1.0 DESCRIPTION
1.1 The provisions
of this section apply to family members who become eligible for
TRICARE as a result of their Reserve Component (RC) sponsor (including
those with delayed effective date active duty orders up to 180 calendar
days) being called or ordered to active duty for more than 30 calendar
days and choose to participate in TRICARE Select, rather than enroll
in TRICARE Prime. The seven RCs include Army National Guard and
the Air National Guard.
1.2 These
provisions help ensure timely access to health care and maintain
clinically appropriate continuity of health care to family members
of activated RC sponsors, limit the out-of-pocket health care expenses
for those family members, and remove potential barriers to health
care access by RC families.
2.0 BACKGROUND
2.1 Section 704 of the National
Defense Authorization Act for Fiscal Year 2005 (NDAA FY 2005) (Public
Law 108-375) amended the authority (10 United States Code (USC)
1095d(a)) to waive the annual TRICARE Select deductible for RC family
members who became eligible for TRICARE as a result of their sponsor’s
activation in support of a contingency operation for more than 30
calendar days.
2.2 Waiving the TRICARE deductible
appropriately limits out-of-pocket expenses for these RC family members,
many of whom may have already paid toward annual deductibles under
their civilian health plans.
2.3 Section 705 of the NDAA FY
2005 established the authority to increase TRICARE payments up to
115% of the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) Maximum Allowable Charge (CMAC), less the applicable
patient cost-share if not previously waived under the provisions
of Section 704, for family members of RC members on active duty
orders for more than 30 calendar days in support of contingency operation,
who receive covered inpatient and outpatient health services from
a provider that does not participate (accept assignment) under TRICARE.
This allows this group of RC family members to continue to see civilian providers
with whom they have established relationships while promoting access
and clinically appropriate continuity of care.
2.4 The provisions outlined above
were previously provided to RC family members under the provisions
of the Operation Noble Eagle/Operation Enduring Freedom Reservist
and National Guard Benefits Demonstration (TRICARE Operations Manual
(TOM),
Chapter 18)
and are now permanent. That demonstration was effective for claims
for services provided on or after September 14, 2001, and before
November 1, 2009.
2.5 Section
748(b) of the NDAA FY 2017 (Public Law 114-328) eliminated the requirement
that the active duty be in support of a contingency operation, effective
December 23, 2016, for family members to obtain benefits stated
in
paragraphs 2.1 and
2.3.
2.6 Section 701 replaces TRICARE
Standard/TRICARE Extra with TRICARE Select effective January 1,
2018. See TRICARE Reimbursement Manual (TRM),
Chapter
2.
3.0 POLICY
3.1 This
benefit is authorized for family members of RC members, excluding
those whose members are Active Guard Reserve (AGR), who are called
or ordered to active duty for a period of more than 30 calendar
days.
Note: This special
benefit does not apply to TRICARE Prime enrollees.
3.3 In
order to protect beneficiaries from incurring greater out-of-pocket
costs under these special procedures, the beneficiary cost-share
for these claims will be limited to what it would have been in the
absence of the higher allowable amount under this benefit. That
is, the cost-share is 20% of the lesser of the CMAC or the billed charge.
Any amounts that are allowed over the CMAC will be paid entirely
by TRICARE.
3.4 The TRICARE
Encounter Data (TED) record for each claim received subsequent to
policy specified in
paragraph 3.1 must reflect the Special Processing
Code
EF.
3.5 TED records submitted for non-participating
professional claims that are reimbursed at the lesser of the balance
billing limit or the billed charge are to be identified with Pricing
Rate Code W, but only if the allowed amount is greater
than the CMAC. If the billed charge equals or is less than the CMAC,
Pricing Rate Code W is not to be used. On the other
hand, when the claim is reimbursed as billed because the billed
charge is greater than the CMAC but less than the balance billing
limit, or the charges are exempt from the balance billing limit,
Pricing Rate Code W is to be used.
3.6 The
TRICARE Standard/TRICARE Extra deductible (effective January 1,
2018, the TRICARE Select deductible) is waived for all beneficiaries
identified by HCDP Special Entitlement codes 02, 03,
or 08.
3.7 Starting
January 1, 2018, family members will have their deductibles waived
and apply the TRICARE Select cost-shares. Paragraphs
3.3 through
3.6 apply.