TRICARE Access to Care Demonstration Project, 12080-12081 [2011-4863]
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Federal Register / Vol. 76, No. 43 / Friday, March 4, 2011 / Notices
AGENCY:
official duties require access to the
information are trained in the proper
safeguarding and use of the information
and received Information Assurance and
Privacy Act training.
RETENTION AND DISPOSAL:
Upon reassignment from DLA, records
are destroyed after 1 year.
Director, DLA Human Resources
Center-Military, Military Personnel and
Administration (DHRC–M), 8725 John J.
Kingman Road, Suite 2533, Fort Belvoir,
VA 22060–6221, and the Heads of the
DLA Primary Level Field Activities.
NOTIFICATION PROCEDURE:
Individuals seeking to determine
whether information about themselves
is contained in this system should
address written inquiries to the DLA
Privacy Office, Headquarters, Defense
Logistics Agency, Attn: DGA, 8725 John
J. Kingman Road, Suite 1644, Fort
Belvoir, VA 22060–6221.
Inquiries should contain the
individual’s full name, SSN, mailing
address and telephone number.
RECORD ACCESS PROCEDURES:
Individuals seeking access to
information about themselves contained
in this system should address written
inquiries to the DLA Privacy Office,
Headquarters, Defense Logistics Agency,
Attn: DGA, 8725 John J. Kingman Road,
Suite 1644, Fort Belvoir, VA 22060–
6221.
Inquiries should contain the
individual’s full name, SSN, mailing
address and telephone number.
CONTESTING RECORD PROCEDURES:
The DLA rules for accessing records,
for contesting contents, and appealing
initial agency determinations are
contained in 32 CFR part 323, or may
be obtained from the DLA Privacy
Office, Headquarters, Defense Logistics
Agency, Attn: DGA, 8725 John J.
Kingman Road, Suite 1644, Fort Belvoir,
VA 22060–6221.
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Information is provided by the
individual, taken from military
personnel records, and position
distribution reports.
EXEMPTIONS CLAIMED FOR THE SYSTEM:
None.
[FR Doc. 2011–4929 Filed 3–3–11; 8:45 am]
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ACTION:
a. Background
Office of the Secretary
TRICARE Access to Care
Demonstration Project
Department of Defense.
Notice of demonstration project.
This notice is to advise
interested parties of a Military Health
System (MHS) Demonstration project
under the authority of Title 10, U.S.
Code, Section 1092, entitled Department
of Defense TRICARE Access to Care
Demonstration Project. The
demonstration project is intended to
improve access to urgent care including
minor illness or injury for Coast Guard
beneficiaries enrolled in TRICARE
Prime or TRICARE Prime Remote while
decreasing emergency room visits and
healthcare costs. Under the
demonstration, Coast Guard active duty
service members (ADSMs) and their
family members who are enrolled in
TRICARE Prime or TRICARE Prime
Remote in the South Region would be
allowed to self-refer, without an
authorization, to a TRICARE network
provider such as an Urgent Care Clinic
(UCC) or Convenience Center for up to
four urgent care visits per year. No
referral from their Primary Care
Manager (PCM) or authorization by a
Health Care Finder will be required and
no Point of Service (POS) deductibles
and cost shares shall apply to these four
unmanaged visits. Additionally, when
outside of the South region, these Coast
Guard TRICARE Prime or Prime Remote
enrollees may use any TRICARE
authorized provider or UCC without
incurring POS deductibles and cost
shares. The ADSM and family member
will be required to notify their PCM of
any urgent/acute care visits to other
than their PCM within 24 hours of the
visit and schedule any follow-up
treatment that might be indicated with
their PCM. If more than the four (4)
authorized urgent care visits are used, or
if the beneficiary seeks care from a non
TRICARE network or non TRICARE
authorized provider, POS deductibles
and cost shares as required by Title 32,
Code of Federal Regulations (CFR),
199.17(n)(3) may apply. Referral
requirements for specialty care and
inpatient authorizations will remain as
currently required by MHS policy.
DATES: This demonstration will be
effective 60 days from the date of this
notice for a period of twenty-four (24)
months.
SUMMARY:
SYSTEM MANAGER(S) AND ADDRESS:
RECORD SOURCE CATEGORIES:
5111 Leesburg Pike, Suite 810, Falls
Church, VA 22041.
FOR FURTHER INFORMATION CONTACT: For
questions pertaining to this
demonstration project, please contact
Ms. Shane Pham at (703) 681–0039.
SUPPLEMENTARY INFORMATION:
DEPARTMENT OF DEFENSE
TRICARE Management
Activity (TMA), Health Plan Operations,
ADDRESSES:
PO 00000
Frm 00068
Fmt 4703
Sfmt 4703
Access for acute episodic primary
care continues to be in high demand by
TRICARE Prime beneficiaries. The
current regulations require that if a
Prime beneficiary seeks care from a
provider other than their PCM, they
must first obtain a referral. Otherwise,
the care will be covered under the
point-of-service option at greater out-ofpocket cost to the Prime beneficiary.
This includes urgent care which
TRICARE defines as medically
necessary treatment for an illness or
injury that would not result in further
disability or death if not treated
immediately but that requires
professional attention within 24 hours.
On the other hand, emergency care
defined as a medical, maternity or
psychiatric condition that would lead a
‘‘prudent layperson’’ (someone with
average knowledge of health and
medicine) to believe that a serious
medical condition existed, or the
absence of medical attention would
result in a threat to his or her life, limb
or sight and requires immediate medical
treatment or which has painful
symptoms requiring immediate
attention to relieve suffering, does not
require an authorization. Often when a
Prime beneficiary needs urgent care
after hours or when the PCM does not
have available appointments, the Prime
beneficiary will seek care from civilian
sources such as emergency rooms (ER).
While many Prime beneficiaries pay no
out-of pocket costs for ER services, the
average cost for an ER visit is much
higher than an urgent care visit. In many
cases, using the ER is not necessary, and
a patient’s condition can be treated
through urgent care. However, TRICARE
has found it difficult to enforce the
required point-of-service charges when
an ER visit was for urgent care and not
a true medical emergency.
There are 25,781 Coast Guard active
duty service members and their family
members enrolled in TRICARE Prime in
the South Region. In the South Region,
beneficiary ER visits are currently
averaging 197 ER visits/1,000
beneficiaries per year and that number
is slowly increasing. Analysis indicates
much of the care rendered in these ER
visits is for acute or chronic conditions
that are not true life threatening
emergencies and may have been better
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Federal Register / Vol. 76, No. 43 / Friday, March 4, 2011 / Notices
suited for care by the PCM or in an
urgent care setting.
b. Implementation
This demonstration will be effective
60 days from the date of this notice for
a period of twenty-four (24) months.
c. Evaluation
The results of this Demonstration will
allow a focused study of the impact of
this process on: (1) The reduction of ER
utilization and resulting costs, (2)
assessment of the availability and
accessibility of less expensive acute care
services such as UCCs, (3) reduction of
administrative processes, and (4) impact
on Coast Guard active duty service
members and their families. The
evaluation/analysis of the
demonstration would use Fiscal Year
2008 as the base line with follow-up
data analysis conducted at each 6month interval throughout the 24 month
period to monitor of ER and TRICARE
authorized UCC utilization workload
and cost (claims data). Success of the
demonstration would be determined by
consistent shifts in health care
utilization from ERs to a TRICARE
authorized UCCs by 15–20%. A less
than 5% shift in utilization from the ER
to a TRICARE authorized UCCs would
be considered insignificant.
Dated: March 1, 2011.
Morgan F. Park,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
[FR Doc. 2011–4863 Filed 3–3–11; 8:45 am]
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DEPARTMENT OF DEFENSE
Office of the Secretary
Notice of Two-Year Continuation of
Disease Management Demonstration
Project for TRICARE Standard
Beneficiaries
Department of Defense.
ACTION: Notice of Two-Year
Continuation of Disease Management
Demonstration Project for TRICARE
Standard Beneficiaries.
AGENCY:
This notice is to advise
interested parties of the continuation of
a Military Health System (MHS)
demonstration project entitled ‘‘Disease
Management Demonstration Project for
TRICARE Standard Beneficiaries’’. The
original demonstration notice was
published on June 13, 2007 (72 FR
32628–32629) and described a
demonstration project to provide
disease management (DM) services to
TRICARE Standard beneficiaries in
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SUMMARY:
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addition to the TRICARE Prime
beneficiaries who were already entitled
to such services. TRICARE began the
demonstration project in March 2007 for
Standard beneficiaries and this
demonstration project has enabled the
MHS to provide uniform policies and
practices on disease and chronic care
management throughout the TRICARE
network. Additionally, the
demonstration has helped determine the
effectiveness of DM programs in
improving the health status of
beneficiaries with targeted chronic
diseases or conditions, and any
associated cost savings. The TRICARE
Management Activity (TMA) chose a
phased approach to determine the
efficacy and cost effectiveness of its
disease management demonstration,
beginning with beneficiaries identified
with the disease states of asthma, heart
failure, and diabetes. TMA now intends
to continue the disease management
services to TRICARE Standard
beneficiaries until a permanent
TRICARE disease management benefit
(per the John Warner National Defense
Authorization Act of 2007, section 734)
is implemented. This continuation of
the disease management demonstration
project will be conducted under the
authority provided in 10 U.S.C. 1092.
DATES: Effective date: The extension of
the demonstration will be effective
April 1, 2011 and will continue for a
period of two years until March 31,
2013.
ADDRESSES: TRICARE Management
Activity (TMA), 5111 Leesburg Pike,
Suite 810, Falls Church, VA 22041–
3206.
FOR FURTHER INFORMATION CONTACT:
Robin Marzullo, Disease Management
Nurse Consultant, Population Health
and Medical Management—TRICARE
Management Activity, telephone (703)
681–6717 x 1214.
SUPPLEMENTARY INFORMATION:
A. Background
For additional information on the
TRICARE demonstration project for
disease management, please see 72 FR
32628–32629 and 74 FR 11089–11090.
The original demonstration notice
focused on explaining the differences
between the disease management
benefits available to TRICARE Standard
and TRICARE Prime beneficiaries and
the manner in which disease
management services had been provided
prior to the demonstration. The prior
notice explained that for purposes of the
demonstration, the Department of
Defense (DoD) would waive, for these
disease management services provided
to Standard beneficiaries, the provisions
PO 00000
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12081
of 10 U.S.C. 1079(a)(13) and 32 CFR
199.4(g)(39) that expressly exclude
clinical preventive services for
TRICARE Standard beneficiaries. The
prior notice also explained the
enrollment process and cap on disease
management costs.
B. Description of Extension of
Demonstration Project
Under this demonstration, DoD has
waived, for disease management
services provided to TRICARE Standard
beneficiaries, the provisions of 10 U.S.C.
1079(a)(13) and 32 CFR 199.4(g)(39) that
expressly exclude clinical preventive
services for TRICARE Standard
beneficiaries in the current benefit. The
Military Health System (MHS) has
enrolled TRICARE Standard
beneficiaries in its disease management
programs. Disease management services
provided to Standard beneficiaries have
included, but have not been limited to:
Clinical preventive examinations,
patient education and counseling
services, and periodic screening exams.
MHS disease management program
costs have been capped not to exceed
the amount approved by the contracting
officer. The disease management
program costs are total costs of disease
management services provided to both
Prime and Standard beneficiaries. Only
those beneficiaries identified by the
TRICARE Management Activity (TMA)
for disease management of asthma, heart
failure, diabetes, COPD, depression,
anxiety, and cancer, have been included
in the current program. Beneficiaries
identified by TMA are included in the
disease management program unless
they choose to opt out. This action
directly reduces variation across the
system and results in improved
consistency and quality for beneficiaries
with targeted chronic illness, regardless
of TRICARE classification. Furthermore,
including TRICARE Standard
beneficiaries in current disease
management efforts informs the MHS
about total potential savings and return
on investment (ROI) associated with
disease management, a stated
requirement of the John Warner
National Defense Authorization Act for
Fiscal Year 2007. Continuing to provide
disease management services to all
TRICARE beneficiaries will continue to
maintain our overall quality of care
throughout the MHS program. By
educating patients about their disease
and helping them manage their
symptoms, many of the complications of
these diseases can be avoided, possibly
slowing the progression of their chronic
disease, thus resulting in significant cost
savings.
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]]>Agencies
[Federal Register Volume 76, Number 43 (Friday, March 4, 2011)]
[Notices]
[Pages 12080-12081]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-4863]
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE Access to Care Demonstration Project
AGENCY: Department of Defense.
ACTION: Notice of demonstration project.
-----------------------------------------------------------------------
SUMMARY: This notice is to advise interested parties of a Military
Health System (MHS) Demonstration project under the authority of Title
10, U.S. Code, Section 1092, entitled Department of Defense TRICARE
Access to Care Demonstration Project. The demonstration project is
intended to improve access to urgent care including minor illness or
injury for Coast Guard beneficiaries enrolled in TRICARE Prime or
TRICARE Prime Remote while decreasing emergency room visits and
healthcare costs. Under the demonstration, Coast Guard active duty
service members (ADSMs) and their family members who are enrolled in
TRICARE Prime or TRICARE Prime Remote in the South Region would be
allowed to self-refer, without an authorization, to a TRICARE network
provider such as an Urgent Care Clinic (UCC) or Convenience Center for
up to four urgent care visits per year. No referral from their Primary
Care Manager (PCM) or authorization by a Health Care Finder will be
required and no Point of Service (POS) deductibles and cost shares
shall apply to these four unmanaged visits. Additionally, when outside
of the South region, these Coast Guard TRICARE Prime or Prime Remote
enrollees may use any TRICARE authorized provider or UCC without
incurring POS deductibles and cost shares. The ADSM and family member
will be required to notify their PCM of any urgent/acute care visits to
other than their PCM within 24 hours of the visit and schedule any
follow-up treatment that might be indicated with their PCM. If more
than the four (4) authorized urgent care visits are used, or if the
beneficiary seeks care from a non TRICARE network or non TRICARE
authorized provider, POS deductibles and cost shares as required by
Title 32, Code of Federal Regulations (CFR), 199.17(n)(3) may apply.
Referral requirements for specialty care and inpatient authorizations
will remain as currently required by MHS policy.
DATES: This demonstration will be effective 60 days from the date of
this notice for a period of twenty-four (24) months.
ADDRESSES: TRICARE Management Activity (TMA), Health Plan Operations,
5111 Leesburg Pike, Suite 810, Falls Church, VA 22041.
FOR FURTHER INFORMATION CONTACT: For questions pertaining to this
demonstration project, please contact Ms. Shane Pham at (703) 681-0039.
SUPPLEMENTARY INFORMATION:
a. Background
Access for acute episodic primary care continues to be in high
demand by TRICARE Prime beneficiaries. The current regulations require
that if a Prime beneficiary seeks care from a provider other than their
PCM, they must first obtain a referral. Otherwise, the care will be
covered under the point-of-service option at greater out-of-pocket cost
to the Prime beneficiary. This includes urgent care which TRICARE
defines as medically necessary treatment for an illness or injury that
would not result in further disability or death if not treated
immediately but that requires professional attention within 24 hours.
On the other hand, emergency care defined as a medical, maternity or
psychiatric condition that would lead a ``prudent layperson'' (someone
with average knowledge of health and medicine) to believe that a
serious medical condition existed, or the absence of medical attention
would result in a threat to his or her life, limb or sight and requires
immediate medical treatment or which has painful symptoms requiring
immediate attention to relieve suffering, does not require an
authorization. Often when a Prime beneficiary needs urgent care after
hours or when the PCM does not have available appointments, the Prime
beneficiary will seek care from civilian sources such as emergency
rooms (ER). While many Prime beneficiaries pay no out-of pocket costs
for ER services, the average cost for an ER visit is much higher than
an urgent care visit. In many cases, using the ER is not necessary, and
a patient's condition can be treated through urgent care. However,
TRICARE has found it difficult to enforce the required point-of-service
charges when an ER visit was for urgent care and not a true medical
emergency.
There are 25,781 Coast Guard active duty service members and their
family members enrolled in TRICARE Prime in the South Region. In the
South Region, beneficiary ER visits are currently averaging 197 ER
visits/1,000 beneficiaries per year and that number is slowly
increasing. Analysis indicates much of the care rendered in these ER
visits is for acute or chronic conditions that are not true life
threatening emergencies and may have been better
[[Page 12081]]
suited for care by the PCM or in an urgent care setting.
b. Implementation
This demonstration will be effective 60 days from the date of this
notice for a period of twenty-four (24) months.
c. Evaluation
The results of this Demonstration will allow a focused study of the
impact of this process on: (1) The reduction of ER utilization and
resulting costs, (2) assessment of the availability and accessibility
of less expensive acute care services such as UCCs, (3) reduction of
administrative processes, and (4) impact on Coast Guard active duty
service members and their families. The evaluation/analysis of the
demonstration would use Fiscal Year 2008 as the base line with follow-
up data analysis conducted at each 6-month interval throughout the 24
month period to monitor of ER and TRICARE authorized UCC utilization
workload and cost (claims data). Success of the demonstration would be
determined by consistent shifts in health care utilization from ERs to
a TRICARE authorized UCCs by 15-20%. A less than 5% shift in
utilization from the ER to a TRICARE authorized UCCs would be
considered insignificant.
Dated: March 1, 2011.
Morgan F. Park,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2011-4863 Filed 3-3-11; 8:45 am]
BILLING CODE 5001-06-P
