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 Defense Health Agency (DHA),
for specific services that are covered under TRICARE. For specified
areas outside the 50 US and the District of Columbia, locality waivers
are defined geographically as a city or country.
2.1.2 When the DHA, or designee,
determines beneficiary access to health care services in a locality
is impaired, the 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 US 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 US and the District
of Columbia shall be submitted to the appropriate 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 US and the District of Columbia
is as follows:
2.3.1 The Executive Director,
TAO will 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 US 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 Medical Readiness issues. Other
relevant factors, unique to the specified location outside the 50
US and the District of Columbia.
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 US 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 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 will conduct a thorough analysis of the
information submitted and supply any missing information to the
waiver request. The Executive Director, TAO
will 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
will be returned to the TAO and the request will 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 (SMEs), 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 DHA, or
designee is the final approval authority. A decision by the 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 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 US and the District
of Columbia. If the 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.