1.0 DESCRIPTION
1.1 The provisions
of this section apply to family members who become eligible for
TRICARE as a result of their Reserve Component (RC) sponsor
(including those with delayed effective date active duty orders
up to 180 days) being called or ordered to active duty for more
than 30 days and choose to participate
in TRICARE Select, rather than enroll
in TRICARE Prime. The seven RCs include Army National Guard and
the Air National Guard.
1.2 These provisions help ensure
timely access to health care and maintain clinically appropriate continuity
of health care to family members of activated RC
sponsors, limit the out-of-pocket health care expenses for those
family members, and remove potential barriers to health care access
by RC families.
2.0 BACKGROUND
2.1 Section 704 of the National Defense Authorization
Act for Fiscal Year 2005 (NDAA FY 2005) (Public Law 108-375) amended the authority (10
United States Code (USC) 1095d(a)) to waive the annual
TRICARE Select deductible for RC family
members who became eligible for TRICARE as a result of their sponsor’s
activation in support of a contingency operation for more than 30
days.
2.2 Waiving the TRICARE deductible
appropriately limits out-of-pocket expenses for these RC family
members, many of whom may have already paid toward annual deductibles
under their civilian health plans.
2.3 Section 705 of the NDAA FY 2005 established
the authority to increase TRICARE payments up to 115% of the Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS) Maximum Allowable
Charge (CMAC), less the applicable patient cost-share if not previously
waived under the provisions of Section 704, for family members of
RC members on active duty orders for more than 30 days in support
of contingency operation, who receive covered inpatient and outpatient
health services from a provider that
does not participate (accept assignment) under TRICARE. This allows
this group of RC family members to continue to see civilian providers
with whom they have established relationships while promoting access
and clinically appropriate continuity of care.
2.4 The provisions outlined above were previously
provided to RC family members under the provisions of the Operation
Noble Eagle/Operation Enduring Freedom Reservist and National Guard Benefits
Demonstration (TRICARE Operations Manual (TOM),
Chapter 18)
and are now permanent. That demonstration was effective for claims
for services provided on or after September 14, 2001, and before
November 1, 2009.
2.5 Section
748(b) of the NDAA FY 2017 (Public Law 114-328) eliminated the requirement
that the active duty be in support of a contingency operation
,
effective December 23, 2016, for family members to obtain benefits
stated in paragraphs 2.1 and 2.3.
2.6 Section 701 replaces TRICARE Standard/Extra
with TRICARE Select effective January 1, 2018. See TRICARE Reimbursement
Manual (TRM),
Chapter 2.
3.0 POLICY
3.1 This
benefit is authorized for family members of RC members
,
excluding those whose members are Active Guard Reserve, who
are called or ordered to active duty for a period of more than 30
days.
Note: This special benefit does not apply
to TRICARE Prime enrollees.
3.2 Through
December 31, 2017, claims are to be paid from financially underwritten
funds. On claims for care from non-participating professional providers,
contractors shall allow the lesser of the billed charges or the
balance billing limit (115% of the allowable charge). If the charges
on a claim from a non-participating professional provider are exempt
from the balance billing limit, the contractor shall allow the billed
charges. This applies to all claims from non-participating professional
providers for services rendered to Standard beneficiaries. In double
coverage situations, normal double coverage requirements shall apply.
3.3 Starting January 1, 2018, TRICARE Select Group
B cost-shares apply. See TOM,
Appendix A,
for definition of Group B.
3.4 In
order to protect beneficiaries from incurring greater out-of-pocket
costs under these special procedures, the beneficiary cost-share
for these claims will be limited to what it would have been in the absence
of the higher allowable amount under this benefit. That is, the
cost-share is 20% of the lesser of the CMAC or the billed charge.
Any amounts that are allowed over the CMAC will be paid entirely
by TRICARE.
3.5 The TRICARE Encounter Data
(TED) record for each claim received subsequent to policy specified
in
paragraph 3.1 must
reflect the Special Processing Code
EF.
3.6 TED records submitted for non-participating
professional claims that are reimbursed at the lesser of the balance
billing limit or the billed charge are to be identified with Pricing
Rate Code W, but only if the allowed amount is greater
than the CMAC. If the billed charge equals or is less than the CMAC,
Pricing Rate Code W is not to be used. On the other
hand, when the claim is reimbursed as billed because the billed
charge is greater than the CMAC but less than the balance billing
limit, or the charges are exempt from the balance billing limit,
Pricing Rate Code W is to be used.
3.7 The
TRICARE Standard/Extra deductible (effective January 1, 2018, the
TRICARE Select deductible) is waived for all beneficiaries identified
by HCDP Special Entitlement codes 02, 03, or 08.
3.8 Starting January 1, 2018, family members will
have their deductibles waived and apply the TRICARE Select cost-shares.
Paragraphs
3.4 through
3.7 apply.