3.1 Through
December 31, 2017, TRICARE offers beneficiaries three health care
options:
3.1.1 TRICARE Prime
Plan
Beneficiaries who enroll in TRICARE Prime
are assigned or select a Primary Care Manager (PCM). A PCM is a
provider of primary care, who furnishes or arranges for all health
care services required by the Prime enrollee. Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM) Commanders have
the authority and responsibility to set priorities for enrollment
to MTF/eMSM PCMs. When an MTF’s/eMSM’s primary care capacity is
full, civilian PCMs, who are all part of the contractor’s network,
are available to provide care to patients.
3.1.1.1 Expanded benefits.
As enrollees of Prime, patients receive certain clinical preventive services
that are provided without cost-share for the patient.
3.1.1.2 Reduced cost.
Prime enrollees’ cost-share for civilian services is substantially
reduced from that which is applicable under TRICARE Extra and TRICARE
Standard. In addition, when a TRICARE Prime enrollee is referred
to a non-participating provider, the enrollee is only responsible
for the copayment amount, but not for any balance billing amount
by the non-participating provider.
3.1.2 TRICARE Extra Plan
Beneficiaries
who do not enroll in Prime may still benefit from using the providers
in the contractor’s network where possible. On a case by case basis,
beneficiaries may participate in TRICARE Extra by receiving care
from a network provider. The beneficiary will take advantage of
the reduced charges under Extra and a reduction in cost-shares.
Covered services are the same as under TRICARE Standard. This option
is terminated as of December 31, 2017 and replaced by TRICARE Select.
3.1.3 TRICARE Standard
Plan
The TRICARE Standard plan is a fee-for-service
program. This option is terminated as of December 31, 2017 and replaced
by TRICARE Select.
3.2 Beginning January 1, 2018, the TRICARE
program consists of three options: TRICARE Prime, TRICARE Select,
and TRICARE For Life (TFL). See 10 United States Code (USC) 1072(7).
3.2.1 TRICARE Prime
Plan
TRICARE Prime is a Health Maintenance Organization
(HMO)-like program. It generally features use of MTFs and substantially
reduced out-of-pocket costs for authorized care provided outside
MTFs. Beneficiaries generally agree to use MTFs and designated civilian
provider networks and to follow certain managed care rules and procedures.
Beneficiaries who enroll in TRICARE Prime are assigned or select
a PCM. A PCM is a provider of primary care, who furnishes or arranges
for all health care services required by the Prime enrollee. MTF/Enhanced
Multi-Service Market (eMSM) Commanders have the authority and responsibility
to set priorities for enrollment to MTF/ eMSM PCMs. When an MTF’s/eMSM’s
primary care capacity is full, civilian PCMs, who are all part of
the contractor’s network, are available to provide care to patients.
3.2.2 TRICARE Select
Plan
TRICARE Select is a self-managed,
Preferred Provider Organization (PPO) program. It allows beneficiaries
to use the TRICARE civilian provider network, with reduced out-of-pocket
costs compared to care from non-network providers, as well as military
facilities (where they exist and when space is available). Similar
to the long-operating “TRICARE Extra” and “TRICARE Standard” plans,
which this replaces, a major feature of TRICARE Select is that enrollees
will not have restrictions on their freedom of choice with respect
to health care providers. TRICARE Select is based primarily on 10
USC 1075 (as added by Section 701 of National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 2017 and 10 USC 1097.
3.2.3 TFL Plan
TFL
is the Medicare wraparound coverage plan under 10 USC 1086(d).
3.3 Eligibility
for TRICARE
3.3.1 Active Duty Eligibility
All
active duty members are considered TRICARE Prime. They must, however,
take action to be enrolled in Prime, and be assigned to a PCM (see
the TRICARE Operations Manual (TOM) for PCM provisions under the
TRICARE Prime Remote (TPR) program).
3.3.2 Non-Active
Duty Eligibility
All individuals entitled to civilian health
care under 10 USC Sections 1079 or 1086, are eligible for TRICARE.
Beginning January 1, 2018, beneficiaries other than TFL beneficiaries
must enroll in a TRICARE plan to receive care outside the Direct
Care (DC) only system. Non-active duty individuals, commonly referred
to as “TRICARE eligibles”, include the spouse and children of active
duty personnel, retirees and their spouses and children, and survivors.
Note: This
group also includes former spouses as defined in 10 USC Section
1072(2). Not included are those individuals who are entitled to
care in the DC system, on a space available basis, but ordinarily are
not entitled to civilian care, such as family member parents and
parents-in-law.
3.3.3 TFL
Pursuant
to Section 712 of the NDAA for FY 2001, Medicare eligible beneficiaries
based on age, whose TRICARE eligibility is determined by 10 USC
Section 1086, are eligible for Medicare Part A, and those who are
enrolled in Medicare Part B, are eligible for the TRICARE benefit
effective October 1, 2001. These beneficiaries are not eligible
to enroll in TRICARE Prime. TFL beneficiaries older than age 65 cannot
enroll in TRICARE Prime (exception for grandfathered Uniformed Services
Family Health Plan (USFHP) enrollees). Retirees and their family
members under age 65 who have Medicare coverage due to disability
or with end stage renal disease can enroll in TRICARE Prime if they
have Medicare Part B. Their Prime enrollment fees are waived if
they have Part B coverage. Retirees, dependents, and survivors with
any Medicare coverage at any age are not eligible to enroll in TRICARE
Select because they are excluded from the “Retired Category” for
TRICARE Select as defined in 10 USC 1075(b)(1)(B).
3.3.4 Supplemental
Health Care Program (SHCP) and TPR Program
See the TOM,
Chapters 16 and
17.
3.3.5 Non-DoD TRICARE
Eligibles
TRICARE eligibles sponsored by non-DoD
uniformed services (the Public Health Service (PHS), the U.S. Coast
Guard (USCG), and the National Oceanic and Atmospheric Administration
(NOAA)) are eligible for TRICARE and may enroll in TRICARE Prime
or TRICARE Select (beginning January 1, 2018).
3.3.6 North Atlantic
Treaty Organization (NATO) And Partnership For Peace (PfP) Beneficiaries
The
Department of Defense equates foreign military members and family
members from PfP countries the same as those from NATO Status of
Forces Agreement (SOFA) countries, in terms of access to outpatient
medical and dental care from DoD medical and dental treatment facilities,
and access to TRICARE Select (TRIARE Standard before January 1,
2018) civilian care. A current list of NATO SOFA countries is at:
https://www.nato.int/cps/ie/natohq/topics_52044.htm.
A current list of NATO PfP countries is at:
https://www.nato.int/cps/en/natohq/51288.htm.
3.3.6.1 NATO or PfP
ADSM
As specified in applicable SOFAs,
active duty members of the armed forces of NATO and PfP nations
qualify for TRICARE outpatient services in similar fashion as their
U.S. Armed Forces active duty counterparts. However, there is no
coverage for inpatient services under TRICARE. No enrollment in
a TRICARE plan is required or authorized. As such contractors shall
not use the government furnished web-based enrollment system/application
to determine eligibility. See the TOM,
Chapter 17, Section 3, and TRM,
Chapter 4, Sections 2 and
4 for more information.
3.3.6.2 NATO or PfP
Family Members
Family members of active duty members
of the armed forces of NATO and PfP nations are only eligible for
outpatient care under TRICARE; there is no coverage for inpatient
services under TRICARE. Effective January 1, 2018, TRICARE Select
Group B cost-shares for Active Duty Family Members (ADFMs) apply.
Prior to January 1, 2018, TRICARE Standard/Extra cost-shares for
ADFMs apply. No enrollment in a TRICARE plan is required or authorized.
As such, contractors shall not use the government furnished web-based
enrollment system/application to determine eligibility. See TOM,
Chapter 17, Section 3; TRM,
Chapter 2, Section 2, and
Chapter 4, Sections 2 and
4; and TRICARE Systems Manual (TSM),
Chapter 2, Addendum L for more information.
3.3.7 Enrollment
Starting in calendar year 2018, beneficiaries
other than active duty members and TFL beneficiaries need to elect
to enroll in TRICARE Select or TRICARE Prime in order to be covered
by the private sector care portion of TRICARE. Enrollment will be
done during an open season period prior to the beginning of each
plan year, which operates with the calendar year. An enrollment
choice will be effective for the plan year. As an exception to the
open season enrollment rule, enrollment changes can be made during
the plan year for certain Qualifying Life Events (QLEs), such as
a change in eligibility status, marriage, divorce, birth of a new
family member, relocation, loss of Other Health Insurance (OHI), or
other events. Beneficiaries eligible to enroll in TRICARE Prime
or TRICARE Select plans who do not enroll or fail to qualify to
maintain their TRICARE Prime or TRICARE Select enrollment status
no longer have coverage under the TRICARE Program (including the
TRICARE retail pharmacy and Mail Order Pharmacy (MOP) programs),
and may not re-enroll until the following annual open season enrollment period
or until the sponsor or an eligible family member experiences a
QLE, whichever comes first. Such beneficiaries eligible to enroll
in TRICARE Prime or TRICARE Select do not lose any statutory entitlement
to space-available care in MTFs/eMSMs.
Note: Included
in all of the TRICARE benefit packages is a retail pharmacy network
and a mail service pharmacy program. Beneficiaries must be enrolled
to a plan to receive pharmacy services outside the DC system.
3.4 Administrative
Policy
3.4.1 Benefit Policy
3.4.1.1 Benefit
policy applies to the scope of services and items which may be considered
for cost-sharing by the TRICARE within the intent of the 32 CFR
199.
3.4.1.2 The
current edition of the American Medical Association’s (AMA’s) Physicians’
Current Procedural Terminology (CPT) is incorporated by reference
into this Manual to describe the scope of services potentially allowable
as a benefit, subject to explicit requirements, limitations, and
exclusions, in this Manual or in the 32 CFR 199.
3.4.1.3 Procedures
listed in the CPT and the Healthcare Common Procedure Coding System (HCPCS)
may be cost-shared only when the procedure is “appropriate medical
care”
and is “medically or psychologically
necessary”
and is not “unproven” as defined
in the
32 CFR 199.4(g)(15), and the procedure is
not explicitly excluded in the TRICARE program.
3.4.2 Program Policy
Program
Policy applies to beneficiary eligibility, provider eligibility,
claims adjudication, and quality assurance. Program policy implementation
instructions are found in the TSM and the TOM.
3.4.3 Any benefit or program administration
issue for which benefits or program operation policy guidance is
required, or when TRICARE policy is silent on an issue, the contractor
shall describe in writing and submit to the Team Chief, MB&RD,
Defense Health Agency (DHA).
3.4.4 Reimbursement
Policy
3.4.4.1 Reimbursement
policy sets forth the payment procedures used for reimbursing TRICARE claims.
The related implementation instructions for these payment procedures
are found in the TSM and the TOM.
3.4.4.2 The
TRM provides the methodology for pricing allowable services and
items and for payment to specific categories and types of authorized
allowable services and items and for payment to specific categories
and types of authorized providers. These methods allow the contractor
to price and render payment for specific examples of services or
items which are not explicitly addressed in the Manual but which
belong to a general category or type which is addressed in the Manual.
3.5 Administrative
and Effective Dates
3.5.1 Issuance Date
The date located
on the first page of each separate policy issuance. This is the
date that the issuance was initially issued by DHA.
3.5.2 Revision
Date
The revision date is at the bottom of each
page that has been revised along with the change number. This is
the date that DHA changed the issuance in any way. Each time an
issuance is changed, the revised page and/or issuance is given a
change number. The revision date and the change number together
identify a unique version of the issuance on a specific subject.
3.5.3 Effective
Date
A date within the body of the text of an
issuance which establishes the specific date that a policy is to
be applied to benefit adjudication or in program administration.
An effective date may be earlier than the issuance or revision date.
This date is explicit (e.g., Effective Date: January 1, 2004). The policy
effective date takes precedence over the issuance date and the revision
date. In the absence of an effective date the policy or instruction
is considered to have always been applicable because the newly published
policy or instruction confirms the application of existing published
program requirements.
3.5.4 Implementation
Date
The implementation date of a policy
or instruction is not noted in the issuance as this date is determined
by the terms of the contract modification between DHA and the contractor.
Unless otherwise directed by DHA, contractors are not to identify
finalized claims for readjudication under revised or new policy.
However, the contractor shall readjudicate any denied claim affected
by the policy that is brought to the contractor’s attention by any
source. Pending claims and denied claims in reconsideration shall
be adjudicated using the current applicable policy.