38558 Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices

Douglas P. DeMaster, Director, National

Marine Mammal Laboratory, National

Marine Fisheries Service, NOAA, 7600

Sand Point Way, NE, BIN C15700, Bldg.

1, Seattle, WA 98115–0070, has

requested an amendment to scientific

research Permit No. 782–1355.

DATES: Written or telefaxed comments

must be received on or before August

17, 1998.

ADDRESSES: The application (File No.

481–1464), amendment request (Permit

No. 782–1355), and related documents

are available for review upon written

request or by appointment in the

following office(s):

Permits and Documentation Division,

Office of Protected Resources, NMFS,

1315 East-West Highway, Room 13130,

Silver Spring, MD 20910 (301/713–

2289);

Regional Administrator, National

Marine Fisheries Service, NOAA,

Alaska Region, P.O. Box 21668, Juneau,

AK 99802–1668 (907/586–7221).

Written comments or requests for a

public hearing on this request should be

submitted to the Chief, Permits and

Documentation Division, F/PR1, Office

of Protected Resources, NMFS, 1315

East-West Highway, Room 13130, Silver

Spring, MD 20910. Those individuals

requesting a hearing should set forth the

specific reasons why a hearing on this

particular amendment request would be

appropriate.

Comments may also be submitted by

facsimile at (301) 713–0376, provided

the facsimile is confirmed by hard copy

submitted by mail and postmarked no

later than the closing date of the

comment period. Please note that

comments will not be accepted by email or other electronic media.

FOR FURTHER INFORMATION CONTACT: Sara

Shapiro or Ruth Johnson, 301/713–2289.

SUPPLEMENTARY INFORMATION: The

subject permit application and

amendment to Permit No. 782–1355,

issued on July 15, 1997 (62 FR 39826)

are requested under the authority of the

Marine Mammal Protection Act of 1972,

as amended (16 U.S.C. 1361 et seq.), the

Regulations Governing the Taking and

Importing of Marine Mammals (50 CFR

part 216), the Endangered Species Act of

1973, as amended (ESA; 16 U.S.C. 1531

et seq.), and the regulations governing

the taking, importing, and exporting of

endangered fish and wildlife (50 CFR

222.23).

Dr. Richardson (File No. 481–1464)

requests authorization to study the

feeding ecology of bowhead whales in

the eastern Alaskan Beaufort Sea

through aerial surveys and sampling of

prey species.

Permit No. 782–1355 authorizes the

permit holder to take Pacific Harbor

seals (Phoca vitulina) in the following

manner: Harass during census flights;

capture, restrain, measure (weight

length, girth), sample (flipper punch,

vibrissa, blood, blubber/muscle biopsy,

ultra sound, enema), radio tag, flipper

tag, and release 500 animals; and

incidentally harass up to 2000 during

the conduct of these activities, and

during collection of scat samples from

haulouts. The permit holder requests

authorization to: increase the number of

seals instrumented with time-depth

recorders, biopsy sampled, and

harassed.

In compliance with the National

Environmental Policy Act of 1969 (42

U.S.C. 4321 et seq.), an initial

determination has been made that the

activities proposed are categorically

excluded from the requirement to

prepare an environmental assessment or

environmental impact statement.

Concurrent with the publication of

this notice in the Federal Register,

NMFS is forwarding copies of this

application to the Marine Mammal

Commission and its Committee of

Scientific Advisors.

Dated: July 7, 1998.

Ann D. Terbush,

Chief, Permits and Documentation Division,

Office of Protected Resources, National

Marine Fisheries Service.

[FR Doc. 98–19122 Filed 7–16–98; 8:45 am]

BILLING CODE 3510–22–F

CONSUMER PRODUCT SAFETY

COMMISSION

Sunshine Act Meeting

AGENCY: U.S. Consumer Product Safety

Commission, Washington, DC 20207.

TIME AND DATE: Wednesday, July 22,

1998, 10:00 a.m.

LOCATION: Room 420, East West Towers,

4330 East West Highway, Bethesda,

Maryland.

STATUS: Open to the Public.

MATTERS TO BE CONSIDERED:

FY 2000 Budget Request

The Commission will consider issues

related to the Commission’s budget for

fiscal year 2000.

For a recorded message containing the

latest agenda information, call (301)

504–0709.

CONTACT PERSON FOR ADDITIONAL

INFORMATION: Sadye E. Dunn, Office of

the Secretary, 4330 East West Highway,

Bethesda, MD 20207 (301) 504–8000.

Dated: July 13, 1998.

Sadye E. Dunn,

Secretary.

[FR Doc. 98–19267 Filed 7–15–98; 2:48 pm]

BILLING CODE 6355–01–M

CONSUMER PRODUCT SAFETY

COMMISSION

Sunshine Act Meeting

AGENCY: U.S. Consumer Product Safety

Commission, Washington, DC 20207.

TIME AND DATE: Monday, July 27, 1998,

2:00 p.m.

LOCATION: Room 410, East West Towers,

4330 East West Highway, Bethesda,

Maryland.

STATUS: Closed to the Public.

MATTERS TO BE CONSIDERED:

Compliance Status Report

The staff will brief the Commission on

the status of various compliance

matters.

For a recorded message containing the

latest agenda information, call (301)

504–0709.

CONTACT PERSON FOR ADDITIONAL

INFORMATION: Sadye E. Dunn, Office of

the Secretary, 4330 East West Highway,

Bethesda, MD 20207, (301) 504–0800.

Dated: July 14, 1998.

Sadye E. Dunn,

Secretary.

[FR Doc. 98–19268 Filed 7–15–98; 2:48 pm]

BILLING CODE 6355–01–M

DEPARTMENT OF DEFENSE

Office of the Secretary

TRICARE Senior Demonstration of

Military Managed Care

AGENCY: Office of the Assistant

Secretary of Defense (Health Affairs).

ACTION: Notice of demonstration project.

SUMMARY: This notice is to advise

interested parties of a demonstration

project in which the Department of

Defense (DoD) will provide health care

services to Medicare-eligible military

retirees in a managed care program,

called TRICARE Senior, and receive

reimbursement for such care from the

Medicare Trust Fund. The program is

authorized by section 1896 of the Social

Security Act, amended by section 4015

of the Balanced Budget Act of 1997 (P.L.

105–33). The statute authorizes DoD and

the Department of Health and Human

Services (HHS) to conduct at six sites

during January 1998 through December

2000, a three-year demonstration under

which dual-eligible beneficiaries will be
Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices 38559

offered enrollment in a DoD-operated

managed care plan, called TRICARE

Senior Prime. The legislation also

authorizes Medicare HMOs to make

payments to DoD for care provided to

HMO enrollees by military treatment

facilities (MTFs) participating in the

demonstration. This part of the

demonstration, to be called Medicare

Partners, will allow DoD to enter into

contracts with Medicare HMOs to

provide specialty and inpatient care to

dual-eligible beneficiaries currently

provided on a space-available basis.

Additional legal authority pertinent to

this demonstration project is 10 U.S.C.

section 1092.

Under TRICARE Senior Prime,

Medicare-eligible military retirees who

enroll in the program will be assigned

primary care managers (PCMs) at the

MTF. Enrollees will be referred to

specialty care providers at the MTF and

to participating members of the existing

TRICARE Prime network. TRICARE

Senior Prime enrollees will be afforded

the same priority access to MTF care as

military retiree and retiree family

member enrollees in TRICARE Prime.

DoD will receive reimbursement from

HCFA on a capitated basis at a rate

which is 95 percent of the rate HCFA

currently pays to Medicare-risk HMOs,

less costs such as capital and graduate

medical education, disproportionate

share hospital payments, and some

capital costs, which are already covered

by DoD’s annual appropriation.

However, under the authorizing statute,

DoD must meet its current level of effort

for its Medicare-eligible beneficiaries

before receiving payments from the

Medicare Trust Fund. That is, DoD must

continue to fund health care at a certain

expenditure level for its Medicareeligible population before it may be

reimbursed by HCFA for care provided

to TRICARE Senior Prime enrollees.

The Balanced Budget Act of 1997

required DoD and HHS to complete a

memorandum of agreement (MOA)

specifying the operational requirements

of the demonstration project. That MOA

was completed on February 13, 1998,

and is published below. Except as

provided in the MOA, TRICARE Senior

Prime will be implemented consistent

with applicable provisions of the

CHAMPUS/TRICARE regulation,

particularly 32 CFR sections 199.17 and

199.18.

EFFECTIVE DATE: July 15, 1998.

FOR FURTHER INFORMATION CONTACT:

Larry Sobel, Office of the Assistant

Secretary of Defense (Health Affairs/

TRICARE Management Activity),

telephone (703) 681–1742.

Dated: July 10, 1998.

L.M. Bynum,

Alternate OSD Federal Register Liaison

Officer, Department of Defense.

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Attachment A—Benefits for Enrollees;

Medicare Demonstration of Military

Managed Care

DoD will provide or arrange for the

provision of a defined benefit package for

enrollees in the Demonstration. The benefit

package will include all services and

supplies covered by the Medicare program,

plus some additional services not covered by

Medicare. The TRICARE Prime program will

be the vehicle for delivery of the benefit

package, except that standard Medicare

coverage of skilled nursing facility care,

home health care, and chiropractic services

will apply. Additional services in the

TRICARE Prime program that are not covered

by Medicare include outpatient pharmacy

services and preventive services. In brief, the

benefit package includes coverage of

medically necessary care as follows:

Medical Services

• Physician’s services;

• Medical and surgical services and

supplies;

• Outpatient hospital treatment;

• Mental health outpatient services;

• Physical and speech therapy;

• Clinical laboratory services and

diagnostic tests;

• Durable medical equipment and

supplies;

• Blood;

• Clinical preventive services;

• Outpatient pharmacy services.

Institutional Services

• Hospitalization: semiprivate room and

board, general nursing and other hospital

services and supplies;

• Skilled nursing facility care: semiprivate

room and board, skilled nursing and

rehabilitative services and other services and

supplies;

• Home health care;

• Hospice care.

Cost sharing for services is described in the

attached charts. It is anticipated that most

services will be provided in military

treatment facilities, at no charge to enrollees.

When enrollees use a civilian provider, a

copayment schedule will apply, featuring a

$12 per visit copayment, an $11 per diem

charge for most inpatient services, and a $9

per prescription charge.
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BILLING CODE 5000–64–C
38606 Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices

Attachment C—Reimbursement

Overview

This attachment, and figures 1 through 19,

describe the specific process for Medicare

Program reimbursement to the Department of

Defense (DoD) and for the end-of-year

reconciliation.

Medicare Interim Payments to DoD

Under the demonstration, DoD may receive

interim payments for the enrollment and

treatment of its dual-eligible beneficiaries.

During the execution of the demonstration

project during any demonstration year, the

department may receive a monthly permember per-month capitated amount for

TRICARE Senior Prime enrollees when the

site’s enrollment is above a specified

threshold. These payments are interim, or

provisional, payments. At the end of each

demonstration year, a reconciliation will be

conducted to determine whether DoD is

entitled to keep any of its interim payments,

and to determine if the amount of

reimbursement was appropriate. This

appendix describes the threshold mechanism

that triggers the interim monthly payments.

Then it describes the reconciliation process.

Thresholds for Reimbursement and

Reconciliation

For each demonstration year and each

demonstration site, DoD and HCFA will

establish a threshold that will determine

whether HCFA will reimburse DoD for

enrollment at the site and determine the size

of the reimbursement. The triggering

threshold derives from each individual site’s

historical level of expenses for its dual

eligible beneficiaries, termed the site’s ‘‘level

of effort’’. Calculation of the site’s baseline

level of effort is described in Appendix D.

The threshold for triggering interim

payments from Medicare will be calculated

from a portion of each site’s level of effort.

The portion will be 30 percent of the site’s

level of effort for the first demonstration year,

40 percent in the second demonstration year,

and 50 percent in the third. The 30 percent

portion for the first demonstration year will

be scaled, or prorated, to the number of

months of care delivery at each site. For

example, if a site’s level of effort was $90

million and delivered care for 5 months of

the first demonstration year, the portion used

to calculate a reimbursement threshold

would be $11.25 million (5⁄12ths of 30 percent

of $90 million).

The monthly threshold that triggers

payments will be calculated by dividing the

total dollar portion determined in the

previous paragraph by the months of care

delivery for the site. Continuing the example

above, the monthly threshold will be $2.25

million ($11.25 million divided by 5

months).

HCFA will calculate the amount that it

would pay for all of DoD’s enrollees under

the demonstration program at a modified per

capita Medicare+Choice reimbursement rate

(described in the next section), and compare

its calculated amount to the site’s monthly

threshold. If the calculated amount exceeds

the monthly threshold, then HCFA will

reimburse DoD for the difference as an

interim payment. If the calculated amount is

below the monthly threshold, HCFA will not

make a payment to DoD for that month.

Failure to enroll up to the threshold in a

month will also result in an adjustment to

interim payments from other months

(described under Annual Reconciliation

below). Payments for all demonstration sites

combined are subject to a global cap for each

demonstration year. The caps are $50 million

for the first demonstration year, $60 million

the second year, and $65 million the third.

No more than 50 percent of the cap in each

year shall be available for Medicare Partners.

Per Capita Reimbursement Rate

To calculate how much it would pay for

TRICARE Senior Prime enrollees in the

reimbursement mechanism (described in the

previous section), HCFA will use the

following rate. The reimbursement rate by

Medicare to DoD is 95 percent of the

applicable Medicare+Choice rate as

determined under the Balanced Budget Act

of 1997 (P.L. 105–33) . In accordance with

the authorizing legislation, the

Medicare+Choice rate for each county will be

adjusted to remove payments for graduate

medical education (GME), indirect medical

education (IME), and disproportionate share

hospital (DSH). In accordance with the

agreement by both Secretaries, 67 percent of

capital will be removed.

Annual Reconciliation

At the end of each demonstration year,

DHHS and DoD will conduct a formal

reconciliation and evaluation to determine

whether (1) all site’s are entitled to retain the

reimbursements they received from Medicare

and (2) whether the amount of

reimbursement were appropriate. The

reconciliation consists of four steps:

1. Accumulate DoD’s Expenses. The first

step will be to determine the total amount of

DoD expenditures across all six

demonstration site for all dual-eligible

beneficiaries residing in the service area.

Two categories of expense will be

accumulated: (1) expenses for care provided

on a space-available basis to non-enrolled

dual eligible beneficiaries (termed ‘‘spaceavailable level of effort’’), and (2) expenses

for care provided to enrollees.

Expenses for providing outpatient

pharmacy services will not be included in

any of the categories; nor will expenses

incurred providing services under a Medicare

Partners contract for services covered by the

contract. Expenses incurred providing

services not covered by a Medicare Partners

agreement will be counted as space-available

care.

Expenses for space-available care are

capped at a maximum of 70 percent of the

combined level of effort across all six sites

during the first demonstration year, 60

percent of the combined level of effort during

the second, and 50 percent during the third.

Because sites will be starting care delivery at

varying time during the first demonstration

year, the demonstration-wide cap on spaceavailable expenses will be prorated during

the first demonstration year as follows. Each

individual site’s level of effort will be

prorated according to the number of months

of care delivery during that first

demonstration year. Then, the prorated

level’s of effort will be added across all six

sites. Finally, 70 percent of the six site total

will be used for the first year space-available

cap.

2. Determine Eligibility for

Reimbursement. The second step will be to

determine whether the demonstration sites

are eligible to retain any reimbursements

from Medicare. There are two tests; both

must be passed. The first compares total

expenditures for all six sites, both for

enrolled and for space available care, to

DoD’s combined level of effort for all sites.

For any site to be eligible to retain

reimbursements from HCFA, DoD must reach

its combined level of effort.

The second test compares DoD’s

expenditures for enrolled care across all

demonstration sites against a minimum

threshold that varies by demonstration year.

The threshold is 30 percent of the combined

six-site level of effort during the first

demonstration year, 40 percent during the

second, and 50 percent during the third.

Again, the first year threshold on expenses

for enrolled care will be prorated by the

number of months of care delivery during

that year in the manner similar to the way

the threshold for space-available care is

prorated (described in 1. above).

3. Determine Amount of Reimbursement. If

DoD has met its level of effort for all

demonstration sites, reimbursements from

HCFA are subject to two adjustments. First,

gross monthly payments from HCFA to a site

will be summed over all months of a

demonstration year (months of care delivery

for the first demonstration year). The

difference between this sum and the level of

effort target will be the annual

reimbursement that DoD is entitled to keep

at each site. If the difference is negative, DoD

will return all payments received to HCFA.

This adjustment is performed at each site.

Second, total reimbursements from HCFA

may be adjusted upwards or downwards

during reconciliation if there is compelling

evidence of adverse or favorable risk

selection in DoD’s enrollment, when

compared with the HCFA population upon

which the Medicare+Choice rates are based.

The determination will be made analytically

during as part of the reconciliation process

and will be based upon submitted claims for

covered services.

Third, DoD is only entitled to retain

reimbursement above the aggregate level of

effort. The level of effort will be prorated

during the first demonstration year on the

basis of months of care delivery at the

various sites.

4. Provide Access to Data. The final step

will be to provide HCFA auditors and the

DHHS IG with access to DoD’s records and

data for demonstration sites. HCFA and DoD

will develop a mutually acceptable process

for settling any disputes that arise over the

data.

Maximum Ceiling on Total Annual Medicare

Reimbursement

For the demonstration project, the

maximum total Medicare reimbursement to

DoD for all six demonstration sites in any

demonstration year shall not exceed $50
Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices 38607

million in calendar year 1998, $60 million in

calendar 1999, and $65 million in calendar

year 2000. The cap for the first demonstration

year will be prorated as described below. All

reimbursements received by DoD for dualeligible enrollees from Medicare or from

Medicare Partners will count towards the

annual ceiling. Should Medicare

reimbursement to DoD meet the statutory cap

in any of the project’s three years, DoD will

remain obligated to continue to provide the

full range of services under the TRICARE

Senior Prime benefit to all project enrollees.

DoD will be financially liable for all care

provided under TRICARE Senior Prime once

the annual reimbursement cap is reached. No

more than 50 percent of the cap in each year

shall be available for Medicare Partners.

For 1998, the $50 million ceiling shall be

prorated based on the estimated enrollment

at each site and the number of months that

each site is operational during 1998. The

ceiling for 1998 will be determined when the

last site to begin in 1998 becomes

operational.

At the end of each month, DoD will report

to HCFA all revenue that it has received

during that month from Medicare+Choice

plans. HCFA will track payments for

TRICARE Senior Prime enrollees. If the

annual cap for that year was exceeded in a

prior month, DoD will remit all such revenue

for each succeeding month to HCFA.

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1By contrast, a ‘‘facility view’’ of a demonstration

area would accumulate the selected DHP expenses

for beneficiaries treated by facilities operating

within the service area, regardless of where such

beneficiaries reside.

Attachment D—Level of Effort

Introduction

Purpose

This attachment describes the methodology

that the Department of Defense (DoD) will

use to compute the FY96 ‘‘level of effort’’

(LOE) for each Medicare Demonstration site.

General Principles for Establishing Medicare

Level-of-Effort

DoD will compute the FY96 level-of-effort

(historical expenditures for its Medicare

eligible beneficiaries) separately for the

service area of each Medicare Demonstration

site. Service areas will be defined by lists of

specific zip-codes for each site. Expenses will

be accumulated from a population

perspective; they will be the sum of all

applicable DHP expenses for all dual eligible

beneficiaries living in the zip-codes defining

the site, regardless of where in the Military

Health System those expenses were

incurred.1

The LOE will include most direct expenses

for inpatient and outpatient care provided by

military Medical Treatment Facilities

(MTFs), with some additional burdening

(explained in detail below) . It will also

include the government’s costs of care for

Medicare eligibles referred to providers in

networks operated by the Department’s

Managed Care Support Contractors. The

FY96 LOE excludes any DoD expenses

comparable to those removed from the

Medicare+Choice rates as a result of the

Balanced Budget Act of 1997 (e.g., expenses

for Graduate Medical Education), or any

types of care specifically excluded by

agreement between DoD and HCFA

(outpatient pharmacy costs). The FY96 LOE

will also exclude DoD’s monthly payments

for dual-eligible enrollees of Uniform

Services Treatment Facilities (USTFs)

residing in the service area, unless they

participate.

It is the agreement of the administering

Secretaries that FY96 will be the baseline.

Detailed Methodology

This section presents the separate

methodologies used to estimate inpatient and

ambulatory expenses.

Terminology

Medicare Demonstration Sites. In

accordance with current legislation, six sites

will be picked for the Medicare

Demonstration. A service area for each site

will be defined geographically by a specific

list of zip-codes.

IDA Add-on. In an analysis performed for

the ‘‘733 Study,’’ the Institute for Defense

Analysis (IDA) determined that certain

expenses should be added to the clinical

expenses reported in the Medical Expense

and Performance Reporting System (MEPRS).

Based upon their analyses, they estimated the

amounts that should be added to inpatient

and outpatient clinical expenses as a

percentage add-on to the expenses routinely

reported in the clinical accounts. Their

recommended adjustments are presented in

Table 1.

Patient-Level Cost Allocation. The

methodology that DoD is evolving to estimate

expenses at the level of the individual patient

encounter. That methodology is described in

a separate document to be provided by DoD.

Inpatient Care

Data Sources

Direct Care

Clinical Data: Standard Inpatient Data

Record (SIDR) for each hospital discharge.

Maintained in the Corporate Executive

Information System (CEIS).

Expenses: Estimated from the Medical

Expense and Performance Reporting

System—Central (MEPRS), part of the

Defense Medical Information System or from

the MEPRS Executive Query System (MEQS),

depending on military department.

MCSC Provider Network

Expenses: Government paid expense on

Health Care Summary Records (HCSRs)

provided by the TRICARE Support Office

(TSO) to the CEIS.

Methodology

Estimates of total inpatient expenses in

each service area are determined by the

following process:

1. Estimate inpatient expenses for care in

Military Treatment Facilities (MTFs) for all

Medicare eligibles in the service area.

a. From the CEIS, isolate the electronic

summary discharge records for all non-active

duty DoD beneficiaries age 65 and older

living in the service area.

b. For each record isolated in step (1),

estimate the cost of each discharge.

(1) Estimate the cost for each individual

discharge using the Patient Level Costing

Allocation (PLCA) methodology, as described

in a separate document to be provided by

DoD.

(2) Apply the IDA add-ons appropriate to

the treating facility.

(a) Burden the cost of each record using

IDA’s percentages for DMSCC, Mgmt HQ, and

Reference Labs, using the percentage

developed for the Military Department of the

hospital in which the care occurred (see

Table 1). By agreement of the two

administering Secretaries, burden the cost on

each record with 1⁄3 of the IDA adjustment for

Construction (see Table 1).

(b) Burden each record for Continuing

Health Education (MEPRS Account FAL) and

Patient Transportation/Movement (FEA/FEB/

FEC) by allocating the actual expenditures in

these accounts for treating facilities in the

demonstration service area, and by the IDA

percentage add-on (Table 1) for treating

facilities outside the demonstration area.

Since these accounts support all patient

categories, as well as both inpatient and

outpatient services, only a portion of their

expenses will be allocated to the inpatient

treatment of Medicare beneficiaries. The

amount of each account allocated to

Medicare inpatient expenses will be in the

same proportion as MEPRS A Expenses

(Inpatient Clinical Expenses) for the

Medicare population are to the total of all

MEPRS A and MEPRS B (Outpatient Clinical

Expenses) in FY96. The amount allocated to

Medicare inpatient expenses will be

uniformly distributed across all Medicare

inpatient records.

c. For records from teaching facilities,

deflate the amount using HCFA’s adjustment

for Indirect Medical Education (IME) based

on that facility’s count of beds and of interns

and residents.

d. Sum the estimated costs for the service

area.

2. Estimate inpatient expenses for care

provided by the MCSC provider networks.

a. Isolate all Health Care Summary Records

for all non-active duty DoD beneficiaries, age

65 and older, living in the service area.

b. Total the government paid portion for all

claims. [DHA1]

Outpatient Care

Data Sources

Direct Care

Clinical Data: Monthly outpatient visits by

patient age and third-level MEPRS from

CHCS, as well as outpatient visits reported by

third-level in MEPRS-Central or MEQS.

Expenses: Dollars by third-level MEPRS

from MEPRS-Central or MEQS.

MCSC Provider Network

Expenses: Government paid expense on

Health Care Summary Records (HCSRs)

provided by the TRICARE Support Office

(TSO) to the CEIS.

Methodology

The following steps will be used to

estimate outpatient expenses in each region:

1. Estimate the outpatient expenses for

Medicare eligibles at all MTFs in the service

area using the following steps.

a. Reconcile CHCS and MEPRS visit data.

(1) Annualize the CHCS data.

(2) Scale CHCS visit accounts to MEPRS or

MEQs, if necessary.

b. From the rescaled CHCS visit data,

determine the proportion of visits in each

workcenter (third-level MEPRS) that are for

non-active duty beneficiaries age 65 and

older.

c. Apply the proportion of non-active duty

beneficiaries age 65 and older to the MEPRS

workcenter costs, excluding outpatient

pharmacy expenses from the stepdown to

ambulatory workcenters.

d. Sum the costs for the beneficiaries under

consideration across all MEPRS workcenters

to get total outpatient visit expenses at the

facility level.

e. Apply the IDA add-ons for outpatient

care.

(1) Inflate each record using IDA’s

percentages for DMSCC, Mgmt HQ, Reference

Labs, and Clinical Investigation, using the

percentage developed for the Military

Department of the hospital in which the care

occurred. By agreement of the two

administering Secretaries, burden the cost on

each record with 1⁄3 of the IDA adjustment for

Construction (see Table 1).

(2) Burden the total expenses from d. by

expenses in Continuing Health Education

(MEPRS Account FAL) by allocating actual

expenditures in the FAL account of the
38616 Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices

treating facility. The amount of each account

allocated to Medicare outpatient expenses in

the same proportion as MEPRS B Expenses

(Outpatient Clinical Expenses) for the

Medicare population are to the total of all

MEPRS A (Inpatient Clinical Expenses) and

MEPRS B in FY96. The amount allocated to

Medicare outpatient expenses will be

uniformly distributed across all Medicare

outpatient records.

f. Sum the estimates for all MTFs within

the service area.

2. Estimate ambulatory expenses for care

provided by the MCSC provider networks.

a. Isolate all Health Care Summary Records

for all non-active duty DoD beneficiaries, age

65 and older, living in the service area.

b. Total the government paid portion for all

claims.

BILLING CODE 5000–04–P
Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices 38617

BILLING CODE 5000–04–C
38618 Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices

Attachment E—Medicare Demonstration of

Military Managed Care

Evaluation

Medicare Demonstration Sample

Evaluation Questions—These questions are

among those which may be addressed in

either the GAO report required by the

demonstration project’s authorizing statute or

in a separate evaluation conducted jointly by

the Department of Defense and the

Department of Health and Human Services.

• Can DoD and Medicare implement a

cost-effective alternative for delivering

accessible and quality care to dual-eligible

beneficiaries?

The Medicare Demonstration should be

able to answer the basic question of whether

DoD and Medicare can meet its objective of

implementing a cost-effective alternative for

delivering care to dual-eligible beneficiaries

through MHS. The answer to this question

can be found by answering questions in four

basic areas: enrollment demand, enrollee

benefits, cost of the program, and impact on

other DoD and Medicare beneficiaries for

TRICARE Senior Prime and Medicare

Partners. In each there should be a question

about whether the demonstration succeeded

and a set of analyses that examines the

details within that area.

(1) Benefits for Enrollees

• Do dual-eligible beneficiaries benefit

from Medicare reimbursement and

enrollment in terms of quality, satisfaction,

health status, access, or out of pocket costs?

• Will individual patients have better

outcomes if treated as a DoD enrollee?

• Will beneficiaries as a whole evince

better health and higher satisfaction when

DoD enrollment is an option?

• Will beneficiaries have wider managed

care choices?

• Will beneficiaries experience improved

access to health care in general?

By definition, enrollees will have at least

as generous a benefit as Medicare

beneficiaries. The basic question will be:

does DoD fulfill this promise and what if any

additional benefits accrue to enrollees?

However, the question will go much deeper

than the structure of the prime benefit. Will

beneficiaries as a whole experience better

health, experience improved access, report

higher satisfaction and encounter lower out

of pocket costs when DoD enrollment is an

option? In this case, we should examine the

levels of satisfaction, health status, and

access between those enrolled versus those

not enrolled and between those in the

demonstration areas versus those outside the

demonstration areas.

As one measure of quality, DoD facilities

are JCAHO accredited and the grid scores

received will give us information on whether

the MHS is maintaining its high standard of

care. Data from the Health Care Survey of

DoD Beneficiaries can be used to assess

levels of satisfaction, access, and health

status.

(2) Cost of Program

• Does Medicare reimbursement and

enrollment occur without increasing the

costs to either the Department of Health and

Human Services and the Department of

Defense?

• Will the Medicare Trust Funds

experience losses or savings?

• Will the government as a whole

experience losses or savings?

• What impact would Medicare

reimbursement and enrollment have on the

budgets of the Department of Health and

Human Services and the Department of

Defense?

Again, by definition, the demonstration

must be budget neutral. However, the

demonstration should provide an accounting

that budget neutrality was achieved and that

no cost were shifted from DoD to Medicare,

i.e. that the Medicare trust funds did not

experience any losses. This should include

an analysis of the level of effort that DoD

expends for the Medicare eligible as well as

any reimbursements from Medicare that may

be triggered during the demonstration.

Analyses should also determine if DoD can

in fact live within the Medicare payment,

and whether its ability to live within it is

determined by the level of the Medicare

payment for different areas. In addition, the

demonstration should highlight any cost

shifting within the DoD to accommodate care

for prime enrollees, both between regions

and among medical programs. For Medicare

Partners payments, analyses should estimate

to what extent graduate medical education

(GME), indirect medical education (IME), and

disproportionate share hospital (DSH)

amounts are included in those payments. It

should also be able to forecast future budget

impacts if the demonstration is continued or

expanded.

Data for this section will be obtained in the

same way that we estimated level of effort for

reimbursement purposes. Sources include

inpatient, ambulatory, and ancillary medical

records and MEPRS accounting data. Because

of the concern of shifting between regions

and among medical programs, some level of

aggregate data will need to be analyzed from

outside the demonstration regions. Changes

in Medicare expenditures to dual eligible

beneficiaries could be accomplished with

merged DoD and HCFA files similar to those

being used for the initial level of effort

analysis.

(3) Impact on Other DoD and Medicare

Beneficiaries

• What impact (access, quality, cost) does

Medicare reimbursement and enrollment

have on medical care for DoD beneficiaries

(active duty, active duty dependents, retirees

and their dependents) other than the dualeligible beneficiaries?

• Will the demonstration affect local

health care providers or non-dual-eligible

Medicare beneficiaries access to quality care?

The effect of the Medicare Demonstration

may go beyond the effects on those who are

Medicare eligible. Providing all inclusive

care for Medicare eligibles may have effects

on the access and priority of other

beneficiaries in getting quality health care.

The demonstration should provide answer to

whether such a new benefit can be

established without negatively impacting

other classes of beneficiaries. In particular,

the main focus of this question should be if

access to non-Medicare eligible individuals

has declined as a result of the demonstration.

This should be examined for the different

classes of beneficiaries and especially for

active duty personnel and their dependents.

The demonstration should also examine the

effects of enrolling these individuals on

CHAMPUS costs if they are displacing other

beneficiaries in the direct care system.

Similar to (1) but for the remaining

beneficiary categories, we propose using the

Health Care Survey of DoD Beneficiaries to

examine trends in access for non-Medicare

eligible individuals.

(4) Enrollment Demand

• Is there sufficient demand to justify

enrollment of and reimbursement for dualeligible beneficiaries in TRICARE Senior

Prime and/or Medicare Partners?

• What impact does Medicare

reimbursement and enrollment have on the

use of the Military Health System by dualeligible beneficiaries?

• Will the Medicare Demonstration fare

differently in different areas?

Up to this point, we do not know the

degree to which Medicare eligibles are

interested in participating in TRICARE

Senior Prime and Medicare Partners. The

demonstration should allow us to gauge the

demand for such services. If few beneficiaries

sign up, then one would question the need

for such a program. Therefore, the basic

question will be the number of Medicare

Prime enrollees. We will also be interested

on the total usage of the DoD system

including space available use. Prior to the

demonstration, beneficiaries fall into three

categories: those who use the military system

exclusively, those who use it for some of

their health care, and those who rely

exclusively on civilian care. With the

demonstration, the first category will be split

into two, those who enroll and those who use

space available care for all their health care.

The demonstration should seek the answer to

who enrolls (e.g. are they prior exclusive

users of DoD), what shifts between categories

occurs, and does DoD continue to support at

least as many beneficiaries as prior to the

demonstration. It will also be of interest in

projecting future enrollment to measure

differences in enrollment between sites. Do

those with greater military health care

capability attract more enrollees than those

with limited capability? Do civilian

capabilities and alternatives influence the

beneficiaries decision to enroll?

Data for this part of the evaluation will be

from three sources. First, the enrollment files

themselves will give us information on the

number and kinds of beneficiaries who sign

up for TRICARE Senior Prime. Second, the

MHS User Survey can estimate the

proportion of dual eligibles in each of the

three categories. This data will also answer

the questions as to what extent access of nonenrollees to space available care and

pharmacy benefits are affected. Finally, the

merging of utilization files from DoD and

HCFA will give another look at what

proportion of care is seen between the two

systems.
Federal Register / Vol. 63, No. 137 / Friday, July 17, 1998 / Notices 38619

DOD Performance Measures Attachment F—

Enrollment Systems

Performance: DoD provides appropriate

enrollment information to HCFA;

applications are handled according to HCFA

requirements.

Criteria DoD can effectively interface with

HCFA systems; applications are dated when

received, handled first-come, first-served.

Grievance and Appeals

Performance: Process exists to handle

beneficiary and provider complaints.

Criteria: DoD keeps an accurate log of

complaints and addresses them promptly and

appropriately.

Marketing

Performance: Process exists for assuring

that beneficiaries are well-informed

(beneficiaries are not misled,

misrepresentations about the Medicare

program are not made).

Criteria: DoD assures that beneficiaries are

well informed, marketing materials are

reviewed by HCFA before DoD distributes

them.

Access/Capacity

Performance: DoD has adequate capacity

and enrollees have adequate access to

services.

Criteria: DoD demonstrates that TRICARE

Senior Prime enrollees are getting the same

priority and the same access as other military

retirees who enroll in TRICARE Prime.

Paying Providers

Performance: Systems exist for processing

payment to providers.

Criteria: DoD demonstrates ability to pay

providers timely and accurately.

Reimbusement/Level of Effort

Performance: DoD has systems that receive

and track payments from HCFA, and DoD can

track actual costs for both space-available

and enrollee care.

Criteria: DoD receives payment without

problems; DoD demonstrates ability to track/

allocate costs for space-available and enrollee

care.

Encounter Data

Performance: DoD submits ‘‘test’’ data to

fiscal intermediaries/carriers.

Criteria: DoD demonstrates successful data

transmission.

[FR Doc. 98–19041 Filed 7–16–98; 8:45 am]

BILLING CODE 5000–04–P

DEPARTMENT OF EDUCATION

Notice of Proposed Information

Collection Requests

AGENCY: Department of Education.

SUMMARY: The Acting Deputy Chief

Information Officer, Office of the Chief

Information Officer, invites comments

on the proposed information collection

requests as required by the Paperwork

Reduction Act of 1995.

DATES: Interested persons are invited to

submit comments on or before

September 15, 1998.

ADDRESSES: Written comments and

requests for copies of the proposed

information collection requests should

be addressed to Patrick J. Sherrill,

Department of Education, 600

Independence Avenue, S.W., Room

5624, Regional Office Building 3,

Washington, D.C. 20202–4651.

FOR FURTHER INFORMATION CONTACT:

Patrick J. Sherrill (202) 708–8196.

Individuals who use a

telecommunications device for the deaf

(TDD) may call the Federal Information

Relay Service (FIRS) at 1–800–877–8339

between 8 a.m. and 8 p.m., Eastern time,

Monday through Friday.

SUPPLEMENTARY INFORMATION: Section

3506 of the Paperwork Reduction Act of

1995 (44 U.S.C. Chapter 35) requires

that the Office of Management and

Budget (OMB) provide interested

Federal agencies and the public an early

opportunity to comment on information

collection requests. OMB may amend or

waive the requirement for public

consultation to the extent that public

participation in the approval process

would defeat the purpose of the

information collection, violate State or

Federal law, or substantially interfere

with any agency’s ability to perform its

statutory obligations. The Acting Deputy

Chief Information Officer, Office of the

Chief Information Officer, publishes this

notice containing proposed information

collection requests prior to submission

of these requests to OMB. Each

proposed information collection,

grouped by office, contains the

following: (1) Type of review requested,

e.g., new, revision, extension, existing

or reinstatement; (2) Title; (3) Summary

of the collection; (4) Description of the

need for, and proposed use of, the

information; (5) Respondents and

frequency of collection; and (6)

Reporting and/or Recordkeeping

burden. OMB invites public comment at

the address specified above. Copies of

the requests are available from Patrick J.

Sherrill at the address specified above.

The Department of Education is

especially interested in public comment

addressing the following issues: (1) is

this collection necessary to the proper

functions of the Department; (2) will

this information be processed and used

in a timely manner, (3) is the estimate

of burden accurate; (4) how might the

Department enhance the quality, utility,

and clarity of the information to be

collected, and (5) how might the

Department minimize the burden of this

collection on the respondents, including

through the use of information

technology.

Dated: July 13, 1998.

Hazel Fiers,

Acting Deputy Chief Information Officer,

Office of the Chief Information Officer.

Office of Educational Research and

Improvement

Type of Review: New.

Title: Third International Mathematics

and Science Study Video—Repeat

(TIMSS–R).

Frequency: On Occasion.

Affected Public: Individuals or

households; not-for-profit institutions.

Reporting and Recordkeeping Hour

Burden:

Responses: 5,600.

Burden Hours: 567.

Abstract: Videotape study of 8th grade

math and science classrooms in the

United States, the Czech Republic,

France, Japan, the Netherlands, and One

Asian Nation during the 1998–1999

school year. Designed and conducted by

the U.S., this study supplements the

Main TIMSS–R academic assessment

data collection in which 45 to 50

countries are expected to participate.

This study is based on and extends the

work of the previous TIMSS video

study. That study included only

mathematics and compared the U.S.

data with two other countries—Japan

and Germany. This study will include

science in addition to mathematics

lessons, will be conducted in five highachieving nations, and will collect and

produce video tapes that will be useful

for improving teaching practices.

Office of Educational Research and

Improvement

Type of Review: Revision.

Title: The Blue Ribbon Schools

Program.

Frequency: One time.

Affected Public: Not-for-profit

institutions; State, local or Tribal Gov’t,

SEAs or LEAs.

Reporting and Recordkeeping Hour

Burden:

Responses: 515.

Burden Hours: 25,750.

Abstract: The Blue Ribbon Schools

award is a national school improvement

strategy with a threefold purpose: (1) to

identify and give public recognition to

outstanding public and private schools

across the nation; (2) to make available

a comprehensive framework of key

criteria for school effectiveness that can

serve as a basis for participatory selfassessment and planning in schools;

and (3) to facilitate communication and

sharing of best practices within and

among schools based on a common