AGENCY:
Office of the Secretary, Department of Defense.
ACTION:
Notice of Calendar Year (CY) 2019 TRICARE Prime and TRICARE Select Out of Pocket Expenses.
SUMMARY:
This notice provides the Calendar Year (CY) 2019 TRICARE Prime and TRICARE Select Out of Pocket Expenses.
DATES:
The CY19 rates contained in this notice are effective for services on or after January 1, 2019, unless otherwise indicated.
ADDRESSES:
Defense Health Agency (DHA), TRICARE Health Plan, 7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042-5101.
FOR FURTHER INFORMATION CONTACT:
Mark A. Ellis, telephone (703) 275-6234.
SUPPLEMENTARY INFORMATION:
The National Defense Authorization Acts (NDAAs) for Fiscal Year (FY) 2012 and 2017 established rates for TRICARE beneficiary out of pocket expenses and how they may be increased by either the annual cost of living adjustment (COLA) percentage used to increase military retired pay or via budget neutrality rules. The FY 2019 retiree COLA increase is 2.8%. The “TRICARE Select and Other TRICARE Reforms” final rule (published February 15, 2019 at 84 FR 4326-4333) allows for adjustments to beneficiary out of pocket expenses for Group A beneficiaries (sponsor enlisted or was commissioned in a Uniformed Service before January 1, 2018) to maintain budget neutrality compared to the previous year.
The DHA has updated the CY19 fees as shown below:
Table 1—TRICARE Prime and TRICARE Select Out of Pocket Expenses for CY19—Retirees and Retiree Family Members
Select Group B retirees CY19| Select Group A retirees CY19 | Prime** Group A retirees CY19 | Prime** Group B retirees CY19 | ||
|---|---|---|---|---|
| Annual enrollment fee: | ||||
| Individual | $0 | $462 | $297 | $360. |
| Family | $0 | $924 | $594 | $720. |
| Annual Deductible: | ||||
| Individual | $150 | $154 (IN); $308 (OON) | $0 | $0. |
| Family | $300 | $308 (IN); $616 (OON) | $0 | $0. |
| Annual catastrophic cap | $3,000 | $3,598 | $3,000 | $3,598. |
| Preventive visit | $0 | $0 | $0 | $0. |
| Primary care | $29 (IN) 25% (OON) | $25 (IN) 25% (OON) | $20 | $20. |
| Specialty care | $41 (IN) 25% (OON) | $41 (IN) 25% (OON) | $30 | $30. |
| ER visit | $111 (IN) 25% (OON) | $82 (IN) 25% (OON) | $61 | $61. |
| Urgent care center visit | $29 (IN) 25% (OON) | $41 (IN) 25% (OON) | $30 | $30. |
| Ambulatory surgery | 20% (IN) 25% (OON) | $97 (IN) 25% (OON) | $61 | $61. |
| Ambulance, outpatient ground | $102 (IN) 25% (OON) | $61 (IN) 25% (OON) | $41 | $41. |
| Ambulance, outpatient air | 25% (IN or OON) | 25% (IN or OON) | $20 | $20. |
| Durable medical equipment | 20% (IN) 25% (OON) | 20% (ON) 25% (OON) | 20% | 20%. |
| Inpatient admission: | ||||
| In-network | $250/day up to 25% of hospital charges, plus 20% of sep. billed services | $179 per adm | $154 per adm | $154 per adm. |
| Out of network | * $953/day up to 25% of hosp. charges, plus 25% of sep. billed services | 25% | $154 per adm | $154 per adm. |
| Inpatient SNF/rehab facility | $250/day up to 25% of hospital charges, plus 20% of sep. billed services (IN); 25% (OON) | $51 per day (IN); lesser of $308 per day or 20% (OON) | $30 per day | $30 per day. |
| IN: In Network. | ||||
| OON: Out of Network. | ||||
| * Per day rate change effective October 1, 2018. | ||||
| ** When TRICARE Prime enrollees other than active duty service members self-refer to specialty or non-emergent inpatient care without a referral from a network provider and/or authorization from the regional contractor, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments. |
Table 2—TRICARE Prime and TRICARE Select Out of Pocket Expenses for CY19—Active Duty Family Members
Select Group B ADFM CY19| Select Group A ADFM CY19 | Prime ** Group A ADFM CY19 | Prime ** Group B ADFM CY19 | ||
|---|---|---|---|---|
| Annual enrollment fee: | ||||
| Individual | $0 | $0 | $0 | $0 |
| Family | $0 | $0 | 0 | 0 |
| Annual Deductible: | ||||
| E1-E4, individual | $50 | $51 | 0 | 0 |
| E1-E4, family | $100 | $102 | 0 | 0 |
| E5 & above, individual | $150 | $154 | 0 | 0 |
| E5 & above, family | $300 | $308 | 0 | 0 |
| Annual catastrophic cap | $1,000 | $1,028 | 1,000 | 1,028 |
| Preventive visit | $0 | $0 | 0 | 0 |
| Primary care | $21 (IN) 20% (OON) | $15 (IN) 20% (OON) | 0 | 0 |
| Specialty care | $31 (IN) 20% (OON) | $25 (IN) 20% (OON) | 0 | 0 |
| ER visit | $83 (IN) 20% (OON) | $41 (IN) 20% (OON) | 0 | 0 |
| Urgent care center visit | $21 (IN) 20% (OON) | $20 (IN) 20% (OON) | 0 | 0 |
| Ambulatory surgery | $25 (IN) 20% (OON) | $25 (IN) 20% (OON) | 0 | 0 |
| Ambulance, outpatient ground | $76 (IN) 20% (OON) | $15 (IN) 20% (OON) | 0 | 0 |
| Ambulance, outpatient air | 20% (IN or OON) | 20% (IN or OON) | 0 | 0 |
| Durable medical equipment | 15% (IN) 20% (OON) | 10% (ON) 20% (OON) | 0 | 0 |
| Inpatient admission | * $19.05 per day; $25 min. per admission | $61 per adm. (IN); 20% (OON) | 0 | 0 |
| Inpatient SNF/rehab facility | *$19.05 per day; $25 min. per admission | $25 per day (IN); $51 per day (OON) | 0 | 0 |
| IN: In Network. | ||||
| OON: Out of Network. | ||||
| * Per day rate change effective October 1, 2018. | ||||
| ** When TRICARE Prime enrollees other than active duty service members self-refer to specialty or non-emergent inpatient care without a referral from a network provider and/or authorization from the regional contractor, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments. |
The above rates are effective for services rendered on or after January 1, 2019 unless otherwise indicated.
Dated: April 5, 2019.
Aaron T. Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2019-07067 Filed 4-9-19; 8:45 am]
BILLING CODE 5001-06-P