1.0 DESCRIPTION
1.1 The National
Defense Authorization Act (NDAA) for Fiscal Years (FYs) 1988 and
1989 (Public Law 100-180) amended Title 10, United States Code (USC),
and established catastrophic loss protection for TRICARE beneficiary families
on a Government fiscal year FY basis (Calendar
Year (CY) beginning January 1, 2018). The law placed fiscal year FY limits
or catastrophic caps on beneficiary liabilities for deductibles
and cost-shares under the TRICARE Basic Program. The NDAA for FY
1993 (Public Law 102-484) amended Title 10, USC, and reduced the
catastrophic cap for beneficiaries other than Active Duty Family
Members (ADFMs). The NDAA for FY 2001 also amended Title 10, USC, and
further reduced the fiscal year catastrophic cap for beneficiaries
other than ADFMs from $7,500 to $3,000.
1.2 32
CFR 199.17, authorizes catastrophic loss protection for
TRICARE Prime beneficiary families on a one-year enrollment period
basis in addition to the protection on
a fiscal year an
FY basis. The enrollment period shall coincide with
the
fiscal year FY (i.e.,
the beneficiary’s initial enrollment date is May 1 with the enrollment
expiration being October 1, all future enrollment periods will be
October 1 to October 1).
The enrollment year coincides
with the CY starting January 1, 2018.
2.0 POLICY
2.1 TRICARE
Standard and TRICARE Extra
2.1.1 Catastrophic
Cap For ADFMs
Under the
TRICARE Extra and TRICARE Standard, the maximum family liability
is $1,000 for deductibles and cost-shares based on allowed charges
for the services and supplies received in an fiscal
year FY.
2.1.2 Catastrophic Cap For All Other
Beneficiaries
For dates
of service on or after October 1, 2000, the fiscal
year FY (CY for dates of service after
December 31, 2017) cap is $3,000.
2.1.3 Cap is Met
For beneficiaries not enrolled
in TRICARE Prime, after the fiscal year FY
(CY for dates of service after December 31, 2017) catastrophic
cap is met, the TRICARE determined allowable amount shall be paid
in full for all covered services and supplies under TRICARE Standard
and TRICARE Extra for the remainder of the fiscal
year FY (CY for dates of service after
December 31, 2017).
2.2 TRICARE Prime
Under TRICARE Prime, in addition
to the catastrophic loss protection based on the
fiscal
year FY, TRICARE Prime enrollees
also have an enrollment year catastrophic cap.
As of
January 1, 2018, the protection is based on CY and enrollment year
as they are both the same. See Section 4 for
catastrophic loss protraction guidance for the beginning January
1, 2018.2.2.1 For TRICARE
Prime enrollees who are ADFMs,.
Out out-of-pocket expenses
accrue toward the $1,000 fiscal year FY catastrophic
cap. The enrollment year catastrophic cap is eliminated effective
December 31, 2017.
2.2.2 For TRICARE
Prime enrollees who are other than active duty personnel or ADFMs
(e.g., retirees, family members of retirees, survivors) out-of-pocket
expenses accrue toward a $3,000 per enrollment year catastrophic cap.
Out-of-pocket expenses also accrue toward the $3,000 fiscal
year FY (CY for dates of services after
December 31, 2017) catastrophic cap.
2.2.3 ForThrough
December 31, 2017, for TRICARE Prime enrollees that
retire other than the first of the month, enrollment in TRICARE
Prime shall be allowed with no break in coverage. The enrollment
anniversary date shall be determined using the existing “20th day
of the month” rule. Additional enrollment fees shall not be collected
for days between the effective enrollment date and the determined
enrollment anniversary date. Any out-of-pocket payments made by
the enrollee between the actual enrollment date and the enrollment
year start date (anniversary date) shall not be applied to the enrollment
year catastrophic cap. Out-of-pocket expenditures shall be applied
to the enrollment year and fiscal year catastrophic
cap as of the enrollment anniversary date.
2.2.4 Through
December 31, 2017, TRICARE Prime enrollees shall pay
no more applicable out-of-pocket expenses for the rest of the
fiscal
year FY once the
fiscal
year FY catastrophic cap is
met.
Note: For FY 2017 only, the
range was extended three months through December 2017 to accommodate transition
to CY. See Section 4 for catastrophic loss protraction
guidance for the plan years beginning January 1, 2018.
2.2.5 TRICARE Prime enrollees shall
pay no more TRICARE Prime copayments or enrollment fees for the
rest of the enrollment year once the enrollment year catastrophic
cap is met.
2.2.6 The following expenses
may
be are credited to a TRICARE
Prime beneficiary’s
fiscal year FY catastrophic cap:
• Enrollment fees,
• The outpatient and inpatient
cost-shares and copayments.
Note: Deductibles and cost-shares imposed
on services provided under the Point of Service (POS) option shall are not be creditable
to the enrollment/fiscal year catastrophic
cap.
2.3 Double
Coverage
For purposes
of catastrophic loss protection, the contractor shall
credit the full deductible and cost-share calculated
according to the TRICARE provisions shall be credited toward
meeting the applicable catastrophic cap (even when double coverage
exists). See an illustration below for an inpatient retiree with
other insurance who is not enrolled in TRICARE Prime:
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Total Amount Billed
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$8,169.11
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Total Amount Allowed
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8,169.11
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Cost-Share (25% of the Total
Amount Allowed)
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2,042.27
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Paid By Beneficiary To Provider
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0.00
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Paid By Other Health Insurance
(OHI)
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7,119.11
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Total TRICARE Payment
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1,050.00
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AMOUNT TO BE CREDITED TOWARD
CAP
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$2,042.27
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Note: NormalThe
contractor shall apply normal double coverage rules,
as provided in
Chapter 4, Section 1,
remain
in effect after the cap has been reached. The
contractor
shall not charge the beneficiary
shall
not have to pay a cost-share after the OHI has made
payment.
2.4 TRICARE Supplemental Plans
The contractor shall
ignore TRICARE supplemental plans which provide coverage
for deductibles, cost-shares, and sometimes for non-covered services,
will be ignored. As with double coverage, the contractor
shall credit the full deductible and cost-share shall
be credited toward meeting the catastrophic cap.
2.5 Multiple Family Situations
MultipleThe
contractor shall treat multiple family
situations-- (e.g.,
sponsor and new spouse and children live together, and sponsor’s
children from previous marriage live elsewhere) --shall
be treated as one family. In other words, for a divorced
and then remarried sponsor with two sets of family members, the
contractor shall combine their deductibles and cost-shares shall
be combined to meet the fiscal year catastrophic
cap.
Note: When a family’s sponsor changes, (e.g.,
a spouse divorces a sponsor and marries another active duty person),
then the contractor shall count only the
new sponsor’s liabilities for deductible and cost-shares in a
fiscal year shall count an FY (CY for
dates of service after December 31, 2017) toward meeting
the cap. In other words, this spouse cannot carry to the new family
those credits accumulated toward the cap under the previous sponsor.
2.6 Former Spouses
Any The
contractor shall treat any TRICARE unremarried eligible
former spouse will be treated as an
“other than ADFM.” For the purpose of determining the catastrophic
cap, the contractor shall treat a former
spouse will be treated as an independent
family and must independently the
former spouse shall meet the catastrophic cap independently.
2.7 Change of Sponsor Status
A change in aWhen
the sponsor’s duty status will have the
following effects on application of changes,
the contractor shall apply the following to the catastrophic
cap.
2.7.1 Claims Subject To The TRICARE
Diagnosis
Related Group (DRG
)-Based Payment
System
2.7.1.1 When the status changes during
a beneficiary’s inpatient stay, the contractor shall
apply the appropriate catastrophic cap shall
apply to that stay according to the beneficiary’s
cost-sharing status for the stay. Effective for services provided
after midnight of the day of discharge from the hospital, the contractor
shall base the catastrophic cap shall
be based on the sponsor’s current status.
2.7.1.2 When the status changes at any
time other than during a beneficiary’s inpatient stay, the contractor shall
apply the appropriate catastrophic cap (according to
the sponsor’s current duty status) shall apply for TRICARE eligible
families for the remaining fiscal year FY
(CY for dates of service after December 21, 2017), (or
until the status changes again) effective for services provided
after midnight of the day the duty status changes.
2.7.1.3 When the status changes, the full contractor
shall credit all deductible and cost-shares credited toward paid
to meeting the previous family cap shall
be credited toward the new cap as the sponsor’s liabilities
in the same fiscal year FY
(CY dates of service after December 31, 2017). However, in no
case shall a change in when a sponsor’s
status changes from retired to active duty, result
in an adjustment to the contractor shall
not adjust previous claims, even if the aggregate cost-share
has exceeded the active duty cap.
2.7.2 Claims
Exempt From The TRICARE DRG-Based Payment System
When a sponsor’s duty status
changes, the contractor shall apply appropriate
cap (according to the sponsor’s current duty status) shall
apply for TRICARE eligible families for the remaining fiscal
year FY (CY dates of service after December
31, 2017) effective for services provided after midnight
of the day the duty status changes. The full contractor
shall credit all deductible and cost-shares credited paid toward
meeting the previous family cap shall be credited
toward to the new cap as the
sponsor’s liabilities in the same fiscal year FY
(CY dates of service after December 31, 2017).
2.8 Inpatient Care Spanning Two
Fiscal
Years FYsWhen the dates of inpatient care
span different fiscal years FYs
(CY dates of service after December 31, 2017), it is absolutely
necessary that the for accurate catastrophic
cap application be as accurate as possible.
If for a claim the ending date of care is in a different fiscal
year FY (CY dates of service after December
31, 2017) from the beginning date of care, the contractor
shall allocate the beneficiary cost-share amount shall
be allocated between the two fiscal
years periods based on upon the
dates of care. For the purpose of the catastrophic cap application
only, the contractor shall apply the following
provisions are applicable:
2.8.1 Cost-Share When Fixed Daily
Amount Is Known
When the
beneficiary cost-share is based on upon a
fixed daily amount (or when such amount can may accurately be
calculated), the contractor shall allocate the actual
daily cost-share amount shall be allocated between
the two fiscal years periods according
to the days of care received in each fiscal year period.
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Example: DRG claim involving per diem
cost-share amounts. Retiree admitted on September 26, 2005 [FY 2005] and
discharged on October 3, 2005 [FY 2006]:
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We know that effective October
1, 2005, the cost-share per diem for other than active
duty dependents ADFMs went
up from $512 to $535. We also know that no per diem cost-share amount shall
be is required for the day
of discharge.
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Step 1: CALCULATE
FY 2005 CATASTROPHIC CAP CREDIT
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FY 2005 care (from 09/26 through
09/30/2005)
FY 2005 cost-share per diem
FY 2005 catastrophic cap credit
[5 days x 512/day = $2,560.00]
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= 5 days
= $512/day
= $2,560.00
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Step 2: CALCULATE
FY 2006 CATASTROPHIC CAP CREDIT
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FY 2006 care (from 10/01 through
10/03/2005)
[excludes day of discharge]
FY 2006 cost-share per diem
FY 2006 catastrophic cap cost-share
credit [2 days X 535/day = $1,070.00]
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= 2 days
= $535/day
= $1,070.00
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2.8.2 Cost-Share
When Fixed Daily Amount Is NOT Known
When a fixed (or actual) daily
amount of cost-share is not known or cannot be accurately determined,
the contractor shall calculate the daily
cost-share amount shall be calculated by
proration, that is, by dividing the claim’s cost-share amount by
the number of days of care (not counting the day of discharge) and allocate the resulting
daily amount shall be allocated between
the two fiscal years periods according
to the days of care received in each fiscal year period.
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Example: Hospital claim involving a
cost-share amount that is 25% of the TRICARE-determined allowable charge.
Retiree admitted on September 29, 2005 [FY 2005] and discharged
on October 8, 2005 [FY 2006] with a TRICARE-determined allowable
charge of $10,000.00:
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Step 1: CALCULATE
TOTAL COST-SHARE AMOUNT
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25% of $10,000.00 allowable
charge
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= $2,500.00
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Step 2: CALCULATE
TOTAL DAYS OF CARE
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Care (from 09/29 through 10/08/2005)
[excludes day of discharge]
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= 9 days
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Step 3: CALCULATE
DAILY COST-SHARE AMOUNT
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$2,500.00 cost-share amount
÷ 9 days of care
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$277.78/day
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Step 4: CALCULATE
FY 2005 CATASTROPHIC CAP CREDIT
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FY 2005 care (from 09/29 through
09/30/2005)
FY 2005 catastrophic cap cost-share
credit [2 days x 277.78/day = $555.56]
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= 2 days
= $555.56
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Step 5: CALCULATE
FY 2006 CATASTROPHIC CAP CREDIT
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FY 2006 care (from 10/01 through
10/08/2005) [excludes day of discharge]
FY 2006 catastrophic cap cost-share
credit [7 days X 277.78/day = $1,944.46]
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= 7 days
= $1,944.46
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3.0 EXCEPTIONS
3.1 NoThe
contractor shall not offer catastrophic loss protection is
available for the North Atlantic Treaty Organization
(NATO)/Partnership for Peace (PfP) family members.
3.2 The contractor shall
not accrue Extended Care Health Option (ECHO) sponsor/beneficiary
liabilities shall not accrue toward meeting the
catastrophic cap.
3.3 BeneficiaryThe
contractor shall not count beneficiary costs for non-covered
services or any beneficiary payments above the TRICARE determined
allowable charge, shall not count toward meeting the
catastrophic cap.
3.4 For TRICARE
Prime enrollees, the contractor shall not cap POS
deductible and cost-share amounts do not have a catastrophic
cap.
4.0 EFFECTIVE DATES
4.1 The fiscal
year FY catastrophic cap is
$7,500 for beneficiaries other than ADFMs effective FY 1993. Effective
October 1, 2000 [FY 2001], the fiscal year FY catastrophic
cap is $3,000 for beneficiaries other than ADFMs.
4.2 The enrollment year catastrophic
cap is $3,000 for beneficiaries other than ADFMs who are enrolled
in TRICARE Prime effective November 1, 1995. It will
apply applies to out-of-pocket
expenses incurred on and after November 1, 1995.
4.3 Effective October 1, 1996, enrollment
fees accrue toward the fiscal year FY catastrophic
cap under TRICARE Prime.
4.4 Effective
October 1, 1996, the calculation for the enrollment period catastrophic
cap for ADFMs enrolled in TRICARE Prime is eliminated.
4.5 Effective January 1,
2018, the catastrophic cap is calculated on a CY basis.