2.3
Review
And Annual Updates
All fees
(including enrollment fees, deductibles, and cost-shares) are subject
to review and annual updating on the calendar year, in accordance
with 10 USC sections 1075 and 1075a.
2.3.1 This section provides the policy
regarding fees and the Calendar Year (CY) 2018 amounts. Annual updates
thereafter will be published on the Defense Health Agency (DHA)
web site at
http://www.health.mil/rates.
2.3.2 Each fee for Group B beneficiaries
shall be annually indexed to the amount by which retired pay is
increased (i.e., the cost-of-living adjustment (COLA)) under 10
USC section 1401a, rounded to the next lowest multiple of $1. The
remaining amount above such multiple of $1 shall be carried over
to, and accumulated with, the amount of the increase for the subsequent
year and made when the aggregate amount of increases carried over
for a year is $1 or more.
2.4
TRICARE
Prime
2.4.1 TRICARE Prime program enrollment
fees and copayments are defined in 10 USC sections 1075 and 1075a.
For information on fees for
TRICARE Prime
enrollees choosing to receive care under the Point of Service Option
(POS), refer to
32 CFR 199.17 and
Section 5.
2.4.1.1 TRICARE Prime ADFMs have no
annual enrollment fee in CY 2018 or subsequent calendar years.
2.4.1.2 TRICARE Prime Group A Retirees
have a CY 2018 enrollment fee of $289.08 for an individual or $578.16
for a family. Annual updates are available at
http://www.health.mil/rates.
2.4.1.3 TRICARE Prime Group B Retirees
have a CY 2018 enrollment fee of $350 for an individual or $700
for a family. Annual updates are available at
http://www.health.mil/rates.
2.4.1.4 Effective March 26, 1998, the
TRICARE Prime enrollment fee is waived for those beneficiaries who
are both eligible for Medicare on the basis of disability or end
stage renal disease and who maintain enrollment in Part B of Medicare
and are otherwise eligible to enroll in TRICARE Prime.
2.4.1.5 Effective FY 2012, Group A TRICARE Prime
beneficiaries who are (1) survivors of active duty deceased sponsors,
or (2) medically retired Uniformed Services members and their family
members, shall have their TRICARE Prime
enrollment fees frozen at the rate in effect when classified and
enrolled in a fee paying TRICARE Prime
plan. (This does not include TYA plans). Beneficiaries in these
two categories who were enrolled in FY 2011 will continue paying
the FY 2011 rate. The beneficiaries who become eligible in either
category and enroll during FY 2012, or in any future fiscal year
through December 31, 2017 or calendar year commencing CY 2018, shall
have their fee frozen at the rate in effect at the time of enrollment
in TRICARE Prime. The fee for these
beneficiaries shall remain frozen as long as at least one family
member remains enrolled in TRICARE Prime.
The fee for the family member(s) of a medically retired Uniformed
Services member shall not change if the family member(s) is later
re-classified a survivor.
2.4.1.6 Group B TRICARE Prime
Retiree beneficiary enrollment fees are not frozen nor waived.
2.4.2 TRICARE Select
TRICARE Select enrollment fees
and copayments are defined in 10 USC sections 1075 and 1075a.
2.4.2.1 TRICARE Select ADFMs have no
enrollment fees.
2.4.2.2 TRICARE Select Group A retirees
have a CY 2021 enrollment fee of $150 for an individual or $300
for a family. Annual updates are available at
http://www.health.mil/rates.
Prior to CY 2021 TRICARE Select Group A retirees had no enrollment
fees.
2.4.2.3 When enrollment fees implemented
for TRICARE Select Group A Retirees. Retirees who are (1) survivors
of active duty deceased sponsors, or (2) medically retired Uniformed
Services members and their family members, have no enrollment fees
in CY 2018 or in any subsequent calendar year. (This does not include
TYA plans). The fee for the family member(s) of a medically retired
Uniformed Services member shall not change if the family member(s)
is later re-classified a survivor.
2.4.2.4 TRICARE Select Group B Retirees
have enrollment fees of $450 per individual or $900/family for CY
2018. These fees shall be updated annually in accordance with
paragraph 2.3.
Annual updates shall be posted at
http://www.health.mil/rates.
2.5 Deductibles
2.5.1 TRICARE Prime ADFMs and Retirees.
Group A and Group B
TRICARE Prime ADFMs
and
TRICARE Prime retirees have no
deductible under TRICARE Prime for health care services obtained
in accordance with
TRICARE Prime rules
and procedures. If otherwise covered health care services are not obtained
in accordance with
TRICARE Prime rules
and procedures, the services may be covered under the POS option
(
Section 5) including a deductible
of $300 per individual or $600 per family.
2.5.2 TRICARE Select. TRICARE Select
beneficiaries have calendar year deductibles that must be fully
met before TRICARE benefits are payable. Once the deductible has
been met, the cost-shares in
paragraph 2.6 apply. The TRICARE Select deductible
applies to the catastrophic cap. The TRICARE Select deductible does
not apply to the preventive care services described in the TPM,
Chapter 7, Sections 2.1,
2.2, and
2.5.
2.5.3 Collection of deductible amounts. The
contractor shall require network providers to collect, at
a minimum, the copayment at the time of service and the Explanation
Of Benefits (EOB) shall inform the provider and beneficiary of additional
amounts owed to satisfy the deductible. Additionally, the contractor
may provide deductible information to network providers in advance
so they may also be collected at the time of the service, at the
discretion of both the contractor and network providers in their
network agreements.
2.5.4 Deductibles
when beneficiaries move between regions. See the TRICARE Operations Manual
(TOM),
Chapter 6, Section 2, regarding
portability.
2.5.5 Beneficiaries
who transfer to TRICARE Prime, and
again to TRICARE Select during the
same calendar year. The deductible for these beneficiaries does
not reset to zero. The amount of the deductible fulfilled shall
carry forward if a beneficiary moves to TRICARE Prime,
and back to TRICARE Select during the
same CY.
2.5.6 Figure 2.2-1 contains
the deductibles that apply to TRICARE Select beneficiaries for CY 2018.
These fees shall be updated annually in accordance with
paragraph 2.4 and
shall be posted at
http://www.health.mil/rates.
Figure 2.2-1 TRICARE Select Deductibles
for CY 2018
|
TRICARE SELECT**
|
Group A ADFM
|
Group B ADFM
|
Group A
|
Group b
|
|
E1-E4
|
e-5 & Above
|
E1-E4
|
e-5 & ABOVE
|
Retirees
|
Retirees
|
|
* Group B Retirees
have a separate out-of-network deductible. The out-of-network deductible
is separate from the in network deductible and must be paid in addition
to the in network deductible. For example, if a Group B retiree
beneficiary had met their $150 network deductible, and then chooses
to see an out-of-network provider, the beneficiary must pay the additional
$300 out-of-network deductible before TRICARE will cost-share out-of-network
care.
** If a beneficiary
has a partially-fulfilled deductible, and the next service will
meet the deductible, the beneficiary must meet their deductible
and then may be subject to the additional copayment, if the remaining
deductible was less than the applicable copayment:
Example 1: An
E1 Group B ADFM has met $25 of their $50 deductible. They visit
their primary care physician, and the visit has an allowable charge
of $100. The beneficiary is responsible for $25 of the service,
and has thus met their deductible.
Example 2: The
same Group B ADFM has met $45 of their $50 deductible. They visit
their primary care physician, and the visit has an allowable charge
of $100. The beneficiary is responsible for the remaining $5 plus
the $15 copayment, for a total of $20.
*** Out-of-network
deductibles apply to the catastrophic cap.
|
|
In-Network
|
$50/$100
|
$150/$300
|
$50/$100
|
$150/$300
|
$150/$300
|
$150/$300
|
|
Out-Of-Network
|
$300/$600*
|
2.6
Cost-Shares
and Copayments
2.6.1 This paragraph
provides an overview of the establishment and general applicability
of TRICARE cost-shares and copayments for each TRICARE plan and
category of beneficiary except for authorized COVID-19 testing in
response to the COVID-19 pandemic. For cost-shares and copayments related
to COVID-19 testing, see
Section 7.
2.6.2 TRICARE Prime Group A and Group
B ADFM Enrollees.
TRICARE Prime enrollees
have $0.00 copayment for covered health care services obtained in
accordance with
TRICARE Prime rules
and procedures. If otherwise covered health care services are not
obtained in accordance with
TRICARE Prime
rules and procedures, the services may be covered under the POS
option (
Section 5), including a separate deductible
of $300 per individual or $600 per family. This would include any
non-emergency out of network care obtained by a
TRICARE Prime
beneficiary without following applicable referral requirements.
Pharmacy copayments are in addition to any TRICARE Prime copayments.
2.6.3 TRICARE Select Group A ADFM
and Retiree Enrollees.
2.6.3.1 Care received from network
providers. The cost-sharing amounts for covered health care services
obtained from a network provider are fixed dollar amounts for each
specified category of care and are set prospectively for each calendar
year with the annual updates available at
http://www.health.mil/rates.
2.6.3.2 Care received from non-network
providers. The cost-sharing amounts for covered health care services
obtained from a non-network provider are as provided in
32
CFR 199.4 and
Section 1.
2.6.4 TRICARE Select Group B ADFM
and Retiree Enrollees. The cost-sharing amounts for covered health
care services for CY 2018 are established by 10 USC 1075 and shall
be updated annually in accordance with
paragraph 2.3, with the annual
updates available at
http://www.health.mil/rates.
The cost-sharing amounts are unique for Group B ADFMs and for Group
B Retirees and include different cost-sharing amounts within each
beneficiary category depending on whether the covered health care services
are obtained from a network provider or from a non-network provider.
2.6.5 CHAMPUS Maximum Allowable Charge
(CMAC) impact on cost-sharing. In instances where the CMAC or allowable
charge is less than the copayment established by this section and
published on the DHA website, network providers may only collect
the lower of the allowable charge or the applicable copayment.
2.6.6 Services with Set Copayments.
Copayments apply only after any applicable deductibles have been
satisfied, except for preventive care, which is available (when
all conditions of coverage are met) with no copayment from network
physicians, regardless of whether or not applicable deductibles have
been satisfied.
2.7 Cost-shares
for services are as follows:
2.7.1 Preventive
Care Outpatient Visits Under TRICARE Prime and Select
2.7.1.1 TRICARE Prime enrollees may
receive
TRICARE Prime clinical preventive
services from any network provider within their region of enrollment
without referral or authorization. See the TRICARE Policy Manual
(TPM),
Chapter 7, Section 2.2 for a list of these
services. If a
TRICARE Prime clinical preventive
service is not available from a network provider, an enrollee may
receive the service from a non-network provider with a referral
from the Primary Care Manager (PCM) and authorization from the contractor.
If an enrollee uses a non-network provider without first obtaining
a referral from their PCM and authorization from the contractor,
payment is made under the POS option only for services that are otherwise
covered under the TRICARE Basic Program and described in the TPM,
Chapter 7, Section 2.1. Payment shall not
be made under the POS option for clinical preventive services that
are not otherwise covered under the TRICARE Basic Program.
2.7.1.2 TRICARE Select enrollees may
receive TRICARE Prime clinical preventive
services when furnished by a network provider. If a TRICARE Select
enrollee uses a non-network provider, payment is made only for clinical
preventive services that are otherwise covered under the TRICARE
Basic Program.
2.7.1.3 No copayments or cost-shares
are required for additional clinical preventive services authorized
under
32 CFR 199.4(e)(28) and described in the TPM,
Chapter 7, Sections 2.1,
2.2,
2.3,
and
2.5 whether
received from network or non-network providers. However, TRICARE
Prime beneficiaries are required to obtain services in accordance
with the rules and procedures of
TRICARE Prime
to avoid POS charges.
2.7.1.4 No copayments or authorizations
are required for covered clinical preventive services not normally
provided as part of the TRICARE Basic program under
32 CFR 199.4(e)(28) when provided to
TRICARE Prime
and
TRICARE Select enrollees by network
providers. These specific set of services shall be established by
the Director, DHA, and announced annually before the open season
enrollment period. Such preventive care outpatient visits may include:
laboratory and imaging tests; cancer screenings; immunizations;
periodic health promotion and disease prevention exams (e.g., well-child care);
blood pressure screening; hearing exams; sigmoidoscopy or colonoscopy;
serologic screening; medical contraceptives; and appropriate education
and counseling services as specified by the Director, DHA. A beneficiary
is not required to pay any portion of the cost of covered, in-network preventive
services even if the beneficiary’s deductible has not yet been fulfilled.
Figure 2.2-2 TRICARE
Prime Cost-Shares for Preventive Care Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
* Those services
listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1 are
exempt from cost-share requirements.
Note: Effective
January 1, 2023, tubal ligation procedures are covered with no-cost
sharing when performed by an in-network provider only.
|
|
TRICARE Prime
Preventive Care Visits (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Basic Preventive Care Visits
(CY 2018), Out-Of-Network* when obtained in accordance with established
rules
|
$0
|
$0
|
$0
|
$0
|
Figure 2.2-3 TRICARE
Select Cost-Shares for Preventive Care Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
* Those services
listed in the TPM, Chapter 7, Section 2.1, paragraph 1.1 are
exempt from cost-share requirements.
Note: Effective
January 1, 2023, tubal ligation procedures are covered with no-cost
sharing when performed by an in-network provider only.
|
|
TRICARE Select
Preventive Care Visits (CY 2018), In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Basic Preventive Care Visits
(CY 2018), Out-Of-Network*
|
$0
|
$0
|
$0
|
$0
|
2.7.2 Primary Care Outpatient Visits
Primary care outpatient visits
to include any PCM as designated in TPM,
Chapter 1, Section 7.1. Includes the services
of the individual professional provider as well as all medical supplies
used within the office and ancillary services and the treatment
room.
Figure 2.2-4 TRICARE
Prime Cost-Shares for Primary Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Primary Care Outpatient Visits
(CY 2018), In-Network
|
$0
|
$0
|
$20
|
$20
|
Figure 2.2-5 TRICARE
Select Cost-Shares for Primary Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Primary Care Outpatient Visits
(CY 2018), In-Network
|
$21
|
$15
|
$28
|
$25
|
|
Primary Care Outpatient Visits
(CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.3 Specialty Care Outpatient Visits
This category applies to outpatient
care provided by provider specialties other than those listed under primary
care outpatient visits. Includes the services of the individual
professional provider as well as all medical supplies used within
the office and ancillary services and the treatment room. This category also
includes partial hospitalization services, intensive outpatient
treatment, and opioid treatment program services. The per visit
fee shall be applied on a per day basis on days services are received,
with the exception of opioid treatment program services reimbursed
in accordance with 32 CFR 199.14
(a)(2)(ix)(A)(3)(i) which per visit fee will
apply on a weekly basis.
Figure 2.2-6 TRICARE
Prime Cost-Shares for Specialty Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Specialty Care Outpatient Visits
(CY 2018)
|
$0
|
$0
|
$30
|
$30
|
Figure 2.2-7 TRICARE
Select Cost-Shares for Specialty Care Outpatient Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Specialty Care Visits (CY 2018),
In-Network
|
$31
|
$25
|
$41
|
$40
|
|
Specialty Care Visits (CY 2018),
Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.4 Ancillary Care
2.7.4.1 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 most up-to-date
codes should be utilized to identify services within each category,
in accordance with the TOM,
Chapter 1, Section 4. When
TRICARE Prime
rules and procedures are not followed, POS charges may apply. 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:
• Diagnostic radiology and ultrasound
services included in the CPT procedure code range from 70010-76999,
or any other code for associated contrast media;
• Diagnostic nuclear medicine
services included in the CPT procedure code range from 78012-78999;Pathology
and laboratory services included in the CPT procedure code range
from 80047- 89398; G0461-G0462 (during 2014); and
• Cardiovascular studies included
in the CPT procedure code range from 93000-93355.
• Venipuncture included in the
CPT procedure code range from 36400-36425.
• Fetal monitoring for CPT procedure
codes 59020, 59025, and 59050.
• Collection of blood specimens
in the CPT procedure codes 36591 and 36592.
Note: Multiple discounting will not
be applied to the following CPT procedure codes for venipuncture,
fetal monitoring, and collection of blood specimens; 36400-36425,
36591, 36592, 59020, 59025, and 59050.
2.7.4.2 TRICARE Select enrollees have
no copayments for ancillary services (defined in
paragraph 2.7.4.1) provided
by network providers. Ancillary services for TRICARE Select beneficiaries
are cost-shared as follows:
Figure 2.2-8 TRICARE
Select Cost-Shares for Ancillary Services
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Ancillary Services (CY 2018),
In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Ancillary Services (CY 2018),
Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.5 Other Radiology Services
Radiology Services are considered
ancillary services for TRICARE Prime enrollees and all
TRICARE Prime rules
and procedures apply. TRICARE Select enrollees who obtain radiology
services from network providers have no cost-share. TRICARE Select
enrollees who receive other radiology services from non-network
providers are subject to the following cost-shares:
Figure 2.2-9 TRICARE
Select Cost-Shares for Other Radiology Services
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Radiology Services (CY 2018),
In-Network
|
$0
|
$0
|
$0
|
$0
|
|
Radiology Services (CY 2018),
Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.6 Eye Examinations
2.7.6.1 TRICARE Prime. One routine
examination per year for TRICARE Prime family members of active
duty sponsors. One routine examination every other year for TRICARE
Prime retirees and their family members per the TPM,
Chapter 7, Section 2.2.
Figure 2.2-10 TRICARE
Prime Cost-Shares for Eye Examinations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Eye Examinations (CY 2018)
|
$0
|
$0
|
$0
|
$0
|
2.7.6.2 TRICARE Select. Eye examinations
received from in-network and out-of-network providers by TRICARE
Select ADFMs may be cost-shared as follows. Eye examinations for
TRICARE Select retirees are not a TRICARE benefit. See the TPM,
Chapter 7, Section 6.1.
Figure 2.2-11 TRICARE
Select Cost-Shares for Eye Examinations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Eye Examinations (CY 2018),
In-Network
|
$0
|
$0
|
NA
|
NA
|
|
Eye Examinations (CY 2018),
Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
NA
|
NA
|
2.7.7 Emergency Room (ER) Visits
Emergency care obtained on
an outpatient basis in network or non-network facilities, in-region
or out-of-region.
2.7.7.1 The TRICARE Prime and Select
copayment requirement for ER services is on a PER VISIT basis; this
means that only one copayment is applicable to the entire ER episode,
regardless of the number of providers involved in the patient’s
care and regardless of their status as network providers.
2.7.7.2 POS charges do not apply to
emergency care. See the TOM,
Chapter 8, Section 5, paragraph 2.6.
Figure 2.2-12 TRICARE
Prime Cost-Shares for Emergency Room (ER) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
ER Visits (CY 2018)
|
$0
|
$0
|
$60
|
$60
|
Figure 2.2-13 TRICARE
Select Cost-Shares for Emergency Room (ER) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
ER Visits (CY 2018), In-Network
|
$81
|
$40
|
$109
|
$80
|
|
ER Visits (CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.8 Urgent Care Visits
The usual TRICARE Prime referral
requirement may be waived for some or all urgent care visits for TRICARE
Prime enrollees other than most active duty members. The specific
number of urgent care visits without a referral for TRICARE Prime
enrollees is determined annually prior to the beginning of the open
season enrollment period. When the urgent care referral is waived,
no POS deductibles and cost-shares shall apply when urgent care
is provided by a TRICARE network provider or a TRICARE-authorized
(network or non-network) Urgent Care Center (UCC) or Convenience
Clinic (CC). If the enrollee seeks care from a non-network provider
(except a TRICARE-authorized UCC or CC), the usual POS deductible
and cost-shares shall apply. See the TOM,
Chapter 8, Section 5, for information on which
TRICARE Prime plan enrollees do not require a referral.
Figure 2.2-14 TRICARE
Prime Cost-Shares for Urgent Care Center (UCC) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
UCC Visits (CY 2018)
|
$0
|
$0
|
$30
|
$30
|
Figure 2.2-15 TRICARE
Select Cost-Shares for Urgent Care Center (UCC) Visits
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
UCC Visits (CY 2018), In-Network
|
$21
|
$20
|
$28
|
$40
|
|
UCC Visits (CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.9 Ambulatory Surgery
Authorized hospital-based or
Freestanding Ambulatory Surgical Center (FASC) that is TRICARE certified. Also
includes prenatal care, outpatient delivery, and postnatal care
provided by a TRICARE authorized birthing center. No cost-share
shall be deducted from a claim for professional services related
to ambulatory surgery. This applies whether the services are performed
in an FASC, or a Hospital Outpatient Department (HOPD). So long
as at least one procedure on the claim is reimbursed as ambulatory
surgery, the claim shall be cost-shared as ambulatory surgery.
Figure 2.2-16 TRICARE
Prime Cost-Shares for Ambulatory Surgery (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Ambulatory Surgery (CY 2018)
|
$0
|
$0
|
$60
|
$60
|
Figure 2.2-17 TRICARE
Select Cost-Shares for Ambulatory Surgery (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Ambulatory Surgery (CY 2018),
In-Network
|
$25
|
$25
|
20% of allowable charge
|
$95
|
|
Ambulatory Surgery (CY 2018),
Out-Of-Network
|
$25
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.10 Ambulance Services
Ambulance services, when medically
necessary as defined in the TPM and when the service is a covered benefit.
POS charges do not apply to emergency care; see the TOM,
Chapter 8, Section 5, paragraph 2.6.
Figure 2.2-18 TRICARE
Prime Cost-Shares for Ambulance Services (Including Birthing Centers)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
* In- and Out-Of-Network.
|
|
Outpatient Ground Ambulance
(CY 2018)*
|
$0
|
$0
|
$40
|
$40
|
|
Outpatient Air Ambulance (CY
2018)*
|
$0
|
$0
|
$20
|
$20
|
|
Inpatient (Transfers rendered
in conjunction with an inpatient stay.) (CY 2018)*
|
$0
|
$0
|
25% of allowable charge
|
25% of allowable charge
|
Figure 2.2-19 TRICARE
Select Cost-Shares for Ambulance Services
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
* In- and Out-Of-Network.
|
|
Outpatient Ground Ambulance
(CY 2018), In-Network
|
$74
|
$15
|
$98
|
$60
|
|
Outpatient Ground Ambulance
(CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
|
Outpatient Air Ambulance (CY
2018)*
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
|
Inpatient (Transfers rendered
in conjunction with an inpatient stay.) (CY 2018)*
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.11 Durable Medical Equipment (DME)
DME, hearing aids for ADFMs,
and medical supplies prescribed by an authorized provider which
are covered benefits, if dispensed for use outside of the office
or after the home visit.
Figure 2.2-20 TRICARE
Prime Cost-Shares for Durable Medical Equipment (DME)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
DME (CY 2018)
|
$0
|
$0
|
20% of allowable charge
|
20% of allowable charge
|
Figure 2.2-21 TRICARE
Select Cost-Shares for Durable Medical Equipment (DME)
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
DME (CY 2018), In-Network
|
15% of allowable charge
|
10% of allowable charge
|
20% of allowable charge
|
20% of allowable charge
|
|
DME (CY 2018), Out-Of-Network
|
20% of allowable charge
|
20% of allowable charge
|
25% of allowable charge
|
25% of allowable charge
|
2.7.12 Inpatient
Hospital Admission
Semiprivate
room (when medically necessary, special care units), general nursing,
and hospital service. Includes inpatient physician and their surgical
services, meals including special diets, drugs, and medication while
an inpatient, operating and recovery room, anesthesia, laboratory
tests, x-ray and other radiology services, necessary medical supplies
and appliances, blood and blood products. Also, includes maternity
hospital and professional services (prenatal, delivery, postnatal).
Includes inpatient hospital admissions in all acute care, specialty
(i.e., cancer and children’s hospitals), and mental health hospitals.
2.7.12.1 For inpatient hospital admissions
subject to the inpatient mental health per diem payment system,
the following special rules apply:
2.7.12.1.1 Lower volume hospitals and
units: For care paid on a regional per diem, the cost-share shall
be calculated in accordance with
Section 1, paragraph 1.3.3.5.4.2.
2.7.12.1.2 A claim subject to the inpatient
mental health per diem payment system which spans a period in which
two separate per diems exist shall have the cost-share computed
on the actual per diem in effect for each day of care.
2.7.12.1.3 Cost-share whenever leave days
are involved. There is no patient cost-share for leave days when
such days are included in a hospital stay.
2.7.12.1.4 Claims for services that are
provided during an inpatient admission which are not included in
the per diem rate shall be cost-shared 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. 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 would include
non-mental health claims and mental health claims submitted by individual
professional providers rendering medically necessary services during
the inpatient admission.
2.7.12.2 All final claims reimbursed
under the TRICARE Diagnosis Related Group (DRG)-based payment system
are to be priced using the rules, weights and rates in effect as
of the date of discharge. Interim claims with “end date of care”
shall be priced using the rules, weights and rates in effect as
of the “end date of care.” See
Chapter 6, Section 3, paragraph 3.3.1.
Figure 2.2-22 TRICARE
Prime Cost-Shares for Inpatient Hospitalizations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Inpatient Hospitalization (CY
2018)
|
$0
|
$0
|
$150/admission
|
$150/admission
|
Figure 2.2-23 TRICARE
Select Cost-Shares for Inpatient Hospitalizations
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
|
|
Inpatient Hospitalization (CY 2018),
In-Network
|
Subsistence charge per day
($18.60), minimum
$25/admission*
|
$60/admission
|
$250/day or 25% of the hospital’s
total charges (based upon the fee schedule negotiated
by the contractor) whichever is less, plus 20% of separately billed
professional charges
|
$175/admission
|
|
Inpatient Hospitalization (CY 2018),
Out-Of-Network
|
Subsistence charge per day
($18.60), minimum
$25/admission*
|
20% of allowable charge
|
DRG per diem ($901/day) or
25% of the hospital’s billed charges for institutional services,
whichever is less, plus 25% of separately billed professional charges
|
25% of allowable charge
|
2.7.13 Inpatient Skilled Nursing/Inpatient
Rehabilitation
This category
includes a Residential Treatment Center (RTC) or Substance Use Disorder Rehabilitation
Facility (SUDRF) residential treatment program. For Skilled Nursing
Facility (SNF) care, this is the same benefit as Medicare except
there is no limitation as to the number of days of coverage. Benefit
includes semiprivate room; regular nursing services; meals including
special diets; physical, occupational, and speech therapy; drugs
furnished by the facility; necessary medical supplies; and appliances.
Figure 2.2-24 TRICARE
Prime Cost-Shares for Skilled Nursing/Rehabilitation Facilities
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
SNF/Rehab Facilities (CY 2018)
|
$0
|
$0
|
$30/day
|
$30/day
|
Figure 2.2-25 TRICARE
Select Cost-Shares for Skilled Nursing/Rehabilitation Facilities
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
|
|
SNF/Rehab Facilities (CY 2018),
In-Network
|
Subsistence charge per day
($18.60), minimum
$25/admission*
|
$25/day
|
$250/day up to 25% of the hospital’s
total charge plus 20% of separately billed services
|
$50/day
|
|
SNF/Rehab Facilities (CY 2018),
Out-Of-Network
|
Subsistence charge per day
($18.60), minimum
$25/admission*
|
$50/day
|
25% of allowable charge
|
Lesser of $300/day or 20% of allowable charge
|
2.7.14 Home
Health and Hospice
Home Health
Care (HHC) provided by a Home Health Agency (HHA) and reimbursed
in accordance with
Chapter 12 has
no cost-share for all beneficiary categories. Hospice care provided
in accordance with
Chapter 11 has
no cost-share for all beneficiary categories.
2.7.15 Maternity Care
For routine maternity episodes,
there is a single beneficiary cost-share or copayment, depending
on the beneficiary category, site of service, and rendering provider.
Maternity care shall be cost-shared as follows:
2.7.15.1 A single inpatient cost-share
applies to maternity care ending in childbirth in, or on the way to,
a hospital inpatient childbirth unit, and for maternity care ending
in a non-birth outcome not otherwise excluded. Inpatient cost-share
formula applies 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. Aside from the applicable single inpatient cost-share, there
is no separate cost-share for separately billed professional charges
or prenatal or postnatal care involved in these routine maternity
episodes.
2.7.15.2 A single ambulatory surgery
cost-share applies 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.
2.7.15.3 A single outpatient cost-share
applies to maternity care which terminates in a planned childbirth
at home. If the care is rendered b a PCM (as defined in the TPM,
Chapter 1, Section 7.1, paragraph 1.1.2),
it shall be cost-shared as a primary care visit. If provided by
a specialist, it shall be cost-shared as a specialty visit.
2.7.15.4 Otherwise covered medical services
and supplies directly related to “complications of pregnancy”, as
defined in the Regulation, will be cost-shared on the same basis
as the related maternity care for a period not to exceed 42 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.
2.7.15.5 Otherwise authorized services
and supplies related to maternity care, including maternity related
prescription drugs, shall be cost-shared on the same basis as the
termination of pregnancy.
2.7.15.6 Claims for pregnancy testing
are cost-shared on an outpatient basis when the delivery is on an
inpatient basis.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 delivery is to be adjudicated as an at-home birth.
2.7.15.8 Claims for prescription drugs
provided on an outpatient basis during the maternity episode but
not directly related to the maternity care are cost-shared on an
outpatient basis.
2.7.15.9 All admissions related to a
single maternity episode shall be considered one confinement regardless
of the number of days between admissions. For ADFMs, the cost-share
shall be applied to the first institutional claim received.
2.7.15.10 Medically necessary treatment
rendered to a pregnant woman for a non-obstetrical medical, anatomical,
or physiological illness or condition shall be cost-shared as a
part of the maternity episode when:
2.7.15.10.1 The treatment is otherwise
allowable as a benefit; and
2.7.15.10.2 Delay of the treatment until
after the conclusion of the pregnancy is medically contraindicated;
and
2.7.15.10.3 The illness or condition is,
or increases the likelihood of, a threat to the life of the mother;
or
2.7.15.10.4 The illness or condition will
cause, or increase the likelihood of, a stillbirth or newborn injury
or illness; or
2.7.15.10.5 The usual course of treatment
must be altered or modified to minimize a defined risk of newborn
injury or illness.
Figure 2.2-26 TRICARE Prime Cost-Shares for
Maternity - Hospital Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity - Hospital Delivery
(CY 2018), In-Network
|
$0
|
$0
|
$150
|
$150
|
|
Maternity - Hospital Delivery
(CY 2018), Out-of-Network
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency
care
|
Figure 2.2-27 TRICARE Select Cost-Shares
for Maternity - Hospital Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity - Hospital Delivery
(CY 2018), In-Network
|
Subsistence charge
per day ($18.60), minimum $25/admission
|
$60
|
$250/day or 25% of the hospital’s
total charges (based upon the fee schedule negotiated
by the contractor), whichever is less, plus 20% of separately billed professional charges
|
$175
|
|
Maternity - Hospital Delivery
(CY 2018), Out-of-Network
|
Subsistence charge
per day ($18.60), minimum $25/admission
|
20% of the allowable charge
|
DRG per diem ($901/day) or 25%
of the hospital’s billed charges for institutional services, whichever
is less, plus 25% of separately billed professional charges
|
25% of the allowable charges
|
Figure 2.2-28 TRICARE Prime Cost-Shares for
Maternity - Birthing Center
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity - Birthing Center
(CY 2018), In-Network
|
$0
|
$0
|
$60
|
$60
|
|
Maternity - Birthing Center
(CY 2018), Out-of-Network
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency
care
|
Figure 2.2-29 TRICARE Select Cost-Shares
for Maternity - Birthing Center
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity - Birthing Center
(CY 2018), In-Network
|
$25
|
$25
|
20% of the allowable charge
|
$95
|
|
Maternity - Birthing Center
(CY 2018), Out-of-Network
|
$25
|
20% of the allowable charge
|
25% of the allowable charge
|
25% of the allowable charge
|
Figure 2.2-30 TRICARE Prime Cost-Shares for
Maternity - Home Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity - Home Delivery (CY
2018), In-Network
|
$0
|
$0
|
$20/$30
|
$20/$30
|
|
Maternity - Home Delivery (CY
2018), Out-of-Network
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency care
|
POS charges may apply to non-emergency
care
|
Figure 2.2-31 TRICARE Select Cost-Shares
for Maternity - Home Delivery
|
|
ADFM
|
Retiree
|
|
Group A
|
Group B
|
Group A
|
Group b
|
|
Maternity - Home Delivery (CY
2018), In-Network (primary care cost-share/specialty care cost-share)
|
$27/$34
|
$15/$25
|
$35/$45
|
$25/$40
|
|
Maternity - Home Delivery (CY
2018), Out-of-Network
|
20% of the allowable charge
|
20% of the allowable charge
|
25% of the allowable charge
|
25% of the allowable charge
|
2.7.16 Newborn
Care
Effective for all inpatient
admissions occurring on or after October 1, 1987, separate claims
must be submitted for the mother and newborn. The cost-share for
inpatient claims for services rendered to a beneficiary newborn
is determined as follows:
2.7.16.1 Same newborn date of birth
and date of admission. For care where a cost-share is determined
on a per diem basis, the cost-share shall be calculated in accordance
with this section; however, the number of days shall be reduced
by three.
2.7.16.2 Different newborn date of birth
and date of admission. The cost-share shall be applied to all days
in an inpatient stay.
2.8 Cost-Shares and Deductibles:
Former Spouses
2.8.1 Deductible.
In accordance with the FY 1991 Appropriations and Authorization
Acts, Sections 8064 and 712 respectively, beginning April 1, 1991,
an eligible former spouse shall pay 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 fiscal year (effective January 1, 2018, in any
one calendar year). 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 will
retain a legal familial relationship with the member or former member
and shall be included 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 (effective January 1,
2018, in any calendar year).
2.8.2 Cost-Share.
An eligible former spouse shall pay cost-sharing
amounts identical to those required for beneficiaries other than
ADFMs.
2.9 Cost-Share
Amount
Under
discounted rate agreements. In cases where the cost-share is calculated
as a percentage rather than a fixed amount, the percentage shall
be applied to (after duplicates and non-covered
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.
If the contractor learns that the participating provider has billed
a beneficiary for a greater cost-share amount, based upon the
provider’s usual billed charges, the contractor shall notify the
provider that such an action is a violation of the provider’s signed
agreement.
2.10 Exceptions
2.10.1 Inpatient Cost-Share: Applicable
To Each Separate Admission
On or after January 1, 2018,
for TRICARE Select Group A ADFMs only, a separate cost-share amount
is applicable to each separate beneficiary for each inpatient admission
EXCEPT:
2.10.1.1 Any readmission to an acute
care hospital which is not more than 60 days from the date of the
last inpatient discharge shall be treated as one inpatient confinement
with the last admission for cost-share amount determination.
2.10.1.2 Certain heart and lung hospitals
are excepted from cost-share requirements. See
Chapter 1, Section 27, entitled “Legal Obligation
To Pay”.
2.10.2 Inpatient
Cost-Share: Maternity Care
All admissions related to a
single maternity episode shall be considered one confinement regardless
of the number of days between admissions. For ADFMs, the cost-share
shall be applied to the first institutional claim received.
2.10.3 See
Section 6 for
waivers of cost-shares and deductibles.