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 apply a deductible for each beneficiary equal to
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 calculate the total deductible amount for all members of a family
with the same sponsor during one FY to not exceed one hundred dollars
($100.00) for claims for 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 apply a deductible for each beneficiary equal to
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 calculate the total applied deductible amount for all members
of a family with the same sponsor during one FY does not exceed
three hundred dollars ($300.00) for claims for care prior
to January 1, 2018.
1.3.1.3 TRICARE-Approved
Ambulatory Surgery Centers (ASCs), Birthing Centers, or Partial Hospitalization
Programs (PHPs)
1.3.1.3.1 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 TRICARE, see
paragraph 1.1.4 for deductible and cost-share
information.
1.3.1.3.2 Allowable
Amount Does Not Exceed Deductible Amount. If FY allowable amounts
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
will
have has been met and the
contractor shall not
reimburse for any TRICARE benefits 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
use apply the
deductible amount specified in
paragraph 1.3.1.2.
Note: The contractor shall apply
the 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.
For
any beneficiary identified The contractor
shall adjust/apply any amount paid in excess against the annual
deductible required under
paragraphs 1.3.1.3.2 and
1.3.1.3.3 who
paid any deductible in excess of the amounts stipulated, the contractor
shall adjust/refund any amount paid in excess against the annual
deductible required for any beneficiary
identified under those
same paragraphs.
1.3.1.3.5 The contractor shall
deem consider
the deductible amounts identified in this section to
be satisfied if the catastrophic cap amounts identified in
Section 2 are met for the same FY
(CY
for claims of care 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
cost-share for ADFM outpatient care equal to 20% of the allowable amount
in excess of the annual deductible amount.
This The
contractor shall include
s the
professional charges of an individual professional provider for
services rendered in a non-TRICARE-approved ASC or Birthing Center.
For family members of active duty members of the armed forces of
NATO/PfP foreign nations who are eligible for outpatient care under
TRICARE per DEERS, see
paragraph 1.1.4.
1.3.3.1.2 Other Beneficiary. The contractor
shall apply a cost-share for outpatient care for other than active duty
and authorized NATO/PfP family member beneficiaries equal to 25%
of the allowable amount in excess of the annual deductible amount.
This includes: partial hospitalization for alcohol rehabilitation
and 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 on or after October 3, 2016, theThe contractor
shall apply the following charges to all services (to include mental
health and SUD services) for ADFMs or their sponsors.
Figure 2.1-1 Uniformed
Services HospitalMilitary Medical Treatment
Facility (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.
|
|
October 1, 2017- September
30, 2018 (for ADFMs not enrolled in TRICARE Prime)
|
$18.60
|
|
October 1, 2018 - December
31, 2019 (for ADFMs not enrolled in TRICARE Prime)
|
$19.05
|
|
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
|
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 (i.e.g.,
Residential Treatment Centers (RTCs)), the contractor shall apply
a cost-share equal to 25% of the allowable charges.
1.3.3.3
Cost-Shares:
Maternity
1.3.3.3.1 Determination. The contractor
shall determine maternity care cost-share
s as
follows:
1.3.3.3.1.1 Apply the inpatient cost-share
formula to maternity care ending in childbirth in, or 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/Military Medical Treatment
Facility (MTF) inpatient
childbirth unit. The contractor shall charge ADFMs a per diem (or
a $25.00 minimum charge) for an admission and the contractor shall not
apply a separate cost-share 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 calendar 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 The contractor shall cost-share
otherwise authorized services and supplies related to maternity care,
including maternity related prescription drugs, 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 WhereWhen the
beneficiary delivers in a professional office birthing suite located
in the office of a physician or certified nurse-midwife (which is
not otherwise a TRICARE-approved birthing center) the contractor shall
adjudicate the delivery 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 the provider submits separate claims for the mother
and newborn. The contractor shall determine the cost-share for inpatient
claims for 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 apply 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 apply a cost-share
equal to the lower of the number of hospital days minus three multiplied
by the per diem amount, OR 25% 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 apply 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 apply 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 calculate the cost-share
based on 25% 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 apply 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 calculate a cost-share
based on 25% 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
• Delay of the treatmentTreatment
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 will may cause,
or increase the likelihood of, a stillbirth or newborn injury or
illness; or
• The usual course of treatment must
be 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 TRICARE For Life (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 a Uniformed
Service hospital 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 apply
a cost-share equal to the lesser of:
1.3.3.4.2.2.1.1 An
amount based
on upon a
single, specific per diem amount which
will shall not
vary regardless of the DRG involved. The DRG inpatient TRICARE Standard
cost-sharing per diems for beneficiaries other than ADFMs. The daily
rate is posted to the Defense Health Agency (DHA) website at
https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement.
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 will
be is the average cost per
day for these beneficiaries.
• Multiply this amount by 0.25.
In this way total cost-sharing amounts will continue
to be 25% of the allowable amount.
• Determine any cost-sharing
amounts which exceed 25% 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 apply 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 for determining to
determine the per diem cost-sharing amount. For claims
involving a same-day discharge which qualify as an inpatient stay
(i.e., the patient was admitted with the expectation of a stay of
several days, but died the same day) the contractor shall count
the charge a cost-share on based
upon a one-day stay. (The number of hospital days must contain
one day in this situation.)
1.3.3.4.2.2.1.2 Twenty-five
percent (25%) of the billed charge. The contractor shall use billed
charges, includes all inpatient institutional line items billed
by the hospital minus any duplicate charges and any charges which can 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 that exceeds the DRG-based amount under any circumstances.
1.3.3.4.2.2.3 Where the dates of service span
different FYs (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 ADFMs 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 provisions
for beneficiaries other than ADFMs is 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 apply a cost-share equal to the first $25 of the
allowable institutional costs incurred with each covered inpatient admission
to a hospital or other authorized institutional provider, or a
per diem rate of 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
not apply a 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, the contractor shall
apply an inpatient cost-share for mental health services equal to
$20 per day for each day of the inpatient admission. The contractor
shall apply this $20 per day cost-share 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, the contractor
shall apply a cost-share of $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
use apply the
inpatient cost-sharing for mental health services
is
that as described in
paragraph 1.3.3.2.1. The contractor shall
apply cost-share
s 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 on the basis of a hospital
specific per diem, the contractor shall apply a cost-share equal
to 25% 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 equal
to 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% of the per diem adjusted so that total
beneficiary cost-shares
will equal
s 25%
of total payments under the inpatient mental health per diem payment
system. DHA will update this fixed daily amount annually and
post
it on the DHA website at
http://www.health.mil/rates.
DHA will also furnish this fixed daily amount to the contractors.
The following fixed daily amounts are effective for services rendered
on or after October 1 of each FY.
• FY 2019
- $248 per day.
• FY 2020
- $255 per day.
• FY 2021
- $261 per day.
1.3.3.5.4.2.2 Twenty-five
percent (25%) of the hospital’s billed charges (less any duplicates).
1.3.3.5.5 Claims which span a period in
which two separate per diems exist. For 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 which spans a period
in which two separate per diems exist, the contractor
shall calculate the cost-share on the actual per diem in effect
for each day of care.
1.3.3.5.6 Cost-share whenever leave days
are involved. The contractor shall not apply a cost-share 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 as an inpatient
claim if the contractor cannot determine where the
service was rendered and the status of the patient status when
the service was provided.
1.3.3.5.8 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, the contractor shall apply an outpatient cost-share PHP IOP
claims. The contractor shall also apply inpatient cost-shares to
the associated psychotherapy billed separately by the individual
professional provider. The contractor shall ensure providers identify
on the claim form that the psychotherapy is related to a partial
hospitalization stay so the proper inpatient cost-sharing can be
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% of the allowed amount. Since inpatient
cost-sharing is being applied, no the contractor
shall not charge a deductible shall be
taken for partial hospitalization regardless of sponsor
status. The contractor shall take a cost-share
for ADFMs shall be taken from the PHP
claim.
1.3.3.6.2 For care rendered on or after
October 3, 2016, the contractor shall apply an outpatient cost-share PHP
IOP
claims services.
The contractor shall also apply outpatient cost-share
s to
the associated psychotherapy
services billed
separately by the individual professional provider. The contractor
shall ensure providers identify on the claim form that the psychotherapy
is related to PHP or IOP care so the
contractor can apply
the proper outpatient
cost-sharing can
be applied cost-share. Cost-shares
for TRICARE Standard beneficiaries
can be found 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.
The contractor shall apply a cost-share of $25 for all services reimbursed
as ambulatory surgery and shall assess it on the facility claim.
The contractor shall not deduct the 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 contractor shall cost-share the claim 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 TRICARE per DEERS, see
paragraph 1.1.4.
1.3.3.7.2 Other Beneficiaries. Since the
cost-share for other beneficiaries is based
on upon a
percentage rather than a set amount, the contractor shall
take
the cost-share
based on from all
ambulatory surgery claims. For professional services, the contractor
shall apply a cost-share equal to 25% of the allowed amount. For
the facility claim, the contractor shall apply a cost-share equal
to the lesser of:
1.3.3.7.2.1 Twenty-five percent (25%) of
the applicable group payment rate (see
Chapter 9, Section 1);
or
1.3.3.7.2.2 Twenty-five percent (25%) of
the billed charges; or
1.3.3.7.2.3 Twenty-five percent (25%) 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 will ensures that
these beneficiaries are not disadvantaged by these procedures. In
most cases, 25% of the group payment rate will be are less,
but because there is some variation within each group, 25% of billed
charges could be is less
in some cases. This will ensures that
the beneficiaries get the benefit of the group payment rates when they such
rates are more advantageous, but they will are never be disadvantaged
by them. If there is no group payment rate for a procedure, the
cost-share shall simply be is 25%
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 one hundred
and fifty dollars ($150.00) of
the reasonable costs/charges for otherwise covered outpatient services
and/or 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 the contractor
shall include them in the member’s or former member’s family deductible.
The contractor shall not require a former spouse cannot 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 must independently meet
the $150.00 deductible in any fiscal year FY
(CY for dates of service after December 31, 2017).
1.3.3.8.2 Cost-Share. The contractor
shall apply cost-sharing 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 there
is the network provider agrees to a
negotiated (discounted) rate agreed to by the network
provider, the contractor shall base the cost-share on 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 contractor shall
apply a cost-share equal to:
• Twenty percent (20%) for outpatient
care to ADFMs;
• Twenty-five percent (25%) for
care to all others) (after duplicates and noncovered 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 contractor shall
apply a cost-share for beneficiaries other than ADFMs equal to 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 (25%) 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). For beneficiaries other than ADFMs, the contractor shall
apply a cost-share equal to 25% 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). For beneficiaries other than ADFMs, the contractor shall
apply a cost-share equal to the LOWER OF EITHER:
• The fixed daily amount supplied
by DHA after the application of the agreed upon discount rate; OR
• Twenty-five percent (25%) of
the billed charge.
1.3.3.9.5 For RTCs, the cost-share for
other than ADFMs shall be is 25%
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 on the basis of the TRICARE-determined
reasonable costs. For beneficiaries other than ADFMs, the contractor
shall apply a cost-share equal to 25% of the allowable billed charges
after it has been adjusted by the discount.
1.3.3.9.6.1 For all inpatient care for
ADFMs. The contractor shall apply a cost-share either the daily
charge or $25 per stay, whichever is higher. There is no change
to the requirement to apply the ADFM’s cost-share to the institutional
charges for inpatient services.
1.3.3.9.6.2 The contractor shall notify the
provider that such an action is a violation of the provider’s signed agreement
if the contractor learns that the participating provider has billed
a beneficiary for a greater cost-share amount
, based
on the provider’s usual billed charges. (Also see
paragraph 1.3.3.4.)
For TRICARE Prime ADFMs, the contractor shall apply a cost-share
equal to $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 apply
copayments or require authorizations for the following preventive services
as 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, the contractor shall not apply cost-shares to the services
listed in the TPM,
Chapter 7, Section 2.1, paragraph 1.1.1.1.2 and
1.1.5 through
1.1.5.12.
Effective January 1, 2018, the contractor shall not apply cost-shares
to 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 charge
beneficiaries 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.