[Federal Register Volume 63, Number 219 (Friday, November 13, 1998)]
[Notices]
[Pages 63456-63458]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-30309]
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DEPARTMENT OF DEFENSE
Office of the Secretary
MacDill 65 Demonstration of Military Managed Care
AGENCY: Department 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 DoD will enroll up to 2,000 Medicare-eligible military
retirees at MacDill Air Force Base to primary care managers. The
MacDill 65 demonstration project seeks to show that a DoD-operated
program can provide primary health care services to beneficiaries
eligible for both military health care and Medicare more effectively
and efficiently than under the current DoD-operated system. In this
project, DoD will grant enrollees in the program priority access to
primary health care at MacDill in exchange for their agreement to
receive all of their primary health care from MacDill AFB. Additional
services, available at the military treatment facility at MacDill AFB,
will be granted to these enrollees at a higher priority than that
granted to other retirees and their family members not enrolled in
TRICARE Prime. Funding for the demonstration for care provided will
come from an additional $2 million per year over the current level of
DoD expenditures on care provided to the MacDill AFB Medicare-eligible
population. Claims for care provided to enrollees outside the MTF will
be submitted to Medicare on a fee-for-service basis by the civilian
provider. At the end of the project, DoD will conduct an analysis of
the benefits and costs of the program. DoD will conduct the
demonstration over three years, from October 1, 1998, to September 30,
2001. This demonstration project is being conducted under the authority
of 10 USC 1092.
EFFECTIVE DATE: October 1, 1998.
FOR FURTHER INFORMATION CONTACT:
Steve Lillie, TRICARE Management Activity (703) 681-1745.
SUPPLEMENTARY INFORMATION:
A. Background
DoD-provided health care for Medicare-eligible military retirees
has always been available at MTFs on a space-available basis. Federal
law (10 U.S.C. 1086(d)) excludes Medicare-eligible military retirees,
survivors, and family members (with the exception of those eligible for
Medicare because of a disability or end-stage renal disease) from
participation in the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS), the DoD-sponsored health care benefit for
military dependents and retirees. When DoD began the transition to the
TRICARE program in 1995, the Department again determined it was
necessary to exclude Medicare beneficiaries from enrollment in TRICARE
Prime, DoD's HMO-like program, based on their exclusion from CHAMPUS
and the statutory requirement that TRICARE Prime not increase costs.
In the past, many Medicare beneficiaries have obtained substantial
amounts of health care at MTFs. However, because of military budget
cutbacks, a series of military base closures, and increased demand for
MTF resources from a growing retiree population, Medicare-eligible
beneficiaries are finding it increasingly difficult to obtain care at
MTFs in many locations.
Also contributing to the reduction of space-available care for
Medicare-eligible beneficiaries is the establishment of a priority
system for access to MTF care. As mandated by 10 U.S.C. 1097(c), first
priority is granted to active duty personnel. Active duty dependents
enrolled in TRICARE Prime are assured of second priority over enrolled
military retirees and their dependents, who enjoy third priority.
Active duty dependents who are not enrolled in Prime are accorded
fourth priority. Medicare-eligible beneficiaries are in the fifth and
lowest priority group, along with other non-enrolled retirees.
[[Page 63457]]
B. Description of MacDill 65 Project
(1) Location of Project: MacDill 65 will be conducted in the
catchment area of MacDill Air Force Base, Florida. The catchment area
is a 40-mile radius around the base and is identified by zip codes.
(2) MacDill 65 Schedule: Prior to the beginning of health care
delivery under this demonstration, 1998, MacDill AFB will issue public
announcements providing information about the MacDill 65 program and
the enrollment process. These announcements will include the posting of
notices in the MTF and publication in local newspapers serving the
MTF's catchment areas. The public announcements will indicate that a
30-day application acceptance period will begin, followed approximately
30 days later by the start date of health care delivery under MacDill
65. The project will continue for a maximum of three years to September
30, 2001.
(3) Eligible Population: To be eligible to be enrolled in MacDill
65, a military retiree must (1) be eligible for care from DoD and
through Medicare's aged program, (2) be enrolled in Medicare Part B,
(3) not be enrolled in a Medicare HMO, (4) reside within the catchment
area of MacDill AFB, and (5) have received medical services at MacDill
AFB as a dual-eligible beneficiary prior to August 1, 1998, or became
eligible for Medicare on or after August 1, 1998.
(4) Enrollment Capacity: There will be 2,000 slots in MacDill 65
enrollment capacity. Additionally, MacDill will offer enrollment to all
otherwise eligible applicants who become Medicare-eligible during the
demonstration and who, immediately prior to reaching age 65, were
enrolled in TRICARE Prime and assigned to a MacDill AFB primary care
manager.
(5) Enrollment: Enrollment will be on a first-come/first-served
basis. Enrollment applications will be accepted by mail at an address
designated by MacDill AFB. If capacity is reached, applications
received on the same day will be placed on a waiting list, up to a
specified limit, again, in the order in which they are received, and
applicants will be granted enrollment as existing enrollment slots are
vacated. MacDill will limit its waiting list to a number equal to 10%
of its maximum MacDill 65 enrollment capacity as described above.
Marketing and educational meetings began July 1998. Applications
were accepted by mail through the month of August. In September, a
lottery was used to select the 2,000 enrollees from the applications
received. During that time, educational briefings were provided.
Applications were available and were accepted by mail.
Enrollment in MacDill 65 is for three years. Beneficiaries may
leave the program at any time by submitting a written request. There
will be no enrollment fees for MacDill 65, although enrollees will be
required to maintain their enrollment in Medicare Part B through the
payment of monthly premiums.
As a condition of enrollment, each dual-eligible beneficiary will
be asked to receive all of his or her primary health care, except
emergency or urgent care, through the MacDill 65 program. If an
enrollee requires medical care beyond the scope of primary care, a
referral will be provided by the primary care manager. The referral
providers may be MTF providers, providers in the TRICARE managed care
support contractor's network or other civilian providers who agree to
accept Medicare assignment. Enrollees may self-refer or accept the
primary care manager's referral. Enrollees may not seek care at an MTF
other than through their MTF primary care manager, to whom they have
been guaranteed priority access as described below. Those Medicare-
eligible beneficiaries who are not enrolled in MacDill 65 will remain
eligible for space-available care at the MTF.
(6) Services Covered: The MacDill 65 benefit is a primary care
benefit with additional services to the extent available at the MTF.
Enrollees will be assigned a primary care manager at MacDill AFB and
will be guaranteed access to primary care at the MTF in accordance with
the TRICARE Prime access standards (32 CFR 199.17(p)(5)). With respect
to non-primary care, additional services, available at the military
treatment facility at MacDill AFB, will be granted to these enrollees
at a higher priority than that granted to other retirees and their
family members not enrolled in TRICARE Prime. Enrollees will not
displace TRICARE Prime enrollees, however. There will be no enrollee
cost shares associated with care provided at the MTF with the exception
of the minimal per diem costs incurred by those receiving inpatient
care.
For medical care not available at MacDill AFB, MacDill AFB will
refer MacDill 65 enrollees to providers who accept Medicare assignment
in the local area. For all medically necessary specialty care, an
appropriate referral will be made. Alternatively, the enrollee may
chose to obtain services from another Medicare-eligible provider. The
cost of care provided outside the MTF is not the responsibility of
MacDill AFB. Rather, claims for care provided by civilian providers for
MacDill 65 enrollees will be submitted to Medicare on a fee-for-service
basis. While an enrollee should receive a referral to the civilian
provider from DoD, Medicare regulations will govern payment for such
care. Accordingly, the Medicare fiscal intermediary or carrier will
have the authority to determine whether a service is a Medicare-covered
benefit and will determine the allowable rates and the applicable cost
shares and deductibles. Depending upon Medicare payments rules, payment
for care by a civilian provider ultimately will be the responsibility
of the MacDill 65 enrollee.
MacDill 65 enrollees will have access to the complete drug
formulary of the MTF, without regard to whether the prescription was
written by an MTF or civilian provider. DoD will not guarantee that a
drug prescribed by a provider, either at the MTF or in the civilian
sector, will be available at the MTF pharmacy. Prescriptions which must
be filled outside the MTF will be the financial responsibility of the
enrollee.
Impact of Demonstration Project on Access to Care for Non-Enrolled
Medicare-Eligible Beneficiaries
The goal of the MacDill 65 project is to develop a primary care
benefit for Medicare-eligible beneficiaries, which will better ensure
their access to military health care. This will enable DoD to offer
more predictable access to military health care to a limited number of
Medicare-eligible beneficiaries and will allow DoD to provide such care
in a more cost-effective manner than the current space-available
system.
Enrollees in MacDill 65 will benefit from improved access to a
broader range of services at MTFs than they currently receive under the
space-available system. The current system provides limited amounts of
care to a large number of Medicare-eligibles. As a result of the
implementation of MacDill 65, those who are not enrolled in the
program, either by choice or lack of available enrollment slots will
probably find their access to space-available MTF care more limited
than it is currently. This is because resources currently devoted to
space-available care are expected to be shifted to the care of MacDill
65 enrollees. It is important to note that the eligibility of non-
enrolled beneficiaries to space-available care in MTFs is not affected
by their enrollment status. However, the actual availability of space
for this group is likely to decrease. While this may result in
[[Page 63458]]
higher out-of-pocket costs and reduced convenience for Medicare-
eligible beneficiaries as they seek health care using their Medicare
benefit, the Department believes that successful conduct of the MacDill
65 project will demonstrate the Department's ability to operate a cost-
effective primary care program for Medicare-eligible beneficiaries.
The Department is also aware that the requirement for all MacDill
65 enrollees to have Medicare Part B represents an increased cost for
those who rely solely on no-cost, space-available care at the MTF.
However, Medicare regulations require Medicare-risk HMO members to also
be enrolled in Part B. As the Department is strongly supportive of
Medicare Subvention legislation, it is one of the reasons the
Department has implemented a policy of encouraging military retirees to
enroll in Part B upon reaching age 65. Also, enrollees in MacDill 65
will require Part B coverage to submit claims to Medicare for civilian
provider services.
Dated: November 6, 1998.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 98-30309 Filed 11-12-98; 8:45 am]
BILLING CODE 5000-04-M