2.3
Review
And Annual Updates
All fees (including enrollment fees, deductibles,
and cost-shares) are subject to review and annual updating on the
calendar year, in accordance with 10 USC sections 1075 and 1075a.
2.3.1 This section provides the policy regarding
fees and the Calendar Year (CY) 2018 amounts. Annual updates thereafter
will be published on the Defense Health Agency (DHA) web site at
http://www.health.mil/rates.
2.3.2 Each fee for Group B beneficiaries
shall be annually indexed to the amount by which retired pay is
increased (i.e., the cost-of-living adjustment (COLA)) under 10
USC section 1401a, rounded to the next lowest multiple of $1. The
remaining amount above such multiple of $1 shall be carried over
to, and accumulated with, the amount of the increase for the subsequent
year and made when the aggregate amount of increases carried over
for a year is $1 or more.
2.4
TRICARE Prime
2.4.1 TRICARE Prime program enrollment
fees and copayments are defined in 10 USC sections 1075 and 1075a.
For information on fees for Prime enrollees choosing to receive
care under the Point of Service Option (POS), refer to
32 CFR 199.17 and
Section 5.
2.4.1.1 TRICARE
Prime ADFMs have no annual enrollment fee in CY 2018 or subsequent
calendar years.
2.4.1.2 TRICARE Prime
Group A Retirees have a CY 2018 enrollment fee of $289.08 for an
individual or $578.16 for a family. Annual updates are available
at
http://www.health.mil/rates.
2.4.1.3 TRICARE
Prime Group B Retirees have a CY 2018 enrollment fee of $350 for
an individual or $700 for a family. Annual updates are available
at
http://www.health.mil/rates.
2.4.1.4 Effective
March 26, 1998, the TRICARE Prime enrollment fee is waived for those beneficiaries
who are both eligible for Medicare on the basis of disability or
end stage renal disease and who maintain enrollment in Part B of
Medicare and are otherwise eligible to enroll in TRICARE Prime.
2.4.1.5 Effective FY 2012, Group A Prime
beneficiaries who are (1) survivors of active duty deceased sponsors,
or (2) medically retired Uniformed Services members and their family
members, shall have their Prime enrollment fees frozen at the rate
in effect when classified and enrolled in a fee paying Prime plan.
(This does not include TYA plans). Beneficiaries in these two categories
who were enrolled in FY 2011 will continue paying the FY 2011 rate.
The beneficiaries who become eligible in either category and enroll
during FY 2012, or in any future fiscal year through December 31,
2017 or calendar year commencing CY 2018, shall have their fee frozen
at the rate in effect at the time of enrollment in Prime. The fee
for these beneficiaries shall remain frozen as long as at least
one family member remains enrolled in Prime. The fee for the family
member(s) of a medically retired Uniformed Services member shall
not change if the family member(s) is later re-classified a survivor.
2.4.1.6 Group
B Prime Retiree beneficiary enrollment fees are not frozen nor waived.
2.4.2 TRICARE Select
TRICARE
Select enrollment fees and copayments are defined in 10 USC sections
1075 and 1075a.
2.4.2.1 TRICARE Select
ADFMs have no enrollment fees.
2.4.2.2 TRICARE
Select Group A retirees have
a CY 2021
enrollment
fee of $150 for an individual or $300 for a family. Annual updates
are available at http://www.health.mil/rates.
Prior to CY 2021 TRICARE Select Group A retirees had no enrollment
fees.
2.4.2.3 When
enrollment fees implemented for TRICARE Select Group A Retirees.
Retirees who are (1) survivors of active duty deceased sponsors,
or (2) medically retired Uniformed Services members and their family
members, have no enrollment fees in CY 2018 or in any subsequent
calendar year. (This does not include TYA plans). The fee for the
family member(s) of a medically retired Uniformed Services member
shall not change if the family member(s) is later re-classified
a survivor.
2.4.2.4 TRICARE
Select Group B Retirees have enrollment fees of $450 per individual
or $900/family for CY 2018. These fees shall be updated annually
in accordance with
paragraph 2.3. Annual updates shall be posted
at
http://www.health.mil/rates.
2.5 Deductibles
2.5.1 TRICARE
Prime ADFMs and Retirees. Group A and Group B Prime ADFMs and Prime
retirees have no deductible under TRICARE Prime for health care
services obtained in accordance with Prime rules and procedures.
If otherwise covered health care services are not obtained in accordance
with Prime rules and procedures, the services may be covered under
the POS option (
Section 6) including a deductible of $300
per individual or $600 per family.
2.5.2 TRICARE
Select. TRICARE Select beneficiaries have calendar year deductibles
that must be fully met before TRICARE benefits are payable. Once
the deductible has been met, the cost-shares in
paragraph 2.6 apply. The TRICARE
Select deductible applies to the catastrophic cap. The TRICARE Select deductible
does not apply to the preventive care services described in the
TPM,
Chapter 7, Sections 2.1,
2.2, and
2.5.
2.5.3 Collection of deductible amounts.
Contractors shall require network providers to collect, at a minimum,
the copayment at the time of service and the Explanation Of Benefits
(EOB) shall inform the provider and beneficiary of additional amounts
owed to satisfy the deductible. Additionally, the contractor may
provide deductible information to network providers in advance so
they may also be collected at the time of the service, at the discretion
of both the contractor and network providers in their network agreements.
2.5.4 Deductibles
when beneficiaries move between regions. See the TRICARE Operations Manual
(TOM),
Chapter 2, Section 2, regarding portability.
2.5.5 Beneficiaries who transfer to Prime,
and again to Select during the same calendar year. The deductible
for these beneficiaries does not reset to zero. The amount of the
deductible fulfilled shall carry forward if a beneficiary moves
to Prime, and back to Select during the same CY.
2.5.6 Figure 2.2-1 contains the deductibles that
apply to TRICARE Select beneficiaries for CY 2018. These fees shall
be updated annually in accordance with
paragraph 2.4 and shall be
posted at
http://www.health.mil/rates.
Figure 2.2-1 TRICARE Select Deductibles
for CY 2018
|
TRICARE SELECT**
|
Group A ADFM
|
Group B ADFM
|
Group A
|
Group b
|
|
E1-E4
|
e-5 & Above
|
E1-E4
|
e-5 & ABOVE
|
Retirees
|
Retirees
|
|
* Group
B Retirees have a separate out-of-network deductible. The out-of-network
deductible is separate from the in network deductible and must be
paid in addition to the in network deductible. For example, if a
Group B retiree beneficiary had met their $150 network deductible,
and then chooses to see an out-of-network provider, the beneficiary
must pay the additional $300 out-of-network deductible before TRICARE
will cost-share out-of-network care.
** If a beneficiary has
a partially-fulfilled deductible, and the next service will meet
the deductible, the beneficiary must meet their deductible and then
may be subject to the additional copayment, if the remaining deductible
was less than the applicable copayment:
Example
1: An E1 Group B ADFM has met $25 of their $50 deductible.
They visit their primary care physician, and the visit has an allowable
charge of $100. The beneficiary is responsible for $25 of the service,
and has thus met their deductible.
Example
2: The same Group B ADFM has met $45 of their $50 deductible.
They visit their primary care physician, and the visit has an allowable
charge of $100. The beneficiary is responsible for the remaining
$5 plus the $15 copayment, for a total of $20.
*** Out-of-network
deductibles apply to the catastrophic cap.
|
|
In-Network
|
$50/$100
|
$150/$300
|
$50/$100
|
$150/$300
|
$150/$300
|
$150/$300
|
|
Out-Of-Network
|
$300/$600*
|
2.6
Cost-Shares
and Copayments
2.6.1 This paragraph provides an overview of
the establishment and general applicability of TRICARE cost-shares
and copayments for each TRICARE plan and category of beneficiary except
for authorized COVID-19 testing in response to the COVID-19 pandemic.
For cost-shares and copayments related to COVID-19 testing, see
Section 7.
2.6.2 TRICARE
Prime Group A and Group B ADFM Enrollees. Prime enrollees have $0.00 copayment
for covered health care services obtained in accordance with Prime
rules and procedures. If otherwise covered health care services
are not obtained in accordance with Prime rules and procedures,
the services may be covered under the POS option (
Section 5), including
a separate deductible of $300 per individual or $600 per family.
This would include any non-emergency out of network care obtained
by a Prime beneficiary without following applicable referral requirements. Pharmacy
copayments are in addition to any TRICARE Prime copayments.
2.6.3 TRICARE
Select Group A ADFM and Retiree Enrollees.
2.6.3.1 Care
received from network providers. The cost-sharing amounts for covered
health care services obtained from a network provider are fixed
dollar amounts for each specified category of care and are set prospectively
for each calendar year with the annual updates available at
http://www.health.mil/rates.
2.6.3.2 Care
received from non-network providers. The cost-sharing amounts for
covered health care services obtained from a non-network provider
are as provided in
32 CFR 199.4 and
Section 1.
2.6.4 TRICARE Select Group B ADFM and
Retiree Enrollees. The cost-sharing amounts for covered health care
services for CY 2018 are established by 10 USC 1075 and shall be
updated annually in accordance with
paragraph 2.3, with the annual
updates available at
http://www.health.mil/rates.
The cost-sharing amounts are unique for Group B ADFMs and for Group
B Retirees and include different cost-sharing amounts within each
beneficiary category depending on whether the covered health care services
are obtained from a network provider or from a non-network provider.
2.6.5 CHAMPUS
Maximum Allowable Charge (CMAC) impact on cost-sharing. In instances
where the CMAC or allowable charge is less than the copayment established
by this section and published on the DHA website, network providers
may only collect the lower of the allowable charge or the applicable
copayment.
2.6.6 Services with Set Copayments. Copayments
apply only after any applicable deductibles have been satisfied,
except for preventive care, which is available (when all conditions
of coverage are met) with no copayment from network physicians,
regardless of whether or not applicable deductibles have been satisfied.
2.7 Cost-shares for services are as
follows:
2.7.1 Preventive
Care Outpatient Visits Under TRICARE Prime and Select
2.7.1.1 TRICARE Prime enrollees may receive
Prime clinical preventive services from any network provider within
their region of enrollment without referral or authorization. See
the TRICARE Policy Manual (TPM),
Chapter 7, Section 2.2 for a list of these
services. If a Prime clinical preventive service is not available
from a network provider, an enrollee may receive the service from
a non-network provider with a referral from the Primary Care Manager
(PCM) and authorization from the contractor. If an enrollee uses
a non-network provider without first obtaining a referral from their
PCM and authorization from the contractor, payment is made under
the POS option only for services that are otherwise covered under
the TRICARE Basic Program and described in the TPM,
Chapter 7, Section 2.1. Payment shall not
be made under the POS option for clinical preventive services that
are not otherwise covered under the TRICARE Basic Program.
2.7.1.2 TRICARE
Select enrollees may receive Prime clinical preventive services
when furnished by a network provider. If a TRICARE Select enrollee
uses a non-network provider, payment is made only for clinical preventive
services that are otherwise covered under the TRICARE Basic Program.
2.7.1.3 No
copayments or cost-shares are required for additional clinical preventive
services authorized under
32 CFR 199.4(e)(28) and described in the TPM,
Chapter 7, Sections 2.1,
2.2, and
2.5 whether
received from network or non-network providers. However, TRICARE
Prime beneficiaries are required to obtain services in accordance
with the rules and procedures of Prime to avoid POS charges.
2.7.1.4 No copayments or authorizations
are required for covered clinical preventive services not normally
provided as part of the TRICARE Basic program under
32 CFR 199.4(e)(28) when provided to Prime
and Select enrollees by network providers. These specific set of
services shall be established by the Director, DHA, and announced
annually before the open season enrollment period. Such preventive
care outpatient visits may include: laboratory and imaging tests;
cancer screenings; immunizations; periodic health promotion and
disease prevention exams (e.g., well-child care); blood pressure
screening; hearing exams; sigmoidoscopy or colonoscopy; serologic
screening; and appropriate education and counseling services as
specified by the Director, DHA. A beneficiary is not required to
pay any portion of the cost of covered, in-network preventive services
even if the beneficiary’s deductible has not yet been fulfilled.
Figure 2.2-2 TRICARE
Prime Cost-Shares for Preventive Care Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
* Those
services listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1 are
exempt from cost-share requirements.
|
|
Prime Preventive
Care Visits (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Basic Preventive
Care Visits (CY 2018), Out-Of-Network* when obtained in accordance
with established rules
|
$0
|
$0
|
$0
|
$0
|
Figure 2.2-3 TRICARE
Select Cost-Shares for Preventive Care Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
* Those
services listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1 are
exempt from cost-share requirements.
|
|
Select Preventive
Care Visits (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Basic Preventive
Care Visits (CY 2018), Out-Of-Network*
|
$0
|
$0
|
$0
|
$0
|
2.7.2 Primary Care
Outpatient Visits
Primary care outpatient visits to include
any PCM as designated in TPM,
Chapter 1, Section 7.1. Includes the services
of the individual professional provider as well as all medical supplies
used within the office and ancillary services and the treatment
room.
Figure 2.2-4 TRICARE
Prime Cost-Shares for Primary Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Primary Care
Outpatient Visits (CY 2018), In-Network
|
$0
|
$0
|
$20
|
$20
|
Figure 2.2-5 TRICARE
Select Cost-Shares for Primary Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Primary Care
Outpatient Visits (CY 2018), In-Network
|
$21
|
$15
|
$28
|
$25
|
|
Primary Care
Outpatient Visits (CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.3 Specialty
Care Outpatient Visits
This category applies to outpatient
care provided by provider specialties other than those listed under
primary care outpatient visits. Includes the services of the individual
professional provider as well as all medical supplies used within
the office and ancillary services and the treatment room. This category
also includes partial hospitalization services, intensive outpatient
treatment, and opioid treatment program services. The per visit
fee shall be applied on a per day basis on days services are received,
with the exception of opioid treatment program services reimbursed
in accordance with 32 CFR 199.14
(a)(2)(ix)(A)(3)(i) which per visit fee will
apply on a weekly basis.
Figure 2.2-6 TRICARE
Prime Cost-Shares for Specialty Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Specialty Care
Outpatient Visits (CY 2018)
|
$0
|
$0
|
$30
|
$30
|
Figure 2.2-7 TRICARE
Select Cost-Shares for Specialty Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Specialty Care
Visits (CY 2018), In-Network
|
$31
|
$25
|
$41
|
$40
|
|
Specialty Care
Visits (CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.4 Ancillary
Care
2.7.4.1 TRICARE
Prime enrollees have no copayments for the ancillary services in
the categories listed below (normal referral and authorization provisions
apply). Current Procedural Terminology (CPT) code ranges are given;
however, these codes are not all-inclusive. The most up-to-date
codes should be utilized to identify services within each category,
in accordance with the TOM,
Chapter 1, Section 4. When Prime rules and
procedures are not followed, POS charges may apply. Additionally,
listing the code ranges does not imply coverage; the codes just
provide the broad range of services that are not subject to copayments
under this provision:
• Diagnostic radiology and ultrasound services
included in the CPT procedure code range from 70010-76999, or any
other code for associated contrast media;
• Diagnostic nuclear medicine services included
in the CPT procedure code range from 78012-78999;Pathology and laboratory
services included in the CPT procedure code range from 80047- 89398;
G0461-G0462 (during 2014); and
• Cardiovascular studies included in the
CPT procedure code range from 93000-93355.
• Venipuncture included in the CPT procedure
code range from 36400-36425.
• Fetal monitoring for CPT procedure codes
59020, 59025, and 59050.
• Collection of blood specimens in the CPT
procedure codes 36591 and 36592.
Note: Multiple
discounting will not be applied to the following CPT procedure codes
for venipuncture, fetal monitoring, and collection of blood specimens;
36400-36425, 36591, 36592, 59020, 59025, and 59050.
2.7.4.2 TRICARE
Select enrollees have no copayments for ancillary services (defined
in
paragraph 2.7.4.1) provided by network providers.
Ancillary services for TRICARE Select beneficiaries are cost-shared
as follows:
Figure 2.2-8 TRICARE
Select Cost-Shares for Ancillary Services
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Ancillary Services
(CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Ancillary Services
(CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.5 Other Radiology
Services
Radiology Services are considered ancillary
services for TRICARE Prime enrollees and all Prime rules and procedures
apply. TRICARE Select enrollees who obtain radiology services from network
providers have no cost-share. TRICARE Select enrollees who receive
other radiology services from non-network providers are subject
to the following cost-shares:
Figure 2.2-9 TRICARE
Select Cost-Shares for Other Radiology Services
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Radiology Services
(CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Radiology Services
(CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.6 Eye
Examinations
2.7.6.1 TRICARE Prime.
One routine examination per year for TRICARE Prime family members
of active duty sponsors. One routine examination every other year
for TRICARE Prime retirees and their family members per the TPM,
Chapter 7, Section 2.2.
Figure 2.2-10 TRICARE Prime Cost-Shares for Eye Examinations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Eye Examinations
(CY 2018)
|
$0
|
$0
|
$0
|
$0
|
2.7.6.2 TRICARE Select.
Eye examinations received from in-network and out-of-network providers by
TRICARE Select ADFMs may be cost-shared as follows. Eye examinations
for TRICARE Select retirees are not a TRICARE benefit. See the TPM,
Chapter 7, Section 6.1.
Figure 2.2-11 TRICARE Select Cost-Shares for Eye Examinations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Eye Examinations
(CY 2018), In-Network
|
$0
|
$0
|
NA
|
NA
|
|
Eye Examinations
(CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
NA
|
NA
|
2.7.7 Emergency
Room (ER) Visits
Emergency care obtained on an outpatient
basis in network or non-network facilities, in-region or out-of-region.
2.7.7.1 The
TRICARE Prime and Select copayment requirement for ER services is
on a PER VISIT basis; this means that only one copayment is applicable
to the entire ER episode, regardless of the number of providers
involved in the patient’s care and regardless of their status as
network providers.
2.7.7.2 POS charges
do not apply to emergency care. See the TOM,
Chapter 8, Section 5, paragraph 2.6.
Figure 2.2-12 TRICARE Prime Cost-Shares for Emergency
Room (ER) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
ER Visits (CY
2018)
|
$0
|
$0
|
$60
|
$60
|
Figure 2.2-13 TRICARE Select Cost-Shares for Emergency
Room (ER) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
ER Visits (CY
2018), In-Network
|
$81
|
$40
|
$109
|
$80
|
|
ER Visits (CY
2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.8 Urgent Care
Visits
The usual TRICARE Prime referral
requirement may be waived for some or all urgent care visits for
TRICARE Prime enrollees other than most active duty members. The
specific number of urgent care visits without a referral for TRICARE
Prime enrollees is determined annually prior to the beginning of
the open season enrollment period. When the urgent care referral
is waived, no POS deductibles and cost-shares shall apply when urgent
care is provided by a TRICARE network provider or a TRICARE-authorized
(network or non-network) Urgent Care Center (UCC) or Convenience
Clinic (CC). If the enrollee seeks care from a non-network provider
(except a TRICARE-authorized UCC or CC), the usual POS deductible
and cost-shares shall apply. See the TOM,
Chapter 8, Section 5, for information on which
TRICARE Prime plan enrollees do not require a referral.
Figure 2.2-14 TRICARE Prime Cost-Shares for Urgent Care
Center (UCC) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
UCC Visits (CY
2018)
|
$0
|
$0
|
$30
|
$30
|
Figure 2.2-15 TRICARE Select Cost-Shares for Urgent Care
Center (UCC) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
UCC Visits (CY
2018), In-Network
|
$21
|
$20
|
$28
|
$40
|
|
UCC Visits (CY
2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.9 Ambulatory
Surgery
Authorized hospital-based or Freestanding
Ambulatory Surgical Center (FASC) that is TRICARE certified. Also
includes prenatal care, outpatient delivery, and postnatal care
provided by a TRICARE authorized birthing center. No cost-share
shall be deducted from a claim for professional services related
to ambulatory surgery. This applies whether the services are performed
in an FASC, or a Hospital Outpatient Department (HOPD). So long
as at least one procedure on the claim is reimbursed as ambulatory
surgery, the claim shall be cost-shared as ambulatory surgery.
Figure 2.2-16 TRICARE Prime Cost-Shares for Ambulatory
Surgery (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Ambulatory Surgery
(CY 2018)
|
$0
|
$0
|
$60
|
$60
|
Figure 2.2-17 TRICARE Select Cost-Shares for Ambulatory
Surgery (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Ambulatory Surgery
(CY 2018), In-Network
|
$25
|
$25
|
20% of allowable charge
|
$95
|
|
Ambulatory Surgery
(CY 2018), Out-Of-Network
|
$25
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.10 Ambulance
Services
Ambulance services, when medically necessary
as defined in the TPM and when the service is a covered benefit.
POS charges do not apply to emergency care; see the TOM,
Chapter 8, Section 5, paragraph 2.6.
Figure 2.2-18 TRICARE Prime Cost-Shares for Ambulance
Services (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
* In-
and Out-Of-Network.
|
|
Outpatient Ground
Ambulance (CY 2018)*
|
$0
|
$0
|
$40
|
$40
|
|
Outpatient Air
Ambulance (CY 2018)*
|
$0
|
$0
|
$20
|
$20
|
|
Inpatient (Transfers
rendered in conjunction with an inpatient stay.) (CY 2018)*
|
$0
|
$0
|
25% of allowable charge
|
25% of allowable charge
|
Figure 2.2-19 TRICARE Select Cost-Shares for Ambulance
Services
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
* In-
and Out-Of-Network.
|
|
Outpatient Ground
Ambulance (CY 2018), In-Network
|
$74
|
$15
|
$98
|
$60
|
|
Outpatient Ground
Ambulance (CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
|
Outpatient Air
Ambulance (CY 2018)*
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
|
Inpatient (Transfers
rendered in conjunction with an inpatient stay.) (CY 2018)*
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.11 Durable Medical
Equipment (DME)
DME, hearing aids for ADFMs, and medical
supplies prescribed by an authorized provider which are covered
benefits, if dispensed for use outside of the office or after the
home visit.
Figure 2.2-20 TRICARE Prime Cost-Shares for Durable Medical
Equipment (DME)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
DME (CY 2018)
|
$0
|
$0
|
20% of allowable charge
|
20% of allowable charge
|
Figure 2.2-21 TRICARE Select Cost-Shares for Durable
Medical Equipment (DME)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
DME (CY 2018),
In-Network
|
15% of allowable charge
|
10% of allowable charge
|
20% of allowable charge
|
20% of allowable charge
|
|
DME (CY 2018),
Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.12 Inpatient Hospital Admission
Semiprivate
room (when medically necessary, special care units), general nursing,
and hospital service. Includes inpatient physician and their surgical
services, meals including special diets, drugs, and medication while
an inpatient, operating and recovery room, anesthesia, laboratory
tests, x-ray and other radiology services, necessary medical supplies
and appliances, blood and blood products. Also, includes maternity
hospital and professional services (prenatal, delivery, postnatal). Includes
inpatient hospital admissions in all acute care, specialty (i.e.,
cancer and children’s hospitals), and mental health hospitals.
2.7.12.1 For inpatient hospital admissions
subject to the inpatient mental health per diem payment system,
the following special rules apply:
2.7.12.1.1 Lower
volume hospitals and units: For care paid on a regional per diem,
the cost-share shall be calculated in accordance with
Section 1, paragraph 1.3.3.5.4.2.
2.7.12.1.2 A claim subject to the inpatient
mental health per diem payment system which spans a period in which
two separate per diems exist shall have the cost-share computed
on the actual per diem in effect for each day of care.
2.7.12.1.3 Cost-share
whenever leave days are involved. There is no patient cost-share
for leave days when such days are included in a hospital stay.
2.7.12.1.4 Claims for services that are provided
during an inpatient admission which are not included in the per
diem rate shall be cost-shared as an inpatient claim if the contractor
cannot determine where the service was rendered and the status of
the patient when the service was provided. The contractor shall
examine the claim for place of service and type of service to determine
if the care was rendered in the hospital while the beneficiary was
an inpatient of the hospital. This would include non-mental health
claims and mental health claims submitted by individual professional providers
rendering medically necessary services during the inpatient admission.
2.7.12.2 All final claims reimbursed under
the TRICARE Diagnosis Related Group (DRG)-based payment system are
to be priced using the rules, weights and rates in effect as of
the date of discharge. Interim claims with “end date of care” shall
be priced using the rules, weights and rates in effect as of the
“end date of care.” See
Chapter 6, Section 3, paragraph 3.3.1.
Figure 2.2-22 TRICARE Prime Cost-Shares for Inpatient
Hospitalizations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Inpatient Hospitalization
(CY 2018)
|
$0
|
$0
|
$150/admission
|
$150/admission
|
Figure 2.2-23 TRICARE Select Cost-Shares for Inpatient
Hospitalizations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
|
|
Inpatient Hospitalization
(CY 2018), In-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
$60/admission
|
$250/day or
25% of the hospital’s total charges (based on the fee schedule negotiated
by the contractor) whichever is less, plus 20% of separately billed
professional charges
|
$175/admission
|
|
Inpatient Hospitalization
(CY 2018), Out-Of-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
20% of allowable charge
|
DRG per diem
($901/day) or 25% of the hospital’s billed charges for institutional
services, whichever is less, plus 25% of separately billed professional
charges
|
25% of allowable charge
|
2.7.13 Inpatient
Skilled Nursing/Inpatient Rehabilitation
This category
includes a Residential Treatment Center (RTC) or Substance Use Disorder Rehabilitation
Facility (SUDRF) residential treatment program. For Skilled Nursing
Facility (SNF) care, this is the same benefit as Medicare except
there is no limitation as to the number of days of coverage. Benefit
includes semiprivate room; regular nursing services; meals including
special diets; physical, occupational, and speech therapy; drugs
furnished by the facility; necessary medical supplies; and appliances.
Figure 2.2-24 TRICARE Prime Cost-Shares for Skilled Nursing/Rehabilitation Facilities
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
SNF/Rehab Facilities
(CY 2018)
|
$0
|
$0
|
$30/day
|
$30/day
|
Figure 2.2-25 TRICARE Select Cost-Shares for Skilled
Nursing/Rehabilitation Facilities
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
|
|
SNF/Rehab Facilities
(CY 2018), In-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
$25/day
|
$250/day up to
25% of the hospital’s total charge plus 20% of separately billed
services
|
$50/day
|
|
SNF/Rehab Facilities
(CY 2018), Out-Of-Network
|
Subsistence
charge per day ($18.60), minimum
$25/admission*
|
$50/day
|
25% of allowable charge
|
Lesser of $300/day
or 20% of allowable charge
|
2.7.14 Home Health and Hospice
Home
Health Care (HHC) provided by a Home Health Agency (HHA) and reimbursed
in accordance with
Chapter 12 has no cost-share for all beneficiary
categories. Hospice care provided in accordance with
Chapter 11 has no cost-share for all beneficiary
categories.
2.7.15 Maternity Care
For routine
maternity episodes, there is a single beneficiary cost-share or
copayment, depending on the beneficiary category, site of service,
and rendering provider. Maternity care shall be cost-shared as follows:
2.7.15.1 A
single inpatient cost-share applies to maternity care ending in
childbirth in, or on the way to, a hospital inpatient childbirth
unit, and for maternity care ending in a non-birth outcome not otherwise
excluded. Inpatient cost-share formula applies to prenatal and postnatal
care provided in the office of a civilian physician or certified
nurse-midwife in connection with maternity care ending in childbirth
or termination of pregnancy in, or on the way to, a Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM) inpatient childbirth
unit. Aside from the applicable single inpatient cost-share, there
is no separate cost-share for separately billed professional charges
or prenatal or postnatal care involved in these routine maternity
episodes.
2.7.15.2 A single ambulatory
surgery cost-share applies to maternity care ending in childbirth
in, or on the way to, a birthing center to which the beneficiary
is admitted, and from which the beneficiary has received prenatal
care, or a hospital-based outpatient birthing room.
2.7.15.3 A single outpatient cost-share applies
to maternity care which terminates in a planned childbirth at home.
If the care is rendered b a PCM (as defined in the TPM,
Chapter 1, Section 7.1, paragraph 1.1.2),
it shall be cost-shared as a primary care visit. If provided by
a specialist, it shall be cost-shared as a specialty visit.
2.7.15.4 Otherwise covered medical services
and supplies directly related to “complications of pregnancy”, as
defined in the Regulation, will be cost-shared on the same basis
as the related maternity care for a period not to exceed 42 days
following termination of the pregnancy and thereafter cost-shared
on the basis of the inpatient or outpatient status of the beneficiary
when medically necessary services and supplies are received.
2.7.15.5 Otherwise authorized services and
supplies related to maternity care, including maternity related
prescription drugs, shall be cost-shared on the same basis as the
termination of pregnancy.
2.7.15.6 Claims for pregnancy
testing are cost-shared on an outpatient basis when the delivery
is on an inpatient basis.Where the beneficiary delivers in a professional
office birthing suite located in the office of a physician or certified
nurse-midwife (which is not otherwise a TRICARE-approved birthing
center) the delivery is to be adjudicated as an at-home birth.
2.7.15.8 Claims
for prescription drugs provided on an outpatient basis during the
maternity episode but not directly related to the maternity care
are cost-shared on an outpatient basis.
2.7.15.9 All admissions related to a single
maternity episode shall be considered one confinement regardless
of the number of days between admissions. For ADFMs, the cost-share
shall be applied to the first institutional claim received.
2.7.15.10 Medically necessary treatment rendered
to a pregnant woman for a non-obstetrical medical, anatomical, or
physiological illness or condition shall be cost-shared as a part
of the maternity episode when:
2.7.15.10.1 The treatment
is otherwise allowable as a benefit; and
2.7.15.10.2 Delay
of the treatment until after the conclusion of the pregnancy is
medically contraindicated; and
2.7.15.10.3 The
illness or condition is, or increases the likelihood of, a threat
to the life of the mother; or
2.7.15.10.4 The illness
or condition will cause, or increase the likelihood of, a stillbirth
or newborn injury or illness; or
2.7.15.10.5 The
usual course of treatment must be altered or modified to minimize
a defined risk of newborn injury or illness.
Figure 2.2-26 TRICARE Prime
Cost-Shares for Maternity - Hospital Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity -
Hospital Delivery (CY 2018), In-Network
|
$0
|
$0
|
$150
|
$150
|
|
Maternity -
Hospital Delivery (CY 2018), Out-of-Network
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS charges
may apply to non-emergency care
|
Figure 2.2-27 TRICARE Select
Cost-Shares for Maternity - Hospital Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity -
Hospital Delivery (CY 2018), In-Network
|
Subsistence charge
per day ($18.60), minimum $25/admission
|
$60
|
$250/day or 25%
of the hospital’s total charges (based on the fee schedule negotiated
by the contractor), whichever is less, plus 20% of separately billed professional charges
|
$175
|
|
Maternity -
Hospital Delivery (CY 2018), Out-of-Network
|
Subsistence charge
per day ($18.60), minimum $25/admission
|
20% of the allowable charge
|
DRG per diem ($901/day)
or 25% of the hospital’s billed charges for institutional services, whichever
is less, plus 25% of separately billed professional charges
|
25% of the allowable charges
|
Figure 2.2-28 TRICARE Prime
Cost-Shares for Maternity - Birthing Center
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity -
Birthing Center (CY 2018), In-Network
|
$0
|
$0
|
$60
|
$60
|
|
Maternity -
Birthing Center (CY 2018), Out-of-Network
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS charges
may apply to non-emergency care
|
Figure 2.2-29 TRICARE Select
Cost-Shares for Maternity - Birthing Center
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity -
Birthing Center (CY 2018), In-Network
|
$25
|
$25
|
20% of the allowable charge
|
$95
|
|
Maternity -
Birthing Center (CY 2018), Out-of-Network
|
$25
|
20% of the allowable charge
|
25% of the allowable charge
|
25% of the allowable charge
|
Figure 2.2-30 TRICARE Prime
Cost-Shares for Maternity - Home Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity -
Home Delivery (CY 2018), In-Network
|
$0
|
$0
|
$20/$30
|
$20/$30
|
|
Maternity -
Home Delivery (CY 2018), Out-of-Network
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS charges may
apply to non-emergency care
|
POS charges
may apply to non-emergency care
|
Figure 2.2-31 TRICARE Select
Cost-Shares for Maternity - Home Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity -
Home Delivery (CY 2018), In-Network (primary care cost-share/specialty
care cost-share)
|
$27/$34
|
$15/$25
|
$35/$45
|
$25/$40
|
|
Maternity -
Home Delivery (CY 2018), Out-of-Network
|
20% of the allowable charge
|
20% of the allowable charge
|
25% of the allowable charge
|
25% of the allowable charge
|
2.7.16 Newborn Care
Effective for
all inpatient admissions occurring on or after October 1, 1987,
separate claims must be submitted for the mother and newborn. The
cost-share for inpatient claims for services rendered to a beneficiary
newborn is determined as follows:
2.7.16.1 Same newborn date of birth and date
of admission. For care where a cost-share is determined on a per
diem basis, the cost-share shall be calculated in accordance with
this section; however, the number of days shall be reduced by three.
2.7.16.2 Different newborn date of birth
and date of admission. The cost-share shall be applied to all days
in an inpatient stay.
2.8 Cost-Shares
and Deductibles: Former Spouses
2.8.1 Deductible. In accordance with the
FY 1991 Appropriations and Authorization Acts, Sections 8064 and
712 respectively, beginning April 1, 1991, an eligible former spouse
is responsible for payment of the first one hundred and fifty dollars
($150.00) of the reasonable costs/charges for otherwise covered
outpatient services and/or supplies provided in any one fiscal year
(effective January 1, 2018, in any one calendar year). Although
the law defines former spouses as family members of the member or
former member, there is no legal familial relationship between the
former spouse and the member or former member. Moreover, any TRICARE-eligible
children of the former spouse will retain a legal familial relationship
with the member or former member and shall be included in the member’s
or former member’s family deductible. The former spouse cannot contribute
to, nor benefit from, any family deductible of the member or former
member to whom the former spouse was married or of that of any TRICARE-eligible
children. In other words, a former spouse must independently meet the
$150.00 deductible in any fiscal year (effective January 1, 2018,
in any calendar year).
2.8.2 Cost-Share. An eligible former spouse is
responsible for payment of cost-sharing amounts identical to those
required for beneficiaries other than ADFMs.
2.9 Cost-Share
Amount
Under discounted rate agreements.
In cases where the cost-share is calculated as a percentage rather
than a fixed amount, the percentage shall be applied to (after duplicates
and noncovered charges are eliminated), the lowest of the billed
charge, the prevailing charge, the maximum allowable prevailing
charge (the Medicare Economic Index (MEI) adjusted prevailing),
or the negotiated (discounted) charge. If the contractor learns
that the participating provider has billed a beneficiary for a greater
cost-share amount, based on the provider’s usual billed charges,
the contractor shall notify the provider that such an action is
a violation of the provider’s signed agreement.
2.10 Exceptions
2.10.1 Inpatient
Cost-Share: Applicable To Each Separate Admission
On or after
January 1, 2018, for TRICARE Select Group A ADFMs only, a separate
cost-share amount is applicable to each separate beneficiary for
each inpatient admission EXCEPT:
2.10.1.1 Any readmission to an acute care
hospital which is not more than 60 days from the date of the last
inpatient discharge shall be treated as one inpatient confinement
with the last admission for cost-share amount determination.
2.10.1.2 Certain
heart and lung hospitals are excepted from cost-share requirements.
See
Chapter 1, Section 27, entitled “Legal Obligation
To Pay”.
2.10.2 Inpatient Cost-Share: Maternity Care
All admissions related to a single
maternity episode shall be considered one confinement regardless
of the number of days between admissions. For ADFMs, the cost-share
shall be applied to the first institutional claim received.
2.10.3 See
Section 6 for waivers of cost-shares and deductibles.