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I.
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SUBJECT
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Department of
Defense (DoD) TRICARE Contractors are entering into Network Participation Agreements
with the Department of Veterans Affairs (DVA) Veterans Health Administration
(VHA) to provide care for TRICARE/Civilian Health and Medical Program
of the Uniformed Services (CHAMPUS) beneficiaries covered by the
TRICARE Contractors, which include Regional Managed Care Support Contractors,
TRICARE Dual Eligibility Fiscal Intermediary (TDEFIC), and all Overseas
Contractors.
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II.
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Purpose
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This Memorandum
of Understanding (MOU) is to establish general requirements between
VHA and DHA for agreements between a DHA TRICARE contractor and
the DHA under which the TRICARE contractor may include VHA facilities
in the contractor’s network. This agreement replaces the agreement
entitled “Memorandum of Understanding between the Department of
Veterans Affairs and the Department of Defense”, signed in 1995,
with the subject, “Department of Defense (DoD) Managed Care Support
Contractors entering into Agreements with the Department of Veterans
Affairs (DVA) Health Care Facilities to Provide Care for CHAMPUS
Beneficiaries Covered by the Regional Managed Care Support Contracts.”
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III.
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Authority
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This agreement
MOU is supported by, Title 38 United States Code (U.S.C) Section
(Sec.) 8111, and by Title 10 U.S.C. Sec. 1104.
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IV.
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Policy
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a.
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Except as otherwise
provided in this MOU, the Network Participation Agreements between the
TRICARE contractor and the VHA shall conform to requirements applicable
to providers under Title 32 Code of Federal Regulations (CFR) Part 199.7 and to network providers under the contract
between the TRICARE contractor and DHA. However, the Secretary of
Veterans Affairs is responsible for the management of VHA facilities
pursuant to Title 38 U.S.C. Sec. 303. Should any requirement conflict
with a policy, statute or regulation governing VA, that conflict
shall be brought to the attention of the DHA TRICARE Contracting
Officer for the region in which the applicable VHA facility or facilities
is/are located to determine if an appropriate resolution is possible.
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b.
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Each VHA facility
covered by a VHA agreement with a DHA TRICARE contractor shall be established
as an authorized participating network provider. DHA shall accept
VHA’s policy and procedures, the parties agree that VHA providers
meeting VHA credentialing requirements including licensure, and
certification, shall be deemed to meet contractor requirements pertaining
to credentialing, licensure and certification for network provider status.
VHA will be exempt from submitting Internal Revenue Service (IRS)
form W9 since VHA facilities are Federal facilities exempt from
taxation.
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c.
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VHA facilities
meeting VHA’s requirements for substance abuse, psychiatric and
rehabilitation hospitals or units shall be deemed to meet TRICARE
requirements for certification and shall be reimbursed in accordance
with the provisions of Title 32 CFR Sec. 199.14, or at 80 percent of VHA’s reasonable
charges, whichever is lower.
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d.
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VHA is responsible
for refunding TRICARE overpayments in a timely fashion. Upon discovery of
an overpayment, the TRICARE contractor will issue written notice
of the basis for the overpayment to the applicable VHA facility,
which will include a request for repayment of an amount due. The
VHA facility will acknowledge receipt within 90 days of the TRICARE contractor’s
notification. In addition, the VHA facility’s acknowledgment will
contain any claim dispute, to include those regarding the overpayment’s
basis or the refund’s calculation. The VHA facility may also request
additional time to investigate potential disputes. If the VHA facility
does not respond or the TRICARE contractor cannot resolve a claim
dispute, the TRICARE contractor will refer the case to the Chief,
Claims Collection at DHA. If the VHA facility does not submit a
claim dispute, VHA will refund the amount due within180 days from
the written notification. Upon resolution of claim disputes, VHA,
if appropriate, will issue a refund within 180 days.
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e.
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VHA shall advise
its providers of the applicable dual compensation/conflict of interest provisions
prohibiting VA employees from being authorized as individual providers
capable of billing in their own names for services provided to TRICARE
beneficiaries.
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f.
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DHA accepts VHA
quality assurance standards.
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g.
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VHA will not
be required to supply VHA provider social security numbers to the
TRICARE Contractors. TRICARE Contractors will not conduct criminal
background investigations on VHA providers.
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h.
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Eligible TRICARE
beneficiaries entitled to health care services under this MOU shall
be defined consistent with the TRICARE Program requirements.
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i.
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TRICARE Beneficiaries
shall be subject to copayments consistent with the TRICARE Uniform Benefit
requirements. If a TRICARE for Life (TFL) beneficiary receives care
at a VHA facility for a non-service related condition, the beneficiary
shall be advised by VHA that the maximum payment by TRICARE will
be limited to the co-payment that TRICARE would have paid had the
beneficiary seen a Medicare provider. The beneficiary shall be advised
that in these cases he or she will be personally liable to the VHA
facility for any remaining charges not covered by other health insurance.
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j.
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With regard to
individuals with dual VA and DoD eligibility (does not include Reserve Component
Service Members on active duty orders for greater than 30 days),
VHA will be responsible for the following beneficiary care: (a)
all care for Veterans for service-connected conditions; and, (b)
care for any Veteran that is a continuation of care for a condition previously
under treatment at the VHA facility. With regard to Reserve Component
Service members serving on orders to active duty for greater than
30 days (Reserve and National Guard service members) DoD eligibility
will take precedence over VA eligibility for care and all applicable
TRICARE rules (i.e. authorizations, etc.) will apply.
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k.
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TRICARE is the
primary payer for service members (on active duty greater than 30
days). Such members cannot use other health insurance. For all other
TRICARE beneficiaries, TRICARE is the secondary payer to all health
benefits and insurance plans, except for Medicaid, TRICARE supplements,
the Indian Health Service, and other programs/plans as identified
by the DHA. The TRICARE contractor will reimburse VHA for care provided
to TRICARE beneficiaries in accordance with the VHA agreement reimbursement
rate schedule. VHA shall make reasonable efforts to obtain third
party health insurance coverage information from TRICARE beneficiaries
other than active duty and will bill and collect from the third
party insurer in accordance with VHA procedures. Pursuant to TRICARE
policy, if VHA is unable to collect from the third party insurer,
TRICARE will pay as primary.
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l.
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Priority of Care:
No service provided under a Network Participation Agreement between
a TRICARE contractor and VHA as determined by the head of the providing
VHA facility, will adversely affect the range of services, quality
of care, or the established priorities for care provided to the
primary/core beneficiaries of the VHA facility providing services
under such agreement.
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V.
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Administrative
Responsibilities
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The Director,
TRICARE Health Plan (J-10) at DHA, in consultation with the VHA
Deputy Under Secretary for Health for Operations and Management,
shall conduct overall program management relating to agreements
between the TRICARE contractors and the VHA under the authorities
of this MOU.
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VI.
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DISPUTE RESOLUTION
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a.
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Both parties
agree, to the extent possible, to resolve all disputes under this
agreement at the lowest possible level. All disputes will be submitted
in writing to the other party.
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b.
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Final disposition
of the dispute lies within the authority of the Parties’ signatory,
or his/her designee, to this Agreement.
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VII.
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MODIFICATION
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Either VHA or
DHA may propose amendments modifying this agreement at any time.
Before any amendment becomes effective, both parties must agree
in writing to the modification. The effective date of any amendments
will be the date agreed upon and specified in the agreement, or,
if no date is specified, the last date upon which representative
officials of both parties have agreed in writing to the amendment.
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VIII.
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EFFECTIVE DATE
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This MOU becomes
effective upon the last signatory date below for a period not to
exceed five years. Either party may cancel this MOU upon 60 calendar
days-written notice.
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___________ //
Original Signed//___________
Raquel V. Bono,
VADM, MD
Director, Defense
Health Agency
Department of
Defense
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___________ //
Original Signed//___________
David J. Shulkin,
MD
Under Secretary
for Health
Department of
Veterans Affairs
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___________ March
16, 2017 ___________
Date of Signature
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___________ January
04, 2017___________
Date of Signature
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