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Child Vaccination Programs
That Use An SVP Per Capita Assessment Approach For Reimbursement
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1.
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DHA will calculate the number
of covered lives (i.e., Active Duty Family Member (ADFM) and Non-Active
Duty Family Member (NADFM) reliants that are not enrolled at a Military
Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) in
Prime, ages 0-18) (see Section 38 for details) each quarter. Defense
Health Agency (DHA) will estimate the percentage of TRICARE non-Active
Duty Dependent (ADD) reliants annually, and exclude any non-ADDs
who are not reliant on TRICARE as their primary form of insurance
in their covered lives population estimate. |
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2.
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Each SVP may have its own time
period for the population to be calculated. The DHA will work with the
state programs to ensure that the population is calculated for the
appropriate time frame in the state. DHA will, on a quarterly basis,
provide the contractors the number of covered lives in each state.
Some SVPs require quarterly payment, while others require annual
payments. DHA will determine which population numbers are appropriate
to use for the SVP-specific calculations.
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3.
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DHA will also provide the contractors
with a TRICARE per capita capped payment amount for the time period
needed for each SVP program. This information may be provided directly
to the contractor or posted on a DHA-approved website.
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4.
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The contractors shall follow
the protocol established by each state to provide them with the number
of TRICARE covered lives for the dates requested by the SVP.
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5.
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The contractors shall identify
whether the SVP per capita assessment amount provided by the SVP is
greater or less than the TRICARE per capita capped payment amount.
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6.
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In some states, the SVPs shall
send an invoice to the contractors for a payment, typically on a quarterly
or annual basis. In other states, the contractors shall proactively
provide payment to the SVPs for the liability amount.
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7.
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The contractors shall pay the
SVPs in one of two ways:
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a.
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If the SVP per capita quarterly
assessment amount is less than the TRICARE per capita quarterly capped
payment amount: The contractors will pay the amount equal to the
SVP per capita assessment amount multiplied by the TRICARE reliant
population
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b.
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If the SVP per capita quarterly
assessment amount is greater than the TRICARE per capita quarterly
capped payment amount: The contractors will calculate the total
TRICARE assessment amount to be paid to the SVP as the number of
TRICARE reliants (i.e., covered lives) in the state multiplied by
the TRICARE per capita capped payment amount.
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8.
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The contractors shall submit
payment to the SVPs either annually or quarterly depending on the SVP.
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9.
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The contractors shall be reimbursed
using non-underwritten funds.
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Child Vaccination Programs
That Use An Alternative Approach - The State Of Massachusetts
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1.
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For Massachusetts, DHA will
calculate the total TRICARE paid amounts made to acute care hospitals and
paid facility charges for hospital outpatient departments and freestanding
Ambulatory Surgery Center (ASC) facilities for a period designated
annually by the Massachusetts Vaccine Association to calculate the
annual Pediatric Immunization Program Assessment (PIPA).
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2.
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DHA will identify the PIPA
surcharge percentage that is published annually by the state of Massachusetts,
and multiply this percentage by the total paid amounts calculated
above.
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3.
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DHA will compare the MA assessment
amount with the TRICARE payment capped amount, as calculated by
DHA using the reliant covered lives under age 19 and an assessment
amount.
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4.
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DHA will provide the contractor
with the total TRICARE assessment amount to be paid to the state and
the contractor shall submit payment to the Massachusetts Vaccine
Purchase Trust.
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5.
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The contractor shall submit
payment to the SVP by June 1st.
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6.
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The contractor shall be reimbursed
using non-underwritten funds.
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Adult Vaccination Programs
That Use An SVP Per Capita Assessment Approach for Reimbursement
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1.
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DHA will calculate the number
of covered lives (i.e., ADFM and NADFM reliants that are not enrolled at
an MTF/eMSM in Prime, for the ages in which adult vaccines are provided
in the state) each quarter. The term “reliants” refers to a subset
of TRICARE eligible beneficiaries who are dependent on TRICARE for
the coverage/reimbursement of vaccines under the well-child and
preventive benefits. All TRICARE ADFMs are considered to be reliant
on TRICARE as their primary form of insurance. DHA will estimate
the percentage of TRICARE non-ADD reliants annually, and will exclude
any non-ADDs who are not reliant on TRICARE as their primary form
of insurance in their covered lives population estimate.
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2.
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Each state adult SVP may have
its own time periods for the population to be calculated. DHA will work
with the state programs to ensure that the population is calculated
for the appropriate time frame in the state. DHA will, on a quarterly
basis, provide the contractors the number of covered lives in each
state.
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3.
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DHA will calculate a state-specific
TRICARE per capita capped payment amount for each quarter using
data from only the adult vaccines that are provided in the state.
DHA will determine if multiple state per capita capped rates are
required based on age. For example, if a state program provides
vaccines to the Medicare-eligible population, DHA will exclude any
Medicare-covered adult vaccines from the calculation of a capped
amount used for the age 65 and older population in that state only.
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4.
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DHA will provide the contractors
with the number of covered reliants in the state, and the TRICARE state-specific
per capita capped payment amount(s). DHA may provide these values
directly to the contractor, or via a website designed for DHA SVP
programs.
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5.
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The contractor provide the
Adult SVP program with the number of adult TRICARE reliants in which ever
mechanism that is agreed upon by the contractor and the state (via
memo, online survey, web-portal, etc.) for each time period requested
by the SVP.
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6.
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In some states, the SVPs shall
send an invoice to the contractors for a payment, typically on a quarterly
or annual basis. In other states, the contractors will proactively
provide payment to the SVPs for the liability amount.
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7.
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The contractor shall identify
whether the SVP Adult per capita assessment amount is greater than the
calculated TRICARE per capita capped payment amount.
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8.
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The contractors shall pay the
SVPs in one of two ways:
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a.
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If the SVP per capita quarterly
assessment amount is less than the TRICARE per capita quarterly capped
payment amount: The contractors will pay the amount equal to the
SVP per capita assessment amount multiplied by the TRICARE reliant
population.
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b.
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If the SVP per capita quarterly
assessment amount is greater than the TRICARE per capita quarterly
capped payment amount: The contractors will calculate the total
TRICARE assessment amount to be paid to the SVP as the number of
TRICARE reliants (i.e., covered lives) in the state multiplied by
the TRICARE per capita capped payment amount.
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9.
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The contractor shall submit
payment to the SVP.
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10.
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The contractor shall be reimbursed
using non-underwritten funds.
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