TRICARE beneficiaries who become entitled to
Medicare Part A, based on age, do not lose TRICARE eligibility if
they are enrolled in Medicare Part B. Special double coverage procedures
are used for these claims in order to minimize out-of-pocket expenditures
for these beneficiaries. These special procedures are used for all
claims for beneficiaries who are eligible for Medicare, including
active duty dependents who are age 65 and over as well as those
beneficiaries under age 65 who are eligible for Medicare for any
reason. (See the TRICARE Operations Manual (TOM),
Chapter 20,
for information on TRICARE Dual Eligible Fiscal Intermediary Contract
(TDEFIC)). The following sections set forth the amounts that TRICARE
will pay if the beneficiary is covered by Medicare and TRICARE.
If a third coverage is involved, TRICARE will be last payer and
payments by the third coverage will reduce the amounts of TRICARE
payment that are set forth below. In all cases where TRICARE is
the primary payer, all claims processing requirements are to be
followed. Additionally, when a beneficiary becomes eligible for
Medicare during any part of his/her inpatient admission, the hospital
claim shall be submitted to Medicare first and TRICARE payment (using
non-financially underwritten funds) will be determined under the
normal double coverage procedures.
1.3.1 Services That Are A Benefit
Under Both Medicare And TRICARE (See
paragraph 1.5 for Pharmacy
Claims)
1.3.1.1 When Medicare makes a payment for benefits
also covered by TRICARE, the beneficiary will generally have no
out-of-pocket expense. For these claims TRICARE will resemble a
Medicare supplement. That is, the allowable amount under Medicare
will be used as the TRICARE allowable, and TRICARE payment will
equal the remaining beneficiary liability after Medicare processes
the claim without regard to any TRICARE deductible and cost-share
amounts that would otherwise be assessed. For example, if it is
the first claim of the year and the billed charge is $50 (which
is also the amount both Medicare and TRICARE allow on the claim),
Medicare will apply the entire amount to the Medicare deductible
and pay nothing. In this case, TRICARE will pay the full $50 so
that the beneficiary has no out-of- pocket expense. Similarly, if
Medicare pays an amount that is greater than what TRICARE normally
would allow for a network provider, TRICARE will still pay any Medicare
deductible and cost-sharing amounts, even if that represents payments
in excess of the normal TRICARE allowable amount.
Note: It is not necessary for the contractor to price
these claims, since the Medicare allowable becomes the TRICARE allowable,
and TRICARE payment is based on the remaining beneficiary liability. The
contractor need only verify eligibility and coverage in processing
the claim. Contractors will not be required to duplicate Medicare’s
provider certification, medical necessity, referral, authorization,
and potential duplicate editing.
1.3.1.2 If
the service or supply is normally a benefit under both Medicare
and TRICARE, but Medicare cannot make any payment because the beneficiary
has exhausted Medicare benefits, TRICARE will make payment as the
primary payer assessing all applicable deductibles and cost-shares. For
example, TRICARE is primary payer for inpatient care beyond 150
days.
1.3.1.3 If
the service or supply is normally a benefit under both Medicare
and TRICARE, but Medicare cannot make any payment because the beneficiary
receives services overseas where Medicare will not make any payment,
TRICARE will process the claim as a primary payer assessing any applicable
deductibles and cost-shares. Since the contractor knows that Medicare
cannot make any payment on such claims, the contractor shall process
the claim without evidence of processing by Medicare. Even though
Medicare cannot make payment overseas, beneficiaries receiving care
overseas must still purchase Part B of Medicare in order to maintain
their TRICARE eligibility.
1.3.1.4 If
the service or supply is normally a benefit under both Medicare
and TRICARE, but Medicare does not make any payment because the
service or supply is not medically necessary, TRICARE cannot make
any payment on the claim. In such cases, the contractor shall deny
the claim. The beneficiary/provider must file an appeal with Medicare.
If Medicare subsequently reverses its medical necessity denial,
Medicare will make payment on the claim and it can then be submitted
to TRICARE for processing. If Medicare does not reverse its medical
necessity denial, the claim cannot be paid by TRICARE, and the Medicare
appeal decision is final. TRICARE will not accept an appeal in such
cases, and the contractor will advise the beneficiary that the final
determination rests with Medicare.
1.3.1.5 When Medicare
does not make a payment because services were rendered by a non-Medicare
provider or effective for services on or after March 1, 2007, because
the provider has a private contract with the beneficiary (also referred
to as “opting out” of Medicare), and the services are a TRICARE
benefit, TRICARE will process the claim as second payer. In these
cases, when TRICARE processes as secondary payer, TRICARE first
payer review and reporting rules apply. The TRICARE payment will
be the amount that TRICARE would have paid (TRICARE cost-shares
and deductibles do not apply) had the Medicare program processed
the claim (normally 20% of the allowable charge). If there is not
an available Medicare allowed amount, the TRICARE allowed amount
shall be calculated and 20% of that amount will be reimbursed (TRICARE
cost-shares and deductibles do not apply). Evidence of processing
by Medicare for non-Medicare providers is not required; rather a
statement from the provider verifying their Medicare status is sufficient
for processing. Opt out providers will be identified based on the
Medicare Part B carriers web sites. In cases where the beneficiary’s
access to medical care is limited (i.e., under served areas), the
TRICARE contractor may waive the 20% of the allowable charge payment
amount and pay 100% of the allowable amount assessing all applicable deductibles
and cost-shares. In most cases, under served areas will be identified
by zip codes for Health Professional Shortage Areas (HPSAs) and
Physician Scarcity Areas (PSAs) on the Centers for Medicare and
Medicaid Services (CMS) web site at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index.html and will
automatically pay 100% of the allowable amount assessing all applicable
deductibles and cost-shares. In cases where the zip code for an underserved
area is not identified on the CMS web site, or in areas where there
are no or limited Medicare participating providers, a written waiver
request with justification identifying the county where the service
was received will be required by the contractor to pay 100% of the
allowable amount assessing all applicable deductibles and cost-shares.
TRICARE contractors will identify HPSA or PSA zip codes or the county
for underserved areas on the above CMS web site and identify opt
out providers based on the Medicare Part B carriers web sites.
1.3.1.6 When Medicare
does not make a payment based on their Competitive Bidding Program (CBP)
for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS), the TRICARE contractor shall process the claim as second
payer for otherwise TRICARE covered items of DMEPOS. In these cases,
when TRICARE processes as secondary payer, TRICARE first payer review
and reporting rules apply. The TRICARE payment shall be the amount
TRICARE would have paid (cost-shares and deductibles do not apply)
had Medicare processed and paid the claim (normally 20% of the allowable charge).
If there is not an available Medicare allowed amount, the TRICARE
allowed amount shall be calculated and 20% of that amount will be
reimbursed (cost-shares and deductibles do not apply). Public use
files containing the competitive bid single payment amounts per
Healthcare Common Procedure Coding System (HCPCS) code are posted
on the CMS’ competitive bidding contractor’s web site:
http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home.
TRICARE contractors shall identify the competitive bid single payment
amount using the above CMS web site to identify what Medicare would
have allowed had the beneficiary followed Medicare’s rules. Implementation
of Medicare’s DMEPOS CBP pricing is effective January 1, 2011.
1.3.1.7 When Medicare
does not make a payment because Medicare rules were not followed
or because the beneficiary failed to meet some other requirement
of coverage (e.g., denied for no referral, no or untimely authorization,
invalid place of service, etc.). TRICARE will process the claim
as second payer as long as the services meet TRICARE coverage rules.
This exception does not include Medicare medical necessity denials.
In these cases, when TRICARE processes as secondary payer, TRICARE
first payer review and reporting rules apply. The TRICARE payment
will be the amount that TRICARE would have paid (TRICARE cost-shares
and deductibles do not apply) had the Medicare program processed the
claim (normally 20% of the allowed charge). If there is not an available
Medicare allowed amount, the TRICARE allowed amount shall be calculated
and 20% of that amount will be reimbursed (TRICARE cost-shares and
deductible do not apply).
Note: TRICARE will
not cost-share items designated by Medicare as “inpatient only”
for Medicare beneficiaries. These services shall be denied, and
TRICARE will make no payment. A list of these services can be found
in the addenda to Medicare’s annual Outpatient Prospective Payment
System Final Rule, available at
https://www.cms.gov/Center/Provider-Type/Hospital-Center.html.
1.3.1.8 Effective
October 28, 2009, TRICARE beneficiaries who are entitled to premium-free Medicare
Part A because of disability, where Social Security Disability Insurance
(SSDI) is awarded on appeal remain eligible for coverage under the
TRICARE program (see the TOM,
Chapter 20, Section 1, paragraph 2.6). Eligible
beneficiaries are required to keep Medicare Part B in order to maintain
their TRICARE coverage for future months, but are considered to
have coverage under the TRICARE program for the retroactive months
of their entitlement to Medicare Part A. For previously processed
claims the contractor that processed the claim shall not initiate
recoupment due to eligibility or jurisdiction and existing actions
should be terminated. Medicare becomes primary payer effective as
of the original Medicare Part B effective date.