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Child Vaccination Programs
That Use An SVP Per Capita Assessment Approach For Reimbursement
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1.
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DHA will calculate the number
of covered lives (i.e., Active Duty Family Member (ADFM) and Non-Active
Duty Family Member (NADFM) reliants that are not enrolled at a Market/Military
Medical Treatment Facility (MTF) in TRICARE Prime, ages 0-18) (see Section 38 for details) each quarter. Defense
Health Agency (DHA) will estimate the percentage of TRICARE non-Active
Duty Dependent (ADD) reliants annually, and exclude any non-ADDs who
are not reliant on TRICARE as their primary form of insurance in
their covered lives population estimate. |
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2.
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Each SVP may have its own time
period for the population to be calculated. The DHA will work with
the state programs to ensure that the population is calculated for
the appropriate time frame in the state. DHA will, on a quarterly
basis, provide the contractors the number of covered lives in each
state. Some SVPs require quarterly payment, while others require
annual payments. DHA will determine which population numbers are appropriate
to use for the SVP-specific calculations.
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3.
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DHA will also provide the contractors
with a TRICARE per capita capped payment amount for the time period needed
for each SVP program. This information may be provided directly
to the contractor or posted on a DHA-approved website.
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4.
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The contractor shall follow
the protocol established by each state to provide them with the
number of TRICARE covered lives for the dates requested by the SVP.
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5.
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The contractor shall identify
whether the SVP per capita assessment amount provided by the SVP
is greater or less than the TRICARE per capita capped payment amount.
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6.
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In some states, the SVPs shall
send an invoice to the contractors for a payment, typically on a
quarterly or annual basis. In other states, the contractors shall
proactively provide payment to the SVPs for the liability amount.
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7.
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The contractor shall pay the
SVPs in one of two ways:
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a.
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If the SVP per capita quarterly
assessment amount is less than the TRICARE per capita quarterly
capped payment amount: The contractors shall pay the amount equal
to the SVP per capita assessment amount multiplied by the TRICARE
reliant population
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b.
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If the SVP per capita quarterly
assessment amount is greater than the TRICARE per capita quarterly
capped payment amount: The contractor shall calculate the total
TRICARE assessment amount to be paid to the SVP as the number of
TRICARE reliants (i.e., covered lives) in the state multiplied by
the TRICARE per capita capped payment amount.
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8.
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The contractor shall submit
payment to the SVPs either annually or quarterly depending on the
SVP.
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9.
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The contractor shall be reimbursed
using non-underwritten funds.
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Child Vaccination Programs
That Use An Alternative Approach - The State Of Massachusetts
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1.
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For Massachusetts, DHA will
calculate the total TRICARE paid amounts made to acute care hospitals
and paid facility charges for hospital outpatient departments and
freestanding Ambulatory Surgery Center (ASC) facilities for a period
designated annually by the Massachusetts Vaccine Association to
calculate the annual Pediatric Immunization Program Assessment (PIPA).
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2.
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DHA will identify the PIPA
surcharge percentage that is published annually by the state of
Massachusetts, and multiply this percentage by the total paid amounts
calculated above.
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3.
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DHA will compare the MA assessment
amount with the TRICARE payment capped amount, as calculated by DHA
using the reliant covered lives under age 19 and an assessment amount.
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4.
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DHA will provide the contractor
with the total TRICARE assessment amount to be paid to the state
and the contractor shall submit payment to the Massachusetts Vaccine
Purchase Trust.
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5.
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The contractor shall submit
payment to the SVP by June 1st.
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6.
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The contractor shall be reimbursed
using non-underwritten funds.
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Adult Vaccination Programs
That Use An SVP Per Capita Assessment Approach for Reimbursement
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1.
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DHA will calculate the number
of covered lives (i.e., ADFM and NADFM reliants that are not enrolled
at a Market/MTF in TRICARE Prime, for the ages in which adult vaccines
are provided in the state) each quarter. The term “reliants” refers
to a subset of TRICARE eligible beneficiaries who are dependent
on TRICARE for the coverage/reimbursement of vaccines under the
well-child and preventive benefits. All TRICARE ADFMs are considered
to be reliant on TRICARE as their primary form of insurance. DHA
will estimate the percentage of TRICARE non-ADD reliants annually,
and will exclude any non-ADDs who are not reliant on TRICARE as
their primary form of insurance in their covered lives population
estimate.
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2.
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Each state adult SVP may have
its own time periods for the population to be calculated. DHA will
work with the state programs to ensure that the population is calculated
for the appropriate time frame in the state. DHA will, on a quarterly
basis, provide the contractors the number of covered lives in each
state.
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3.
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DHA will calculate a state-specific
TRICARE per capita capped payment amount for each quarter using
data from only the adult vaccines that are provided in the state.
DHA will determine if multiple state per capita capped rates are
required based on age. For example, if a state program provides
vaccines to the Medicare-eligible population, DHA will exclude any
Medicare-covered adult vaccines from the calculation of a capped amount
used for the age 65 and older population in that state only.
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4.
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DHA will provide the contractors
with the number of covered reliants in the state, and the TRICARE
state-specific per capita capped payment amount(s). DHA may provide
these values directly to the contractor, or via a website designed
for DHA SVP programs.
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5.
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The contractor shall provide
the Adult SVP program with the number of adult TRICARE reliants
in which ever mechanism that is agreed upon by the contractor and
the state (e.g., via memo, online survey, web-portal) for each time
period requested by the SVP.
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6.
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In some states, the SVPs shall
send an invoice to the contractors for a payment, typically on a
quarterly or annual basis. In other states, the contractor shall
proactively provide payment to the SVPs for the liability amount.
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7.
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The contractor shall identify
whether the SVP Adult per capita assessment amount is greater than
the calculated TRICARE per capita capped payment amount.
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8.
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The contractor shall pay the
SVPs in one of two ways:
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a.
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If the SVP per capita quarterly
assessment amount is less than the TRICARE per capita quarterly
capped payment amount: The contractor shall pay the amount equal
to the SVP per capita assessment amount multiplied by the TRICARE
reliant population.
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b.
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If the SVP per capita quarterly
assessment amount is greater than the TRICARE per capita quarterly
capped payment amount: The contractor shall calculate the total
TRICARE assessment amount to be paid to the SVP as the number of
TRICARE reliants (i.e., covered lives) in the state multiplied by
the TRICARE per capita capped payment amount.
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9.
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The contractor shall submit
payment to the SVP.
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10.
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The contractor shall be reimbursed
using non-underwritten funds.
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