[Federal Register Volume 76, Number 43 (Friday, March 4, 2011)]
[Notices]
[Pages 12080-12081]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-4863]


-----------------------------------------------------------------------

DEPARTMENT OF DEFENSE

Office of the Secretary


TRICARE Access to Care Demonstration Project

AGENCY: Department of Defense.

ACTION: Notice of demonstration project.

-----------------------------------------------------------------------

SUMMARY: This notice is to advise interested parties of a Military 
Health System (MHS) Demonstration project under the authority of Title 
10, U.S. Code, Section 1092, entitled Department of Defense TRICARE 
Access to Care Demonstration Project. The demonstration project is 
intended to improve access to urgent care including minor illness or 
injury for Coast Guard beneficiaries enrolled in TRICARE Prime or 
TRICARE Prime Remote while decreasing emergency room visits and 
healthcare costs. Under the demonstration, Coast Guard active duty 
service members (ADSMs) and their family members who are enrolled in 
TRICARE Prime or TRICARE Prime Remote in the South Region would be 
allowed to self-refer, without an authorization, to a TRICARE network 
provider such as an Urgent Care Clinic (UCC) or Convenience Center for 
up to four urgent care visits per year. No referral from their Primary 
Care Manager (PCM) or authorization by a Health Care Finder will be 
required and no Point of Service (POS) deductibles and cost shares 
shall apply to these four unmanaged visits. Additionally, when outside 
of the South region, these Coast Guard TRICARE Prime or Prime Remote 
enrollees may use any TRICARE authorized provider or UCC without 
incurring POS deductibles and cost shares. The ADSM and family member 
will be required to notify their PCM of any urgent/acute care visits to 
other than their PCM within 24 hours of the visit and schedule any 
follow-up treatment that might be indicated with their PCM. If more 
than the four (4) authorized urgent care visits are used, or if the 
beneficiary seeks care from a non TRICARE network or non TRICARE 
authorized provider, POS deductibles and cost shares as required by 
Title 32, Code of Federal Regulations (CFR), 199.17(n)(3) may apply. 
Referral requirements for specialty care and inpatient authorizations 
will remain as currently required by MHS policy.

DATES: This demonstration will be effective 60 days from the date of 
this notice for a period of twenty-four (24) months.

ADDRESSES: TRICARE Management Activity (TMA), Health Plan Operations, 
5111 Leesburg Pike, Suite 810, Falls Church, VA 22041.

FOR FURTHER INFORMATION CONTACT: For questions pertaining to this 
demonstration project, please contact Ms. Shane Pham at (703) 681-0039.

SUPPLEMENTARY INFORMATION:

a. Background

    Access for acute episodic primary care continues to be in high 
demand by TRICARE Prime beneficiaries. The current regulations require 
that if a Prime beneficiary seeks care from a provider other than their 
PCM, they must first obtain a referral. Otherwise, the care will be 
covered under the point-of-service option at greater out-of-pocket cost 
to the Prime beneficiary. This includes urgent care which TRICARE 
defines as medically necessary treatment for an illness or injury that 
would not result in further disability or death if not treated 
immediately but that requires professional attention within 24 hours. 
On the other hand, emergency care defined as a medical, maternity or 
psychiatric condition that would lead a ``prudent layperson'' (someone 
with average knowledge of health and medicine) to believe that a 
serious medical condition existed, or the absence of medical attention 
would result in a threat to his or her life, limb or sight and requires 
immediate medical treatment or which has painful symptoms requiring 
immediate attention to relieve suffering, does not require an 
authorization. Often when a Prime beneficiary needs urgent care after 
hours or when the PCM does not have available appointments, the Prime 
beneficiary will seek care from civilian sources such as emergency 
rooms (ER). While many Prime beneficiaries pay no out-of pocket costs 
for ER services, the average cost for an ER visit is much higher than 
an urgent care visit. In many cases, using the ER is not necessary, and 
a patient's condition can be treated through urgent care. However, 
TRICARE has found it difficult to enforce the required point-of-service 
charges when an ER visit was for urgent care and not a true medical 
emergency.
    There are 25,781 Coast Guard active duty service members and their 
family members enrolled in TRICARE Prime in the South Region. In the 
South Region, beneficiary ER visits are currently averaging 197 ER 
visits/1,000 beneficiaries per year and that number is slowly 
increasing. Analysis indicates much of the care rendered in these ER 
visits is for acute or chronic conditions that are not true life 
threatening emergencies and may have been better

[[Page 12081]]

suited for care by the PCM or in an urgent care setting.

b. Implementation

    This demonstration will be effective 60 days from the date of this 
notice for a period of twenty-four (24) months.

c. Evaluation

    The results of this Demonstration will allow a focused study of the 
impact of this process on: (1) The reduction of ER utilization and 
resulting costs, (2) assessment of the availability and accessibility 
of less expensive acute care services such as UCCs, (3) reduction of 
administrative processes, and (4) impact on Coast Guard active duty 
service members and their families. The evaluation/analysis of the 
demonstration would use Fiscal Year 2008 as the base line with follow-
up data analysis conducted at each 6-month interval throughout the 24 
month period to monitor of ER and TRICARE authorized UCC utilization 
workload and cost (claims data). Success of the demonstration would be 
determined by consistent shifts in health care utilization from ERs to 
a TRICARE authorized UCCs by 15-20%. A less than 5% shift in 
utilization from the ER to a TRICARE authorized UCCs would be 
considered insignificant.

    Dated: March 1, 2011.
Morgan F. Park,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2011-4863 Filed 3-3-11; 8:45 am]
BILLING CODE 5001-06-P