1.0 CM
The contractor shall provide
CM (medical and behavioral health) to TRICARE beneficiaries who
are eligible for the contractor’s CM services, including those beneficiaries
who are still receiving care under the Custodial Care Transitional
Policy (CCTP) and Individual Case Management Program For Persons
With Extraordinary Conditions (ICMP-PEC) programs. Medicare/TRICARE
dual eligible beneficiaries are not eligible for the contractor’s
CM program, except for care under the CCTP and ICMP-PEC programs.
For reporting requirements, see DD Form 1423, Contract Data Requirements
List (CDRL), located in Section J of the applicable contract.
1.1 The contractor shall provide
a dedicated clinical case manager (i.e., Registered Nurse (RN) or
social worker) to each beneficiary in the CM program to support
each beneficiary in a personalized way throughout their health care
experience.
1.2 The
contractor shall ensure that case managers are knowledgeable of
local, county, state, and federal level resources where the CM enrolled
beneficiary is located.
1.3 The
contractor shall connect beneficiaries with resources that are targeted
to address their unique physical and mental health needs as identified
in their CM assessment and care plan.
1.4 The
contractor shall also provide CM to Active Duty Service Members
(ADSMs) who meet the conditions outlined above, when care occurs
or is projected to occur, in whole or in part in, the private sector
care.
1.5 The
contractor’s case managers shall manage beneficiaries through the
continuum of care as it relates to institutional inpatient and outpatient
care (TRICARE Policy Manual (TPM),
Chapter 11, Section 1.1). The case manager
shall prepare individuals and families for hospital admissions and
discharges, and collaborate to coordinate care across the continuum.
1.5.1 The contractor’s case manager
shall ensure the discharge plan is appropriate and aligns with the services
outlined in the TRICARE benefit.
1.5.2 The
case manager shall assist with coordinating care prior to and following
discharge, if the discharge plan is for a non-covered service.
1.5.3 The
contractor shall utilize a multidisciplinary team approach to address
the unique needs of each beneficiary. The multidisciplinary team
includes both clinical and non-clinical subject matter experts as
applicable, i.e., physical therapist, dietician, pharmacist, community
health workers, peer support specialists, etc.
1.6 The contractor shall provide
Markets/Military Medical Treatment Facilities (MTFs) with visibility
via electronic access to all CM assignment information as identified
in
Chapter 7, Section 1.
2.0 CARE COORDINATION
2.1 The contractor shall ensure
care coordination programs and services are available at the start
of healthcare delivery and for the duration of the contract for
both medical and behavioral health conditions and services.
2.2 The
contractor shall utilize a multidisciplinary team approach to address
the unique needs of each beneficiary. The multidisciplinary team
includes both clinical and non-clinical subject matter experts as
applicable, i.e., physical therapist, dietician, pharmacist, community
health workers, peer support specialists, etc.
2.3 The contractor shall communicate,
collaborate, and coordinate with private sector care providers, Markets/MTFs
and Government Designated Authority (GDA) to transfer stabilized
patients from one location to another on a 24 hours a day/seven
days a week (24/7) basis. Transfers may occur as a result of medical,
social, or financial reasons and include moves of non-institutionalized
and institutionalized patients to include mental healthcare.
2.4 The contractor shall coordinate
care with the Market/MTF clinical staff, as well as the civilian
providers, when care occurs outside a Market/MTF.
2.4.1 The
contractor shall notify the member’s enrolled Market/MTF within
two business days of notification of the care taking place, or notify
the Defense Health Agency-Great Lakes (DHA-GL) within two business
days of notification for members enrolled to civilian Primary Care
Managers (PCMs), when managing the care of an ADSM.
2.4.2 The contractor shall assist
the beneficiaries’ understanding on how to utilize, access and navigate
the health benefits under the TRICARE program.
2.4.3 The contractor shall provide
a dedicated care coordinator to support each beneficiary requiring assistance
throughout their coordination and transition of care.
2.5 Coordination of transition
of care within the contractor’s geographic area of responsibility
(intraregional/interregional transition of care):
2.5.1 The
contractor shall communicate, collaborate, and coordinate transition
of care/services with the affected Market/MTF(s), the Department
of Veterans Affairs/Veterans Health Administration (DVA/VHA), GDA,
or private sector care provider(s) upon beneficiary or GDA request.
2.5.2 The contractor shall provide
coordination of transition of care services to all eligible beneficiaries except
non-active duty TRICARE/Medicare dual eligible beneficiaries.
2.5.3 The contractor shall provide
a dedicated care coordinator to each beneficiary requiring assistance
to support each beneficiary in a personalized way throughout their
transition of care.
2.5.4 The
contractor shall commence transition of care/services within three
business days of beneficiary or GDA notification.
2.5.5 The contractor shall provide
transition of care/services to the following beneficiaries:
• ADSMs during Permanent Change
of Station (PCS) involving TRICARE-eligible family members who are enrolled
in the Exceptional Family Member Program (EFMP).
• ADSMs separating/retiring from
active duty service.
• ADSMs transitioning to the
DVA/VHA.
• TRICARE beneficiaries registered
in the Extended Care Health Option (ECHO) program.
• Seriously ill or injured ADSMs
in receipt of benefit coverage comparable to the ECHO program in
accordance with
Chapter 17, Section 3.
• TRICARE beneficiaries receiving
CM services and moving from one geographical location to another
with an active referral, as outlined in
Chapter 7, Section 5, paragraph 4.9.
2.5.6 The contractor’s coordination
of care shall include all appropriate providers and services needed
for transition to a new location or change in level of care setting.