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.