1.0 APPLICABILITY
The
policy is mandatory for reimbursement of services provided by either
network or non-network providers. However, alternative network reimbursement
methodologies are permitted when approved by the Defense Health
Agency (DHA) and specifically included in the network provider agreement.
3.0 POLICY
3.1 A supplemental
insurance plan is a health insurance policy or other health benefit
plan offered by a private entity to a TRICARE beneficiary, that
primarily is designed, advertised, marketed, or otherwise held out
as providing payment for expenses incurred for services or items
that are not reimbursed under TRICARE due to program limitations,
or beneficiary liabilities imposed by law. TRICARE recognizes two
types of supplemental insurance plans; general indemnity plans,
and those offered through a direct service Health Maintenance Organization
(HMO).
3.2 An
indemnity supplemental insurance plan must meet all of the following
criteria:
3.2.1 It
provides insurance coverage, regulated by state insurance agencies,
which is available only to beneficiaries of TRICARE.
3.2.2 It is premium-based
and all premiums relate only to TRICARE supplemental coverage.
3.2.3 Its benefits
are limited to non-covered services, to the deductible and cost-share
portions of the predetermined allowable charges, and to amounts
exceeding the allowable charges for covered services.
3.2.4 It provides
reimbursement by making payment directly to the TRICARE beneficiary
or to the participating provider.
3.2.5 It does not operate in a manner which results
in lower deductibles or cost-shares than those imposed by law, or
that waives the legally imposed deductibles or cost-shares.
3.3 A supplemental
insurance plan offered by a HMO must meet all of the following criteria:
3.3.1 The HMO must
be authorized and must operate under relevant provisions of state
law.
3.3.2 The
HMO supplemental plan must be premium-based and all premiums must
relate only to TRICARE supplemental coverage.
3.3.3 The HMO’s benefits,
above those which are directly reimbursed by TRICARE, must be limited
predominantly to services not covered by TRICARE and TRICARE deductible
and cost-share amounts.
3.3.4 The HMO must provide services directly
to TRICARE beneficiaries through its affiliated providers who, in
turn, are reimbursed by TRICARE.
3.3.5 The HMO’s premium structure must be
designed so that no overall reduction in the amount of the beneficiary
deductibles or cost-shares will result.