1.0 BACKGROUND
1.1 National Defense Authorization
Act for Fiscal Year 2017 (NDAA FY 2017), Section 701, made significant
changes to the TRICARE Program, especially to TRICARE Prime; TRICARE
Extra, which is replaced by TRICARE Select; and to the third option,
TRICARE Standard, which was terminated as of December 31, 2017,
and is also replaced by TRICARE Select. TRICARE Select is a self-managed,
Preferred Provider Option (PPO) under the TRICARE Program, and replaces
the TRICARE Extra and Standard programs and adopts a number of improvements,
including fixed copayments rather than percentage copays for covered
benefits provided by a civilian network provider. It also features
freedom of choice of providers, with reduced beneficiary out-of-pocket
costs for covered care received from a civilian network provider.
The NDAA also included the continuation of TRICARE Prime as a managed
care, Health Maintenance Organization (HMO)-like option under the
TRICARE Program. TRICARE Prime adopts a number of changes to conform
to specifications in the new law, including categories of health care
services applicable to the determination of catastrophic loss protection.
Other features of the NDAA include preservation of benefits for
Active Duty Family Members (ADFMs) and TRICARE For Life (TFL) beneficiaries
and conforming changes to generally incorporate TRICARE Select into
the TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), TRICARE
Retired Reserve (TRR), and Continued Health Care Benefits Program
(CHCBP).
1.2 With respect to beneficiary catastrophic loss
protection, the NDAA FY 2017 established the catastrophic caps for
each identified beneficiary group, specified certain annual updates,
and converted the coverage from a fiscal year to a calendar year
basis. The law also introduced a new split of beneficiaries into
two groups: one group (Group A or grandfathered beneficiaries) consists
of sponsors and their family members who first became affiliated
with the military through enlistment or appointment before January
1, 2018, and the second group (Group B or non-grandfathered beneficiaries)
who first became affiliated on or after that date.
1.3 With respect to beneficiary
catastrophic loss protection, the NDAA FY 2017 preserved the benefits
for TFL beneficiaries. TFL means the Medicare wraparound coverage
option of the TRICARE program made available to the beneficiary
by reason of 10 United States Code (USC) section 1086(d).
1.4 Fees under the Extended Care
Health Option (ECHO) are defined in
32 CFR 199.5.
1.5 Fees under the TRICARE Pharmacy
Benefit Program are defined in
32 CFR 199.21.
2.0 POLICY
2.1 TRICARE Prime And TRICARE
Select
2.1.1 Catastrophic
cap for ADFMs under TRICARE Prime and TRICARE Select, the calendar
year cap is:
2.1.1.1 Group A:
$1,000.
2.1.1.2 Group B: $1,000 for calendar year (CY) 2018,
adjusted annually thereafter indexed to the amount of increase under
10 USC section 1401a.
2.1.2 Catastrophic
cap for all other beneficiaries under:
2.1.2.1 TRICARE
Prime:
2.1.2.1.1 Group A
retirees have a calendar year cap of $3,000.
2.1.2.1.2 Group B
retirees have an annual cap of $3,500 in calendar year 2018, adjusted
annually thereafter indexed to the amount of increase under 10 USC
section 1401a.
2.1.2.2 TRICARE
Select:
2.1.2.2.1 Group A
retirees have an annual cap of $3,000 for CYs 2018 through 2020;
except for certain beneficiaries described in
paragraph 2.1.2.2.2, in CY
2021 the cap is $3,500, adjusted annually thereafter indexed to
the amount of increase under 10 USC section 1401a.
2.1.2.2.2 Group
A retirees consisting of survivors of active duty deceased sponsors
or medically retired Uniformed Services members and their dependents
have a calendar year cap of $3,000.
2.1.2.2.3 Group B
retirees have an annual cap of $3,500 for CY 2018; adjusted annually
thereafter indexed to the amount of increase under 10 USC section
1401a.
2.2 TFL. Under the catastrophic
cap for TFL beneficiaries, an individual or family group of two
or more beneficiaries may not be required to pay a total of more
than $3,000 for health care received during any calendar year. See
Chapter 4, Section 4 for information regarding
specific double coverage actions involving Medicare for TFL beneficiaries.
Note: ADFMs with Medicare (not TFL) shall be subject
to the catastrophic cap limitations in
paragraph 2.1.2.
2.3 TYA, TRR, TRS, and CHCBPEnrollees in these plans have
Group B catastrophic cap limitations shown under paragraph 2.1 based
on the coverage (TRICARE Prime or TRICARE Select) the plan provides.
3.0 Cap is Met
3.1 For TRICARE Prime, TRICARE Select, and TFL
beneficiaries, after the applicable calendar
year catastrophic cap is met, the TRICARE determined allowable amount
shall be paid in full for all covered services and supplies for
the remainder of the calendar year.
3.2 For TYA, TRR, TRS, and CHCBP
enrollees, after the Group B calendar year catastrophic cap is met, the
TRICARE determined allowable amount shall be paid in full for all
covered services and supplies for the remainder of the calendar
year.
4.0 The following
expenses may be credited to a TRICARE Prime, TRICARE Select, or
TFL sponsor’s calendar year catastrophic cap:
• Deductibles.
• The outpatient
and inpatient cost-shares and copayments.
5.0 Other Coverage Situations
5.1 TRICARE Supplemental Plans
TRICARE supplemental plans which provide coverage
for deductibles, cost-shares, and sometimes for non-covered services,
will be ignored. As with double coverage, the full deductible and cost-share
will be credited toward meeting the catastrophic cap.
5.2 Multiple Family Situations
Multiple family situations--e.g., sponsor and
new spouse and children live together, and sponsor’s children from
previous marriage live elsewhere--will be treated as one family.
In other words, for a divorced and then remarried sponsor with two
sets of family members, their deductibles and cost-shares will be
combined to meet the calendar year catastrophic cap.
Note: When a family’s sponsor changes, e.g., a spouse
divorces a sponsor and marries another active duty person, then
only the new sponsor’s liabilities for deductible and cost-shares
in a calendar year will count toward meeting the cap. In other words,
this spouse cannot carry to the new family those credits accumulated
toward the cap under the previous sponsor.
5.3 Former Spouses
Any TRICARE eligible former spouse will be
treated as an “other than ADFM.” For the purpose of determining
the catastrophic cap, a former spouse will be treated as an independent
family and must independently meet the catastrophic cap.
5.4 Change Of Sponsor Status
A change in a sponsor’s duty status will have
the following effects on application of the catastrophic cap.
5.4.1 Claims Subject To The TRICARE
Diagnosis Related Group (DRG)-Based Payment System
5.4.1.1 When the
status changes during a beneficiary’s inpatient stay, the appropriate
catastrophic cap will apply to that stay according to the beneficiary’s
cost-sharing status for the stay. Effective for services provided
after midnight of the day of discharge from the hospital, the catastrophic
cap will be based on the sponsor’s current status.
5.4.1.2 When the
status changes at any time other than during a beneficiary’s inpatient
stay, the appropriate catastrophic cap (according to the sponsor’s
current duty status) will apply for TRICARE eligible families for
the remaining calendar year (or until the status changes again)
effective for services provided after midnight of the day the duty
status changes.
5.4.1.3 When the status changes, the full deductible
and cost-shares credited toward meeting the previous family cap
will be credited toward the new cap as the sponsor’s liabilities
in the same calendar year. However, in no case will a change in
a sponsor’s status from retired to active duty result in an adjustment
to previous claims, even if the aggregate cost-share had exceeded
the active duty cap.
5.4.2 Claims Exempt From The TRICARE
DRG-Based Payment System
When a sponsor’s
duty status changes, the appropriate cap (according to the sponsor’s current
duty status) will apply for TRICARE eligible families for the remaining
calendar year effective for services provided after midnight of
the day the duty status changes. The full deductible and cost-shares
credited toward meeting the previous family cap will be credited
toward the new cap as the sponsor’s liabilities in the same calendar
year.
5.5 Inpatient
Care Spanning Two Calendar Years
When the
dates of inpatient care span different calendar years, it is absolutely
necessary that the catastrophic cap application be as accurate as
possible. If for a claim the ending date of care is in a different
calendar year from the beginning date of care, the beneficiary cost-share
amount must be allocated between the two calendar years based on
the dates of care.
5.6 Cost-Share
When Fixed Daily Amount Is NOT Known
When
a fixed (or actual) daily amount of cost-share is not known or cannot
be accurately determined, the daily cost-share amount will be calculated
by proration, that is, by dividing the claim’s cost-share amount
by the number of days of care (not counting the day of discharge)
and the resulting daily amount will be allocated between the two
calendar years according to the days of care received in each calendar
year.
6.0 EXCEPTIONS
6.1 No catastrophic loss protection
is available for the North Atlantic Treaty Organization (NATO) or Partnership
For Peace (PfP) family members.
6.2 The Extended Care Health Option
(ECHO) sponsor/beneficiary liabilities do not accrue toward meeting
the catastrophic cap.
6.3 Beneficiary costs for non-covered services
or any beneficiary payments above the TRICARE determined allowable
charge, shall not count toward meeting the catastrophic cap.
6.4 For TRICARE Prime enrollees,
POS deductible and cost-share amounts do not have a catastrophic
cap.