Military Health System

Double coverage consists of medical benefits coverage by both TRICARE and another medical/hospital insurance, medical service, or health plan (with the exception of Medicaid and certain other programs identified by Defense Health Agency (DHA), e.g., the Indian Health Service (IHS) and State Victims Assistance Plans). Prior to payment of any claim for services or supplies rendered to any TRICARE beneficiary, regardless of eligibility status, it must be determined whether other coverage exists. If other coverage exists, TRICARE coverage is available only as secondary payer, and only after a claim has been filed with the other plan and a payment determination issued. This must be done regardless of any provisions contained in the other coverage. For example, a dependent child who is eligible for TRICARE through his/her natural parent may also be eligible for some other coverage through a step-parent. The step-parent’s coverage is primary payer, regardless of any provision in that coverage which provides that the natural parent’s coverage is primary. A contractor shall coordinate benefits and obtain the information regarding the other insurance payment to determine what the TRICARE liability is to assure that:

Except for certain situations in which Medicare is the primary payer (see Section 4, paragraph 1.0), no more can be paid as secondary payer than would have been paid in the absence of other coverage. TRICARE, as secondary payor, cannot reimburse charges for any services or supplies which are not otherwise covered under the program. TRICARE benefits cannot be paid for services received prior to TRICARE eligibility. The application of double coverage provisions does not extend or add to the usual payment amounts under TRICARE.

Amounts which have been denied by the other coverage simply because the claim was not filed timely with the other coverage or because the beneficiary failed to meet some other requirement of coverage cannot be paid. If a statement from the other coverage as to how much would have been paid had the claim met the other coverage’s requirements is provided to the contractor, the claim can be processed as if the other coverage actually paid the amount shown on the statement. If no such statement is received, the claim is to be denied.

Beneficiaries may not waive benefits due from any plan which meets the above definitions. If a double coverage plan provides, or may provide, benefits for the services, a claim must be filed with the double coverage plan. Refusal by the beneficiary to claim benefits from the other coverages must result in a denial of TRICARE benefits. Benefits are considered to be the services available. For example, if the other plan includes psychotherapy as a benefit, but only by a psychiatrist, the beneficiary cannot elect to waive this benefit in order to receive services from a psychologist. For TRICARE for Life (TFL) claims, an exception exists for mental health counselors and pastoral counselors as well as for services received under a private contract (see Section 4, paragraph 1.3.1.4).

In all double coverage situations, a beneficiary’s liability is limited by all TRICARE provisions. As a result, a provider cannot collect from a TRICARE beneficiary any amount that would result in total payment to the provider that exceeds TRICARE limitations. For example, a beneficiary is not liable for any cost-sharing or deductible amounts required by the primary payer, if the sum of the primary payer’s and payments made by TRICARE are at least equal to 115% of the allowable amount authorized by TRICARE for a nonparticipating provider. This is true whether TRICARE actually makes any payment or not. This also applies to claims from participating non-network providers and from network providers. Because of the payment calculations, the provider usually will receive payments from the primary payer and from TRICARE that equal the billed charges. In those rare cases where this does not occur, the provider cannot collect any amount from the beneficiary that would result in payment that exceeds the allowable amount authorized under TRICARE.

When double coverage exists on a claim processed under the DRG-based payment system or the inpatient mental health per diem payment system, the payment cannot exceed an amount that, when combined with the primary payment, equals the lesser of the DRG-based amount, the inpatient mental health per diem based amount, or the hospital’s charges for the services (including any discount arrangements). Thus, when the DRG-based amount or the inpatient mental health per diem based amount is greater than the hospital’s actual billed charge, and the primary payer has paid the full billed charge, no additional payment will be made under TRICARE. Similarly, when the DRG-based amount or the inpatient mental health per diem based amount is less than the hospital’s actual billed charge, and the primary payer has paid the full DRG-based amount or inpatient mental health per diem based amount, no additional payment can be made. Nor can the hospital bill the beneficiary for any additional amounts in these cases.

When double coverage exists on a claim processed under the reasonable cost method for CAHs, the payment under TRICARE cannot exceed an amount that when combined with the primary payment equals the lesser of the established cap amount multiplied by the billed charges or 101% of reasonable cost. The reasonable cost method for CAHs is the lesser of the established/determined Cost-to-Charge Ratio (CCR) cap (reference Chapter 15, Section 1 for Fiscal Year (FY) inpatient and outpatient CCR cap) multiplied by billed charges or 101% of reasonable costs [1.01 x (hospital-specific CCR x billed charges)].

Payment should not be extended for services and supplies for which the beneficiary or sponsor has no legal obligation to pay; or for which no charge would be made if the beneficiary was not an eligible TRICARE beneficiary. Whenever possible, all double coverage claims should be accompanied by an Explanation Of Benefits (EOB) from the primary insurer. If the existence of a participating agreement limiting liability of a beneficiary is evident on the EOB, payment shall be limited to that liability; however, if it is not clearly evident, the claim shall be processed as if no such agreement exists.

When double coverage exists on a claim processed under the CCR methodology for SCHs, the payment under TRICARE cannot exceed an amount that when combined with the primary payment equals the lesser of billed charges, negotiated rate, or the CCR methodology as described in Chapter 15, Section 1.