1.0 APPLICABILITY
The policy is mandatory for reimbursement of
services provided by either network or non-network providers. However,
alternative network reimbursement methodologies are permitted when approved
by the Defense Health Agency (DHA) and specifically included in
the network provider agreement.
3.0 POLICY
3.1 A supplemental
insurance plan is a health insurance policy or other health benefit
plan offered by a private entity to a TRICARE beneficiary, that
primarily is designed, advertised, marketed, or otherwise held out
as providing payment for expenses incurred for services or items
that are not reimbursed under TRICARE due to program limitations,
or beneficiary liabilities imposed by law. TRICARE recognizes two
types of supplemental insurance plans; general indemnity plans,
and those offered through a direct service Health Maintenance Organization
(HMO).
3.2 An indemnity supplemental insurance plan must
meet all of the following criteria:
3.2.1 It provides insurance coverage,
regulated by state insurance agencies, which is available only to
beneficiaries of TRICARE.
3.2.2 It is premium-based and all
premiums relate only to TRICARE supplemental coverage.
3.2.3 Its benefits
are limited to non-covered services, to the deductible and cost-share
portions of the predetermined allowable charges, and to amounts
exceeding the allowable charges for covered services.
3.2.4 It provides
reimbursement by making payment directly to the TRICARE beneficiary
or to the participating provider.
3.2.5 It does not operate in a manner
which results in lower deductibles or cost-shares than those imposed
by law, or that waives the legally imposed deductibles or cost-shares.
3.3 A supplemental
insurance plan offered by a HMO must meet all of the following criteria:
3.3.1 The HMO
must be authorized and must operate under relevant provisions of
state law.
3.3.2 The HMO supplemental plan must be premium-based
and all premiums must relate only to TRICARE supplemental coverage.
3.3.3 The HMO’s
benefits, above those which are directly reimbursed by TRICARE,
must be limited predominantly to services not covered by TRICARE
and TRICARE deductible and cost-share amounts.
3.3.4 The HMO
must provide services directly to TRICARE beneficiaries through
its affiliated providers who, in turn, are reimbursed by TRICARE.
3.3.5 The HMO’s
premium structure must be designed so that no overall reduction
in the amount of the beneficiary deductibles or cost-shares will
result.