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 Executive 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 Executive 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:
• Executive 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 Executive 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 Medical 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 Executive Director,
TAO or designated staff shall conduct a thorough analysis of the information
submitted and supply any missing information to the waiver request.
The Executive 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 Executive 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.