Civilian health and medical program of uniformed services (CHAMPUS): TRICARE program— Senior Prime managed care program; Medicare Trust Fund reimbursement,

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Federal Register: July 17, 1998 (Volume 63, Number 137)NoticesPage 38558-38619From the Federal Register Online via GPO Access [wais.access.gpo.gov]

DOCID:fr17jy98-44

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

[Page 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 Medicare-eligible 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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[Page 38572]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

<bullet> Physician's services;

<bullet> Medical and surgical services and supplies;

<bullet> Outpatient hospital treatment;

<bullet> Mental health outpatient services;

<bullet> Physical and speech therapy;

<bullet> Clinical laboratory services and diagnostic tests;

<bullet> Durable medical equipment and supplies;

<bullet> Blood;

<bullet> Clinical preventive services;

<bullet> Outpatient pharmacy services.

Institutional Services

<bullet> Hospitalization: semiprivate room and board, general nursing and other hospital services and supplies;

<bullet> Skilled nursing facility care: semiprivate room and board, skilled nursing and rehabilitative services and other services and supplies;

<bullet> Home health care;

<bullet> 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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[Page 38606]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 per-member 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 (\5/12\ths 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 ``space-available 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 space- available 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

[Page 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 dual-eligible 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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[Page 38615]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\

\1\ By 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.

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

[Page 38616]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.

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[Page 38618]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.

<bullet> 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

<bullet> Do dual-eligible beneficiaries benefit from Medicare reimbursement and enrollment in terms of quality, satisfaction, health status, access, or out of pocket costs?

<bullet> Will individual patients have better outcomes if treated as a DoD enrollee?

<bullet> Will beneficiaries as a whole evince better health and higher satisfaction when DoD enrollment is an option?

<bullet> Will beneficiaries have wider managed care choices?

<bullet> 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

<bullet> Does Medicare reimbursement and enrollment occur without increasing the costs to either the Department of Health and Human Services and the Department of Defense?

<bullet> Will the Medicare Trust Funds experience losses or savings?

<bullet> Will the government as a whole experience losses or savings?

<bullet> 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

<bullet> 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 dual-eligible beneficiaries?

<bullet> 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

<bullet> Is there sufficient demand to justify enrollment of and reimbursement for dual-eligible beneficiaries in TRICARE Senior Prime and/or Medicare Partners?

<bullet> What impact does Medicare reimbursement and enrollment have on the use of the Military Health System by dual-eligible beneficiaries?

<bullet> 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 non-enrollees 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.

[Page 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. 98-19041Filed7-16-98; 8:45 amBILLING CODE 5000-04-P

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