TRICARE Manuals - Display Chap 2 Sect 1 (Baseline, Dec 5, 2022)

Beneficiary Liability

Chapter 2

Section 1

Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries

Issue Date: October 20, 2017

Authority: 32 CFR 199.4, 32 CFR 199.5 and 32 CFR 199.17

Revision:

1.0 POLICY

1.1 General

1.1.1 National Defense Authorization Act for Fiscal Year 2017 (NDAA FY 2017), Section 701, made significant changes to the TRICARE Program including establishing new health plans, new classifications for beneficiary eligibility for the health plans, and unique cost-shares, deductibles, and catastrophic loss protection applicable to services received on or after January 1, 2018 (see Section 2). This section sets forth the cost-shares and deductibles applicable to TRICARE services received on or after January 1, 2018, by TFL beneficiaries and certain other beneficiaries otherwise as specified in Section 2.

1.1.2 For services received prior to January 1, 2018, the contractor shall apply deductibles and catastrophic loss protection are on an FY basis. For services received on or after January 1, 2018, the contractor shall apply deductibles and catastrophic loss protection are on a Calendar Year (CY) basis. In order to transition deductibles and catastrophic loss protection from an FY to a CY basis, the deductible and catastrophic loss protection amounts for FY 2017 will be applicable to services received during the 15 month period of October 1, 2016, through December 31, 2017.

1.1.3 Effective January 1, 2018, the contractor shall apply Group B cost-shares, Catastrophic Cap and Deductibles (CCDs) for beneficiaries enrolled in TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young Adult (TYA), and the Continued Health Care Benefit Program (CHCBP) regardless of when the sponsor initially enlisted or was appointed in a Uniformed Service. The contractor shall apply CCD amounts are for Active Duty Family Member (ADFM) or retiree as appropriate to the sponsor’s status and plan selected. The contractor shall follow the rules for TRICARE Standard/TRICARE Extra to calculate cost-shares for care received prior to January 1, 2018.

1.1.4 The contractor shall apply Group B TRICARE Select ADFMs cost-shares and deductibles for family members of active duty members of the armed forces of North Atlantic Treaty Organization (NATO) and Partnership for Peace (PfP) foreign nations who are eligible for outpatient care under TRICARE per the Defense Enrollment Eligibility Reporting System (DEERS). See TRICARE Policy Manual (TPM), Chapter 1, Section 1.1. The contractor shall not apply any catastrophic protection (see Section 4). The contractor shall follow the rules for TRICARE Standard/TRICARE Extra to calculate cost-shares for care received prior to January 1, 2018.

1.1.5 Applicable Terms And Conditions

1.1.5.1 TRICARE Standard means the TRICARE Program made available prior to January 1, 2018, with program deductible and cost-share amounts identical to those applied under the TRICARE Basic program in 32 CFR 199.4. Although TRICARE Standard is generally terminated as of January 1, 2018, under Section 701(e) of the NDAA FY 2017, in accordance with section 1075(f) of Title 10, United States Code (USC), the contractor shall continue to calculate cost-shares for TFL beneficiaries for services received on or after January 1, 2018, as if the beneficiary were enrolled in TRICARE Standard as if TRICARE Standard were still being carried out by the Department of Defense (DoD).

1.1.5.2 TRICARE Extra means the preferred-provider option of the TRICARE Program made available prior to January 1, 2018, under which TRICARE Standard beneficiaries obtained discounts on cost-sharing as a result of using TRICARE network providers.

1.1.5.3 TRICARE Prime means the managed care option of the TRICARE Program. For enrollment fees and copayments TRICARE Prime enrollees choosing to receive care under the Point of Service (POS) option, refer to Section 5.

1.1.5.4 TFL means the Medicare wraparound coverage option of the TRICARE program made available to the beneficiary by reason of section 1086(d) of 10 USC.

1.1.5.5 Fees under the Extended Care Health Option (ECHO) are defined in 32 CFR 199.5.

1.1.5.6 Fees under the TRICARE Pharmacy (TPharm) Benefits Program are defined in 32 CFR 199.21.

1.1.5.7 Addendum A contains a complete listing of cost-share and deductible information applicable to services received prior to January 1, 2018, as well as those applicable to services received by TFL beneficiaries as if they were enrolled in TRICARE Standard on or after January 1, 2018.

1.1.5.8 Addendum B contains a listing of fee information applicable to the TPharm Benefits Program.

1.1.5.9 Waiver of cost-sharing and deductible. See Section 6.

1.2 TRICARE Prime

1.2.1 TRICARE Prime copayments and enrollment fees are subject to review and annual updating. See Addendum A for additional information on the benefits and costs. In accordance with NDAA FY 2001, Section 752, Public Law 106-398, for services provided on or after April 1, 2001, the contractor shall charge TRICARE Prime ADFMs enrollees a $0 copayment. However, NDAA FY 2001 did not waive pharmacy copayments and POS charges.

1.2.2 In instances where the CMAC or allowable charge is less than the copayment shown on Addendum A, the contractor shall ensure network providers only collect the lower of the allowable charge or the applicable copayment.

1.2.3 The TRICARE Prime copayment requirement for emergency room services is on a PER VISIT basis; this means the contractor shall apply only one copayment to the entire emergency room episode, regardless of the number of providers involved in the patient’s care and regardless of their status as network providers.

1.2.4 TRICARE Prime enrollees have no copayments for the ancillary services in the categories listed below (normal referral and authorization provisions apply). Current Procedural Terminology (CPT) code ranges are given; however, these codes are not all-inclusive. The contractor shall use the most up-to-date codes to identify services within each category, in accordance with the TOM, Chapter 1, Section 4. Additionally, listing the code ranges does not imply coverage; the codes just provide the broad range of services that are not subject to copayments under this provision:

1.2.4.1 Diagnostic radiology and ultrasound services included in the CPT code range from 70010-76999, or any other code for associated contrast media;

1.2.4.2 Diagnostic nuclear medicine services included in the CPT code range from 78012-78999;

1.2.4.3 Pathology and laboratory services included in the CPT code range from 80047-89398; G0461-G0462 (during 2014); and

1.2.4.4 Cardiovascular studies included in the CPT code range from 93000-93355.

1.2.4.5 Venipuncture included in the CPT code range from 36400-36425.

1.2.4.6 Collection of blood specimens in the CPT codes 36591 and 36592.

1.2.4.7 Fetal monitoring for CPT codes 59020, 59025, and 59050.

Note: The contractor shall not apply multiple discounting to the following CPT codes for venipuncture, fetal monitoring, and collection of blood specimens; 36400-36425, 36591, 36592, 59020, 59025, and 59050.

1.2.5 POS option. See Section 5.

1.3 Basic Program: TRICARE Standard

1.3.1 Deductible Amount: Outpatient Care

1.3.1.1 Active Duty Sponsor in Pay Grade E-4 or Below

1.3.1.1.1 Deductible, Individual: The contractor shall apply a deductible for each beneficiary equal to the first fifty dollars ($50.00) of the allowable amount on claims for care provided in the same FY.

1.3.1.1.2 Deductible, Family: The contractor shall calculate the total deductible amount for all members of a family with the same sponsor during one FY to not exceed one hundred dollars ($100.00).

1.3.1.2 All TRICARE Beneficiaries Except Family Members of Active Duty Sponsors in Pay Grade E-4 or Below

1.3.1.2.1 Deductible, Individual: The contractor shall apply a deductible for each beneficiary equal to the first $150.00 of the allowable amount on claims for care provided in the same FY.

1.3.1.2.2 Deductible, Family: The contractor shall calculate the total applied deductible amount for all members of a family with the same sponsor during one FY does not exceed three hundred dollars ($300.00).

1.3.1.3 TRICARE-Approved Ambulatory Surgery Centers (ASCs), Birthing Centers, or Partial Hospitalization Programs (PHPs)

1.3.1.3.1 The contractor shall not apply a deductible to allowable amounts for services or items rendered to ADFMs. For family members of active duty members of the armed forces of NATO/PfP foreign nations who are eligible for outpatient care under TRICARE, see paragraph 1.1.4 for deductible and cost-share information.

1.3.1.3.2 Allowable Amount Does Not Exceed Deductible Amount. If FY allowable amounts for two or more beneficiary members of a family total less than $100.00 (or $300.00 if paragraph 1.3.1.2, applies), and no one beneficiary’s allowable amounts exceed $50.00 (or $150.00 if paragraph 1.3.1.2 applies), neither the family nor the individual deductible will have been met and the contractor shall not reimburse for any TRICARE benefits.

1.3.1.3.3 In the case of family members of an active duty member of pay grade E-5 or above, with Persian Gulf conflict service who is, or was, entitled to special pay for hostile fire/imminent danger authorized by 37 USC 310, for services in the Persian Gulf area in connection with Operation Desert Shield or Operation Desert Storm, the contractor shall use the deductible amount specified in paragraph 1.3.1.2.

Note: The contractor shall apply provisions of paragraph 1.3.1.3.3 to family members of Service members who were killed in the Gulf, or who died subsequent to Gulf service; and to Service members who retired prior to October 1, 1991, after having served in the Gulf war, and to their family members.

1.3.1.3.4 Adjustment of Excess. For any beneficiary identified under paragraphs 1.3.1.3.2 and 1.3.1.3.3 who paid any deductible in excess of the amounts stipulated, the contractor shall adjust/refund any amount paid in excess against the annual deductible required under those paragraphs.

1.3.1.3.5 The contractor shall deem deductible amounts identified in this section to be satisfied if the catastrophic cap amounts identified in Section 2 are met for the same FY in which the deductible applies.

1.3.2 Deductible Amount: Inpatient Care

None.

1.3.3 Cost-Share Amount

1.3.3.1 Outpatient Care

1.3.3.1.1 The contractor shall apply a cost-share for ADFM outpatient care equal to 20% of the allowable amount in excess of the annual deductible amount. This includes the professional charges of an individual professional provider for services rendered in a non-TRICARE-approved ASC or Birthing Center. For family members of active duty members of the armed forces of NATO/PfP foreign nations who are eligible for outpatient care under TRICARE per DEERS, see paragraph 1.1.4.

1.3.3.1.2 Other Beneficiary. The contractor shall apply a cost-share for outpatient care for other than active duty and authorized NATO/PfP family member beneficiaries equal to 25% of the allowable amount in excess of the annual deductible amount. This includes: partial hospitalization for alcohol rehabilitation and professional charges of an individual professional provider for services rendered in a non-TRICARE-approved ASC.

Note: Per paragraphs 1.3.3.10 and 1.4.4, the contractor shall not apply any annual deductible requirements to the preventive care services described in the TPM, Chapter 7, Sections 2.1 and 2.5.

1.3.3.2 Inpatient Care

1.3.3.2.1 ADFM: For services on or after October 3, 2016, the contractor shall apply the following charges to all services (to include mental health and SUD services) for ADFMs or their sponsors.

Figure 2.1-1 Uniformed Services Hospital Daily Charge Amounts
Period	Daily Charge
Use the daily charge (per diem rate) in effect for each day of the stay to calculate a cost-share for a stay which spans periods.
October 1, 2017- September 30, 2018 (for ADFMs not enrolled in TRICARE Prime)	$18.60
October 1, 2018 - December 31, 2019 (for ADFMs not enrolled in TRICARE Prime)	$19.05
January 1, 2020 - December 31, 2020 (for ADFMs not enrolled in TRICARE Prime)	$19.55
January 1, 2021 - December 31, 2021 (for ADFMs not enrolled in TRICARE Prime)	$20.15

1.3.3.2.2 Other Beneficiaries: For services exempt from the Diagnosis Related Group (DRG)-based payment system and the mental health per diem payment system and services provided by institutions other than hospitals (i.e., Residential Treatment Centers (RTCs)), the contractor shall apply a cost-share equal to 25% of the allowable charges.

1.3.3.3 Cost-Shares: Maternity

1.3.3.3.1 Determination. The contractor shall determine maternity care cost-share as follows:

1.3.3.3.1.1 Apply the inpatient cost-share formula to maternity care ending in childbirth in, or not otherwise excluded.

Note: Apply the inpatient cost-share formula to prenatal and postnatal care provided in the office of a civilian physician or certified nurse-midwife in connection with maternity care ending in childbirth or termination of pregnancy in, or on the way to, a Market/Military Medical Treatment Facility (MTF) inpatient childbirth unit. The contractor shall charge ADFMs a per diem (or a $25.00 minimum charge) for an admission and the contractor shall not apply a separate cost-share for separately billed professional charges or prenatal or postnatal care.

1.3.3.3.1.2 Apply the ambulatory surgery cost-share formula to maternity care ending in childbirth in, or on the way to, a birthing center to which the beneficiary is admitted, and from which the beneficiary has received prenatal care, or a hospital-based outpatient birthing room.

1.3.3.3.1.3 Apply the outpatient cost-share formula to maternity care which terminates in a planned childbirth at home.

1.3.3.3.1.4 The contractor shall cost-share otherwise covered medical services and supplies directly related to “complications of pregnancy”, as defined in the Regulation, on the same basis as the related maternity care for a period not to exceed 42 calendar days following termination of the pregnancy and thereafter cost-shared on the basis of the inpatient or outpatient status of the beneficiary when medically necessary services and supplies are received.

1.3.3.3.2 The contractor shall cost-share otherwise authorized services and supplies related to maternity care, including maternity related prescription drugs, on the same basis as the termination of pregnancy.

1.3.3.3.3 The contractor shall cost-share claims for pregnancy testing on an outpatient basis when the delivery is on an inpatient basis.

1.3.3.3.4 Where the beneficiary delivers in a professional office birthing suite located in the office of a physician or certified nurse-midwife (which is not otherwise a TRICARE-approved birthing center) the contractor shall adjudicate the delivery as an at-home birth.

1.3.3.3.5 The contractor shall cost-share claims for prescription drugs provided on an outpatient basis during the maternity episode but not directly related to the maternity care on an outpatient basis.

1.3.3.3.6 Newborn cost-share. Effective for all inpatient admissions occurring on or after October 1, 1987, contractor shall ensure the provider submits separate claims for the mother and newborn. The contractor shall determine the cost-share for inpatient claims for services rendered to a beneficiary newborn as follows:

1.3.3.3.6.1 In a DRG hospital:

1.3.3.3.6.1.1 Same newborn date of birth and date of admission:

• For ADFMs, the contractor shall not apply a cost-share during the period the newborn is deemed enrolled in TRICARE Prime.

• For newborn family members of other than active duty members, unless the newborn is deemed enrolled in TRICARE Prime, the contractor shall apply a cost-share equal to the lower of the number of hospital days minus three multiplied by the per diem amount, OR 25% of the total billed charges (less duplicates and DRG non-reimbursables such as hospital-based professional charges).

1.3.3.3.6.1.2 Different newborn date of birth and date of admission:

• For ADFMs, the contractor shall not apply a cost-share during the period the newborn is deemed enrolled in TRICARE Prime.

• For all other beneficiaries, the contractor shall apply a cost-share to all days in the inpatient stay unless the newborn is deemed enrolled in TRICARE Prime.

1.3.3.3.6.2 In DRG exempt hospital:

1.3.3.3.6.2.1 Same newborn date of birth and date of admission:

• For ADFMs, the contractor shall not apply a cost-share during the period the newborn is deemed enrolled in TRICARE Prime.

• For family members of other than active duty members, the contractor shall calculate the cost-share based on 25% of the total allowed charges unless the newborn is deemed enrolled in TRICARE Prime.

1.3.3.3.6.2.2 Different newborn date of birth and date of admission:

• For ADFMs, the contractor shall not apply a cost-share during the period the newborn is deemed enrolled in TRICARE Prime.

• For family members of other than active duty members, the contractor shall calculate a cost-share based on 25% of the total allowed charges unless the newborn is deemed enrolled in TRICARE Prime.

1.3.3.3.7 Maternity Related Care. The contractor shall cost-share medically necessary treatment rendered to a pregnant woman for a non-obstetrical medical, anatomical, or physiological illness or condition as a part of the maternity episode when:

• The treatment is otherwise allowable as a benefit; and

• Delay of the treatment until after the conclusion of the pregnancy is medically contraindicated; and

• The illness or condition is, or increases the likelihood of, a threat to the life of the mother; or

• The illness or condition will cause, or increase the likelihood of, a stillbirth or newborn injury or illness; or

• The usual course of treatment must be altered or modified to minimize a defined risk of newborn injury or illness.

1.3.3.4 Cost-Shares: DRG-Based Payment System

1.3.3.4.1 General

The contractor shall apply these special cost-sharing procedures only to claims paid under the DRG-based payment system.

1.3.3.4.2 TRICARE Standard

1.3.3.4.2.1 Cost-shares for ADFMs. The contractor shall charge ADFMs or their sponsors the first $25 of the allowable institutional costs incurred with each covered inpatient admission to a hospital or other authorized institutional provider, or the amount the beneficiary or sponsor would have been charged had the inpatient care been provided in a Uniformed Service hospital, whichever is greater.

1.3.3.4.2.2 Cost-shares for beneficiaries other than ADFMs.

1.3.3.4.2.2.1 The contractor shall apply a cost-share equal to the lesser of:

1.3.3.4.2.2.1.1 An amount based on a single, specific per diem amount which will not vary regardless of the DRG involved. The DRG inpatient TRICARE Standard cost-sharing per diems for beneficiaries other than ADFMs. The daily rate is posted to the Defense Health Agency (DHA) website at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement.

1.3.3.4.2.2.1.1.1 The contractor shall calculate the per diem amount as follows:

• Determine the total allowable DRG-based amounts for services subject to the DRG-based payment system and for beneficiaries other than ADFMs during the same database period used for determining the DRG weights and rates.

• Add in the allowance for Capital and Direct Medical Education (CAP/DME) which have been paid to hospitals during the same database period used for determining the DRG weights and rates.

• Divide this amount by the total number of patient days for these beneficiaries. This amount will be the average cost per day for these beneficiaries.

• Multiply this amount by 0.25. In this way total cost-sharing amounts will continue to be 25% of the allowable amount.

• Determine any cost-sharing amounts which exceed 25% of the billed charge (see paragraph 1.3.3.4.2.2.1.2) and divide this amount by the total number of patient days in paragraph 1.3.3.4.2.2.1.1). Add this amount to the amount in paragraph 1.3.3.4.2.2.1.1. This is the per diem cost-share to be used for these beneficiaries.

1.3.3.4.2.2.1.1.2 The contractor shall apply the per diem amount for each actual day of the beneficiary’s hospital stay which the DRG-based payment covers except for the day of discharge. When the payment ends on a specific day because eligibility ends on a short-stay outlier day, the contractor shall count the last day of eligibility for determining the per diem cost-sharing amount. For claims involving a same-day discharge which qualify as an inpatient stay (i.e., the patient was admitted with the expectation of a stay of several days, but died the same day) the contractor shall count the cost-share on a one-day stay. (The number of hospital days must contain one day in this situation.)

1.3.3.4.2.2.1.2 Twenty-five percent (25%) of the billed charge. The contractor shall use billed charges, includes all inpatient institutional line items billed by the hospital minus any duplicate charges and any charges which can be billed separately (e.g., hospital-based professional services, outpatient services). The net billed charges for the cost-share computation include comfort and convenience items.

1.3.3.4.2.2.2 The contractor shall not charge a cost-share that exceeds the DRG-based amount under any circumstances.

1.3.3.4.2.2.3 Where the dates of service span different FYs, the contractor shall apply a per diem cost-share amount for each year to the appropriate days of the stay.

1.3.3.4.3 TRICARE Extra

1.3.3.4.3.1 Cost-shares for ADFMs. The contractor shall apply cost-sharing provisions for ADFMs the same as those for TRICARE Standard.

1.3.3.4.3.2 Cost-shares for beneficiaries other than ADFMs. The contractor shall apply cost-sharing provisions for beneficiaries other than ADFMs is the same as those for TRICARE Standard, except the per diem copayment is $250.

1.3.3.4.4 TRICARE Prime

The contractor shall not apply a cost-share for ADFMs. For beneficiaries other than ADFMs, the contractor shall apply a cost-share equal to the first $25 of the allowable institutional costs incurred with each covered inpatient admission to a hospital or other authorized institutional provider, or a per diem rate of $11, whichever is greater.

1.3.3.4.5 Maternity Services

See paragraph 1.3.3.3, for the cost-sharing provisions for maternity services.

1.3.3.5 Cost-Shares: Inpatient Mental Health Per Diem Payment System

1.3.3.5.1 General. The contractor shall not apply a special cost-sharing procedures only to claims paid under the inpatient mental health per diem payment system. For inpatient claims exempt from this system, the procedures in paragraph 1.3.3.2 or 1.3.3.4.

1.3.3.5.2 Cost-shares for ADFMs. For dates of service prior to October 3, 2016, the contractor shall apply an inpatient cost-share for mental health services equal to $20 per day for each day of the inpatient admission. The contractor shall apply this $20 per day cost-share to admissions to any hospital for mental health services, any RTC, any Substance Use Disorder Rehabilitation Facility (SUDRF), and any PHP providing mental health or SUD rehabilitation services. For TRICARE Prime ADFMs, the contractor shall apply a cost-share of $0 per day. See Addendum A for further information.

1.3.3.5.3 For dates of service on or after October 3, 2016, the contractor shall use the inpatient cost-sharing for mental health services is that described in paragraph 1.3.3.2.1. The contractor shall apply cost-share to admissions to any hospital for mental health services, any RTC, and any inpatient/residential SUD detoxification and rehabilitation program. For TRICARE Prime ADFMs, the contractor shall apply a cost-share of $0 per day. See Addendum A for further information.

1.3.3.5.4 Cost-shares for beneficiaries other than ADFMs.

1.3.3.5.4.1 Higher volume hospitals and units. With respect to care paid for on the basis of a hospital specific per diem, the contractor shall apply a cost-share equal to 25% of the hospital specific per diem amount.

1.3.3.5.4.2 Lower volume hospitals and units. For care paid for on the basis of a regional per diem, the contractor shall apply a cost-share equal to the lower of paragraphs 1.3.3.5.4.2.1 or 1.3.3.5.4.2.2:

1.3.3.5.4.2.1 A fixed daily amount multiplied by the number of covered days. The fixed daily amount is 25% of the per diem adjusted so that total beneficiary cost-shares will equal 25% of total payments under the inpatient mental health per diem payment system. DHA will update this fixed daily amount annually and on the DHA website at http://www.health.mil/rates. DHA will also furnish this fixed daily amount to the contractors. The following fixed daily amounts are effective for services rendered on or after October 1 of each FY.

• FY 2019 - $248 per day.

• FY 2020 - $255 per day.

• FY 2021 - $261 per day.

1.3.3.5.4.2.2 Twenty-five percent (25%) of the hospital’s billed charges (less any duplicates).

1.3.3.5.5 Claims which span a period in which two separate per diems exist. For claims subject to the inpatient mental health per diem payment system which spans a period in which two separate per diems exist, the contractor shall calculate the cost-share on the actual per diem in effect for each day of care.

1.3.3.5.6 Cost-share whenever leave days are involved. The contractor shall not apply a cost-share for leave days when such days are included in a hospital stay.

1.3.3.5.7 The contractor shall cost-share claims for services that are provided during an inpatient admission which are not included in the per diem rate as an inpatient claim if the contractor cannot determine where the service was rendered and the status of the patient when the service was provided.

1.3.3.5.8 The contractor shall examine the claim for place of service and type of service to determine if the care was rendered in the hospital while the beneficiary was an inpatient of the hospital. This includes non-mental health claims and mental health claims submitted by individual professional providers rendering medically necessary services during the inpatient admission.

1.3.3.6 Cost-Shares: PHPs And Intensive Outpatient Program (IOPs)

1.3.3.6.1 For care rendered prior to October 3, 2016, the contractor shall apply an outpatient cost-share PHP IOP claims. The contractor shall also apply inpatient cost-shares to the associated psychotherapy billed separately by the individual professional provider. The contractor shall ensure providers identify on the claim form that the psychotherapy is related to a partial hospitalization stay so the proper inpatient cost-sharing can be applied. The cost-share for ADFMs enrolled in TRICARE Prime for inpatient mental health services is $0. For retirees and their family members, the cost-share is 25% of the allowed amount. Since inpatient cost-sharing is being applied, no deductible shall be taken for partial hospitalization regardless of sponsor status. The cost-share for ADFMs shall be taken from the PHP claim.

1.3.3.6.2 For care rendered on or after October 3, 2016, the contractor shall apply an outpatient cost-share PHP IOP claims. The contractor shall also apply outpatient cost-share to the associated psychotherapy billed separately by the individual professional provider. The contractor shall ensure providers identify on the claim form that the psychotherapy is related to PHP or IOP care so the proper outpatient cost-sharing can be applied. Cost-shares for TRICARE Standard beneficiaries can be found in paragraph 1.3; cost-sharing requirements for TRICARE Prime beneficiaries are in paragraph 1.2.

1.3.3.7 Cost-Shares: Ambulatory Surgery

1.3.3.7.1 For non-TRICARE Prime ADFMs. The contractor shall apply a cost-share of $25 for all services reimbursed as ambulatory surgery and shall assess it on the facility claim. The contractor shall not deduct the cost-share from a claim for professional services related to ambulatory surgery. This applies whether the services are provided in a freestanding ASC, a hospital outpatient department or a hospital emergency room. So long as at least one procedure on the claim is reimbursed as ambulatory surgery, the contractor shall cost-share the claim as ambulatory surgery as required by this section. For family members of active duty members of the armed forces of NATO/PfP foreign nations who are eligible for outpatient care under TRICARE per DEERS, see paragraph 1.1.4.

1.3.3.7.2 Other Beneficiaries. Since the cost-share for other beneficiaries is based on a percentage rather than a set amount, the contractor shall cost-share based on all ambulatory surgery claims. For professional services, the contractor shall apply a cost-share equal to 25% of the allowed amount. For the facility claim, the contractor shall apply a cost-share equal to the lesser of:

1.3.3.7.2.1 Twenty-five percent (25%) of the applicable group payment rate (see Chapter 9, Section 1); or

1.3.3.7.2.2 Twenty-five percent (25%) of the billed charges; or

1.3.3.7.2.3 Twenty-five percent (25%) of the allowed amount as determined by the contractor.

1.3.3.7.2.4 The special cost-sharing provisions for beneficiaries other than ADFMs will ensure that these beneficiaries are not disadvantaged by these procedures. In most cases, 25% of the group payment rate will be less, but because there is some variation within each group, 25% of billed charges could be less in some cases. This will ensure that the beneficiaries get the benefit of the group payment rates when they are more advantageous, but they will never be disadvantaged by them. If there is no group payment rate for a procedure, the cost-share shall simply be 25% of the allowed amount.

1.3.3.8 Cost-Shares and Deductible: Former Spouses

1.3.3.8.1 Deductible. In accordance with the FY 1991 Appropriations and Authorization Acts, Sections 8064 and 712 respectively, beginning April 1, 1991, the contractor shall charge an eligible former spouse the first one hundred and fifty dollars ($150.00) of the reasonable costs/charges for otherwise covered outpatient services and/or supplies provided in any one FY. Although the law defines former spouses as family members of the member or former member, there is no legal familial relationship between the former spouse and the member or former member. Moreover, any TRICARE-eligible children of the former spouse retain a legal familial relationship with the member or former member and the contractor shall include them in the member’s or former member’s family deductible. The former spouse cannot contribute to, nor benefit from, any family deductible of the member or former member to whom the former spouse was married or of that of any TRICARE-eligible children. In other words, a former spouse must independently meet the $150.00 deductible in any fiscal year.

1.3.3.8.2 Cost-Share. The contractor shall apply cost-sharing amounts identical to those required for beneficiaries other than ADFMs.

1.3.3.9 Cost-Share Amount: Under Discounted Rate Agreements

Under managed care, where there is a negotiated (discounted) rate agreed to by the network provider, the contractor shall base the cost-share on the following:

1.3.3.9.1 For non-institutional providers providing outpatient care, and for institution-based professional providers rendering both inpatient and outpatient care. The contractor shall apply a cost-share equal to:

• Twenty percent (20%) for outpatient care to ADFMs;

• Twenty-five percent (25%) for care to all others) (after duplicates and noncovered charges are eliminated);

• The lowest of the billed charge;

• The prevailing charge, the maximum allowable prevailing charge (the Medicare Economic Index (MEI) adjusted prevailing); or

• The negotiated (discounted) charge.

1.3.3.9.2 For institutional providers subject to the DRG-based reimbursement methodology, the contractor shall apply a cost-share for beneficiaries other than ADFMs equal to the LOWER OF EITHER:

• The single, specific per diem supplied by DHA after the application of the agreed upon discount rate; OR

• Twenty-five percent (25%) of the billed charge.

1.3.3.9.3 For institutional providers subject to the Mental Health Per Diem Payment System (high volume hospitals and units). For beneficiaries other than ADFMs, the contractor shall apply a cost-share equal to 25% of the hospital per diem amount after it has been adjusted by the discount.

1.3.3.9.4 For institutional providers subject to the Mental Health per diem payment system (low volume hospitals and units). For beneficiaries other than ADFMs, the contractor shall apply a cost-share equal to the LOWER OF EITHER:

• The fixed daily amount supplied by DHA after the application of the agreed upon discount rate; OR

• Twenty-five percent (25%) of the billed charge.

1.3.3.9.5 For RTCs, the cost-share for other than ADFMs shall be 25% of the TRICARE rate after it has been adjusted by the discount.

1.3.3.9.6 For institutions and for institutional services being reimbursed on the basis of the TRICARE-determined reasonable costs. For beneficiaries other than ADFMs, the contractor shall apply a cost-share equal to 25% of the allowable billed charges after it has been adjusted by the discount.

1.3.3.9.6.1 For all inpatient care for ADFMs. The contractor shall apply a cost-share either the daily charge or $25 per stay, whichever is higher. There is no change to the requirement to apply the ADFM’s cost-share to the institutional charges for inpatient services.

1.3.3.9.6.2 The contractor shall notify the provider that such an action is a violation of the provider’s signed agreement if the contractor learns that the participating provider has billed a beneficiary for a greater cost-share amount, based on the provider’s usual billed charges. (Also see paragraph 1.3.3.4.) For TRICARE Prime ADFMs, the contractor shall apply a cost-share equal to $0 for care provided on or after April 1, 2001.

1.3.3.10 Preventive Services

1.3.3.10.1 The contractor shall not apply copayments or require authorizations for the following preventive services as described in the TPM, Chapter 7, Sections 2.1 and 2.5:

1.3.3.10.1.1 Colorectal cancer screening.

1.3.3.10.1.2 Breast cancer screening.

1.3.3.10.1.3 Cervical cancer screening.

1.3.3.10.1.4 Prostate cancer screening.

1.3.3.10.1.5 Immunizations.

1.3.3.10.1.6 Well-child visits for children under six years of age.

1.3.3.10.1.7 Visits for all other beneficiaries over age six when the purpose of the visit is for one or more of the covered benefits listed in paragraphs 1.3.3.10.1.1 through 1.3.3.10.1.5. If one or more of the procedure codes described in the TPM, Chapter 7, Section 2.1 for those preventive services listed in paragraphs 1.3.3.10.1.1 through 1.3.3.10.1.5 is billed on a claim, then the contractor shall waive the cost-share for the visit.

1.3.3.10.2 In addition to the services listed in paragraph 1.3.3.10.1, effective January 1, 2017, the contractor shall not apply cost-shares to the services listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1.1.1.2 and 1.1.5 through 1.1.5.12. Effective January 1, 2018, the contractor shall not apply cost-shares to the services listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1.5.13.

1.3.3.10.3 The contractor shall not charge beneficiaries any portion of the cost of these preventive services even if the beneficiary has not satisfied the deductible for that year.

1.3.3.10.4 This waiver does not apply to any TRICARE beneficiary who is a Medicare-eligible beneficiary.

1.3.3.10.5 The contractor shall apply appropriate cost-share and deductibles shall apply for all other preventive services described in the TPM, Chapter 7, Section 2.1, paragraph 1.2 and Section 2.5.

1.4 TRICARE Extra

1.4.1 For TRICARE Extra deductibles and cost-shares, see Addendum A.

1.4.2 If non-enrolled TRICARE beneficiary receives care from a network provider out of the geographic area of residence, and if the beneficiary has not met the FY catastrophic cap, the beneficiary shall pay the TRICARE Extra cost-share to the provider.

1.4.3 For the beneficiary’s residence the contractor shall process the claim under TRICARE Extra claims processing procedures if the TRICARE Encounter Provider Record (TEPRV) shows the provider to be contracted.

1.4.4 Preventive Services

1.4.4.1 The contractor shall not require any copayments or authorizations for the following preventive services as described in the TPM, Chapter 7, Sections 2.1 and 2.5:

1.4.4.1.1 Colorectal cancer screening.

1.4.4.1.2 Breast cancer screening.

1.4.4.1.3 Cervical cancer screening.

1.4.4.1.4 Prostate cancer screening.

1.4.4.1.5 Immunizations.

1.4.4.1.6 Well-child visits for children under six years of age.

1.4.4.1.7 Visits for all other beneficiaries over age six when the purpose of the visit is for one or more of the covered benefits listed in paragraphs 1.4.4.1.1 through 1.4.4.1.5. If one or more of the procedure codes described in the TPM, Chapter 7, Section 2.1 for those preventive services listed in paragraphs 1.4.4.1.1 through 1.4.4.1.5 are billed on a claim, then the contractor shall waive the cost-share for the visit.

1.4.4.2 In addition to the services listed in paragraph 1.4.4.1, effective January 1, 2017, the contractor shall not apply cost-shares to the services listed in the TPM, Chapter 7, Section 2.1. Effective January 1, 2018, the contractor shall not apply cost-shares to the services listed in the TPM, Chapter 7, Section 2.1.

1.4.4.3 The contractor shall not require appropriate beneficiaries to pay any portion of the cost of these preventive services even if the beneficiary has not satisfied the deductible for that year.

1.4.4.4 This waiver does not apply to any TRICARE beneficiary who is a Medicare-eligible beneficiary.

1.4.4.5 The contractor shall apply appropriate cost-share and deductibles to all other preventive services described in the TPM, Chapter 7, Sections 2.1 and 2.5.

1.5 Cost-Shares: Ambulance Services

1.5.1 For the basis of payment of ambulance services, see Chapter 1, Section 14.

1.5.2 Outpatient. The following are beneficiary copayment/cost-sharing requirements for medically necessary ambulance services when paid on an outpatient basis:

1.5.2.1 TRICARE Prime

1.5.2.1.1 For care provided for pay grades E-1 through E-4, $0. See Addendum A for further information.

1.5.2.1.2 For care provided for pay grades E-5 and above, $0. See Addendum A for further information.

1.5.2.1.3 For retirees and their family members, the contractor shall charge a $20 copayment.

1.5.2.2 TRICARE Extra

1.5.2.2.1 The contractor shall apply a cost-share of 15% of the fee negotiated by the contractor for ADFMs.

1.5.2.2.2 The contractor shall apply a cost-share of 20% of the fee negotiated by the contractor for retirees, their family members, and survivors.

1.5.2.3 TRICARE Standard

1.5.2.3.1 The contractor shall apply a cost-share of 20% of the allowable charge for ADFMs.

1.5.2.3.2 The contractor shall apply a cost-share of 25% of the allowable charge for retirees, their family members, and survivors.

1.5.2.4 Inpatient: Non-Network Providers

1.5.2.4.1 ADFMs. The contractor shall not apply cost-share for ambulance services (transfers) rendered in conjunction with an inpatient stay.

1.5.2.4.2 Beneficiaries other than ADFMs. The contractor shall apply a cost-share equal to 25% of the allowable amount for inpatient care.

1.6 Exceptions

1.6.1 Inpatient Cost-Share Applicable To Each Separate Admission

Prior to January 1, 2018, for TRICARE ADFMs only, the contractor shall apply a separate cost-share amount to each separate beneficiary for each inpatient admission EXCEPT:

1.6.1.1 The contractor shall treat any readmission to an acute care hospital which is not more than 60 calendar days from the date of the last inpatient discharge as one inpatient confinement with the last admission for cost-share amount determination.

1.6.1.2 Certain heart and lung hospitals. See Chapter 1, Section 27, entitled “Legal Obligation To Pay”.

1.6.2 Inpatient Cost-Share: Maternity Care

See paragraph 1.3.3.3. The contractor shall treat all admissions related to a single maternity episode as one confinement regardless of the number of days between admissions. For ADFMs, the contractor shall apply the cost-share to the first institutional claim received.

1.6.3 Special Cost-Share Provisions

1.6.3.1 For services provided prior to International Classification of Diseases, 10th Revision (ICD-10) implementation. Effective October 1, 1987, the contractor shall not charge an inpatient cost-share amount from DRG-exempt institutional provider claims in the following categories which exceeds that which would have been imposed if the service were subject to the DRG-based payment system. This shall not affect ADFMs. For all other beneficiaries, the contractor shall apply the cost-share equal to the lesser of:

• That calculated according to paragraph 1.3.3.2.2; or

• That calculated according to paragraph 1.3.3.4.2.

1.6.3.1.1 Child Bone Marrow Transplant (BMT)

All services related to discharges involving BMT for a beneficiary less than 18 years old as classified in International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).

1.6.3.1.2 Child Human Immunodeficiency Virus (HIV) Seropositivity

All services related to discharges involving HIV seropositive beneficiary less than 18 years old with ICD-9-CM principal or secondary diagnosis codes 042, 079.53, and 795.71.

1.6.3.1.3 Child Cystic Fibrosis

All services related to discharges involving beneficiary less than 18 years old with ICD-9-CM principal or secondary diagnosis code 277.0 (cystic fibrosis).

1.6.3.2 For services provided on or after the date specified by the Centers for Medicare and Medicaid Services (CMS) in the Final Rule as published in the Federal Register. Effective October 1,1987, the contractor shall ensure the inpatient cost-share amount from DRG-exempt institutional provider claims in the following categories do not exceed that which would have been imposed if the service were subject to the DRG-based payment system. This shall not affect ADFMs. For all other beneficiaries, the contractor shall apply a cost-share equal to the lesser of:

• That calculated according to paragraph 1.3.3.2.2; or

• That calculated according to paragraph 1.3.3.4.2.

1.6.3.2.1 Child BMT

All services related to discharges involving BMT for a beneficiary less than 18 years old as classified in International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

1.6.3.2.2 HIV Seropositivity

All services related to discharges involving HIV seropositive beneficiary less than 18 years old with ICD-10-CM principal or secondary diagnosis codes B20, B97.35, and R75.

1.6.3.2.3 Child Cystic Fibrosis

All services related to discharges involving beneficiary less than 18 years old with ICD-10-CM principal or secondary diagnosis code E84 (cystic fibrosis).

1.6.3.2.4 Cost-Sharing for Family Members of a Member who Dies While on Active Duty

Those in Transitional Survivor status, are not distinguished from other ADFMs for cost-sharing purposes. After the Transitional Survivor status ends, eligible TRICARE beneficiaries may be placed in Survivor status and will be responsible for retiree cost-shares. See the Transitional Survivor Status policy in the TPM, Chapter 10, Section 7.1.

1.6.4 See Section 6 for waivers of cost-shares and deductibles.

1.7 Catastrophic Loss Protection

See Section 3.

1.8 Coronavirus 2019 (COVID-19) Testing

For cost-shares and copayments related to COVID-19 testing, see Section 7.

2.0 Effective Date

October 3, 2016, PHP and IOP as outpatient mental health and SUD services.

- END -

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.