[Federal Register Volume 61, Number 189 (Friday, September 27, 1996)]
[Notices]
[Pages 50808-50810]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-24815]
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DEPARTMENT OF DEFENSE
Office of Secretary
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS)/TRICARE Program Overseas
AGENCY: Office of the Secretary, DoD.
ACTION: Notice of the TRICARE program to be implemented overseas.
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SUMMARY: The purpose of this notice is to describe the means by which
managed care activities designed to improve the delivery and financing
of health care services in the Military Health Services System (MHSS)
are carried out overseas.
In September, 1994 and August, 1995, (59 FR 45668 and 60 FR 43436
respectively) the Department of Defense (DoD) published a notice of a
CHAMPUS demonstration project to be implemented in Europe and the
exercise of the first of two option years, respectively. Under this
program, active duty family members who were unable to access services
in a military treatment facility (MTF) could obtain both inpatient and
outpatient services through local national medical facilities. Care
received under this demonstration project required neither the cost
shares nor deductibles normally collected for services under standard
CHAMPUS. This demonstration was proposed for the purpose of testing
whether special agreements with host nation medical providers, together
with the elimination of CHAMPUS deductibles and cost shares, could
enhance beneficiary access to required care. This demonstration is
scheduled to conclude at the end of the current fiscal year. In
October, 1995 (60 FR 52078) the TRICARE rule was published. With the
publication of this rule, DoD officially embarked on a new program to
improve the quality, cost, and accessibility of services for its
beneficiaries.
The fundamental role of U.S. military medical assets overseas is to
maximize the operational readiness of our military forces. This program
honors that fundamental responsibility and acknowledges that
operational readiness requires a commitment to active duty military
members, their families residing with them overseas and support
personnel of the Department of Defense overseas.
Unique to TRICARE overseas are several different initiatives which
will be utilized to enhance beneficiary access, to ensure quality, and
to facilitate efficiency of health care delivery, made more
challenging, given the many different countries, significant cultural
differences and languages involved. A special CHAMPUS/TRICARE program
is authorized by 32 CFR 199.17(u) for family members of active duty
members who accompany the members in their assignments in foreign
countries. Under this special program, a preferred provider network
will be established through contracts or agreements with selected
health care providers. Under the network, CHAMPUS covered services will
be provided to active duty family members who enroll in TRICARE
``Prime'' (the Health Maintenance Organization-type program) with all
CHAMPUS requirements for deductibles and copayments waived. It is
expected that, by October 1, 1997, the preferred provider network will
have been more completely developed and the mechanism for enrollment
will have matured to the extend that those who choose to enroll in
Prime and who do not obtain preauthorization for emergency care from a
non-participating provider will be subject to copays and deductibles.
Emergency care will be reimbursed at the TRICARE Prime rate. Until that
time, active duty family members who are not enrolled in TRICARE Prime,
but who obtain care from a participating provider in the network will
have cost shares and deductibles waived. After October 1, 1997, those
family members who choose not to enroll in TRICARE Prime will be
subject to the CHAMPUS copayments and deductibles. They will, of
course, retain access to the direct care system, on a space available
basis, and will be able to choose TRICARE Standard.
The Department has noted significant improvement in health care
delivery services for its beneficiaries overseas. Service members and
their families, particularly those in remote areas, have experienced
improved access to health care services. Billing practices, once a
source of major dissatisfaction among local providers, have been
streamlined, resulting in far fewer payment delays. A firm foundation
has now been installed for the Overseas TRICARE Preferred Provider
Networks, and may host nation health care providers, of all
specialities, are interested in participating. The time has come to
formalize the establishment of a basic structure for the enrollment
system, the benefit, and the network of preferred providers.
A key ingredient of most private sector health plans is enrollment
of beneficiaries in their respective health care plans. The basis
structure of health care enrollment for the MHSS, established in the
TRICARE regulation, will also apply overseas. Under this structure, all
health care beneficiaries who enroll in the TRICARE Prime option become
participants in TRICARE. Beneficiaries are classified into one of five
categories:
(1) Active duty members, all of whom will be automatically enrolled
in TRICARE Prime;
(2) TRICARE Prime enrollees, who (except for active duty members)
must be CHAMPUS-eligible;
(3) TRICARE Standard participants, which include all CHAMPUS-
eligible beneficiaries who do not enroll in TRICARE Prime; and
(4) CHAMPUS-eligible retirees who will be considered for
enrollment, beginning October 1, 1997; and
(5) Medicare-eligible beneficiaries, and other non-CHAMPUS-eligible
DoD beneficiaries, who, although not eligible for TRICARE Prime, may
participate in many features of TRICARE.
The TRICARE program overseas will employ a dual option benefit.
CHAMPUS-eligible beneficiaries will be offered two options: they may
(1) enroll to receive health care in the Health Maintenance
Organization (HMO)-type program called ``TRICARE Prime'' and have cost
shares and deductibles waived; or (2) choose to receive care under
``TRICARE Standard'' (TRICARE Standard is the same as standard
CHAMPUS), and will be subject to CHAMPUS copayments after October 1,
1997. TRICARE Prime enrollees retain the freedom to obtain services
from civilian providers on a point-of-service basis. In such cases, all
requirements applicable to standard CHAMPUS
[[Page 50809]]
apply, except that there are higher deductible and cost sharing
requirements. Under Prime, for care not authorized by the PCM or Health
Care Finder, the deductible is $300 per person and $600 per family. The
beneficiary cost share is fifty percent of the allowable charge for
inpatient and outpatient care, after the deductible.
All beneficiaries continue to be eligible to receive care in MTFs,
but active duty family members who enroll in TRICARE Prime will have
priority over other non-active duty beneficiaries.
Health benefits established for the Uniform HMO Benefit option are
applicable to CHAMPUS-eligible enrollees in TRICARE Prime overseas.
The Health Care Finder function will be established overseas. The
Health Care Finder is an administrative office that assist
beneficiaries in being referred to appropriate health care providers,
especially the MTF and civilian network providers. Health Care Finder
services are available to all Prime enrollees.
Physician liaisons will be utilized in TRICARE overseas. They will
be qualified, bilingual, host-nation providers who will serve as
liaisons to the military medical community in the local area.
Each Prime enrollee will select or be assigned a Primary Care
Manager who typically will be the enrollee's health care provider for
most services, and will serve as a referral agent to authorize more
specialized treatment, if needed. Health Care Finder offices will also
assist enrollees in obtaining referrals to appropriate providers.
Referrals for care will give first priority to the local MTF; other
referral priorities and practices will be specified during the
enrollment process.
Enrollment will occur through completion of an enrollment
application, which is processed by a TRICARE Service Center. A complete
explanation of the features, rules and procedures of the program in the
particular locality involved will be available at the time enrollment
is offered. These features, rules and procedures may be revised over
time, coincident with reenrollment opportunities.
A TRICARE Service Center will be available for each medical
treatment facility. This office will serve as the enrollees' resource
for health care information regarding health care appointments,
referrals to military or civilian health care providers, the local
preferred provider network, and patient liaison representatives.
To the extent applicable overseas, all requirements of the CHAMPUS
basic program relating to quality assurance, utilization review, and
preauthorization of care apply to the CHAMPUS components. These
requirements and procedures may also be made available to MTF services.
A major feature of the TRICARE Program is the civilian preferred
provider network. Providers in the preferred provider network are not
employees or agents of the Department of Defense or the United States
Government. Rather, they are independent entities having business
arrangements with the government. Although network providers must
follow numerous rules and procedures of the TRICARE program, on matters
of professional judgment and professional practice, the network
provider is independent and not operating under jurisdiction and
control of the Department of Defense. Overseas, the ``any qualified
provider'' method will be used. Basically, each provider will be
required to meet certain criteria, such as, speak English or provide
interpreter services, accept CHAMPUS assignment, submit bills, and
maintain credentials as required by the applicable host nation. Network
providers must be approved by the cognizant MTF commander. MTF
commanders will evaluate host nation providers for inclusion in the
network on the basis of a good record of quality, according to
guidelines and standards established and agreed upon by the Executive
Steering Committee, the Lead Agent, and/or MTF commanders, as
appropriate.
TRICARE Prime overseas will meet the same access standards as
TRICARE CONUS. Included within these standards are maximum waiting
times for primary care appointments of one day for acute care, one week
for routine care and four weeks for a well visit. Maximum wait times
for specialty care appointments are one day for urgent care and four
weeks for a routine visit (or as specified by the primary care
manager). Travel time for primary care should not exceed thirty
minutes. Travel time for specialty care is subject to local conditions
and reliance on aeromedical evacuation. Emergency and urgent care
services must be available 24 hours a day, seven days a week.
The network shall include a sufficient number and mix of qualified
specialists to meet reasonably the anticipated needs of enrollees.
Travel time for specialty care shall not exceed one hour under normal
circumstances, unless a longer time is necessary because of the absence
of providers (including providers not part of the network) in the area.
Enrollees who require services while visiting in CONUS will be
required to call a designated toll-free number for assistance with
authorization, referrals, and claims and will be subject to the normal
fees required of TRICARE Prime enrollees in CONUS, generally $6 or $12
per visit and $30 for emergency room services.
The MTF commander (or other authorized official) may establish a
preferred provider network by following the ``any qualified provider''
method set forth in the following section.
The ``any qualified provider'' method may be used to establish a
civilian preferred provider network. Under this method, any CHAMPUS-
authorized provider within the geographic area involved who meets the
qualification standards established by the MTF commander (or other
authorized official) may become a part of the preferred provider
network.
Qualifications include:
(1) The provider must be approved by the appropriate military
authority.
(2) The provider must be a Participating Provider under CHAMPUS for
all claims.
(3) The provider must meet all other qualification requirements,
and agree to all other rules and procedures that are established,
publicly announced, and uniformly applied by the commander (or other
authorized official) in a specific geographic location.
(4) The provider must enter into a formal preferred provider
network agreement covering all applicable requirements. Such agreements
will be for a duration of one year, are renewable, and may be canceled
by the provider or the MTF commander (or other authorized official)
upon appropriate notice to the other party. The Deputy Assistant
Secretary (Health Services Financing) shall establish an agreement
model or other guidelines to promote uniformity in the agreements.
All fraud, abuse, and conflict of interest requirements for the
basic CHAMPUS program are applicable to the TRICARE program overseas.
Some portions of the TRICARE program overseas may be implemented
separately; for example, a program covering a subset of health care
services, such as mental health services. In addition, a partial
implementation of TRICARE may include offering TRICARE Prime to limited
groups of beneficiaries in remote sites; some of the normal
requirements of TRICARE Prime may be waived in this regard.
The Assistant Secretary of Defense (Health Affairs), the Director,
TRICARE Support Office, and MTF commanders (or other authorized
officials) are authorized to establish administrative requirements and
procedures, consistent
[[Page 50810]]
with this section, this part, and other applicable DoD Directives or
Instructions, for the implementation and operation of the TRICARE
program overseas.
The benefit referred to in this Notice for TRICARE Prime enrollees
is the HMO Benefit option, outlined in the TRICARE regulation, which
incorporates the existing CHAMPUS benefit package, with potential
additions of preventive services and a case management program to
approve coverage of usually noncovered health care services (such as
home health services) in special situations.
EFFECTIVE DATE: October 1, 1996.
POINT OF CONTACT: Carol Ortega, Chief, Special Projects and Policy
Formulation, OASD(HA)(HSF Policy), (703) 697-8975.
Dated: September 24, 1996.
L. M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 96-24815 Filed 9-26-96; 8:45 am]
BILLING CODE 5000-04-M
