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UnclassifiedPEBLO/PAD TB_v1.0tcw Bureau of Medicine and Surgery TRICARE Updates PEBLO / Patient Administration Annual Symposium - 19 May 2008.

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Presentation on theme: "UnclassifiedPEBLO/PAD TB_v1.0tcw Bureau of Medicine and Surgery TRICARE Updates PEBLO / Patient Administration Annual Symposium - 19 May 2008."— Presentation transcript:

1 UnclassifiedPEBLO/PAD TB_v1.0tcw Bureau of Medicine and Surgery TRICARE Updates PEBLO / Patient Administration Annual Symposium - 19 May 2008

2 UnclassifiedPEBLO/PAD TB_v1.0tcw Topics  Active Duty TRICARE Prime Enrollment  Multiplicious Enrollment  June 2007 DoD Task Force on Mental Health  Access to Care – Mental Health  Contractor Wounded Warrior Initiatives  Reserve Component Health Plan Coverage  TRICARE Reserve Select  Third Generation (T3) TRICARE Contracts  Misc TRICARE Program Updates

3 UnclassifiedPEBLO/PAD TB_v1.0tcw Active Duty TRICARE Prime Enrollment  Active Duty Service Members (ADSMs) are required to be enrolled in TRICARE Prime –Health Affairs Policy: 05-014 – Policy Guidance for Active Duty Service Member Enrollment to TRICARE Prime –Chief, BUMED ltr 6320 Ser/04UM3H1204046 of 8 Feb 05  Enrollment critical to identify enrolled population to structure and refine access to care initiatives and medical management programs  MTFs / PADs must continually coordinate with installation organizations to maintain enrollment during in-processing

4 UnclassifiedPEBLO/PAD TB_v1.0tcw Enrollment Guidelines ADSMs meeting the following criteria are enrolled to a Defense Medical Information System (DMIS) code specific to the MTF/Clinic responsible for providing care: ADSMs not in an initial training/student status (179 days or less) ADSMs not assigned to operational forces with organic medical assets ADSMs not (or will not be ) assigned to TRICARE Prime Remote areas

5 UnclassifiedPEBLO/PAD TB_v1.0tcw Enrollment Guidelines Cont’d Initial Entry Training/ Student Enrollment: ADSMs in initial entry training (e.g., recruit training, OCS, etc.) are not enrolled ADSMs remain in a non-enrolled status until either they arrive at their first permanent duty station or begin training at a school lasting > 179 days Post entry training students will not have their enrollment transferred during the period of training unless the school’s length is > than 179 days Students attending schools lasting ≥ 180 days are enrolled at the closest MTF

6 UnclassifiedPEBLO/PAD TB_v1.0tcw Operational Forces Enrollment ADSMs assigned to Navy and Marine Corps operational units having their own organic medical personnel (medical assets assigned to operational units, funded by the Line and staffed with at least an IDC) DMIS ID codes created in support of enrolling operational forces that are permanently stationed near a CONUS MTF Includes afloat personnel and personnel assigned to Marine Corps operational platforms OCONUS DMIS ID codes created for known concentration of permanently stationed operational forces ADSMs assigned to operational forces will be enrolled to the appropriate operational forces DMIS ID affiliated with the Parent DMIS

7 UnclassifiedPEBLO/PAD TB_v1.0tcw Current Statistics Branch of Service # Not Enrolled Total AD (>180-days) % Not Enrolled USPH3235,8225.55% USMC32,648184,54817.69% USA68,832611,70411.25% CG1,06141,3352.57% USN38,076339,17711.22% NOAA12790.36% USAF9,547339,6662.81% Total150,4811,522,5319.88%

8 UnclassifiedPEBLO/PAD TB_v1.0tcw Multiplicious Enrollment  Beneficiaries enrolled multiple times for TRICARE benefits reflecting dual-eligibility (multiplicious enrollment) –Joint Service marriages with Dependents enrolled under both Service Members –Retiree married to an AD member –Dependent child joins the Military –Spouse gets recalled / activated to AD  Critical for each MTF to identify its enrolled population to structure and refine access to care initiatives and medical management programs

9 UnclassifiedPEBLO/PAD TB_v1.0tcw Multiplicious Enrollment Cont’d DEERS to produce data extract of multiple enrollments to BUMED Distribution to MTF (enrollment site) to facilitate correction w/ Service member updating DEERS

10 UnclassifiedPEBLO/PAD TB_v1.0tcw June 2007 DoD Task Force on Mental Health  Findings Published  Comprehensive agenda for assuring that service members and family members has timely, easy access to world-class care: –Full continuum of care to support psychological health –TRICARE contractors and subcontractors monitor and report on network adequacy –Revise TRICARE standards to equate access to basic mental health services with access for basic primary medical care – seven days or fewer (depending on the severity of the presenting concern)

11 UnclassifiedPEBLO/PAD TB_v1.0tcw Mental Health Routine (ROUT) Access to Care  NAVMED Policy 008-001 forwarded to Navy Regional Commanders on 16 Jan 08 –Initial mental health assessment for new, non-urgent patient presenting with behavioral health condition or exacerbation of a previously diagnosed condition must be completed within 7-days (ROUT) –NAVMED Regional Commanders responsible for implementing, monitoring and reporting on ROUT mental health access standards beginning 31 Jan 08  Access to care (ATC) summary reports available at the TRICARE Operations Center (TOC) web site: areSummary_Rollup/

12 UnclassifiedPEBLO/PAD TB_v1.0tcw ATC TOC Data  Methodology used for ATC Summary Reports available on the TOC does not capture data from (specialty) referrals within the ROUT appointment ATC measures  Mental Health Clinics use referrals to schedule self-referral and walk-in appointments  ATC Summary Reports on TOC incorrectly reflect minimal compliance with new policy  Pending review by TOC Program Manager – Ms Jamie Miles

13 UnclassifiedPEBLO/PAD TB_v1.0tcw Contractor Wounded Warrior Initiatives  Health Net Federal Services ® (HealthNet) Warrior Care Support (WCS) Program  HealthNet’s goal is to help the member and their family focus on recovery and healing  Provides complete health care planning and coordination services for Warriors who have severely injured or combat related behavioral health diagnosis and their families  Individual Health Care Coordinator assigned for each Warrior

14 UnclassifiedPEBLO/PAD TB_v1.0tcw  Humana Military Healthcare Services® (HMHS) - Warrior Navigation and Assistance Program  Created to help guide warriors and their families through the maze of health care systems  Goal to return them to productive lives and help them over the hurdles thy encounter  Web based portal / 1-888-4GO-WNAP Contractor Wounded Warrior Initiatives

15 UnclassifiedPEBLO/PAD TB_v1.0tcw Contractor Wounded Warrior Initiatives  TriWest Healthcare Alliance ®  Dedicated Staff member poised to Address Complex Health Care Cases  Developed Specialized Units (pods) in each Hub for Warrior Care Coordination and Case Management –Extended to family members –Available to manage or to team with others managing warrior care Care Cordination Nurse Case Manager Behavioral Health Clinician

16 UnclassifiedPEBLO/PAD TB_v1.0tcw Reserve Component Health Plan Coverage RC / Guard Member Reports for Active Duty RC / Guard Member Separation Date / Release from Active Duty TRICARE Prime (Eligible 90-days Prior to Reporting) Transition Assistance Management Program (TAMP – 180 Days) Continued Health Care Benefit Program (CHCBP 18 – 36 months) TRICARE Reserve Select Critical Period Requiring Guidance

17 UnclassifiedPEBLO/PAD TB_v1.0tcw TRICARE Reserve Select (TRS) Health Plan  Premium-based health plan for qualified National Guard (NG) and Reserve members may purchase –Member of the Selected Reserve (the Sailor drills one weekend per month) of the Ready Reserve –Not eligible for or enrolled in the Federal Employees Health Benefits (FEHBP) Program  TRS coverage similar to TRICARE Standard and TRICARE Extra

18 UnclassifiedPEBLO/PAD TB_v1.0tcw TRS Restructure Effective 1 Oct 07  Eliminated three-tier program  TRS member-only = $81 / month  TRS member-and-family coverage = $251 / month  Catastrophic Cap = $1,000 (max amt you will pay for health care out of pocket each federal fiscal year) TRS Member Paygrade Member-Only Coverage Member-and- Family Coverage E-4 and below$50$100 E-5 and above$150$300 Type of ProviderOutpatient Cost-Share TRICARE Network15% of the negotiated rate TRICARE-Authorized, Non-network 20% of the allowable charge; plus fees up to 15% above the allowable charge Source:

19 UnclassifiedPEBLO/PAD TB_v1.0tcw TRICARE Contracts  Third Generation (T3) TRICARE Contract - Three Regions remain - Transition to start June 2009 w/ 10 month transition period  TRICARE Overseas Prime Contract - Three overseas Regions (Europe/Pacific/ TLAC) - RFP has not been released

20 UnclassifiedPEBLO/PAD TB_v1.0tcw Philosophy Readiness Delivery of Quality Health Care to our Beneficiaries Managed Care Support Contracts MCSCs supplement the Direct Care System Navy MTFs Navy Clinics

21 UnclassifiedPEBLO/PAD TB_v1.0tcw Contract Objectives  Optimize the delivery of health care services in the direct care system  Highest level of Beneficiary satisfaction throughout the contract  Attain “best value health care”  Fully operational services and systems at the start of health care delivery and minimal disruption to Beneficiaries at MTFs  Full and real time access to Contractor maintained data

22 UnclassifiedPEBLO/PAD TB_v1.0tcw Contract Requirements  Provider Networks  Referral Management  Medical Management –Utilization –Clinical Quality –Case –Disease Mngt –Patient transfer  Enrollment  Customer Service  Claims Processing – South Region Contractor continues to manage the Continued Health Care Benefit Program (CHCBP)  Management – multitude of program specific requirements

23 UnclassifiedPEBLO/PAD TB_v1.0tcw BUMED T3 Contract Transition Strategy  Develop and Charter Overarching Integrated Process Team (OIPT) to address T3 TRICARE Contract  Develop Transition POA&M to support T3 contract implementation  Revise/draft Navy Medicine Policy/ guidance to support T3 contract  Liaison w/ Army & Air Force OTSG TRICARE Representatives = consistency among the Services  Evaluate transition and make adjustments

24 UnclassifiedPEBLO/PAD TB_v1.0tcw Key Issues  Be aware of the T3 TRICARE Contract transition  Healthcare is local – ensure you are familiar with the benefits and the coordination between your MTF and the supporting Managed Care Support Contractor  MOU between MTF & MCSC “spells out” relationship and requirements  Referral Management services have changed –MCSC required to provide the name of the provider, date and time of appointment –Clear and Legible Reporting (CLR) of encounter now an MTF responsibility

25 UnclassifiedPEBLO/PAD TB_v1.0tcw Misc. TRICARE Updates  TRICARE Prime Travel Benefit for PCM referrals to specialists >100 miles (one way) from PCMs office  Managed Care Support Contractors implemented a Behavioral Health Care Provider Locator and Appointing (TOM, Chapter 12, Section 11) to ease the burden of locating a mental health provider for an ADSM, ADFM enrolled in TRICARE Prime, or TRICARE Prime Remote or TRICARE Prime Overseas (TOP) enrollee who has temporarily returned to the Continental U.S. (22 Dec 07)

26 UnclassifiedPEBLO/PAD TB_v1.0tcw Misc. TRICARE Updates Cont’d Access to Care (ATC) & Prime Service Area Standards –Implementation Guidance for TRICARE Policy for Access to Care and Prime Service Area Standards released by OASD ( HA) memorandum on 16 Aug 07 –Waivers of the access-to-care drive-time standards (drive less than 100 miles to the MTF to visit their PCM) for non-active duty beneficiaries through MTF Commanders to effect enrollment to the MTF –Managed Care Support Contractor (MCSC) must use at least one Web-based mapping program to estimate the driving time from the residence of an enrollee applicant to the MTF –MCSC required to keep signed, approved waivers on file on behalf of the MTF Commanders

27 UnclassifiedPEBLO/PAD TB_v1.0tcw Misc. TRICARE Updates Cont’d  Voluntary Autism Demonstration Project effective for claims on or after 15 March 08 - Enhancement to the TRICARE Extended Care Health Option (ECHO) Program for those beneficiaries w/ certain diagnosis for autism spectrum disorders - Reimbursement for behavioral-based tutoring services - Maximum cumulative Government cost-share through both ECHO and demonstration may not exceed $2,500 / any single month

28 UnclassifiedPEBLO/PAD TB_v1.0tcw Point of Contact  BUMED –CDR Tom Whippen, MSC, USN (202) 762-3146ll –Mr. Skip Katon (202) 762- 3144 –TBD/Contractor (202) 762-3774  Navy Regional TRICARE Operations –NCA CAPT Jan Carrio (301) 319-4135 / –NMW CAPT Jane Hourigan (619) 767-6586 / LCDR Scott Waniewski (619) 767-6583 / Ms. Jolene McGarvey (619) 767-6052 / –NME CAPT Deidra Flanary (757) 953-0501 / Ms. Shelley Huffman (757) 953-0456 /

29 UnclassifiedPEBLO/PAD TB_v1.0tcw Government SOW A “How to” Document Restricts design solutions Lengthy Prone to incorrect interpretation SOO Top Level Objectives Offers Flexibility Minimal Page Count Contractor Proposes the Statement of Work Supplemented by: - System Req Doc- SRD - Technical Req Doc- TRD Contractor SOW Cost effective solutions Exhibits “know-how” Encourages innovative alternatives Demonstrates understanding of problem Supplemented by spec Contracting Methodology

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