TRICARE beneficiaries who become
entitled to Medicare Part A, based on age, do not lose TRICARE eligibility
if they are enrolled in Medicare Part B. Special double coverage
procedures are used for these claims in order to minimize out-of-pocket
expenditures for these beneficiaries. These special procedures are
used for all claims for beneficiaries who are eligible for Medicare,
including active duty dependents who are age 65 and over as well
as those beneficiaries under age 65 who are eligible for Medicare
for any reason. (See the TRICARE Operations Manual (TOM),
Chapter
20, for information on TRICARE Medicare Eligible Program
(TMEP)). The following sections set forth the amounts that TRICARE
will pay if the beneficiary is covered by Medicare and TRICARE.
If a third coverage is involved, TRICARE will be last payer and
payments by the third coverage will reduce the amounts of TRICARE payment
that are set forth below. In all cases where TRICARE is the primary
payer, all claims processing requirements are to be followed. Additionally,
when a beneficiary becomes eligible for Medicare during any part
of his or her inpatient admission, the hospital claim shall be submitted
to Medicare first and TRICARE payment (using non-financially underwritten
funds) will be determined under the normal double coverage procedures.
1.3.1 Services That Are A Benefit
Under Both Medicare And TRICARE (See
paragraph 1.5 for Pharmacy Claims)
1.3.1.1 When Medicare makes a payment
for benefits also covered by TRICARE, the beneficiary will generally have
no out-of-pocket expense. For these claims TRICARE will resemble
a Medicare supplement. That is, the allowable amount under Medicare
will be used as the TRICARE allowable, and TRICARE payment will
equal the remaining beneficiary liability after Medicare processes
the claim without regard to any TRICARE deductible and cost-share
amounts that would otherwise be assessed. For example, if it is
the first claim of the year and the billed charge is $50 (which
is also the amount both Medicare and TRICARE allow on the claim),
Medicare will apply the entire amount to the Medicare deductible
and pay nothing. In this case, TRICARE will pay the full $50 so
that the beneficiary has no out-of-pocket expense. Similarly, if
Medicare pays an amount that is greater than what TRICARE normally
would allow for a network provider, TRICARE will still pay any Medicare
deductible and cost-sharing amounts, even if that represents payments
in excess of the normal TRICARE allowable amount.
Note: It is not required that the
contractor price these claims, since the Medicare allowable becomes
the TRICARE allowable, and TRICARE payment is based on the remaining
beneficiary liability. The contractor need only verify eligibility
and coverage in processing the claim. Contractors will not be required
to duplicate Medicare’s provider certification, medical necessity,
referral, authorization, and potential duplicate editing.
1.3.1.2 If
the service or supply is normally a benefit under both Medicare
and TRICARE, but Medicare cannot make any payment because the beneficiary
has exhausted Medicare benefits, TRICARE will make payment as the primary
payer assessing all applicable deductibles and cost-shares. For
example, TRICARE is primary payer for inpatient care beyond 150
calendar days.
1.3.1.3 If
the service or supply is normally a benefit under both Medicare
and TRICARE, but Medicare cannot make any payment because the beneficiary
receives services overseas where Medicare will not make any payment, TRICARE
will process the claim as a primary payer assessing any applicable
deductibles and cost-shares.
1.3.1.4 The contractor shall process
the claim without evidence of processing by Medicare, since the contractor
knows that Medicare cannot make any payment on such claims. Even
though Medicare cannot make payment overseas, beneficiaries receiving
care overseas must still purchase Part B of Medicare in order to
maintain their TRICARE eligibility.
1.3.1.5 If
the service or supply is normally a benefit under both Medicare
and TRICARE, but Medicare does not make any payment because the
service or supply is not medically necessary, TRICARE cannot make
any payment on the claim. In such cases, the contractor shall deny
the claim. The beneficiary/provider must file an appeal with Medicare.
If Medicare subsequently reverses its medical necessity denial,
Medicare will make payment on the claim and it can then be submitted
to TRICARE for processing. If Medicare does not reverse its medical necessity
denial, the claim cannot be paid by TRICARE, and the Medicare appeal
decision is final. TRICARE will not accept an appeal in such cases,
and the contractor will advise the beneficiary that the final determination
rests with Medicare.
1.3.1.6 When Medicare does not make
a payment because services were rendered by a non-Medicare provider
or effective for services on or after March 1, 2007, because the
provider has a private contract with the beneficiary (also referred
to as “opting out” of Medicare), and the services are a TRICARE
benefit, TRICARE will process the claim as second payer. In these
cases, when TRICARE processes as secondary payer, TRICARE first
payer review and reporting rules apply. The TRICARE payment will
be the amount that TRICARE would have paid (TRICARE cost-shares
and deductibles do not apply) had the Medicare program processed
the claim (normally 20% of the allowable charge). If there is not
an available Medicare allowed amount, the TRICARE allowed amount
shall be calculated and 20% of that amount will be reimbursed (TRICARE
cost-shares and deductibles do not apply). Evidence of processing
by Medicare for non-Medicare providers is not required; rather a
statement from the provider verifying their Medicare status is sufficient
for processing. Opt out providers will be identified based on the Medicare
Part B carriers websites. In cases where the beneficiary’s access
to medical care is limited (i.e., under served areas), the TRICARE
contractor may waive the 20% of the allowable charge payment amount
and pay 100% of the allowable amount assessing all applicable deductibles
and cost-shares. In most cases, under served areas will be identified
by ZIP codes for Health Professional Shortage Areas (HPSAs) and
Physician Scarcity Areas (PSAs) on the Centers for Medicare and
Medicaid Services (CMS) website at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index.html and
will automatically pay 100% of the allowable amount assessing all
applicable deductibles and cost-shares. In cases where the ZIP code
for an underserved area is not identified on the CMS website, or
in areas where there are no or limited Medicare participating providers,
a written waiver request with justification identifying the county
where the service was received will be required by the contractor
to pay 100% of the allowable amount assessing all applicable deductibles
and cost-shares. TRICARE contractors will identify HPSA or PSA ZIP
codes or the county for underserved areas on the above CMS website
and identify opt out providers based on the Medicare Part B carriers
websites.
1.3.1.7 When Medicare does not make
a payment based on their Competitive Bidding Program (CBP) for Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS),
the TRICARE contractor shall process the claim as second payer for
otherwise TRICARE covered items of DMEPOS. In these cases, when
TRICARE processes as secondary payer, TRICARE first payer review
and reporting rules apply. The TRICARE payment shall be the amount
TRICARE would have paid (cost-shares and deductibles do not apply)
had Medicare processed and paid the claim (normally 20% of the allowable
charge). If there is not an available Medicare allowed amount, the TRICARE
allowed amount shall be calculated and 20% of that amount will be
reimbursed (cost-shares and deductibles do not apply). Public use
files containing the competitive bid single payment amounts per
Healthcare Common Procedure Coding System (HCPCS) code are posted
on the CMS’ competitive bidding contractor’s website:
http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home.
TRICARE contractors shall identify the competitive bid single payment
amount using the above CMS website to identify what Medicare would have
allowed had the beneficiary followed Medicare’s rules. Implementation
of Medicare’s DMEPOS CBP pricing is effective January 1, 2011.
1.3.1.8 When Medicare does not make
a payment because Medicare rules were not followed or because the beneficiary
failed to meet some other requirement of coverage (e.g., denied
for no referral, no or untimely authorization, invalid place of
service). TRICARE will process the claim as second payer as long
as the services meet TRICARE coverage rules. This exception does
not include Medicare medical necessity denials. In these cases,
when TRICARE processes as secondary payer, TRICARE first payer review
and reporting rules apply. The TRICARE payment will be the amount
that TRICARE would have paid (TRICARE cost-shares and deductibles
do not apply) had the Medicare program processed the claim (normally
20% of the allowed charge). If there is not an available Medicare allowed
amount, the TRICARE allowed amount shall be calculated and 20% of
that amount will be reimbursed (TRICARE cost-shares and deductible
do not apply).
Note: TRICARE
will not cost-share items designated by Medicare as “inpatient only”
for Medicare beneficiaries. These services shall be denied, and
TRICARE will make no payment. A list of these services can be found
in the addenda to Medicare’s annual Outpatient Prospective Payment
System Final Rule, available at
https://www.cms.gov/Center/Provider-Type/Hospital-Center.html.
1.3.1.9 Effective October 28, 2009, TRICARE
beneficiaries who are entitled to premium-free Medicare Part A because
of disability, where Social Security Disability Insurance (SSDI)
is awarded on appeal remain eligible for coverage under the TRICARE
program Program (see
the TOM,
Chapter 20, Section 1). Eligible beneficiaries
are required to keep Medicare Part B in order to maintain their
TRICARE coverage for future months, but are considered to have coverage
under the TRICARE program for the retroactive months of their entitlement
to Medicare Part A. For previously processed claims the contractor
that processed the claim shall not initiate recoupment due to eligibility
or jurisdiction and existing actions should be terminated. Medicare
becomes primary payer effective as of the original Medicare Part
B effective date.
1.3.4 Services
That Are Provided In A Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) Facility
1.3.4.1 If services or supplies are
provided in a TRICARE authorized DVA/VHA hospital pursuant to the
TPM,
Chapter 11, Section 2.1, Medicare will make
no payment. In such cases TRICARE will process the claim as a second payer.
In these cases, when TRICARE processes as secondary payer, TRICARE
first payer review and reporting rules apply. The TRICARE payment
will be the amount that TRICARE would have paid (TRICARE cost-shares
and deductibles do not apply) had the Medicare program processed
the claim (normally 20% of the allowable charge).
1.3.4.2 For TRICARE beneficiaries who
are not enrolled in Medicare Part B because they are exempt from enrolling,
TRICARE will process the outpatient claims as the primary payer
assessing any applicable deductibles and cost-shares, in accordance
with the TOM,
Chapter 20, Section 3.
Note: In order to achieve status
as a TRICARE authorized provider, DVA/VHA facilities must comply
with the provisions of the TPM,
Chapter 11, Section 2.1.