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TRICARE Operations Manual 6010.62-M, April 2021
Demonstrations, Pilot Projects, and Value-Based Initiatives
Chapter 18
Section 4
Expired - Department of Defense (DoD) Hearing Center of Excellence (HCE)/Department of Veteran Affairs (VA) Hearing Aid Procurement Model (HAPM) Expansion Demonstration
The purpose of this phased demonstration is to identify cost savings achieved through expansion and scalability of the interagency DoD HCE/VA HAPM for TRICARE Prime-eligible Active Duty Service Members (ADSMs) and Active Duty Family Members (ADFMs). This demonstration is intended to assess the feasibility and return on investment for expanding the DoD/VA hearing aid procurement interagency resource sharing agreement to include the purchased care network, and mirror the VA Community Care Network (CCN) Durable Medical Equipment (DME) polices for hearing aids to inform the current and future TRICARE contracts.
2.1  An initiative developed by the DoD HCE and the VA Denver Logistics Center (DLC) in 2013 granted Military Medical Treatment Facility (MTF) audiologists access to, and directed their use of the VA’s Remote Ordering Entry System (ROES). This initiative, outlined in an Interagency Agreement in accordance with Section 801 of the National Defense Authorization Act for Fiscal Year 2008, allows MTF audiologists to order hearing aids and related supplies using the VA’s National Hearing Aid and Wireless Systems (NHAWS) contract that is reimbursed through a centralized Defense Health Agency (DHA) Military Interdepartmental Purchase Request (MIPR). The Military Health System (MHS) has realized substantial savings using the VA’s NHAWS contract for TRICARE beneficiaries receiving hearing aids prescribed by MTF audiologists.
2.2  In October 2014, DoD issued policy authorizing referral of ADSMs to network audiologists when they either reside outside the catchment area or the specific audiology service is unavailable at the MTF. Purchased care network audiologists, when medically necessary, order hearing aid devices and accessories for their TRICARE patients directly from companies at a significant mark-up over the VA contract price. The purchase of the same devices for ADSMs treated at MTFs has been economically achieved through collaboration between the DoD HCE and VA per DoD policy established in 2013.
2.3  On April 11, 2018, the DoD Reform Management Group chaired by the Chief Management Officer, Office of the Secretary of Defense published a Decision Memorandum notice of record to approve the TRICARE Health Plan (THP) Managed Care Support Contract (MCSC) Reform Plan, directing the exploration of duplicating the VA hearing aid procurement practices through its CCN via expansion of the DoD/VA HAPM utilized in the DoD Direct Care (DC) system to utilization of it in the purchased care network as well (National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, Section 713).
3.1  A demonstration evaluating the efficacy and cost avoidance of expansion of the project DoD HCE/VA HAPM was initiated by the DoD HCE in collaboration with the VA DLC, and the MCSCs. This two year demonstration program will continue until the program is transitioned to policy or terminated early if the DHA Director or VA Audiology Program Office determine that the cost or quality does not support continuation of the endeavor. Termination will be via a separate notice two years from the start date. Hearing aids and associated devices under the TRICARE benefit will continue to be covered in accordance with Federal regulations governing the procurement of DME.
3.2  The demonstration will expire on the date two years following initiation of demonstration. Requirements of this Chapter as related to this demonstration cease at midnight on the date of expiration.
3.2.1  The MCSC shall implement the demonstration to TRICARE Prime beneficiaries, as defined by the demonstration “phase” (Phase 1 ADSMs in California; Phase 2 adds ADSMs in Texas; Phase 3 expands the demonstration to qualifying TRICARE Prime ADFMs in California and Texas). Timeline and dates of phase implementation will be identified in the Demonstration Implementation Plan governing the demonstration.
3.2.2  The contractor shall not pay claims to audiologists for codes associated with acquisition of hearing aids; rather, they shall only be paid for the portions of the patient encounter leading to medically necessary prescription of a hearing aid or medical device and any associated fitting/follow-up care, excluding reimbursement for acquisition of the device as outlined in paragraphs 7.0 and 8.0.
3.3  All medical care, treatments, or testing, must be a TRICARE covered benefit provided to TRICARE-eligible beneficiaries. This applies to all care rendered during or after the end date of this demonstration.
3.4  The records management requirements described in Chapter 9 apply to this demonstration.
3.5  The benefit, standard of care, and quality of health care for services rendered to the TRICARE beneficiaries receiving purchased care network audiology treatment shall not be negatively impacted in any way.
4.1  This demonstration applies to eligible ADSMs and TRICARE Prime-enrolled ADFM beneficiaries in the states identified in the Demonstration Implementation Plan receiving care that requires the prescription of hearing aids and associated medical devices deemed medically necessary.
4.2  The benefit for hearing aids and associated devices approved under this demonstration program are the same as the TRICARE Basic Program benefit. Coverage inquiries shall be submitted to, and resolved by the appropriate contractor (referencing the DoD HCE/VA HAPM Demonstration). Regarding a beneficiary with other insurance that provides primary coverage, any medical necessity reviews the contractor believes are necessary, to act as a secondary payer, shall be performed on a retrospective basis.
4.3  This demonstration only applies to TRICARE authorized in-network audiologists.
5.1  The contractor shall preauthorize all prescriptions for hearing aids and associated devices to verify that the TRICARE authorized provider has determined the eligible beneficiary’s medical need, and administered appropriate tests for diagnosis based on the beneficiary’s clinical diagnoses which support the medical need. Following the contractor’s identification of an appropriate request for prescription of a hearing aid or associated device, as is determined within the benefit, the TRICARE authorized provider requesting/ordering the hearing medical devices shall be notified that the DoD HCE is procuring the device to be mailed to their practice for dispensing and fitting to the beneficiary.
5.1.1  The contractor shall notify the ordering provider they are not authorized to procure the hearing aid or associated devices for the beneficiary from any other source.
5.1.2  The contractor shall issue the notification of decision to authorize procurement of the hearing medical device via the DoD HCE/VA interagency Hearing Aid Procurement Program in writing to both the applicant provider, the DoD HCE, and the beneficiary receiving the hearing aid device with instructions to schedule follow-up with the ordering provider to receive the device.
5.2  All prescriptions for hearing aids and associated devices shall be submitted by network audiologist to the contractor. Prescriptions for medically necessary hearing aids and associated devices will be based on vendors and devices available through the VA’s (NHAWS) contract.
5.3  The DoD HCE will alert the MCSC of the initial device and vendors available through the VA NHAWS contract, as well as any changes in the availability throughout the demonstration.
5.4  The contractor shall submit order forms and other documentation (i.e., audiograms or patient information) as determined necessary for prescribed hearing aids and associated devices to the DoD HCE.
5.5  The DoD HCE will enter the order for hearing aid devices into the VA procurement system for the hearing aid manufacturer to fulfill.
5.6  The DoD HCE will provide the ROES order form and confirmation to the MCSC and the ordering provider.
5.7  If custom items are required (e.g., ear molds), the audiologist will provide the necessary earmold impressions, and other information as required, to the manufacturer, following the order confirmation, using the order form and confirmation from the ROES system.
5.8  If the patient has a prior history of hearing aids and has an ear mold impression on file with the DLC or the vendor, it can be used for the new order.
5.9  The hearing aid manufacturer shall ship the hearing aid devices to the prescribing network audiology office as is done with the VA CCN providers.
5.10  The network audiologist shall see the patient for follow-up and dispense medical devices according to the standard of care (providing education, fitting/programming, necessary follow-up care, etc.), billing for all rendered services covered by the benefit, with the exception of acquisition of the hearing aid and associated devices.
5.11  All claims for audiology care will be submitted to the contractor for adjudication.
5.12  The DoD HCE shall reimburse the VA DLC in accordance with the interagency agreement.
6.1  THP will perform periodic review and evaluation of the demonstration claims adjudication process.
6.2  The DoD HCE will continue to purchase and acquire the hearing aids and associated devices for ADSMs seen in the DC system through the DoD/VA interagency resource sharing agreement for DME. This process shall be expanded to apply to ADSMs seen by network audiologists in the state of California and Texas (Phases 1 and 2) and qualified TRICARE Prime ADFMs in California and Texas (Phase 3) of the demonstration program.
6.3  The DoD HCE will coordinate with the MCSC directly for logistical processing of the procurement orders.
6.4  The DoD HCE will continue to reimburse the VA for procurement of medical devices.
6.5  The hearing aid manufacturer will ship the hearing aid devices to the prescribing network audiologist office in accordance with policies and procedures in the Demonstration Implementation Plan.
7.1  The contractor shall ensure that all hearing aids and associated device prescriptions are submitted using the DoD HCE/VA order forms provided during the implementation phase within two business days of health care services from which the prescription was generated.
7.2  The contractor shall ensure all network audiologist prescriptions for hearing aids and associated devices are submitted to the DoD HCE for review and fulfillment accompanied by pertinent hearing test results reported according to the DoD HCE template provided during the implementation phase.
7.3  The contractor shall comply with these network requirements for facilitating the procurement of hearing aids and associated devices for all eligible ADSMs and TRICARE Prime ADFMs in the designated geographic region undergoing care by network audiologists in accordance with the phase of the demonstration (Phase 1 ADSMs - California; Phase 2 ADSMs - Texas, Phase 3 eligible TRICARE Prime ADFMs in California and Texas who meet the TRICARE definition of profound hearing loss and are five years of age or older).
7.4  The contractor shall educate all network audiologists and keep TRICARE informed of the progress of this education regarding the change in hearing device procurement for TRICARE beneficiaries required by this demonstration, with 100% contact made 30 calendar days prior to demonstration start date with continuing education of audiologists throughout.
7.5  The contractor shall verify the beneficiary’s eligibility on the Defense Enrollment Eligibility Reporting System (DEERS) to verify plan type and beneficiary category.
7.6  The contractor shall issue an authorization letter to the applicant provider and beneficiary with instructions once a determination is made. Sample education materials and forms shall be provided by the DoD HCE during implementation.
7.7  The contractor shall submit order forms for prescribed hearing aids and associated devices to the DoD HCE. They shall address discrepancies/missing data (tests) with network audiologists and resolve issues.
7.8  The contractor shall hold the network audiologists accountable for delivering the medical standard of care necessary for follow-up care, including patient education, training, fitting, and adjustment for the prescribed item.
7.9   The hearing aid manufacturer shall send the prescribed item to the prescribing provider location, unless specified otherwise, for the prescribing provider to provide follow-up care and the item(s) to the beneficiary. An order form is only submitted by the audiologist if custom item is required and there is no prior custom order prescription on file.
7.10  The contractor shall ensure part of their network provider education and preauthorization notification informs that DoD reserves the right to order/issue comparable, functionally equivalent hearing aids and associated devices, if deemed appropriate.
7.11  The contractor shall provide a report with data elements that demonstrate compliance with the procurement of hearing aids and associated devices contained within this chapter, as well as to assist with evaluating the success of this demonstration. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
8.1  The contractor shall ensure no payment is made to the dispensing network provider for the hearing aids and associated devices.
8.2  The contractor shall correctly voucher the TRICARE Encounter Data (TED) records for payment.
8.3  The contractor shall manage and resolve all inquiries related to the demonstration including claims issues.
The effective date for this demonstration is proposed for July 1, 2021 for commencement of Phase 1 with anticipated dates for transition to Phase 2, of July 1, 2022, and Phase 3, of January 1, 2023.
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