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Child
Vaccination Programs That Use An SVP Per Capita Assessment Approach
For Reimbursement
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1.
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DHA
will calculate the number of covered lives (i.e., Active Duty Family
Member (ADFM) and Non-Active Duty Family Member (NADFM) reliants
that are not enrolled at a Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (eMSM) in Prime, ages 0-18) (see Section 38 for details) each quarter. Defense
Health Agency (DHA) will estimate the percentage of TRICARE non-Active
Duty Dependent (ADD) reliants annually, and exclude any non-ADDs
who are not reliant on TRICARE as their primary form of insurance
in their covered lives population estimate. |
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2.
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Each
SVP may have its own time period for the population to be calculated.
The DHA will work with the state programs to ensure that the population
is calculated for the appropriate time frame in the state. DHA will,
on a quarterly basis, provide the contractors the number of covered
lives in each state. Some SVPs require quarterly payment, while
others require annual payments. DHA will determine which population
numbers are appropriate to use for the SVP-specific calculations.
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3.
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DHA
will also provide the contractors with a TRICARE per capita capped
payment amount for the time period needed for each SVP program.
This information may be provided directly to the contractor or posted
on a DHA-approved website.
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4.
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The
contractors shall follow the protocol established by each state
to provide them with the number of TRICARE covered lives for the
dates requested by the SVP.
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5.
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The
contractors shall identify whether the SVP per capita assessment
amount provided by the SVP is greater or less than the TRICARE per
capita capped payment amount.
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6.
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In
some states, the SVPs shall send an invoice to the contractors for
a payment, typically on a quarterly or annual basis. In other states,
the contractors shall proactively provide payment to the SVPs for
the liability amount.
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7.
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The
contractors shall pay the SVPs in one of two ways:
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a.
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If the SVP per
capita quarterly assessment amount is less than the TRICARE per
capita quarterly capped payment amount: The contractors will pay
the amount equal to the SVP per capita assessment amount multiplied
by the TRICARE reliant population
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b.
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If the SVP per
capita quarterly assessment amount is greater than the TRICARE per
capita quarterly capped payment amount: The contractors will calculate
the total TRICARE assessment amount to be paid to the SVP as the
number of TRICARE reliants (i.e., covered lives) in the state multiplied
by the TRICARE per capita capped payment amount.
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8.
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The
contractors shall submit payment to the SVPs either annually or
quarterly depending on the SVP.
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9.
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The
contractors shall be reimbursed using non-underwritten funds.
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Child
Vaccination Programs That Use An Alternative Approach - The State
Of Massachusetts
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1.
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For
Massachusetts, DHA will calculate the total TRICARE paid amounts
made to acute care hospitals and paid facility charges for hospital
outpatient departments and freestanding Ambulatory Surgery Center
(ASC) facilities for a period designated annually by the Massachusetts
Vaccine Association to calculate the annual Pediatric Immunization
Program Assessment (PIPA).
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2.
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DHA
will identify the PIPA surcharge percentage that is published annually
by the state of Massachusetts, and multiply this percentage by the
total paid amounts calculated above.
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3.
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DHA
will compare the MA assessment amount with the TRICARE payment capped
amount, as calculated by DHA using the reliant covered lives under
age 19 and an assessment amount.
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4.
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DHA
will provide the contractor with the total TRICARE assessment amount
to be paid to the state and the contractor shall submit payment
to the Massachusetts Vaccine Purchase Trust.
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5.
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The
contractor shall submit payment to the SVP by June 1st.
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6.
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The
contractor shall be reimbursed using non-underwritten funds.
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Adult
Vaccination Programs That Use An SVP Per Capita Assessment Approach
for Reimbursement
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1.
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DHA
will calculate the number of covered lives (i.e., ADFM and NADFM
reliants that are not enrolled at an MTF/eMSM in Prime, for the
ages in which adult vaccines are provided in the state) each quarter.
The term “reliants” refers to a subset of TRICARE eligible beneficiaries
who are dependent on TRICARE for the coverage/reimbursement of vaccines
under the well-child and preventive benefits. All TRICARE ADFMs
are considered to be reliant on TRICARE as their primary form of insurance.
DHA will estimate the percentage of TRICARE non-ADD reliants annually,
and will exclude any non-ADDs who are not reliant on TRICARE as
their primary form of insurance in their covered lives population
estimate.
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2.
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Each
state adult SVP may have its own time periods for the population
to be calculated. DHA will work with the state programs to ensure
that the population is calculated for the appropriate time frame
in the state. DHA will, on a quarterly basis, provide the contractors
the number of covered lives in each state.
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3.
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DHA
will calculate a state-specific TRICARE per capita capped payment
amount for each quarter using data from only the adult vaccines
that are provided in the state. DHA will determine if multiple state
per capita capped rates are required based on age. For example,
if a state program provides vaccines to the Medicare-eligible population,
DHA will exclude any Medicare-covered adult vaccines from the calculation
of a capped amount used for the age 65 and older population in that
state only.
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4.
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DHA
will provide the contractors with the number of covered reliants
in the state, and the TRICARE state-specific per capita capped payment
amount(s). DHA may provide these values directly to the contractor,
or via a website designed for DHA SVP programs.
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5.
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The
contractor provide the Adult SVP program with the number of adult
TRICARE reliants in which ever mechanism that is agreed upon by
the contractor and the state (via memo, online survey, web-portal,
etc.) for each time period requested by the SVP.
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6.
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In
some states, the SVPs shall send an invoice to the contractors for
a payment, typically on a quarterly or annual basis. In other states,
the contractors will proactively provide payment to the SVPs for
the liability amount.
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7.
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The
contractor shall identify whether the SVP Adult per capita assessment
amount is greater than the calculated TRICARE per capita capped
payment amount.
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8.
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The
contractors shall pay the SVPs in one of two ways:
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a.
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If the SVP per
capita quarterly assessment amount is less than the TRICARE per
capita quarterly capped payment amount: The contractors will pay
the amount equal to the SVP per capita assessment amount multiplied
by the TRICARE reliant population.
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b.
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If the SVP per
capita quarterly assessment amount is greater than the TRICARE per
capita quarterly capped payment amount: The contractors will calculate
the total TRICARE assessment amount to be paid to the SVP as the
number of TRICARE reliants (i.e., covered lives) in the state multiplied
by the TRICARE per capita capped payment amount.
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9.
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The
contractor shall submit payment to the SVP.
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10.
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The
contractor shall be reimbursed using non-underwritten funds.
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