(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 NDAA-17, 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 this paragraph (f)(4) 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 TRICARE Prime enrollees, the enrollment fee, catastrophic
cap, and cost sharing amounts are as set forth in 10 U.S.C. 1075a.
The cost sharing requirements applicable to services not specifically
addressed in the table set forth in 10 U.S.C. 1075a(b)(1) shall
be determined by the Director, DHA.
(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 TRICARE
Select 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. The cost sharing requirements applicable to services
not specifically addressed in 10 U.S.C. 1075 shall be determined
by the Director, DHA.
(3) Special
cost-sharing rules.
(i) 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.
(ii) Cost-sharing
for maternity care services shall be determined in accordance with
Sec. 199.4(e)(16).
(iii) Cost-sharing and copayments
(including deductibles) shall be waived for in-network telehealth services
during the national emergency for the global coronavirus 2019 (COVID-19)
pandemic.
(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)(iii)
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; 84 FR 4333, Feb 15, 2019;
85 FR 27927, May 12, 2020]