If a beneficiary requires services under EHHC that cost more than the highest SNF RUG rate, who would be financially responsible for the balance?
The sponsor/beneficiary would be responsible for services in excess of the monthly benefit cap, in accordance with TRICARE Policy Manual, Chapter 9, Section 16.1. However, network providers who bill TRICARE may have the beneficiary sign a Waiver of Non-Covered Services (that meets the specificity requirements of TRICARE) for services provided in excess of the monthly benefit cap. If such an appropriate waiver is signed, the provider could collect their contractual allowable amount from the beneficiary. Non-network providers may bill the beneficiary up to 115% of the TRICARE allowable amount for services in excess of the monthly benefit cap.
