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.