your money yet, don’t hesitate to send them a message through the website, or to call them directly to make an inquiry.
This is the process in a nutshell. As government processes do change and evolve, I’ve not included things here like claim forms (which are very straightforward) or some of the various procedural issues that may come up with complicated claims. Again, for guidance that goes beyond what I’ve included above, contact the Tricare Overseas
The VA Foreign Medical Program & the New Clinic in Cuenca
For those veterans who have service-connected medical conditions that have been rated by the VA at a certain percentage (even “zero” percent is acceptable, as long as it’s recognized as a service-connected condition), the Foreign Medical Program (FMP) will soon become much easier to use right here in Cuenca. The FMP has actually been around for some time, and has been available to veterans living abroad to pay for the treatment of qualifying medical conditions. Like Tricare Overseas, you usually have to pay for the medical care up-front, then wait for a reimbursement from the VA. But we’re not going to discuss the process for filing a claim in this article, because Cuenca will soon have its own clinic up and running that will accept your VA benefits without you having to file an FMP claim directly with the VA.
The clinic in Cuenca will be opening very soon, right after they finish dealing with a bit of remaining “red tape.” The clinic is privately owned and operated by Health Care Alliance Global. They started over 20 years ago in Panama, and have expanded throughout Panama and Colombia; this will be the first one opening in Ecuador. They will be providing care directly to qualifying veterans living in Ecuador, once they sign up for their services. It’s located on Gran Colombia and Unidad Nacional, just two doors down from the Fybeca Pharmacy on one side, and then about a quarter-block from the restaurant Common Grounds if looking in the other direction.
This clinic will be staffed by a primary care doctor, a mental health specialist, a general manager and an administrative assistant. They are also hoping to add a physical therapist soon. They will be able to cover the cost of things like imaging studies as well – but you’ll need to check with the Veterans Service Officer (VSO), who is an expat and a veteran who works out of the same HCA office. His contact information is as follows (shared with permission):
VSO: Mark Tomlinson
Phone/WhatsApp: +593 99 215 2108
In order to get the ball rolling and be ready to use the clinic when it opens, you’ll need to obtain and provide the VSO with a copy of your DD-214 (military discharge document), plus a copy of your full disability breakdown letter that shows all of your service-connected disabilities and the percentage awarded for each. You can obtain a copy of your DD-214 via an online service; it’s a little cumbersome, but it works. For the disability breakdown letter, you’ll need to call the VA directly and request that. Keep in mind that this is the breakdown document that lists each service-connected condition individually, plus the percentage of disability awarded for each condition – it is not the basic “award letter” that only shows your overall combined disability rating, but the one that lists each condition individually. Once you have these documents and a copy of either your cédula or passport, call Mark and make an appointment to visit him in his office. There are a few more documents he will have you fill out, and the process will be started to get you enrolled into the Foreign Medical Program and into the HCA database. From there, the Admin Assistant will start working with you to get your first screening appointment with the doctor.
You Don’t Have Any Service-Connected Disabilities?
It’s never too late to file a claim if you have qualifying issues that the VA might rate as a disability. First of all, “service-connected” does not necessarily mean that the condition was directly related to your military duties, but rather, it could apply to any injury or illness that came about while on active duty. For instance, one of my rated conditions is for “fibromyalgia,” which had nothing to do with my job in the military – I just happened to be in the military when I developed the condition. When I was just about to retire from the Air Force, another military member from the base hospital interviewed me as we went through my medical records, and we used those findings as the basis for my disability claim. But some things were missed, so I’m actually in the process of putting together a new claim for those items, and a few “secondary conditions” (mentioned below).
Many vets never had someone help them with this process, and, as such, have gone uncompensated for decades for things that might have qualified for disability compensation. Were you exposed to Agent Orange? Did you tear up a knee while parachuting? Did you have (and do you still have) migraines or other illnesses or conditions that can be found mentioned in your active-duty medical records? Tinnitus? Torn rotator cuff? Cancer? Surgeries? Of course it will depend on what it says in your records and in any other supporting documentation you may have, but all of these sorts of things (and more) can be rated as service-connected under the right circumstances. The only way to know for sure is to file, and VSO Tomlinson is more than happy to assist you with that process.
Secondary Conditions
Even if you’ve already been rated for a given condition, that condition may have led to some other condition(s) that only exists because of the primary condition. This is merely an example, but let’s say you developed diabetes in the military, and you were service-connected for that condition. However, later down the road you may have developed any number of additional health problems that only exist because of the same diabetes you were diagnosed with while on active duty. Those new conditions (say, something like peripheral neuropathy or vision problems) that can be directly tied to your diabetes may qualify as “secondary conditions” that could boost your overall disability rating. Again, the only way you’ll ever know is to apply!
NOTE: If you qualify for both TRICARE and the FMP, you can choose whichever one you wish to use. For VA-awarded service-connected conditions, you’ll probably want to stick with the HCA clinic. For everything else, I’d recommend using whichever TRICARE plan you might qualify for.
What About CHAMPVA?
CHAMPVA is a program that benefits qualified family members of veterans who were rated as 100 percent “permanently and totally” disabled. For vets who have been rated as such, they can apply for CHAMPVA following instructions on the Veterans Administration website. Once CHAMPVA has been established for a given vet, his or her qualifying family members may use it here in Ecuador to cover any medical condition that they might be treated for in the U.S. It is important to note that the family member must pay for the treatment up-front, and then file a claim with the VA after the fact. As I have no experience with filing CHAMPVA claims, your best bet would be to check the VA website, or call the main customer-service line at 1-800-827-1000.
Remember that CHAMPVA is only for family members. Also, be aware that TRICARE-eligible family members do not qualify for CHAMPVA; if they qualify for TRICARE, then that’s what they must use if they seek healthcare overseas. The two programs are mutually exclusive, so family members can only use one or the other.
The 100 percent P&T veteran is still limited to whatever the VA Foreign Medical Program will pay for, and those conditions can be found on your disability breakdown letter. However, if the vet is also TRICARE-eligible, then it’s possible to use either or both programs. To use them both, it’s important that you coordinate with both agencies and determine how to submit the claim forms properly and maximize your reimbursement amount.
Wrapping it Up
It may not always be convenient, and having to pay up-front for future TRICARE claims is a bit of a pain, but hey – you earned the benefit, so why not use it? As for the FMP, that should all be pretty seamless and easy to use once you’ve provided all the necessary information and the new clinic is open.
One place where you can keep up with any new developments for the HCA clinic is by joining my group, Military Veterans in Ecuador. Also, from one vet to another, I would also like to invite you to join my general Expat group, Expats Without Agendas – Ecuador. We’re a friendly group that’s always ready and willing to help out other expats with any number of issues that you may encounter here in Ecuador.
