Tricare Stops Covering Molecular Pathology Tests

Tricare, which provides medical services for military families and retirees, has stopped reimbursing clinical laboratories for more than 100 molecular pathology tests, saying that new CPT codes for these tests have provided greater transparency into what it has been paying for and that it believes many of the tests it previously paid for should not be covered. According to a report in Stars and Stripes, the Defense Health Agency says the new codes allow the agency to “identify specific laboratory tests that 1) have not been approved or cleared by the Food and Drug Administration and/or 2) failed to meet Tricare criteria for coverage.” Among the tests that are no longer covered is a genetic test to determine if a woman who is pregnant carries a marker for cystic fibrosis, which would increase the chance of the baby having the disease. In a Jan. 9 letter to the assistant secretary of defense for health affairs, the Military Coalition, a consortium of military and veterans organization representing more than 5.5 million members plus their families and survivors, said the lack of Tricare reimbursement for these laboratory tests creates two standards of care for uniformed service members, retirees, and their families. “Beneficiaries who receive their health care at a [military treatment facility (MTF)] are covered for MoPath laboratory tests while beneficiaries who access care in the civilian provider network are denied coverage of these valuable tests,” writes the coalition. “In short, Tricare beneficiaries without access to the MTF are relegated to second-class health care. This is troubling on multiple levels.” According to Julie Khani, vice president of the American Clinical Laboratory Association, beneficiaries haven’t complained yet because labs had been continuing to perform tests ordered by physicians. To date, she said, labs have provided about $10 million worth of free tests to Tricare users. “That’s obviously unsustainable,” she told Stars and Stripes. Takeaway: Tricare’s decision to stop reimbursing for many molecular pathology tests administered in the civilian provider network creates two levels of care for military personnel and their families.