Child Vaccination ProgramsThat Use An SVP Per Capita Assessment Approach For Reimbursem*nt
1.
DHA will calculate the numberof covered lives (i.e., Active Duty Family Member (ADFM) and Non-ActiveDuty Family Member (NADFM) reliants that are not enrolled at a Market/MilitaryMedical Treatment Facility (MTF) in TRICARE Prime, ages 0-18) (see Section 38 for details) each quarter. DefenseHealth Agency (DHA) will estimate the percentage of TRICARE non-ActiveDuty Dependent (ADD) reliants annually, and exclude any non-ADDs whoare not reliant on TRICARE as their primary form of insurance intheir covered lives population estimate.
2.
Each SVP may have its own timeperiod for the population to be calculated. The DHA will work withthe state programs to ensure that the population is calculated forthe appropriate time frame in the state. DHA will, on a quarterlybasis, provide the contractors the number of covered lives in eachstate. Some SVPs require quarterly payment, while others requireannual payments. DHA will determine which population numbers are appropriateto use for the SVP-specific calculations.
3.
DHA will also provide the contractorswith a TRICARE per capita capped payment amount for the time period neededfor each SVP program. This information may be provided directlyto the contractor or posted on a DHA-approved website.
4.
The contractor shall followthe protocol established by each state to provide them with thenumber of TRICARE covered lives for the dates requested by the SVP.
5.
The contractor shall identifywhether the SVP per capita assessment amount provided by the SVPis greater or less than the TRICARE per capita capped payment amount.
6.
In some states, the SVPs shallsend an invoice to the contractors for a payment, typically on aquarterly or annual basis. In other states, the contractors shallproactively provide payment to the SVPs for the liability amount.
7.
The contractor shall pay theSVPs in one of two ways:
a.
If the SVP per capita quarterlyassessment amount is less than the TRICARE per capita quarterlycapped payment amount: The contractors shall pay the amount equalto the SVP per capita assessment amount multiplied by the TRICAREreliant population
b.
If the SVP per capita quarterlyassessment amount is greater than the TRICARE per capita quarterlycapped payment amount: The contractor shall calculate the totalTRICARE assessment amount to be paid to the SVP as the number ofTRICARE reliants (i.e., covered lives) in the state multiplied bythe TRICARE per capita capped payment amount.
8.
The contractor shall submitpayment to the SVPs either annually or quarterly depending on theSVP.
9.
The contractor shall be reimbursedusing non-underwritten funds.
Child Vaccination ProgramsThat Use An Alternative Approach - The State Of Massachusetts
1.
For Massachusetts, DHA willcalculate the total TRICARE paid amounts made to acute care hospitalsand paid facility charges for hospital outpatient departments andfreestanding Ambulatory Surgery Center (ASC) facilities for a perioddesignated annually by the Massachusetts Vaccine Association tocalculate the annual Pediatric Immunization Program Assessment (PIPA).
2.
DHA will identify the PIPAsurcharge percentage that is published annually by the state ofMassachusetts, and multiply this percentage by the total paid amountscalculated above.
3.
DHA will compare the MA assessmentamount with the TRICARE payment capped amount, as calculated by DHAusing the reliant covered lives under age 19 and an assessment amount.
4.
DHA will provide the contractorwith the total TRICARE assessment amount to be paid to the stateand the contractor shall submit payment to the Massachusetts VaccinePurchase Trust.
5.
The contractor shall submitpayment to the SVP by June 1st.
6.
The contractor shall be reimbursedusing non-underwritten funds.
Adult Vaccination ProgramsThat Use An SVP Per Capita Assessment Approach for Reimbursem*nt
1.
DHA will calculate the numberof covered lives (i.e., ADFM and NADFM reliants that are not enrolledat a Market/MTF in TRICARE Prime, for the ages in which adult vaccinesare provided in the state) each quarter. The term “reliants” refersto a subset of TRICARE eligible beneficiaries who are dependenton TRICARE for the coverage/reimbursem*nt of vaccines under thewell-child and preventive benefits. All TRICARE ADFMs are consideredto be reliant on TRICARE as their primary form of insurance. DHAwill estimate the percentage of TRICARE non-ADD reliants annually,and will exclude any non-ADDs who are not reliant on TRICARE astheir primary form of insurance in their covered lives populationestimate.
2.
Each state adult SVP may haveits own time periods for the population to be calculated. DHA willwork with the state programs to ensure that the population is calculatedfor the appropriate time frame in the state. DHA will, on a quarterlybasis, provide the contractors the number of covered lives in eachstate.
3.
DHA will calculate a state-specificTRICARE per capita capped payment amount for each quarter usingdata from only the adult vaccines that are provided in the state.DHA will determine if multiple state per capita capped rates arerequired based on age. For example, if a state program providesvaccines to the Medicare-eligible population, DHA will exclude anyMedicare-covered adult vaccines from the calculation of a capped amountused for the age 65 and older population in that state only.
4.
DHA will provide the contractorswith the number of covered reliants in the state, and the TRICAREstate-specific per capita capped payment amount(s). DHA may providethese values directly to the contractor, or via a website designedfor DHA SVP programs.
5.
The contractor shall providethe Adult SVP program with the number of adult TRICARE reliantsin which ever mechanism that is agreed upon by the contractor andthe state (e.g., via memo, online survey, web-portal) for each timeperiod requested by the SVP.
6.
In some states, the SVPs shallsend an invoice to the contractors for a payment, typically on aquarterly or annual basis. In other states, the contractor shallproactively provide payment to the SVPs for the liability amount.
7.
The contractor shall identifywhether the SVP Adult per capita assessment amount is greater thanthe calculated TRICARE per capita capped payment amount.
8.
The contractor shall pay theSVPs in one of two ways:
a.
If the SVP per capita quarterlyassessment amount is less than the TRICARE per capita quarterlycapped payment amount: The contractor shall pay the amount equalto the SVP per capita assessment amount multiplied by the TRICAREreliant population.
b.
If the SVP per capita quarterlyassessment amount is greater than the TRICARE per capita quarterlycapped payment amount: The contractor shall calculate the totalTRICARE assessment amount to be paid to the SVP as the number ofTRICARE reliants (i.e., covered lives) in the state multiplied bythe TRICARE per capita capped payment amount.
9.
The contractor shall submitpayment to the SVP.
10.
The contractor shall be reimbursedusing non-underwritten funds.
