3.1 Through
December 31, 2017, TRICARE offers beneficiaries three health care
options:
3.1.1 TRICARE Prime Plan
Beneficiaries who enroll in TRICARE
Prime are assigned or select a Primary Care Manager (PCM). A PCM is
a provider of primary care, who furnishes or arranges for all health
care services required by the Prime enrollee. Market/Military Medical Treatment
Facility (MTF) Directors have the authority
and responsibility to set priorities for enrollment to Market/MTF PCMs.
When a Market’s/MTF’s primary
care capacity is full, civilian PCMs, who are all part of the contractor’s
network, are available to provide care to patients.
3.1.1.1 Expanded benefits. As enrollees
of Prime, patients receive certain clinical preventive services
that are provided without cost-share for the patient.
3.1.1.2 Reduced cost. Prime enrollees’
cost-share for civilian services is substantially reduced from that
which is applicable under TRICARE Extra and TRICARE Standard. In
addition, when a TRICARE Prime enrollee is referred to a non-participating
provider, the enrollee is only responsible for the copayment amount,
but not for any balance billing amount by the non-participating
provider.
3.1.2 TRICARE
Extra Plan
Beneficiaries
who do not enroll in Prime may still benefit from using the providers
in the contractor’s network where possible. On a case by case basis,
beneficiaries may participate in TRICARE Extra by receiving care
from a network provider. The beneficiary will take advantage of
the reduced charges under Extra and a reduction in cost-shares.
Covered services are the same as under TRICARE Standard. This option
is terminated as of December 31, 2017 and replaced by TRICARE Select.
3.1.3 TRICARE Standard Plan
The TRICARE Standard plan is
a fee-for-service program. This option is terminated as of December
31, 2017 and replaced by TRICARE Select.
3.2 Beginning January 1, 2018,
the TRICARE program consists of three options: TRICARE Prime, TRICARE
Select, and TRICARE For Life (TFL). See 10 United States Code (USC)
1072(7).
3.2.1 TRICARE Prime Plan
TRICARE Prime is a Health Maintenance
Organization (HMO)-like program. It generally features use of MTFs
and substantially reduced out-of-pocket costs for authorized care
provided outside MTFs. Beneficiaries generally agree to use MTFs
and designated civilian provider networks and to follow certain
managed care rules and procedures. Beneficiaries who enroll in TRICARE
Prime are assigned or select a PCM. A PCM is a provider of primary
care, who furnishes or arranges for all health care services required
by the Prime enrollee. Market/MTF Directors have
the authority and responsibility to set priorities for enrollment
to Market/MTF PCMs.
When a Market’s/MTF’s primary
care capacity is full, civilian PCMs, who are all part of the contractor’s
network, are available to provide care to patients.
3.2.2 TRICARE Select Plan
TRICARE Select is a self-managed,
Preferred Provider Organization (PPO) program. It allows beneficiaries
to use the TRICARE civilian provider network, with reduced out-of-pocket
costs compared to care from non-network providers, as well as military
facilities (where they exist and when space is available). Similar
to the long-operating “TRICARE Extra” and “TRICARE Standard” plans,
which this replaces, a major feature of TRICARE Select is that enrollees
will not have restrictions on their freedom of choice with respect
to health care providers. TRICARE Select is based primarily on 10
USC 1075 (as added by Section 701 of National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 2017 and 10 USC 1097.
3.2.3 TFL Plan
TFL is the Medicare wraparound
coverage plan under 10 USC 1086(d).
3.3 Eligibility for TRICARE
3.3.1 Active Duty Eligibility
All active duty members are
considered TRICARE Prime. They must, however, take action to be
enrolled in Prime, and be assigned to a PCM (see the TRICARE Operations
Manual (TOM) for PCM provisions under the TRICARE Prime Remote (TPR)
program).
3.3.2 Non-Active
Duty Eligibility
All individuals
entitled to civilian health care under 10 USC Sections 1079 or 1086,
are eligible for TRICARE. Beginning January 1, 2018, beneficiaries
other than TFL beneficiaries must enroll in a TRICARE plan to receive
care outside the Direct Care (DC) only system. Non-active duty individuals,
commonly referred to as “TRICARE eligibles”, include the spouse
and children of active duty personnel, retirees and their spouses
and children, and survivors.
Note: This group also includes former
spouses as defined in 10 USC Section 1072(2). Not included are those
individuals who are entitled to care in the DC system, on a space
available basis, but ordinarily are not entitled to civilian care,
such as family member parents and parents-in-law.
3.3.3 TFL
Pursuant to Section 712 of
the NDAA for FY 2001, Medicare eligible beneficiaries based on age,
whose TRICARE eligibility is determined by 10 USC Section 1086,
are eligible for Medicare Part A, and those who are enrolled in
Medicare Part B, are eligible for the TRICARE benefit effective
October 1, 2001. These beneficiaries are not eligible to enroll
in TRICARE Prime. TFL beneficiaries older than age 65 cannot enroll
in TRICARE Prime (exception for grandfathered Uniformed Services
Family Health Plan (USFHP) enrollees). Retirees and their family
members under age 65 who have Medicare coverage due to disability
or with end stage renal disease can enroll in TRICARE Prime if they
have Medicare Part B. Their Prime enrollment fees are waived if
they have Part B coverage. Retirees, dependents, and survivors with
any Medicare coverage at any age are not eligible to enroll in TRICARE
Select because they are excluded from the “Retired Category” for
TRICARE Select as defined in 10 USC 1075(b)(1)(B).
3.3.4 Supplemental Health Care Program
(SHCP) and TPR Program
See the
TOM,
Chapters 16 and
17.
3.3.5 Non-DoD TRICARE Eligibles
TRICARE eligibles sponsored
by non-DoD uniformed services (the Public Health Service (PHS),
the U.S. Coast Guard (USCG), and the National Oceanic and Atmospheric
Administration (NOAA)) are eligible for TRICARE and may enroll in
TRICARE Prime or TRICARE Select (beginning January 1, 2018).
3.3.6 North Atlantic Treaty Organization
(NATO) And Partnership For Peace (PfP) Beneficiaries
The Department of Defense equates
foreign military members and family members from PfP countries the
same as those from NATO Status of Forces Agreement (SOFA) countries,
in terms of access to outpatient medical and dental care from DoD
medical and dental treatment facilities, and access to TRICARE Select
(TRIARE Standard before January 1, 2018) civilian care. A current
list of NATO SOFA countries is at:
https://www.nato.int/cps/ie/natohq/topics_52044.htm.
A current list of NATO PfP countries is at:
https://www.nato.int/cps/en/natohq/51288.htm.
3.3.6.1 NATO or PfP ADSM
As specified in applicable
SOFAs, active duty members of the armed forces of NATO and PfP nations qualify
for TRICARE outpatient services in similar fashion as their U.S.
Armed Forces active duty counterparts. However, there is no coverage
for inpatient services under TRICARE. No enrollment in a TRICARE
plan is required or authorized. As such contractors shall not use
the government furnished web-based enrollment system/application
to determine eligibility. See the TOM,
Chapter 17, Section 3, and TRM,
Chapter 4, Sections 2 and
4 for more information.
3.3.6.2 NATO or PfP Family Members
Family members of active duty
members of the armed forces of NATO and PfP nations are only eligible for
outpatient care under TRICARE; there is no coverage for inpatient
services under TRICARE. Effective January 1, 2018, TRICARE Select
Group B cost-shares for Active Duty Family Members (ADFMs) apply. Prior
to January 1, 2018, TRICARE Standard/Extra cost-shares for ADFMs
apply. No enrollment in a TRICARE plan is required or authorized.
As such, contractors shall not use the government furnished web-based
enrollment system/application to determine eligibility. See TOM,
Chapter 17, Section 3; TRM,
Chapter 2, Section 2, and
Chapter 4, Sections 2 and
4; and TRICARE Systems Manual (TSM),
Chapter 2, Addendum L for more information.
3.3.7 Enrollment
Starting in calendar year 2018,
beneficiaries other than active duty members and TFL beneficiaries need
to elect to enroll in TRICARE Select or TRICARE Prime in order to
be covered by the private sector care portion of TRICARE. Enrollment
will be done during an open season period prior to the beginning of
each plan year, which operates with the calendar year. An enrollment
choice will be effective for the plan year. As an exception to the
open season enrollment rule, enrollment changes can be made during the
plan year for certain Qualifying Life Events (QLEs), such as a change
in eligibility status, marriage, divorce, birth of a new family
member, relocation, loss of Other Health Insurance (OHI), or other
events. Beneficiaries eligible to enroll in TRICARE Prime or TRICARE
Select plans who do not enroll or fail to qualify to maintain their
TRICARE Prime or TRICARE Select enrollment status no longer have
coverage under the TRICARE Program (including the TRICARE retail
pharmacy and Mail Order Pharmacy (MOP) programs), and may not re-enroll
until the following annual open season enrollment period or until
the sponsor or an eligible family member experiences a QLE, whichever
comes first. Such beneficiaries eligible to enroll in TRICARE Prime
or TRICARE Select do not lose any statutory entitlement to space-available
care in Markets/MTFs.
Note: Included in all of the TRICARE
benefit packages is a retail pharmacy network and a mail service
pharmacy program. Beneficiaries must be enrolled to a plan to receive
pharmacy services outside the DC system.
3.4 Administrative Policy
3.4.1 Benefit Policy
3.4.1.1 Benefit policy applies to the
scope of services and items which may be considered for cost-sharing
by the TRICARE within the intent of the 32 CFR 199.
3.4.1.2 The
current edition of the American Medical Association’s (AMA’s) Physicians’
Current Procedural Terminology (CPT) is incorporated by reference
into this Manual to describe the scope of services potentially allowable
as a benefit, subject to explicit requirements, limitations, and
exclusions, in this Manual or in the 32 CFR 199.
3.4.1.3 Procedures listed in the CPT
and the Healthcare Common Procedure Coding System (HCPCS) may be
cost-shared only when the procedure is “appropriate medical care”
and is
“medically or psychologically necessary”
and is
not “unproven” as defined in the
32 CFR 199.4(g)(15), and the procedure is
not explicitly excluded in the TRICARE program.
3.4.2 Program Policy
Program Policy applies to beneficiary
eligibility, provider eligibility, claims adjudication, and quality assurance.
Program policy implementation instructions are found in the TSM
and the TOM.
3.4.3 Any benefit or program administration
issue for which benefits or program operation policy guidance is
required, or when TRICARE policy is silent on an issue, the contractor
shall describe in writing and submit to the Team Chief, MB&RD,
Defense Health Agency (DHA).
3.4.4 Reimbursement Policy
3.4.4.1 Reimbursement policy sets forth
the payment procedures used for reimbursing TRICARE claims. The
related implementation instructions for these payment procedures
are found in the TSM and the TOM.
3.4.4.2 The TRM provides the methodology
for pricing allowable services and items and for payment to specific
categories and types of authorized allowable services and items
and for payment to specific categories and types of authorized providers.
These methods allow the contractor to price and render payment for
specific examples of services or items which are not explicitly
addressed in the Manual but which belong to a general category or
type which is addressed in the Manual.
3.5 Administrative and Effective
Dates
3.5.1 Issuance
Date
The date located on the first
page of each separate policy issuance. This is the date that the
issuance was initially issued by DHA.
3.5.2 Revision Date
The revision date is at the
bottom of each page that has been revised along with the change
number. This is the date that DHA changed the issuance in any way.
Each time an issuance is changed, the revised page and/or issuance
is given a change number. The revision date and the change number together
identify a unique version of the issuance on a specific subject.
3.5.3 Effective Date
A date within the body of the
text of an issuance which establishes the specific date that a policy
is to be applied to benefit adjudication or in program administration.
An effective date may be earlier than the issuance or revision date.
This date is explicit (e.g., Effective Date: January 1, 2004). The
policy effective date takes precedence over the issuance date and
the revision date. In the absence of an effective date the policy
or instruction is considered to have always been applicable because
the newly published policy or instruction confirms the application
of existing published program requirements.
3.5.4 Implementation Date
The implementation date of
a policy or instruction is not noted in the issuance as this date
is determined by the terms of the contract modification between
DHA and the contractor. Unless otherwise directed by DHA, contractors
are not to identify finalized claims for readjudication under revised
or new policy. However, the contractor shall readjudicate any denied
claim affected by the policy that is brought to the contractor’s
attention by any source. Pending claims and denied claims in reconsideration
shall be adjudicated using the current applicable policy.