Attachment_J-18,_Draft_TPM_Ch12.pdf

TRICARE Policy Manual 6010.60-M, April 1, 2015

TRICARE Overseas Program (TOP)

Chapter 12 Section 1.1

TRICARE Overseas Program (TOP)

Issue Date:

Authority: 32 CFR 199.17(u)

1.0 GENERAL

1.1 The TOP is the Department of Defense’s (DoD’s) program for the delivery of health care support services overseas (all locations outside of the 50 United States (U.S.) and the District of Columbia). The delivery of health care services overseas represents a unique situation that cannot be effectively addressed by applying all of the standards that apply in the 50 U.S. and the District of Columbia. TOP blends many of the features of the TRICARE program in the U.S. while allowing for significant cultural differences unique to health care practices and services in overseas locations.

1.2 TOP provides health care coverage for all overseas beneficiaries, including Service members, eligible Reserve Component (RC) personnel, Active Duty Family Members (ADFMs) (including family members of eligible RC personnel), retired military and their respective family members, and transitional survivors. This coverage applies regardless of where the services are received. TOP also provides health care coverage for stateside beneficiaries residing in the 50 U.S. or the District of Columbia (excluding beneficiaries enrolled to the Uniformed Services Family Health Plan (USFHP) and the Continued Health Care Benefit Program (CHCBP)) who receive health care in an overseas location.

TOP coverage includes all dental care for Service members permanently assigned to, and receiving dental care in, a remote overseas location. TOP coverage also includes urgent and emergency dental care for Service members who are Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, deployed or deployed on liberty in remote overseas locations. Specific TOP program eligibility and health care coverage is based upon beneficiary status, location, and enrollment elections. All beneficiaries must be eligible for TRICARE as verified via the Defense Enrollment Eligibility Reporting System (DEERS).

Note: USFHP enrollees must be authorized to receive care by their USFHP Primary Care Manager (PCM), regardless of where the care is rendered. Claims for overseas care rendered to USFHP enrollees shall be sent to the USFHP for processing and payment. Claims for overseas care rendered to CHCBP enrollees shall be sent to the CHCBP contractor for processing and payment.

1.3 TOP health care services are provided by Military Treatment Facilities (MTFs)/Enhanced Multi- Service Markets (eMSMs), MTF/eMSM Partnership Providers, and a complement of network- and non-network purchased care sector providers and institutions.

1.4 Three geographic regions have been identified for the oversight of health care delivery overseas: TRICARE Eurasia-Africa (including the European continent, the Middle East, and Africa), TRICARE Pacific (including Asia, Australia, and the islands of the Pacific and Indian Oceans), and

DRAFT

Chapter 12, Section 1.1

TRICARE Overseas Program (TOP)

TRICARE Latin America and Canada (TLAC) (including Puerto Rico, the Caribbean basin, Latin America, South America, and Canada). Three TRICARE Area Offices (TAOs) have been established for these geographic regions to provide management and oversight of TOP health care delivery for eligible TRICARE beneficiaries. The TAO Directors, working in concert with the MTFs/eMSMs and their respective services, are responsible for organizing and managing health care delivery for beneficiaries in their respective regions. A single TRICARE Overseas health care support contractor (hereinafter referred to as the “TOP contractor”) supports the TAOs, MTFs/eMSMs, services, beneficiaries, and purchased care sector providers by providing or arranging for the delivery of health care services, claims processing services, and a variety of health care administrative services.

2.0 TRICARE PROGRAMS/SERVICES IN OVERSEAS LOCATIONS

2.1 The following TRICARE programs or services are available under the TOP contract: TOP Prime, TOP Prime Remote, TOP StandardSelect, TOP TRICARE for Life (TFL), TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Plus, the Extended Care Health Option (ECHO), TRICARE Young Adult (TYA), and the Transitional Assistance Management Program (TAMP). Beginning January 1, 2018, TOP Select replaces TOP Standard.

2.2 The following TRICARE programs or services may be available in certain overseas locations, but are not administered under the TOP contract: TRICARE Dental Program (TDP), TRICARE Retiree Dental Program (TRDP), TFL, TRICARE Pharmacy (TPharm) Program, TRICARE Active Duty Dental Program (ADDP), and the CHCBP.

2.3 TRICARE Extra is not available outside the 50 U.S. and the District of Columbia.

3.0 TOP BENEFIT POLICY

3.1 TOP benefit policy applies to the scope of services and items which may be considered for coverage by TRICARE within the intent of 32 CFR 199.4 and 32 CFR 199.5. Specifically, TRICARE may cost-share a procedure that is determined to be appropriate medical care, is medically or psychologically necessary, is not unproven as defined in 32 CFR 199.2, and the service or supply is not specifically limited in coverage or explicitly excluded by statute, regulation, or policy.

3.2 While “appropriate medical care” references the norm for medical practice in the U.S., TOP gives consideration to the significant cultural differences unique to foreign countries. The TOP contractor shall exercise reasonable judgment to accommodate cultural differences relevant to the practices and delivery of host nation health care services. Services and supplies which otherwise fall within the range of TRICARE benefits (including, but not limited to, clinical preventive services, prescription drugs, and Durable Equipment (DE)/Durable Medical Equipment (DME)) may be eligible for coverage under TOP when the diagnosis or description of illness supports the reasonableness of the procedure, service, or supply and is commonly accepted practice in an overseas location. Services and supplies, which are specifically excluded from TRICARE coverage cannot be covered under TOP simply because of cultural differences. A specific waiver is required if the service or supply would not normally be considered a TRICARE benefit. Refer to Section 1.2 for a list of authorized benefit variations for TOP.

3.3 Cultural differences may apply to things like location of care (provider comes to the patient’s home) or the manner in which care is provided (services commonly done by a provider class in the U.S.

may be performed by a provider assistant or physician overseas, depending on the country). Cultural differences may also apply to the manner in which claims are submitted to TRICARE. For example, certain countries may require a separate delineation of charges for health care delivery and administrative practices that are attendant to the delivery of health care. These charges may be payable under TRICARE if they are determined to be reasonable and customary for a particular overseas location. Also, due to cultural differences, purchased care sector providers may, and frequently do submit claims containing narrative summaries in lieu of diagnostic and/or procedural codes. These claims may be payable under TRICARE; however, the TOP contractor shall establish processes to ensure that narrative claims are converted to codes that accurately describe the services rendered and billed by the host nation provider. Fees for transplant donor searches in Germany may be reimbursed on a global flat fee basis since the German Government does not permit health care facilities to itemize such charges. Itemized fees for supplies that are related or incidental to inpatient treatment in Japanese hospitals (e.g., hospital gowns) may be reimbursed if similar supplies would be covered under reimbursement methodologies used within the U.S. In some countries, multi-specialty group practices may submit claims that do not identify the name of the provider who actually rendered the care, the individual’s professional status, or the provider number. Such cultural differences in billing practices shall be accommodated for foreign multi-specialty group practices (subject to all provider licensure/ certification requirements in the contract). The TOP contractor shall implement internal management controls to ensure that all payments are reasonable and customary for the location.

3.4 The TOP benefit package includes pharmacy services through the TOP contractor for drugs dispensed by purchased care sector pharmacies, institutions, and providers. TOP beneficiaries may also receive limited services through the TPharm contract, to include retail network pharmacy services (in U.S. territories) and mail order pharmacy (MOP) services. The TPharm MOP may be used by all TOP beneficiaries provided certain criteria are met, such as a U.S. credentialed provider to write the prescription and a U.S. zip coded address to ship to (Army Post Office (APO), Fleet Post Office (FPO), or Diplomatic Pouch Mail). Some countries, such as Germany, prohibit prescription drugs being mailed from the United States or any other country. Additionally, Service members or ADFMs assigned to U.S.

Embassies/State Departments may also use TPharm MOP services. TOP beneficiaries who are covered by Other Health Insurance (OHI) with a prescription drug benefit may not use TPharm MOP services unless the OHI plan does not cover the medication needed, or the OHI coverage limit has been met. The TPharm MOP cannot ship drugs which must be refrigerated (e.g., insulin) to an address outside the 50 U.S. and the District of Columbia.

Note: The TPharm retail network pharmacy benefit is available in the 50 U.S., the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands.

4.0 APPLICABILITY OF TRICARE REQUIREMENTS

4.1 All TRICARE requirements set forth in the TRICARE Policy Manual (TPM), the TRICARE Reimbursement Manual (TRM), TRICARE Operations Manual (TOM), and the TRICARE Systems Manual (TSM) apply to the TOP, unless specifically waived or superseded by the TOP contract, this chapter, or the TOM, Chapter 24.

4.2 For purposes of TOP implementation, any applicable manual language that refers to “TRICARE Prime” and “TRICARE Prime Remote” shall apply to TOP Prime and TOP Prime Remote, language that refers to “Director, TRICARE Regional Offices” shall apply to TAO Directors, language that refers to “TRICARE StandardSelect” shall apply to TOP Select Standard. Beginning January 1, 2018, language that refers to TRICARE Select shall apply to TOP Select.

4.3 Waiver of rigid application of the requirements for processing/review of claims has been granted by the Director, Defense Health Agency (DHA) to overcome variations between U.S. standards of health care practice and standards of health care practice in foreign countries. Examples of these variations are:

• TOP purchased care sector providers, (both network and non-network) are not required to meet all TRICARE provider certification requirements to become a TOP host nation authorized provider; or

• Charges for taxi companies for driving physicians to accidents or private residences.

5.0 CONTRACTOR R ESP ON SIBIL IT IES

The TOP contractor shall support the best value in the coordination and delivery of health care services in overseas locations for Service member, ADFMs, and other TRICARE-eligible beneficiaries.

This includes all health care services provided in an overseas location, regardless of the beneficiary’s enrollment location or residence address. Contractor responsibilities under this contract include (but are not limited to) enrollment processing, purchased care sector provider certification, network development and maintenance, Beneficiary and Provider Services (BPS) (including education and marketing), MTF/eMSM optimization, medical management, fraud and abuse prevention and detection, medically-necessary patient evacuations and transfers, active duty dental care in remote overseas locations (except for U.S. territories), and claims processing. The contractor shall provide a designated Point of Contact (POC) to assist the TAO Directors or designee(s). Additionally, every stateside regional contractor shall offer traveling TOP beneficiaries use of existing toll free Health Care Finders (HCFs) numbers/services to locate a stateside TRICARE network provider. Specific contractor responsibilities are addressed in the TRICARE Manuals and in the TRICARE Overseas health care support contract. Refer to the TOM, Chapter 24 for additional TOP program instructions.

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Chapter 12 Section 1.2

TRICARE Overseas Program (TOP) Medical Benefit Variations

Issue Date:

Authority: 32 CFR 199.17(u) Revision:

1.0 GENERAL

1.1 TOP medical benefits are based upon the scope of services and items which may be considered for coverage by TRICARE within the intent of 32 CFR 199.4 and 32 CFR 199.5. Specifically, TRICARE may cost-share a procedure that is determined to be appropriate medical care, is medically or psychologically necessary, is not unproven as defined in 32 CFR 199.2, and the TRICARE Policy Manual (TPM) does not explicitly exclude or limit coverage of the service or supply.

1.2 Unique health care issues and challenges may arise in locations outside of the 50 United States (U.S.) and the District of Columbia. In some situations, TRICARE may authorize coverage for a specific service or supply under the TOP, even though the service or supply would normally be excluded from coverage by TRICARE. Such situations are expected to be rare and must be approved by the Government.

2.0 AUTHORIZED TOP MEDICAL BENEFIT VARIATIONS

2.1 Tick Borne Encephalitis (TBE) Vaccine

Cost-sharing of the TBE vaccine is authorized in endemic areas of Europe and Asia when an at-risk Active Duty Family Member (ADFM), retiree, or retiree family member receives the vaccine from a TRICARE authorized provider. When covered, the TBE vaccine shall be cost-shared as a clinical preventive service. See Chapter 7, Sections 2.1 and 2.2.

2.2 Medicare Certification of Organ Transplant Facilities

Medicare certification for organ transplant centers is only required for transplants performed in the 50 U.S., the District of Columbia, and U.S. territories where Medicare is available. Organ transplantation is within the range of TRICARE covered benefits and is covered in overseas locations when it is medically necessary, reasonable, and commonly accepted practice in the country where the transplant is performed.

2.3 Non-U.S. Food and Drug Administration (FDA) Approved Drugs

Non-FDA approved prescription drugs may be cost-shared in foreign countries if the TOP contractor has substantiated that the drug is commonly used for the intended purpose in the host nation. The TOP contractor shall substantiate that the drug is commonly used in the host nation based

Chapter 12, Section 1.2 TRICARE Overseas Program (TOP) Medical Benefit Variations on past claims/country experience or by a web search on the drug in question. If a claim for a non-FDA approved drug is submitted by a provider that is required to comply the National Drug Coding (NDC) requirements as outlined in TRICARE Operations Manual (TOM), Chapter 24, Section 14, the TOP contractor shall contact the Defense Health Agency (DHA) for assistance prior to processing the claim.

Note: FDA approval is required for all prescription drugs in the U.S. commonwealths and territories.

2.4 Therapeutic Mud Baths

Therapeutic mud baths (a form of balneotherapy which is used in some foreign countries to treat back pain, arthritis, or other medical conditions) is not a covered TRICARE benefit unless it can be established that pharmacological or other non-pharmacological treatments are unavailable in that particular country. Such cases are expected to be very rare and will require Government review and approval prior to payment.

2.5 Private Hospital Room Charges

Effective September 1, 2016, Service members in locations designated in the TOP contract are authorized to receive private accommodations in a hospital or other authorized institution, regardless of whether semiprivate accommodations are available.

2.6 Sub-Acute Care

2.6.1 Medically necessary and appropriate skilled nursing services and other medically necessary services, such as Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST), which are otherwise covered benefits under Title 10 United States Code (USC) Chapter 55, rendered to covered beneficiaries overseas who are receiving sub-acute inpatient care may be covered. Payment for any facility charges and other non-covered services related to the inpatient care, whether rendered at an inappropriate inpatient level or in a non-Medicare certified Skilled Nursing Facility (SNF) or similar institution, shall be denied.

2.6.2 Part-time or intermittent Home Health Care (HHC) and hospice services may only be provided in the same manner and under the same conditions as Medicare (e.g. provided in a Medicare certified facility) and thus are not available overseas; however, coverage may still be extended for otherwise covered services and supplies provided to eligible homebound and hospice beneficiaries overseas.

2.6.3 Payment shall be based upon the lesser of billed charges or the negotiated reimbursement rate in accordance with the TRICARE Manuals and the overseas contract. Covered services must be provided by individuals who would otherwise meet the requirements to be a TRICARE authorized individual professional provider. The contractor shall provide copies of all requested records to assist the Government in the annual retrospective review of these claims to ensure appropriate reimbursement and to identify any potential issues related to these services and the reimbursement amounts associated with these services.

Chapter 12 Section 1.3

Outside The 50 United States And The District Of Columbia Locality-Based Reimbursement Rate Waiver

Issue Date: April 7, 2008 Authority: 32 CFR 199.14(n) and (o) Revision:

1.0 APPLICABILITY

1.1 This policy is mandatory for waiver of TRICARE established reimbursement schedules for professional providers outside the 50 United States (U.S.) and the District of Columbia locations.

Reimbursement rate waivers are available to TRICARE eligible beneficiaries in specified locations outside the 50 U.S. and the District of Columbia where the Government has established reimbursement rate schedules. Please reference the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 35.

1.2 Except for medical evacuations, care in the U.S. commonwealths and territories adheres to reimbursement rates used for the 50 U.S. and the District of Columbia (which align with Medicare’s prospective payment systems). (See TRM, Chapter 1, Section 35, paragraph 1.0). Please refer the TRM, Chapter 5, Section 2 for the applicable CHAMPUS Maximum Allowable Charge (CMAC) waiver process for these locations.

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.

Chapter 12, Section 1.3

Outside The 50 United States And The District Of Columbia Locality-Based Reimbursement Rate Waiver

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 Regional 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 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:

• 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 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 Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs) and MTF/eMSM 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 w a i v e r .

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