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.