2.0 POLICY
2.1 Under this reimbursement
rate waiver process, a locality-based waivers may be submitted for consideration
in the waiver of professional providers receiving TRICARE established
reimbursement rates:
2.1.1 If
it is determined that access to specific health care services is
impaired, higher payment rates may be authorized or established,
by the Director, Defense Health Agency (DHA), for specific services
that are covered under TRICARE. For specified areas outside the
50 U.S. and the District of Columbia, locality waivers are defined
geographically as a city or country.
2.1.2 When the Director, DHA, or designee, determines
beneficiary access to health care services in a locality is impaired,
the Director, DHA, or designee, may establish rates, as deemed appropriate
and cost efficient by the following methodologies to assure adequate
access to health care services.
2.1.2.1 A percent factor
may be applied or added to the allowed and established by TRICARE
under the TRM,
Chapter 1, Section 35.
2.1.2.2 A prevailing
charge for a specified location outside the 50 U.S. and the District
of Columbia may be applied. TRICARE may use any appropriate methodology
to substantiate and establish prevailing charges.
2.1.2.3 Other appropriate
payment schedules, if applicable.
2.2 All waiver
requests for specified locations outside the 50 U.S. and the District
of Columbia shall be submitted to the appropriate Regional Director,
TRICARE Area Offices (TAOs), to ensure that the TAO agrees with
such request and that all available evidence in support of the locality-based
waiver request has been submitted for consideration.
2.3 The procedure
to be followed for specified locations outside the 50 U.S. and the
District of Columbia is as follows:
2.3.1 The Director, TAO shall validate
that the access to care is impaired in localities where the Government
has established reimbursement schedules.
2.3.2 Who can apply:
• Director, TAO.
• Providers in the affected specified localities
outside the 50 U.S. and the District of Columbia.
• TRICARE Overseas Program (TOP) contractor.
• TRICARE beneficiaries in the locality.
2.3.3 How to apply:
2.3.3.1 Applicant must
submit a written waiver request to the Director, TAO. The request
must specify the type of waiver the application is for and justify
that access to health care services is impaired due to low TRICARE
reimbursement rates.
2.3.3.2 Justification
for the waiver must include at the minimum:
2.3.3.2.1 Total number
of providers (primary care, specialty, or other) in a designated
locality.
2.3.3.2.2 Mix of primary/specialty
providers needed to meet patient access standards (refer to the
Department of Defense (DoD) access standards. Example, DoD access
standards require one Primary Care Physician (PCP) per 1,000 beneficiaries).
2.3.3.2.3 Current number
of providers who accept or work with TRICARE.
2.3.3.2.4 Number of eligible
beneficiaries in the locality.
2.3.3.2.5 A description
of any efforts that have been attempted to locate alternative providers
of service, as well as the results of those efforts.
2.3.3.2.6 Availability
of Military Treatment Facilities (MTFs) and
MTF providers, if applicable.
2.3.3.2.7 Geographic characteristics
or other unique characteristics.
2.3.3.2.8 Applicable defined
cultural issues.
2.3.3.2.9 Cost effectiveness
of granting a waiver.
2.3.3.2.10 Provider letters
of intent.
2.3.3.2.11 Evidence of
the existence and/or evidence of provider acceptance of country
specific prevailing fees, usual and customary fees, or commercial
fee schedules.
2.3.3.2.12 Other relevant
factors, unique to the specified location outside the 50 U.S. and
the District of Columbia.
2.3.3.2.13 Medical Readiness
issues.
2.4 Exceptions.
2.4.1 A provider request for beneficiary
payment “up front” for health care services or beneficiary payment
for higher cost share amounts in specified locations outside the
50 U.S. and the District of Columbia, shall not be considered as
a basis for requesting a locality-based waiver.
2.4.2 Any provider
who has been placed on Program Integrity Watch by DHA’s Chief, Program Integrity
Office, or designee, or the overseas claims processor is not eligible
for a reimbursement fee waiver until removed from Program Integrity
Watch status.
2.5 The Director, TAO or designated
staff shall conduct a thorough analysis of the information submitted
and supply any missing information to the waiver request. The Director,
TAO shall review and forward their recommendations with a preliminary
cost estimate to the Chief, TRICARE Overseas Program Office (TOPO).
The Chief, TOPO will indicate agreement, document the receipt of
the waiver and track the waiver request. The Director, TOP, will
subsequently forward the waiver request to the DHA Contracting Officer
(CO) and to DHA Medical Benefits and Reimbursement Section (MB&RS). Should
the Chief, TOPO, disagree with the TAO waiver request it shall be
returned to the TAO and the request shall be cancelled. In processing
waivers, the appropriate TRICARE Contracting staff (CO, Contracting
Officer’s Representative (COR), etc.) along with DHA MB&RS will
confer with other TRICARE analysts, other Subject Matter Experts,
obtain an Independent Government Cost Estimate (IGCE), and/or perform
additional analysis to ensure that the requested increase in reimbursement
shall alleviate access problems.
2.6 Disapprovals by the Director, TAO,
will be forwarded to the Chief, TOPO, for recording purposes, but
will not be forwarded for additional action or waiver process completion.
2.7 Final Authority.
The Director, DHA, or designee is the final approval authority.
A decision by the Director, DHA, or designee to authorize, not authorize,
terminate, or modify the authorization of higher payment amounts
is not subject to appeal or hearing procedures. The Director, DHA,
or designee has the discretion to review at unspecified intervals
any previously enforced decision for fee schedule modifications,
revisions, reversals, or other actions as he/she deems appropriate.
2.8 Implementation
of waivers in specified areas outside the 50 U.S. and the District
of Columbia. If the Director, DHA, or designee approves a higher
payment rate for certain services in a locality, reimbursement rates
for those procedure codes in those locations would be adjusted by
the overseas claims processor, in order to improve the access to
services.