Master Table of Contents, page 1 Master Table of Contents, page 1

Transcription

1

2 CHANGE M OCTOBER 20, 2017 REMOVE PAGE(S) INSERT PAGE(S) Master Table of Contents, page 1 Master Table of Contents, page 1 CHAPTER 1 Section 2, page 1 Section 2, page 1 Section 28, pages 1 and 2 Section 28, pages 1 and 2 Section 33, pages 1 through 3 Section 33, pages 1 through 3 Section 34, pages 1 through 4 Section 34, pages 1 through 4 Section 35, pages 1 and 2 Section 35, pages 1 and 2 CHAPTER 2 Table of Contents, page 1 Table of Contents, pages 1 and 2 Section 1, pages 1 through 17 Section 1, pages 1 through 17 Section 2, pages 1 through 6 Section 2, pages 1 through 17 Section 3, pages 1 and 2 Section 3, pages 1 through 6 Section 4, pages 1 through 4 Section 5, pages 1 and 2 Section 6, pages 1 and 2 Addendum A, pages 1 through 12 Addendum A, pages 1 through 11 CHAPTER 3 Section 3, pages 1 and 2 Section 3, pages 1 and 2 CHAPTER 4 Section 3, pages 1 through 18 Section 3, pages 1 through 19 Section 4, pages 5 and 6 Section 4, pages 5 and 6 CHAPTER 8 Section 1, pages 11 and 12 Section 1, pages 11 and 12 2

3 CHANGE M OCTOBER 20, 2017 REMOVE PAGE(S) INSERT PAGE(S) CHAPTER 11 Section 1, page 3 Section 1, page 3 Section 4, pages 21 and 22 Section 4, pages 21 and 22 CHAPTER 12 Table of Contents, pages 1 and 2 Table of Contents, pages 1 and 2 Section 1, pages 5 through 8 Section 1, pages 5 through 8 Section 2, pages 25 through 30 Section 2, pages 25 through 30 Section 4, pages 25 and 26 Section 4, pages 25 and 26 Section 5, pages 1 through 8 Section 5, pages 1 through 7 CHAPTER 13 Section 1, pages 9 through 11 Section 1, pages 9 through 11 Section 3, pages 5-8, 15, 16, 21-24, 35, and 36 Section 3, pages 5-8, 15, 16, 21-24, 35, and 36 INDEX pages 1 through 4 3

4

5 Revision: For Definitions, see the TRICARE Operations Manual (TOM), Appendix A. Foreword Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 - General - Beneficiary Liability - Operational Requirements - Double Coverage - Allowable Charges - Diagnosis Related Groups (DRGs) - Mental Health - Skilled Nursing Facilities (SNFs) - Ambulatory Surgery Centers (ASCs) Chapter 10 - Birthing Centers Chapter 11 - Hospice Chapter 12 - Home Health Care (HHC) Chapter 13 - Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 14 - Sole Community Hospitals (SCHs) Chapter 15 - Critical Access Hospitals (CAHs) 1

6

7 General Chapter 1 Section 2 Accommodation Of Discounts Under Provider Reimbursement Methods Issue Date: December 7, 1990 Authority: 32 CFR 199.4(f)(10) and 32 CFR (l) Revision: 1.0 APPLICABILITY This policy is mandatory for reimbursement of services provided by either network or nonnetwork providers. However, alternative network reimbursement methodologies are permitted when approved by the Defense Health Agency (DHA) and specifically included in the network provider agreement. 2.0 POLICY 2.1 A provider shall be reimbursed at an amount below the amount usually paid pursuant to this chapter when the provider has agreed to the lower amount. This applies only when both the provider and the DHA have agreed to the discounted payment rates for non-network providers. 2.2 In the case of individual health care professionals and other non-institutional providers, if the discounted fee is below the provider s normal billed charge and the allowable charge level, the discounted fee shall be the provider s actual billed charge and the TRICARE allowable charge. 2.3 In the case of institutional providers normally paid on the basis of a pre-set amount (such as DRG-based amount or per diem amount), if the discount rate is lower than the pre-set rate, the discounted rate shall be the TRICARE-determined allowable cost. This is an exception to the usual rule that the pre-set rate is paid regardless of the institutional provider s billed charges or other factors. - END - 1

8

9 General Chapter 1 Section 28 Reduction Of Payment For Noncompliance With Utilization Review Requirements Issue Date: July 17, 1996 Authority: 32 CFR 199.4(e)(12) and 32 CFR (b)(4)(iii) Revision: 1.0 ISSUE Reduction of payment for noncompliance with utilization review requirements. 2.0 POLICY In the case of a provider s failure to obtain a required preauthorization, the provider s payment shall be reduced by 10% of the amount otherwise allowable. Under the managed care contracts, a network provider s payment can be subject to a greater than 10% reduction or a denial if the network provider has agreed to such a reduction or denial in the agreement. 2.1 Types of Care Subject to Payment Reduction For a provider s failure to obtain a required preauthorization or preadmission authorization, the provider s payment will be reduced in connection with the following types of care: All non-emergency mental health admissions to hospitals All admissions for residential treatment, substance use disorder rehabilitation, and psychiatric partial hospitalization. None of these can be considered emergency care Psychoanalysis. It cannot be considered as an emergency service Adjunctive dental care Organ and stem cell transplants Skilled Nursing Facility (SNF) care received in the U.S. and U.S. territories for TRICARE dual eligible beneficiaries once TRICARE is primary payer Infusion drug therapy delivered in the home. 1

10 Chapter 1, Section 28 Reduction Of Payment For Noncompliance With Utilization Review Requirements Additional procedures and services as prescribed by the contractors except when the beneficiary has other insurance as provided in the TRICARE Policy Manual (TPM), Chapter 1, Section 6.1, paragraph 1.12, Note. 2.2 Applicability of Payment Reduction This section shall apply to participating (including network providers and participating Department of Veterans Affairs (DVA) facilities) and nonparticipating providers. For a provider s failure to obtain the required preauthorization, the payment reduction shall be subject to the policy in this section In the case of an admission to a hospital, Substance Use Disorder Rehabilitation Facility (SUDRF), Residential Treatment Center (RTC), or a Partial Hospitalization Program (PHP) (or a SNF) when applicable, for network providers the payment reduction shall apply to the institutional charges and any associated professional charges of the attending or admitting provider. Services of other providers shall be subject to the payment reduction as provided under the network provider agreements, but not less than 10% The amount of the reduction for non-network providers shall be 10% of the amount otherwise allowable (consistent with paragraphs 2.3, 2.4, and 2.5) for services for which preauthorization should have been obtained, but was not obtained The amount of the reduction for network providers shall be in accordance with the provider s contract with the respective contractor, but not less than 10% The payment reduction shall apply under the Point of Service (POS) option. 2.3 Diagnosis Related Group (DRG) Reimbursed Facilities In the case of admissions reimbursed under the DRG-based payment system, the reduction shall be taken against the percentage (between 0 and 100%) of the total reimbursement equal to the number of days of care provided without preauthorization, divided by the total Length-Of-Stay (LOS) for the admission. See the example in Chapter 3, Section Non-DRG Facilities/Units (Includes RTCs, Mental Health Per Diem Hospitals, and PHPs) In the case of admissions to non-drg facilities/units, the reduction shall be taken only against the days of care provided without preauthorization. See the example in Chapter 3, Section Care Paid on Per-Service Basis For the care for which payment is on a per-service basis, e.g., outpatient adjunctive dental care, the reduction shall be taken only against the amount that relates to the services provided without prospective authorization. See the example in Chapter 3, Section 4. 2

11 General Chapter 1 Section 33 Bonus Payments In Health Professional Shortage Areas (HPSAs) Issue Date: April 18, 2003 Authority: 32 CFR (j)(2) Copyright: CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Revision: 1.0 APPLICABILITY This policy is mandatory for reimbursement of services provided by either network or nonnetwork providers. However, alternative network reimbursement methodologies are permitted when approved by the Defense Health Agency (DHA) and specifically included in the network provider agreement. 2.0 ISSUE How are bonus payments in medically underserved areas made? 3.0 POLICY 3.1 Background On April 15, 2002, the Final Rule was published in the Federal Register (67 FR 18114), allowing for bonus payments, in addition to the amount normally paid under the allowable charge methodology, to providers in medically underserved areas. Medically underserved areas are the same as those determined by the Secretary of Health and Human Services (HHS) for the Medicare program, designated as HPSAs found in all 50 states and Puerto Rico. HPSAs include both primary care and mental health identified HPSAs The bonus payments shall be equal to the bonus payments authorized by Medicare, except as necessary to recognize any unique or distinct characteristics or requirements of the TRICARE program, and as described in instructions issued by the Deputy Director, DHA HPSAs include both primary care and mental health identified HPSAs The bonus payment applies to both assigned and non-assigned claims. It also applies to network and non-network physicians The bonus payment is based on the zip code of the location where the service is actually performed, which must be in an HPSA, rather than the zip code of the billing office or other location. 1

12 Chapter 1, Section 33 Bonus Payments In Health Professional Shortage Areas (HPSAs) The bonus payment is based solely on the amount paid for professional services. Professional services are those that are paid by the professional CHAMPUS Maximum Allowable Charge (CMAC) file, excluding codes that are clinical laboratory services or that are entirely technical in nature. Claims submitted for the technical component only of a service (i.e., have a -TC modifier), if a service can have both professional and technical components, are also ineligible for the HPSA bonus. Thus, all Durable Equipment (DE), injectable drugs, vaccines, facility charges, supplies, etc., are not included in the paid amounts used to calculate the HPSA bonus. The professional service CMAC file s documentation describes how codes can be detected which are considered entirely technical or clinical lab. Anesthesia services by physicians paid through the anesthesia Relative Value Unit (RVU) and Conversion Factor (CF) files are also to be included as eligible services for the HPSA bonus calculation. Services that are performed by physicians and are professional services (not supplies, drugs, or other such charges) but do not have CMACs may be included in the HPSA bonus calculation, also, such as unlisted or not elsewhere specified CPT codes 27599, 27899, 30999, etc For dates of service prior to January 1, 2018, bonus payments apply under TRICARE Prime, Extra, and Standard for services provided in medically underserved areas. For dates of service on or after January 1, 2018, bonus payments apply under TRICARE Prime and Select for services provided in medically underserved areas TRICARE Prime Remote (TPR) and Supplemental Health Care Program (SHCP) shall be included in the bonus payment process Under TRICARE For Life (TFL), only those claims where TRICARE is primary would qualify for the bonus payment For Other Health Insurance (OHI) claims, the bonus payment would apply, but only on the amount paid by the Government. 3.2 Scope Of Benefit HPSA An additional payment shall be made quarterly to physicians who qualify and provide services in medically underserved areas (HPSAs) The bonus payment for HPSA, both primary care and mental health areas, is 10% of the amount actually paid, not 10% of the amount allowed, e.g., CMAC. The HPSA bonus payment only applies to physician s, podiatrist s, oral surgeon s, and optometrist s services rendered in these medically underserved areas. The modifier AQ effective January 1, As of October 1, 2013, the AQ modifier is no longer required except in those instances where zip codes do not fall entirely within a full county HPSA as noted in paragraph The bonus shall be calculated based on 10% of the amount actually paid a physician during a calendar quarter for services rendered in a medically underserved area Bonus payments are pass-through payments, non-financially underwritten payments The contractor shall sum all claim payments that qualify for the quarter and pay an additional 10% for the claims. There are no retroactive payments, adjustments or appeals, for obtaining 2

13 Chapter 1, Section 33 Bonus Payments In Health Professional Shortage Areas (HPSAs) a bonus payment. On or after October 1, 2013, the contractor requirements in paragraphs , , and shall apply and serve as validation of the HPSA payment Only professional services are to be included in the calculation of the bonus payment (see paragraph 3.1.6). For example, for services with both a professional and technical component only the professional component is included in the calculation of the bonus payment. The bonus payment is based on where the service is performed, which must be in the medically underserved area not the billing office, or other location (see paragraph 3.1.5) The contractor shall have 30 calendar days from the end of the calendar quarter to make the payments to the providers who qualify Contractors shall send bonus payments directly to the non-participating physician When a modifier is required for payment, the modifier must be reported on the TRICARE Encounter Data (TED) record The HPSA bonus payment shall be paid by the contractor when provided in zip code areas that fall in a county designated as a full-county HPSA. Primary care and mental health HPSA zip code files are downloadable from the Medicare web site at Service-Payment/HPSAPSAPhysicianBonuses/ Zip codes that do not fall entirely within a full county HPSA Effective October 1, 2013, the AQ modifier shall be entered on the claim in order to receive the bonus when services are provided in zip code areas that: Do not fall entirely within a designated full county HPSA bonus area; or Fall partially within a full county HPSA but are not considered to be in that county based on the United States Postal Service (USPS) dominance decision; or Fall partially within a non-full county HPSA; or Were included in the automated file of HPSA areas based on the date of the data run used to create the file When claims are received with an AQ modifier that do not entirely fall within a full county HPSA, the contractor shall review the Health Resources and Services Administration (HRSA) website for the most recent designations to determine if the service qualifies to receive the bonus payment ( When a claim includes an AQ modifier, the contractors shall verify that the location where the care was provided is included in an HPSA area. - END - 3

14

15 General Chapter 1 Section 34 Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia Issue Date: September 9, 2004 Authority: 32 CFR 199.1(b) and 32 CFR (m), (n), and (o) Revision: 1.0 APPLICABILITY This policy is mandatory for reimbursement of all hospital inpatient services provided in the locations identified in paragraph 4.2. This policy revises, replaces, and supersedes the previously issued policy, effective October 1, 2004, for hospital reimbursement in the Philippines. Puerto Rico follows Continental United States (CONUS) based reimbursement methodologies used for the 50 U.S. and the District of Columbia. 2.0 ISSUE 4.2? How are specified inpatient hospital services reimbursed in the locations specified in paragraph 3.0 POLICY The institutional per diem for those specified locations outside the 50 U.S. and the District of Columbia is the maximum amount TRICARE will authorize to be paid for inpatient services on a per diem basis. The allowable institutional rates for those specified locations outside the 50 U.S. and the District of Columbia, shall be the lesser of (a) billed charges or; (b) the amount based on prospectively determined per diems which are adjusted by a country specific index factor. 4.0 BACKGROUND Reimbursement Systems: 4.1 General Payment for inpatient hospital stays in specified locations outside the 50 U.S. and the District of Columbia, are made utilizing the lesser of: Billed charges; or The prospectively determined per diems adjusted by a country specific index. 1

16 Chapter 1, Section 34 Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia The prospectively determined per diem rates for specified locations outside the 50 U.S. and the District of Columbia, are developed into reimbursement groupings by utilizing diagnosis codes. For services provided before the mandated date, as directed by Health and Human Services (HHS), for International Classification of Diseases, 10th Revision (ICD-10) implementation, use diagnosis codes as contained in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation, use diagnosis codes as contained in the ICD-10-CM. The per diem rates are the maximum allowable amounts that TRICARE shall reimburse and the amount on which patient cost-shares are calculated. The National U.S. per diem rate is multiplied by a unique country specific index factor which adjusts the National U.S. per diems for the applicable country. The country specific hospital per diem, for those specified locations outside the 50 U.S. and the District of Columbia is the product of the National U.S. per diem and the country specific index. 4.2 Applicability This payment system applies to all hospitals providing services in: The Philippines. Panama. Other as designated by the Government This payment system will be applied by the foreign claims processor. It applies to hospital inpatient services furnished to retirees or their eligible family members or non-prime Active Duty Family Members (ADFMs) falling under the claims processing jurisdiction of the foreign claims processor Institutional providers accepting, admitting and treating TRICARE beneficiaries will receive the per diem reimbursement on applicable hospital services included on inpatient claims. This payment system is to be used regardless of the type of hospital inpatient services provided. The prospectively determined per diem rates established under this system are all-inclusive and are intended to include, but not be limited to, a standard amount for nursing and technician services; room, board and meals; drugs including any take home drugs; biologicals; surgical dressings, splints, casts; Durable Medical Equipment (DME) for use in the hospital and is related to the provision of a surgical service, procedure or procedures, equipment related to the provision and performance of surgical procedures; laboratory services and testing; X-ray or other diagnostic procedures directly related to the inpatient Episode Of Care (EOC); special unit operating costs, such as intensive care units; malpractice costs, if applicable, or other administrative costs related to the services furnished to the patients, recordkeeping and the provision of records; housekeeping items and services; and capital costs The per diem rates do not include such items as physicians fees, irrespective of a physician s employment status with the hospital. The per diem rates do not include other professional providers (e.g., nurse anesthetist) recognized by TRICARE who render directly related inpatient services and bill independently from the hospital for them. A valid primary ICD-9-CM code or narrative description of services must be submitted by the hospital or institutional provider for services provided before the mandated date, as directed by HHS, for ICD-10 implementation. A valid primary ICD-10-CM code or narrative description of services must be submitted by the hospital or institutional provider for 2

17 Chapter 1, Section 34 Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation. The medical description provided shall be able to support development of the claim by the overseas claims processor prior to reimbursement. 4.3 Country Specific Index The country specific index is a factor obtained from the World Bank s International Comparison Program. The index factor, known as Purchasing Power Parity (PPP) conversion factor, is based on a large array of goods and services or market basket within the specific country which is then standardized and weighted to a U.S. standard and currency. The World Bank defines PPP conversion factor as: Number of units of a country s currency required to buy the same amount of goods and services in the domestic market that a U.S. dollar would buy in the U.S. The use of the country specific index enables a conversion and therefore creates parity between the U.S. and the specific country in the purchasing of the same amount and type of medical services. TRICARE is utilizing the World Bank s International Comparison Program country specific index as provided in Figure Institutional Payment Rates For services provided before the mandated date, as directed by HHS, for ICD-10 implementation: National per diems are included in Figure and Figure The figures contain the ICD-9-CM code, code range, or groups of related diagnosis codes. The first three digits of the principal ICD-9-CM diagnosis code determines placement into a diagnosis group as well as a reimbursement group. The adjusted per diems will be available at: Business-Support/Rates-and-Reimbursement/Foreign-Rates For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation: National per diems are included in Figure The figures contain the ICD-10-CM code, code range, or groups of related diagnosis codes. The first alpha character and two digits of the principal ICD-10-CM diagnosis code determines placement into a diagnosis group as well as a reimbursement group. The adjusted per diems will be available at: Health-Topics/Business-Support/Rates-and-Reimbursement/Foreign-Rates The rate setting methodology was developed as follows: For services provided before the mandated date, as directed by HHS, for ICD-10 implementation: A rate setting methodology utilizing the first three digits of a primary diagnosis code. Eighteen diagnosis groupings were defined and designed based on the groupings and definitions contained in the ICD-9-CM publication. For example, Group 1 is defined as ICD-9-CM codes 001 to 139, or Infectious and Parasitic Diseases. The first three digits of a primary diagnosis code are utilized for placement into one of the 18 groups. 3

18 Chapter 1, Section 34 Hospital Inpatient Reimbursement In Locations Outside The 50 United States (U.S.) And The District Of Columbia The payment rate for each of the 18 diagnostic groups was the average allowed amount per day over all the ICD-9-CM codes in a diagnosis group, based upon the claim s primary diagnosis, plus an add-on to reimburse for capital costs For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation: A rate setting methodology utilizing the first alpha character and two digits of a primary diagnosis code. Eighteen diagnosis groupings were defined and designed based on the groupings and definitions contained in the ICD-10-CM publication. For example, Group 1 is defined as ICD-10-CM codes A00 to B99, or Infectious and Parasitic Diseases. The first alpha character and two digits of a primary diagnosis code are utilized for placement into one of the 18 groups. The payment rate for each of the 18 diagnostic groups was the average allowed amount per day over all the ICD-10-CM codes in a diagnosis group, based upon the claim s primary diagnosis, plus an add-on to reimburse for capital costs Group payments were calculated by dividing total allowed charges by total inpatient days for the group Once the 18 groupings were defined, certain unique admissions were identified for reimbursement separately from the 18 groupings. These are listed in Figure Payments General. For services provided before the mandated date, as directed by HHS, for ICD-10 implementation, the per diem group payment rate will be based on the first three digits of the primary diagnosis code. For services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation, the per diem group payment rate will be based on the first alpha character and two digits of the primary diagnosis code. The maximum amount allowed by TRICARE and the amount reimbursed for hospital inpatient care shall be the lesser of: Actual billed charges for hospital inpatient care; or The U.S. National per diem rate authorized under TRICARE, multiplied by the country specific index factor, is the country specific hospital per diem. This per diem is multiplied by the number of covered days of hospital inpatient care and equals the maximum amount allowed by TRICARE to be paid for the episode on inpatient care Only the primary diagnosis code, on the date of admission, will be taken into consideration when determining the group for a payment rate. Only one payment group can be assigned to each independent episode of inpatient care. For services provided before the mandated date, as directed by HHS, for ICD-10 implementation, each institutional claim for service reimbursement must contain a valid ICD-9-CM code or narrative description of services, and must be used to represent the primary 4

19 General Chapter 1 Section 35 Professional Provider Reimbursement In Specified Locations Outside The 50 United States (U.S.) And The District Of Columbia Issue Date: April 7, 2008 Authority: 32 CFR (m), (n), and (o) Copyright: CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Revision: 1.0 APPLICABILITY This policy is mandatory for reimbursement of providers of professional services in specified locations outside the 50 U.S. and the District of Columbia. This policy revises, replaces, and supersedes the current reimbursement policies for professional reimbursement, effective March 2004, in the Philippines. The Commonwealth of Puerto Rico, the U.S. Virgin Islands, American Samoa, the Northern Mariana Islands, and Guam follow the reimbursement methodologies used for the 50 U.S. and the District of Columbia. Aeromedical evacuation reimbursement for the Commonwealth of Puerto Rico and the U.S. territories will continue to be at billed charges, unless otherwise directed by the Government. 2.0 ISSUE How are providers of professional services in locations specified in paragraph 4.1 reimbursed? 3.0 POLICY 3.1 The term allowable charge is the maximum amount TRICARE will reimburse for covered health care services: 3.2 The allowable charge is the lowest of: (a) the actual billed charge or (b) the maximum allowable charge. The maximum allowable charge is developed prospectively and utilizes the U.S. National CHAMPUS Maximum Allowable Charge (CMAC) which incorporates Relative Value Units (RVUs). For any covered service, the U.S. National CMAC rate is multiplied by a country specific index factor. This standardizes the U.S. National CMAC for that country and thus represents the maximum allowable TRICARE will reimburse in that country for that service. 1

20 Chapter 1, Section 35 Professional Provider Reimbursement In Specified Locations Outside The 50 United States (U.S.) And The District Of Columbia 4.0 BACKGROUND 4.1 Reimbursement Systems Locations Affected. This payment system applies to covered professional services delivered in all designated locations outside the 50 U.S. and the District of Columbia. The designated locations are: The Philippines. Panama. Other as designated by the Government Applicability. This payment system will be applied by the foreign claims processor. It applies to professional services furnished to retirees or their eligible family members or non-prime Active Duty Family Members (ADFMs) falling under the claims processing jurisdiction of the foreign claims processor. 4.2 General Methodology Payment for non-ancillary professional services, in specified locations outside the 50 U.S. and the District of Columbia, are made utilizing the lesser of (a) billed charges or (b) prospectively determined rates that multiplies the U.S. National CMAC rates by a country specific index factor. The U.S. National CMAC rates are comprised of approximately 7,000 Current Procedural Terminology (CPT) codes. Each CPT code associates with an established CMAC rate. There are a limited number of CPT codes that do not have a U.S. National CMAC established. If these CPT codes are billed to the TRICARE program, they shall be reimbursed at billed charges. The U.S. National CMAC rates utilized in specified locations outside the 50 U.S. and the District of Columbia are paid at the site of service location of physicians office without regard of the actual location where the service is delivered. This site of service location (physicians office) represents the highest reimbursement allowed for all physicians. For example, should a physician, in a specified location outside the 50 U.S. and the District of Columbia, deliver a service in the emergency room, his payment will be based on the CPT code submitted, and paid at the site of service level of physician office (the highest). Each CPT code rate is multiplied by a specific country index factor and represents the maximum allowed to be paid to professional providers in designated locations outside the 50 U.S. and the District of Columbia The payment rates are all inclusive. An eligible and a representative procedure code or narrative description must be submitted by the provider or developed by the overseas claims processor. 4.3 Country Specific Index The country specific index factor is obtained from the World Bank s International Comparison Program. The index factor, known as Purchasing Power Parity (PPP) conversion factor, is based upon a large array of goods and services or market basket within a specific country which is then standardized and weighted to a U.S. standard and currency. The World Bank defines PPP conversion factor as: Number of units of a country s currency required to buy the same amount of goods and services in the domestic market that a U.S. dollar would buy in the U.S. The use of a country specific index enables a 2

21 Chapter 2 Beneficiary Liability Revision: Section/Addendum Subject/Addendum Title 1 Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries Figure Uniformed Services Hospital Daily Charge Amounts 2 Cost-Shares And Deductibles For TRICARE Services Received On Or After January 1, 2018 Figure TRICARE Select Deductibles for CY 2018 Figure TRICARE Prime Cost-Shares for Preventive Care Visits Figure TRICARE Select Cost-Shares for Preventive Care Visits Figure TRICARE Prime Cost-Shares for Primary Care Outpatient Visits Figure TRICARE Select Cost-Shares for Primary Care Outpatient Visits Figure TRICARE Prime Cost-Shares for Specialty Care Outpatient Visits Figure TRICARE Select Cost-Shares for Specialty Care Outpatient Visits Figure TRICARE Select Cost-Shares for Ancillary Services Figure TRICARE Select Cost-Shares for Other Radiology Services Figure TRICARE Prime Cost-Shares for Eye Examinations Figure TRICARE Select Cost-Shares for Eye Examinations Figure TRICARE Prime Cost-Shares for Emergency Room (ER) Visits Figure TRICARE Select Cost-Shares for Emergency Room (ER) Visits Figure TRICARE Prime Cost-Shares for Urgent Care Center (UCC) Visits Figure TRICARE Select Cost-Shares for Urgent Care Center (UCC) Visits Figure TRICARE Prime Cost-Shares for Ambulatory Surgery (Including Birthing Centers) Figure TRICARE Select Cost-Shares for Ambulatory Surgery (Including Birthing Centers) Figure TRICARE Prime Cost-Shares for Ambulance Services (Including Birthing Centers) Figure TRICARE Select Cost-Shares for Ambulance Services Figure TRICARE Prime Cost-Shares for Durable Medical Equipment (DME) Figure TRICARE Select Cost-Shares for Durable Medical Equipment (DME) Figure TRICARE Prime Cost-Shares for Inpatient Hospitalizations Figure TRICARE Select Cost-Shares for Inpatient Hospitalizations Figure TRICARE Prime Cost-Shares for Skilled Nursing/Rehabilitation Facilities Figure TRICARE Select Cost-Shares for Skilled Nursing/Rehabilitation Facilities 1

22 Chapter 2, Beneficiary Liability Section/Addendum Subject/Addendum Title 3 Catastrophic Loss Protection For TRICARE Services Received Prior To January 1, 2018; And For TRICARE Services Received On Or After January 1, 2018, By TRICARE For Life (TFL) Beneficiaries 4 Catastrophic Loss Protection For TRICARE Services Received On Or After January 1, Point Of Service (POS) Option 6 Waivers of Cost-Shares and Deductibles A B Benefits And Beneficiary Payments Under The TRICARE Program For Services Received Prior To January 1, 2018; And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries Pharmacy Benefits Program - Cost-Shares 2

23 Beneficiary Liability Chapter 2 Section 1 Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries Issue Date: October 20, 2017 Authority: 32 CFR 199.4, 32 CFR 199.5, and 32 CFR Copyright: CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Revision: 1.0 POLICY 1.1 General National Defense Authorization Act for Fiscal Year 2017 (NDAA FY 2017), Section 701, made significant changes to the TRICARE Program including establishing new health plans, new classifications for beneficiary eligibility for the health plans, and unique cost-shares, deductibles, and catastrophic loss protection applicable to services received on or after January 1, 2018 (see Section 2). This section sets forth the cost-shares and deductibles applicable to TRICARE services received on or after January 1, 2018, by TFL beneficiaries and certain other beneficiaries otherwise as specified in Section For services received prior to January 1, 2018, deductibles and catastrophic loss protection are applicable on a fiscal year basis. For services received on or after January 1, 2018, deductibles and catastrophic loss protection are applicable on a calendar year basis. In order to transition deductibles and catastrophic loss protection from a fiscal year to a calendar basis, the deductible and catastrophic loss protection amounts for FY 2017 will be applicable to services received during the 15 month period of October 1, 2016, through December 31, Special Transition Rules for October 1, 2017 through December 31, A Prime beneficiary s enrollment fee for this period is one-fourth the enrollment fee for FY The deductible amounts and catastrophic cap amounts for fiscal year 2017 shall be applicable to the 15-month period of October 1, 2016 through December 31,

24 Chapter 2, Section 1 Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries Applicable Terms And Conditions TRICARE Standard means the TRICARE Program made available prior to January 1, 2018, with program deductible and cost-share amounts identical to those applied under the TRICARE Basic program in 32 CFR Although TRICARE Standard is generally terminated as of January 1, 2018, under Section 701(e) of the NDAA FY 2017, in accordance with section 1075(f) of title 10, United States Code (USC), a TFL beneficiary will continue to have their cost-sharing requirements calculated for services received on or after January 1, 2018, as if the beneficiary were enrolled in TRICARE Standard as if TRICARE Standard were still being carried out by the Department of Defense (DoD) TRICARE Extra means the preferred-provider option of the TRICARE Program made available prior to January 1, 2018, under which TRICARE Standard beneficiaries obtained discounts on cost-sharing as a result of using TRICARE network providers TRICARE Prime means the managed care option of the TRICARE Program. For enrollment fees and copayments TRICARE Prime enrollees choosing to receive care under the Point of Service (POS) option, refer to Section TFL means the Medicare wraparound coverage option of the TRICARE program made available to the beneficiary by reason of section 1086(d) of 10 USC Fees under the Extended Care Health Option (ECHO) are defined in 32 CFR Fees under the TRICARE Pharmacy Benefits Program are defined in 32 CFR Addendum A contains a complete listing of cost-share and deductible information applicable to services received prior to January 1, 2018, as well as those applicable to services received by TFL beneficiaries as if they were enrolled in TRICARE Standard on or after January 1, Addendum B contains a listing of fee information applicable to the TRICARE Pharmacy Benefits Program Waiver of cost-sharing and deductible. See Section TRICARE Prime Copayments and enrollment fees under TRICARE Prime are subject to review and annual updating. See Addendum A for additional information on the benefits and costs. In accordance with NDAA FY 2001, Section 752, Public Law , for services provided on or after April 1, 2001, a $0 copayment shall be charged to TRICARE Prime ADFMs of Service members who are enrolled in TRICARE Prime. Pharmacy copayments and POS charges are not waived by the NDAA for FY In instances where the CMAC or allowable charge is less than the copayment shown on Addendum A, network providers may only collect the lower of the allowable charge or the applicable copayment. 2

25 Chapter 2, Section 1 Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries The TRICARE Prime copayment requirement for emergency room services is on a PER VISIT basis; this means that only one copayment is applicable to the entire emergency room episode, regardless of the number of providers involved in the patient s care and regardless of their status as network providers Prime enrollees have no copayments for the ancillary services in the categories listed below (normal referral and authorization provisions apply). Current Procedural Terminology (CPT) code ranges are given; however, these codes are not all-inclusive. The most up-to-date codes should be utilized to identify services within each category, in accordance with the TOM, Chapter 1, Section 4. Additionally, listing the code ranges does not imply coverage; the codes just provide the broad range of services that are not subject to copayments under this provision: Diagnostic radiology and ultrasound services included in the CPT procedure code range from , or any other code for associated contrast media; Diagnostic nuclear medicine services included in the CPT procedure code range from ; Pathology and laboratory services included in the CPT procedure code range from ; G0461-G0462 (during 2014); and Cardiovascular studies included in the CPT procedure code range from Venipuncture included in the CPT procedure code range from Collection of blood specimens in the CPT procedure codes and Fetal monitoring for CPT procedure codes 59020, 59025, and Note: Multiple discounting will not be applied to the following CPT procedure codes for venipuncture, fetal monitoring, and collection of blood specimens; , 36591, 36592, 59020, 59025, and Point of Service option. See Section Basic Program: TRICARE Standard Deductible Amount: Outpatient Care Active Duty Sponsor in Pay Grade E-4 or Below Deductible, Individual: Each beneficiary is liable for the first fifty dollars ($50.00) of the allowable amount on claims for care provided in the same fiscal year Deductible, Family: The total deductible amount for all members of a family with the same sponsor during one fiscal year shall not exceed one hundred dollars ($100.00). 3

26 Chapter 2, Section 1 Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries All TRICARE Beneficiaries Except Family Members of Active Duty Sponsors in Pay Grade E-4 or Below Deductible, Individual: Each beneficiary is liable for the first $ of the allowable amount on claims for care provided in the same fiscal year Deductible, Family: The total deductible amount for all members of a family with the same sponsor during one fiscal year shall not exceed $ TRICARE-Approved Ambulatory Surgery Centers (ASCs), Birthing Centers, or Partial Hospitalization Programs (PHPs) No deductible shall be applied to allowable amounts for services or items rendered to ADFMs or authorized North Atlantic Treaty Organization (NATO) family members Allowable Amount Does Not Exceed Deductible Amount. If fiscal year allowable amounts for two or more beneficiary members of a family total less than $ (or $ if paragraph , applies), and no one beneficiary s allowable amounts exceed $50.00 (or $ if paragraph applies), neither the family nor the individual deductible will have been met and no TRICARE benefits are payable 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 deductible shall be the amount specified in paragraph Note: The provisions of paragraph , also apply 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 Adjustment of Excess. Any beneficiary identified under paragraphs and who paid any deductible in excess of the amounts stipulated is entitled to an adjustment of any amount paid in excess against the annual deductible required under those paragraphs The deductible amounts identified in this section shall be deemed to have been satisfied if the catastrophic cap amounts identified in Section 2 have been met for the same fiscal year in which the deductible applies Deductible Amount: Inpatient Care None. 4

27 Chapter 2, Section 1 Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries Cost-Share Amount Outpatient Care ADFM or Authorized NATO Beneficiary. The cost-share for outpatient care is 20% of the allowable amount in excess of the annual deductible amount. This includes the professional charges of an individual professional provider for services rendered in a non-tricare-approved ASC or Birthing Center Other Beneficiary. The cost-share applicable to outpatient care for other than active duty and authorized NATO family member beneficiaries is 25% of the allowable amount in excess of the annual deductible amount. This includes: partial hospitalization for alcohol rehabilitation; professional charges of an individual professional provider for services rendered in a non-tricare-approved ASC Inpatient Care ADFM: Except in the case of mental health services, ADFMs or their sponsors are responsible for the payment of the first $25 of the allowable institutional costs incurred with each covered inpatient admission to a hospital or other authorized institutional provider, or the daily charge the beneficiary or sponsor would have been charged had the inpatient care been provided in a Uniformed Service hospital, whichever is greater. (Please reference daily rate chart below.) FIGURE UNIFORMED SERVICES HOSPITAL DAILY CHARGE AMOUNTS PERIOD DAILY CHARGE October 1, September 30, 2012 (for ADFMs not enrolled in Prime) $17.05 October 1, September 30, 2013 (for ADFMs not enrolled in Prime) $17.35 October 1, September 30, 2014 (for ADFMs not enrolled in Prime) $17.65 October 1, September 30, 2015 (for ADFMs not enrolled in Prime) $17.80 October 1, September 30, 2016 (for ADFMs not enrolled in Prime) $18.00 October 1, September 30, 2017 (for ADFMs not enrolled in Prime) $18.20 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 Other Beneficiaries: For services exempt from the DRG-based payment system and the mental health per diem payment system and services provided by institutions other than hospitals (i.e., Residential Treatment Centers (RTCs)), the cost-share shall be 25% of the allowable charges Cost-Shares: Maternity Determination. Maternity care cost-share shall be determined as follows: Inpatient cost-share formula applies to maternity care ending in childbirth in, or on the way to, a hospital inpatient childbirth unit, and for maternity care ending in a non-birth outcome not otherwise excluded. 5

28 Chapter 2, Section 1 Cost-Shares And Deductibles For TRICARE Services Received Prior To January 1, 2018 And For TRICARE Services Received On Or After January 1, 2018 By TRICARE For Life (TFL) Beneficiaries Note: Inpatient cost-share formula applies 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 Military Treatment Facility (MTF)/Enhanced Multi- Service Market (emsm) inpatient childbirth unit. ADFMs pay a per diem charge (or a $25.00 minimum charge) for an admission and there is no separate cost-share for them for separately billed professional charges or prenatal or postnatal care Ambulatory surgery cost-share formula applies 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 Outpatient cost-share formula applies to maternity care which terminates in a planned childbirth at home Otherwise covered medical services and supplies directly related to complications of pregnancy, as defined in the Regulation, shall be cost-shared on the same basis as the related maternity care for a period not to exceed 42 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 Otherwise authorized services and supplies related to maternity care, including maternity related prescription drugs, shall be cost-shared on the same basis as the termination of pregnancy Claims for pregnancy testing shall be cost-shared on an outpatient basis when the delivery is on an inpatient basis Where 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 delivery shall be adjudicated as an at-home birth Claims for prescription drugs provided on an outpatient basis during the maternity episode but not directly related to the maternity care shall be cost-shared on an outpatient basis Newborn cost-share. Effective for all inpatient admissions occurring on or after October 1, 1987, separate claims must be submitted for the mother and newborn. The cost-share for inpatient claims for services rendered to a beneficiary newborn is determined as follows: In a DRG hospital: Same newborn date of birth and date of admission: For ADFMs, there shall be no cost-share during the period the newborn is deemed enrolled in Prime. For newborn family members of other than active duty members, unless the newborn is deemed enrolled in Prime, the cost-share shall be the lower of the 6