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.