1.0 POLICY
1.1 Existence
of Other Coverage
Double coverage consists
of medical benefits coverage by both TRICARE and another medical/hospital
insurance, medical service, or health plan (with the exception of
Medicaid and certain other programs identified by Defense Health
Agency (DHA), e.g., the Indian Health Service (IHS) and State Victims
Assistance Plans). Prior to payment of any claim for services or
supplies rendered to any TRICARE beneficiary, regardless of eligibility
status, it must be determined whether other coverage exists. If
other coverage exists, TRICARE coverage is available only as secondary
payer, and only after a claim has been filed with the other plan
and a payment determination issued. This must be done regardless
of any provisions contained in the other coverage. For example,
a dependent child who is eligible for TRICARE through his/her natural
parent may also be eligible for some other coverage through a step-parent.
The step-parent’s coverage is primary payer, regardless of any provision
in that coverage which provides that the natural parent’s coverage
is primary. A contractor shall coordinate benefits and obtain the
information regarding the other insurance payment to determine what
the TRICARE liability is to assure that:
1.1.1 TRICARE beneficiaries receive
maximum benefits from their health coverage, but no more than they
are entitled to receive, and
1.1.2 The combined payments under
TRICARE and the double coverage plan do not exceed the total charges.
1.2 Last Pay
Limitation
Except for certain situations
in which Medicare is the primary payer (see
Section 4, paragraph 1.0), no more can be
paid as secondary payer than would have been paid in the absence
of other coverage. TRICARE, as secondary payor, cannot reimburse
charges for any services or supplies which are not otherwise covered
under the program. TRICARE benefits cannot be paid for services
received prior to TRICARE eligibility. The application of double
coverage provisions does not extend or add to the usual payment
amounts under TRICARE.
1.3 Lack of Payment by Other Health
Insurer
Amounts which have been denied by
the other coverage simply because the claim was not filed timely
with the other coverage or because the beneficiary failed to meet
some other requirement of coverage cannot be paid. If a statement
from the other coverage as to how much would have been paid had
the claim met the other coverage’s requirements is provided to the
contractor, the claim can be processed as if the other coverage
actually paid the amount shown on the statement. If no such statement
is received, the claim is to be denied.
1.4 Definitions
1.4.1 Insurance
Plan
1.4.1.1 An insurance plan is any plan or program which
is designed to provide compensation or coverage for expenses incurred
by a beneficiary for medical services and supplies. It includes
plans or programs for which the beneficiary pays a premium to an
issuing agent as well as those plans or programs to which the beneficiary
is entitled by law or as a result of employment or membership in,
or association with, an organization or group. An insurance plan
provided to a beneficiary as a result of his or her status as a
student (student insurance) is also included.
1.4.1.2 Not included
are:
• So-called
supplemental insurance plans which, for all categories of beneficiaries, provide
solely for cash payment of deductibles, cost-shares, and amounts
for non-covered services due to program limitations or for which
the enrollee is liable (see
Chapter 1, Section 26);
or
• Income
maintenance programs which provide cash payments for periods of hospitalization
or disability, regardless of the amount or type of services required
or the expenses incurred. These plans are not intended to actually
pay for medical services, but are intended only to supplement the
beneficiary’s income during a time of increased expenses, and perhaps
lowered income. On the other hand, a plan which varies its benefits
depending on the care received or the patient’s diagnosis would
be considered health insurance coverage as opposed to an income
supplement and would be primary payer to TRICARE. Any payment made
directly to the provider of care as opposed to the beneficiary can
be assumed to be an insurance plan and not an income supplement;
or
• State
Victims of Crime Compensation Programs.
• Automobile liability/no
fault insurance which provide compensation for health and medical
expenses relating to a personal injury arising from the operation
of a motor vehicle.
1.4.2 Medical Service
Or Health Plan
1.4.2.1 A medical service or health plan is any plan
or program of an organized health care group, corporation or other
entity for the provision of health care to an individual from plan
providers, both professional and institutional. It includes plans
or programs for which the beneficiary pays a premium to an issuing
agent as well as those plans or programs to which the beneficiary
is entitled by law or as a result of employment or membership in,
or association with, an organization or group.
1.4.2.2 Not included
are:
• Certain
federal Government programs which are designed to provide benefits
to a distinct beneficiary population and for which entitlement does
not derive from either premium payment or monetary contribution
(e.g., Medicaid and Worker’s Compensation).
• Health care delivery
systems not considered within the definition of either an insurance plan,
medical service or health plan including the Department of Veterans
Affairs (DVA)/Veterans Health Administration (VHA),
the Maternal and Child Health Program, the Indian Health Services
(IHS), and entitlement to receive care from the designated provider.
These programs are designed to provide benefits to a distinct beneficiary population,
and they require no premium payment or monetary contribution prior
to obtaining care.
1.5 No Waiver
of Benefit From Other Insurer
Beneficiaries
may not waive benefits due from any plan which meets the above definitions.
If a double coverage plan provides, or may provide, benefits for
the services, a claim must be filed with the double coverage plan.
Refusal by the beneficiary to claim benefits from the other coverages
must result in a denial of TRICARE benefits. Benefits are considered
to be the services available. For example, if the other plan includes
psychotherapy as a benefit, but only by a psychiatrist, the beneficiary
cannot elect to waive this benefit in order to receive services
from a psychologist. For TRICARE for Life (TFL) claims, an exception
exists for mental health counselors and pastoral counselors as well
as for services received under a private contract (see
Section 4, paragraph 1.3.1.4).
1.6 Beneficiary
Liability
In all double coverage situations,
a beneficiary’s liability is limited by all TRICARE provisions.
As a result, a provider cannot collect from a TRICARE beneficiary
any amount that would result in total payment to the provider that
exceeds TRICARE limitations. For example, a beneficiary is not liable
for any cost-sharing or deductible amounts required by the primary
payer, if the sum of the primary payer’s and payments made by TRICARE
are at least equal to 115% of the allowable amount authorized by TRICARE
for a nonparticipating provider. This is true whether TRICARE actually
makes any payment or not. This also applies to claims from participating
non-network providers and from network providers. Because of the
payment calculations, the provider usually will receive payments
from the primary payer and from TRICARE that equal the billed charges.
In those rare cases where this does not occur, the provider cannot
collect any amount from the beneficiary that would result in payment
that exceeds the allowable amount authorized under TRICARE.
Note: It is important to note that this paragraph addresses
beneficiary liability and does not change in any way the amounts
the TRICARE Program will pay based on provisions elsewhere in this chapter.
1.7 Claims Processed
Under the Diagnosis Related Group (DRG)-Based Payment System or the
Inpatient Mental Health Per Diem Payment System
When
double coverage exists on a claim processed under the DRG-based
payment system or the inpatient mental health per diem payment system,
the payment cannot exceed an amount that, when combined with the
primary payment, equals the lesser of the DRG-based amount, the
inpatient mental health per diem based amount, or the hospital’s
charges for the services (including any discount arrangements).
Thus, when the DRG-based amount or the inpatient mental health per
diem based amount is greater than the hospital’s actual billed charge,
and the primary payer has paid the full billed charge, no additional
payment will be made under TRICARE. Similarly, when the DRG-based
amount or the inpatient mental health per diem based amount is less
than the hospital’s actual billed charge, and the primary payer
has paid the full DRG-based amount or inpatient mental health per
diem based amount, no additional payment can be made. Nor can the
hospital bill the beneficiary for any additional amounts
in these cases.
1.8 Claims Processed Under The
Reasonable Cost Method For Critical Access Hospitals (CAHs)
When double coverage exists on a claim processed
under the reasonable cost method for CAHs, the payment under TRICARE
cannot exceed an amount that when combined with the primary payment
equals the lesser of the established cap amount multiplied by the
billed charges or 101% of reasonable cost. The reasonable cost method
for CAHs is the lesser of the established/determined Cost-to-Charge
Ratio (CCR) cap (reference
Chapter 15, Section 1 for
Fiscal Year (FY) inpatient and outpatient CCR cap) multiplied by
billed charges or 101% of reasonable costs [1.01 x (hospital-specific
CCR x billed charges)].
1.9
No
Legal Obligation to Pay
Payment should not
be extended for services and supplies for which the beneficiary
or sponsor has no legal obligation to pay; or for which no charge
would be made if the beneficiary was not an eligible TRICARE beneficiary.
Whenever possible, all double coverage claims should be accompanied
by an Explanation Of Benefits (EOB) from the primary insurer. If
the existence of a participating agreement limiting liability of
a beneficiary is evident on the EOB, payment shall be limited to
that liability; however, if it is not clearly evident, the claim
shall be processed as if no such agreement exists.
1.10 Claims Processed
Under The CCR Methodology for Sole Community Hospitals (SCHs)
When double coverage exists on a claim processed
under the CCR methodology for SCHs, the payment under TRICARE cannot
exceed an amount that when combined with the primary payment equals
the lesser of billed charges, negotiated rate, or the CCR methodology
as described in
Chapter 15, Section 1.