1.0 BACKGROUND
1.1 National Defense Authorization Act for
Fiscal Year 2017 (NDAA FY 2017), Section 701, made significant changes
to the TRICARE Program, especially to TRICARE Prime; TRICARE Extra,
which is replaced by TRICARE Select; and to the third option, TRICARE
Standard, which was terminated as of December 31, 2017, and is also
replaced by TRICARE Select. TRICARE Select is a self-managed, Preferred Provider
Option (PPO) under the TRICARE Program, and replaces the TRICARE
Extra and Standard programs and adopts a number of improvements,
including fixed copayments rather than percentage copays for covered
benefits provided by a civilian network provider. It also features
freedom of choice of providers, with reduced beneficiary out-of-pocket
costs for covered care received from a civilian network provider.
The NDAA also included the continuation of TRICARE Prime as a managed
care, Health Maintenance Organization (HMO)-like option under the
TRICARE Program. TRICARE Prime adopts a number of changes to conform
to specifications in the new law, including categories of health care
services applicable to the determination of catastrophic loss protection.
Other features of the NDAA include preservation of benefits for
Active Duty Family Members (ADFMs) and TRICARE For Life (TFL) beneficiaries
and conforming changes to generally incorporate TRICARE Select into
the TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), TRICARE
Retired Reserve (TRR), and Continued Health Care Benefits Program
(CHCBP).
1.2 With
respect to beneficiary catastrophic loss protection, the NDAA FY
2017 established the catastrophic caps for each identified beneficiary
group, specified certain annual updates, and converted the coverage
from a fiscal year to a calendar year basis. The law also introduced
a new split of beneficiaries into two groups: one group (Group A
or grandfathered beneficiaries) consists of sponsors and their family
members who first became affiliated with the military through enlistment
or appointment before January 1, 2018, and the second group (Group
B or non-grandfathered beneficiaries) who first became affiliated
on or after that date.
1.3 With
respect to beneficiary catastrophic loss protection, the NDAA FY
2017 preserved the benefits for TFL beneficiaries. TFL means the
Medicare wraparound coverage option of the TRICARE program made
available to the beneficiary by reason of 10 United States Code
(USC) section 1086(d).
1.4 Fees
under the Extended Care Health Option (ECHO) are defined in
32 CFR 199.5.
1.5 Fees under the TRICARE Pharmacy Benefit
Program are defined in
32 CFR 199.21.
2.0 POLICY
2.1 TRICARE Prime And TRICARE Select
2.1.1 Catastrophic cap for ADFMs under TRICARE
Prime and TRICARE Select, the calendar year cap is:
2.1.1.1 Group A: $1,000.
2.1.1.2 Group B: $1,000
for calendar year (CY) 2018, adjusted annually thereafter indexed
to the amount of increase under 10 USC section 1401a.
2.1.2 Catastrophic
cap for all other beneficiaries under:
2.1.2.1 TRICARE Prime:
2.1.2.1.1 Group A retirees
have a calendar year cap of $3,000.
2.1.2.1.2 Group B retirees
have an annual cap of $3,500 in calendar year 2018, adjusted annually thereafter
indexed to the amount of increase under 10 USC section 1401a.
2.1.2.2 TRICARE Select:
2.1.2.2.1 Group A retirees
have an annual cap of $3,000 for CYs 2018 through 2020; except for certain
beneficiaries described in
paragraph 2.1.2.2.2, in CY 2021 the cap is
$3,500, adjusted annually thereafter indexed to the amount of increase
under 10 USC section 1401a.
2.1.2.2.2 Group
A retirees consisting of survivors of active duty deceased sponsors
or medically retired Uniformed Services members and their dependents
have a calendar year cap of $3,000.
2.1.2.2.3 Group B retirees
have an annual cap of $3,500 for CY 2018; adjusted annually thereafter indexed
to the amount of increase under 10 USC section 1401a.
2.2 TFL. Under the catastrophic cap
for TFL beneficiaries, an individual or family group of two or more
beneficiaries may not be required to pay a total of more than $3,000
for health care received during any calendar year. See
Chapter 4, Section 4 for information regarding
specific double coverage actions involving Medicare for TFL beneficiaries.
Note: ADFMs
with Medicare (not TFL) shall be subject to the catastrophic cap
limitations in
paragraph 2.1.2.
2.3 TYA, TRR,
TRS, and CHCBP
Enrollees in these plans have Group B catastrophic
cap limitations shown under
paragraph 2.1 based on the coverage (TRICARE
Prime or TRICARE Select) the plan provides.
3.0 Cap is Met
3.1 For TRICARE Prime, TRICARE Select,
and TFL beneficiaries, after the applicable calendar year catastrophic
cap is met, TRICARE Prime or TRICARE Select enrollment
fees will no longer be collected, and a fee waiver is then applied
for TRICARE Prime or TRICARE Select enrollment fees for the remainder of
the calendar year. At that point, the TRICARE determined
allowable amount shall be paid in full for all covered services
and supplies for the remainder of the calendar year.
3.2 For TYA, TRR, TRS, and CHCBP enrollees,
after the Group B calendar year catastrophic cap is met, the TRICARE
determined allowable amount shall be paid in full for all covered
services and supplies for the remainder of the calendar year.
4.0 The following
expenses may be credited to a TRICARE Prime, TRICARE Select, or
TFL sponsor’s calendar year catastrophic cap:
• Enrollment
fees (TRICARE Prime and TRICARE Select).
• Deductibles.
• The outpatient
and inpatient cost-shares and copayments.
5.0 Other Coverage Situations
5.1 TRICARE Supplemental Plans
TRICARE supplemental plans which provide
coverage for deductibles, cost-shares, and sometimes for non-covered
services, will be ignored. As with double coverage, the full deductible
and cost-share will be credited toward meeting the catastrophic
cap.
5.2 Multiple
Family Situations
Multiple family situations--e.g.,
sponsor and new spouse and children live together, and sponsor’s
children from previous marriage live elsewhere--will be treated
as one family. In other words, for a divorced and then remarried
sponsor with two sets of family members, their deductibles and cost-shares
will be combined to meet the calendar year catastrophic cap.
Note: When
a family’s sponsor changes, e.g., a spouse divorces a sponsor and
marries another active duty person, then only the new sponsor’s
liabilities for deductible and cost-shares in a calendar year will
count toward meeting the cap. In other words, this spouse cannot
carry to the new family those credits accumulated toward the cap
under the previous sponsor.
5.3 Former Spouses
Any TRICARE
eligible former spouse will be treated as an “other than ADFM.”
For the purpose of determining the catastrophic cap, a former spouse
will be treated as an independent family and must independently
meet the catastrophic cap.
5.4 Change Of Sponsor Status
A change in a sponsor’s duty status
will have the following effects on application of the catastrophic
cap.
5.4.1 Claims Subject
To The TRICARE Diagnosis Related Group (DRG)-Based Payment System
5.4.1.1 When the
status changes during a beneficiary’s inpatient stay, the appropriate
catastrophic cap will apply to that stay according to the beneficiary’s
cost-sharing status for the stay. Effective for services provided
after midnight of the day of discharge from the hospital, the catastrophic
cap will be based on the sponsor’s current status.
5.4.1.2 When the
status changes at any time other than during a beneficiary’s inpatient
stay, the appropriate catastrophic cap (according to the sponsor’s
current duty status) will apply for TRICARE eligible families for
the remaining calendar year (or until the status changes again)
effective for services provided after midnight of the day the duty
status changes.
5.4.1.3 When the status changes, the full
deductible and cost-shares credited toward meeting the previous
family cap will be credited toward the new cap as the sponsor’s
liabilities in the same calendar year. However, in no case will
a change in a sponsor’s status from retired to active duty result
in an adjustment to previous claims, even if the aggregate cost-share
had exceeded the active duty cap.
5.4.2 Claims Exempt From The TRICARE DRG-Based
Payment System
When a sponsor’s duty status changes,
the appropriate cap (according to the sponsor’s current duty status)
will apply for TRICARE eligible families for the remaining calendar
year effective for services provided after midnight of the day the
duty status changes. The full deductible and cost-shares credited
toward meeting the previous family cap will be credited toward the
new cap as the sponsor’s liabilities in the same calendar year.
5.5 Inpatient Care Spanning Two Calendar
Years
When the dates of inpatient care span different
calendar years, it is absolutely necessary that the catastrophic
cap application be as accurate as possible. If for a claim the ending
date of care is in a different calendar year from the beginning
date of care, the beneficiary cost-share amount must be allocated
between the two calendar years based on the dates of care.
5.6 Cost-Share When Fixed Daily Amount Is
NOT Known
When a fixed (or actual) daily amount
of cost-share is not known or cannot be accurately determined, the
daily cost-share amount will be calculated by proration, that is,
by dividing the claim’s cost-share amount by the number of days
of care (not counting the day of discharge) and the resulting daily
amount will be allocated between the two calendar years according
to the days of care received in each calendar year.
6.0 EXCEPTIONS
6.1 No catastrophic loss protection is available
for the North Atlantic Treaty Organization (NATO) or Partnership
For Peace (PfP) family members.
6.2 The Extended Care Health Option (ECHO)
sponsor/beneficiary liabilities do not accrue toward meeting the
catastrophic cap.
6.3 Beneficiary costs for non-covered
services or any beneficiary payments above the TRICARE determined
allowable charge, shall not count toward meeting the catastrophic
cap.
6.4 For TRICARE
Prime enrollees, POS deductible and cost-share amounts do not have
a catastrophic cap.