[Federal Register Volume 63, Number 137 (Friday, July 17, 1998)]
[Notices]
[Pages 38558-38619]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-19041]
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DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE Senior Demonstration of Military Managed Care
AGENCY: Office of the Assistant Secretary of Defense (Health Affairs).
ACTION: Notice of demonstration project.
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SUMMARY: This notice is to advise interested parties of a demonstration
project in which the Department of Defense (DoD) will provide health
care services to Medicare-eligible military retirees in a managed care
program, called TRICARE Senior, and receive reimbursement for such care
from the Medicare Trust Fund. The program is authorized by section 1896
of the Social Security Act, amended by section 4015 of the Balanced
Budget Act of 1997 (P.L. 105-33). The statute authorizes DoD and the
Department of Health and Human Services (HHS) to conduct at six sites
during January 1998 through December 2000, a three-year demonstration
under which dual-eligible beneficiaries will be
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offered enrollment in a DoD-operated managed care plan, called TRICARE
Senior Prime. The legislation also authorizes Medicare HMOs to make
payments to DoD for care provided to HMO enrollees by military
treatment facilities (MTFs) participating in the demonstration. This
part of the demonstration, to be called Medicare Partners, will allow
DoD to enter into contracts with Medicare HMOs to provide specialty and
inpatient care to dual-eligible beneficiaries currently provided on a
space-available basis. Additional legal authority pertinent to this
demonstration project is 10 U.S.C. section 1092.
Under TRICARE Senior Prime, Medicare-eligible military retirees who
enroll in the program will be assigned primary care managers (PCMs) at
the MTF. Enrollees will be referred to specialty care providers at the
MTF and to participating members of the existing TRICARE Prime network.
TRICARE Senior Prime enrollees will be afforded the same priority
access to MTF care as military retiree and retiree family member
enrollees in TRICARE Prime.
DoD will receive reimbursement from HCFA on a capitated basis at a
rate which is 95 percent of the rate HCFA currently pays to Medicare-
risk HMOs, less costs such as capital and graduate medical education,
disproportionate share hospital payments, and some capital costs, which
are already covered by DoD's annual appropriation. However, under the
authorizing statute, DoD must meet its current level of effort for its
Medicare-eligible beneficiaries before receiving payments from the
Medicare Trust Fund. That is, DoD must continue to fund health care at
a certain expenditure level for its Medicare-eligible population before
it may be reimbursed by HCFA for care provided to TRICARE Senior Prime
enrollees.
The Balanced Budget Act of 1997 required DoD and HHS to complete a
memorandum of agreement (MOA) specifying the operational requirements
of the demonstration project. That MOA was completed on February 13,
1998, and is published below. Except as provided in the MOA, TRICARE
Senior Prime will be implemented consistent with applicable provisions
of the CHAMPUS/TRICARE regulation, particularly 32 CFR sections 199.17
and 199.18.
EFFECTIVE DATE: July 15, 1998.
FOR FURTHER INFORMATION CONTACT: Larry Sobel, Office of the Assistant
Secretary of Defense (Health Affairs/TRICARE Management Activity),
telephone (703) 681-1742.
Dated: July 10, 1998.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
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Attachment A--Benefits for Enrollees; Medicare Demonstration of
Military Managed Care
DoD will provide or arrange for the provision of a defined
benefit package for enrollees in the Demonstration. The benefit
package will include all services and supplies covered by the
Medicare program, plus some additional services not covered by
Medicare. The TRICARE Prime program will be the vehicle for delivery
of the benefit package, except that standard Medicare coverage of
skilled nursing facility care, home health care, and chiropractic
services will apply. Additional services in the TRICARE Prime
program that are not covered by Medicare include outpatient pharmacy
services and preventive services. In brief, the benefit package
includes coverage of medically necessary care as follows:
Medical Services
Physician's services;
Medical and surgical services and supplies;
Outpatient hospital treatment;
Mental health outpatient services;
Physical and speech therapy;
Clinical laboratory services and diagnostic tests;
Durable medical equipment and supplies;
Blood;
Clinical preventive services;
Outpatient pharmacy services.
Institutional Services
Hospitalization: semiprivate room and board, general
nursing and other hospital services and supplies;
Skilled nursing facility care: semiprivate room and
board, skilled nursing and rehabilitative services and other
services and supplies;
Home health care;
Hospice care.
Cost sharing for services is described in the attached charts.
It is anticipated that most services will be provided in military
treatment facilities, at no charge to enrollees. When enrollees use
a civilian provider, a copayment schedule will apply, featuring a
$12 per visit copayment, an $11 per diem charge for most inpatient
services, and a $9 per prescription charge.
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Attachment C--Reimbursement
Overview
This attachment, and figures 1 through 19, describe the specific
process for Medicare Program reimbursement to the Department of
Defense (DoD) and for the end-of-year reconciliation.
Medicare Interim Payments to DoD
Under the demonstration, DoD may receive interim payments for
the enrollment and treatment of its dual-eligible beneficiaries.
During the execution of the demonstration project during any
demonstration year, the department may receive a monthly per-member
per-month capitated amount for TRICARE Senior Prime enrollees when
the site's enrollment is above a specified threshold. These payments
are interim, or provisional, payments. At the end of each
demonstration year, a reconciliation will be conducted to determine
whether DoD is entitled to keep any of its interim payments, and to
determine if the amount of reimbursement was appropriate. This
appendix describes the threshold mechanism that triggers the interim
monthly payments. Then it describes the reconciliation process.
Thresholds for Reimbursement and Reconciliation
For each demonstration year and each demonstration site, DoD and
HCFA will establish a threshold that will determine whether HCFA
will reimburse DoD for enrollment at the site and determine the size
of the reimbursement. The triggering threshold derives from each
individual site's historical level of expenses for its dual eligible
beneficiaries, termed the site's ``level of effort''. Calculation of
the site's baseline level of effort is described in Appendix D.
The threshold for triggering interim payments from Medicare will
be calculated from a portion of each site's level of effort. The
portion will be 30 percent of the site's level of effort for the
first demonstration year, 40 percent in the second demonstration
year, and 50 percent in the third. The 30 percent portion for the
first demonstration year will be scaled, or prorated, to the number
of months of care delivery at each site. For example, if a site's
level of effort was $90 million and delivered care for 5 months of
the first demonstration year, the portion used to calculate a
reimbursement threshold would be $11.25 million (\5/12\ths of 30
percent of $90 million).
The monthly threshold that triggers payments will be calculated
by dividing the total dollar portion determined in the previous
paragraph by the months of care delivery for the site. Continuing
the example above, the monthly threshold will be $2.25 million
($11.25 million divided by 5 months).
HCFA will calculate the amount that it would pay for all of
DoD's enrollees under the demonstration program at a modified per
capita Medicare+Choice reimbursement rate (described in the next
section), and compare its calculated amount to the site's monthly
threshold. If the calculated amount exceeds the monthly threshold,
then HCFA will reimburse DoD for the difference as an interim
payment. If the calculated amount is below the monthly threshold,
HCFA will not make a payment to DoD for that month. Failure to
enroll up to the threshold in a month will also result in an
adjustment to interim payments from other months (described under
Annual Reconciliation below). Payments for all demonstration sites
combined are subject to a global cap for each demonstration year.
The caps are $50 million for the first demonstration year, $60
million the second year, and $65 million the third. No more than 50
percent of the cap in each year shall be available for Medicare
Partners.
Per Capita Reimbursement Rate
To calculate how much it would pay for TRICARE Senior Prime
enrollees in the reimbursement mechanism (described in the previous
section), HCFA will use the following rate. The reimbursement rate
by Medicare to DoD is 95 percent of the applicable Medicare+Choice
rate as determined under the Balanced Budget Act of 1997 (P.L. 105-
33) . In accordance with the authorizing legislation, the
Medicare+Choice rate for each county will be adjusted to remove
payments for graduate medical education (GME), indirect medical
education (IME), and disproportionate share hospital (DSH). In
accordance with the agreement by both Secretaries, 67 percent of
capital will be removed.
Annual Reconciliation
At the end of each demonstration year, DHHS and DoD will conduct
a formal reconciliation and evaluation to determine whether (1) all
site's are entitled to retain the reimbursements they received from
Medicare and (2) whether the amount of reimbursement were
appropriate. The reconciliation consists of four steps:
1. Accumulate DoD's Expenses. The first step will be to
determine the total amount of DoD expenditures across all six
demonstration site for all dual-eligible beneficiaries residing in
the service area. Two categories of expense will be accumulated: (1)
expenses for care provided on a space-available basis to non-
enrolled dual eligible beneficiaries (termed ``space-available level
of effort''), and (2) expenses for care provided to enrollees.
Expenses for providing outpatient pharmacy services will not be
included in any of the categories; nor will expenses incurred
providing services under a Medicare Partners contract for services
covered by the contract. Expenses incurred providing services not
covered by a Medicare Partners agreement will be counted as space-
available care.
Expenses for space-available care are capped at a maximum of 70
percent of the combined level of effort across all six sites during
the first demonstration year, 60 percent of the combined level of
effort during the second, and 50 percent during the third. Because
sites will be starting care delivery at varying time during the
first demonstration year, the demonstration-wide cap on space-
available expenses will be prorated during the first demonstration
year as follows. Each individual site's level of effort will be
prorated according to the number of months of care delivery during
that first demonstration year. Then, the prorated level's of effort
will be added across all six sites. Finally, 70 percent of the six
site total will be used for the first year space-available cap.
2. Determine Eligibility for Reimbursement. The second step will
be to determine whether the demonstration sites are eligible to
retain any reimbursements from Medicare. There are two tests; both
must be passed. The first compares total expenditures for all six
sites, both for enrolled and for space available care, to DoD's
combined level of effort for all sites. For any site to be eligible
to retain reimbursements from HCFA, DoD must reach its combined
level of effort.
The second test compares DoD's expenditures for enrolled care
across all demonstration sites against a minimum threshold that
varies by demonstration year. The threshold is 30 percent of the
combined six-site level of effort during the first demonstration
year, 40 percent during the second, and 50 percent during the third.
Again, the first year threshold on expenses for enrolled care will
be prorated by the number of months of care delivery during that
year in the manner similar to the way the threshold for space-
available care is prorated (described in 1. above).
3. Determine Amount of Reimbursement. If DoD has met its level
of effort for all demonstration sites, reimbursements from HCFA are
subject to two adjustments. First, gross monthly payments from HCFA
to a site will be summed over all months of a demonstration year
(months of care delivery for the first demonstration year). The
difference between this sum and the level of effort target will be
the annual reimbursement that DoD is entitled to keep at each site.
If the difference is negative, DoD will return all payments received
to HCFA. This adjustment is performed at each site.
Second, total reimbursements from HCFA may be adjusted upwards
or downwards during reconciliation if there is compelling evidence
of adverse or favorable risk selection in DoD's enrollment, when
compared with the HCFA population upon which the Medicare+Choice
rates are based. The determination will be made analytically during
as part of the reconciliation process and will be based upon
submitted claims for covered services.
Third, DoD is only entitled to retain reimbursement above the
aggregate level of effort. The level of effort will be prorated
during the first demonstration year on the basis of months of care
delivery at the various sites.
4. Provide Access to Data. The final step will be to provide
HCFA auditors and the DHHS IG with access to DoD's records and data
for demonstration sites. HCFA and DoD will develop a mutually
acceptable process for settling any disputes that arise over the
data.
Maximum Ceiling on Total Annual Medicare Reimbursement
For the demonstration project, the maximum total Medicare
reimbursement to DoD for all six demonstration sites in any
demonstration year shall not exceed $50
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million in calendar year 1998, $60 million in calendar 1999, and $65
million in calendar year 2000. The cap for the first demonstration
year will be prorated as described below. All reimbursements
received by DoD for dual-eligible enrollees from Medicare or from
Medicare Partners will count towards the annual ceiling. Should
Medicare reimbursement to DoD meet the statutory cap in any of the
project's three years, DoD will remain obligated to continue to
provide the full range of services under the TRICARE Senior Prime
benefit to all project enrollees. DoD will be financially liable for
all care provided under TRICARE Senior Prime once the annual
reimbursement cap is reached. No more than 50 percent of the cap in
each year shall be available for Medicare Partners.
For 1998, the $50 million ceiling shall be prorated based on the
estimated enrollment at each site and the number of months that each
site is operational during 1998. The ceiling for 1998 will be
determined when the last site to begin in 1998 becomes operational.
At the end of each month, DoD will report to HCFA all revenue
that it has received during that month from Medicare+Choice plans.
HCFA will track payments for TRICARE Senior Prime enrollees. If the
annual cap for that year was exceeded in a prior month, DoD will
remit all such revenue for each succeeding month to HCFA.
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Attachment D--Level of Effort
Introduction
Purpose
This attachment describes the methodology that the Department of
Defense (DoD) will use to compute the FY96 ``level of effort'' (LOE)
for each Medicare Demonstration site.
General Principles for Establishing Medicare Level-of-Effort
DoD will compute the FY96 level-of-effort (historical
expenditures for its Medicare eligible beneficiaries) separately for
the service area of each Medicare Demonstration site. Service areas
will be defined by lists of specific zip-codes for each site.
Expenses will be accumulated from a population perspective; they
will be the sum of all applicable DHP expenses for all dual eligible
beneficiaries living in the zip-codes defining the site, regardless
of where in the Military Health System those expenses were
incurred.\1\
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\1\ By contrast, a ``facility view'' of a demonstration area
would accumulate the selected DHP expenses for beneficiaries treated
by facilities operating within the service area, regardless of where
such beneficiaries reside.
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The LOE will include most direct expenses for inpatient and
outpatient care provided by military Medical Treatment Facilities
(MTFs), with some additional burdening (explained in detail below) .
It will also include the government's costs of care for Medicare
eligibles referred to providers in networks operated by the
Department's Managed Care Support Contractors. The FY96 LOE excludes
any DoD expenses comparable to those removed from the
Medicare+Choice rates as a result of the Balanced Budget Act of 1997
(e.g., expenses for Graduate Medical Education), or any types of
care specifically excluded by agreement between DoD and HCFA
(outpatient pharmacy costs). The FY96 LOE will also exclude DoD's
monthly payments for dual-eligible enrollees of Uniform Services
Treatment Facilities (USTFs) residing in the service area, unless
they participate.
It is the agreement of the administering Secretaries that FY96
will be the baseline.
Detailed Methodology
This section presents the separate methodologies used to
estimate inpatient and ambulatory expenses.
Terminology
Medicare Demonstration Sites. In accordance with current
legislation, six sites will be picked for the Medicare
Demonstration. A service area for each site will be defined
geographically by a specific list of zip-codes.
IDA Add-on. In an analysis performed for the ``733 Study,'' the
Institute for Defense Analysis (IDA) determined that certain
expenses should be added to the clinical expenses reported in the
Medical Expense and Performance Reporting System (MEPRS). Based upon
their analyses, they estimated the amounts that should be added to
inpatient and outpatient clinical expenses as a percentage add-on to
the expenses routinely reported in the clinical accounts. Their
recommended adjustments are presented in Table 1.
Patient-Level Cost Allocation. The methodology that DoD is
evolving to estimate expenses at the level of the individual patient
encounter. That methodology is described in a separate document to
be provided by DoD.
Inpatient Care
Data Sources
Direct Care
Clinical Data: Standard Inpatient Data Record (SIDR) for each
hospital discharge. Maintained in the Corporate Executive
Information System (CEIS).
Expenses: Estimated from the Medical Expense and Performance
Reporting System--Central (MEPRS), part of the Defense Medical
Information System or from the MEPRS Executive Query System (MEQS),
depending on military department.
MCSC Provider Network
Expenses: Government paid expense on Health Care Summary Records
(HCSRs) provided by the TRICARE Support Office (TSO) to the CEIS.
Methodology
Estimates of total inpatient expenses in each service area are
determined by the following process:
1. Estimate inpatient expenses for care in Military Treatment
Facilities (MTFs) for all Medicare eligibles in the service area.
a. From the CEIS, isolate the electronic summary discharge
records for all non-active duty DoD beneficiaries age 65 and older
living in the service area.
b. For each record isolated in step (1), estimate the cost of
each discharge.
(1) Estimate the cost for each individual discharge using the
Patient Level Costing Allocation (PLCA) methodology, as described in
a separate document to be provided by DoD.
(2) Apply the IDA add-ons appropriate to the treating facility.
(a) Burden the cost of each record using IDA's percentages for
DMSCC, Mgmt HQ, and Reference Labs, using the percentage developed
for the Military Department of the hospital in which the care
occurred (see Table 1). By agreement of the two administering
Secretaries, burden the cost on each record with \1/3\ of the IDA
adjustment for Construction (see Table 1).
(b) Burden each record for Continuing Health Education (MEPRS
Account FAL) and Patient Transportation/Movement (FEA/FEB/FEC) by
allocating the actual expenditures in these accounts for treating
facilities in the demonstration service area, and by the IDA
percentage add-on (Table 1) for treating facilities outside the
demonstration area. Since these accounts support all patient
categories, as well as both inpatient and outpatient services, only
a portion of their expenses will be allocated to the inpatient
treatment of Medicare beneficiaries. The amount of each account
allocated to Medicare inpatient expenses will be in the same
proportion as MEPRS A Expenses (Inpatient Clinical Expenses) for the
Medicare population are to the total of all MEPRS A and MEPRS B
(Outpatient Clinical Expenses) in FY96. The amount allocated to
Medicare inpatient expenses will be uniformly distributed across all
Medicare inpatient records.
c. For records from teaching facilities, deflate the amount
using HCFA's adjustment for Indirect Medical Education (IME) based
on that facility's count of beds and of interns and residents.
d. Sum the estimated costs for the service area.
2. Estimate inpatient expenses for care provided by the MCSC
provider networks.
a. Isolate all Health Care Summary Records for all non-active
duty DoD beneficiaries, age 65 and older, living in the service
area.
b. Total the government paid portion for all claims. [DHA1]
Outpatient Care
Data Sources
Direct Care
Clinical Data: Monthly outpatient visits by patient age and
third-level MEPRS from CHCS, as well as outpatient visits reported
by third-level in MEPRS-Central or MEQS.
Expenses: Dollars by third-level MEPRS from MEPRS-Central or
MEQS.
MCSC Provider Network
Expenses: Government paid expense on Health Care Summary Records
(HCSRs) provided by the TRICARE Support Office (TSO) to the CEIS.
Methodology
The following steps will be used to estimate outpatient expenses
in each region:
1. Estimate the outpatient expenses for Medicare eligibles at
all MTFs in the service area using the following steps.
a. Reconcile CHCS and MEPRS visit data.
(1) Annualize the CHCS data.
(2) Scale CHCS visit accounts to MEPRS or MEQs, if necessary.
b. From the rescaled CHCS visit data, determine the proportion
of visits in each workcenter (third-level MEPRS) that are for non-
active duty beneficiaries age 65 and older.
c. Apply the proportion of non-active duty beneficiaries age 65
and older to the MEPRS workcenter costs, excluding outpatient
pharmacy expenses from the stepdown to ambulatory workcenters.
d. Sum the costs for the beneficiaries under consideration
across all MEPRS workcenters to get total outpatient visit expenses
at the facility level.
e. Apply the IDA add-ons for outpatient care.
(1) Inflate each record using IDA's percentages for DMSCC, Mgmt
HQ, Reference Labs, and Clinical Investigation, using the percentage
developed for the Military Department of the hospital in which the
care occurred. By agreement of the two administering Secretaries,
burden the cost on each record with \1/3\ of the IDA adjustment for
Construction (see Table 1).
(2) Burden the total expenses from d. by expenses in Continuing
Health Education (MEPRS Account FAL) by allocating actual
expenditures in the FAL account of the
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treating facility. The amount of each account allocated to Medicare
outpatient expenses in the same proportion as MEPRS B Expenses
(Outpatient Clinical Expenses) for the Medicare population are to
the total of all MEPRS A (Inpatient Clinical Expenses) and MEPRS B
in FY96. The amount allocated to Medicare outpatient expenses will
be uniformly distributed across all Medicare outpatient records.
f. Sum the estimates for all MTFs within the service area.
2. Estimate ambulatory expenses for care provided by the MCSC
provider networks.
a. Isolate all Health Care Summary Records for all non-active
duty DoD beneficiaries, age 65 and older, living in the service
area.
b. Total the government paid portion for all claims.
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Attachment E--Medicare Demonstration of Military Managed Care
Evaluation
Medicare Demonstration Sample Evaluation Questions--These
questions are among those which may be addressed in either the GAO
report required by the demonstration project's authorizing statute
or in a separate evaluation conducted jointly by the Department of
Defense and the Department of Health and Human Services.
Can DoD and Medicare implement a cost-effective
alternative for delivering accessible and quality care to dual-
eligible beneficiaries?
The Medicare Demonstration should be able to answer the basic
question of whether DoD and Medicare can meet its objective of
implementing a cost-effective alternative for delivering care to
dual-eligible beneficiaries through MHS. The answer to this question
can be found by answering questions in four basic areas: enrollment
demand, enrollee benefits, cost of the program, and impact on other
DoD and Medicare beneficiaries for TRICARE Senior Prime and Medicare
Partners. In each there should be a question about whether the
demonstration succeeded and a set of analyses that examines the
details within that area.
(1) Benefits for Enrollees
Do dual-eligible beneficiaries benefit from Medicare
reimbursement and enrollment in terms of quality, satisfaction,
health status, access, or out of pocket costs?
Will individual patients have better outcomes if
treated as a DoD enrollee?
Will beneficiaries as a whole evince better health and
higher satisfaction when DoD enrollment is an option?
Will beneficiaries have wider managed care choices?
Will beneficiaries experience improved access to health
care in general?
By definition, enrollees will have at least as generous a
benefit as Medicare beneficiaries. The basic question will be: does
DoD fulfill this promise and what if any additional benefits accrue
to enrollees? However, the question will go much deeper than the
structure of the prime benefit. Will beneficiaries as a whole
experience better health, experience improved access, report higher
satisfaction and encounter lower out of pocket costs when DoD
enrollment is an option? In this case, we should examine the levels
of satisfaction, health status, and access between those enrolled
versus those not enrolled and between those in the demonstration
areas versus those outside the demonstration areas.
As one measure of quality, DoD facilities are JCAHO accredited
and the grid scores received will give us information on whether the
MHS is maintaining its high standard of care. Data from the Health
Care Survey of DoD Beneficiaries can be used to assess levels of
satisfaction, access, and health status.
(2) Cost of Program
Does Medicare reimbursement and enrollment occur
without increasing the costs to either the Department of Health and
Human Services and the Department of Defense?
Will the Medicare Trust Funds experience losses or
savings?
Will the government as a whole experience losses or
savings?
What impact would Medicare reimbursement and enrollment
have on the budgets of the Department of Health and Human Services
and the Department of Defense?
Again, by definition, the demonstration must be budget neutral.
However, the demonstration should provide an accounting that budget
neutrality was achieved and that no cost were shifted from DoD to
Medicare, i.e. that the Medicare trust funds did not experience any
losses. This should include an analysis of the level of effort that
DoD expends for the Medicare eligible as well as any reimbursements
from Medicare that may be triggered during the demonstration.
Analyses should also determine if DoD can in fact live within the
Medicare payment, and whether its ability to live within it is
determined by the level of the Medicare payment for different areas.
In addition, the demonstration should highlight any cost shifting
within the DoD to accommodate care for prime enrollees, both between
regions and among medical programs. For Medicare Partners payments,
analyses should estimate to what extent graduate medical education
(GME), indirect medical education (IME), and disproportionate share
hospital (DSH) amounts are included in those payments. It should
also be able to forecast future budget impacts if the demonstration
is continued or expanded.
Data for this section will be obtained in the same way that we
estimated level of effort for reimbursement purposes. Sources
include inpatient, ambulatory, and ancillary medical records and
MEPRS accounting data. Because of the concern of shifting between
regions and among medical programs, some level of aggregate data
will need to be analyzed from outside the demonstration regions.
Changes in Medicare expenditures to dual eligible beneficiaries
could be accomplished with merged DoD and HCFA files similar to
those being used for the initial level of effort analysis.
(3) Impact on Other DoD and Medicare Beneficiaries
What impact (access, quality, cost) does Medicare
reimbursement and enrollment have on medical care for DoD
beneficiaries (active duty, active duty dependents, retirees and
their dependents) other than the dual-eligible beneficiaries?
Will the demonstration affect local health care
providers or non-dual-eligible Medicare beneficiaries access to
quality care?
The effect of the Medicare Demonstration may go beyond the
effects on those who are Medicare eligible. Providing all inclusive
care for Medicare eligibles may have effects on the access and
priority of other beneficiaries in getting quality health care. The
demonstration should provide answer to whether such a new benefit
can be established without negatively impacting other classes of
beneficiaries. In particular, the main focus of this question should
be if access to non-Medicare eligible individuals has declined as a
result of the demonstration. This should be examined for the
different classes of beneficiaries and especially for active duty
personnel and their dependents. The demonstration should also
examine the effects of enrolling these individuals on CHAMPUS costs
if they are displacing other beneficiaries in the direct care
system.
Similar to (1) but for the remaining beneficiary categories, we
propose using the Health Care Survey of DoD Beneficiaries to examine
trends in access for non-Medicare eligible individuals.
(4) Enrollment Demand
Is there sufficient demand to justify enrollment of and
reimbursement for dual-eligible beneficiaries in TRICARE Senior
Prime and/or Medicare Partners?
What impact does Medicare reimbursement and enrollment
have on the use of the Military Health System by dual-eligible
beneficiaries?
Will the Medicare Demonstration fare differently in
different areas?
Up to this point, we do not know the degree to which Medicare
eligibles are interested in participating in TRICARE Senior Prime
and Medicare Partners. The demonstration should allow us to gauge
the demand for such services. If few beneficiaries sign up, then one
would question the need for such a program. Therefore, the basic
question will be the number of Medicare Prime enrollees. We will
also be interested on the total usage of the DoD system including
space available use. Prior to the demonstration, beneficiaries fall
into three categories: those who use the military system
exclusively, those who use it for some of their health care, and
those who rely exclusively on civilian care. With the demonstration,
the first category will be split into two, those who enroll and
those who use space available care for all their health care. The
demonstration should seek the answer to who enrolls (e.g. are they
prior exclusive users of DoD), what shifts between categories
occurs, and does DoD continue to support at least as many
beneficiaries as prior to the demonstration. It will also be of
interest in projecting future enrollment to measure differences in
enrollment between sites. Do those with greater military health care
capability attract more enrollees than those with limited
capability? Do civilian capabilities and alternatives influence the
beneficiaries decision to enroll?
Data for this part of the evaluation will be from three sources.
First, the enrollment files themselves will give us information on
the number and kinds of beneficiaries who sign up for TRICARE Senior
Prime. Second, the MHS User Survey can estimate the proportion of
dual eligibles in each of the three categories. This data will also
answer the questions as to what extent access of non-enrollees to
space available care and pharmacy benefits are affected. Finally,
the merging of utilization files from DoD and HCFA will give another
look at what proportion of care is seen between the two systems.
[[Page 38619]]
DOD Performance Measures Attachment F--
Enrollment Systems
Performance: DoD provides appropriate enrollment information to
HCFA; applications are handled according to HCFA requirements.
Criteria DoD can effectively interface with HCFA systems;
applications are dated when received, handled first-come, first-
served.
Grievance and Appeals
Performance: Process exists to handle beneficiary and provider
complaints.
Criteria: DoD keeps an accurate log of complaints and addresses
them promptly and appropriately.
Marketing
Performance: Process exists for assuring that beneficiaries are
well-informed (beneficiaries are not misled, misrepresentations
about the Medicare program are not made).
Criteria: DoD assures that beneficiaries are well informed,
marketing materials are reviewed by HCFA before DoD distributes
them.
Access/Capacity
Performance: DoD has adequate capacity and enrollees have
adequate access to services.
Criteria: DoD demonstrates that TRICARE Senior Prime enrollees
are getting the same priority and the same access as other military
retirees who enroll in TRICARE Prime.
Paying Providers
Performance: Systems exist for processing payment to providers.
Criteria: DoD demonstrates ability to pay providers timely and
accurately.
Reimbusement/Level of Effort
Performance: DoD has systems that receive and track payments
from HCFA, and DoD can track actual costs for both space-available
and enrollee care.
Criteria: DoD receives payment without problems; DoD
demonstrates ability to track/allocate costs for space-available and
enrollee care.
Encounter Data
Performance: DoD submits ``test'' data to fiscal intermediaries/
carriers.
Criteria: DoD demonstrates successful data transmission.
[FR Doc. 98-19041 Filed 7-16-98; 8:45 am]
BILLING CODE 5000-04-P
