Updates to TRICARE’s Dialysis Benefit and New COVID-19 Treatment Add-On Payment
Friday, June 30, 2023
Changes to TRICARE’s coverage of end stage renal disease (ESRD)- and dialysis-related services goes into effect July 3, 2023, retroactive to Jan. 12, 2023. Separately, TRICARE has implemented a temporary New COVID-19 Treatments Add-On Payment (NCTAP) for diagnosis-related groups (DRG) for dates of service that occurred between Jan. 12, 2023, through May 11, 2023.
Dialysis-Covered Services Changes
TRICARE has expanded its dialysis coverage to include peritoneal dialysis and treatment for acute kidney injury. Details of TRICARE’s dialysis coverage now include inpatient and outpatient dialysis treatments, home dialysis (including training and equipment/ supplies), and other necessary drugs, services, and supplies for dialysis care. All services must be medically necessary and appropriate, and the frequency of dialysis services and training must be documented in the patient's medical record. Services provided by dialysis aids, attendants, or assistants are not covered.
More details can be found on our Dialysis page.
Freestanding Kidney Dialysis Facility Provider Type and Reimbursement Changes
TRICARE has removed freestanding kidney dialysis facilities (freestanding ESRD facilities), from the corporate services provider list and added these facilities to TRICARE’s authorized institutional provider list. To be considered a freestanding kidney dialysis facility, facilities must be Medicare certified and meet all Medicare conditions for coverage; be TRICARE participating; and accept payment as full payment as defined per TRICARE Policy Manual (TPM) Chapter 11, Section 2.10.
Freestanding kidney dialysis facilities will be reimbursed a single, flat, per-session fee, which covers facility use, general nursing services, ESRD-related lab services, pharmaceuticals, and supplies. Refer to TRICARE Reimbursement Manual (TRM), Chapter 18, Section 1 for more information.
Temporary Adoption of New COVID-19 Treatments Add-On Payment for Diagnosis-Related Groups
For dates of service between Jan. 12, 2023, through May 11, 2023, TRICARE adopted the Centers for Medicare & Medicaid Services’ (CMS) NCTAP for DRGs under CMS’ Inpatient Prospective Payment System. Hospitals can request NCTAPs for eligible inpatient TRICARE beneficiaries who received FDA-approved COVID-19 treatments during this period. We can accept NCTAP review requests via our customer service line, through our "Ask Us" secure tool (log in required), or by postal mail at Health Net Federal Services, LLC c/o PGBA, LLC/TRICARE, TRICARE West – Claims Correspondence, PO Box 202100, Florence, SC 29502-2100.
To be eligible for an NCTAP, cases must have met all three of the following criteria:
- An FDA-approved drug or biological product authorized by CMS to treat COVID-19 was used
- Dates of service(s) were between Jan. 12, 2023, through May 11, 2023
- Operating costs of the case exceeded the full DRG payment, including the DRG adjustment and any other adjustments under Section 3710 of the CARES Act
For more information on NCTAPs, refer to TRM, Chapter 1, Section 42 or CMS’ NCTAP page.
