[Federal Register Volume 81, Number 120 (Wednesday, June 22, 2016)]
[Notices]
[Pages 40680-40681]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-14786]



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DEPARTMENT OF DEFENSE

Office of the Secretary


Access to Healthcare Under the TRICARE Program for Beneficiaries 
of TRICARE Prime

AGENCY: Office of the Secretary, Department of Defense.

ACTION: Notice of access to health care standards for TRICARE Prime 
beneficiaries under the TRICARE Program.

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SUMMARY: This notice is to advise interested parties of the Military 
Health System's access to health care standards addressed in Title 32, 
Code of Federal Regulations (32 CFR), Section 199.17 for TRICARE Prime 
beneficiaries under the TRICARE Program and how the Secretary of 
Defense plans to ensure that beneficiaries under TRICARE Prime who are 
seeking an appointment for health care will obtain an appointment 
within established access to health care standards. Access to health 
care under the TRICARE Program for TRICARE Prime beneficiaries was 
established in October 1995 and remains current.

ADDRESSES: Defense Health Agency, TRICARE Health Plan, 7700 Arlington 
Boulevard, Suite 5101, Falls Church, Virginia 22042-5101.

FOR FURTHER INFORMATION CONTACT: Ms. Michelle Graves, TRICARE Health 
Plan, telephone (703) 681-0039.

SUPPLEMENTARY INFORMATION: 

A. Background on Access to Health Care for TRICARE Prime Beneficiaries 
Under the TRICARE Program

    Section 704 of the National Defense Authorization Act for Fiscal 
Year 2016 (NDAA for FY16) requires the Secretary of Defense to 
establish and publicize access to care standards for beneficiaries 
enrolled in TRICARE Prime at military treatment facilities (MTFs) or 
with civilian network providers. The Department has already established 
Prime maximum wait times and travel distances for Prime primary and 
specialty care appointments as required by Section 704 of the NDAA for 
FY 2016.
    Access to care standards for TRICARE Prime enrollees have been in 
place since the start of the TRICARE Prime program in 1995. TRICARE 
Prime access standards were published in a Federal Register notice on 
October 5, 1995 (60 FR 52100-52101) and promulgated in 32 CFR 
199.17(p)(5)(i-v). These same standards are also disseminated 
throughout the Military Health System via Assistant Secretary of 
Defense (Health Affairs) Memorandum 11-005, ``TRICARE Policy for Access 
to Care,'' dated February 23, 2011. Finally, these standards are 
incorporated by reference in existing and future TRICARE regional 
support contracts. TRICARE Prime access to health care standards apply 
regardless of the location of the beneficiary's primary care manager 
(military treatment facility or civilian network).

B. Description of the Health Care Access Standards for TRICARE Prime 
Beneficiaries

    The health care access standards outlined in this notice are set 
forth in 32 CFR 199.17(p)(5)(i-v). These access standards remain 
current and in force without any amendment to date.
    Access standards. Preferred provider networks will have attributes 
of size, composition, mix of providers, and geographical distribution 
so that the networks, coupled with the MTF capabilities, can adequately 
address the health care needs of the enrollees. The capabilities of the 
MTF plus preferred provider network will meet the following access 
standards with respect to the needs of the expected number of 
enrollees:
    (i) Under normal circumstances, enrollee travel time may not exceed 
30 minutes from home to primary care delivery site unless a longer time 
is necessary because of the absence of providers (including providers 
not part of the network) in the area.
    (ii) The wait time for an appointment for a well-patient visit or a 
specialty care referral shall not exceed four weeks; for a routine 
visit, the wait time for an appointment shall not exceed one week; and 
for an urgent care visit the wait time for an appointment shall be 
within 24 hours. (The specialty care time standard does not apply in 
the case of a follow-up appointment that for clinical reasons is 
specifically stated for a later period.)
    (iii) Emergency services shall be available and accessible to 
handle emergencies (and urgent care visits if not available from other 
primary care providers pursuant to paragraph (p)(5)(ii) of 32 CFR 
199.17), within the service area 24 hours a day, seven days a week.
    (iv) The network shall include a sufficient number and mix of board 
certified 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. This requirement does not apply under the 
Specialized Treatment Services Program.
    (v) Office waiting times in non-emergency circumstances shall not 
exceed 30 minutes, except when emergency care is being provided to 
patients, and the normal schedule is disrupted.

C. Description of How the Secretary of Defense Plans To Ensure That 
Beneficiaries Under TRICARE Prime Who Are Seeking an Appointment for 
Health Care Will Obtain an Appointment Within Established Access to 
Health Care Standards

    In an effort to ensure TRICARE Prime beneficiaries obtain an 
appointment within access to health care standards at an MTF, the 
Military Health System implemented a first-call resolution policy in 
calendar year 2015. This policy outlines standard processes to ensure 
TRICARE Prime beneficiaries are not asked to call back to the MTFs if 
no appointments are available within the established access to health 
care standards. The policy also identifies responsibilities of MTF 
Directors, primary care, specialist care and other stakeholders 
identified in the appointing process to ensure patient satisfaction for 
our beneficiaries. The policy outlines specific procedures to correctly 
transfer calls in accordance with existing access to care standards, 
referral management protocols and proper use of managing clinic 
schedules to ensure appointing success the first time one of our 
beneficiaries seeks access. In addition, a Joint Outpatient Experience 
Survey will be used to measure the impact of the first-call resolution 
policy from beneficiaries' perspectives on whether they obtained an 
appointment within health care access standards.
    For those TRICARE Prime beneficiaries seeking an appointment with a 
TRICARE Prime civilian network provider, if the beneficiary cannot be 
scheduled for a visit in the MTF or TRICARE Prime network within the 
access to care standards, the beneficiary will be authorized an out-of-
network provider visit with no point-of-service charge. The TRICARE 
Reimbursement Manual will be revised to reflect the above statement. In 
addition, as stated in the TRICARE Operations Manual (TOM Chapter 1, 
Section 3, Paragraph 1.0), ``Contractors are charged with providing or 
arranging for delivery of quality, timely health care services and have 
the responsibility for providing the timely and accurate processing of 
all claims received into their custody, whether for network or non-
network care.''

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D. Communications

    The Defense Health Agency will post the TRICARE Prime access to 
care standards on the TRICARE.mil Web site and execute a strategic 
communication plan to educate beneficiaries enrolled in TRICARE Prime 
about the access to care standards.

    Dated: June 17, 2016.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2016-14786 Filed 6-21-16; 8:45 am]
 BILLING CODE 5001-06-P