1.3.1 Deductible Amount: Outpatient
Care
1.3.1.1 Active Duty Sponsor in Pay
Grade E-4 or Below
1.3.1.1.1 Deductible, Individual: The
contractor shall charge each beneficiary for the first fifty dollars
($50.00) of the allowable amount on claims for care provided in
the same FY prior to January 1, 2018.
1.3.1.1.2 Deductible, Family: The contractor
shall not charge a total deductible amount for all members of a
family with the same sponsor during one FY more than one hundred
dollars ($100.00) for claims of care provided prior to January 1,
2018.
1.3.1.2
All
TRICARE Beneficiaries Except Family Members of Active Duty Sponsors
in Pay Grade E-4 or Below
1.3.1.2.1 Deductible, Individual: The
contractor shall charge each beneficiary for the first $150.00 of
the allowable amount on claims for care provided in the same FY
prior to January 1, 2018.
1.3.1.2.2 Deductible, Family: The contractor
shall not charge a total deductible amount for all members of a
family with the same sponsor during one FY more than $300.00 for
claims of care provided prior to January 1, 2018.
1.3.1.3 TRICARE-Approved Ambulatory
Surgery Centers (ASCs), Birthing Centers (BCs), or Partial Hospitalization
Programs (PHPs)
1.3.1.3.1 TRICARE-Approved ASCs, BCs,
or PHPs. The contractor shall not apply a deductible to allowable
amounts for services or items rendered to ADFMs. For family members
of active duty members of the armed forces of NATO/PfP foreign nations
who are eligible for outpatient care under the TRICARE Program,
see
paragraph 1.1.5 for deductible and cost-share
information.
1.3.1.3.2 Allowable
Amount Does Not Exceed Deductible Amount. If FY allowable amounts
(CY for services provided after December 31, 2017) for two or more
beneficiary members of a family total less than $100.00 (or $300.00
if
paragraph 1.3.1.2, applies), and no one beneficiary’s
allowable amounts exceed $50.00 (or $150.00 if
paragraph 1.3.1.2 applies),
neither the family nor the individual deductible has been met and
the contractor shall not pay toward the care.
1.3.1.3.3 In
the case of family members of an active duty member of pay grade
E-5 or above, with Persian Gulf conflict service who is, or was,
entitled to special pay for hostile fire/imminent danger authorized
by 37 USC 310, for services in the Persian Gulf area in connection
with Operation Desert Shield or Operation Desert Storm, the contractor
shall apply the deductible amount specified in
paragraph 1.3.1.2.
Note: The contractor shall apply
provisions of
paragraph 1.3.1.3.3, to family members of
Service members who were killed in the Gulf, or who died subsequent
to Gulf service; and to Service members who retired prior to October
1, 1991, after having served in the Gulf war, and to their family
members.
1.3.1.3.4 Adjustment of Excess. The contractor
shall adjust any amount paid in excess against the annual deductible
required under
paragraphs 1.3.1.3.2 and
1.3.1.3.3 for
any beneficiary identified under those paragraphs.
1.3.1.3.5 The contractor shall consider
the deductible amounts identified in this section as satisfied if
the catastrophic cap amounts identified in
Section 2 have
been met for the same FY (CY for claims of care provided after December
31, 2017) in which the deductible applies.
1.3.3 Cost-Share Amount
1.3.3.1 Outpatient
Care
1.3.3.1.1 The contractor shall apply
a 20 percent cost-share of the allowable amount in excess of the
annual deductible amount for ADFM outpatient care. The contractor
shall include the professional charges of an individual professional
provider for services rendered in a non-TRICARE-approved ASC or BC.
For family members of active duty members of the armed forces of
NATO/PfP foreign nations who are eligible for outpatient care under
the TRICARE Program per DEERS, see
paragraph 1.1.5.
1.3.3.1.2 Other Beneficiary. The contractor
shall apply a cost-share to outpatient care for other than active
duty and authorized NATO/PfP family member beneficiaries of 25 percent
of the allowable amount in excess of the annual deductible amount.
The contractor shall include: partial hospitalization for alcohol
rehabilitation; professional charges of an individual professional
provider for services rendered in a non-TRICARE-approved ASC.
1.3.3.2
Inpatient
Care
1.3.3.2.1 ADFM:
For services prior to October 3, 2016, except in the case of mental
health and Substance Use Disorder (SUD) services, ADFMs or their
sponsors are responsible for the payment of the first $25 of the
allowable institutional costs incurred with each covered inpatient
admission to a hospital or other authorized institutional provider,
or the daily charge the beneficiary or sponsor would have been charged
had the inpatient care been provided in a Military Treatment Facility
(MTF), whichever is greater. (Please reference daily rate chart
below.) For services on or after October 3, 2016, the contractor
shall apply the following chart to all services (to include mental
health and SUD services) for ADFMs or their sponsors.
Figure 2.1-1 MTF
Daily Charge Amounts
|
Period
|
Daily Charge
|
|
Use the daily charge (per diem
rate) in effect for each day of the stay to calculate a cost-share
for a stay which spans periods.
|
|
January 1, 2020
- December 31, 2020 (for ADFMs not enrolled in TRICARE Prime)
|
$19.55
|
|
January 1, 2021- December 31,
2021 (for ADFMs not enrolled in TRICARE Prime)
|
$20.15
|
|
January 1, 2022- December 31,
2022 (for ADFMs not enrolled in TRICARE Prime)
|
$20.75
|
|
January 1, 2023- December 31,
2023 (for ADFMs not enrolled in TRICARE Prime)
|
$21.30
|
|
January 1, 2024- December
31, 2024 (for ADFMs not enrolled in TRICARE Prime)
|
$22.30
|
1.3.3.2.2 Other
Beneficiaries: For services exempt from the Diagnosis Related Group
(DRG)-based payment system and the mental health per diem payment
system and services provided by institutions other than hospitals
(e.g., Residential Treatment Centers (RTCs)), the contractor shall
apply a cost-share of 25 percent of the allowable charges.
1.3.3.3
Cost-Shares:
Maternity
1.3.3.3.1 Determination. The contractor
shall determine maternity care cost-shares as follows:
1.3.3.3.1.1 Apply the inpatient cost-share
formula 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.
Note: Apply the inpatient cost-share
formula 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/MTF inpatient childbirth unit. The
contractor shall charge ADFMs a per diem (or a $25.00 minimum charge)
for an admission and shall not charge separate cost-share for them
for separately billed professional charges or prenatal or postnatal
care.
1.3.3.3.1.2 Apply the ambulatory surgery
cost-share formula 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.
1.3.3.3.1.3 Apply the outpatient cost-share
formula to maternity care which terminates in a planned childbirth
at home.
1.3.3.3.1.4 The contractor shall cost-share
otherwise covered medical services and supplies directly related
to “complications of pregnancy”, as defined in the Regulation, 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.
1.3.3.3.2 Otherwise authorized services
and supplies related to maternity care, including maternity related
prescription drugs, are cost-shared on the same basis as the termination
of pregnancy.
1.3.3.3.3 The contractor shall cost-share
claims for pregnancy testing on an outpatient basis when
the delivery is on an inpatient basis.
1.3.3.3.4 When the beneficiary delivers
in a professional office birthing suite located in
the office of a physician or certified nurse-midwife (which is not
an otherwise TRICARE-approved BC) the contractor shall adjudicate
the claim as an at-home birth.
1.3.3.3.5 The contractor shall cost-share
claims for prescription drugs provided on an outpatient
basis during the maternity episode but not directly related to the
maternity care on an outpatient basis.
1.3.3.3.6 Newborn cost-share. Effective
for all inpatient admissions occurring on or after October 1, 1987,
the contractor shall ensure separate claims are submitted for the
mother and newborn. The contractor shall cost-share for inpatient
claims services rendered to a beneficiary newborn as follows:
1.3.3.3.6.1 In a DRG hospital:
1.3.3.3.6.1.1 Same newborn date of birth
and date of admission:
• For ADFMs, the contractor shall
not charge a cost-share during the period the newborn is deemed enrolled
in TRICARE Prime.
• For newborn family members
of other than active duty members, unless the newborn is deemed enrolled
in TRICARE Prime, the contractor shall charge a cost-share the lower
of the number of hospital days minus three multiplied by the per
diem amount, OR 25 percent of the total billed charges (less duplicates
and DRG non-reimbursables such as hospital-based professional charges).
1.3.3.3.6.1.2 Different newborn date of birth
and date of admission:
• For ADFMs, the contractor shall
not charge a cost-share during the period the newborn is deemed enrolled
in TRICARE Prime.
• For all other beneficiaries,
the contractor shall apply a cost-share to all days in the inpatient
stay, unless the newborn is deemed enrolled in TRICARE Prime.
1.3.3.3.6.2 In DRG exempt hospital:
1.3.3.3.6.2.1 Same newborn date of birth
and date of admission:
• For ADFMs, the contractor shall
not charge a cost-share during the period the newborn is deemed enrolled
in TRICARE Prime.
• For family members of other
than active duty members, the contractor shall charge a cost-share
of 25 percent of the total allowed charges unless the newborn is
deemed enrolled in TRICARE Prime.
1.3.3.3.6.2.2 Different newborn date of birth
and date of admission:
• For ADFMs, the contractor shall
not charge a cost-share during the period the newborn is deemed enrolled
in TRICARE Prime.
• For family members of other
than active duty members, the contractor shall charge a cost-share
of 25 percent of the total allowed charges unless the newborn is
deemed enrolled in TRICARE Prime.
1.3.3.3.7 Maternity Related Care. The
contractor shall cost-share medically necessary treatment rendered
to a pregnant woman for a non-obstetrical medical, anatomical, or
physiological illness or condition as a part of the maternity episode
when:
• The treatment is otherwise
allowable as a benefit; and
• Treatment delay until after
the conclusion of the pregnancy is medically contraindicated; and
• The illness or condition is,
or increases the likelihood of, a threat to the life of the mother;
or
• The illness or condition may
cause, or increase the likelihood of, a stillbirth or newborn injury
or illness; or
• The usual course of treatment
is altered or modified to minimize a defined risk of newborn injury
or illness.
1.3.3.4
Cost-Shares:
DRG-Based Payment System
1.3.3.4.1 General
The contractor shall apply
these special cost-sharing procedures only to claims paid under
the DRG-based payment system for dates of service prior to January
1, 2018, and to all TFL claims before and after January 1, 2018.
1.3.3.4.2
TRICARE
Standard
1.3.3.4.2.1 Cost-shares for ADFMs. The
contractor shall charge ADFMs or their sponsors the first $25 of
the allowable institutional costs incurred with each covered inpatient
admission to a hospital or other authorized institutional provider,
or the amount the beneficiary or sponsor would have been charged
had the inpatient care been provided in an MTF, whichever is greater.
1.3.3.4.2.2 Cost-shares for beneficiaries
other than ADFMs.
1.3.3.4.2.2.1 The contractor shall charge
a cost-share the lesser of:
1.3.3.4.2.2.1.1 An
amount based upon a single, specific per diem amount, which shall
not vary regardless of the DRG involved. The following is the DRG
inpatient TRICARE Standard cost-sharing per diems for beneficiaries
other than ADFMs.
• For FY 2014, the daily rate
is $744.
• For FY 2015, the daily rate
is $764.
1.3.3.4.2.2.1.1.1 The contractor shall calculate
the per diem amount as follows:
• Determine the total allowable
DRG-based amounts for services subject to the DRG-based payment system
and for beneficiaries other than ADFMs during the same database
period used for determining the DRG weights and rates.
• Add in the allowance for Capital
and Direct Medical Education (CAP/DME) which have been paid to hospitals
during the same database period used for determining the DRG weights
and rates.
• Divide this amount by the total
number of patient days for these beneficiaries. This amount is the average
cost per day for these beneficiaries.
• Multiply this amount by 0.25.
In this way total cost-sharing amounts continue to be 25 percent
of the allowable amount.
• Determine any cost-sharing
amounts which exceed 25 percent of the billed charge (see
paragraph 1.3.3.4.2.2.1.2) and divide this
amount by the total number of patient days in
paragraph 1.3.3.4.2.2.1.1).
Add this amount to the amount in
paragraph 1.3.3.4.2.2.1.1. This is the per
diem cost-share to be used for these beneficiaries.
1.3.3.4.2.2.1.1.2 The contractor shall charge
the per diem amount for each actual day of the beneficiary’s hospital
stay which the DRG-based payment covers except for the day of discharge.
When the payment ends on a specific day because eligibility ends
on a short-stay outlier day, the contractor shall count the last
day of eligibility to determine the per diem cost-sharing amount.
For claims involving a same-day discharge which qualify as an inpatient
stay (e.g., the patient was admitted with the expectation of a stay
of several days, but died the same day) the contractor shall charge
a cost-share based upon a one-day stay. (The number of hospital
days contain one day in this situation.)
1.3.3.4.2.2.1.2 Twenty-five
percent of the billed charge. The contractor shall use billed charge
to include all inpatient institutional line items billed by the
hospital minus any duplicate charges and any charges which may be
billed separately (e.g., hospital-based professional services, outpatient
services). The net billed charges for the cost-share computation
include comfort and convenience items.
1.3.3.4.2.2.2 The contractor shall not charge
a cost-share exceeding the DRG-based amount.
1.3.3.4.2.2.3 Where the dates of service
span different FYs (or CY for dates of service after December 31,
2017), the contractor shall apply a per diem cost-share amount for
each year to the appropriate days of the stay.
1.3.3.4.3 TRICARE Extra
1.3.3.4.3.1 Cost-shares for ADFMs. The
contractor shall apply cost-sharing provisions for the same as those
for TRICARE Standard.
1.3.3.4.3.2 Cost-shares for beneficiaries
other than ADFMs. The contractor shall apply cost-sharing the same
as those for TRICARE Standard, except the per diem copayment is
$250.
1.3.3.4.4 TRICARE
Prime
The contractor
shall not apply a cost-share for ADFMs. For beneficiaries other
than ADFMs, the contractor shall charge a cost-share of the first
$25 of the allowable institutional costs incurred with each covered
inpatient admission to a hospital or other authorized institutional
provider; or, an $11 per diem rate, whichever is greater.
1.3.3.4.5 Maternity Services
See
paragraph 1.3.3.3, for the
cost-sharing provisions for maternity services.
1.3.3.5 Cost-Shares: Inpatient Mental
Health Per Diem Payment System
1.3.3.5.1 General. The contractor shall
apply these special cost-sharing procedures only to claims paid
under the inpatient mental health per diem payment system. For inpatient
claims exempt from this system, the contractor shall follow the
procedures in
paragraph 1.3.3.2 or
1.3.3.4.
1.3.3.5.2 Cost-shares for ADFMs. For
dates of service prior to October 3, 2016, inpatient cost-sharing
for mental health services is $20 per day for each day of the inpatient
admission. This $20 per day cost-share applies to admissions to
any hospital for mental health services, any RTC, any Substance Use
Disorder Rehabilitation Facility (SUDRF), and any PHP providing
mental health or SUD rehabilitation services. For TRICARE Prime
ADFMs cost-share is $0 per day. See
Addendum A for
further information.
1.3.3.5.3 For dates of service on or
after October 3, 2016 and ending on December 31, 2017, the contractor
shall apply inpatient cost-sharing for mental health services as
described in
paragraph 1.3.3.2.1. The contractor shall
apply cost-shares to admissions to any hospital for mental health
services, any RTC, and any inpatient/residential SUD detoxification
and rehabilitation program. For TRICARE Prime ADFMs, the contractor
shall apply a cost-share of $0 per day. See
Addendum A for
further information.
1.3.3.5.4 Cost-shares for beneficiaries
other than ADFMs.
1.3.3.5.4.1 Higher volume hospitals and
units. With respect to care paid for based upon a hospital specific
per diem, the contractor shall apply a cost-share of 25 percent
of the hospital specific per diem amount.
1.3.3.5.4.2 Lower
volume hospitals and units. For care paid for on the basis of a
regional per diem, the contractor shall apply a cost-share of the
lower of
paragraphs 1.3.3.5.4.2.1 or
1.3.3.5.4.2.2:
1.3.3.5.4.2.1 A
fixed daily amount multiplied by the number of covered days. The
fixed daily amount is 25 percent of the per diem adjusted so that
total beneficiary cost-share equals 25 percent of total payments
under the inpatient mental health per diem payment system. This
fixed daily amount is only applicable when the TRICARE Program is
first payer. DHA updates this fixed daily amount annually and posts
it on the DHA website at
http://www.health.mil/rates.
DHA will also furnish this fixed daily amount to the contractor.
The following fixed daily amounts are effective for services rendered
on or after October 1 of each FY.
• 2020 - $255 per day.
• 2021 - $261 per day.
• 2022 - $268 per day.
1.3.3.5.4.2.2 Twenty-five
percent of the hospital’s billed charges (less any duplicates).
1.3.3.5.5 Claims that span a period in
which two separate per diems exist. The contractor shall compute
the cost-share on the actual per diem in effect for each day of
care for claims subject to the inpatient mental health per diem
payment system that spans a period in which two separate per diems exist.
1.3.3.5.6 Cost-share whenever leave days
are involved. The contractor shall not charge for leave days when
such days are included in a hospital stay.
1.3.3.5.7 The contractor shall apply
inpatient cost-shares to claims for services that are provided during
an inpatient admission which are not included in the per diem rate
if the contractor cannot determine where the service was rendered
and the patient status 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 includes non-mental
health claims and mental health claims submitted by individual professional
providers rendering medically necessary services during the inpatient
admission.
1.3.3.6 Cost-Shares:
PHPs And Intensive Outpatient Program (IOPs)
1.3.3.6.1 For care rendered prior to
October 3, 2016, cost-sharing for partial hospitalization is on an
inpatient basis. The inpatient cost-share also applies to the associated
psychotherapy billed separately by the individual professional provider.
These providers shall identify on the claim form that the psychotherapy
is related to a partial hospitalization stay so the proper inpatient
cost-sharing is applied. The cost-share for ADFMs enrolled in TRICARE
Prime for inpatient mental health services is $0. For retirees and
their family members, the cost-share is 25 percent of the allowed
amount. Since inpatient cost-sharing is being applied, no deductible
is taken for partial hospitalization regardless of sponsor status.
The cost-share for ADFMs is taken from the PHP claim.
1.3.3.6.2 For care rendered on or after
October 3, 2016, the contractor shall apply outpatient cost-shares
for PHP and IOP services. The contractor shall also apply outpatient
cost-shares to associated psychotherapy billed separately by the
individual professional provider. The contractor shall ensure these
providers identify on the claim form that the psychotherapy is related
to PHP or IOP care so the contractor shall apply the proper outpatient
cost-share. Cost-shares for standard beneficiaries are in
paragraph 1.3;
cost-sharing requirements for TRICARE Prime beneficiaries are in
paragraph 1.2.
1.3.3.7
Cost-Shares:
Ambulatory Surgery
1.3.3.7.1 For non-TRICARE Prime ADFMs,
for all services reimbursed as ambulatory surgery, the contractor
shall charge a $25 cost-share on the facility claim. The contractor
shall not deduct a cost-share from a claim for professional services
related to ambulatory surgery. This applies whether the services
are provided in a freestanding ASC, a hospital outpatient department
or a hospital emergency room. So long as at least one procedure
on the claim is reimbursed as ambulatory surgery, the cost-share
shall be as ambulatory surgery as required by this section. For
family members of active duty members of the armed forces of NATO/PfP
foreign nations who are eligible for outpatient care under the TRICARE
Program per DEERS, see
paragraph 1.1.5.
1.3.3.7.2 Other Beneficiaries. Since
the cost-share for other beneficiaries is based upon a percentage
rather than a set amount, the contractor shall take the cost-share
from all ambulatory surgery claims. For professional services, the
contractor shall charge cost-share of 25 percent of the allowed
amount. For the facility claim, the contractor shall charge a cost-share
that is the lesser of:
1.3.3.7.2.2 Twenty-five percent of the
billed charges; or
1.3.3.7.2.3 Twenty-five percent of the
allowed amount as determined by the contractor.
1.3.3.7.2.4 The special cost-sharing provisions
for beneficiaries other than ADFMs ensures that these beneficiaries
are not disadvantaged by these procedures. In most cases, 25 percent
of the group payment rate will be less, but because there is some
variation within each group, 25 percent of billed charges may be
less in some cases. This ensures that the beneficiaries get the
benefit of the group payment rates when such rate are more advantageous,
but they are never disadvantaged by them. If there is no group payment
rate for a procedure, the cost-share is simply 25 percent of the
allowed amount.
1.3.3.8 Cost-Shares
and Deductible: Former Spouses
1.3.3.8.1 Deductible. In accordance with
the FY 1991 Appropriations and Authorization Acts, Sections 8064
and 712 respectively, beginning April 1, 1991, the contractor shall
charge an eligible former spouse the first $150.00 of the reasonable
costs/charges for otherwise covered outpatient services and supplies
provided in any one FY (CY for dates of service after December 31,
2017). 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 retain a legal
familial relationship with the member or former member and are included
in the member’s or former member’s family deductible. The contractor
shall not require the former spouse to 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 shall independently meet
the $150.00 deductible in any FY (CY for dates of service after
December 31, 2017).
1.3.3.8.2 Cost-Share. The contractor
shall charge an eligible former spouse cost-share amounts identical
to those required for beneficiaries other than ADFMs.
1.3.3.9 Cost-Share Amount: Under Discounted
Rate Agreements
Under
managed care, where the network provider agrees to a negotiated
(discounted) rate, the contractor shall base the cost-share upon
the following:
1.3.3.9.1 For non-institutional providers
providing outpatient care, and for institution-based professional
providers rendering both inpatient and outpatient care; the cost-share
(20 percent for outpatient care to ADFMs, 25 percent for care to
all others) is 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.
1.3.3.9.2 For institutional providers
subject to the DRG-based reimbursement methodology, the cost-share
for beneficiaries other than ADFMs is the LOWER OF EITHER:
• The single, specific per diem
supplied by DHA after the application of the agreed upon discount rate;
OR
• Twenty-five percent of the
billed charge.
1.3.3.9.3 For institutional providers
subject to the Mental Health Per Diem Payment System (high volume
hospitals and units), the cost-share for beneficiaries other than
ADFMs is 25 percent of the hospital per diem amount after it has
been adjusted by the discount.
1.3.3.9.4 For institutional providers
subject to the Mental Health per diem payment system (low volume
hospitals and units), the cost-share for beneficiaries other than
ADFMs is the LOWER OF EITHER:
• The fixed daily amount supplied
by DHA after the application of the agreed upon discount rate; OR
• Twenty-five percent of the
billed charge.
1.3.3.9.5 For RTCs, the cost-share for
other than ADFMs is 25 percent of the TRICARE rate after it has
been adjusted by the discount.
1.3.3.9.6 For institutions and for institutional
services being reimbursed based upon the TRICARE-determined reasonable
costs, the cost-share for beneficiaries other than ADFMs is 25 percent of
the allowable billed charges after it has been adjusted by the discount.
Note: For all inpatient care for
ADFMs, the cost-share continues to be either the daily charge or $25
per stay, whichever is higher. There is no change to the requirement
that the ADFM’s cost-share is applied to the institutional charges
for inpatient services. 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. (Also see
paragraph 1.3.3.4.) For TRICARE Prime ADFMs,
the cost-share is $0 for care provided on or after April 1, 2001.
1.3.3.10
Preventive
Services
1.3.3.10.1 The contractor shall not require
copayments or authorizations for the following preventive services
described in the TPM,
Chapter 7, Sections 2.1 and
2.5:
1.3.3.10.1.1 Colorectal
cancer screening.
1.3.3.10.1.2 Breast cancer screening.
1.3.3.10.1.3 Cervical cancer screening.
1.3.3.10.1.4 Prostate cancer screening.
1.3.3.10.1.5 Immunizations.
1.3.3.10.1.6 Well-child visits for children
under six years of age.
1.3.3.10.2 In addition to the services
listed in
paragraph 1.3.3.10.1, effective January 1,
2017, cost-shares are eliminated for the services listed in the
TPM,
Chapter 7, Section 2.1, paragraphs 1.1.1.1.2 and
1.1.5.1 through
1.1.5.12.
Effective January 1, 2018, cost-shares are eliminated for the services
listed in the TPM,
Chapter 7, Section 2.1, paragraph 1.1.5.13.
1.3.3.10.3 The contractor shall not require
a beneficiary to pay any portion of the cost of these preventive
services even if the beneficiary has not satisfied the deductible
for that year.
1.3.3.10.4 This waiver does not apply
to any TRICARE beneficiary who is a Medicare-eligible beneficiary.