3.1 Through
December 31, 2017, TRICARE offers beneficiaries three health care
options:
3.1.1 TRICARE Prime Plan
Beneficiaries who enroll in
TRICARE Prime are assigned or select a Primary Care Manager (PCM).
A PCM is a provider of primary care, who furnishes or arranges for
all health care services required by the Prime enrollee. Military
Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) Commanders
have the authority and responsibility to set priorities for enrollment
to MTF/eMSM PCMs. When an MTF’s/eMSM’s primary care capacity is
full, civilian PCMs, who are all part of the contractor’s network,
are available to provide care to patients.
3.1.1.1 Expanded benefits. As enrollees
of Prime, patients receive certain clinical preventive services
that are provided without cost-share for the patient.
3.1.1.2 Reduced cost. Prime enrollees’
cost-share for civilian services is substantially reduced from that
which is applicable under TRICARE Extra and TRICARE Standard. In
addition, when a TRICARE Prime enrollee is referred to a non-participating
provider, the enrollee is only responsible for the copayment amount,
but not for any balance billing amount by the non-participating
provider.
3.1.2 TRICARE
Extra Plan
Beneficiaries
who do not enroll in Prime may still benefit from using the providers
in the contractor’s network where possible. On a case by case basis,
beneficiaries may participate in TRICARE Extra by receiving care
from a network provider. The beneficiary will take advantage of
the reduced charges under Extra and a reduction in cost-shares.
Covered services are the same as under TRICARE Standard. This option
is terminated as of December 31, 2017 and replaced by TRICARE Select.
3.1.3 TRICARE Standard Plan
The TRICARE Standard plan is
a fee-for-service program. This option is terminated as of December
31, 2017 and replaced by TRICARE Select.
3.2 Beginning
January 1, 2018, the TRICARE program consists of three options:
TRICARE Prime, TRICARE Select, and TRICARE For Life (TFL). See 10
United States Code (USC) 1072(7).
3.2.1 TRICARE
Prime Plan
TRICARE
Prime is a Health Maintenance Organization (HMO)-like program. It
generally features use of MTFs and substantially reduced out-of-pocket
costs for authorized care provided outside MTFs. Beneficiaries generally
agree to use MTFs and designated civilian provider networks and to
follow certain managed care rules and procedures. Beneficiaries
who enroll in TRICARE Prime are assigned or select a PCM. A PCM
is a provider of primary care, who furnishes or arranges for all
health care services required by the Prime enrollee. MTF/Enhanced
Multi-Service Market (eMSM) Commanders have the authority and responsibility
to set priorities for enrollment to MTF/ eMSM PCMs. When an MTF’s/eMSM’s
primary care capacity is full, civilian PCMs, who are all part of
the contractor’s network, are available to provide care to patients.
3.2.2 TRICARE Select Plan
TRICARE
Select is a self-managed, Preferred Provider Organization (PPO)
program. It allows beneficiaries to use the TRICARE civilian provider
network, with reduced out-of-pocket costs compared to care from
non-network providers, as well as military facilities (where they
exist and when space is available). Similar to the long-operating
“TRICARE Extra” and “TRICARE Standard” plans, which this replaces,
a major feature of TRICARE Select is that enrollees will not have
restrictions on their freedom of choice with respect to health care
providers. TRICARE Select is based primarily on 10 USC 1075 (as added
by Section 701 of National Defense Authorization Act (NDAA) for
Fiscal Year (FY) 2017 and 10 USC 1097.
3.2.3 TFL Plan
TFL is the Medicare wraparound
coverage plan under 10 USC 1086(d).
3.3 Eligibility for TRICARE
3.3.1 Active Duty Eligibility
All active duty members are
considered TRICARE Prime. They must, however, take action to be
enrolled in Prime, and be assigned to a PCM (see the TRICARE Operations
Manual (TOM) for PCM provisions under the TRICARE Prime Remote (TPR)
program).
3.3.2 Non-Active
Duty Eligibility
All individuals
entitled to civilian health care under 10 USC Sections 1079 or 1086,
are eligible for TRICARE. Beginning January 1, 2018, beneficiaries
other than TFL beneficiaries must enroll in a TRICARE plan to receive
care outside the Direct Care (DC) only system. Non-active duty individuals, commonly
referred to as “TRICARE eligibles”, include the spouse and children
of active duty personnel, retirees and their spouses and children,
and survivors.
Note: This group also includes former
spouses as defined in 10 USC Section 1072(2). Not included are those
individuals who are entitled to care in the DC system, on a space
available basis, but ordinarily are not entitled to civilian care,
such as family member parents and parents-in-law.
3.3.3 TFL
Pursuant to Section 712 of
the NDAA for FY 2001, Medicare eligible beneficiaries based on age,
whose TRICARE eligibility is determined by 10 USC Section 1086,
are eligible for Medicare Part A, and those who are enrolled in
Medicare Part B, are eligible for the TRICARE benefit effective
October 1, 2001. These beneficiaries are not eligible to enroll
in TRICARE Prime. TFL beneficiaries older than age 65 cannot enroll
in TRICARE Prime (exception for grandfathered Uniformed Services
Family Health Plan (USFHP) enrollees). Retirees and their family
members under age 65 who have Medicare coverage due to disability
or with end stage renal disease can enroll in TRICARE Prime if they
have Medicare Part B. Their Prime enrollment fees are waived if
they have Part B coverage. Retirees, dependents, and survivors with
any Medicare coverage at any age are not eligible to enroll in TRICARE
Select because they are excluded from the “Retired Category” for
TRICARE Select as defined in 10 USC 1075(b)(1)(B).
3.3.4 Supplemental Health Care Program
(SHCP) and TPR Program
See the
TOM,
Chapters 16 and
17.
3.3.5 Non-DoD TRICARE Eligibles
TRICARE eligibles sponsored
by non-DoD uniformed services (the Public Health Service (PHS),
the U.S. Coast Guard (USCG), and the National Oceanic and Atmospheric
Administration (NOAA)) are eligible for TRICARE and may enroll in
TRICARE Prime or TRICARE Select (beginning January 1, 2018).
3.3.6 North Atlantic Treaty Organization
(NATO) And Partnership For Peace (PfP) Beneficiaries
The Department of Defense equates
foreign military members and family members from PfP countries the
same as those from NATO Status of Forces Agreement (SOFA) countries,
in terms of access to outpatient medical and dental care from DoD
medical and dental treatment facilities, and access to TRICARE Select
(TRIARE Standard before January 1, 2018) civilian care. A current
list of NATO SOFA countries is at:
https://www.nato.int/cps/ie/natohq/topics_52044.htm.
A current list of NATO PfP countries is at:
https://www.nato.int/cps/en/natohq/51288.htm.
3.3.6.1 NATO or PfP ADSM
As
specified in applicable SOFAs, active duty members of the armed
forces of NATO and PfP nations qualify for TRICARE outpatient services
in similar fashion as their U.S. Armed Forces active duty counterparts.
However, there is no coverage for inpatient services under TRICARE.
No enrollment in a TRICARE plan is required or authorized. As such
contractors shall not use the government furnished web-based enrollment
system/application to determine eligibility. See the TOM,
Chapter 17, Section 3, and TRM,
Chapter 4, Sections 2 and
4 for more information.
3.3.6.2 NATO or PfP Family Members
Family
members of active duty members of the armed forces of NATO and PfP
nations are only eligible for outpatient care under TRICARE; there
is no coverage for inpatient services under TRICARE. Effective January
1, 2018, TRICARE Select Group B cost-shares for Active Duty Family
Members (ADFMs) apply. Prior to January 1, 2018, TRICARE Standard/Extra
cost-shares for ADFMs apply. No enrollment in a TRICARE plan is
required or authorized. As such, contractors shall not use the government
furnished web-based enrollment system/application to determine eligibility.
See TOM,
Chapter 17, Section 3; TRM,
Chapter 2, Section 2, and
Chapter 4, Sections 2 and
4; and TRICARE Systems Manual (TSM),
Chapter 2, Addendum L for more information.
3.3.7 Enrollment
Starting in calendar year 2018,
beneficiaries other than active duty members and TFL beneficiaries
need to elect to enroll in TRICARE Select or TRICARE Prime in order
to be covered by the private sector care portion of TRICARE. Enrollment
will be done during an open season period prior to the beginning
of each plan year, which operates with the calendar year. An enrollment
choice will be effective for the plan year. As an exception to the
open season enrollment rule, enrollment changes can be made during
the plan year for certain Qualifying Life Events (QLEs), such as
a change in eligibility status, marriage, divorce, birth of a new
family member, relocation, loss of Other Health Insurance (OHI), or
other events. Beneficiaries eligible to enroll in TRICARE Prime
or TRICARE Select plans who do not enroll or fail to qualify to
maintain their TRICARE Prime or TRICARE Select enrollment status
no longer have coverage under the TRICARE Program (including the
TRICARE retail pharmacy and Mail Order Pharmacy (MOP) programs),
and may not re-enroll until the following annual open season enrollment period
or until the sponsor or an eligible family member experiences a
QLE, whichever comes first. Such beneficiaries eligible to enroll
in TRICARE Prime or TRICARE Select do not lose any statutory entitlement
to space-available care in MTFs/eMSMs.
Note: Included in all of the TRICARE
benefit packages is a retail pharmacy network and a mail service
pharmacy program. Beneficiaries must be enrolled to a plan to receive
pharmacy services outside the DC system.
3.4 Administrative Policy
3.4.1 Benefit Policy
3.4.1.1 Benefit policy applies to the
scope of services and items which may be considered for cost-sharing
by the TRICARE within the intent of the 32 CFR 199.
3.4.1.2 The
current edition of the American Medical Association’s (AMA’s) Physicians’
Current Procedural Terminology (CPT) is incorporated by reference
into this Manual to describe the scope of services potentially allowable
as a benefit, subject to explicit requirements, limitations, and
exclusions, in this Manual or in the 32 CFR 199.
3.4.1.3 Procedures listed in the CPT
and the Healthcare Common Procedure Coding System (HCPCS) may be
cost-shared only when the procedure is “appropriate medical care”
and is
“medically or psychologically necessary”
and is
not “unproven” as defined in the
32 CFR 199.4(g)(15), and the procedure is
not explicitly excluded in the TRICARE program.
3.4.2 Program Policy
Program Policy applies to beneficiary
eligibility, provider eligibility, claims adjudication, and quality
assurance. Program policy implementation instructions are found
in the TSM and the TOM.
3.4.3 Any
benefit or program administration issue for which benefits or program
operation policy guidance is required, or when TRICARE policy is
silent on an issue, the contractor shall describe in writing and
submit to the Team Chief, MB&RD, Defense Health Agency (DHA).
3.4.4 Reimbursement Policy
3.4.4.1 Reimbursement policy sets forth
the payment procedures used for reimbursing TRICARE claims. The
related implementation instructions for these payment procedures
are found in the TSM and the TOM.
3.4.4.2 The TRM provides the methodology
for pricing allowable services and items and for payment to specific
categories and types of authorized allowable services and items
and for payment to specific categories and types of authorized providers.
These methods allow the contractor to price and render payment for
specific examples of services or items which are not explicitly
addressed in the Manual but which belong to a general category or
type which is addressed in the Manual.
3.5 Administrative and Effective
Dates
3.5.1 Issuance
Date
The date
located on the first page of each separate policy issuance. This
is the date that the issuance was initially issued by DHA.
3.5.2 Revision Date
The revision date is at the
bottom of each page that has been revised along with the change
number. This is the date that DHA changed the issuance in any way.
Each time an issuance is changed, the revised page and/or issuance
is given a change number. The revision date and the change number
together identify a unique version of the issuance on a specific
subject.
3.5.3 Effective
Date
A date
within the body of the text of an issuance which establishes the
specific date that a policy is to be applied to benefit adjudication
or in program administration. An effective date may be earlier than
the issuance or revision date. This date is explicit (e.g., Effective
Date: January 1, 2004). The policy effective date takes precedence
over the issuance date and the revision date. In the absence of an
effective date the policy or instruction is considered to have always
been applicable because the newly published policy or instruction
confirms the application of existing published program requirements.
3.5.4 Implementation Date
The
implementation date of a policy or instruction is not noted in the
issuance as this date is determined by the terms of the contract
modification between DHA and the contractor. Unless otherwise directed
by DHA, contractors are not to identify finalized claims for readjudication
under revised or new policy. However, the contractor shall readjudicate
any denied claim affected by the policy that is brought to the contractor’s
attention by any source. Pending claims and denied claims in reconsideration
shall be adjudicated using the current applicable policy.