Access to Healthcare Under the TRICARE Program for Beneficiaries of TRICARE Prime

AGENCY:

Office of the Secretary, Department of Defense.

ACTION:

Notice of access to health care standards for TRICARE Prime beneficiaries under the TRICARE Program.

SUMMARY:

This notice is to advise interested parties of the Military Health System's access to health care standards addressed in Title 32, Code of Federal Regulations (32 CFR), Section 199.17 for TRICARE Prime beneficiaries under the TRICARE Program and how the Secretary of Defense plans to ensure that beneficiaries under TRICARE Prime who are seeking an appointment for health care will obtain an appointment within established access to health care standards. Access to health care under the TRICARE Program for TRICARE Prime beneficiaries was established in October 1995 and remains current.

ADDRESSES:

Defense Health Agency, TRICARE Health Plan, 7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042-5101.

FOR FURTHER INFORMATION CONTACT:

Ms. Michelle Graves, TRICARE Health Plan, telephone (703) 681-0039.

SUPPLEMENTARY INFORMATION:

A. Background on Access to Health Care for TRICARE Prime Beneficiaries Under the TRICARE Program

Section 704 of the National Defense Authorization Act for Fiscal Year 2016 (NDAA for FY16) requires the Secretary of Defense to establish and publicize access to care standards for beneficiaries enrolled in TRICARE Prime at military treatment facilities (MTFs) or with civilian network providers. The Department has already established Prime maximum wait times and travel distances for Prime primary and specialty care appointments as required by Section 704 of the NDAA for FY 2016.

Access to care standards for TRICARE Prime enrollees have been in place since the start of the TRICARE Prime program in 1995. TRICARE Prime access standards were published in a Federal Register notice on October 5, 1995 (60 FR 52100-52101) and promulgated in 32 CFR 199.17(p)(5)(i-v). These same standards are also disseminated throughout the Military Health System via Assistant Secretary of Defense (Health Affairs) Memorandum 11-005, “TRICARE Policy for Access to Care,” dated February 23, 2011. Finally, these standards are incorporated by reference in existing and future TRICARE regional support contracts. TRICARE Prime access to health care standards apply regardless of the location of the beneficiary's primary care manager (military treatment facility or civilian network).

B. Description of the Health Care Access Standards for TRICARE Prime Beneficiaries

The health care access standards outlined in this notice are set forth in 32 CFR 199.17(p)(5)(i-v). These access standards remain current and in force without any amendment to date.

Access standards. Preferred provider networks will have attributes of size, composition, mix of providers, and geographical distribution so that the networks, coupled with the MTF capabilities, can adequately address the health care needs of the enrollees. The capabilities of the MTF plus preferred provider network will meet the following access standards with respect to the needs of the expected number of enrollees:

(i) Under normal circumstances, enrollee travel time may not exceed 30 minutes from home to primary care delivery site unless a longer time is necessary because of the absence of providers (including providers not part of the network) in the area.

(ii) The wait time for an appointment for a well-patient visit or a specialty care referral shall not exceed four weeks; for a routine visit, the wait time for an appointment shall not exceed one week; and for an urgent care visit the wait time for an appointment shall be within 24 hours. (The specialty care time standard does not apply in the case of a follow-up appointment that for clinical reasons is specifically stated for a later period.)

(iii) Emergency services shall be available and accessible to handle emergencies (and urgent care visits if not available from other primary care providers pursuant to paragraph (p)(5)(ii) of 32 CFR 199.17), within the service area 24 hours a day, seven days a week.

(iv) The network shall include a sufficient number and mix of board certified specialists to meet reasonably the anticipated needs of enrollees. Travel time for specialty care shall not exceed one hour under normal circumstances, unless a longer time is necessary because of the absence of providers (including providers not part of the network) in the area. This requirement does not apply under the Specialized Treatment Services Program.

(v) Office waiting times in non-emergency circumstances shall not exceed 30 minutes, except when emergency care is being provided to patients, and the normal schedule is disrupted.

C. Description of How the Secretary of Defense Plans To Ensure That Beneficiaries Under TRICARE Prime Who Are Seeking an Appointment for Health Care Will Obtain an Appointment Within Established Access to Health Care Standards

In an effort to ensure TRICARE Prime beneficiaries obtain an appointment within access to health care standards at an MTF, the Military Health System implemented a first-call resolution policy in calendar year 2015. This policy outlines standard processes to ensure TRICARE Prime beneficiaries are not asked to call back to the MTFs if no appointments are available within the established access to health care standards. The policy also identifies responsibilities of MTF Directors, primary care, specialist care and other stakeholders identified in the appointing process to ensure patient satisfaction for our beneficiaries. The policy outlines specific procedures to correctly transfer calls in accordance with existing access to care standards, referral management protocols and proper use of managing clinic schedules to ensure appointing success the first time one of our beneficiaries seeks access. In addition, a Joint Outpatient Experience Survey will be used to measure the impact of the first-call resolution policy from beneficiaries' perspectives on whether they obtained an appointment within health care access standards.

For those TRICARE Prime beneficiaries seeking an appointment with a TRICARE Prime civilian network provider, if the beneficiary cannot be scheduled for a visit in the MTF or TRICARE Prime network within the access to care standards, the beneficiary will be authorized an out-of-network provider visit with no point-of-service charge. The TRICARE Reimbursement Manual will be revised to reflect the above statement. In addition, as stated in the TRICARE Operations Manual (TOM Chapter 1, Section 3, Paragraph 1.0), “Contractors are charged with providing or arranging for delivery of quality, timely health care services and have the responsibility for providing the timely and accurate processing of all claims received into their custody, whether for network or non-network care.”

D. Communications

The Defense Health Agency will post the TRICARE Prime access to care standards on the TRICARE.mil Web site and execute a strategic communication plan to educate beneficiaries enrolled in TRICARE Prime about the access to care standards.