[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