2.0 POLICY
AND ELIGIBILITY
2.1 All provisions of
Section 11 apply to care rendered overseas,
unless they are specifically modified by this section.
2.2 The contractor
shall ensure beneficiaries located overseas and/or enrolled to the
TRICARE Overseas Program (TOP) contractor meet all requirements
of
Section 11 unless the requirement is specifically
modified by this section.
2.3 Beneficiaries located overseas
and/or enrolled to the TOP contractor under TRICARE Prime, TRICARE
Prime Remote (TPR), or TRICARE Select are eligible to receive services
beginning January 1, 2025, through the end of the demonstration.
2.4 The TOP
contractor shall ensure providers furnishing services to beneficiaries
enrolled to the TOP contractor meet all requirements of
Section 11 unless the requirement is specifically
modified by this section.
2.5 Authorized providers located
overseas are eligible to be reimbursed for services furnished to TRICARE
beneficiaries beginning January 1, 2025.
2.6 The contractor
shall not reimburse international telehealth services (i.e., telehealth
services performed by a provider in one country to beneficiaries
in another country, to include providers and beneficiaries located
in the United States (U.S.)). The contractor shall reimburse telehealth
services permitted under
Section 11 when
provided internal to a country and only if otherwise meeting all TRICARE
and demonstration telehealth requirements and the telehealth requirements
of the host nation (host nation requirements include those established
by any entity responsible for regulating the provision of telehealth
services where furnished and where the beneficiary resides, whether
at the local, regional, or national level).
3.0 ENROLLMENT
3.1 The TOP
contractor shall create an enrollment process for the demonstration
for beneficiaries enrolled to the TOP contractor. At the time of
enrollment, the TOP contractor shall issue an authorization for
services under the demonstration (for Prime enrolled beneficiaries)
or initiate a benefit review (for TRICARE Select enrollees).
3.2 The TOP
contractor shall encourage beneficiaries to enroll in the demonstration
a soon as possible in their pregnancy. The TOP contractor shall
not deny enrollment based on gestational age of the pregnancy but
should make sure the beneficiary is aware of the gestational age
at which the beneficiary will be eligible for services. The gestational
age to receive childbirth support services is 20 weeks (see
Section 11, paragraph 4.4). The gestational
age to receive breastfeeding support is 27 weeks or upon delivery
of the child if the delivery occurs before 27 weeks (see the TRICARE
Policy Manual (TPM),
Chapter 8, Section 2.6, paragraph 3.2).
3.3 The TOP
contractor shall begin enrolling beneficiaries in the demonstration
no later than 90 days prior to the start of the demonstration overseas.
For enrollments that occur prior to the start of the demonstration,
the TOP contractor shall notify the beneficiary that any services
received prior to January 1, 2025, will not be eligible for reimbursement.
If the beneficiary requires breastfeeding support services prior
to the start of the demonstration, the TOP contractor shall connect
the beneficiary with breastfeeding support from a non-demonstration
provider (for example, a TRICARE-authorized registered nurse who
is also a lactation consultant or counselor), as allowed under the
TPM,
Chapter 8, Section 2.6.
3.4 Once the
TOP contractor enrolls a beneficiary in the demonstration, the TOP
contractor shall aid the beneficiary in locating eligible providers
under the demonstration. The TOP contractor shall identify and qualify
providers on a best effort basis.
3.5 If the
TOP contractor determines there are no eligible providers available
and/or willing to furnish services under the demonstration in the
beneficiary’s location (either in person, or, for breastfeeding
support, remotely), the TOP contractor shall notify the beneficiary
that services are not available. The contractor shall provide notification
to the beneficiary within 14 days of enrollment (or earlier, if
appropriate for the stage of the pregnancy). In some countries for
which TOP deliveries are rare (fewer than 10), the 14-day notification
may be a status update, with additional updates provided a minimum
of every 14 days until the TOP contractor identifies a provider
or determines that there are no providers available.
3.6 If the
beneficiary enrolls in the demonstration in a country/location where
access to demonstration services is limited due to in-country practices
(e.g., if a country does not allow doulas to provide support during
labor and delivery), the TOP contractor shall inform the beneficiary
of this anticipated limitation. This notification shall occur when
the beneficiary first enrolls in the demonstration in cases where
the TOP contractor is already aware of the practices in that country.
This notification may occur later if the TOP contractor was not
aware of the limitation at the time of beneficiary enrollment.
3.7 A beneficiary
enrolled to the TOP contractor but planning to give birth in the
U.S. must enroll in the demonstration with the TOP contractor.
3.7.1 The TOP
contractor shall use the in-network and out-of-network directories
established by the appropriate U.S. Managed Care Support Contractor
(MCSC) for the demonstration to assist the beneficiary in locating
a provider.
3.7.2 If a provider is not available
in the U.S. location where the beneficiary plans to give birth, the
TOP contractor shall advise the beneficiary that if the beneficiary
has a provider they would like to use, the beneficiary should encourage
the provider to contact the appropriate U.S. MCSC about becoming
authorized under that MCSC. The TOP contractor may also coordinate
with the U.S. MCSC to identify a provider for the beneficiary.
3.7.3 The TOP
contractor shall advise TOP-enrolled beneficiaries who give birth
in the U.S. that it is their responsibility to confirm demonstration
provider eligibility with that provider and/or the U.S. MCSC prior
to receiving services, even if the provider is listed on the U.S.
MCSC provider directory and the provider’s name was furnished to
the beneficiary by the TOP contractor.
3.7.4 The contractor
shall apply requirements of
Section 11 to
providers located in the U.S., even if furnishing services to beneficiaries
enrolled to the TOP contractor.
3.8 The TOP
contractor shall only reimburse claims for services under the demonstration
if the beneficiary has enrolled in the demonstration prior to receiving
services. The TOP contractor may, on a case-by-case basis, reimburse
claims for care received from a lactation consultant or counselor
for a beneficiary not enrolled in the demonstration when such care
was needed to address urgent breastfeeding issues and when all other
requirements of the demonstration were otherwise met. In such cases,
the TOP contractor shall retroactively enroll the beneficiary in
the demonstration.
3.9 The TOP contractor shall not
enroll a beneficiary in the demonstration if the beneficiary intends to
give birth in a location that does not offer appropriate standard
of care locally for prenatal and/or maternal care, as determined
by the TOP contractor under existing processes.
3.10 Enrollment
by the beneficiary in the demonstration is not a guarantee of receipt
of services; that is, in some cases a beneficiary may enroll in
the demonstration but be unable to receive services because no qualified
providers are able to provide services under the demonstration.
3.11 The TOP
contractor shall report the number of beneficiaries enrolled to
the demonstration, the number who receive services under the demonstration,
the number who are not able to obtain services, and other data regarding
beneficiary participation in the demonstration in the Contract Data Requirements
List (CDRL) required by
Section 11, paragraph 7.4.
4.0 BREASTFEEDING
SUPPORT BENEFIT MODIFICATIONS
4.1 Certified Lactation Consultant
Qualification Hierarchy
The contractor
shall prefer providers with a certification listed in
paragraph 4.1.1 when
sufficient quantities of providers exist to serve the TRICARE population,
but may use the alternative certification process in
paragraph 4.1.2 as
necessary to ensure beneficiary access to care.
4.1.1 Certification by the International
Board of Lactation Consultant Examiners as an International Board
Certified Lactation Consultant (IBCLC) or by the Academy of Lactation
Policy and Practice (ALPP) as an Advanced Nurse Lactation Consultant
(ANLC) or an Advanced Lactation Consultant (ALC).
4.1.2 Certification by a body assessed
by the TOP contractor to be comparable to the IBCLC, ANLC, or ALC
certification.
4.1.3 The TOP contractor shall not
require lactation consultants to have a National Provider Identification
(NPI) number.
4.1.4 The TOP contractor shall require
certified lactation consultants to meet all requirements of
Section 11, paragraph 5.1 not modified in
this section (i.e., license and Cardiopulmonary Resuscitation (CPR)
requirements).
4.2 Certified Lactation Counselor
Qualification Hierarchy
The contractor
shall prefer providers with a certification listed in
paragraph 4.2.1 when
sufficient quantities of providers exist to serve the TRICARE population,
but may use the alternative certification process in
paragraph 4.2.2 as
necessary to ensure beneficiary access to care.
4.2.1 Certification by ALPP as a
certified lactation counselor.
4.2.2 Certification
by a body assessed by the TOP contractor to be comparable to the
ALPP certified lactation counselor certification.
4.2.3 The TOP
contractor shall not accept certification as a peer counselor, lactation
educator, or similar because those types of providers are not covered
under the demonstration.
4.2.4 The TOP contractor shall not
require lactation counselors to have an NPI.
4.2.5 The TOP
contractor shall require certified lactation counselors to meet
all requirements of
Section 11, paragraph 5.2 not modified in
this section (i.e., license and CPR requirements).
4.3 In determining
whether a certification is comparable to one selected by Defense
Health Agency (DHA), the contractor shall consider education, experience/clinical
practice, examination, and code of conduct/ethics requirements.The
TOP contractor shall be required to report any lactation consultant
or counselor credentialing bodies authorized under
paragraphs 4.1.2 and
4.2.2 in
the CDRL required by
Section 11, paragraph 7.4.
7.0 PROVIDER
NETWORKS
7.1 The TOP contractor shall begin
building networks and evaluating whether services under the demonstration
are generally available no later than 120 days prior to the start
of the demonstration overseas in the locations in which TOP beneficiaries
give birth the most frequently each year. The top locations are
Germany, Italy, South Korea, Puerto Rico, Japan, and the United
Kingdom. The TOP contractor may focus network building on locations
within each country where beneficiaries are most likely to give
birth (i.e., around Military Medical Treatment Facilities (MTFs)).
The TOP contractor shall notify providers that demonstration services
performed prior to January 1, 2025, will not be eligible for reimbursement.
7.2 For other
locations, the TOP contractor shall research cultural-specific information
and availability of providers when a beneficiary enrolls in the
demonstration in that location.
9.0 BENEFICIARY
AND PROVIDER EDUCATION
9.1 The TOP contractor shall perform
all beneficiary education activities in
Section 11, paragraph 7.9, except for the
requirement in
Section 11, paragraph 7.9.1 which requires
the contractor to inform the beneficiary that they are participating
in a demonstration.
9.2 The TOP contractor shall educate
beneficiaries on the demonstration implementation overseas, to include:
the requirement to enroll; that it is preferred that beneficiaries
enroll early in pregnancy to get access to a qualified provider;
that some services may not be available in certain countries/locations
due to cultural variances in the delivery of health care; and that,
because this is a demonstration, access to a provider is not guaranteed.
The TOP contractor shall begin beneficiary education activities
at least 90 days prior to the start of the demonstration overseas.
9.3 The TOP
contractor shall educate providers on the demonstration implementation
overseas, to include: the requirement that beneficiaries must enroll
in the demonstration before receipt of services and unique qualification
criteria for the location in which the provider practices.