TRICARE Reforms in 2018 | Participant Questions

In one of our recent webinars, TRICARE Reforms in 2018, there were many participant questions that were unanswered due to time restraints. Our presenter, Mark Ellis, has provided answers to these questions below.

 

How does a person call the Nurse Advice Line? What is the number?

RESPONSE: 

  • Beneficiaries located in the 50 United States access the NAL by calling 1-800-TRICARE, option 1.
  • Beneficiaries who are enrolled to overseas MTFs located outside the 50 United States access the NAL by calling a “country-specific number” listed on the NAL beneficiary website at:  https://mhsnurseadviceline.com/home
  • The NAL beneficiary website at https://mhsnurseadviceline.com/home also allows beneficiaries to access the NAL via text chat or virtual video chat.
  • DHA distributed a full publicity package for MTFs through the Service Public Affairs Offices.

Where are those expanded hours being implemented? Will the expanded hours include additional staff?

RESPONSE: 

Each Service and the National Capital Region Medical Directorate (NCR MD) evaluated each MTF’s individual demand signal to determine the feasibility of expanded hours based on the criteria in DHA-PI 6025.03 “Standard Processes and Criteria for Establishing Urgent Care (UC) Services and Expanded Hours and Appointment Availability in Primary Care in Medical Treatment Facilities (MTFs) to Support an Integrated Health Care System (IHCS)” dated January 2018.  The full DHA-PI is available at:  https://health.mil under the “Policies” tab.  Please reach out to your Service access lead if you have questions on your MTF’s expanded hours plan.  As of February 2018, 90 percent of MTFs were already in compliance with Service MTF expanded hours plans.  Full compliance is required by 1 August 2018.

 

Service access leads are:

 

How is that being assessed for access to care, and needs in those areas? Is there any pressure or recommendation being made to MTFs that have a high referral rate to Emergency Services?

RESPONSE: 

DHA-PI 6025.03 “Standard Processes and Criteria for Establishing Urgent Care (UC) Services and Expanded Hours and Appointment Availability in Primary Care in Medical Treatment Facilities (MTFs) to Support an Integrated Health Care System (IHCS)” dated January 2018, identifies the criteria and standard data sources used to make decisions on establishing a MTF or market urgent care clinic/ER fast track clinic or for expanding hours in Primary Care.

The criteria identified in DHA-PI 6025.03 includes:

  1. Costs
  2. Demand and Utilization
  3. Distance, Geography and Local Competition
  4. Space
  5. Single Service or eMSM resources
  6. Readiness requirements
  7. Network UC Clinic adequacy

Emergency Services utilization is included in criteria b above; however, only low acuity E&M codes 99281/99282 are considered when evaluating the need for MTF UC or expanded hours in primary care. The Tri-Service Emergency Medicine consultants reviewed the data and consider only care coded as 99281 and 99282 to be recapturable to primary care or urgent care.  Relatedly, these same low-acuity ER visits are the only ER visits included in the Primary Care Leakage Core Measure on the MHS Dashboard on Carepoint.  The ER is considered to be the clinically appropriate venue for care for all other ER visits, per the Services’ Emergency Medicine Consultants.

 

Is US Family Health Plan available to widows/widowers? Is information about this option communicated to beneficiaries if they move into an area covered by that plan?

RESPONSE: 

Widows/Widowers may enroll in a Uniformed Services Family Health Plan (USFHP) if they are eligible military beneficiary under age 65 and live in a designated USFHP service area.  There is no notification to beneficiaries when they move into an area as to the availability of TRICARE health plans.  We encourage you to use the TRICARE Plan Finder function on the tricare.mil website to find out what health plans are available in your area.

 

Can you elaborate on the enhancements TRICARE is providing regarding special needs and autism?

RESPONSE:

Enhancements TRICARE is considering include:

  • Specialized case management and/or care coordination teams assigned to each family are essential to the comprehensive management of this unique population. Care coordination teams will allow a centralized focus around the special needs of military families including continuity of care as families’ transition from region to region due to permanent change of station or retirement from active duty. Families should have a single point-of-contact who guides them through the system related to their child’s care.

 

  • Several solutions to utilization management have introduced decision support for ASD and it is recommended DHA explore such solutions as part of a way forward. DHA will implement evidence-based utilization management solutions that consistently review impairments, level of functioning, and treatment goals and protocols (treatment plan) to ensure the needs of the beneficiary and family are being met.

 

  • Discharge planning is another critical component of a comprehensive ABA Benefit Program and discharge criteria must be implemented through modifications to the current MCSC and TOP contracts. Such criteria should be included in the initial assessment and treatment plan/goals in measurable terms to ensure the beneficiary is progressing.

 

  • Parental involvement and support is imperative to a beneficiary’s success. Per available research, outcomes are better when parents are actively involved.   Requiring their participation in the process and commitment to their child’s ABA TP with reinforcements or consequences, also enables the managed benefit to move from an external dependency to a family competence for long term care.  If families cannot support intensive ABA services, then family issues should be addressed first.

 

  • Parents of children diagnosed with ASD have a great deal of stress and need support. Thus, respite care is an important component of a supportive ABA Program.  DHA currently offers 16 hours of respite care per month for active duty families under Extended Care Health Option (ECHO).  Expansion of respite care to all families with a child who has a diagnosis ASD was recommended as it can provide needed relief and enhance parental involvement by means of resilience in the family members.

 

Are you able to provide additional guidance with enrollment into TRICARE ECHO?

RESPONSE: 

The active duty sponsor (or other authorized individual acting on behalf of the beneficiary) will submit the following to the contractor or TRICARE Overseas Program (TOP) contractor responsible for administering the Extended Care Health Option (ECHO) in the geographic area where the beneficiary resides:

 

  • Evidence that the sponsor is a Service member in one of the Uniformed Services.

 

  • Medical records, as determined necessary by the contractor or TOP contractor which demonstrate that the Active Duty Family Member (ADFM) has a qualifying condition in accordance with Sections 2.2 through 2.4, and who otherwise meets all applicable ECHO requirements.

 

  • Evidence, as provided by the sponsor’s branch of service, that the family, or family member seeking ECHO registration, is enrolled in the Exceptional Family Member Program (EFMP) provided by the sponsor’s branch of service. Can be waived.

 

  • To avoid delaying receipt of ECHO services while completing the ECHO registration process, in particular awaiting completion of enrollment in the EFMP of the sponsor’s service, the contractor or TAO Director may grant otherwise ECHO-eligible beneficiaries a provisional eligibility status for a period of not more than 90 days during which ECHO benefits will be authorized and payable. This provisional status is portable across managed care support contract regions and, except for the ECHO Home Health Care (EHHC) benefit, it applies to the TRICARE Overseas Program (TOP).

 

What about Soldiers who need to add a parent due to parent being dependent on them for support/unable to support themselves?

RESPONSE: 

Eligibility for military medical benefits is the responsibility of each Uniformed Service, not TRICARE.  Please contact your local Army personnel or RAPIDS office for assistance or call the DEERS Support Office at 1-800-538-9552.

 

What is the expected timeframe from when a newborn of ADSM is registered in DEERS to the time they auto-enroll in Prime?

RESPONSE:

Per the Defense Manpower Data Center, automatic enrollment transactions for newly eligible family members of active duty service members (ADSMs) added to DEERS may take up to 24 hours to post to DEERS.

 

Is the enrollment fee a one-time fee?

RESPONSE: 

By law, enrollment fees for TRICARE Prime and TRICARE Select are an annual amount that may be adjusted each year if there is an increase in the military retiree cost of living allowance (COLA).

 

Can we describe Prime as HMO and Select as PPO?

RESPONSE: 

Generally speaking, yes.

 

What about when a family has guardianship over their adult child due to limited capacity. What then?

RESPONSE: 

If your question relates to how a Uniformed Service sponsor can request military health care benefits for an incapacitated adult child, please contact your local military personnel or RAPIDS office or call the DEERS Support Office at 1-800-538-9552 for assistance.    Eligibility for military medical benefits is the responsibility of each Uniformed Service, not TRICARE.

 

Can people communicate their preferences prior to the open enrollment period, or will every beneficiary be reaching out to TRICARE during that one-month window?

RESPONSE: 

Yes. Calendar year 2018 is designated as a TRICARE enrollment grace period so you can elect to enroll in or change your TRICARE Prime or TRICARE Select health plan coverage at any time during 2018 if you want the coverage to start the date of your request or the date of your qualifying life event. Otherwise, requests to enroll in or change your TRICARE Prime or TRICARE Select coverage to take effect on January 1, 2018 can be accepted by your regional TRICARE contractor as early as October 1, 2018 (90 days prior to the effective start date), during the annual open enrollment period from November 12, to December 10, 2018, or due to the 2018 enrollment grace period, through December 31, 2018.

 

As a reminder, if you’re happy with your current TRICARE Prime or TRICARE Select coverage and desire it to continue starting on January 1, 2019 for the rest of 2019, then do nothing.  Your TRICARE health plan coverage on December 31, 2018 will be automatically renewed by DEERS for calendar year 2019.

 

 

Are there still Tricare ECHO Case Managers on the West?

RESPONSE: 

This is an issue that TRICARE is currently addressing with the contractor.

 

How does a Young Adult prime patient access Mental health care, do they need a referral from their PCM?

RESPONSE: 

If enrolled in TRICARE Young Adult Prime coverage, a Primary Care Manager (PCM) referral is not required for outpatient, office-based mental health or substance use disorder (SUD) visits; however, all other outpatient mental health and SUD services require a referral from the PCM or other network TRICARE authorized institutional or individual professional mental health or SUD provider.

 

Who can we contact beyond the assigned PERS rep?

RESPONSE: 

You should ask for their supervisor. If the issue cannot be resolved, please email dha.acd@mail.mil.

 

 

 

Be sure to join MFLN Military Caregiving on June 13 at 11:00 a.m. ET for our webinar entitled, Mental Health Care in TRICARE: Recent Enhancements to a Great Benefit.


This MFLN-Military Caregiving concentration blog post was published on June 1, 2018.

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