[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