1.0 BACKGROUND
1.1 National
Defense Authorization Act for Fiscal Year 2017 (NDAA FY 2017), Section
701, made significant changes to the TRICARE Program, especially
to TRICARE Prime; TRICARE Extra, which is replaced by TRICARE Select; and
to the third option, TRICARE Standard, which was terminated as of
December 31, 2017, and is also replaced by TRICARE Select. TRICARE
Select is a self-managed, Preferred Provider Option (PPO) under
the TRICARE Program, and replaces the TRICARE Extra and Standard
programs and adopts a number of improvements, including fixed copayments
rather than percentage copays for covered benefits provided by a
civilian network provider. It also features freedom of choice of
providers, with reduced beneficiary out-of-pocket costs for covered
care received from a civilian network provider. The NDAA also included
the continuation of TRICARE Prime as a managed care, Health Maintenance
Organization (HMO)-like option under the TRICARE Program. TRICARE
Prime adopts a number of changes to conform to specifications in
the new law, including categories of health care services applicable
to the determination of catastrophic loss protection. Other features
of the NDAA include preservation of benefits for Active Duty Family
Members (ADFMs) and TRICARE For Life (TFL) beneficiaries and conforming
changes to generally incorporate TRICARE Select into the TRICARE
Young Adult (TYA), TRICARE Reserve Select (TRS), TRICARE Retired
Reserve (TRR), and Continued Health Care Benefits Program (CHCBP).
1.2 With respect
to beneficiary catastrophic loss protection, the NDAA FY 2017 established
the catastrophic caps for each identified beneficiary group, specified
certain annual updates, and converted the coverage from a fiscal
year to a calendar year basis. The law also introduced a new split
of beneficiaries into two groups: one group (Group A or grandfathered
beneficiaries) consists of sponsors and their family members who
first became affiliated with the military through enlistment or
appointment before January 1, 2018, and the second group (Group
B or non-grandfathered beneficiaries) who first became affiliated
on or after that date.
1.3 With respect to beneficiary
catastrophic loss protection, the NDAA FY 2017 preserved the benefits
for TFL beneficiaries. TFL means the Medicare wraparound coverage
option of the TRICARE program made available to the beneficiary
by reason of 10 United States Code (USC) section 1086(d).
1.4 Fees under
the Extended Care Health Option (ECHO) are defined in
32
CFR 199.5.
1.5 Fees under the TRICARE Pharmacy
(TPharm) Benefit Program are defined in
32
CFR 199.21.
2.0 POLICY
2.1 TRICARE Prime And TRICARE Select
2.1.1 Catastrophic
cap for ADFMs under TRICARE Prime and TRICARE Select, the calendar
year cap is:
2.1.1.1 Group A: $1,000.
2.1.1.2 Group B: $1,000 for calendar
year (CY) 2018, adjusted annually thereafter indexed to the amount
of increase under 10 USC section 1401a.
2.1.2 Catastrophic
cap for all other beneficiaries under:
2.1.2.1 TRICARE Prime:
2.1.2.1.1 Group A retirees have a calendar
year cap of $3,000.
2.1.2.1.2 Group B retirees have an annual
cap of $3,500 in calendar year 2018, adjusted annually thereafter indexed
to the amount of increase under 10 USC section 1401a.
2.1.2.2 TRICARE Select:
2.1.2.2.1 Group A retirees have an annual
cap of $3,000 for CYs 2018 through 2020; except for certain beneficiaries
described in
paragraph 2.1.2.2.2, in CY 2021 the cap is
$3,500, adjusted annually thereafter indexed to the amount of increase
under 10 USC section 1401a.
2.1.2.2.2 Group
A retirees consisting of survivors of active duty deceased sponsors
or medically retired Uniformed Services members and their dependents
have a calendar year cap of $3,000.
2.1.2.2.3 Group B retirees have an annual
cap of $3,500 for CY 2018; adjusted annually thereafter indexed
to the amount of increase under 10 USC section 1401a.
2.2 TFL. Under
the catastrophic cap for TFL beneficiaries, an individual or family
group of two or more beneficiaries may not be required to pay a
total of more than $3,000 for health care received during any calendar year.
See
Chapter 4, Section 4 for information regarding
specific double coverage actions involving Medicare for TFL beneficiaries.
Note: ADFMs with Medicare (not TFL)
shall be subject to the catastrophic cap limitations in
paragraph 2.1.2.
2.3 TYA, TRR, TRS, and CHCBP
Enrollees in these plans have
Group B catastrophic cap limitations shown under
paragraph 2.1 based
on the coverage (TRICARE Prime or TRICARE Select) the plan provides.
3.0 Cap
is Met
3.1 For TRICARE Prime, TRICARE
Select, and TFL beneficiaries, after the applicable calendar year
catastrophic cap is met, TRICARE Prime or TRICARE Select enrollment
fees will no longer be collected, and a fee waiver is then applied
for TRICARE Prime or TRICARE Select enrollment fees for the remainder
of the calendar year. At that point, the TRICARE determined allowable
amount shall be paid in full for all covered services and supplies
for the remainder of the calendar year.
3.2 For TYA, TRR, TRS, and CHCBP
enrollees, after the Group B calendar year catastrophic cap is met,
the TRICARE determined allowable amount shall be paid in full for
all covered services and supplies for the remainder of the calendar
year.
4.0 The following expenses may
be credited to a TRICARE Prime, TRICARE Select, or TFL sponsor’s
calendar year catastrophic cap:
• Enrollment fees (TRICARE Prime
and TRICARE Select).
• Deductibles.
• The outpatient and inpatient
cost-shares and copayments.
5.0 Other
Coverage Situations
5.1 TRICARE Supplemental Plans
TRICARE supplemental plans
which provide coverage for deductibles, cost-shares, and sometimes
for non-covered services, will be ignored. As with double coverage,
the full deductible and cost-share will be credited toward meeting
the catastrophic cap.
5.2 Multiple Family Situations
Multiple family situations--e.g.,
sponsor and new spouse and children live together, and sponsor’s
children from previous marriage live elsewhere--will be treated
as one family. In other words, for a divorced and then remarried sponsor
with two sets of family members, their deductibles and cost-shares
will be combined to meet the calendar year catastrophic cap.
Note: When a family’s sponsor changes,
e.g., a spouse divorces a sponsor and marries another active duty person,
then only the new sponsor’s liabilities for deductible and cost-shares
in a calendar year will count toward meeting the cap. In other words,
this spouse cannot carry to the new family those credits accumulated
toward the cap under the previous sponsor.
5.3 Former
Spouses
Any TRICARE
eligible former spouse will be treated as an “other than ADFM.”
For the purpose of determining the catastrophic cap, a former spouse
will be treated as an independent family and must independently
meet the catastrophic cap.
5.4 Change
Of Sponsor Status
A change
in a sponsor’s duty status will have the following effects on application
of the catastrophic cap.
5.4.1 Claims Subject To The TRICARE
Diagnosis Related Group (DRG)-Based Payment System
5.4.1.1 When the status changes during
a beneficiary’s inpatient stay, the appropriate catastrophic cap
will apply to that stay according to the beneficiary’s cost-sharing
status for the stay. Effective for services provided after midnight
of the day of discharge from the hospital, the catastrophic cap
will be based on the sponsor’s current status.
5.4.1.2 When the status changes at
any time other than during a beneficiary’s inpatient stay, the appropriate catastrophic
cap (according to the sponsor’s current duty status) will apply
for TRICARE eligible families for the remaining calendar year (or
until the status changes again) effective for services provided
after midnight of the day the duty status changes.
5.4.1.3 When the status changes, the
full deductible and cost-shares credited toward meeting the previous family
cap will be credited toward the new cap as the sponsor’s liabilities
in the same calendar year. However, in no case will a change in
a sponsor’s status from retired to active duty result in an adjustment
to previous claims, even if the aggregate cost-share had exceeded
the active duty cap.
5.4.2 Claims
Exempt From The TRICARE DRG-Based Payment System
When a sponsor’s duty status
changes, the appropriate cap (according to the sponsor’s current
duty status) will apply for TRICARE eligible families for the remaining
calendar year effective for services provided after midnight of the
day the duty status changes. The full deductible and cost-shares
credited toward meeting the previous family cap will be credited
toward the new cap as the sponsor’s liabilities in the same calendar
year.
5.5 Inpatient Care Spanning Two
Calendar Years
When the
dates of inpatient care span different calendar years, it is absolutely
necessary that the catastrophic cap application be as accurate as
possible. If for a claim the ending date of care is in a different
calendar year from the beginning date of care, the beneficiary cost-share
amount must be allocated between the two calendar years based on
the dates of care.
5.6 Cost-Share When Fixed Daily
Amount Is NOT Known
When a fixed (or actual) daily
amount of cost-share is not known or cannot be accurately determined,
the daily cost-share amount will be calculated by proration, that
is, by dividing the claim’s cost-share amount by the number of days
of care (not counting the day of discharge) and the resulting daily
amount will be allocated between the two calendar years according
to the days of care received in each calendar year.
6.0 EXCEPTIONS
6.1 No catastrophic
loss protection is available for the North Atlantic Treaty Organization
(NATO) or Partnership For Peace (PfP) family members.
6.2 The ECHO
sponsor/beneficiary liabilities do not accrue toward meeting the
catastrophic cap.
6.3 Beneficiary costs for non-covered
services or any beneficiary payments above the TRICARE determined allowable
charge, shall not count toward meeting the catastrophic cap.
6.4 For TRICARE
Prime enrollees, POS deductible and cost-share amounts do not have
a catastrophic cap.