TRICARE SNF Payment Policies Impacted by PDPM

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TRICARE provides health care benefits to active military personnel and their families.  TRICARE has three regions: East, West, and Overseas.  Each TRICARE region has its own managed care support contractor (MCSC) who is responsible for administering the TRICARE program in each region. The MCSCs establish the provider networks and conduct provider education.  At a minimum, all TRICARE providers must be authorized/certified under TRICARE Regulation and must have their authorization/certification status verified by the managed care support contractors (MCSCs) in each region.  There are two types of TRICARE-authorized providers: Network and Non-Network Providers 

Network Providers:  To become a network provider, a SNF will sign a contractual agreement with the MCSC in the applicable region. In the contract the SNF will: 1) Agree to provide care to TRICARE beneficiaries at a negotiated rate, 2) Accept the beneficiaries' copayment or cost share as payment in full, and 3) File claims with TRICARE for the remaining amount.

Non-Network Providers:   If a SNF doesn’t want to sign a contract, the center can be a non-network provider, but the SNF must be certified by the MCSC.  As a non-network provider the SNF can decide to be a "participating provider" or a "non-participating provider".  Participating providers agree to file claims for beneficiaries, to accept payment directly from TRICARE and to accept the TRICARE allowable charge as payment in full for their services.  Non-participating providers do not agree to accept the TRICARE allowable charge or file beneficiary claims. Non-network providers can choose to participate on a claim-by-claim basis. A SNF doesn’t have to be participating or non-participating all of the time.

TRICARE Relationship with PDPM:  Historically, the TRICARE coverage and payments to SNFs have mirrored the Medicare SNF PPS payment model, however it appears that TRICARE is not converting to PDPM at this time.  This toolkit contains the most current available information related to the TRICARE SNF payment policies.

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TRICARE General Provider Information Web Page
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TRICARE Reimbursement Manual, Chapter 8, Skilled Nursing Facilities (SNFs) Revision C-41, September 20, 2019
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TRICARE Letter To Skilled Nursing Facility (SNF) Regarding Participation Agreement, Revision C-41, September 20, 2019
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NCAL AHCA