In accordance with Title 10,
United States Code (USC), Section 1079(i)(2), the amount to be paid to
hospitals, Skilled Nursing Facilities (SNFs), and other institutional
providers under the TRICARE program, “shall be determined to the
extent practicable in accordance with the same reimbursement rules
as apply to payments to providers of services of the same type under
Medicare.” This statutory authority has been implemented through
an Interim Final Rule (IFR) with Request for Comment, published
in the Federal Register on September 3, 2020, amending the TRICARE
regulation by adding 32 Code of Federal Regulations (CFR)
32 CFR 199.14(a)(1)(iii)(E)(5) to allow adoption
of Medicare NTAP payment adjustments to TRICARE DRG reimbursements.
Under the amended TRICARE regulation, any Medicare approved NTAP
reimbursement of hospitals subject to the Medicare program as required under
42 CFR 412.88 will be adopted or adopted as modified for TRICARE
unless the Assistant Secretary of Defense for Health Affairs (ASD(HA))
determines that it is not practicable for TRICARE to adopt the Medicare
NTAP. The Director, Defense Health Agency will issue necessary guidance
regarding any Medicare NTAP not adopted by the ASD(HA) or any modification
of a Medicare NTAP deemed necessary for adoption by TRICARE.
4.1 Payment Method
4.1.1 NTAP payment
adjustments apply for discharges on or after January 1, 2020.
4.1.2 The
contractor shall reimburse hospitals subject to NTAPs using the
list of NTAPs and reimbursement rules in the current Fiscal Year
(FY) IPPS Final Rule Home Page found on the CMS website. The reimbursement
amounts in the current FY IPPS Final rule represent the maximum
add on payment that will be provided for each NTAP.
4.1.3 The
contractor shall determine each procedure code eligible for an NTAP
payment according to 42 CFR 412.87, which provides the reference
to the most recent
Federal Register with a list of
approved NTAPs and the procedure codes used to identify use of the
technology. Each year in the IPPS Final Rule, the list of NTAPs
is updated by CMS.
4.1.3.1 The
contractor shall maintain a list of procedure codes eligible for
NTAP payments.
4.1.3.2 The
contractor shall update the list of procedure codes eligible for
NTAPs within ten business days of publication by CMS.
4.1.4 The
contractor shall also determine the maximum NTAP payment amount
for each technology according to 42 CFR 412.87, which provides the
reference to the most recent
Federal Register with
the maximum payment for each approved NTAP. Each year the maximum
NTAP payment amounts are updated by CMS.
4.1.4.1 The contractor shall maintain
a list of the maximum NTAP payment amounts for each technology.
4.1.4.2 The contractor shall update
the list of the maximum NTAP payment amounts for each technology
within ten business days of publication by CMS.
4.1.5 The
contractor shall apply the separate NTAP payment using the appropriate
formula from the IPPS Final Rule and as documented in 42 CFR 412.88.
The contractor shall calculate for each eligible NTAP case on a
claim, the appropriate NTAP payment, where the payment rate is equal
to the lesser of:
• The
designated percentage of the amount by which the
total covered costs of the case exceed the Medicare Severity (MS)-DRG
payment, as determined by CMS, as published in the
current FY IPPS Final rule, or
• The maximum
NTAP payment amount for the specific technology, as determined by CMS.
The
resulting NTAP amount shall then be reimbursed in addition to the
MS-TRICARE DRG payment amount.