1.0 POLICY
1.1 Existence
of Other Coverage
1.1.1 Double coverage consists of
medical benefits coverage by both TRICARE and another medical/hospital insurance,
medical service, or health plan (with the exception of Medicaid
and certain other programs identified by Defense Health Agency (DHA),
e.g., the Indian Health Service (IHS) and State Victims Assistance
Plans). Prior to payment of any claim for services or supplies rendered
to any TRICARE beneficiary, regardless of eligibility status, it must
be determined whether other coverage exists. If other coverage exists,
TRICARE coverage is available only as secondary payer, and only
after a claim has been filed with the other plan and a payment determination
issued. This must be done regardless of any provisions contained
in the other coverage. For example, a dependent child who is eligible
for TRICARE through his or her natural parent may also be eligible
for some other coverage through a step-parent. The step-parent’s
coverage is primary payer, regardless of any provision in that coverage
which provides that the natural parent’s coverage is primary.
1.1.2 A contractor
shall coordinate benefits and obtain the information regarding the
other insurance payment to determine what the TRICARE liability
is to assure that:
1.1.2.1 TRICARE beneficiaries receive
maximum benefits from their health coverage, but no more than they are
entitled to receive, and
1.1.2.2 The combined payments under
TRICARE and the double coverage plan do not exceed the total charges.
1.2 Last Pay Limitation
Except for certain situations
in which Medicare is the primary payer (see
Section 4), no
more can be paid as secondary payer than would have been paid in
the absence of other coverage. TRICARE, as secondary payor, cannot reimburse
charges for any services or supplies which are not otherwise covered
under the program. TRICARE benefits cannot be paid for services
received prior to TRICARE eligibility. The application of double
coverage provisions does not extend or add to the usual payment
amounts under TRICARE.
1.3 Lack
of Payment by Other Health Insurer
Amounts which have been denied
by the other coverage simply because the claim was not filed timely
with the other coverage or because the beneficiary failed to meet
some other requirement of coverage cannot be paid. If a statement
from the other coverage as to how much would have been paid had
the claim met the other coverage’s requirements is provided to the
contractor, the claim can be processed as if the other coverage
actually paid the amount shown on the statement. If no such statement
is received, the claim is to be denied.
1.4 Definitions
1.4.1 Insurance
Plan
1.4.1.1 An insurance plan is any plan
or program which is designed to provide compensation or coverage
for expenses incurred by a beneficiary for medical services and
supplies. It includes plans or programs for which the beneficiary
pays a premium to an issuing agent as well as those plans or programs
to which the beneficiary is entitled by law or as a result of employment
or membership in, or association with, an organization or group.
An insurance plan provided to a beneficiary as a result of his or
her status as a student (student insurance) is also included.
1.4.1.2 Not included are:
• So-called supplemental insurance
plans which, for all categories of beneficiaries, provide solely
for cash payment of deductibles, cost-shares, and amounts for non-covered
services due to program limitations or for which the enrollee is
liable (see
Chapter 1, Section 26); or
• Income maintenance programs
which provide cash payments for periods of hospitalization or disability, regardless
of the amount or type of services required or the expenses incurred.
These plans are not intended to actually pay for medical services,
but are intended only to supplement the beneficiary’s income during
a time of increased expenses, and perhaps lowered income. On the
other hand, a plan which varies its benefits depending on the care
received or the patient’s diagnosis would be considered health insurance
coverage as opposed to an income supplement and would be primary
payer to TRICARE. Any payment made directly to the provider of care
as opposed to the beneficiary can be assumed to be an insurance
plan and not an income supplement; or
• State Victims of Crime Compensation
Programs.
• Automobile liability/no fault
insurance which provide compensation for health and medical expenses
relating to a personal injury arising from the operation of a motor
vehicle.
1.4.2 Medical
Service Or Health Plan
1.4.2.1 A medical service or health
plan is any plan or program of an organized health care group, corporation
or other entity for the provision of health care to an individual
from plan providers, both professional and institutional. It includes
plans or programs for which the beneficiary pays a premium to an
issuing agent as well as those plans or programs to which the beneficiary
is entitled by law or as a result of employment or membership in,
or association with, an organization or group.
1.4.2.2 Not included are:
• Certain federal Government
programs which are designed to provide benefits to a distinct beneficiary population
and for which entitlement does not derive from either premium payment
or monetary contribution (e.g., Medicaid and Worker’s Compensation).
• Health care delivery systems
designed to provide benefits to a distinct beneficiary population
that require no premium payment or monetary contribution prior to
obtaining care and therefore are not considered either an insurance
plan, medical service or health plan. These include the Department
of Veterans Affairs (DVA)/Veterans Health Administration (VHA),
the Maternal and Child Health Program, the IHS, and entitlement
to receive care from the designated provider.
1.5 No Waiver of Benefit From Other
Insurer
Beneficiaries
may not waive benefits due from any plan which meets the above definitions.
If a double coverage plan provides, or may provide, benefits for
the services, a claim must be filed with the double coverage plan. Refusal
by the beneficiary to claim benefits from the other coverages must
result in a denial of TRICARE benefits. Benefits are considered
to be the services available. For example, if the other plan includes
psychotherapy as a benefit, but only by a psychiatrist, the beneficiary
cannot elect to waive this benefit in order to receive services
from a psychologist. For TRICARE for Life (TFL) claims, an exception
exists for mental health counselors and pastoral counselors as well
as for services received under a private contract (see
Section 4).
1.6 Beneficiary
Liability
In all
double coverage situations, a beneficiary’s liability is limited
by all TRICARE provisions. As a result, a provider cannot collect
from a TRICARE beneficiary any amount that would result in total
payment to the provider that exceeds TRICARE limitations. For example,
a beneficiary is not liable for any cost-sharing or deductible amounts required
by the primary payer, if the sum of the primary payer’s and payments
made by TRICARE are at least equal to 115% of the allowable amount
authorized by TRICARE for a nonparticipating provider. This is true
whether TRICARE actually makes any payment or not. This also applies
to claims from participating non-network providers and from network
providers. Because of the payment calculations, the provider usually
will receive payments from the primary payer and from TRICARE that
equal the billed charges. In those rare cases where this does not
occur, the provider cannot collect any amount from the beneficiary
that would result in payment that exceeds the allowable amount authorized
under TRICARE.
Note: It is important to note that
this paragraph addresses beneficiary liability and does not change
in any way the amounts the TRICARE Program will pay based on provisions
elsewhere in this chapter.
1.7 Claims
Processed Under the Diagnosis Related Group (DRG)-Based Payment
System or the Inpatient Mental Health Per Diem Payment System
When double coverage exists
on a claim processed under the DRG-based payment system or the inpatient
mental health per diem payment system, the payment cannot exceed
an amount that, when combined with the primary payment, equals the
lesser of the DRG-based amount, the inpatient mental health per
diem based amount, or the hospital’s charges for the services (including
any discount arrangements). Thus, when the DRG-based amount or the
inpatient mental health per diem based amount is greater than the
hospital’s actual billed charge, and the primary payer has paid
the full billed charge, no additional payment will be made under
TRICARE. Similarly, when the DRG-based amount or the inpatient mental
health per diem based amount is less than the hospital’s actual billed
charge, and the primary payer has paid the full DRG-based amount
or inpatient mental health per diem based amount, no additional
payment can be made. Nor can the hospital bill the beneficiary for any additional amounts
in these cases.
1.8 Claims
Processed Under The Reasonable Cost Method For Critical Access Hospitals
(CAHs)
When double
coverage exists on a claim processed under the reasonable cost method
for CAHs, the payment under TRICARE cannot exceed an amount that
when combined with the primary payment equals the lesser of the established
cap amount multiplied by the billed charges or 101% of reasonable
cost. The reasonable cost method for CAHs is the lesser of the established/determined
Cost-to-Charge Ratio (CCR) cap (reference
Chapter 15, Section 1 for
Fiscal Year (FY) inpatient and outpatient CCR cap) multiplied by
billed charges or 101% of reasonable costs [1.01 x (hospital-specific
CCR x billed charges)].
1.9
No
Legal Obligation to Pay
Payment
should not be extended for services and supplies for which the beneficiary
or sponsor has no legal obligation to pay; or for which no charge
would be made if the beneficiary was not an eligible TRICARE beneficiary. Whenever
possible, all double coverage claims should be accompanied by an
Explanation Of Benefits (EOB) from the primary insurer. If the existence
of a participating agreement limiting liability of a beneficiary
is evident on the EOB, payment shall be limited to that liability;
however, if it is not clearly evident, the claim shall be processed
as if no such agreement exists.
1.10 Claims
Processed Under The CCR Methodology for Sole Community Hospitals
(SCHs)
When double
coverage exists on a claim processed under the CCR methodology for
SCHs, the payment under TRICARE cannot exceed an amount that when
combined with the primary payment equals the lesser of billed charges,
negotiated rate, or the CCR methodology as described in
Chapter 14, Section 1.