1.0 APPLICABILITY
The policy is mandatory for
reimbursement of services provided by either network or non-network
providers. However, alternative network reimbursement methodologies
are permitted when approved by the Defense Health Agency (DHA) and
specifically included in the network provider agreement.
3.0 POLICY
3.1 A supplemental
insurance plan is a health insurance policy or other health benefit
plan offered by a private entity to a TRICARE beneficiary, that
primarily is designed, advertised, marketed, or otherwise held out
as providing payment for expenses incurred for services or items
that are not reimbursed under TRICARE due to program limitations,
or beneficiary liabilities imposed by law. TRICARE recognizes two
types of supplemental insurance plans; general indemnity plans,
and those offered through a direct service Health Maintenance Organization
(HMO).
3.2 An indemnity supplemental insurance
plan must meet all of the following criteria:
3.2.1 It provides
insurance coverage, regulated by state insurance agencies, which
is available only to beneficiaries of TRICARE.
3.2.2 It is premium-based and all
premiums relate only to TRICARE supplemental coverage.
3.2.3 Its benefits are limited to
non-covered services, to the deductible and cost-share portions
of the predetermined allowable charges, and to amounts exceeding
the allowable charges for covered services.
3.2.4 It provides reimbursement by
making payment directly to the TRICARE beneficiary or to the participating
provider.
3.2.5 It does not operate in a manner
which results in lower deductibles or cost-shares than those imposed by
law, or that waives the legally imposed deductibles or cost-shares.
3.3 A supplemental insurance plan
offered by an HMO must meet all of the following criteria:
3.3.1 The HMO must be authorized
and must operate under relevant provisions of state law.
3.3.2 The HMO supplemental plan must
be premium-based and all premiums must relate only to TRICARE supplemental
coverage.
3.3.3 The HMO’s benefits, above those
which are directly reimbursed by TRICARE, must be limited predominantly
to services not covered by TRICARE and TRICARE deductible and cost-share
amounts.
3.3.4 The HMO must provide services
directly to TRICARE beneficiaries through its affiliated providers
who, in turn, are reimbursed by TRICARE.
3.3.5 The HMO’s
premium structure must be designed so that no overall reduction
in the amount of the beneficiary deductibles or cost-shares will
result.