Wednesday, June 25, 2008
Questions? Post Them Here and We'll Get Back to You
Posted by U.S. Military Retirees Residing in the Philippines at 9:30 AM
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3 comments:
Isn't there a $3000 "Catastrophic Cap" out-of-pocket limit per year?
Don Wong
MSG (R), USA
Don;
Yes there is a $3,000 catastrophic cap, but that is only for out of pocket cost that are not above the Champus Maximum Allowable Amount, (CMAC). To put it a different way; if the cost of the procedure is $1,000 and the CMAC is $500, the beneficiary will only be reimbursed the $500 minus his/her co-pay of $125. The check will be for $375. The $125 co-pay is applied to the catastrophic cap, but the amount over the CMAC is not applied to the catastrophic cap because it is above the CMAC. Bottom line, the beneficiary pays $625 for a $1,000 procedure, or 62.5% of the normal and customary charges of the medical provider for the area where the care was provided.
Ken
Don,
Yes there is but "out-of-pocket limit" is not true. The cap of $3,000 per year is only made up of a families deductibles and co-pays. In other words for a family their $300 deductible is applied to the cap. Then for a retiree the 25% co-pays are also applied. But any amounts that are disallowed because they exceed the maximum allowable charge are not included. In the US there is a law that says a provider cannot balance bill a Tricare beneficiary for more than 115% of the maximum allowable charge. Overseas this law does not apply.
So for an overseas retiree that has a heart bypass surgery admission costing $10,000 (It would run much more in the US.) he may find that the new maximum allowable charge is $7,000. So the retiree would be responsible for $1,750 of the $7,000 allowed plus the $3,000 above the allowed amount or $4,750 or almost 50%.
To add insult to injury TMA may not even reimburse a retiree in the Philippines his 75% even in this case. That's because in some instances, and we are not told when or why, they ask for a cancelled check or credit card receipt showing we paid the provider(s). It doesn't matter that 90% of the providers here will not accept checks or credit cards as they work on cash only and that we have an itemized bill and official government numbered receipt showing payment, they will simply not pay the claim. The regulations/manuals don't even require that a retiree pay the bill in advance and in the US it is common practice to not pay the bill in advance but to wait for Tricare to pay first. But it seems they make up the rules as they go for us.
Jim
1SG, Army Retired
Naga City, Bicol
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