1.3.1 Deductible
Amount: Outpatient Care
1.3.1.1 Active
Duty Sponsor in Pay Grade E-4 or Below
1.3.1.1.1 Deductible, Individual: The
contractor shall charge each beneficiary for
the first fifty dollars ($50.00) of the allowable amount on claims
for care provided in the same FY prior to January
1, 2018.
1.3.1.1.2 Deductible, Family: The contractor
shall not charge a total deductible amount for all members
of a family with the same sponsor during one FY more
than one hundred dollars ($100.00) for claims
of care provided prior to January 1, 2018.
1.3.1.2
All
TRICARE Beneficiaries Except Family Members of Active Duty Sponsors
in Pay Grade E-4 or Below
1.3.1.2.1 Deductible, Individual: The
contractor shall charge each beneficiary for
the first $150.00 of the allowable amount on claims for care provided
in the same FY prior to January 1, 2018.
1.3.1.2.2 Deductible, Family: The contractor
shall not charge a total deductible amount for all members
of a family with the same sponsor during one FY more
than $300.00 for claims of care provided
prior to January 1, 2018.
1.3.1.3 TRICARE-Approved Ambulatory
Surgery Centers (ASCs), Birthing Centers
(BCs),
or Partial Hospitalization Programs (PHPs)
1.3.1.3.1 TRICARE-Approved
ASCs,
BCs,
or
PHPs.
The contractor
shall not apply a deductible
to allowable
amounts for services or items rendered to ADFMs. For family members
of active duty members of the armed forces of NATO/PfP foreign nations
who are eligible for outpatient care under
the TRICARE
Program,
see
paragraph 1.1.5 for deductible and cost-share
information.
1.3.1.3.2 Allowable
Amount Does Not Exceed Deductible Amount. If
FY allowable
amounts
(CY for services provided after December 31,
2017) for two or more beneficiary members of a family
total less than $100.00 (or $300.00 if
paragraph 1.3.1.2, applies),
and no one beneficiary’s allowable amounts exceed $50.00 (or $150.00
if
paragraph 1.3.1.2 applies), neither the family
nor the individual deductible
has been
met and
the contractor shall not pay toward the care.
1.3.1.3.3 In
the case of family members of an active duty member of pay grade
E-5 or above, with Persian Gulf conflict service who is, or was,
entitled to special pay for hostile fire/imminent danger authorized
by 37 USC 310, for services in the Persian Gulf area in connection
with Operation Desert Shield or Operation Desert Storm, the
contractor
shall apply the deductible
amount
specified in
paragraph 1.3.1.2.
Note: The
contractor
shall apply provisions of
paragraph 1.3.1.3.3,
to
family members of Service members who were killed in the Gulf, or
who died subsequent to Gulf service; and to Service members who
retired prior to October 1, 1991, after having served in the Gulf
war, and to their family members.
1.3.1.3.4 Adjustment of Excess.
The
contractor shall adjust any amount paid in excess against the annual
deductible required under
paragraphs 1.3.1.3.2 and
1.3.1.3.3 for
any beneficiary identified under those paragraphs.
1.3.1.3.5 The
contractor
shall consider the deductible amounts identified
in this section
as satisfied
if the catastrophic cap amounts identified in
Section 2 have
been met for the same
FY (CY for claims of care provided
after December 31, 2017) in which the deductible
applies.
1.3.3 Cost-Share Amount
1.3.3.1 Outpatient
Care
1.3.3.1.1 The
contractor
shall apply a 20% cost-share
of the
allowable amount in excess of the annual deductible amount for ADFM
outpatient
car
e.
The contractor
shall include the professional charges of an individual
professional provider for services rendered in a non-TRICARE-approved
ASC or
BC. For family members of active
duty members of the armed forces of NATO/PfP foreign nations who are
eligible for outpatient care under
the TRICARE
Program per
DEERS, see
paragraph 1.1.5.
1.3.3.1.2 Other Beneficiary. The contractor
shall apply a cost-share to
outpatient care for other than active duty and authorized NATO/PfP
family member beneficiaries of 25%
of the allowable amount in excess of the annual deductible amount. The
contractor shall include: partial hospitalization for
alcohol rehabilitation; professional charges of an individual professional
provider for services rendered in a non-TRICARE-approved ASC.
1.3.3.2
Inpatient
Care
1.3.3.2.1 ADFM:
For services prior to October 3, 2016, except in the case of mental
health and Substance Use Disorder (SUD) services, ADFMs or their
sponsors are responsible for the payment of the first $25 of the
allowable institutional costs incurred with each covered inpatient
admission to a hospital or other authorized institutional provider,
or the daily charge the beneficiary or sponsor would have been charged
had the inpatient care been provided in a
Military
Treatment Facility (MTF), whichever is greater. (Please
reference daily rate chart below.) For services on or after October
3, 2016, the
contractor shall apply the following
chart to
all services (to include mental health and SUD services) for ADFMs
or their sponsors.
Figure 2.1-1 MTF Daily
Charge Amounts
|
Period
|
Daily Charge
|
|
Use the daily charge (per diem
rate) in effect for each day of the stay to calculate a cost-share
for a stay which spans periods.
|
|
October 1, 2017 - September
30, 2018 (for ADFMs not enrolled in TRICARE Prime)
|
$18.60
|
|
October 1, 2018 - December
31, 2019 (for ADFMs not enrolled in TRICARE Prime)
|
$19.05
|
|
January 1, 2020 - December
31, 2020 (for ADFMs not enrolled in TRICARE Prime)
|
$19.55
|
|
January 1, 2021- December 21,
2021 (for ADFMs not enrolled in TRICARE Prime)
|
$20.15
|
1.3.3.2.2 Other
Beneficiaries: For services exempt from the Diagnosis
Related Group (DRG)-based
payment system and the mental health per diem payment system and
services provided by institutions other than hospitals (e.g.,
Residential Treatment Centers (RTCs)), the contractor
shall apply a cost-share of 25%
of the allowable charges.
1.3.3.3
Cost-Shares:
Maternity
1.3.3.3.1 Determination.
The
contractor shall determine maternity care cost-share
s as
follows:
1.3.3.3.1.1 Apply the inpatient
cost-share formula
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.
Note: Apply the inpatient
cost-share formula 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 Market/MTF inpatient
childbirth unit. The contractor shall charge ADFMs a
per diem (or a $25.00 minimum charge)
for an admission and shall not charge separate
cost-share for them for separately billed professional charges or
prenatal or postnatal care.
1.3.3.3.1.2 Apply the ambulatory
surgery cost-share formula 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.
1.3.3.3.1.3 Apply the outpatient
cost-share formula to maternity care
which terminates in a planned childbirth at home.
1.3.3.3.1.4 The contractor
shall cost-share otherwise covered medical services
and supplies directly related to “complications of pregnancy”, as
defined in the Regulation, 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.
1.3.3.3.2 Otherwise authorized services
and supplies related to maternity care, including maternity related
prescription drugs, are cost-shared
on the same basis as the termination of pregnancy.
1.3.3.3.3 The contractor
shall cost-share claims for pregnancy testing on
an outpatient basis when the delivery is on an inpatient basis.
1.3.3.3.4 When the
beneficiary delivers in a professional office birthing suite located
in the office of a physician or certified nurse-midwife (which is
not an otherwise TRICARE-approved BC)
the contractor shall adjudicate the claim as
an at-home birth.
1.3.3.3.5 The contractor
shall cost-share claims for prescription drugs provided
on an outpatient basis during the maternity episode but not directly
related to the maternity care on an outpatient
basis.
1.3.3.3.6 Newborn
cost-share. Effective for all inpatient admissions occurring on
or after October 1, 1987,
the contractor shall ensure separate
claims
are submitted for the mother
and newborn. The
contractor shall cost-share
for inpatient claims
services rendered
to a beneficiary newborn
as follows:
1.3.3.3.6.1 In a DRG hospital:
1.3.3.3.6.1.1 Same
newborn date of birth and date of admission:
• For
ADFMs, the contractor shall not charge a cost-share
during the period the newborn is deemed enrolled in Prime.
• For
newborn family members of other than active duty members, unless
the newborn is deemed enrolled in TRICARE Prime,
the contractor shall charge a cost-share the
lower of the number of hospital days minus three multiplied by the
per diem amount, OR 25% of the total billed charges (less duplicates
and DRG non-reimbursables such as hospital-based professional charges).
1.3.3.3.6.1.2 Different
newborn date of birth and date of admission:
• For
ADFMs, the contractor shall not charge a cost-share
during the period the newborn is deemed enrolled in TRICARE Prime.
• For
all other beneficiaries, the contractor shall apply
a cost-share to all
days in the inpatient stay, unless
the newborn is deemed enrolled in TRICARE Prime.
1.3.3.3.6.2 In DRG exempt hospital:
1.3.3.3.6.2.1 Same
newborn date of birth and date of admission:
• For
ADFMs, the contractor shall not charge a cost-share
during the period the newborn is deemed enrolled in TRICARE Prime.
• For
family members of other than active duty members, the contractor
shall charge a cost-share of 25%
of the total allowed charges unless the newborn is deemed enrolled
in TRICARE Prime.
1.3.3.3.6.2.2 Different
newborn date of birth and date of admission:
• For
ADFMs, the contractor shall not charge a cost-share
during the period the newborn is deemed enrolled in TRICARE Prime.
• For
family members of other than active duty members, the contractor
shall charge a cost-share of 25%
of the total allowed charges unless the newborn is deemed enrolled
in TRICARE Prime.
1.3.3.3.7 Maternity Related Care.
The
contractor shall cost-share medically necessary treatment rendered
to a pregnant woman for a non-obstetrical medical, anatomical, or
physiological illness or condition
as
a part of the maternity episode when:
• The treatment
is otherwise allowable as a benefit; and
• Treatment
delay until after the
conclusion of the pregnancy is medically contraindicated; and
• The illness
or condition is, or increases the likelihood of, a threat to the
life of the mother; or
• The
illness or condition may cause, or
increase the likelihood of, a stillbirth or newborn injury or illness;
or
• The usual course of treatment is altered
or modified to minimize a defined risk of newborn injury or illness.
1.3.3.4
Cost-Shares:
DRG-Based Payment System
1.3.3.4.1 General
The contractor
shall apply these special cost-sharing procedures only
to claims paid under the DRG-based payment system for
dates of service prior to January 1, 2018, and to all TRICARE For
Life (TFL) claims before and after January 1, 2018.
1.3.3.4.2
TRICARE
Standard
1.3.3.4.2.1 Cost-shares for ADFMs. The
contractor shall charge ADFMs or their sponsors the
first $25 of the allowable institutional costs incurred with each
covered inpatient admission to a hospital or other authorized institutional
provider, or the amount the beneficiary or sponsor would have been charged
had the inpatient care been provided in an MTF,
whichever is greater.
1.3.3.4.2.2 Cost-shares for beneficiaries
other than ADFMs.
1.3.3.4.2.2.1 The
contractor
shall charge a cost-share
the
lesser of:
1.3.3.4.2.2.1.1 An
amount based
upon a single, specific
per diem amount which
shall not vary regardless
of the DRG involved. The following is the DRG inpatient TRICARE
Standard cost-sharing per diems for beneficiaries other than ADFMs.
1.3.3.4.2.2.1.1.1 The
contractor
shall calculate the per diem amount
as
follows:
• Determine
the total allowable DRG-based amounts for services subject to the
DRG-based payment system and for beneficiaries other than ADFMs during
the same database period used for determining the DRG weights and
rates.
• Add in the allowance for Capital
and Direct Medical Education (CAP/DME) which have been paid to hospitals
during the same database period used for determining the DRG weights
and rates.
• Divide this amount by the total
number of patient days for these beneficiaries. This amount is the
average cost per day for these beneficiaries.
• Multiply
this amount by 0.25. In this way total cost-sharing amounts continue
to be 25% of the allowable amount.
• Determine
any cost-sharing amounts which exceed 25% of the billed charge (see
paragraph 1.3.3.4.2.2.1.2) and divide this
amount by the total number of patient days in
paragraph 1.3.3.4.2.2.1.1).
Add this amount to the amount in
paragraph 1.3.3.4.2.2.1.1. This is the per
diem cost-share to be used for these beneficiaries.
1.3.3.4.2.2.1.1.2 The contractor
shall charge the per diem amount for
each actual day of the beneficiary’s hospital stay which the DRG-based
payment covers except for the day of discharge. When the payment
ends on a specific day because eligibility ends on a short-stay
outlier day, the contractor shall count the last
day of eligibility to determine the
per diem cost-sharing amount. For claims involving a same-day discharge
which qualify as an inpatient stay (e.g., the patient was admitted
with the expectation of a stay of several days, but died the same
day) the contractor shall charge a cost-share based upon a
one-day stay. (The number of hospital days contain
one day in this situation.)
1.3.3.4.2.2.1.2 Twenty-five
percent (25%) of the billed charge. The contractor
shall use billed charge to include
all inpatient institutional line items billed by the hospital minus
any duplicate charges and any charges which may be
billed separately (e.g., hospital-based professional services, outpatient
services). The net billed charges for
the cost-share computation include comfort and convenience items.
1.3.3.4.2.2.2 The contractor
shall not charge a cost-share exceeding the
DRG-based amount.
1.3.3.4.2.2.3 Where the dates of service
span different FYs (or CY for dates of service after December
31, 2017), the contractor shall apply
a per diem cost-share amount for each year to
the appropriate days of the stay.
1.3.3.4.3 TRICARE Extra
1.3.3.4.3.1 Cost-shares for ADFMs. The contractor
shall apply cost-sharing provisions for the
same as those for TRICARE Standard.
1.3.3.4.3.2 Cost-shares for beneficiaries
other than ADFMs. The contractor shall apply cost-sharing the
same as those for TRICARE Standard, except the per diem copayment
is $250.
1.3.3.4.4 TRICARE
Prime
The
contractor shall not apply a cost-share for ADFMs.
For beneficiaries other than ADFMs, the contractor
shall charge a cost-share of the
first $25 of the allowable institutional costs incurred with each
covered inpatient admission to a hospital or other authorized institutional
provider; or, an $11 per
diem rate, whichever is greater.
1.3.3.4.5 Maternity Services
See
paragraph 1.3.3.3, for the
cost-sharing provisions for maternity services.
1.3.3.5 Cost-Shares: Inpatient Mental
Health Per Diem Payment System
1.3.3.5.1 General.
The
contractor shall apply these special cost-sharing
procedures
only to claims paid under
the inpatient mental health per diem payment system. For inpatient
claims exempt from this system, the
contractor shall
follow the procedures in
paragraph 1.3.3.2 or
1.3.3.4.
1.3.3.5.2 Cost-shares for ADFMs. For
dates of service prior to October 3, 2016, inpatient cost-sharing
for mental health services is $20 per day for each day of the inpatient
admission. This $20 per day cost-share applies to admissions to
any hospital for mental health services, any RTC, any Substance Use
Disorder Rehabilitation Facility (SUDRF), and any PHP providing
mental health or SUD rehabilitation services. For
TRICARE Prime
ADFMs cost-share is $0 per day. See
Addendum A for
further information.
1.3.3.5.3 For dates of service on or
after October 3, 2016
and ending on December 31, 2017,
the
contractor shall apply inpatient
cost-sharing for mental health services
as described
in
paragraph 1.3.3.2.1. The
contractor
shall apply cost-share
s to
admissions to any hospital for mental health services, any RTC,
and any inpatient/residential SUD detoxification and rehabilitation
program. For
TRICARE Prime ADFMs, the
contractor
shall apply a cost-share
of $0
per day. See
Addendum A for further information.
1.3.3.5.4 Cost-shares for beneficiaries
other than ADFMs.
1.3.3.5.4.1 Higher volume hospitals and
units. With respect to care paid for on the basis of a hospital
specific per diem, the contractor shall apply a cost-share of 25%
of the hospital specific per diem amount.
1.3.3.5.4.2 Lower
volume hospitals and units. For care paid for on the basis of a
regional per diem, the
contractor shall apply a cost-share
of the
lower of
paragraphs 1.3.3.5.4.2.1 or
1.3.3.5.4.2.2:
1.3.3.5.4.2.1 A
fixed daily amount multiplied by the number of covered days. The
fixed daily amount
is 25% of the per
diem adjusted so that total beneficiary cost-share
equal
s 25%
of total payments under the inpatient mental health per diem payment
system.
This fixed daily amount is only applicable
with TRICARE is first payer. DHA updates this fixed
daily amount
annually and
posts
it on the DHA website at
http://www.health.mil/rates.
DHA
will also furnish this fixed daily amount
to
the contractor
. The
following fixed daily amounts are effective for services rendered
on or after October 1 of each
FY.
• 2019
- $248 per day.
• 2020
- $255 per day.
• 2021
- $261 per day.
1.3.3.5.4.2.2 Twenty-five
percent (25%) of the hospital’s billed charges (less any duplicates).
1.3.3.5.5 Claims which span a period
in which two separate per diems exist. The contractor
shall compute the cost-share on the actual per diem in effect for
each day of care for claims subject
to the inpatient mental health per diem payment system which spans
a period in which two separate per diems exist.
1.3.3.5.6 Cost-share whenever leave days
are involved. The contractor shall not charge for
leave days when such days are included in a hospital stay.
1.3.3.5.7 The contractor
shall apply inpatient cost-shares to claims for services
that are provided during an inpatient admission which are not included
in the per diem rate if the contractor
cannot determine where the service was rendered and the patient status 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 includes non-mental
health claims and mental health claims submitted by individual professional
providers rendering medically necessary services during the inpatient
admission.
1.3.3.6 Cost-Shares:
PHPs And Intensive Outpatient Program (IOPs)
1.3.3.6.1 For
care rendered prior to October 3, 2016, cost-sharing for partial
hospitalization is on an inpatient basis. The inpatient cost-share
also applies to the associated psychotherapy billed separately by
the individual professional provider. These providers shall identify
on the claim form that the psychotherapy is related to a partial
hospitalization stay so the proper inpatient cost-sharing is applied.
The cost-share for ADFMs enrolled in TRICARE Prime
for inpatient mental health services is $0. For retirees and their
family members, the cost-share is 25% of the allowed amount. Since
inpatient cost-sharing is being applied, no deductible is taken
for partial hospitalization regardless of sponsor status. The cost-share
for ADFMs is taken from the PHP claim.
1.3.3.6.2 For
care rendered on or after October 3, 2016,
the contractor
shall apply outpatient cost-
shares for
PHP
and IOP
services.
The
contractor shall also apply outpatient
cost-share
s to
associated
psychotherapy billed separately by the individual professional provider.
The
contractor shall ensure these providers
identify
on the claim form that the psychotherapy is related to PHP or IOP
care so the
contractor can apply the proper
outpatient cost-
share. Cost-shares
for standard beneficiaries
are in
paragraph 1.3;
cost-sharing requirements for
TRICARE Prime
beneficiaries
are in
paragraph 1.2.
1.3.3.7
Cost-Shares:
Ambulatory Surgery
1.3.3.7.1 For
non-TRICARE Prime ADFMs,
the contractor shall, for
all services reimbursed as ambulatory surgery,
charge
a $25 cost-share
on
the facility claim.
The contractor shall not deduct
a cost-share
from a
claim for professional services related to ambulatory surgery. This
applies whether the services are provided in a freestanding ASC,
a hospital outpatient department or a hospital emergency room. So
long as at least one procedure on the claim is reimbursed as ambulatory
surgery, the
cost-
share shall
be as ambulatory surgery as required by this section.
For family members of active duty members of the armed forces of
NATO/PfP foreign nations who are eligible for outpatient care under
TRICARE per DEERS, see
paragraph 1.1.5.
1.3.3.7.2 Other Beneficiaries. Since
the cost-share for other beneficiaries is based
upon a percentage
rather than a set amount, the
contractor shall take
the cost-share
from
all ambulatory surgery claims. For professional services, the
contractor
shall charge cost-share
of 25%
of the allowed amount. For the facility claim, the
contractor
shall charge a cost-share
that is
the lesser of:
1.3.3.7.2.1 Twenty-five percent (25%) of
the applicable group payment rate (see
Chapter 9, Section 1);
or
1.3.3.7.2.2 Twenty-five percent (25%) of
the billed charges; or
1.3.3.7.2.3 Twenty-five percent (25%) of
the allowed amount as determined by the contractor.
1.3.3.7.2.4 The special cost-sharing provisions
for beneficiaries other than ADFMs ensures that these
beneficiaries are not disadvantaged by these procedures. In most
cases, 25% of the group payment rate will be less, but because there
is some variation within each group, 25% of billed charges may be
less in some cases. This ensures that
the beneficiaries get the benefit of the group payment rates when such
rate are more advantageous, but they are never disadvantaged
by them. If there is no group payment rate for a procedure, the
cost-share is simply 25%
of the allowed amount.
1.3.3.8 Cost-Shares
and Deductible: Former Spouses
1.3.3.8.1 Deductible. In accordance with
the FY 1991 Appropriations and Authorization Acts, Sections 8064
and 712 respectively, beginning April 1, 1991, the
contractor shall charge an eligible former spouse the
first $150.00 of
the reasonable costs/charges for otherwise covered outpatient services
and supplies provided in any one FY
(CY for dates of service after December 31, 2017). 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 retain
a legal familial relationship with the member or former member and are included
in the member’s or former member’s family deductible. The contractor
shall not require the former spouse to 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 FY (CY for dates of
service after December 31, 2017).
1.3.3.8.2 Cost-Share. The
contractor shall charge an eligible former spouse cost-share amounts identical
to those required for beneficiaries other than ADFMs.
1.3.3.9 Cost-Share Amount: Under Discounted
Rate Agreements
Under
managed care, where the network provider agrees to a
negotiated (discounted) rate, the contractor
shall base the cost-share upon the
following:
1.3.3.9.1 For
non-institutional providers providing outpatient care, and for institution-based professional
providers rendering both inpatient and outpatient care; the cost-share
(20% for outpatient care to ADFMs,
25% for care to all others) is 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.
1.3.3.9.2 For institutional providers
subject to the DRG-based reimbursement methodology, the cost-share
for beneficiaries other than ADFMs
is the
LOWER OF EITHER:
• The single,
specific per diem supplied by DHA after the application of the agreed upon
discount rate; OR
• Twenty-five percent (25%) of
the billed charge.
1.3.3.9.3 For institutional providers
subject to the Mental Health Per Diem Payment System (high volume
hospitals and units), the cost-share for beneficiaries other than
ADFMs is 25% of the hospital per diem
amount after it has been adjusted by the discount.
1.3.3.9.4 For institutional providers
subject to the Mental Health per diem payment system (low volume
hospitals and units), the cost-share for beneficiaries other than
ADFMs
is the LOWER OF EITHER:
• The fixed
daily amount supplied by DHA after the application of the agreed
upon discount rate; OR
• Twenty-five
percent (25%) of the billed charge.
1.3.3.9.5 For RTCs, the cost-share for
other than ADFMs is 25% of the TRICARE
rate after it has been adjusted by the discount.
1.3.3.9.6 For institutions and for institutional
services being reimbursed on the basis of the TRICARE-determined
reasonable costs, the cost-share for beneficiaries other than ADFMs
is 25%
of the allowable billed charges after it has been adjusted by the
discount.
Note: For
all inpatient care for ADFMs, the cost-share
continue
s to
be either the daily charge or $25 per stay, whichever is higher.
There is no change to the requirement
that the
ADFM’s cost-share
is applied to the
institutional charges for inpatient services. If the contractor
learns that the participating provider has billed a beneficiary
for a greater cost-share amount, based
upon 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. (Also see
paragraph 1.3.3.4.) For
TRICARE Prime
ADFMs, the cost-share is $0 for care provided on or after April
1, 2001.
1.3.3.10
Preventive
Services
1.3.3.10.1 The contractor
shall not require copayments or authorizations
for
the following preventive services
described
in the TPM,
Chapter 7, Sections 2.1 and
2.5:
1.3.3.10.1.1 Colorectal
cancer screening.
1.3.3.10.1.2 Breast cancer screening.
1.3.3.10.1.3 Cervical cancer screening.
1.3.3.10.1.4 Prostate cancer screening.
1.3.3.10.1.5 Immunizations.
1.3.3.10.1.6 Well-child visits for children
under six years of age.
1.3.3.10.2 In addition to the services
listed in
paragraph 1.3.3.10.1, effective January 1,
2017, cost-shares are eliminated for the services listed in the
TPM,
Chapter 7, Section 2.1, paragraphs 1.1.1.1.2 and
1.1.5.1 through
1.1.5.12.
Effective January 1, 2018, cost-shares are eliminated for the services
listed in the TPM,
Chapter 7, Section 2.1, paragraph 1.1.5.13.
1.3.3.10.3 The contractor
shall not require a beneficiary to
pay any portion of the cost of these preventive services even if
the beneficiary has not satisfied the deductible for that year.
1.3.3.10.4 This waiver does not apply
to any TRICARE beneficiary who is a Medicare-eligible beneficiary.