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Subject:
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Department
of Defense (DoD) Managed Care Support Contractors (MCSCs) entering
into Agreements with the Department of Veterans Affairs (DVA) Health
Care Facilities to Provide Care for TRICARE Beneficiaries Covered
by the Regional Managed Care Support Contracts.
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I.
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Purpose
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This
Memorandum of Understanding (MOU) is to establish general requirements
for agreements between a DoD regional managed care support (MCS)
contractor and a VA health care facility under which the MCS contractor
may include the facility in the contractor’s networks.
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II.
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Authority
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This
MOU is authorized by Section 201 of the Veterans Health Care Act
of 1992, Pub. L. 102-585, 38 USC 8111, 10 USC 1104, and the MOU
of February 3, 1994, between the Secretaries of Veterans Affairs
and Defense.
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III.
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Policy
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1.
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Except
as otherwise provided in this MOU, the agreement between the MCS
contractor and the VA facility shall conform to all requirements
applicable to providers under the 32 CFR 199 and to network providers
under the contract between the MCS contractor and the DoD.
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2.
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The
VA facility shall be established as an authorized participating
provider. VA individual providers meeting VA requirements for licensure
shall be deemed to meet contractor requirements pertaining to licensure.
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3.
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Agreements
established under this MOU shall be subject to review and approval
by the VA Central Office and DoD (acting through an office designated
by the Assistant Secretary of Defense (Health Affairs)) and shall
not become effective until completion of the VA certification requirements
of Public Law 102-585, Section 202.
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4.
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The
MCS contractor shall reimburse the VA facility for hospital inpatient
care and for professional services, including outpatient care in
accordance with the MCS contract requirements for reimbursement
of network providers, with the exception that, incentive payments
used to entice providers into the network shall not be authorized.
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5.
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The
MCS contractor shall provide the VA facility with a Provider Identification
Number (PIN), by provider category, to be used in billing for services
provided under this agreement.
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6.
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The
VA shall advise facility employed individual providers of the dual
compensation/conflict of interest provisions prohibiting VA employees
from being authorized as individual providers capable of billing
in their own names for services provided to beneficiaries. The Director, TRICARE
Management Activity, or his designee, may authorize exceptions to
this policy, on a case-by-case basis for part-time physician (M.D.)
employees only who file claims for services furnished in their private,
non-VA employment practice.
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7.
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The
VA facility shall be subject to the same utilization management
and quality assurance requirements applicable to other network providers,
including designation of a primary care provider, preauthorization
for care, etc.
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8.
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Eligible
beneficiaries entitled to health care services under this MOU shall
be defined consistent with the MCS contract requirements.
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9.
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Beneficiaries
shall be subject to copayments consistent with the MCS contract
requirements.
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10.
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For
individuals with dual VA and DoD eligibility, VA will be responsible
for ensuring that an individual veteran’s non-discretionary VA benefits
are exhausted before utilizing TRICARE benefits. With regard to
individuals with dual VA and DoD eligibility. VA will be responsible
for the following beneficiary care: (a) all care for mandatory/non-discretionary
veterans; (b) all care for veterans for service-connected conditions:
and, (c) care for any veteran that is a continuation of care for
a condition previously under treatment at the VA facility.
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11.
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VA
will be responsible for obtaining information regarding possible
third party health insurance coverage of the DoD beneficiary. VA
will collect from the third party insurer in accordance with VA
procedures and bill the balance to the MCS contractor, which will reimburse
claims involving third party health insurance in accordance with
established policy. In the event that VA is unable to collect from
a third party insurer for health care services that would be covered
by the insurer if provided by a private provider, no bill will be
presented by the VA to the MCS contractor.
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IV.
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Administrative
Responsibilities
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The
Assistant Secretary of Defense for Health Affairs, in consultation
with the Under Secretary for Health of the Department of Veterans
Affairs, shall conduct overall program management relating to agreements
between the MCS contractors and VA facilities under the authorities
of this MOU.
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V.
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Issue
Resolution
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Throughout
the course of this agreement, issues involving interpretation of
its provisions, unanticipated technical matters, and proposed modifications
in the interests of equity can be expected. The Departments agree
to work together in a collegial manner and in good faith to resolve
such issues in a manner that is fair, equitable, supportive of the
objectives of VA/DoD sharing law, and responsive to the needs of
VA and DoD beneficiaries.
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VI.
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Points
Of Contact
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a.
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For
the Department of Veterans Affairs:
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Arthur
S. Hamerschlag
Director,
Medical Sharing Office (166)
VA
Central Office
Washington,
DC 20520
(202) 535-7564
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b.
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For
the Department of Defense
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Thomas
F. Carrato, RADM, MCS, USPHS
Chief,
Operating Officer, TMA OASD (HA) TMA
1B657, The Pentagon
Washington, DC 20301-1200
(703) 614-4639
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VII.
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Modification
Or Termination
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a.
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Either
the VA or DoD may propose amendments modifying this agreement at
any time. Before any amendment will become effective, both parties
must agree in writing to the modification. The effective date of
any amendments will be the date agreed upon and specified in the agreement,
or, if no date is specified, the last date upon which representative
officials of both parties have agreed in writing to the amendment.
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b.
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This
MOU terminates 1) upon expiration of the authorities of Title II
of Public Law 102-585 (October 1, 1996), unless this law is extended
or made permanent, or 2) may be terminated at any date upon 60 days
notice in writing to the other party.
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