3.1 Through December 31, 2017, TRICARE offers beneficiaries
three health care options:
3.1.1 TRICARE Prime Plan
Beneficiaries who enroll in TRICARE Prime are
assigned or select a Primary Care Manager (PCM). A PCM is a provider
of primary care, who furnishes or arranges for all health care services required
by the Prime enrollee. Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (eMSM) Commanders have the authority and responsibility
to set priorities for enrollment to MTF/eMSM PCMs. When an MTF’s/eMSM’s
primary care capacity is full, civilian PCMs, who are all part of
the contractor’s network, are available to provide care to patients.
3.1.1.1 Expanded
benefits. As enrollees of Prime, patients receive certain clinical
preventive services that are provided without cost-share for the
patient.
3.1.1.2 Reduced cost. Prime enrollees’ cost-share for
civilian services is substantially reduced from that which is applicable
under TRICARE Extra and TRICARE Standard. In addition, when a TRICARE
Prime enrollee is referred to a non-participating provider, the
enrollee is only responsible for the copayment amount, but not for
any balance billing amount by the non-participating provider.
3.1.2 TRICARE Extra
Plan
Beneficiaries who do not enroll in Prime
may still benefit from using the providers in the contractor’s network
where possible. On a case by case basis, beneficiaries may participate
in TRICARE Extra by receiving care from a network provider. The
beneficiary will take advantage of the reduced charges under Extra
and a reduction in cost-shares. Covered services are the same as
under TRICARE Standard. This option is terminated as of December
31, 2017 and replaced by TRICARE Select.
3.1.3 TRICARE Standard
Plan
The TRICARE Standard plan is a fee-for-service
program. This option is terminated as of December 31, 2017 and replaced
by TRICARE Select.
3.2 Beginning January 1, 2018, the TRICARE program
consists of three options: TRICARE Prime, TRICARE Select, and TRICARE
For Life (TFL). See 10 United States Code (USC) 1072(7).
3.2.1 TRICARE
Prime Plan
TRICARE Prime is a Health Maintenance
Organization (HMO)-like program. It generally features use of MTFs
and substantially reduced out-of-pocket costs for authorized care
provided outside MTFs. Beneficiaries generally agree to use MTFs
and designated civilian provider networks and to follow certain
managed care rules and procedures. Beneficiaries who enroll in TRICARE
Prime are assigned or select a PCM. A PCM is a provider of primary
care, who furnishes or arranges for all health care services required
by the Prime enrollee. MTF/Enhanced Multi-Service Market (eMSM)
Commanders have the authority and responsibility to set priorities
for enrollment to MTF/ eMSM PCMs. When an MTF’s/eMSM’s primary care
capacity is full, civilian PCMs, who are all part of the contractor’s
network, are available to provide care to patients.
3.2.2 TRICARE
Select Plan
TRICARE Select is a self-managed,
Preferred Provider Organization (PPO) program. It allows beneficiaries
to use the TRICARE civilian provider network, with reduced out-of-pocket
costs compared to care from non-network providers, as well as military
facilities (where they exist and when space is available). Similar
to the long-operating “TRICARE Extra” and “TRICARE Standard” plans,
which this replaces, a major feature of TRICARE Select is that enrollees
will not have restrictions on their freedom of choice with respect
to health care providers. TRICARE Select is based primarily on 10
USC 1075 (as added by Section 701 of National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 2017 and 10 USC 1097.
3.2.3 TFL
Plan
TFL is the Medicare wraparound coverage
plan under 10 USC 1086(d).
3.3 Eligibility
for TRICARE
3.3.1 Active Duty Eligibility
All active duty members are considered TRICARE
Prime. They must, however, take action to be enrolled in Prime,
and be assigned to a PCM (see the TRICARE Operations Manual (TOM)
for PCM provisions under the TRICARE Prime Remote (TPR) program).
3.3.2 Non-Active
Duty Eligibility
All individuals entitled
to civilian health care under 10 USC Sections 1079 or 1086, are eligible
for TRICARE. Beginning January 1, 2018, beneficiaries other than
TFL beneficiaries must enroll in a TRICARE plan to receive care
outside the Direct Care (DC) only system. Non-active duty individuals, commonly
referred to as “TRICARE eligibles”, include the spouse and children
of active duty personnel, retirees and their spouses and children,
and survivors.
Note: This group also
includes former spouses as defined in 10 USC Section 1072(2). Not
included are those individuals who are entitled to care in the DC
system, on a space available basis, but ordinarily are not entitled
to civilian care, such as family member parents and parents-in-law.
3.3.3 TFL
Pursuant to Section 712 of the NDAA for FY
2001, Medicare eligible beneficiaries based on age, whose TRICARE
eligibility is determined by 10 USC Section 1086, are eligible for
Medicare Part A, and those who are enrolled in Medicare Part B,
are eligible for the TRICARE benefit effective October 1, 2001.
These beneficiaries are not eligible to enroll in TRICARE Prime. TFL
beneficiaries older than age 65 cannot enroll in TRICARE Prime (exception
for grandfathered Uniformed Services Family Health Plan (USFHP) enrollees).
Retirees and their family members under age 65 who have Medicare
coverage due to disability or with end stage renal disease can enroll
in TRICARE Prime if they have Medicare Part B. Their Prime enrollment
fees are waived if they have Part B coverage. Retirees, dependents,
and survivors with any Medicare coverage at any age are not eligible
to enroll in TRICARE Select because they are excluded from the “Retired
Category” for TRICARE Select as defined in 10 USC 1075(b)(1)(B).
3.3.4 Supplemental
Health Care Program (SHCP) and TPR Program
See
the TOM,
Chapters 16 and
17.
3.3.5 Non-DoD
TRICARE Eligibles
TRICARE eligibles sponsored
by non-DoD uniformed services (the Public Health Service (PHS),
the U.S. Coast Guard (USCG), and the National Oceanic and Atmospheric
Administration (NOAA)) are eligible for TRICARE and may enroll in
TRICARE Prime or TRICARE Select (beginning January 1, 2018).
3.3.6 North
Atlantic Treaty Organization (NATO) And Partnership For Peace (PfP) Beneficiaries
The Department of Defense equates foreign military
members and family members from PfP countries the same as those
from NATO Status of Forces Agreement (SOFA) countries, in terms
of access to outpatient medical and dental care from DoD medical
and dental treatment facilities, and access to TRICARE Select (TRIARE
Standard before January 1, 2018) civilian care. A current list of
NATO SOFA countries is at:
https://www.nato.int/cps/ie/natohq/topics_52044.htm.
A current list of NATO PfP countries is at:
https://www.nato.int/cps/en/natohq/51288.htm.
3.3.6.1 NATO
or PfP ADSM
As specified in applicable SOFAs,
active duty members of the armed forces of NATO and PfP nations
qualify for TRICARE outpatient services in similar fashion as their
U.S. Armed Forces active duty counterparts. However, there is no
coverage for inpatient services under TRICARE. No enrollment in
a TRICARE plan is required or authorized. As such contractors shall
not use the government furnished web-based enrollment system/application
to determine eligibility. See the TOM,
Chapter 17, Section 3, and TRM,
Chapter 4, Sections 2 and
4 for more information.
3.3.6.2 NATO
or PfP Family Members
Family members of active
duty members of the armed forces of NATO and PfP nations are only eligible
for outpatient care under TRICARE; there is no coverage for inpatient
services under TRICARE. Effective January 1, 2018, TRICARE Select
Group B cost-shares for Active Duty Family Members (ADFMs) apply.
Prior to January 1, 2018, TRICARE Standard/Extra cost-shares for
ADFMs apply. No enrollment in a TRICARE plan is required or authorized.
As such, contractors shall not use the government furnished web-based
enrollment system/application to determine eligibility. See TOM,
Chapter 17, Section 3; TRM,
Chapter 2, Section 2, and
Chapter 4, Sections 2 and
4; and TRICARE Systems Manual (TSM),
Chapter 2, Addendum L for more information.
3.3.7 Enrollment
Starting in calendar year 2018, beneficiaries
other than active duty members and TFL beneficiaries need to elect
to enroll in TRICARE Select or TRICARE Prime in order to be covered
by the private sector care portion of TRICARE. Enrollment will be
done during an open season period prior to the beginning of each
plan year, which operates with the calendar year. An enrollment
choice will be effective for the plan year. As an exception to the
open season enrollment rule, enrollment changes can be made during
the plan year for certain Qualifying Life Events (QLEs), such as
a change in eligibility status, marriage, divorce, birth of a new
family member, relocation, loss of Other Health Insurance (OHI), or
other events. Beneficiaries eligible to enroll in TRICARE Prime
or TRICARE Select plans who do not enroll or fail to qualify to
maintain their TRICARE Prime or TRICARE Select enrollment status no
longer have coverage under the TRICARE Program (including the TRICARE
retail pharmacy and Mail Order Pharmacy (MOP) programs), and may
not re-enroll until the following annual open season enrollment period
or until the sponsor or an eligible family member experiences a QLE,
whichever comes first. Such beneficiaries eligible to enroll in
TRICARE Prime or TRICARE Select do not lose any statutory entitlement
to space-available care in MTFs/eMSMs.
Note: Included in all of the TRICARE benefit packages
is a retail pharmacy network and a mail service pharmacy program. Beneficiaries
must be enrolled to a plan to receive pharmacy services outside
the DC system.
3.4 Administrative
Policy
3.4.1 Benefit Policy
3.4.1.1 Benefit policy applies to the scope of services
and items which may be considered for cost-sharing by the TRICARE
within the intent of the 32 CFR 199.
3.4.1.2 The
current edition of the American Medical Association’s (AMA’s) Physicians’
Current Procedural Terminology (CPT) is incorporated by reference
into this Manual to describe the scope of services potentially allowable
as a benefit, subject to explicit requirements, limitations, and
exclusions, in this Manual or in the 32 CFR 199.
3.4.1.3 Procedures listed in the CPT and the Healthcare
Common Procedure Coding System (HCPCS) may be cost-shared only when
the procedure is “appropriate medical care”
and is
“medically or psychologically necessary”
and is
not “unproven” as defined in the
32 CFR 199.4(g)(15), and the procedure is
not explicitly excluded in the TRICARE program.
3.4.2 Program
Policy
Program Policy applies to beneficiary
eligibility, provider eligibility, claims adjudication, and quality
assurance. Program policy implementation instructions are found
in the TSM and the TOM.
3.4.3 Any benefit or program administration issue
for which benefits or program operation policy guidance is required,
or when TRICARE policy is silent on an issue, the contractor shall
describe in writing and submit to the Team Chief, MB&RD, Defense
Health Agency (DHA).
3.4.4 Reimbursement
Policy
3.4.4.1 Reimbursement
policy sets forth the payment procedures used for reimbursing TRICARE claims.
The related implementation instructions for these payment procedures
are found in the TSM and the TOM.
3.4.4.2 The TRM provides the methodology for pricing
allowable services and items and for payment to specific categories
and types of authorized allowable services and items and for payment to
specific categories and types of authorized providers. These methods
allow the contractor to price and render payment for specific examples
of services or items which are not explicitly addressed in the Manual
but which belong to a general category or type which is addressed
in the Manual.
3.5 Administrative
and Effective Dates
3.5.1 Issuance Date
The date located on the first page of each
separate policy issuance. This is the date that the issuance was
initially issued by DHA.
3.5.2 Revision
Date
The revision date is at the bottom of
each page that has been revised along with the change number. This
is the date that DHA changed the issuance in any way. Each time
an issuance is changed, the revised page and/or issuance is given
a change number. The revision date and the change number together
identify a unique version of the issuance on a specific subject.
3.5.3 Effective
Date
A date within the body of the text of
an issuance which establishes the specific date that a policy is
to be applied to benefit adjudication or in program administration.
An effective date may be earlier than the issuance or revision date.
This date is explicit (e.g., Effective Date: January 1, 2004). The policy
effective date takes precedence over the issuance date and the revision
date. In the absence of an effective date the policy or instruction
is considered to have always been applicable because the newly published
policy or instruction confirms the application of existing published
program requirements.
3.5.4 Implementation
Date
The implementation date of a policy
or instruction is not noted in the issuance as this date is determined
by the terms of the contract modification between DHA and the contractor.
Unless otherwise directed by DHA, contractors are not to identify
finalized claims for readjudication under revised or new policy.
However, the contractor shall readjudicate any denied claim affected
by the policy that is brought to the contractor’s attention by any
source. Pending claims and denied claims in reconsideration shall
be adjudicated using the current applicable policy.