Back to Top Skip to main content

Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Double Coverage
Chapter 4
Section 1
Double Coverage
Issue Date:  
Authority:  32 CFR 199.8
Revision:  C-41, September 20, 2019
1.0  POLICY
1.1  Existence of Other Coverage
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/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. A contractor shall coordinate benefits and obtain the information regarding the other insurance payment to determine what the TRICARE liability is to assure that:
1.1.1  TRICARE beneficiaries receive maximum benefits from their health coverage, but no more than they are entitled to receive, and
1.1.2  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, paragraph 1.0), 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 not considered within the definition of either an insurance plan, medical service or health plan including the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA), the Maternal and Child Health Program, the Indian Health Services (IHS), and entitlement to receive care from the designated provider. These programs are designed to provide benefits to a distinct beneficiary population, and they require no premium payment or monetary contribution prior to obtaining care.
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, paragraph 1.3.1.4).
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 15, Section 1.
- END -

Utility Navigation Links

DoD Seal

tricare.mil is the offical website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Help Resources page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.

v4.5.7082.22297

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.