In accordance with Title 10, United
States Code (USC), Section 1079(i)(2), the amount to be paid to
hospitals, Skilled Nursing Facilities (SNFs), and other institutional
providers under the TRICARE program, “shall be determined to the
extent practicable in accordance with the same reimbursement rules
as apply to payments to providers of services of the same type under
Medicare.” This statutory authority has been implemented through
an Interim Final Rule (IFR) with Request for Comment, published
in the Federal Register on September 3, 2020, amending the TRICARE
regulation by adding 32 Code of Federal Regulations (CFR)
32 CFR 199.14(a)(1)(iii)(E)(5) to allow adoption
of Medicare NTAP payment adjustments to TRICARE DRG reimbursements.
Under the amended TRICARE regulation, any Medicare approved NTAP
reimbursement of hospitals subject to the Medicare program as required under
42 CFR 412.88 will be adopted or adopted as modified for TRICARE
unless the Assistant Secretary of Defense for Health Affairs (ASD(HA))
determines that it is not practicable for TRICARE to adopt the Medicare
NTAP. The Director, Defense Health Agency will issue necessary guidance
regarding any Medicare NTAP not adopted by the ASD(HA) or any modification
of a Medicare NTAP deemed necessary for adoption by TRICARE.
4.1 Payment Method
4.1.1 NTAP payment adjustments apply for discharges
on or after January 1, 2020.
4.1.2 The contractor shall reimburse hospitals
subject to NTAPs using the list of NTAPs and reimbursement rules
in the current Fiscal Year (FY) IPPS Final Rule Home Page found
on the CMS website. The reimbursement amounts in the current FY
IPPS Final rule represent the maximum add on payment that will be
provided for each NTAP.
4.1.3 The contractor shall determine each
procedure code eligible for an NTAP payment according to 42 CFR
412.87, which provides the reference to the most recent
Federal
Register with a list of approved NTAPs and the procedure
codes used to identify use of the technology. Each year in the IPPS
Final Rule, the list of NTAPs is updated by CMS.
4.1.3.1 The contractor
shall maintain a list of procedure codes eligible for NTAP payments.
4.1.3.2 The contractor
shall update the list of procedure codes eligible for NTAPs within
ten business days of publication by CMS.
4.1.4 The contractor shall also determine
the maximum NTAP payment amount for each technology according to
42 CFR 412.87, which provides the reference to the most recent
Federal Register with
the maximum payment for each approved NTAP. Each year the maximum
NTAP payment amounts are updated by CMS.
4.1.4.1 The contractor
shall maintain a list of the maximum NTAP payment amounts for each technology.
4.1.4.2 The contractor
shall update the list of the maximum NTAP payment amounts for each technology
within ten business days of publication by CMS.
4.1.5 The contractor shall apply the separate
NTAP payment using the appropriate formula from the IPPS Final Rule
and as documented in 42 CFR 412.88. The contractor shall calculate
for each eligible NTAP case on a claim, the appropriate NTAP payment,
where the payment rate is equal to the lesser of:
• The designated percentage of
the amount by which the total covered costs of the case exceed the
Medicare Severity (MS)-DRG payment, as determined
by CMS, as published in the current FY IPPS Final rule, or
• The maximum NTAP payment amount for the
specific technology, as determined by CMS.
The resulting NTAP amount shall
then be reimbursed in addition to the MS-TRICARE DRG payment amount.