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Child
Vaccination Programs That Use An SVP Per Capita Assessment Approach
For Reimbursement
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1.
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DHA will
calculate the number of covered lives (i.e., Active Duty Family
Member (ADFM) and Non-Active Duty Family Member (NADFM) reliants
that are not enrolled at a Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (eMSM) in Prime, ages 0-18) (see Section 38 for details) each quarter. Defense
Health Agency (DHA) will estimate the percentage of TRICARE non-Active
Duty Dependent (ADD) reliants annually, and exclude any non-ADDs
who are not reliant on TRICARE as their primary form of insurance
in their covered lives population estimate. |
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2.
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Each SVP
may have its own time period for the population to be calculated.
The DHA will work with the state programs to ensure that the population
is calculated for the appropriate time frame in the state. DHA will,
on a quarterly basis, provide the contractors the number of covered
lives in each state. Some SVPs require quarterly payment, while
others require annual payments. DHA will determine which population
numbers are appropriate to use for the SVP-specific calculations.
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3.
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DHA will
also provide the contractors with a TRICARE per capita capped payment
amount for the time period needed for each SVP program. This information
may be provided directly to the contractor or posted on a DHA-approved
website.
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4.
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The contractors
shall follow the protocol established by each state to provide them
with the number of TRICARE covered lives for the dates requested
by the SVP.
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5.
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The contractors
shall identify whether the SVP per capita assessment amount provided
by the SVP is greater or less than the TRICARE per capita capped
payment amount.
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6.
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In some
states, the SVPs shall send an invoice to the contractors for a
payment, typically on a quarterly or annual basis. In other states,
the contractors shall proactively provide payment to the SVPs for
the liability amount.
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7.
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The contractors
shall pay the SVPs in one of two ways:
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a.
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If the
SVP per capita quarterly assessment amount is less than the TRICARE
per capita quarterly capped payment amount: The contractors will
pay the amount equal to the SVP per capita assessment amount multiplied
by the TRICARE reliant population
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b.
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If the
SVP per capita quarterly assessment amount is greater than the TRICARE
per capita quarterly capped payment amount: The contractors will
calculate the total TRICARE assessment amount to be paid to the
SVP as the number of TRICARE reliants (i.e., covered lives) in the
state multiplied by the TRICARE per capita capped payment amount.
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8.
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The contractors
shall submit payment to the SVPs either annually or quarterly depending
on the SVP.
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9.
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The
contractors shall be reimbursed using non-underwritten funds.
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Child
Vaccination Programs That Use An Alternative Approach - The State
Of Massachusetts
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1.
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For Massachusetts,
DHA will calculate the total TRICARE paid amounts made to acute
care hospitals and paid facility charges for hospital outpatient
departments and freestanding Ambulatory Surgery Center (ASC) facilities
for a period designated annually by the Massachusetts Vaccine Association
to calculate the annual Pediatric Immunization Program Assessment
(PIPA).
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2.
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DHA will
identify the PIPA surcharge percentage that is published annually
by the state of Massachusetts, and multiply this percentage by the
total paid amounts calculated above.
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3.
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DHA will
compare the MA assessment amount with the TRICARE payment capped
amount, as calculated by DHA using the reliant covered lives under
age 19 and an assessment amount.
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4.
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DHA will
provide the contractor with the total TRICARE assessment amount
to be paid to the state and the contractor shall submit payment
to the Massachusetts Vaccine Purchase Trust.
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5.
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The contractor
shall submit payment to the SVP by June 1st.
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6.
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The contractor
shall be reimbursed using non-underwritten funds.
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Adult
Vaccination Programs That Use An SVP Per Capita Assessment Approach
for Reimbursement
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1.
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DHA will
calculate the number of covered lives (i.e., ADFM and NADFM reliants
that are not enrolled at an MTF/eMSM in Prime, for the ages in which
adult vaccines are provided in the state) each quarter. The term
“reliants” refers to a subset of TRICARE eligible beneficiaries
who are dependent on TRICARE for the coverage/reimbursement of vaccines
under the well-child and preventive benefits. All TRICARE ADFMs
are considered to be reliant on TRICARE as their primary form of insurance.
DHA will estimate the percentage of TRICARE non-ADD reliants annually,
and will exclude any non-ADDs who are not reliant on TRICARE as
their primary form of insurance in their covered lives population
estimate.
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2.
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Each state
adult SVP may have its own time periods for the population to be
calculated. DHA will work with the state programs to ensure that
the population is calculated for the appropriate time frame in the
state. DHA will, on a quarterly basis, provide the contractors the
number of covered lives in each state.
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3.
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DHA will
calculate a state-specific TRICARE per capita capped payment amount
for each quarter using data from only the adult vaccines that are
provided in the state. DHA will determine if multiple state per
capita capped rates are required based on age. For example, if a
state program provides vaccines to the Medicare-eligible population,
DHA will exclude any Medicare-covered adult vaccines from the calculation
of a capped amount used for the age 65 and older population in that
state only.
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4.
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DHA will
provide the contractors with the number of covered reliants in the
state, and the TRICARE state-specific per capita capped payment
amount(s). DHA may provide these values directly to the contractor,
or via a website designed for DHA SVP programs.
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5.
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The contractor
provide the Adult SVP program with the number of adult TRICARE reliants
in which ever mechanism that is agreed upon by the contractor and
the state (via memo, online survey, web-portal, etc.) for each time
period requested by the SVP.
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6.
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In some
states, the SVPs shall send an invoice to the contractors for a
payment, typically on a quarterly or annual basis. In other states,
the contractors will proactively provide payment to the SVPs for
the liability amount.
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7.
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The contractor
shall identify whether the SVP Adult per capita assessment amount
is greater than the calculated TRICARE per capita capped payment
amount.
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8.
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The contractors
shall pay the SVPs in one of two ways:
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a.
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If the
SVP per capita quarterly assessment amount is less than the TRICARE
per capita quarterly capped payment amount: The contractors will
pay the amount equal to the SVP per capita assessment amount multiplied
by the TRICARE reliant population.
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b.
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If the
SVP per capita quarterly assessment amount is greater than the TRICARE
per capita quarterly capped payment amount: The contractors will
calculate the total TRICARE assessment amount to be paid to the
SVP as the number of TRICARE reliants (i.e., covered lives) in the
state multiplied by the TRICARE per capita capped payment amount.
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9.
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The contractor
shall submit payment to the SVP.
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10.
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The
contractor shall be reimbursed using non-underwritten funds.
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