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TRICARE Policy Manual 6010.63-M, April 2021
Administration
Chapter 1
Section 1.1
General Policy And Responsibilities
Issue Date:  
Authority:  32 CFR 199
Revision:  
1.0  Program Description
TRICARE is the Department of Defense’s (DoD) program to deliver a comprehensive managed health care program which is closely integrated with the Military Medical Treatment Facilities (MTFs) of the DoD. The TRICARE program is established for the purpose of implementing a comprehensive managed health care program for the delivery and financing of health care services in the Military Health System (MHS).
2.0  Office Of Record
The Medical Benefits and Reimbursement Section (MB&RS) is the “office of record” for the TRICARE Policy Manual (TPM) and TRICARE Reimbursement Manual (TRM). In accordance with Federal Acquisition Regulations (FAR), Subpart 37.203, contractors cannot make policy decisions, as this is an inherent Government function. Consistent with Subpart 7.503, the Office of MB&RS has the responsibility for ensuring that all medical benefits considered for cost-sharing under TRICARE are supported by scientific peer reviewed literature and within the constraints of the law and regulation. These responsibilities include promulgating policy interpretations and maintaining continuous regulatory and policy updates based on Congressional mandate and the current standards of medical care.
3.0  General Policy
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 TRICARE Prime enrollee. Market/MTF Directors have the authority and responsibility to set priorities for enrollment to Market/MTF PCMs. When a Market’s/MTF’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 TRICARE 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 TRICARE 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
3.2.1.1  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 TRICARE Prime enrollee. Market/MTF Directors have the authority and responsibility to set priorities for enrollment to Market/MTF PCMs. When a Market’s/MTF’s primary care capacity is full, civilian PCMs, who are all part of the contractor’s network, are available to provide care to patients.
3.2.1.2  The Uniformed Services Family Health Plan (USFHP) is a contracted TRICARE program under which the TRICARE Prime benefit is offered. The USFHP requires beneficiaries to enroll and is offered through six participating non-profit plans in different geographic areas of the country.
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. When qualified, active duty members may be eligible for enrollment in the TRICARE Prime Remote (TPR) program (see the TRICARE Operations Manual (TOM) for PCM provisions for TPR).
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 and Medicare Wraparound Coverage
3.3.3.1  TFL
3.3.3.1.1  By law, 10 USC 1072(13), “The term ‘TRICARE for Life’ means the Medicare wraparound coverage option of the TRICARE program made available to the beneficiary by reason of section 1086(d) of this title.” Section 1086(d) (i.e., TFL) only applies to those beneficiaries otherwise eligible under section 1086(c) who become eligible for Medicare Part A: Specifically, Section 1086(c)(1) are members and former members entitled to retired or retainer pay (i.e., eligible under section 1074(b)) and their dependents other than parents/parents-in-law (i.e., eligible under section 1076(b)); 1086(c)(2) are surviving dependents; and 1086(c)(3) are certain former spouses.
3.3.3.1.2  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.
3.3.3.1.3  TFL beneficiaries older than age 65 cannot enroll in TRICARE Prime (exception for grandfathered USFHP enrollees).
3.3.3.1.4  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 TRICARE Prime enrollment fees are waived if they have Part B coverage.
3.3.3.1.5  Retirees, dependents, and survivors who are not entitled to premium-free Medicare Part A on their own record, or the record of their current, former, or deceased spouse may enroll in TRICARE Prime or TRICARE Select. Enrollment fees are not waived.
3.3.3.1.6  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).
3.3.3.2  Other Medicare Wraparound Coverage
Eligible beneficiaries other than those listed paragraph 3.3.3.1.1 who are eligible for Medicare A may qualify for Medicare wraparound coverage.
3.3.3.2.1  Active Duty Service Members (ADSMs)
ADSMs with Medicare Part A qualify for Medicare wraparound coverage without enrolling in Medicare Part B. ADSMs may only enroll in TRICARE Prime or TPR (when qualified).
3.3.3.2.2  Active Duty Family Members (ADFMs)
3.3.3.2.2.1  ADFMs with Medicare Part A and enrolled in Medicare Part B qualify for Medicare wraparound coverage and are not required to enroll in either TRICARE Prime or TRICARE Select. Their claims are processed according to TFL claims rules.
3.3.3.2.2.2  ADFMs with Medicare Part A but not Medicare Part B must elect to enroll in either TRICARE Prime (where available) or TRICARE Select for their TRICARE coverage to qualify as Medicare wraparound coverage.
3.3.3.2.3  TRICARE Retired Reserve (TRR), TRICARE Reserve Select (TRS), and TRICARE Young Adult (TYA) Enrollees
Enrollees in these plans with Medicare Part A and/or Medicare Part B have their claims processed as Medicare wraparound coverage which is dependent whether they have Medicare A, Medicare B, or both.
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 United States 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 DoD 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 (TRICARE 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
The contractor shall use only the DEERS claims eligibility response to determine eligibility for TRICARE-covered services for active duty members of the armed forces of NATO and PfP nations. 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 US Armed Forces active duty counterparts. However, there is no coverage for inpatient servicesunder TRICARE. No enrollment in a TRICARE plan is required or authorized. 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
The contractor shall not use the Government furnished web-based enrollment system/application to determine eligibility. 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.
3.3.7.1  Open Season
3.3.7.1.1  TRICARE Select or TRICARE Prime: 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.
3.3.7.1.2  Such beneficiaries eligible to enroll in TRICARE Prime or TRICARE Select do not lose any statutory entitlement to space-available care in Markets/MTFs.
3.3.7.2  Open Enrollment
TRS, TRR and TYA have open enrollment, i.e., they may elect to enroll in coverage at any time when qualified and not subject to being locked out for failure to pay premiums. The plan effective date of coverage is the date the completed request is received by the contractor or a date up to 90 calendar days in the future as specified by the requestor as indicated on the request. (See the TOM, Chapter 22, Section 8.)
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 TRICARE private sector plan or to Continued Health Care Benefits Program (CHCBP) 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.
3.4.2.1  The contractor shall ensure that, in cases where the TPM is silent regarding a specific drug, device, procedure, or service, or specific HCPCS, CPT, or other descriptor, care reimbursed is medically or psychologically necessary for the treatment of a covered condition, in accordance with statute, regulation, and TRICARE policy (including applicable general policy provisions).
3.4.2.2  The contractor shall, upon request, provide the Utilization Management (UM) criteria or clinical review utilized for services that: (1) exceed 1000 claims, annually; or (2) have an allowable charge for a claim line in excess of $1,000. The UM criteria or clinical review criteria shall be made available to the Defense Health Agency (DHA) within five business days of request.
3.4.2.3  The contractor shall make available on a public-facing website its medical coverage policies for drugs, devices, and procedures that meet the criteria in paragraph 3.4.3.2, and ensure that these policies comply with all the requirements in the TPM. The medical coverage policies shall include, but is not limited to, the procedure in question, whether the procedure in question is covered or not covered, any limitations on or requirements for coverage, and applicable HCPCS, CPT, and International Classification of Diseases, 10th Revision (ICD-10) codes.
3.4.2.4  The contractor shall describe in writing and submit to the Government Designated Authority (GDA) 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.
3.4.3  Reimbursement Policy
3.4.3.1  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.
3.4.3.2  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
3.5.4.1  The contractor shall readjudicate any denied claim affected by the policy that is brought to the contractor’s attention by any source. 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.
3.5.4.2  The contractor shall adjudicate pending claims and denied claims in reconsideration using the current applicable policy.
4.0  General Responsibilities
4.1  Regional GDA
The Regional GDA, working with all the Markets/MTFs within the region, is responsible for organizing and managing health care delivery for all TRICARE and the MHS beneficiaries in the region. Supporting the Regional GDA is a contractor with responsibility for establishing a network of health care providers to supplement the care available at the Markets/MTFs and for performing a variety of health care administrative services on behalf of the Regional GDA. The Regional GDA is also responsible for planning and delivering services to meet the health needs of the beneficiaries in the region, whether through the Markets/MTFs or the contractor. The Regional GDA is primarily responsible for oversight and administration of those tasks in the Managed Care Support (MCS) contract that relate to the delivery and management of care.
4.2  Market Directors/MTF Directors
Market Directors/MTF Directors are responsible for managing health care delivery for the active duty personnel and TRICARE eligibles who are enrolled in TRICARE Prime with Market/MTF PCMs, as well as for providing care to other TRICARE and the MHS beneficiaries who are eligible for care in Markets/MTFs. The Market Director/MTF Director sets priorities for assignment of Market/MTF PCMs and works directly with the contractor in network development, resource sharing arrangements and similar local initiatives (see the TOM, Chapter 17 for SHCP).
4.3  MCS and TRICARE Overseas Contractor
The contractor (MCS and TRICARE Overseas) shall be responsible for establishing provider networks in those Prime Service Areas (PSAs) and Base Realignment and Closure (BRAC) sites designated by the appropriate GDA.
4.3.1  The contractor shall establish provider networks, effective January 1, 2018, in non-PSAs accessible by at least 85% of TRICARE Select enrollees in the geographic area of responsibility and in overseas areas where a preferred network provider is determined by DHA to be economically in the best interest of the DoD.
4.3.2  The contractor shall establish provider networks that include both primary care providers and specialists.
4.3.3  The contractor shall ensure that first priority for referral of Prime enrollees for specialty care or inpatient care is the Market/MTF.
4.3.4  The contractor shall process all claims for all beneficiaries, except for TFL, who reside in the geographic area of responsibility and performs other tasks specified in the contracts and the manuals.
4.3.5  The TRICARE overseas contractor shall process all TFL claims when care is received overseas (except for US territories noted in paragraph 4.4) regardless of where the beneficiary lives.
4.4  TRICARE Medicare Eligible Program (TMEP) Contractor
The TMEP contractor shall process all TRICARE claims for services rendered within the 50 US and the District of Columbia, as well as US territories: Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Mariana Islands, to dual eligible TRICARE/Medicare beneficiaries.
4.5  Administrative Personnel
The Contracting Officer (CO) and the Contracting Officer’s Representative (COR) are DHA personnel who oversee the functions of the MCS contract, with special emphasis in areas such as claims processing, and who coordinate contract oversight and administration among the variety of TRICARE staff. The CO is the sole authority for directing the contractor or modifying provisions of the contract.
4.6  Assistant Secretary Of Defense (Health Affairs) (ASD(HA))
Overall policy for TRICARE is established by the ASD(HA).
5.0  Geographic Availability
5.1  TRICARE is effective throughout the US TRICARE Overseas Program (TOP) geographic areas of responsibility are established but operate under different procedures than TRICARE in the US.
5.2  The contractor shall create a provider network to support PSAs and BRAC sites, within a geographic area of responsibility.
5.3  The contractor shall provide a network, beginning January 1, 2018, to meet TRICARE Select standards.
5.4  The contractor shall establish a network as authorized by DHA to support a special TRICARE Prime program; this network may be accessed by Select enrollees based on available resources, in overseas geographic areas of responsibility.
5.5  The contractor shall, in addition to support the TOP Prime program, establish a network for TOP Select enrollees only in geographical areas determined by DHA to be economically in the best interest of the DoD.
5.6  The contractor shall establish a provider network, on or before December 31, 2017, sufficient to support offering TRICARE Extra in as many non-PSAs as patient population (including enrollees in the TPR Program) and provider availability make cost-effective.
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