2.3
Review
And Annual Updates
All fees (including enrollment
fees, deductibles, and cost-shares) are subject to review and annual
updating on the calendar year, in accordance with 10 USC sections
1075 and 1075a.
2.3.1 This section provides the
policy regarding fees and the Calendar Year (CY) 2018 amounts. Annual
updates thereafter will be published on the Defense Health Agency
(DHA) web site at
http://www.health.mil/rates.
2.3.2 Each fee for Group B beneficiaries shall be
annually indexed to the amount by which retired pay is increased
(i.e., the cost-of-living adjustment (COLA)) under 10 USC section
1401a, rounded to the next lowest multiple of $1. The remaining
amount above such multiple of $1 shall be carried over to, and accumulated
with, the amount of the increase for the subsequent year and made
when the aggregate amount of increases carried over for a year is
$1 or more.
2.4
TRICARE
Prime
2.4.1 TRICARE Prime program enrollment fees and copayments
are defined in 10 USC sections 1075 and 1075a. For information on
fees for Prime enrollees choosing to receive care under the Point
of Service Option (POS), refer to
32 CFR 199.17 and
Section 5.
2.4.1.1 TRICARE
Prime ADFMs have no annual enrollment fee in CY 2018 or subsequent
calendar years.
2.4.1.2 TRICARE
Prime Group A Retirees have a CY 2018 enrollment fee of $289.08
for an individual or $578.16 for a family. Annual updates are available
at
http://www.health.mil/rates.
2.4.1.3 TRICARE Prime Group B Retirees have a CY 2018
enrollment fee of $350 for an individual or $700 for a family. Annual
updates are available at
http://www.health.mil/rates.
2.4.1.4 Effective March 26, 1998, the TRICARE Prime
enrollment fee is waived for those beneficiaries who are both eligible
for Medicare on the basis of disability or end stage renal disease
and who maintain enrollment in Part B of Medicare and are otherwise
eligible to enroll in TRICARE Prime.
2.4.1.5 Effective FY 2012, Group A Prime beneficiaries
who are (1) survivors of active duty deceased sponsors, or (2) medically
retired Uniformed Services members and their family members, shall
have their Prime enrollment fees frozen at the rate in effect when
classified and enrolled in a fee paying Prime plan. (This does not
include TYA plans). Beneficiaries in these two categories who were
enrolled in FY 2011 will continue paying the FY 2011 rate. The beneficiaries
who become eligible in either category and enroll during FY 2012,
or in any future fiscal year through December 31, 2017 or calendar year
commencing CY 2018, shall have their fee frozen at the rate in effect
at the time of enrollment in Prime. The fee for these beneficiaries
shall remain frozen as long as at least one family member remains enrolled
in Prime. The fee for the family member(s) of a medically retired
Uniformed Services member shall not change if the family member(s)
is later re-classified a survivor.
2.4.1.6 Group B Prime Retiree beneficiary enrollment
fees are not frozen nor waived.
2.4.2 TRICARE
Select
TRICARE Select enrollment fees and
copayments are defined in 10 USC sections 1075 and 1075a.
2.4.2.1 TRICARE Select ADFMs have no enrollment fees.
2.4.2.2 TRICARE Select Group A retirees have no enrollment
fees until CY 2021.
2.4.2.3 When enrollment
fees implemented for TRICARE Select Group A Retirees. Retirees who
are (1) survivors of active duty deceased sponsors, or (2) medically
retired Uniformed Services members and their family members, have
no enrollment fees in CY 2018 or in any subsequent calendar year.
(This does not include TYA plans). The fee for the family member(s)
of a medically retired Uniformed Services member shall not change
if the family member(s) is later re-classified a survivor.
2.4.2.4 TRICARE Select Group B Retirees have enrollment
fees of $450 per individual or $900/family for CY 2018. These fees
shall be updated annually in accordance with
paragraph 2.3. Annual updates shall
be posted at
http://www.health.mil/rates.
2.5 Deductibles
2.5.1 TRICARE Prime ADFMs and Retirees. Group A and
Group B Prime ADFMs and Prime retirees have no deductible under
TRICARE Prime for health care services obtained in accordance with
Prime rules and procedures. If otherwise covered health care services
are not obtained in accordance with Prime rules and procedures,
the services may be covered under the POS option (
Section 6) including
a deductible of $300 per individual or $600 per family.
2.5.2 TRICARE Select. TRICARE Select beneficiaries
have calendar year deductibles that must be fully met before TRICARE
benefits are payable. Once the deductible has been met, the cost-shares
in
paragraph 2.6 apply.
The TRICARE Select deductible applies to the catastrophic cap. The
TRICARE Select deductible does not apply to the preventive care
services described in the TPM,
Chapter 7, Sections 2.1,
2.2, and
2.5.
2.5.3 Collection of deductible amounts. Contractors
shall require network providers to collect, at a minimum, the copayment
at the time of service and the Explanation Of Benefits (EOB) shall
inform the provider and beneficiary of additional amounts owed to
satisfy the deductible. Additionally, the contractor may provide
deductible information to network providers in advance so they may
also be collected at the time of the service, at the discretion
of both the contractor and network providers in their network agreements.
2.5.4 Deductibles when beneficiaries move between
regions. See the TRICARE Operations Manual (TOM),
Chapter 2, Section 2, regarding portability.
2.5.5 Beneficiaries who transfer to Prime, and again
to Select during the same calendar year. The deductible for these
beneficiaries does not reset to zero. The amount of the deductible
fulfilled shall carry forward if a beneficiary moves to Prime, and
back to Select during the same CY.
2.5.6 Figure 2.2-1 contains the deductibles that
apply to TRICARE Select beneficiaries for CY 2018. These fees shall
be updated annually in accordance with
paragraph 2.4 and shall be
posted at
http://www.health.mil/rates.
Figure 2.2-1 TRICARE
Select Deductibles for CY 2018
|
TRICARE SELECT**
|
Group
A ADFM
|
Group
B ADFM
|
Group
A
|
Group
b
|
|
E1-E4
|
e-5 &
Above
|
E1-E4
|
e-5 &
ABOVE
|
Retirees
|
Retirees
|
|
* Group
B Retirees have a separate out-of-network deductible. The out-of-network
deductible is separate from the in network deductible and must be
paid in addition to the in network deductible. For example, if a
Group B retiree beneficiary had met their $150 network deductible,
and then chooses to see an out-of-network provider, the beneficiary
must pay the additional $300 out-of-network deductible before TRICARE
will cost-share out-of-network care.
** If a beneficiary has a partially-fulfilled
deductible, and the next service will meet the deductible, the beneficiary
must meet their deductible and then may be subject to the additional
copayment, if the remaining deductible was less than the applicable
copayment:
Example
1: An E1 Group B ADFM has met $25 of their $50 deductible.
They visit their primary care physician, and the visit has an allowable
charge of $100. The beneficiary is responsible for $25 of the service,
and has thus met their deductible.
Example 2: The same Group
B ADFM has met $45 of their $50 deductible. They visit their primary
care physician, and the visit has an allowable charge of $100. The
beneficiary is responsible for the remaining $5 plus the $15 copayment,
for a total of $20.
*** Out-of-network
deductibles apply to the catastrophic cap.
|
|
In-Network
|
$50/$100
|
$150/$300
|
$50/$100
|
$150/$300
|
$150/$300
|
$150/$300
|
|
Out-Of-Network
|
$300/$600*
|
2.6
Cost-Shares
and Copayments
2.6.1 This paragraph provides an
overview of the establishment and general applicability of TRICARE
cost-shares and copayments for each TRICARE plan and category of
beneficiary.
2.6.2 TRICARE Prime Group A and
Group B ADFM Enrollees. Prime enrollees have $0.00 copayment for
covered health care services obtained in accordance with Prime rules
and procedures. If otherwise covered health care services are not
obtained in accordance with Prime rules and procedures, the services
may be covered under the POS option (
Section 5), including
a separate deductible of $300 per individual or $600 per family.
This would include any non-emergency out of network care obtained
by a Prime beneficiary without following applicable referral requirements. Pharmacy
copayments are in addition to any TRICARE Prime copayments.
2.6.3 TRICARE Select Group A ADFM and Retiree Enrollees.
2.6.3.1 Care received from network providers. The cost-sharing
amounts for covered health care services obtained from a network
provider are fixed dollar amounts for each specified category of
care and are set prospectively for each calendar year with the annual
updates available at
http://www.health.mil/rates.
2.6.3.2 Care received from non-network providers. The
cost-sharing amounts for covered health care services obtained from
a non-network provider are as provided in
32 CFR 199.4 and
Section 1.
2.6.4 TRICARE Select Group B ADFM and Retiree Enrollees.
The cost-sharing amounts for covered health care services for CY
2018 are established by 10 USC 1075 and shall be updated annually
in accordance with
paragraph 2.3, with the annual updates available
at
http://www.health.mil/rates.
The cost-sharing amounts are unique for Group B ADFMs and for Group
B Retirees and include different cost-sharing amounts within each
beneficiary category depending on whether the covered health care services
are obtained from a network provider or from a non-network provider.
2.6.5 CHAMPUS Maximum Allowable Charge (CMAC) impact
on cost-sharing. In instances where the CMAC or allowable charge
is less than the copayment established by this section and published
on the DHA website, network providers may only collect the lower
of the allowable charge or the applicable copayment.
2.6.6 Services with Set Copayments. Copayments apply
only after any applicable deductibles have been satisfied, except
for preventive care, which is available (when all conditions of
coverage are met) with no copayment from network physicians, regardless
of whether or not applicable deductibles have been satisfied.
2.7 Cost-shares for services are as follows:
2.7.1 Preventive
Care Outpatient Visits Under TRICARE Prime and Select
2.7.1.1 TRICARE Prime enrollees may receive Prime clinical
preventive services from any network provider within their region
of enrollment without referral or authorization. See the TRICARE
Policy Manual (TPM),
Chapter 7, Section 2.2 for a list of these
services. If a Prime clinical preventive service is not available
from a network provider, an enrollee may receive the service from
a non-network provider with a referral from the Primary Care Manager
(PCM) and authorization from the contractor. If an enrollee uses
a non-network provider without first obtaining a referral from their
PCM and authorization from the contractor, payment is made under
the POS option only for services that are otherwise covered under
the TRICARE Basic Program and described in the TPM,
Chapter 7, Section 2.1. Payment shall not
be made under the POS option for clinical preventive services that
are not otherwise covered under the TRICARE Basic Program.
2.7.1.2 TRICARE Select enrollees may receive Prime
clinical preventive services when furnished by a network provider.
If a TRICARE Select enrollee uses a non-network provider, payment
is made only for clinical preventive services that are otherwise
covered under the TRICARE Basic Program.
2.7.1.3 No copayments or cost-shares are required for
additional clinical preventive services authorized under
32 CFR 199.4(e)(28) and described in the TPM,
Chapter 7, Sections 2.1,
2.2, and
2.5 whether
received from network or non-network providers. However, TRICARE
Prime beneficiaries are required to obtain services in accordance
with the rules and procedures of Prime to avoid POS charges.
2.7.1.4 No copayments or authorizations are required
for covered clinical preventive services not normally provided as
part of the TRICARE Basic program under
32 CFR 199.4(e)(28) when provided to Prime
and Select enrollees by network providers. These specific set of
services shall be established by the Director, DHA, and announced
annually before the open season enrollment period. Such preventive
care outpatient visits may include: laboratory and imaging tests;
cancer screenings; immunizations; periodic health promotion and
disease prevention exams (e.g., well-child care); blood pressure
screening; hearing exams; sigmoidoscopy or colonoscopy; serologic
screening; and appropriate education and counseling services as
specified by the Director, DHA. A beneficiary is not required to
pay any portion of the cost of covered, in-network preventive services
even if the beneficiary’s deductible has not yet been fulfilled.
Figure 2.2-2 TRICARE Prime Cost-Shares for
Preventive Care Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
* Those
services listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1 are
exempt from cost-share requirements.
|
|
Prime Preventive
Care Visits (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Basic Preventive
Care Visits (CY 2018), Out-Of-Network* when obtained in accordance
with established rules
|
$0
|
$0
|
$0
|
$0
|
Figure 2.2-3 TRICARE Select Cost-Shares for
Preventive Care Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
* Those
services listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1 are
exempt from cost-share requirements.
|
|
Select Preventive
Care Visits (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Basic Preventive
Care Visits (CY 2018), Out-Of-Network*
|
$0
|
$0
|
$0
|
$0
|
2.7.2 Primary
Care Outpatient Visits
Primary care outpatient
visits to include any PCM as designated in TPM,
Chapter 1, Section 7.1. Includes the services
of the individual professional provider as well as all medical supplies
used within the office and ancillary services and the treatment
room.
Figure 2.2-4 TRICARE Prime Cost-Shares for
Primary Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Primary Care
Outpatient Visits (CY 2018), In-Network
|
$0
|
$0
|
$20
|
$20
|
Figure 2.2-5 TRICARE Select Cost-Shares for
Primary Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Primary
Care Outpatient Visits (CY 2018), In-Network
|
$21
|
$15
|
$28
|
$25
|
|
Primary
Care Outpatient Visits (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.3 Specialty
Care Outpatient Visits
This category applies
to outpatient care provided by provider specialties other than those listed
under primary care outpatient visits. Includes the services of the
individual professional provider as well as all medical supplies
used within the office and ancillary services and the treatment
room. This category also includes partial hospitalization services,
intensive outpatient treatment, and opioid treatment program services.
The per visit fee shall be applied on a per day basis on days services
are received, with the exception of opioid treatment program services
reimbursed in accordance with 32 CFR 199.14
(a)(2)(ix)(A)(3)(i) which per visit fee will
apply on a weekly basis.
Figure 2.2-6 TRICARE Prime Cost-Shares for
Specialty Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Specialty
Care Outpatient Visits (CY 2018)
|
$0
|
$0
|
$30
|
$30
|
Figure 2.2-7 TRICARE Select Cost-Shares for
Specialty Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Specialty
Care Visits (CY 2018), In-Network
|
$31
|
$25
|
$41
|
$40
|
|
Specialty
Care Visits (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.4 Ancillary
Care
2.7.4.1 TRICARE
Prime enrollees have no copayments for the ancillary services in
the categories listed below (normal referral and authorization provisions
apply). Current Procedural Terminology (CPT) code ranges are given;
however, these codes are not all-inclusive. The most up-to-date
codes should be utilized to identify services within each category,
in accordance with the TOM,
Chapter 1, Section 4. When Prime rules and
procedures are not followed, POS charges may apply. Additionally,
listing the code ranges does not imply coverage; the codes just
provide the broad range of services that are not subject to copayments
under this provision:
• Diagnostic radiology
and ultrasound services included in the CPT procedure code range
from 70010-76999, or any other code for associated contrast media;
• Diagnostic nuclear
medicine services included in the CPT procedure code range from 78012-78999;Pathology
and laboratory services included in the CPT procedure code range
from 80047- 89398; G0461-G0462 (during 2014); and
• Cardiovascular studies
included in the CPT procedure code range from 93000-93355.
• Venipuncture included
in the CPT procedure code range from 36400-36425.
• Fetal monitoring for
CPT procedure codes 59020, 59025, and 59050.
• Collection of blood
specimens in the CPT procedure codes 36591 and 36592.
Note: Multiple discounting will not be applied to the
following CPT procedure codes for venipuncture, fetal monitoring,
and collection of blood specimens; 36400-36425, 36591, 36592, 59020, 59025,
and 59050.
2.7.4.2 TRICARE
Select enrollees have no copayments for ancillary services (defined
in
paragraph 2.7.4.1) provided by network providers.
Ancillary services for TRICARE Select beneficiaries are cost-shared
as follows:
Figure 2.2-8 TRICARE Select Cost-Shares for
Ancillary Services
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Ancillary
Services (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Ancillary
Services (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.5 Other
Radiology Services
Radiology Services are
considered ancillary services for TRICARE Prime enrollees and all Prime
rules and procedures apply. TRICARE Select enrollees who obtain
radiology services from network providers have no cost-share. TRICARE
Select enrollees who receive other radiology services from non-network
providers are subject to the following cost-shares:
Figure 2.2-9 TRICARE Select Cost-Shares for
Other Radiology Services
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Radiology
Services (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Radiology
Services (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.6 Eye Examinations
2.7.6.1 TRICARE
Prime. One routine examination per year for TRICARE Prime family
members of active duty sponsors. One routine examination every other
year for TRICARE Prime retirees and their family members per the
TPM,
Chapter 7, Section 2.2.
Figure 2.2-10 TRICARE Prime Cost-Shares for
Eye Examinations
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Eye Examinations
(CY 2018)
|
$0
|
$0
|
$0
|
$0
|
2.7.6.2 TRICARE
Select. Eye examinations received from in-network and out-of-network
providers by TRICARE Select ADFMs may be cost-shared as follows.
Eye examinations for TRICARE Select retirees are not a TRICARE benefit.
See the TPM,
Chapter 7, Section 6.1.
Figure 2.2-11 TRICARE Select Cost-Shares for
Eye Examinations
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Eye
Examinations (CY 2018), In-Network
|
$0
|
$0
|
NA
|
NA
|
|
Eye
Examinations (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
NA
|
NA
|
2.7.7 Emergency
Room (ER) Visits
Emergency care obtained
on an outpatient basis in network or non-network facilities, in-region
or out-of-region.
2.7.7.1 The TRICARE
Prime and Select copayment requirement for ER services is on a PER
VISIT basis; this means that only one copayment is applicable to
the entire ER episode, regardless of the number of providers involved
in the patient’s care and regardless of their status as network
providers.
2.7.7.2 POS charges
do not apply to emergency care. See the TOM,
Chapter 8, Section 5, paragraph 2.6.
Figure 2.2-12 TRICARE Prime Cost-Shares for
Emergency Room (ER) Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
ER
Visits (CY 2018)
|
$0
|
$0
|
$60
|
$60
|
Figure 2.2-13 TRICARE Select Cost-Shares for
Emergency Room (ER) Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
ER
Visits (CY 2018), In-Network
|
$81
|
$40
|
$109
|
$80
|
|
ER
Visits (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.8 Urgent
Care Visits
The usual TRICARE Prime referral
requirement may be waived for some or all urgent care visits for
TRICARE Prime enrollees other than most active duty members. The
specific number of urgent care visits without a referral for TRICARE
Prime enrollees is determined annually prior to the beginning of
the open season enrollment period. When the urgent care referral
is waived, no POS deductibles and cost-shares shall apply when urgent
care is provided by a TRICARE network provider or a TRICARE-authorized
(network or non-network) Urgent Care Center (UCC) or Convenience
Clinic (CC). If the enrollee seeks care from a non-network provider
(except a TRICARE-authorized UCC or CC), the usual POS deductible
and cost-shares shall apply. See the TOM,
Chapter 8, Section 5, for information on which
TRICARE Prime plan enrollees do not require a referral.
Figure 2.2-14 TRICARE Prime Cost-Shares for
Urgent Care Center (UCC) Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
UCC
Visits (CY 2018)
|
$0
|
$0
|
$30
|
$30
|
Figure 2.2-15 TRICARE Select Cost-Shares for
Urgent Care Center (UCC) Visits
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
UCC
Visits (CY 2018), In-Network
|
$21
|
$20
|
$28
|
$40
|
|
UCC
Visits (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.9 Ambulatory
Surgery
Authorized hospital-based or Freestanding Ambulatory Surgical Center (FASC) that
is TRICARE certified. Also includes prenatal care, outpatient delivery,
and postnatal care provided by a TRICARE authorized birthing center.
No cost-share shall be deducted from a claim for professional services
related to ambulatory surgery. This applies whether the services
are performed in an FASC, or a Hospital Outpatient Department (HOPD).
So long as at least one procedure on the claim is reimbursed as
ambulatory surgery, the claim shall be cost-shared as ambulatory
surgery.
Figure 2.2-16 TRICARE Prime Cost-Shares for
Ambulatory Surgery (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Ambulatory
Surgery (CY 2018)
|
$0
|
$0
|
$60
|
$60
|
Figure 2.2-17 TRICARE Select Cost-Shares for
Ambulatory Surgery (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Ambulatory
Surgery (CY 2018), In-Network
|
$25
|
$25
|
20%
of allowable charge
|
$95
|
|
Ambulatory
Surgery (CY 2018), Out-Of-Network
|
$25
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.10 Ambulance
Services
Ambulance services, when medically
necessary as defined in the TPM and when the service is a covered
benefit. POS charges do not apply to emergency care; see the TOM,
Chapter 8, Section 5, paragraph 2.6.
Figure 2.2-18 TRICARE Prime Cost-Shares for
Ambulance Services (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
* In-
and Out-Of-Network.
|
|
Outpatient
Ground Ambulance (CY 2018)*
|
$0
|
$0
|
$40
|
$40
|
|
Outpatient
Air Ambulance (CY 2018)*
|
$0
|
$0
|
$20
|
$20
|
|
Inpatient (Transfers
rendered in conjunction with an inpatient stay.) (CY 2018)*
|
$0
|
$0
|
25%
of allowable charge
|
25%
of allowable charge
|
Figure 2.2-19 TRICARE Select Cost-Shares for
Ambulance Services
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
* In-
and Out-Of-Network.
|
|
Outpatient
Ground Ambulance (CY 2018), In-Network
|
$74
|
$15
|
$98
|
$60
|
|
Outpatient
Ground Ambulance (CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
|
Outpatient
Air Ambulance (CY 2018)*
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
|
Inpatient (Transfers
rendered in conjunction with an inpatient stay.) (CY 2018)*
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.11 Durable
Medical Equipment (DME)
DME, hearing aids
for ADFMs, and medical supplies prescribed by an authorized provider which
are covered benefits, if dispensed for use outside of the office
or after the home visit.
Figure 2.2-20 TRICARE Prime Cost-Shares for
Durable Medical Equipment (DME)
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
DME
(CY 2018)
|
$0
|
$0
|
20%
of allowable charge
|
20%
of allowable charge
|
Figure 2.2-21 TRICARE Select Cost-Shares for
Durable Medical Equipment (DME)
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
DME
(CY 2018), In-Network
|
15%
of allowable charge
|
10%
of allowable charge
|
20%
of allowable charge
|
20%
of allowable charge
|
|
DME
(CY 2018), Out-Of-Network
|
20%
of allowable charge
|
20%
of allowable charge
|
25%
of allowable charge
|
25%
of allowable charge
|
2.7.12 Inpatient Hospital Admission
Semiprivate room (when medically necessary,
special care units), general nursing, and hospital service. Includes
inpatient physician and their surgical services, meals including
special diets, drugs, and medication while an inpatient, operating
and recovery room, anesthesia, laboratory tests, x-ray and other
radiology services, necessary medical supplies and appliances, blood
and blood products. Also, includes maternity hospital and professional
services (prenatal, delivery, postnatal). Includes inpatient hospital
admissions in all acute care, specialty (i.e., cancer and children’s
hospitals), and mental health hospitals.
2.7.12.1 For inpatient hospital admissions subject to
the inpatient mental health per diem payment system, the following
special rules apply:
2.7.12.1.1 Lower volume
hospitals and units: For care paid on a regional per diem, the cost-share shall
be calculated in accordance with
Section 1, paragraph 1.3.3.5.4.2.
2.7.12.1.2 A claim subject to the inpatient mental health
per diem payment system which spans a period in which two separate
per diems exist shall have the cost-share computed on the actual
per diem in effect for each day of care.
2.7.12.1.3 Cost-share whenever leave days are involved.
There is no patient cost-share for leave days when such days are
included in a hospital stay.
2.7.12.1.4 Claims
for services that are provided during an inpatient admission which
are not included in the per diem rate shall be cost-shared as an
inpatient claim if the contractor cannot determine where the service
was rendered and the status of the patient when the service was provided.
The contractor shall examine the claim for place of service and
type of service to determine if the care was rendered in the hospital
while the beneficiary was an inpatient of the hospital. This would include
non-mental health claims and mental health claims submitted by individual
professional providers rendering medically necessary services during
the inpatient admission.
2.7.12.2 All final claims reimbursed under the TRICARE
Diagnosis Related Group (DRG)-based payment system are to be priced
using the rules, weights and rates in effect as of the date of discharge. Interim
claims with “end date of care” shall be priced using the rules,
weights and rates in effect as of the “end date of care.” See
Chapter 6, Section 3, paragraph 3.3.1.
Figure 2.2-22 TRICARE Prime Cost-Shares for
Inpatient Hospitalizations
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Inpatient Hospitalization
(CY 2018)
|
$0
|
$0
|
$150/admission
|
$150/admission
|
Figure 2.2-23 TRICARE Select Cost-Shares for
Inpatient Hospitalizations
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
|
|
Inpatient
Hospitalization (CY 2018), In-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
$60/admission
|
$250/day
or 25% of the hospital’s total charges (based on the fee schedule negotiated
by the contractor) whichever is less, plus 20% of separately billed
professional charges
|
$175/admission
|
|
Inpatient
Hospitalization (CY 2018), Out-Of-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
20%
of allowable charge
|
DRG
per diem ($901/day) or 25% of the hospital’s billed charges for institutional
services, whichever is less, plus 25% of separately billed professional
charges
|
25%
of allowable charge
|
2.7.13 Inpatient
Skilled Nursing/Inpatient Rehabilitation
This
category includes a Residential Treatment Center (RTC) or Substance
Use Disorder Rehabilitation Facility (SUDRF) residential treatment
program. For Skilled Nursing Facility (SNF) care, this is the same
benefit as Medicare except there is no limitation as to the number
of days of coverage. Benefit includes semiprivate room; regular
nursing services; meals including special diets; physical, occupational,
and speech therapy; drugs furnished by the facility; necessary medical
supplies; and appliances.
Figure 2.2-24 TRICARE Prime Cost-Shares for
Skilled Nursing/Rehabilitation Facilities
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
SNF/Rehab Facilities
(CY 2018)
|
$0
|
$0
|
$30/day
|
$30/day
|
Figure 2.2-25 TRICARE Select Cost-Shares for
Skilled Nursing/Rehabilitation Facilities
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
|
|
SNF/Rehab
Facilities (CY 2018), In-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
$25/day
|
$250/day
up to 25% of the hospital’s total charge plus 20% of separately billed
services
|
$50/day
|
|
SNF/Rehab
Facilities (CY 2018), Out-Of-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
$50/day
|
25%
of allowable charge
|
Lesser
of $300/day or 20% of allowable charge
|
2.7.14 Home Health and Hospice
Home Health Care (HHC) provided by a Home Health
Agency (HHA) and reimbursed in accordance with
Chapter 12 has
no cost-share for all beneficiary categories. Hospice care provided
in accordance with
Chapter 11 has no cost-share for all beneficiary
categories.
2.7.15 Maternity Care
For routine maternity episodes, there is a
single beneficiary cost-share or copayment, depending on the beneficiary
category, site of service, and rendering provider. Maternity care
shall be cost-shared as follows:
2.7.15.1 A single inpatient cost-share applies to maternity
care ending in childbirth in, or on the way to, a hospital inpatient
childbirth unit, and for maternity care ending in a non-birth outcome
not otherwise excluded. Inpatient cost-share formula applies to
prenatal and postnatal care provided in the office of a civilian
physician or certified nurse-midwife in connection with maternity
care ending in childbirth or termination of pregnancy in, or on
the way to, a Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) inpatient childbirth unit. Aside from the applicable
single inpatient cost-share, there is no separate cost-share for
separately billed professional charges or prenatal or postnatal
care involved in these routine maternity episodes.
2.7.15.2 A single ambulatory surgery cost-share applies
to maternity care ending in childbirth in, or on the way to, a birthing
center to which the beneficiary is admitted, and from which the
beneficiary has received prenatal care, or a hospital-based outpatient
birthing room.
2.7.15.3 A single
outpatient cost-share applies to maternity care which terminates
in a planned childbirth at home. If the care is rendered b a PCM
(as defined in the TPM,
Chapter 1, Section 7.1, paragraph 1.1.2),
it shall be cost-shared as a primary care visit. If provided by
a specialist, it shall be cost-shared as a specialty visit.
2.7.15.4 Otherwise covered medical services and supplies
directly related to “complications of pregnancy”, as defined in
the Regulation, will be cost-shared on the same basis as the related
maternity care for a period not to exceed 42 days following termination
of the pregnancy and thereafter cost-shared on the basis of the
inpatient or outpatient status of the beneficiary when medically
necessary services and supplies are received.
2.7.15.5 Otherwise authorized services and supplies
related to maternity care, including maternity related prescription
drugs, shall be cost-shared on the same basis as the termination
of pregnancy.
2.7.15.6 Claims
for pregnancy testing are cost-shared on an outpatient basis when
the delivery is on an inpatient basis.Where the beneficiary delivers
in a professional office birthing suite located in the office of a
physician or certified nurse-midwife (which is not otherwise a TRICARE-approved
birthing center) the delivery is to be adjudicated as an at-home
birth.
2.7.15.8 Claims
for prescription drugs provided on an outpatient basis during the
maternity episode but not directly related to the maternity care
are cost-shared on an outpatient basis.
2.7.15.9 All admissions related to a single maternity
episode shall be considered one confinement regardless of the number
of days between admissions. For ADFMs, the cost-share shall be applied
to the first institutional claim received.
2.7.15.10 Medically necessary treatment rendered to a
pregnant woman for a non-obstetrical medical, anatomical, or physiological
illness or condition shall be cost-shared as a part of the maternity episode
when:
2.7.15.10.1 The treatment
is otherwise allowable as a benefit; and
2.7.15.10.2 Delay of the treatment until after the conclusion
of the pregnancy is medically contraindicated; and
2.7.15.10.3 The illness or condition is, or increases the
likelihood of, a threat to the life of the mother; or
2.7.15.10.4 The illness or condition will cause, or increase
the likelihood of, a stillbirth or newborn injury or illness; or
2.7.15.10.5 The usual course of treatment must be altered
or modified to minimize a defined risk of newborn injury or illness.
Figure 2.2-26 TRICARE
Prime Cost-Shares for Maternity - Hospital Delivery
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Maternity
- Hospital Delivery (CY 2018), In-Network
|
$0
|
$0
|
$150
|
$150
|
|
Maternity
- Hospital Delivery (CY 2018), Out-of-Network
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS
charges may apply to non-emergency care
|
POS
charges may apply to non-emergency care
|
Figure 2.2-27 TRICARE
Select Cost-Shares for Maternity - Hospital Delivery
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Maternity
- Hospital Delivery (CY 2018), In-Network
|
Subsistence charge
per day ($18.60), minimum $25/admission
|
$60
|
$250/day
or 25% of the hospital’s total charges (based on the fee schedule negotiated
by the contractor), whichever is less, plus 20% of separately billed professional charges
|
$175
|
|
Maternity
- Hospital Delivery (CY 2018), Out-of-Network
|
Subsistence charge
per day ($18.60), minimum $25/admission
|
20% of the allowable charge
|
DRG per diem ($901/day)
or 25% of the hospital’s billed charges for institutional services, whichever
is less, plus 25% of separately billed professional charges
|
25% of the allowable charges
|
Figure 2.2-28 TRICARE
Prime Cost-Shares for Maternity - Birthing Center
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Maternity
- Birthing Center (CY 2018), In-Network
|
$0
|
$0
|
$60
|
$60
|
|
Maternity
- Birthing Center (CY 2018), Out-of-Network
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS
charges may apply to non-emergency care
|
POS
charges may apply to non-emergency care
|
Figure 2.2-29 TRICARE
Select Cost-Shares for Maternity - Birthing Center
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Maternity
- Birthing Center (CY 2018), In-Network
|
$25
|
$25
|
20%
of the allowable charge
|
$95
|
|
Maternity
- Birthing Center (CY 2018), Out-of-Network
|
$25
|
20%
of the allowable charge
|
25%
of the allowable charge
|
25%
of the allowable charge
|
Figure 2.2-30 TRICARE
Prime Cost-Shares for Maternity - Home Delivery
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Maternity
- Home Delivery (CY 2018), In-Network
|
$0
|
$0
|
$20/$30
|
$20/$30
|
|
Maternity
- Home Delivery (CY 2018), Out-of-Network
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS
charges may apply to non-emergency care
|
POS
charges may apply to non-emergency care
|
Figure 2.2-31 TRICARE
Select Cost-Shares for Maternity - Home Delivery
|
|
ADFM
|
Retiree
|
|
Group
A
|
Group
B
|
Group
A
|
Group
b
|
|
Maternity
- Home Delivery (CY 2018), In-Network (primary care cost-share/specialty
care cost-share)
|
$27/$34
|
$15/$25
|
$35/$45
|
$25/$40
|
|
Maternity
- Home Delivery (CY 2018), Out-of-Network
|
20%
of the allowable charge
|
20%
of the allowable charge
|
25%
of the allowable charge
|
25%
of the allowable charge
|
2.7.16 Newborn Care
Effective for all inpatient admissions occurring
on or after October 1, 1987, separate claims must be submitted for
the mother and newborn. The cost-share for inpatient claims for
services rendered to a beneficiary newborn is determined as follows:
2.7.16.1 Same newborn date of birth and date of admission.
For care where a cost-share is determined on a per diem basis, the
cost-share shall be calculated in accordance with this section; however,
the number of days shall be reduced by three.
2.7.16.2 Different newborn date of birth and date of
admission. The cost-share shall be applied to all days in an inpatient
stay.
2.8 Cost-Shares and Deductibles:
Former Spouses
2.8.1 Deductible. In accordance
with the FY 1991 Appropriations and Authorization Acts, Sections
8064 and 712 respectively, beginning April 1, 1991, an eligible
former spouse is responsible for payment of the first one hundred
and fifty dollars ($150.00) of the reasonable costs/charges for otherwise
covered outpatient services and/or supplies provided in any one
fiscal year (effective January 1, 2018, in any one calendar year).
Although the law defines former spouses as family members of the
member or former member, there is no legal familial relationship
between the former spouse and the member or former member. Moreover,
any TRICARE-eligible children of the former spouse will retain a
legal familial relationship with the member or former member and
shall be included in the member’s or former member’s family deductible.
The former spouse cannot contribute to, nor benefit from, any family
deductible of the member or former member to whom the former spouse
was married or of that of any TRICARE-eligible children. In other
words, a former spouse must independently meet the $150.00 deductible
in any fiscal year (effective January 1, 2018, in any calendar year).
2.8.2 Cost-Share. An eligible former spouse is responsible
for payment of cost-sharing amounts identical to those required
for beneficiaries other than ADFMs.
2.9 Cost-Share
Amount
Under discounted rate agreements.
In cases where the cost-share is calculated as a percentage rather
than a fixed amount, the percentage shall be applied to (after duplicates
and noncovered charges are eliminated), the lowest of the billed
charge, the prevailing charge, the maximum allowable prevailing
charge (the Medicare Economic Index (MEI) adjusted prevailing),
or the negotiated (discounted) charge. If the contractor learns
that the participating provider has billed a beneficiary for a greater
cost-share amount, based on the provider’s usual billed charges,
the contractor shall notify the provider that such an action is
a violation of the provider’s signed agreement.
2.10 Exceptions
2.10.1 Inpatient
Cost-Share: Applicable To Each Separate Admission
On
or after January 1, 2018, for TRICARE Select Group A ADFMs only,
a separate cost-share amount is applicable to each separate beneficiary
for each inpatient admission EXCEPT:
2.10.1.1 Any readmission to an acute care hospital which
is not more than 60 days from the date of the last inpatient discharge
shall be treated as one inpatient confinement with the last admission
for cost-share amount determination.
2.10.1.2 Certain heart and lung hospitals are excepted
from cost-share requirements. See
Chapter 1, Section 27,
entitled “Legal Obligation To Pay”.
2.10.2 Inpatient
Cost-Share: Maternity Care
All admissions
related to a single maternity episode shall be considered one confinement regardless
of the number of days between admissions. For ADFMs, the cost-share
shall be applied to the first institutional claim received.
2.10.3 See
Section 6 for
waivers of cost-shares and deductibles.