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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Beneficiary Liability
Chapter 2
Section 6
Waivers of Cost-Shares and Deductibles
Issue Date:  October 20, 2017
Authority:  32 CFR 199.17
Revision:  C-6, October 20, 2017
1.0  Description
Cost-shares and deductibles are waived for certain categories of beneficiaries.
2.0  Policy
2.1  Operation Desert Shield/Desert Storm
2.1.1  The Operation Desert Shield/Desert Storm Supplemental Appropriations Act of 1991, Public Law 102-28, April 10, 1991, allowed medical providers to voluntarily waive the patient cost-share and/or deductible for medical services provided family members of active duty personnel from August 2, 1990, until the date the “Persian Gulf conflict” ends as prescribed by Presidential proclamation or by law.
2.1.1.1  Operation Desert Storm. Operations of the United States (U.S.) Armed Forces conducted as a consequence of the invasion of Kuwait by Iraq (including operations known as Operation Desert Shield and Operation Desert Storm).
2.1.1.2  Persian Gulf Conflict. The period beginning on August 2, 1990, and ending thereafter on the date prescribed by Presidential proclamation or by law.
2.1.1.3  A Civilian Health Care (CHC) provider may voluntarily waive, in whole or in part, the cost-share and/or deductible of Active Duty Family Members (ADFMs) if the provider certifies in writing that the amount charged the federal Government for such health care was not increased above the amount that the health care provider would have charged the federal Government for such health care had the payment not been waived.
2.1.1.3.1  The legislation only provides a temporary exemption to the cost-sharing provisions. Once the President officially proclaims an end to the “Persian Gulf conflict”, the cost-sharing provision will be reinstated.
2.1.1.3.2  The legislation does not require modification of the existing claims processing guidelines. The contractors shall process the claims normally, reflecting the appropriate deductible, cost-share, and catastrophic cap on the claims history, payment records, TRICARE Explanation of Benefits (EOB), etc. The waiver of cost-sharing is between the ADFM and the provider and does not affect the contractor’s claims processing procedures, except as prescribed in the Program Integrity provisions in the TRICARE Operations Manual (TOM), Chapter 13.
2.1.1.3.3  The waiver of cost-sharing is based on the dates of care/service.
2.1.1.3.4  The waiver applies to both the Basic Program and the Extended Care Health Option (ECHO) and is applicable to both inpatient and outpatient care.
2.1.1.3.5  The waiver of cost-sharing only applies to family members of active duty personnel. The other categories of TRICARE beneficiaries are still subject to the cost-sharing and deductible requirements set forth in 10 United States Code (USC) 1079 and 1086.
2.1.2  The exception to the cost-sharing requirements is effective for services rendered from August 2, 1990, until the date the “Persian Gulf conflict” ends as prescribed by Presidential proclamation or by law.
2.2  Operation Joint Endeavor
2.2.1  Under legislation passed for Operation Joint Endeavor, the TRICARE Standard deductible has been waived for family members of certain reserve members called to active duty. However, this provision does not provide for voluntary waiver of cost-shares or the deductibles by providers allowed under Operation Desert Storm. If the family is enrolled in TRICARE Prime, the deductible for POS is not waived for this provision.
2.2.2  The exception to the deductible requirements under Operation Joint Endeavor for TRICARE Standard and Extra is effective for services rendered from December 8, 1995 until such time as Executive Order 12982 expires.
2.3  Operation Noble Eagle/Operation Enduring Freedom
2.3.1  The TRICARE Standard and Extra deductible is waived for family members of members of the reserves or National Guard who have been ordered to active duty in support of operations that result from the terrorist attacks on the World Trade Center (WTC) and the Pentagon on September 11, 2001.
2.3.2  The cost-share is partially waived in certain cases for these beneficiaries. On claims from non-participating professional providers for services rendered to Standard beneficiaries, the allowable amount is the lesser of the billed charge or the balance billing limit (115%) of the CHAMPUS Maximum Allowable Charge (CMAC)). In these cases, the cost-share is 20% of the lesser of the CMAC or the billed charge, and the cost-share for any amounts over the CMAC that are allowed is waived. Any amounts that are allowed over the CMAC will be paid entirely by TRICARE.
2.4  For Certain Reservists
See the TRICARE Policy Manual (TPM), Chapter 10, Section 8.1.
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