TRICARE Manuals - Display Chap 12 Sect 1.2 (Change 86, Jul 14, 2021)

TRICARE Overseas Program (TOP)

Chapter 12

Section 1.2

TRICARE Overseas Program (TOP) Medical Benefit Variations

Issue Date:

Revision: C-70, September 10, 2020

1.0 GENERAL

1.1 TOP medical benefits are based upon the scope of services and items which may be considered for coverage by TRICARE within the intent of 32 CFR 199.4 and 32 CFR 199.5. Specifically, TRICARE may cost-share a procedure that is determined to be appropriate medical care, is medically or psychologically necessary, is not unproven as defined in 32 CFR 199.2, and the TRICARE Policy Manual (TPM) does not explicitly exclude or limit coverage of the service or supply.

1.2 Unique health care issues and challenges may arise in locations outside of the 50 United States (U.S.) and the District of Columbia. In some situations, TRICARE may authorize coverage for a specific service or supply under the TOP, even though the service or supply would normally be excluded from coverage by TRICARE. Such situations are expected to be rare and must be approved by the Government.

2.0 Authorized TOP Medical Benefit Variations

2.1 Tick Borne Encephalitis (TBE) Vaccine

Cost-sharing of the TBE vaccine is authorized in endemic areas of Europe and Asia when an at-risk Active Duty Family Member (ADFM), retiree, or retiree family member receives the vaccine from a TRICARE authorized provider. When covered, the TBE vaccine shall be cost-shared as a clinical preventive service. See Chapter 7, Sections 2.1 and 2.2.

2.2 Medicare Certification of Organ Transplant Facilities

Medicare certification for organ transplant centers is only required for transplants performed in the 50 U.S., the District of Columbia, and U.S. territories where Medicare is available. Organ transplantation is within the range of TRICARE covered benefits and is covered in overseas locations when it is medically necessary, reasonable, and commonly accepted practice in the country where the transplant is performed.

2.3 Non-U.S. Food and Drug Administration (FDA) Approved Drugs

Non-FDA approved prescription drugs may be cost-shared in foreign countries if the TOP contractor has substantiated that the drug is commonly used for the intended purpose in the host nation. The TOP contractor shall substantiate that the drug is commonly used in the host nation based on past claims/country experience or by a web search on the drug in question. If a claim for a non-FDA approved drug is submitted by a provider that is required to comply the National Drug Coding (NDC) requirements as outlined in TRICARE Operations Manual (TOM), Chapter 24, Section 14, the TOP contractor shall contact the Defense Health Agency (DHA) for assistance prior to processing the claim.

Note: FDA approval is required for all prescription drugs in the U.S. commonwealths and territories.

2.4 Therapeutic Mud Baths

Therapeutic mud baths (a form of balneotherapy which is used in some foreign countries to treat back pain, arthritis, or other medical conditions) is not a covered TRICARE benefit unless it can be established that pharmacological or other non-pharmacological treatments are unavailable in that particular country. Such cases are expected to be very rare and will require Government review and approval prior to payment.

2.5 Private Hospital Room Charges

Service members in locations designated in the TOP contract are authorized to receive private accommodations in a hospital or other authorized institution, regardless of whether semiprivate accommodations are available.

2.6 Sub-Acute Care

2.6.1 Medically necessary and appropriate skilled nursing services and other medically necessary services, such as Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST), which are otherwise covered benefits under Title 10 United States Code (USC) Chapter 55, rendered to covered beneficiaries overseas who are receiving sub-acute inpatient care may be covered. Payment for any facility charges and other non-covered services related to the inpatient care, whether rendered at an inappropriate inpatient level or in a non-Medicare certified Skilled Nursing Facility (SNF) or similar institution, shall be denied.

2.6.2 Part-time or intermittent Home Health Care (HHC) and hospice services may only be provided in the same manner and under the same conditions as Medicare (e.g. provided in a Medicare certified facility) and thus are not available overseas; however, coverage may still be extended for otherwise covered services and supplies provided to eligible homebound and hospice beneficiaries overseas.

2.6.3 Payment shall be based upon the lesser of billed charges or the negotiated reimbursement rate in accordance with the TRICARE Manuals and the overseas contract. Covered services must be provided by individuals who would otherwise meet the requirements to be a TRICARE authorized individual professional provider. The contractor shall provide copies of all requested records to assist the Government in the annual retrospective review of these claims to ensure appropriate reimbursement and to identify any potential issues related to these services and the reimbursement amounts associated with these services.

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