TRICARE Manuals - Display Chap 2 Sect 7 (Change 67, Mar 27, 2023)

Beneficiary Liability

Chapter 2

Section 7

Temporary Waivers of Copayments and Cost-Shares (Including Deductibles) in Response to Coronavirus 2019 (COVID-19) Pandemic

Issue Date: December 24, 2020

Authority: 32 CFR 199.17(l)(3)(iii) and National Defense Authorization Act (NDAA) of Fiscal Year (FY) 2017, Section 718(d)

Revision: C-64, August 3, 2022

1.0 DESCRIPTION

This policy provides information on temporary waivers of copayments and cost-shares (including deductibles) in response to the COVID-19 pandemic.

2.0 POLICY

2.1 Waiver of Copayments and Cost-Shares (Including Deductibles) for Authorized Telemedicine Services Provided by Network Providers in Response to the COVID-19 Pandemic

Existing regulations require copayments and cost-sharing for telemedicine services to be the same as if the service was provided in person. TRICARE’s cost-shares and copayments are set by law. However, the NDAA FY 2017, Section 718(d) authorized the Secretary of Defense to reduce or eliminate copayments or cost-shares when deemed appropriate for covered beneficiaries in connection with the receipt of telemedicine services under the TRICARE Program.

2.1.1 The contractor shall waive copayments and cost-shares (including deductibles) for in-network telemedicine services for all otherwise-covered services delivered via telemedicine, not just those related to COVID-19. This applies to all TRICARE Prime and TRICARE Select beneficiaries in all geographic regions.

2.1.2 The TRICARE Program rules still apply. For example, the contractor shall still require TRICARE Prime beneficiaries to have a referral from their Primary Care Manager (PCM) for a specialty care visit; however, under this rule modification, the contractor shall not charge a copayment or cost-share for either the PCM visit or the specialty care visit (if performed via in-network telemedicine).

2.1.3 There are no changes to copayments and cost-shares for ancillary services, Durable Medical Equipment (DME), prescriptions, or other referrals or care that are ordered due to or result from the telemedicine service.

2.2 Waiver of Copayments and Other Cost-Sharing for Authorized COVID-19 Testing and Related Services in Response to the COVID-19 Pandemic

2.2.1 The TRICARE Program will waive copayments or other cost-sharing (including deductibles and Point-of-Service (POS) charges) for:

2.2.1.1 In vitro diagnostic (IVD) tests, including antibody or serology tests, that meet the requirements established under the Families First Coronavirus Response Act (FFCRA) as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The United States (US) Food and Drug Administration (FDA) remains responsible for oversight of these IVD tests. A test that meets the FFCRA and CARES Act criteria is one that:

2.2.1.1.1 Is approved, cleared, or authorized under section 510(k), 513, 515, or 564 of the Federal Food, Drug, and Cosmetic Act (21 United States Code (USC) 360(k), 360c, 360e, 360bbb-3).

2.2.1.1.2 The developer has requested, or intends to request, emergency use authorization under section 564 of the Federal Food, Drug, and Cosmetic Act (21 USC 360bbb-3), unless and until the emergency use authorization request under such section 564 has been denied or the developer of such test does not submit a request under such section within a reasonable timeframe.

2.2.1.1.3 Is developed in and authorized by a state that has notified the Secretary of Health and Human Services (HHS) of its intention to review tests intended to diagnose COVID-19.

2.2.1.1.4 Other tests that the Secretary determines appropriate in guidance.

Note: TRICARE Policy Manual (TPM), Chapter 12, Section 1.2, paragraph 1.2 permits coverage overseas when unique health care issues or challenges arise for services or supplies that are normally excluded. The lack of FDA regulated tests outside of the US is a unique situation permitting the overseas contractor to follow the established guidelines/standards of care for COVID-19 testing for the country, host-nation, and/or regional health authority (e.g., World Health Organization (WHO)), where the beneficiary is treated. The Assistant Secretary of Defense (Health Affairs) (ASD(HA)) has directed the Director, DHA to issue guidance to the contractor implementing the FFCRA, which includes the amendment added by the CARES Act. Therefore, under paragraph (1)(D) of Section 3201 of the CARES Act, tests approved by the overseas contractor under those established guidelines/standards are determined to be appropriate tests for purposes of granting waivers of cost-shares and copayments.

2.2.1.2 Services and supplies related to the furnishing or administration of an IVD test meeting the criteria of paragraph 2.2.1.1.

2.2.1.3 The evaluation of an individual at TRICARE-authorized provider office visits, Urgent Care Center (UCC) visits, or Emergency Room (ER) visits (to include covered telemedicine visits) to determine the need for such an IVD test listed in paragraph 2.2.1.1 when those visits result in an order for or administration of approved, cleared, or authorized SARS-CoV-2/COVID-19 IVD products.

2.2.2 Copayments, cost-shares, deductibles, and/or POS charges for services and supplies not related to the administration of or evaluation for the need for an IVD test listed in paragraph 2.2.1.1 apply, even if those services or supplies are administered at a visit that results in an IVD test listed in paragraph 2.2.1.1.

2.2.3 The contractor shall use its best business practices (including identifying evaluation and management visits, associated testing and utilizing the new International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code, U07.1, 2019-nCoV acute respiratory disease) in identifying those visits that resulted in an order for or administration of SARS-CoV-2/COVID-19 IVD products. Due to coding variances, it may not be possible to waive all copayments and cost-shares in real time for beneficiaries. Beneficiaries may be required to pay a copayment or cost-share at the provider’s office and receive reimbursement for services on or after the effective date. The contractor shall make a best-effort to ensure that this occurs as infrequently as possible.

2.2.4 The following are examples of how the contractor shall administer the cost-sharing and copayment waivers under this provision. These are only examples and are not all-inclusive:

Example 1: Patient visits a provider with flu-like symptoms. A flu test is administered and the patient tests positive. The provider does not order a SARS-CoV-2/COVID-19 IVD test. The contractor shall not waive copayments and cost-shares.

Example 2: Patient visits an out-of-network primary care provider with flu-like symptoms. A flu test is administered and the patient tests negative. The patient is referred for an FDA-authorized SARS-CoV-2/COVID-19 IVD molecular assay (not a serology test). Because the patient is diabetic, the physician orders a laboratory test for an A1C level check and the patient is evaluated for a diabetic ulcer. The out-of-network cost-share for the visit, the flu test, and the SARS-CoV-2/COVID-19 IVD test shall be waived. The contractor shall not waive cost-share for the out-of-network A1C test.

Example 3: Patient visits the ER with a broken leg. While evaluating the patient, the doctor identifies symptoms of COVID-19 and orders an FDA-authorized SARS-CoV-2/ COVID-19 IVD molecular assay (not a serology test). The contractor shall waive cost-share for the visit and the test, but the contractor shall not waive any cost-shares associated solely with the diagnosis and treatment of the broken leg (e.g., x-rays and casting of the leg, DME-related cost-shares for crutches).

Example 4: Patient visits an urgent care facility in Germany and is evaluated for COVID-19 symptoms. The doctor orders a COVID-19 IVD molecular assay (not a serology test), and a non-FDA-authorized IVD molecular assay is administered. The contractor shall waive cost-shares and copayments for the test or the urgent care visit if the test administered meets established guidelines/standards-of-care for COVID-19 testing in Germany.

Example 5: Patient visits a network provider with symptoms consistent with COVID-19 seeking an IVD test. The provider does not have access to an FDA approved IVD molecular assay. However, the provider does have access to an FDA approved and appropriately validated serology test that is designed to be very specific to SARS-CoV-2. The provider tests the patient using the serology test kit to determine if the patient has IgM antibodies which may indicate a current COVID-19 infection. The provider uses the test as the results may impact the medical management of the patient (e.g., determine if the patient needs to be hospitalized or to receive any available treatments or drugs for COVID-19). In this example, the test result is not the sole basis for diagnosis, but instead is used along with the patient’s medical history and symptoms that are consistent with SARS-CoV-2. The contractor shall waive the cost-share for the visit and the serology test.

2.2.5 The contractor shall ensure medical necessity requirements are met prior to covering COVID-19 serology tests and waiving their associated cost-shares and copayments (including deductibles). For example, if the serology testing may impact the medical management of the patient (as in the example above), it may be considered medically necessary and appropriate. Please note that guidance regarding the use of serology testing is continually evolving and publicly available from the Centers for Disease Control and Prevention (CDC) and the FDA. Unfortunately, there are several instances where COVID-19 serology tests are not medically necessary for the diagnosis or treatment of a beneficiary and are not covered by TRICARE. Examples of when these tests are not covered include, but are not limited to:

• Idle curiosity by an asymptomatic beneficiary who just wants to know if they may have had COVID-19 at some point in the past;

• To determine an employee’s ability to return to work;

• To determine a student’s ability to return to school;

• To determine a donor’s ability to donate blood or plasma; or,

• When conducted as part of epidemiological research, surveillance studies, or for other public health reasons.

3.0 TRICARE Encounter Data (TED) Records SUBMISSION

The contractor shall populate the Cost-Share, Copay, Deductible field with the amount the beneficiary would have paid had no waiver been granted and report Special Processing Code (SPC) = CC (Cost-Share, Co-Pay, Deductible Amount Reported-Waived (Effective 11/01/2019)) (TRICARE Systems Manual (TSM), Chapter 2, Section 2.8, Data Element 1-185 or 2-305).

4.0 EFFECTIVE DATES

4.1 March 10, 2020, for the waiver of copayments and cost-shares for telemedicine services for the TRICARE Overseas Program (TOP) contractor.

4.2 March 18, 2020, for the waiver of copayments and cost-shares for IVD tests for the detection of SARS-CoV-2 or the diagnosis of COVID-19.

4.3 May 12, 2020, for the waiver of copayments and cost-shares for telemedicine services.

5.0 EXPIRATION

5.1 For the waiver of copayments and cost-shares for telemedicine services in the US, these manual provisions terminate July 1, 2022 or upon expiration of the President’s national emergency for the COVID-19 outbreak, whichever occurs earlier. This termination applies in the United States and at all overseas locations.

5.2 Under section 319 of the Public Health Service (PHS) Act, a Public Health Emergency (PHE) declaration lasts until the Secretary of HHS declares the PHE no longer exists, or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary will extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist, and will terminate the declaration whenever he determines the PHE has ceased to exist. The manual provisions related to the waiver of copayments and cost-shares for IVD tests for the detection of SARS-CoV-2 or the diagnosis of COVID-19 in the United States terminate upon expiration of the COVID-19 PHE declared by the Secretary of HHS.

5.3 Unless otherwise specified in this section, for services provided outside the 50 US, District of Columbia, and US territories including the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands, these provisions expire upon conclusion of the COVID-19 pandemic, as determined by the ASD(HA).

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

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