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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Beneficiary Liability
Chapter 2
Addendum A
Benefits And Beneficiary Payments Under The TRICARE Program For Services Received Prior To January 1, 2018; And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries
Revision:  C-22, June 15, 2018
This addendum applies to services received before January 1, 2018. It also applies to services received on or after January 1, 2018 by TFL beneficiaries and other beneficiaries as specified in Section 2. For all other beneficiaries receiving services on or after January 1, 2018, see Section 2 and the Defense Health Agency (DHA) web site at http://www.health.mil/rates for enrollment fees, deductibles, and cost-shares for dates of service on or after January 1, 2018. Beneficiary copayments (i.e., beneficiary payments expressed as a specified amount) and enrollment fees may be updated for inflation annually (cumulative effect applied and rounded to the nearest whole dollar) by the national Urban Consumer Price Index (CPI-U) medical index (the medical component of the CPI-U). Beneficiary cost-shares (i.e., beneficiary payments expressed as a percentage of the provider’s fee) will not be similarly updated.
These charts are not intended to be a comprehensive listing of all services covered under TRICARE. All care is subject to review for medical necessity and appropriateness:
1.0  TRICARE PRIME PROGRAM ANNUAL ENROLLMENT FEES
Does not apply to the TRICARE Extra Program (also see paragraph 5.0, “Point of Service (POS) Option”):
TRICARE Prime Program
EFFECTIVE DATE OF FEES
ACTIVE DUTY FAMILY MEMBERS (ADFMs)
Retirees, Their Family Members, Eligible Former Spouses, & Survivors
E1 - E4
E5 & Above
FY 1996 - FY 2011
None
None
$230 per Retiree or Family Member
$460 Maximum per Family
FY 2012
None
None
$260 per Retiree or Family Member
$520 Maximum per Family
FY 2013
None
None
$269.28 per Retiree or Family Member
$538.56 Maximum per Family
FY 2014
None
None
$273.84 per Retiree or Family Member
$547.68 Maximum per Family
FY 2015
None
None
$277.92 per Retiree or Family Member
$555.84 Maximum per Family
FY 2016 - December 31, 2017
None
None
$282.60 per Retiree or Family Member
$565.20 Maximum per Family
EXCEPTIONS:
1.  Effective March 26, 1998, the enrollment fee is waived for those beneficiaries who are eligible for Medicare on the basis of disability or end stage renal disease and who maintain enrollment in Part B of Medicare.
2.  Effective Fiscal Year (FY) 2012, beneficiaries who are (1) survivors of active duty deceased sponsors, or (2) medically retired Uniformed Services members and their dependents, shall have their Prime enrollment fees frozen at the rate in effect when classified and enrolled in a fee paying Prime plan. (This does not include TRICARE Young Adult (TYA) plans). Beneficiaries in these two categories who were enrolled in FY 2011 will continue paying the FY 2011 rate. The beneficiaries who become eligible in either category and enroll during FY 2012, or in any future fiscal year, shall have their fee frozen at the rate in effect at the time of enrollment in Prime. The fee for these beneficiaries shall remain frozen as long as at least one family member remains enrolled in Prime. The fee for the dependent(s) of a medically retired Uniformed Services member shall not change if the dependent(s) is later re-classified a survivor.
2.0  TRICARE standard and EXTRA PROGRAM ANNUAL FISCAL YEAR DEDUCTIBLE
Applies to all outpatient services, does not apply to the TRICARE Prime Program (also see paragraph 5.0, “POS Option”):
TRICARE Standard and Extra Program
ADFMs
Retirees, Their Family Members, & Survivors
E1 - E4
E5 & Above
$50 per Individual
$100 Maximum per Family
$150 per Individual
$300 Maximum per Family
$150 per Individual
$300 Maximum per Family
3.0  OUTPATIENT SERVICES
Beneficiary Copayment/Cost-Share (See POS Option) (See Note 4)
TRICARE Benefits
TRICARE Prime Program (See Note 1)
TRICARE Extra Program
TRICARE Standard Program
Type Of Service
ADFMs
Retirees, Their Family Members, & Survivors
E1 - E4
E5 & Above
INDIVIDUAL PROVIDER SERVICES
Office visits; urgent care; outpatient office-based medical and surgical care; consultation, diagnosis and treatment by a specialist; allergy tests and treatment; osteopathic manipulation; medical supplies used within the office including casts, dressings, and splints.
$0 copayment per visit.
$0 copayment per visit.
$12 copayment per visit.
ADFMs:
Cost-share--15% of the fee negotiated by the contractor.
Retirees, their Family Members, & Survivors:
Cost-share--20% of the fee negotiated by the contractor.
ADFMs:
Cost-share--20% of the allowable charge.
Retirees, their Family Members, & Survivors:
Cost-share--25% of the allowable charge.
OUTPATIENT HOSPITAL DEPARTMENTS
Clinics visits; urgent care; therapy visits; medical supplies; consultations; treatment room; etc.
Note: Use other parts of this table for cost-sharing of ASC services, ER services, DME, etc.
$0 copayment per visit.
$0 copayment per visit.
$12 copayment per visit.
No separate copayment/cost-share for separately billed professional charges.
ADFMs:
Cost-share--15% of the fee negotiated by the contractor.
Retirees, their Family Members, & Survivors:
Cost-share--20% of the fee negotiated by the contractor.
ADFMs:
Cost-share--20% of the allowable charge.
Retirees, their Family Members, & Survivors:
Cost-share--25% of the allowable charge.
ANCILLARY SERVICES
Refer to Section 1 for specific services considered as ancillary services.
$0 copayment per visit.
$0 copayment per visit.
No copayment (see Note 3).
OTHER RADIOLOGY SERVICES
Not considered as ancillary services.
$0 copayment per visit.
$0 copayment per visit.
$12 copayment per visit.
ROUTINE PAP SMEARS
Frequency to depend on physician recommendations based on the published guidelines of the American Academy of Obstetrics and Gynecology (see Note 1).
No copayment.
No copayment.
No copayment.
$0 cost-share.
$0 cost-share.
AMBULANCE SERVICES
When medically necessary as defined in the TRICARE Policy Manual (TPM) and the service is a covered benefit.
$0 copayment per visit.
$0 copayment per visit.
$20 copayment per occurrence.
ADFMs:
Cost-share--15% of the fee negotiated by contractor.
Retirees, their Family Members, & Survivors:
Cost-share--20% of the fee negotiated by the contractor.
ADFMs:
Cost-share--20% of the allowable charge.
Retirees, their Family Members, & Survivors:
Cost-share--25% of the allowable charge.
EMERGENCY SERVICES
Emergency care obtained on an outpatient basis, both network and non-network, and in and out of the Region.
$0 copayment per visit.
$0 copayment per visit.
$30 copayment per emergency room visit.
DME, HEARING AIDS FOR ADFMs, AND MEDICAL SUPPLIES PRESCRIBED BY AN AUTHORIZED PROVIDER WHICH ARE COVERED BENEFITS
(If dispensed for use outside of the office or after the home visit.)
$0 copayment per visit.
$0 copayment per visit.
Cost-share - 20% of the fee negotiated by the contractor.
HOME HEALTH CARE
Part-time or intermittent skilled nursing and home health aide services, physical, speech, & occupational therapy, medical social services, routine and non-routine medical services.
Note: DME, osteoporosis drugs, pneumoccocal pneumonia, influenza virus and hepatitis B vaccines, oral cancer drugs, antiemetic drugs, orthotics, prosthetics, enteral and parenteral nutritional therapy and drugs/biologicals administered by other than oral methods are services that can be paid in addition to the prospective payment amount subject to applicable copayment/cost-sharing and deductible amounts.
$0 copayment.
$0 copayment.
$0 copayment.
$0 cost-share.
$0 cost-share.
HOSPICE CARE
Note: A separate cost-share may be (optional) collected by the individual hospice for outpatient drugs and biologicals and inpatient respite care.
$0 copayment.
$0 copayment.
$0 copayment.
$0 cost-share.
$0 cost-share.
WELL CHILD CARE
Up to the age of six.
$0 copayment per visit.
$0 copayment per visit.
$0 copayment per visit.
FAMILY HEALTH SERVICES
Family planning. The exclusions listed in the TPM will apply.
$0 copayment per visit.
$0 copayment per visit.
$12 copayment per visit (see Note 1).
ADFMs:
Cost-share--15% of the fee negotiated by contractor.
Retirees, their Family Members, & Survivors:
Cost-share--20% of the fee negotiated by the contractor.
ADFMs:
Cost-share--20% of the allowable charge (see Note 10).
Retirees, their Family Members, & Survivors:
Cost-share--25% of the allowable charge.
OUTPATIENT MENTAL HEALTH TO INCLUDE HOME CARE, PARTIAL HOSPITALIZATION, INTENSIVE OUTPATIENT PROGRAMS (IOPs), AND OPIOD TREATMENT PROGRAMS (OTPs)
$0 copayment per visit.
$0 copayment per visit.
$12 copayment for visits (see Note 2).
AMBULATORY SURGERY (same day)
Authorized hospital-based or freestanding Ambulatory Surgical Center (ASC) that is TRICARE certified.
$0 copayment per visit.
$0 copayment per visit.
$25 copayment.
ADFMs:
Cost-share--$25. for ASC.
Retirees, their Family Members, & Survivors:
Cost-share--20% of the fee negotiated by the contractor.
ADFMs:
$25.
Retirees, their Family Members, & Survivors: Lesser of 25% of group rate or 25% of billed charge.
ALL SURGICAL PROCEDURES REGARDLESS OF WHERE THEY ARE PERFORMED
With the exclusion of those surgical procedures referenced Section 1, paragraphs 1.2.4.5 and 1.2.4.7.
BIRTHING CENTER
Prenatal care, outpatient delivery, and postnatal care provided by TRICARE authorized birthing center.
IMMUNIZATIONS
Immunizations required for active duty family members whose sponsors have permanent change of station orders to overseas locations.
Note: Immunizations provided in accordance with TPM, Chapter 7, Sections 2.1, 2.2, and 2.5 are also covered as a clinical preventive service (see below).
$0 copayment per visit.
$0 copayment per visit.
N/A
ADFMs:
N/A.
Retirees, their Family Members, & Survivors:
N/A.
ADFMs:
N/A.
Retirees, their Family Members, & Survivors:
N/A.
EYE EXAMINATIONS (See Note 5)
One routine examination per year for family members of active duty sponsors.
Note: Routine eye examinations once every two years provided in accordance with TPM, Chapter 7, Section 2.2, are covered as a clinical preventive service (see below) for Prime enrollees.
$0 copayment per visit.
$0 copayment per visit.
N/A
ADFMs:
N/A.
Retirees, their Family Members, & Survivors:
N/A.
ADFMs:
N/A.
Retirees, their Family Members, & Survivors:
N/A.
CLINICAL PREVENTIVE SERVICES
Includes those services listed in the TPM, Chapter 7, Sections 2.1, 2.2, and 2.5.
$0 copayment.
$0 copayment.
$0 copayment.
ADFMs:
N/A.
Retirees, their Family Members, & Survivors:
N/A.
ADFMs:
N/A.
Retirees, their Family Members, & Survivors:
N/A.
4.0  INPATIENT SERVICES
Beneficiary Copayment/Cost-Share (see note 4)
TRICARE Benefits
TRICARE Prime Program
TRICARE Extra Program
TRICARE Standard Program
Type Of Service
ADFMs
Retirees, Their Family Members, & Survivors
HOSPITALIZATION
Semiprivate room (and when medically necessary, special care units), general nursing, and hospital service. Includes inpatient physician and their surgical services, meals including special diets, drugs and medications while an inpatient, operating and recovery room, anesthesia, laboratory tests, x-ray and other radiology services, necessary medical supplies and appliances, blood and blood products.
$0 copayment per visit.
$11 per diem charge ($25 minimum charge per admission).
No separate copayment/cost-share for separately billed professional charges.
ADFMs:
Per diem charge ($25 minimum charge per admission). No separate cost-share for separately billed professional charges.
Retirees, their Family Members, & Survivors:
$250 per diem copayment or 25% cost-share of total charges (based on the fee schedule negotiated by the contractor), whichever is less, for institutional services, whichever is less, plus 20% cost-share of separately billed professional charges (based on the fee schedule negotiated by the contractor).
ADFMs:
Per diem charge ($25 minimum charge per admission). No separate cost-share for separately billed professional charges.
Retirees, their Family Members, & Survivors:
DRG per diem copayment or 25% cost-share of billed charges for institutional services, whichever is less, plus 25% cost-share of allowable for separately billed professional charges.
MATERNITY
Hospital and professional services (prenatal, delivery, postnatal).
NEWBORN/ADOPTEE CARE (See Note 6)
Hospital and professional services.
$0 copayment.
No separate copayment/cost-share for separately billed professional charges.
Same newborn date of birth and date of admission:
$11 per day ($25 minimum charge) applies to the fourth and subsequent days of the newborn’s inpatient stay.
ADFMs:
$0 as newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes. No separate cost-share for separately billed professional charges.
ADFMs:
$0 as newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes. No separate cost-share for separately billed professional charges.
Different newborn date of birth and date of admission:
$11 per day ($25 minimum charge) applies to all days of the newborn’s inpatient stay.
Retirees, their Family Members, & Survivors:
Same newborn date of birth and date of admission:
Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus three multiplied by $250 OR 25% of TRICARE contractor negotiated charges for institutional services, plus 20% cost-share of separately billed contractor negotiated professional charges.
Different newborn date of birth and date of admission:
Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by $250 or 25% of TRICARE contractor negotiated charges for institutional services, plus 20% cost-share of separately billed contractor negotiated professional charges.
Retirees, their Family Members, & Survivors:
DRG Hospital: Same newborn date of birth and date of admission:
Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus three multiplied by DRG per diem copayment OR 25% of billed charges for institutional services, plus 25% cost-share of allowable separately billed professional charges.
Different newborn date of birth and date of admission:
Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by DRG per diem copayment OR 25% of billed charges for institutional services, plus 25% cost-share of allowable separately billed professional charges.
DRG Exempt Hospital:
Unless the newborn is deemed enrolled in Prime, the cost-share will be 25% of allowed charges for institutional services, plus 25% cost-share of allowable separately billed professional charges.
SKILLED NURSING FACILITY (SNF) CARE
Same benefit as Medicare except that there is no limitation to the number of days of coverage. Benefit includes semiprivate room, regular nursing services, meals including special diets, physical, occupational and speech therapy, drugs furnished by the facility, necessary medical supplies, and appliances.
$0 copayment per visit.
$11 per diem charge ($25 minimum charge per admission).
No separate copayment/cost-share for separately billed professional charges.
ADFMs:
Per diem charge ($25 minimum charge per admission).
Retirees, their Family Members, & Survivors:
$250 per diem copayment or 20% cost-share of total charges (based on the fee schedule negotiated by the contractor), whichever is less, for institutional services, plus 20% cost-share of separately billed professional charges (based on the fee schedule negotiated by the contractor).
ADFMs:
Per diem charge ($25 minimum charge per admission).
Retirees, their Family Members, & Survivors:
25% cost-share of allowed charges for institutional services, plus 25% cost-share of allowable for separately billed professional charges.
FOR MENTAL HEALTH TREATMENT
Including residential treatment for children and adolescents (See Note 8).
$0 copayment per visit.
$11 per diem charge ($25 minimum charge per admission).
No separate copayment/cost-share for separately billed professional charges.
See Note 9.
ADFMs:
Per diem charge ($25 minimum charge per admission). No separate cost-share for separately billed professional charges.
Retirees, their Family Members, & Survivors:
Cost-share--20% of total charges (based on the fee schedule negotiated by the contractor) for institutional services, plus 20% cost-share of separately billed professional charges (based on the fee schedule negotiated by the contractor).
ADFMs:
$20 per diem charge ($25 minimum charge per admission). No separate cost-share for separately billed professional charges.
Retirees, their Family Members, & Survivors:
Inpatient High Volume Hospital: Cost-share--25% hospital specific per diem.
Inpatient Low Volume Hospital:
Lower of fixed daily amount or 25% hospital billed charges.
RTC:
Cost-share--25% of the TRICARE allowed amount.
INPATIENT SUBSTANCE USE TREATMENT
5.0  POINT OF SERVICE (POS)
Beneficiary Copayment/Cost-Share (See Note 4)
TRICARE Benefits
TRICARE Prime Program
TRICARE Extra Program
TRICARE Standard Program
Type Of Service
ADFMs
Retirees, Their Family Members, & Survivors
A Prime enrollee may receive services under the Point of Service option by self-referring for non-emergency care. Refer to Section 5, for policy on the POS option.
Outpatient Deductible:
$300.00 individual $600.00 family.
Inpatient and Outpatient Cost-Share:
50% of the allowed charges (see Note 7).
Outpatient Deductible:
$300.00 individual $600.00 family.
Inpatient and Outpatient Cost-Share:
50% of the allowed charges (see Note 7).
POS option does NOT apply to TRICARE Extra beneficiaries.
POS option does NOT apply to TRICARE Standard beneficiaries.
Refer to Sections 2 and 3 for information on catastrophic loss protection.
Note 1:  As indicated in the TPM, Chapter 7, Section 2.2, there are no copayments associated with covered preventive services for TRICARE Prime beneficiaries. Effective for dates of service on or after October 14, 2008, cost-shares are eliminated for certain preventive services for TRICARE Standard and Extra beneficiaries, as described in Section 1, paragraphs 1.3.3.10 and 1.4.3. Effective January 1, 2017, cost-shares are eliminated for the services listed in the TPM, Chapter 7, Section 2.1, paragraphs 1.1.1.1.2 and 1.1.5.1 through 1.1.5.12. Effective January 1, 2018, cost-shares are eliminated for the services listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1.5.13.
Note 2:  For services rendered prior to October 3, 2016, Prime retirees, their family members, and survivors are subject to a $25 copayment for individual visits and a $17 copayment for group visits. For services rendered on or after October 3, 2016, a $12 copayment per visit applies (the $12 copayment is applied per day of services for Partial Hospitalization Program (PHP) or IOP services). For methadone OTPs, cost-sharing is on a weekly basis (e.g., for Prime retirees, only one $12 cost-share will be assessed per week of OTP treatment). See Chapter 7, Section 5.
Note 3:  For dates of service on or after March 26, 1998, under TRICARE Prime, services defined as “ancillary services” in Section 1 require no copayment.
Note 4:  An eligible former spouse is responsible for payment of copayment/cost-sharing amounts identical to those required for beneficiaries other than family members of active duty members.
Note 5:  Eye examinations are covered under the TRICARE Prime Program’s “clinical preventive services”. See the TPM, Chapter 7, Section 2.2.
Note 6:  The Director, TRICARE Regional Offices (TROs) and the Director of each TRICARE Area Office (TAO) shall be granted the authority to extend the deemed period up to 120 days, on a case-by-case or regional basis.
Note 7:  TRICARE reimbursement will be limited to 50% of the billed/allowed charges.
Note 8:  For dates of service prior to October 3, 2016, PHPs are cost-shared as inpatient services, and the same cost-sharing requirements as those for inpatient admissions for mental health treatment apply.
Note 9:  For dates of service prior to October 3, 2016, Prime retirees, dependents, and survivors are subject to a $40 per diem charge, with no separate copayment/cost-share for separately billed professional charges. For dates of service prior to October 3, 2016, these cost-sharing requirements also apply to PHP.
Note 10:  For dates of service prior to October 3, 2016, TRICARE Standard ADFMs are subject to a $20 per diem charge ($25 minimum charge per admission). For dates of service prior to October 3, 2016, PHP care is cost-shared on an inpatient basis. The cost-share for PHP is 25% of the TRICARE allowed amount, plus 25% cost-share of allowable charges for separately billed professional charges.
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