(a) Establishment. The
TRICARE program is established for the purpose of implementing a comprehensive
managed health care program for the delivery and financing of health
care services in the Military Health System.
(1) Purpose. The
TRICARE program implements a number of improvements primarily through modernized
managed care support contracts that include special arrangements
with civilian sector health care providers and better coordination
between military medical treatment facilities (MTFs) and these civilian
providers to deliver an integrated, health care delivery system
that provides beneficiaries with access to high quality healthcare.
Implementation of these improvements, to include enhanced access,
improved health outcomes, increased efficiencies and elimination
of waste, in addition to improving and maintaining operational medical
force readiness, includes adoption of special rules and procedures
not ordinarily followed under CHAMPUS or MTF requirements. This
section establishes those special rules and procedures.
(2) Statutory
authority. Many of the provisions of this
section are authorized by statutory authorities other than those
which authorize the usual operation of the CHAMPUS program, especially
10 U.S.C. 1079 and 1086. The TRICARE program also relies upon other
available statutory authorities, including 10 U.S.C. 1075 (TRICARE
Select), 10 U.S.C. 1075a (TRICARE Prime cost sharing), 10 U.S.C.
1095f (referrals and preauthorizations under TRICARE Prime), 10
U.S.C. 1099 (health care enrollment system), 10 U.S.C. 1097 (contracts
for medical care for retirees, dependents and survivors: Alternative
delivery of health care), and 10 U.S.C. 1096 (resource sharing agreements).
(3) Scope of the program. The
TRICARE program is applicable to all the uniformed services. TRICARE Select
and TRICARE-for-Life shall be available in all areas, including
overseas as authorized in paragraph (u) of this section. The geographic
availability of TRICARE Prime is generally limited as provided in
this section. The Assistant Secretary of Defense (Health Affairs)
may also authorize modifications to TRICARE program rules and procedures
as may be appropriate to the area involved.
(4) Rules and procedures
affected. Much of this section relates
to rules and procedures applicable to the delivery and financing
of health care services provided by civilian providers outside military treatment
facilities. This section provides that certain rules, procedures,
rights and obligations set forth elsewhere in this part (and usually
applicable to CHAMPUS) are different under the TRICARE program. To
the extent that TRICARE program rules, procedures, rights and obligations
set forth in this section are not different from or otherwise in
conflict with those set forth elsewhere in this part as applicable
to CHAMPUS, the CHAMPUS provisions are incorporated into the TRICARE
program. In addition, some rules, procedures, rights and obligations
relating to health care services in military treatment facilities are
also different under the TRICARE program. In such cases, provisions
of this section take precedence and are binding.
(5) Implementation
based on local action. The TRICARE
program is not automatically implemented in all respects in all
areas where it is potentially applicable. Therefore, not all provisions
of this section are automatically implemented. Rather, implementation
of the TRICARE program and this section requires an official action
by the Director, Defense Health Agency. Public notice of the initiation
of portions of the TRICARE program will be achieved through appropriate
communication and media methods and by way of an official announcement
by the Director identifying the military medical treatment facility catchment
area or other geographical area covered.
(6) Major
features of the TRICARE program. The major features
of the TRICARE program, described in this section, include the following:
(i) Beneficiary categories. Under
the TRICARE program, health care beneficiaries are generally classified
into one of several categories:
(A) Active
duty members, who are covered by 10 U.S.C. 1074(a).
(B) Active
duty family members, who are beneficiaries covered by 10 U.S.C.
1079 (also referred to in this section as “active duty family category”).
(C) Retirees
and their family members (also referred to in this section as “retired
category”), who are beneficiaries covered by 10 U.S.C. 1086(c) other
than those beneficiaries eligible for Medicare Part A.
(D) Medicare
eligible retirees and Medicare eligible retiree family members who
are beneficiaries covered by 10 U.S.C. 1086(d) as each become individually
eligible for Medicare Part A and enroll in Medicare Part B.
(E) Military
treatment facility (MTF) only beneficiaries are beneficiaries eligible
for health care services in military treatment facilities, but not
eligible for a TRICARE plan covering non-MTF care.
(ii) Health plans available. The
major TRICARE health plans are as follows:
(A) TRICARE Prime. “TRICARE
Prime” is a health maintenance organization (HMO)-like program.
It generally features use of military treatment facilities and substantially
reduced out-of-pocket costs for care provided outside MTFs. Beneficiaries
generally agree to use military treatment facilities and designated
civilian provider networks and to follow certain managed care rules
and procedures. The primary purpose of TRICARE Prime is to support
the effective operation of an MTF, which exists to support the medical
readiness of the armed forces and the readiness of medical personnel.
TRICARE Prime will be offered in areas where the Director determines
that it is appropriate to support the effective operation of one
or more MTFs.
(B) TRICARE
Select. “TRICARE Select” is a self-managed,
preferred provider organization (PPO) program. It allows beneficiaries
to use the TRICARE provider civilian network, with reduced out-of-pocket
costs compared to care from non-network providers, as well as military
treatment facilities (where they exist and when space is available).
TRICARE Select enrollees will not have restrictions on their freedom
of choice with respect to authorized health care providers. However,
when a TRICARE Select beneficiary receives services covered under
the basic program from an authorized health care provider who is
not part of the TRICARE provider network that care is covered by
TRICARE but is subject to higher cost sharing amounts for “out-of-network”
care. Those amounts are the same as under the basic program under
Sec. 199.4.
(C) TRICARE
for Life. “TRICARE for Life” is the Medicare
wraparound coverage plan under 10 U.S.C. 1086(d). Rules applicable
to this plan are unaffected by this section; they are generally
set forth in Secs. 199.3 (Eligibility), 199.4 (Basic Program Benefits),
and 199.8 (Double Coverage).
(D) TRICARE Standard. “TRICARE
Standard” generally referred to the basic CHAMPUS program of benefits
under Sec. 199.4. While the law required termination of TRICARE
Standard as a distinct TRICARE plan December 31, 2017, the CHAMPUS
basic program benefits under Sec. 199.4 continues as the baseline
of benefits common to the TRICARE Prime and TRICARE Select plans.
(iii) Comprehensive enrollment
system. The TRICARE program includes
a comprehensive enrollment system for all categories of beneficiaries
except TRICARE-for-Life beneficiaries. When eligibility for enrollment
for TRICARE Prime and/or TRICARE Select exists, a beneficiary must
enroll in one of the plans. Refer to paragraph (o) of this section
for TRICARE program enrollment procedures.
(7) Preemption of State
laws. (i) Pursuant to 10 U.S.C.
1103 the Department of Defense has determined that in the administration
of 10 U.S.C. chapter 55, preemption of State and local laws relating
to health insurance, prepaid health plans, or other health care
delivery or financing methods is necessary to achieve important
Federal interests, including but not limited to the assurance of
uniform national health programs for military families and the operation
of such programs at the lowest possible cost to the Department of
Defense, that have a direct and substantial effect on the conduct
of military affairs and national security policy of the United States.
(ii) Based
on the determination set forth in paragraph (a)(7)(i) of this section,
any State or local law relating to health insurance, prepaid health
plans, or other health care delivery or financing methods is preempted
and does not apply in connection with TRICARE regional contracts.
Any such law, or regulation pursuant to such law, is without any
force or effect, and State or local governments have no legal authority
to enforce them in relation to the TRICARE regional contracts. (However,
the Department of Defense may by contract establish legal obligations
of the part of TRICARE contractors to conform with requirements
similar or identical to requirements of State or local laws or regulations).
(iii) The
preemption of State and local laws set forth in paragraph (a)(7)(ii)
of this section includes State and local laws imposing premium taxes
on health or dental insurance carriers or underwriters or other
plan managers, or similar taxes on such entities. Such laws are
laws relating to health insurance, prepaid health plans, or other
health care delivery or financing methods, within the meaning of
the statutes identified in paragraph (a)(7)(i) of this section.
Preemption, however, does not apply to taxes, fees, or other payments
on net income or profit realized by such entities in the conduct
of business relating to DoD health services contracts, if those
taxes, fees or other payments are applicable to a broad range of
business activity. For purposes of assessing the effect of Federal
preemption of State and local taxes and fees in connection with
DoD health and dental services contracts, interpretations shall
be consistent with those applicable to the Federal Employees Health
Benefits Program under 5 U.S.C. 8909(f).
(b) TRICARE Prime and TRICARE
Select health plans in general. The two primary
plans for beneficiaries in the active duty family category and the
retired category (which does not include most Medicare-eligible
retirees/dependents) are TRICARE Prime and TRICARE Select. This
paragraph (b) further describes the TRICARE Prime and TRICARE Select
health plans.
(1) TRICARE
Prime. TRICARE Prime is a managed care
option that provides enhanced medical services to beneficiaries
at reduced cost-sharing amounts for eneficiaries whose care is managed
by a designated primary care manager and provided by an MTF or network
provider. TRICARE Prime is offered in a location in which an MTF
is located (other than a facility limited to members of the armed forces)
that has been designated by the Director as a Prime Service Area.
In addition, where TRICARE Prime is offered it may be limited to
active duty family members if the Director determines it is not practicable
to offer TRICARE Prime to retired category beneficiaries. TRICARE
Prime is not offered in areas where the Director determines it is
impracticable. If TRICARE Prime is not offered in a geographical
area, certain active duty family members residing in the area may
be eligible to enroll in TRICARE Prime Remote program under paragraph
(g) of this section.
(2) TRICARE Select. TRICARE
Select is the self-managed option under which beneficiaries may
receive authorized basic program benefits from any TRICARE authorized
provider. The TRICARE Select health care plan also provides enhanced
program benefits to beneficiaries with access to a preferred provider network
with broad geographic availability within the United States at reduced
out-of-pocket expenses. However, when a beneficiary receives services
from an authorized health care provider who is not part of the TRICARE
provider network, only basic program benefits (not enhanced Select
care) are covered by TRICARE and the beneficiary is subject to higher
cost sharing amounts for “out-of-network” care. Those amounts are
the same as under the basic program under Sec. 199.4.
(c) Eligibility
for enrollment in TRICARE Prime and TRICARE Select. Beneficiaries
in the active duty family category and the retired category are
eligible to enroll in TRICARE Prime and/or TRICARE Select as outlined
in this paragraph (c). A retiree or retiree family member who becomes
eligible for Medicare Part A is not eligible to enroll in TRICARE
Select; however, as provided in this paragraph (c), some Medicare
eligible retirees/family members may be allowed to enroll in TRICARE
Prime where available. In general, when a retiree or retiree family
member becomes individually eligible for Medicare Part A and enrolls
in Medicare Part B, he/she is automatically eligible for TRICARE-for-Life
and is required to enroll in the Defense Enrollment Eligibility
Reporting System (DEERS) to verify eligibility. Further, some rules
and procedures are different for dependents of active duty members
and retirees, dependents, and survivors.
(1) Active duty members. Active
duty members are required to enroll in Prime where it is offered. Active
duty members shall have first priority for enrollment in Prime.
(2) Dependents of active
duty members. Beneficiaries in the active
duty family member category are eligible to enroll in Prime (where
offered) or Select.
(3) Survivors
of deceased members.(i) The surviving spouse
of a member who dies while on active duty for a period of more than
30 days is eligible to enroll in Prime (where offered) or Select
for a 3 year period beginning on the date of the member's death
under the same rules and provisions as dependents of active duty
members.
(ii) A dependent child or
unmarried person (as described in Sec. 199.3(b)(2)(ii) or (iv))
of a member who dies while on active duty for a period of more than
30 days whose death occurred on or after October 7, 2001, is eligible
to enroll in Prime (where offered) or Select and is subject to the
same rules and provisions of dependents of active duty members for
a period of three years from the date the active duty sponsor dies
or until the surviving eligible dependent:(A) Attains
21 years of age; or
(B) Attains
23 years of age or ceases to pursue a full-time course of study
prior to attaining 23 years of age, if, at 21 years of age, the
eligible surviving dependent is enrolled in a full-time course of
study in a secondary school or in a full-time course of study in
an institution of higher education approved by the Secretary of
Defense and was, at the time of the sponsor's death, in fact dependent
on the member for over onehalf of such dependent’s support.
(4) Retired,
dependents of retirees, and survivors (other than survivors of deceased
members covered under paragraph (c)(3) of this section). All
retirees, dependents of retirees, and survivors who are not eligible
for Medicare Part A are eligible to enroll in Select. dditionally,
retirees, dependents of retirees, and survivors who are not eligible
for Medicare Part A based on age are also eligible to enroll in TRICARE
Prime in locations where it is offered and where an MTF has, in
the judgment of the Director, a significant number of health care
providers, including specialty care providers, and sufficient capability to
support the efficient operation of TRICARE Prime for projected retired
beneficiary enrollees in that location.
(d) Health
benefits under TRICARE Prime--(1) Military
treatment facility (MTF) care--(i) In
general. All participants
in Prime are eligible to receive care in military treatment facilities.
Participants in Prime will be given priority for such care over
other beneficiaries. Among the following beneficiary groups, access priority
for care in military treatment facilities where TRICARE is implemented
as follows:
(A) Active duty service
members;
(B) Active duty service
members' dependents and survivors of service members who died on
active duty, who are enrolled in TRICARE Prime;
(C) Retirees,
their dependents and survivors, who are enrolled in TRICARE Prime;
(D) Active
duty service members' dependents and survivors of deceased members,
who are not enrolled in TRICARE Prime; and
(E) Retirees,
their dependents and survivors who are not enrolled in TRICARE Prime.
For purposes of this paragraph (d)(1), survivors of members who
died while on active duty are considered as among dependents of
active duty service members.
(ii) Special provisions. Enrollment
in Prime does not affect access priority for care in military treatment
facilities for several miscellaneous beneficiary groups and special
circumstances. Those include Secretarial designees, NATO and other
foreign military personnel and dependents authorized care through
international agreements, civilian employees under workers' compensation
programs or under safety programs, members on the Temporary Disability
Retired List (for statutorily required periodic medical examinations),
members of the reserve components not on active duty (for covered medical
services), military prisoners, active duty dependents unable to
enroll in Prime and temporarily away from place of residence, and
others as designated by the Assistant Secretary of Defense (Health Affairs).
Additional exceptions to the normal Prime enrollment access priority
rules may be granted for other categories of individuals, eligible
for treatment in the MTF, whose access to care is necessary to provide
an adequate clinical case mix to support graduate medical education
programs or readiness-related medical skills sustainment activities,
to the extent approved by the ASD(HA).
(2) Non-MTF care for active
duty members. Under Prime, non-MTF care needed
by active duty members continues to be arranged under the supplemental
care program and subject to the rules and procedures of that program,
including those set forth in Sec. 199.16.
(3) Civilian sector Prime
benefits. Health benefits for Prime enrollees
for care received from civilian providers are those under Sec. 199.4
and the additional benefits identified in paragraph (f) of this section.
(e) Health
benefits under the TRICARE extra plan--(1) Civilian sector care. The
health benefits under TRICARE Select for enrolled beneficiaries
received from civilian providers are those under Sec. 199.4, and,
in addition, those in paragraph (f) of this section when received
from a civilian network provider.
(2) Military treatment facility
(MTF) care. All TRICARE Select enrolled
beneficiaries continue to be eligible to receive care in military
treatment facilities on a space available basis.
(f) Benefits under TRICARE
Prime and TRICARE Select--(1) In
general. Except as specifically provided
or authorized by this section, all benefits provided, and benefit
limitations established, pursuant to this part, shall apply to TRICARE
Prime and TRICARE Select.
(2) Preventive care services. Certain
preventive care services not normally provided as part of basic program
benefits under Sec. 199.4 are covered benefits when provided to
Prime or Select enrollees by providers in the civilian provider
network. Such additional services are authorized under 10 U.S.C.
1097, including preventive care services not part of the entitlement
under 10 U.S.C. 1074d and services that would otherwise be excluded
under 10 U.S.C. 1079(a)(10). Other authority for such additional
services includes section 706 of the National Defense Authorization
Act for Fiscal Year 2017. The specific set of such services shall
be established by the Director and announced annually before the
open season enrollment period. Standards for preventive care services
shall be developed based on guidelines from the U.S. Department
of Health and Human Services. Such standards shall establish a specific
schedule, including frequency or age specifications for services
that may include, but are not limited to:
(i) Laboratory
and imaging tests, including blood lead, rubella, cholesterol, fecal
occult blood testing, and mammography;
(ii) Cancer
screenings (including cervical, breast, lung, prostate, and colon
cancer screenings);
(iii) Immunizations;
(iv) Periodic
health promotion and disease prevention exams;
(v) Blood
pressure screening;
(vi) Hearing
exams;
(vii) Sigmoidoscopy or colonoscopy;
(viii) Serologic
screening; and
(ix) Appropriate
education and counseling services. The exact services offered shall
be established under uniform standards established by the Director.
(3) Treatment
of obesity. Under the authority of 10 U.S.C.
1097 and sections 706 and 729 of the National Defense Authorization
Act for Fiscal Year 2017, notwithstanding 10 U.S.C. 1079(a)(10), treatment
of obesity is covered under TRICARE Prime and TRICARE Select even
if it is the sole or major condition treated. Such services must
be provided by a TRICARE network provider and be medically necessary
and appropriate in the context of the particular patient’s treatment.
(4) High
value services.
Under the authority of 10 U.S.C.
1097 and other authority, including sections 706 and 729 of the
National Defense Authorization Act for Fiscal Year 2017, for purposes
of improving population based health outcomes and incentivizing
medical intervention programs to address chronic diseases and other
conditions and healthy lifestyle interventions, the Director may
waive or reduce cost sharing requirements for TRICARE Prime and
TRICARE Select enrollees for care received from network providers
for certain health care services designated for this purpose. The
specific services designated for this purpose will be those the
Director determines provide especially high value in terms of better
health outcomes. The specific services affected for any plan year
will be announced by the Director prior to the open season enrollment
period for that plan year. Services affected by actions of the Director
under paragraph (f)(5) of this section may be associated with actions
taken for high value medications under Sec. 199.21(j)(3) for select
pharmaceutical agents to be cost-shared at a reduced or zero dollar
rate.
(5) Other
services. In addition to services provided
pursuant to paragraphs (f)(2) through (4) of this section, other
benefit enhancements may be added and other benefit restrictions
may be waived or relaxed in connection with health care services
provided to TRICARE Prime and TRICARE Select enrollees. Any such
other enhancements or changes must be approved by the Director based
on uniform standards.
(g) TRICARE Prime Remote
for Active Duty Family Members-- (1) In
general. In geographic areas in which
TRICARE Prime is not offered and in which eligible family members
reside, there is offered under 10 U.S.C. 1079(p) TRICARE Prime Remote
for Active Duty Family Members as an enrollment option. TRICARE
Prime Remote for Active Duty Family Members (TPRADFM) will generally
follow the rules and procedures of TRICARE Prime, except as provided
in this paragraph (g) and otherwise except to the extent the Director
determines them to be infeasible because of the remote area.
(2) Active
duty family member. For purposes
of this paragraph (g), the term “active duty family member” means
one of the following dependents of an active duty member of the
Uniformed Services:
(i) Spouse,
child, or unmarried person, as defined in Sec. 199.3(b)(2)(i), (ii),
or (iv);
(ii) For a 3-year period,
the surviving spouse of a member who dies while on active duty for
a period of more than 30 days whose death occurred on or after October
7, 2001; and
(iii) The surviving dependent
child or unmarried person, as defined in Sec. 199.3(b)(2)(ii) or
(iv), of a member who dies while on active duty for a period of
more than 30 days whose death occurred on or after October 7, 2001.
Active duty family member status is for a period of 3 years from
the date the active duty sponsor dies or until the surviving eligible
dependent:(A) Attains 21 years of
age; or
(B) Attains 23 years of
age or ceases to pursue a full-time course of study prior to attaining
23 years of age, if, at 21 years of age, the eligible surviving
dependent is enrolled in a full-time course of study in a secondary
school or in a full-time course of study in an institution of higher
education approved by the Secretary of Defense and was, at the time
of the sponsor's death, in fact dependent on the member for over
one half of such dependent’s support.
(3) Eligibility. (i) An
active duty family member is eligible for TRICARE Prime Remote for
Active Duty Family Members if he or she is eligible for CHAMPUS
and, on or after December 2, 2003, meets the criteria of paragraphs
(g)(3)(i)(A) and (B) or paragraph (g)(3)(i)(C) of this section or
on or after October 7, 2001, meets the criteria of paragraph (g)(3)(i)(D)
or (E) of this section:(A) The family member's
active duty sponsor has been assigned permanent duty as a recruiter;
as an instructor at an educational institution, an administrator
of a program, or to provide administrative services in support of
a program of instruction for the Reserve Officers' Training Corps;
as a full-time adviser to a unit of a reserve component; or any
other permanent duty designated by the Director that the Director
determines is more than 50 miles, or approximately one hour driving
time, from the nearest military treatment facility that is adequate
to provide care.
(B) The
family members and active duty sponsor, pursuant to the assignment
of duty described in paragraph (g)(3)(i)(A) of this section, reside
at a location designated by the Director, that the Director determines
is more than 50 miles, or approximately one hour driving time, from
the nearest military medical treatment facility adequate to provide
care.
(C) The family member, having
resided together with the active duty sponsor while the sponsor served
in an assignment described in paragraph (g)(3)(i)(A) of this section,
continues to reside at the same location after the sponsor relocates
without the family member pursuant to orders for a permanent change
of duty station, and the orders do not authorize dependents to accompany
the sponsor to the new duty station at the expense of the United
States.
(D) For a 3 year period,
the surviving spouse of a member who dies while on active duty for
a period of more than 30 days whose death occurred on or after October
7, 2001.
(E) The surviving dependent
child or unmarried person as defined in Sec. 199.3(b)(2)(ii) or
(iv), of a member who dies while on active duty for a period of
more than 30 days whose death occurred on or after October 7, 2001,
for three years from the date the active duty sponsor dies or until
the surviving eligible dependent:(1) Attains
21 years of age; or
(2) Attains
23 years of age or ceases to pursue a full-time course of study
prior to attaining 23 years of age, if, at 21 years of age, the
eligible surviving dependent is enrolled in a full-time course of
study in a secondary school or in a full-time course of study in
an institution of higher education approved by the Secretary of
Defense and was, at the time of the sponsor’s death, in fact dependent
on the member for over one half of such dependent's support.
(ii) A
family member who is a dependent of a reserve component member is
eligible for TRICARE Prime Remote for Active Duty Family Members
if he or she is eligible for CHAMPUS and meets all of the following
additional criteria:(A) The reserve component
member has been ordered to active duty for a period of more than
30 days.
(B) The family member resides
with the member.
(C) The
Director, determines the residence of the reserve component member
is more than 50 miles, or approximately one hour driving time, from
the nearest military medical treatment facility that is adequate
to provide care.
(D) “Resides
with” is defined as the TRICARE Prime Remote residence address at
which the family resides with the activated reservist upon activation.
(4) Enrollment. TRICARE
Prime Remote for Active Duty Family Members requires enrollment
under procedures set forth in paragraph (o) of this section or as
otherwise established by the Director.
(5) Health
care management requirements under TRICARE Prime Remote for Active
Duty Family Members. The additional
health care management requirements applicable to Prime enrollees
under paragraph (n) of this section are applicable under TRICARE
Prime Remote for Active Duty Family Members unless the Director
determines they are infeasible because of the particular remote
location. Enrollees will be given notice of the applicable management
requirements in their remote location.
(6) Cost
sharing. Beneficiary cost sharing requirements
under TRICARE Prime Remote for Active Duty Family Members are the
same as those under TRICARE Prime under paragraph (m) of this section, except
that the higher point-of-service option cost sharing and deductible
shall not apply to routine primary health care services in cases
in which, because of the remote location, the beneficiary is not assigned
a primary care manager or the Director determines that care from
a TRICARE network provider is not available within the TRICARE access
standards under paragraph (p)(5) of this section. The higher point-of-service
option cost sharing and deductible shall apply to specialty health
care services received by any TRICARE Prime Remote for Active Duty
Family Members enrollee unless an appropriate referral/preauthorization
is obtained as required by paragraph (n) of this section under TRICARE
Prime. In the case of pharmacy services under Sec. 199.21, where
the Director determines that no TRICARE network retail pharmacy
has been established within a reasonable distance of the residence
of the TRICARE Prime Remote for Active Duty Family Members enrollee,
cost sharing applicable to TRICARE network retail pharmacies will
be applicable to all CHAMPUS eligible pharmacies in the remote area.
(h) Resource sharing agreements. Under
the TRICARE program, any military medical treatment facility (MTF)
commander may establish resource sharing agreements with the applicable
managed care support contractor for the purpose of providing for
the sharing of resources between the two parties. Internal resource
sharing and external resource sharing agreements are authorized.
The provisions of this paragraph (h) shall apply to resource sharing
agreements under the TRICARE program.
(1) In
connection with internal resource sharing agreements, beneficiary
cost sharing requirements shall be the same as those applicable
to health care services provided in facilities of the uniformed services.
(2) Under
internal resource sharing agreements, the double coverage requirements
of Sec. 199.8 shall be replaced by the Third Party Collection procedures
of 32 CFR part 220, to the extent permissible under such part. In
such a case, payments made to a resource sharing agreement provider
through the TRICARE managed care support contractor shall be deemed
to be payments by the MTF concerned.
(3) Under
internal or external resource sharing agreements, the commander
of the MTF concerned may authorize the provision of services, pursuant
to the agreement, to Medicare-eligible beneficiaries, if such services
are not reimbursable by Medicare, and if the commander determines
that this will promote the most cost-effective provision of services
under the TRICARE program.
(4) Under
external resource sharing agreements, there is no cost sharing applicable
to services provided by military facility personnel. Cost sharing
for non-MTF institutional and related ancillary charges shall be
as applicable to services provided under TRICARE Prime or TRICARE
Select, as appropriate.
(i) General
quality assurance, utilization review, and preauthorization requirements
under the TRICARE program. All quality
assurance, utilization review, and preauthorization requirements for
the basic CHAMPUS program, as set forth in this part (see especially
applicable provisions in Secs. 199.4 and 199.15), are applicable
to Prime and Select except as provided in this chapter. Pursuant
to an agreement between a military medical treatment facility and
TRICARE managed care support contractor, quality assurance, utilization
review, and preauthorization requirements and procedures applicable
to health care services outside the military medical treatment facility
may be made applicable, in whole or in part, to health care services
inside the military medical treatment facility.
(j) Pharmacy services. Pharmacy
services under Prime and Select are as provided in the Pharmacy Benefits
Program (see Sec. 199.21).
(k) Design of cost sharing
structures under TRICARE Prime and TRICARE Select--(1) In general. The
design of the cost sharing structures under TRICARE Prime and TRICARE
Select includes several major factors: beneficiary category (e.g.,
active duty family member category or retired category, and there
are some special rules for survivors of active duty deceased sponsors
and medically retired members and their dependents); date of initial
military affiliation (i.e., before or on or after January 1, 2018),
category of health care service received, and network or non-network
status of the provider.
(2) Categories
of health care services. This paragraph
(k)(2) describes the categories of health care services relevant
to determining copayment amounts.
(i) Preventive care visits. These
are outpatient visits and related services described in paragraph
(f)(2) of this section. There are no cost sharing requirements for
preventive care listed under Secs. 199.4(e)(28)(i) through (iv)
and 199.17(f)(2). Beneficiaries shall not be required to pay any
portion of the cost of these preventive services even if the beneficiary
has not satisfied any applicable deductible for that year.
(ii) Primary care outpatient
visits. These are outpatient visits,
not occurring in an ER or urgent care center, with the following
provider specialties:
(A) General
Practice.
(B) Family Practice.
(C) Internal
Medicine.
(D) OB/GYN.
(E) Pediatrics.
(F) Physician's
Assistant.
(G) Nurse Practitioner.
(H) Nurse
Midwife.
(iii) Specialty
care outpatient visits. This category
applies to outpatient care provided by provider specialties other
than those listed under primary care outpatient visits under paragraph
(k)(2)(ii) of this section and not specifically included in one
of the other categories of care (e.g., emergency room visits etc.)
under paragraph (k)(2) of this section. This category also includes
partial hospitalization services, intensive outpatient treatment,
and opioid treatment program services. The per visit fee shall be applied
on a per day basis on days services are received, with the exception
of opioid treatment program services reimbursed in accordance with
Sec. 199.14(a)(2)(ix)(A)(3)(i) which per visit fee will apply on
a weekly basis.
(iv) Emergency
room visits.
(v) Urgent
care center visits.
(vi) Ambulance
services. This is for ground ambulance
services.
(vii) Ambulatory
surgery. This is for facility-based outpatient
ambulatory surgery services.
(viii) Inpatient
hospital admissions.
(ix) Skilled
nursing facility or rehabilitation facility admissions. This
category includes a residential treatment center, or substance use
disorder rehabilitation facility residential treatment program.
(x) Durable
medical equipment, prosthetic devices, and other authorized supplies.
(xi) Outpatient prescription
pharmaceuticals. These are addressed in Sec.
199.21.
(3) Beneficiary
categories further subdivided. For purposes
of both TRICARE Prime and TRICARE Select, enrollment fees and cost
sharing by beneficiary category (e.g., active duty family member category
or retired category) are further differentiated between two groups.
(i) Group
A consists of Prime or Select enrollees whose sponsor originally
enlisted or was appointed in a uniformed service before January
1, 2018.
(ii) Group B consists of
Prime or Select enrollees whose sponsor originally enlisted or was
appointed in a uniformed service on or after January 1, 2018.
(l) Enrollment fees and
cost sharing (including deductibles and catastrophic cap) amounts.This paragraph (l) provides enrollment
fees and cost sharing requirements applicable to TRICARE Prime and
TRICARE Select enrollees.
(1) Enrollment
fee and cost sharing under TRICARE Prime. (i) For
Group A enrollees:(A) There is no enrollment
fee for the active duty family member category.
(B) The
retired category enrollment fee in calendar year 2018 is equal to
the Prime enrollment fee for fiscal year 2017, indexed to calendar
year 2018 and thereafter in accordance with 10 U.S.C. 1097. The Assistant
Secretary of Defense (Health Affairs) may exempt survivors of active
duty deceased sponsors and medically retired Uniformed Services
members and their dependents from future increases in enrollment
fees. The Assistant Secretary of Defense (Health Affairs) may also
waive the enrollment fee requirements for Medicare-eligible beneficiaries.
(C) The
cost sharing amounts are established annually in connection with
the open season enrollment period. An amount is established for
each category of care identified in paragraph (k)(2) of this section,
taking into account all applicable statutory provisions, including
10 U.S.C. chapter 55. The amount for each category of care may not
exceed the amount for Group B as set forth in 10 U.S.C. 1075a.
(D) The
catastrophic cap is $1,000 for active duty families and $3,000 for
retired category families.
(ii) For
Group B enrollees, the enrollment fee, catastrophic cap and cost
sharing amounts are as set forth in 10 U.S.C. 1075a
(iii) For
both Group A and Group B, for health care services obtained by a
Prime enrollee but not obtained in accordance with the rules and
procedures of Prime (e.g. failure to obtain a primary care manager
referral when such a referral is required or seeing a non-network
provider when Prime rules require use of a network provider and
one is available) will not be paid under Prime rules but may be covered
by the point-of-service option. For services obtained under the
point-of-service option, the deductible is $300 per person and $600
per family. The beneficiary cost share is 50 percent of the allowable
charges for inpatient and outpatient care, after the deductible.
Point-of-service charges do not count against the annual catastrophic
cap.
(2) Enrollment
fee and cost sharing under TRICARE Select. (i) For
Group A enrollees:(A) The enrollment fee in
calendar years 2018 through 2020 is zero and the catastrophic cap
is as provided in 10 U.S.C. 1079 or 1086. The enrollment fee and
catastrophic cap in 2021 and thereafter for certain beneficiaries
in the retired category is as provided in 10 U.S.C. 1075(e), except
the enrollment fee and catastrophic cap adjustment shall not apply
to survivors of active duty deceased sponsors and medically retired
Uniformed Services members and their dependents.
(B) The
cost sharing amounts for network care for Group A enrollees are
calculated for each category of care described in paragraph (k)(2)
of this section by taking into account all applicable statutory provisions,
including 10 U.S.C. chapter 55, as if TRICARE Extra and Standard
programs were still being implemented. When determined practicable,
including efficiency and effectiveness in administration, the amounts
established are converted to fixed dollar amounts for each category
of care for which a fixed dollar amount is established by 10 U.S.C.
1075. When determined not to be practicable, as in the categories
of care including ambulatory surgery, inpatient admissions, and
inpatient skilled nursing/rehabilitation admissions, the calculated
cost-sharing amounts are not converted to fixed dollar amounts.
The fixed dollar amount for each category is set prospectively for
each calendar year as the amount (rounded down to the nearest dollar
amount) equal to 15% for enrollees in the active duty family beneficiary
category or 20% for enrollees in the retired beneficiary category
of the projected average allowable payment amount for each category
of care during the year, as estimated by the Director. The projected
average allowable payment amount for primary care (including urgent
care) and specialty care outpatient appointments include payments
for ancillary services (e.g., laboratory and radiology services)
that are provided in connection with the respective outpatient visit.
As such, there is no separate cost sharing for these ancillary services.
(C) The
cost share for care received from non-network providers is as provided
in Sec. 199.4.
(D) The
annual deductible amount is as provided in 10 U.S.C. 1079 or 1086.
(ii) For
Group B enrollees, the enrollment fee, annual deductible for services
received while in an outpatient status, catastrophic cap and cost
sharing amounts are as provided in 10 U.S.C. 1075 and as consistent
with this section.
(3) Special
cost-sharing rules. (A) There is no separate
cost-sharing applicable to ancillary health care services obtained
in conjunction with an outpatient primary or specialty care visit
under TRICARE Prime or from network providers under TRICARE Select.
(B) Cost-sharing
for maternity care services shall be determined in accordance with
Sec. 199.4(e)(16).
(4) Special
transition rule for the last quarter of calendar year 2017. In
order to transition enrollment fees, deductibles, and catastrophic
caps from a fiscal year basis to a calendar year basis, the following special
rules apply for the last quarter of calendar year 2017:.
(A) A
Prime enrollee's enrollment fee for the quarter is one-fourth of
the enrollment fee for fiscal year 2017.
(B) The
deductible amount and the catastrophic cap amount for fiscal year
2017 will be applicable to the 15-month period of October 1, 2016
through December 31, 2017.
(m) Limit on out-of-pocket
costs under TRICARE Prime and TRICARE Select. For
the purpose of this paragraph (m), out-of-pocket costs means all
payments required of beneficiaries under paragraph (l) of this section,
including enrollment fees, deductibles, and cost sharing amounts,
with the exception of point-of-service charges. In any case in which
a family reaches their applicable catastrophic cap, all remaining
payments that would have been required of the beneficiary under
paragraph (l) of this section for authorized care, with the exception
of applicable point-of-service charges pursuant to paragraph (l)(1)(iii)
of this section, will be paid by the program for the remainder of
that calendar year.
(n) Additional health care
management requirements under TRICARE Prime. Prime
has additional, special health care management requirements not
applicable under TRICARE Select.
(1) Primary care manager. (i) All
active duty members and Prime enrollees will be assigned a primary care
manager pursuant to a system established by the Director, and consistent
with the access standards in paragraph (p)(5)(i) of this section.
The primary care manager may be an individual, physician, a group
practice, a clinic, a treatment site, or other designation. The
primary care manager may be part of the MTF or the Prime civilian
provider network. The enrollee will be given the opportunity to
register a preference for primary care manager from a list of choices
provided by the Director. This preference will be entered on a TRICARE
Prime enrollment form or similar document. Preference requests will
be considered, but primary care manager assignments will be subject
to availability under the MTF beneficiary category priority system
under paragraph (d) of this section and subject to other operational
requirements.
(ii) Prime enrollees who
are dependents of active duty members in pay grades E–1 through
E–4 shall have priority over other active duty dependents for enrollment
with MTF PCMs, subject to MTF capacity.
(2) Referral
and preauthorization requirements.(i) Under
TRICARE Prime there are certain procedures for referral and preauthorization.(A) For
the purpose of this paragraph (n)(2), referral addresses the issue
of who will provide authorized health care services. In many cases,
Prime beneficiaries will be referred by a primary care manager to
a medical department of an MTF if the type of care needed is available
at the MTF. In such a case, failure to adhere to that referral will
result in the care being subject to point-of-service charges. In other
cases, a referral may be to the civilian provider network, and again,
point-of-service charges would apply to a failure to follow the
referral.
(B) In contrast to referral,
preauthorization addresses the issue of whether particular services
may be covered by TRICARE, including whether they appear necessary
and appropriate in the context of the patient's diagnosis and circumstances.
A major purpose of preauthorization is to prevent surprises about
coverage determinations, which are sometimes dependent on particular
details regarding the patient's condition and circumstances. While
TRICARE Prime has referral requirements that do not exist for TRICARE
Select, TRICARE Select has some preauthorization requirements that
do not exist for TRICARE Prime.
(C) In
any other special circumstances identified by the Director, generally
with notice provided in connection with the open season enrollment
period for the plan year.
(ii) Except
as otherwise provided in this paragraph (n)(2), a beneficiary enrolled
in TRICARE Prime is required to obtain a referral for care through
a designated primary care manager (or other authorized care coordinator)
prior to obtaining care under the TRICARE program.
(iii) There
is no referral requirement under paragraph (n)(2)(i) of this section
in the following circumstances.(A) In
emergencies;
(B) For urgent care services
for a certain number of visits per year (zero to unlimited), with
the number specified by the Director and notice provided in connection
with the open season enrollment period preceding the plan year;
and
(C) In any other special
circumstances identified by the Director, generally with notice
provided in connection with the open season enrollment period for
the plan year.
(iv) A
primary care manager who believes a referral to a specialty care
provider is medically necessary and appropriate need not obtain
preauthorization from the managed care support contractor before referring
a patient to a network specialty care provider. Such preauthorization
is only required with respect to a primary care manager's referral
for:(A) Inpatient
hospitalization;
(B) Inpatient
care at a skilled nursing facility;
(C) Inpatient
care at a rehabilitation facility; and
(D) Inpatient
care at a residential treatment facility.
(v) The
restrictions in paragraph (n)(2)(iv) of this section on preauthorization
requirements do not apply to any preauthorization requirements that
are generally applicable under TRICARE, independent of TRICARE Prime
referrals, such as:(A) Under the Pharmacy Benefits
Program under 10 U.S.C. 1074g and Sec. 199.21.
(B) For
laboratory and other ancillary services.
(C) Durable
medical equipment.
(vi) The
cost-sharing requirement for a beneficiary enrolled in TRICARE Prime
who does not obtain a referral for care when it is required, including
care from a non-network provider, is as provided in paragraph (l)(1)(iv)
of this section concerning point-of-service care.
(vii) In
the case of care for which preauthorization is not required under
paragraph (n)(2)(iv) of this section, the Director may authorize
a managed care support contractor to offer a voluntary pre-authorization
program to enable beneficiaries and providers to confirm covered
benefit status and/or medical necessity or to understand the criteria
that will be used by the managed care support contractor to adjudicate
the claim associated with the proposed care. A network provider
may not be required to use such a program with respect to a referral.
(3) Restrictions
on the use of providers. The requirements
of this paragraph (n)(3) shall be applicable to health care utilization
under TRICARE Prime, except in cases of emergency care and under
point-of-service option (see paragraph (n)(4) of this section).
(i) Prime
enrollees must obtain all primary health care from the primary care
manager or from another provider to which the enrollee is referred
by the primary care manager or otherwise authorized.
(ii) For
any necessary specialty care and non-emergent inpatient care, the
primary care manager or other authorized individual will assist
in making an appropriate referral.
(iii) Though
referrals for specialty care are generally the responsibility of
the primary care managers, subject to discretion exercised by the
TRICARE Regional Directors, and established in regional policy or memoranda
of understanding, specialist providers may be permitted to refer
patients for additional specialty consultation appointment services
within the TRICARE contractor's network without prior authorization
by primary care managers.
(iv) The
following procedures will apply to health care referrals under TRICARE
Prime:(A) The first priority for
referral for specialty care or inpatient care will be to the local
MTF (or to any other MTF in which catchment area the enrollee resides).
(B) If
the local MTF(s) are unavailable for the services needed, but there
is another MTF at which the needed services can be provided, the
enrollee may be required to obtain the services at that MTF. However,
this requirement will only apply to the extent that the enrollee
was informed at the time of (or prior to) enrollment that mandatory
referrals might be made to the MTF involved for the service involved.
(C) If
the needed services are available within civilian preferred provider
network serving the area, the enrollee may be required to obtain
the services from a provider within the network. Subject to availability,
the enrollee will have the freedom to choose a provider from among
those in the network.
(D) If
the needed services are not available within the civilian preferred
provider network serving the area, the enrollee may be required
to obtain the services from a designated civilian provider outside the
area. However, this requirement will only apply to the extent that
the enrollee was informed at the time of (or prior to) enrollment
that mandatory referrals might be made to the provider involved
for the service involved (with the provider and service either identified
specifically or in connection with some appropriate classification).
(E) In
cases in which the needed health care services cannot be provided
pursuant to the procedures identified in paragraphs (n)(3)(iv)(A)
through (D) of this section, the enrollee will receive authorization to
obtain services from a TRICARE-authorized civilian provider(s) of
the enrollee's choice not affiliated with the civilian preferred
provider network.
(v) When
Prime is operating in noncatchment areas, the requirements in paragraphs
(n)(3)(iv)(B) through (E) of this section shall apply.
(4) Point-of-service option. TRICARE
Prime enrollees retain the freedom to obtain services from civilian
providers on a point-of service basis. Any health care services
obtained by a Prime enrollee, but not obtained in accordance with
the rules and procedures of Prime, will be covered by the point-of-service
option. In such cases, all requirements applicable to health benefits
under Sec. 199.4 shall apply, except that there shall be higher
deductible and cost sharing requirements (as set forth in paragraph (l)(1)(iii))
of this section). However, Prime rules may cover such services if
the enrollee did not know and could not reasonably have been expected
to know that the services were not obtained in accordance with the
utilization management rules and procedures of Prime.
(5) Prime travel benefit. In
accordance with guidelines issues by the Assistant Secretary of
Defense (Health Affairs), certain travel expenses may be reimbursed
when a TRICARE Prime enrollee is referred by the primary care manager
for medically necessary specialty care more than 100 miles away
from the primary care manager's office. Such guidelines shall be
consistent with appropriate provisions of generally applicable Department
of Defense rules and procedures governing travel expenses.
(o) TRICARE program enrollment
procedures. There are certain requirements
pertaining to procedures for enrollment in TRICARE Prime, TRICARE
Select, and TRICARE Prime Remote for Active Duty Family Members.
(These procedures do not apply to active duty members, whose enrollment
is mandatory and automatic.)
(1) Annual open season enrollment.(i) As
a general rule, enrollment (or a modification to a previous enrollment)
must occur during the open season period prior to the plan year,
which is on a calendar year basis. The open season enrollment period
will be of at least 30 calendar days duration. An enrollment choice
will be applicable for the plan year.
(ii) Open
season enrollment procedures may include automatic reenrollment
in the same plan for the next plan year for enrollees or sponsors
that will occur in the event the enrollee does not take other action
during the open season period.
(2) Exceptions
to the calendar year enrollment process. The
Director will identify certain qualifying events that may be the
basis for a change in enrollment status during a plan year, such
as a change in eligibility status, marriage, divorce, birth of a
new family member, relocation, loss of other health insurance, or
other events. In the case of such an event, a beneficiary eligible
to enroll in a plan may newly enroll, disenroll, or modify a previous
enrollment during the plan year. Initial payment of the applicable
enrollment fee shall be collected for new enrollments in accordance
with established procedures. Any applicable enrollment fee will
be pro-rated. A beneficiary who dis-enrolls without enrolling at
the same time in another plan is not eligible to enroll in a plan
later in the same plan year unlessthere is another qualifying event.
A beneficiary who is dis-enrolled for failure to pay a required enrollment
fee installment is not eligible to re-enroll in a plan later in
the same plan year unless there is another qualifying event. Generally,
the effective date of coverage will coincide with the date of the qualifying
event.
(3) Installment
payments of enrollment fee. The Director
will establish procedures for installment payments of enrollment
fees.
(4) Effect
of failure to enroll. Beneficiaries
eligible to enroll in Prime or Select and who do not enroll will
no longer have coverage under the TRICARE program until the next
annual open season enrollment or they have a qualifying event, except
that they do not lose any statutory eligibility for space-available
care in military medical treatment facilities. There is a limited
grace period exception to this enrollment requirement for calendar
year 2018, as provided in section 701(d)(3) of the National Defense
Authorization Act for Fiscal Year 2017.
(5) Automatic
enrollment for certain dependents. Under
10 U.S.C. 1097a, in the case of dependents of active duty members
in the grade of E–1 to E–4, such dependents who reside in a catchment
area of a military treatment facility shall be enrolled in TRICARE
Prime. The Director may provide for the automatic enrollment in
TRICARE Prime for such dependents of active duty members in the
grade of E–5 and higher. In any case of automatic enrollment under
this paragraph (o)(5), the member will be provided written notice
and the automatic enrollment may be cancelled at the election of
the member.
(6) Grace
periods. The Director may make provisions
for grace periods for enrollment-related actions to facilitate effective
operation of the enrollment program.
(p) Civilian preferred provider
networks. A major feature of the TRICARE
program is the civilian preferred provider network.
(1) Status of network providers. Providers
in the preferred provider network are not employees or agents of
the Department of Defense or the United States Government. Although
network providers must follow numerous rules and procedures of the
TRICARE program, on matters of professional judgment and professional
practice, the network provider is independent and not operating
under the direction and control of the Department of Defense.
(2) Utilization
management policies. Preferred providers
are required to follow the utilization management policies and procedures
of the TRICARE program. These policies and procedures are part of
discretionary judgments by the Department of Defense regarding the
methods of delivering and financing health care services that will
best achieve health and economic policy objectives.
(3) Quality
assurance requirements. A number of
quality assurance requirements and procedures are applicable to
preferred network providers. These are for the purpose of assuring
that the health care services paid for with government funds meet
the standards called for in the contract and provider agreement.
(4) Provider
qualifications. All preferred providers must
meet the following qualifications:
(i) They
must be TRICARE-authorized providers and TRICARE-participating providers.
In addition, a network provider may not require payment from the
beneficiary for any excluded or excludable services that the beneficiary
received from the network provider (i.e., the beneficiary will be
held harmless) except as follows:(A) If
the beneficiary did not inform the provider that he or she was a
TRICARE beneficiary, the provider may bill the beneficiary for services
provided.
(B) If the beneficiary was
informed in writing that the specific services were excluded or
excludable from TRICARE coverage and the beneficiary agreed in writing,
in advance of the services being provided, to pay for the services,
the provider may bill the beneficiary.
(ii) All
physicians in the preferred provider network must have staff privileges
in a hospital accredited by The Joint Commission (TJC) or other
accrediting body determined by the Director. This requirement may
be waived in any case in which a physician's practice does not include
the need for admitting privileges in such a hospital, or in locations
where no accredited facility exists. However, in any case in which
the requirement is waived, the physician must comply with alternative
qualification standards as are established by the Director.
(iii) All
preferred providers must agree to follow all quality assurance,
utilization management, and patient referral procedures established
pursuant to this section, to make available to designated DoD utilization
management or quality monitoring contractors medical records and
other pertinent records, and to authorize the release of information
to MTF Commanders regarding such quality assurance and utilization
management activities.
(iv) All
preferred network providers must be Medicare participating providers,
unless this requirement is waived based on extraordinary circumstances.
This requirement that a provider be a Medicare participating provider
does not apply to providers not eligible to be participating providers under
Medicare.
(v) The network provider
must be available to all TRICARE beneficiaries.
(vi) The
provider must agree to accept the same payment rates negotiated
for Prime enrollees for any person whose care is reimbursable by
the Department of Defense, including, for example, Select participants,
supplemental care cases, and beneficiaries from outside the area.
(vii) All
preferred providers must meet all other qualification requirements,
and agree to comply with all other rules and procedures established
for the preferred provider network.
(viii) In
locations where TRICARE Prime is not available, a TRICARE provider
network will, to the extent practicable, be available for TRICARE
Select enrollees. In these locations, the minimal requirements for network
participation are those set forth in paragraph (p)(4)(i) of this
section. Other requirements of this paragraph (p) will apply unless
waived by the Director.
(5) 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 (when applicable), can adequately address the health
care needs of the enrollees. In the event that a Prime enrollee
seeks to obtain from the managed care support contractor an appointment
for care but is not offered an appointment within the access time
standards from a network provider, the enrollee will be authorized
to receive care from a non-network provider without incurring the
additional fees associated with point-of-service care. The following
are the access standards:
(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 generally
not exceed 24 hours.
(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 this section), 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 nonemergency circumstances shall not exceed 30
minutes, except when emergency care is being provided to patients,
and the normal schedule is disrupted.
(6) Special
reimbursement methods for network providers. The
Director, may establish, for preferred provider networks, reimbursement
rates and methods different from those established pursuant to Sec.
199.14. Such provisions may be expressed in terms of percentage
discounts off CHAMPUS allowable amounts, or in other terms. In circumstances
in which payments are based on hospital-specific rates (or other
rates specific to particular institutional providers), special reimbursement methods
may permit payments based on discounts off national or regional
prevailing payment levels, even if higher than particular institution
specific payment rates.
(q) Preferred provider network
establishment.(1) The any qualified provider
method may be used to establish a civilian preferred provider network.
Under this method, any TRICARE-authorized provider that meets the
qualification standards established by the Director, or designee,
may become a part of the preferred provider network. Such standards
must be publicly announced and uniformly applied. Also under this
method, any provider who meets all applicable qualification standards
may not be excluded from the preferred provider network. Qualifications
include:(i) The provider must meet
all applicable requirements in paragraph (p)(4) of this section.
(ii) The
provider must agree to follow all quality assurance and utilization
management procedures established pursuant to this section.
(iii) The
provider must be a participating provider under TRICARE for all
claims.
(iv) The provider must meet
all other qualification requirements, and agree to all other rules
and procedures, that are established, publicly announced, and uniformly
applies by the Director (or other authorized official).
(v) The
provider must sign a preferred provider network agreement covering
all applicable requirements. Such agreements will be for a duration
of one year, are renewable, and may be canceled by the provider
or the Director (or other authorized official) upon appropriate
notice to the other party. The Director shall establish an agreement
model or other guidelines to promote uniformity in the agreements.
(2) In
addition to the above requirements, the Director, or designee, may
establish additional categories of preferred providers of high quality/high
value that require additional qualifications.
(r) General fraud, abuse,
and conflict of interest requirements under TRICARE program. All fraud,
abuse, and conflict of interest requirements for the basic CHAMPUS
program, as set forth in this part (see especially applicable provisions
of Sec. 199.9) are applicable to the TRICARE program.
(s) [Reserved]
(t) Inclusion of Department
of Veterans Affairs Medical Centers in TRICARE networks. TRICARE
preferred provider networks may include Department of Veterans Affairs
health facilities pursuant to arrangements, made with the approval
of the Assistant Secretary of Defense (Health Affairs), between
those centers and the Director, or designated TRICARE contractor.
(u) Care
provided outside the United States. The
TRICARE program is not automatically implemented in all respects
outside the United States. This paragraph (u) sets forth the provisions
of this section applicable to care received outside the United States
under the following TRICARE health plans.
(1) TRICARE Prime. The
Director may, in conjunction with implementation of the TRICARE
program, authorize a special Prime program for command sponsored
dependents of active duty members who accompany the members in their
assignments in foreign countries. Under this special program, a preferred
provider network may be established through contracts or agreements
with selected health care providers. Under the network, Prime covered
services will be provided to the enrolled covered dependents subject
to applicable Prime deductibles, copayments, and point-of-service
charges. To the extent practicable, rules and procedures applicable
to TRICARE Prime under this section shall apply unless specific
exemptions are granted in writing by the Director. The use of this
authority by the Director for any particular geographical area will
be published on the primary publicly available Internet Web site
of the Department and on the publicly available Internet Web site
of the managed care support contractor that has established the
provider network under the TRICARE program. Published information
will include a description of the preferred provider network program
and other pertinent information. The Director shall also issue policies,
instructions, and guidelines necessary to implement this special
program.
(2) TRICARE
Select. The TRICARE Select option shall
be available outside the United States except that a preferred provider
network of providers shall only be established in areas where the
Director determines that it is economically in the best interest
of the Department of Defense. In such a case, the Director shall
establish a preferred provider network through contracts or agreements
with selected health care providers for eligible beneficiaries to
receive covered benefits subject to the enrollment and cost-sharing
amounts applicable to the specific category of beneficiary. When
an eligible beneficiary, other than a TRICARE for Life beneficiary,
receives covered services from an authorized TRICARE non-network
provider, including in areas where a preferred provider network
has not been established by the Director, the beneficiary shall
be subject to cost-sharing amounts applicable to out-of-network care.
To the extent practicable, rules and procedures applicable to TRICARE
Select under this section shall apply unless specific exemptions
are granted in writing by the Director. The use of this authority by
the Director to establish a TRICARE preferred provider network for
any particular geographical area will be published on the primary
publicly available Internet Web site of the Department and on the publicly
available Internet Web site of the managed care support contractor
that has established the provider network under the TRICARE program.
Published information will include a description of the preferred
provider network program and other pertinent information. The Director
shall also issue policies, instructions, and guidelines necessary
to implement this special program.
(3) TRICARE for Life. The
TRICARE for Life (TFL) option shall be available outside the United
States. Eligible TFL beneficiaries may receive covered services
and supplies authorized under Sec. 199.4, subject to the applicable
catastrophic cap, deductibles and costshares under Sec. 199.4, whether received
from a network provider or any authorized TRICARE provider not in
a preferred provider network. However, if a TFL beneficiary receives
covered services from a PPN provider, the beneficiary's out-of-pocket
costs will generally be lower.
(v) Administration of the
TRICARE program in the state of Alaska. In
view of the unique geographical and environmental characteristics
impacting the delivery of health care in the state of Alaska, administration
of the TRICARE program in the state of Alaska will not include financial underwriting
of the delivery of health care by a TRICARE contractor. All other
provisions of this section shall apply to administration of the
TRICARE program in the state of Alaska as they apply to the other
49 states and the District of Columbia.
(w) Administrative procedures. The
Assistant Secretary of Defense (Health Affairs), the Director, and
MTF Commanders (or other authorized officials) are authorized to
establish administrative requirements and procedures, consistent
with this section, this part, and other applicable DoD Directives
or Instructions, for the implementation and operation of the TRICARE
program.
[60 FR 52095, Oct 5, 1995, as amended at
63 FR 9142, Feb 24, 1998; 63 FR 48447, Sep 10, 1998; 64 FR 13913,
Mar 23, 1999; 65 FR 39805, Jun 28, 2000; 65 FR 45425, Jul 21, 2000;
66 FR 9655, Feb 9, 2001; 66 FR 40608, Aug 3, 2001; 67 FR 5479, Feb
6, 2002; 67 FR 6409, Feb 12, 2002; 68 FR 23033, Apr 30, 2003; 68
FR 32363, May 30, 2003; 68 FR 44883, Jul 31, 2003; 68 FR 44881,
Jul 31, 2003; 70 FR 19266, Apr 13, 2005; 71 FR 50349, Aug 25, 2006;
72 FR 2448, Jan 19, 2007; 73 FR 30478, May 28, 2008; 75 FR 47713,
Aug 9, 2010; 75 FR 50884, Aug 18, 2010; 76 FR 81370, Dec 28, 2011;
82 FR 45448, Sep 29, 2017]