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TREA Legislative Update
August 25, 2006
It is another quiet and slow news week in Washington DC with members of Congress either on vacation or out and about campaigning around the Country. The President is back in town working on Iraq and out of town working on the election (but see below). THERE WILL BE NO UPDATE NEXT WEEK. TREA is having its National Convention in Nashville from August 30 to September 2, 2006 Hope to see many of you there.
1. President signs Executive Order on Medical Health Records
On Tuesday, August 22, President Bush signed an executive order requiring the federal departments that pay for health care to move towards requiring records to be “transparent” and that all medical records be electronic. The four agencies affected by the order are the following agencies: the Department of Health and Human Services, which oversees Medicare; the Department of Veterans Affairs; the Defense Department; and the Office of Personnel Management, which oversees the Federal Employee Health Benefit Program. The House (HR4157) and the Senate (S1418) have passed different IT medical record bills and there is concern that they will not have a conference to settle final language before the end of this session. This order will, therefore, put the weight of the federal government's purchasing power behind this push for a fully electronic system and “transparency” of information. The Order is effective January 1, 2007. We believe there will be many meetings in Washington in the near future analyzing exactly what this will mean for DOD and the VA. The full order is below:
Executive Order: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs
By the authority vested in me as President by the Constitution and the laws of the United States, and in order to promote federally led efforts to implement more transparent and high-quality health care, it is hereby ordered as follows:
Section 1. Purpose. It is the purpose of this order to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. It is the further purpose of this order to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector. Consistent with the purpose of improving the quality and efficiency of health care, the actions and steps taken by Federal Government agencies should not incur additional costs for the Federal Government.
Sec. 2. Definitions. For purposes of this order:
(a) "Agency" means an agency of the Federal Government that administers or sponsors a Federal health care program.
(b) "Federal health care program" means the Federal Employees Health Benefit Program, the Medicare program, programs operated directly by the Indian Health Service, the TRICARE program for the Department of Defense and other uniformed services, and the health care program operated by the Department of Veterans Affairs. For purposes of this order, "Federal health care program" does not include State operated or funded federally subsidized programs such as Medicaid, the State Children's Health Insurance Program, or services provided to Department of Veterans' Affairs beneficiaries under 38 U.S.C. 1703.
(c) "Interoperability" means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data such that clinical or operational purpose and meaning of the data are preserved and unaltered.
(d) "Recognized interoperability standards" means interoperability standards recognized by the Secretary of Health and Human Services (the "Secretary"), in accordance with guidance developed by the Secretary, as existing on the date of the implementation, acquisition, or upgrade of health information technology systems under subsections (1) or (2) of section 3(a) of this order.
Sec. 3. Directives for Agencies. Agencies shall perform the following functions:
(a) Health Information Technology.
(1) For Federal Agencies. As each agency implements, acquires, or upgrades health information technology systems used for the direct exchange of health information between agencies and with non-Federal entities, it shall utilize, where available, health information technology systems and products that meet recognized interoperability standards.
(2) For Contracting Purposes. Each agency shall require in contracts or agreements with health care providers, health plans, or health insurance issuers that as each provider, plan, or issuer implements, acquires, or upgrades health information technology systems, it shall utilize, where available, health information technology systems and products that meet recognized interoperability standards.
(b) Transparency of Quality Measurements.
(1) In General. Each agency shall implement programs measuring the quality of services supplied by health care providers to the beneficiaries or enrollees of a Federal health care program. Such programs shall be based upon standards established by multi-stakeholder entities identified by the Secretary or by another agency subject to this order. Each agency shall develop its quality measurements in collaboration with similar initiatives in the private and non-Federal public sectors.
(2) Facilitation. An agency satisfies the requirements of this subsection if it participates in the aggregation of claims and other appropriate data for the purposes of quality measurement. Such aggregation shall be based upon standards established by multi-stakeholder entities identified by the Secretary or by another agency subject to this order.
(c) Transparency of Pricing Information. Each agency shall make available (or provide for the availability) to the beneficiaries or enrollees of a Federal health care program (and, at the option of the agency, to the public) the prices that it, its health insurance issuers, or its health insurance plans pay for procedures to providers in the health care program with which the agency, issuer, or plan contracts. Each agency shall also, in collaboration with multi-stakeholder groups such as those described in subsection (b)(1), participate in the development of information regarding the overall costs of services for common episodes of care and the treatment of common chronic diseases.
(d) Promoting Quality and Efficiency of Care. Each agency shall develop and identify, for beneficiaries, enrollees, and providers, approaches that encourage and facilitate the provision and receipt of high-quality and efficient health care. Such approaches may include pay-for-performance models of reimbursement consistent with current law. An agency will satisfy the requirements of this subsection if it makes available to beneficiaries or enrollees consumer-directed health care insurance products.
Sec. 4. Implementation Date. Agencies shall comply with the requirements of this order by January 1, 2007.
Sec. 5. Administration and Judicial Review.
(a) This order does not assume or rely upon additional Federal resources or spending to promote quality and efficient health care. Further, the actions directed by this order shall be carried out subject to the availability of appropriations and to the maximum extent permitted by law.
(b) This order shall be implemented in new contracts or new contract cycles as they may be renewed from time to time. Renegotiation outside of the normal contract cycle processes should be avoided.
(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.
GEORGE W. BUSH
THE WHITE HOUSE,
August 22, 2006.
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2. Latest TRS enrollment numbers
TRICARE Reserve Select enrollment numbers
As of August 18, 2006:
Step 1–48,886 entered agreements by member
Step 2–28,175 executed agreements on DEERS
Step 3–11,465 Total plans (count by RC v. TRICARE region)
3,457 Total plans disenrolled
14,922 Total plans ever enrolled
3,638 member-only plan
1,088 member-only plans disenrolled
4,726 Total member-only ever enrolled
7,827 family plans and 2,369 family plans disenrolled
10,196 family plans ever enrolled
32,728 Total beneficiaries entered in DEERS
9,826 Total beneficiaries disenrolled.
42,554 Total beneficiaries ever enrolled.
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3. New TRICARE Fact Sheet: “What Happens to My Benefit When I Retire
Today DOD put out the following comprehensive fact sheet on what the military retiree health care benefit is. This should be helpful for anyone to track down what he or she is entitled to. You may wish to print this out to hand out at chapter meetings or just to friends and neighbors.
Tricare Management Activity - Fact Sheets
August 25, 2006
What Happens to My Benefit When I Retire
TRICARE has exceptional health plans for our military service members, retirees and their families. If you are a uniformed service member preparing for retirement, there are important health care issues you need to consider. Here is a quick and simple guide to help you understand your medical, dental and pharmacy benefits and assist in your smooth transition. There are additional resources and Web sites listed below each chart.
Plan
When You Are On Active Duty
When You Retire
Things To Consider
TRICARE PRIME
Enrollment
- Active Duty members are required to be Prime or Prime Remote.
- Your family members can choose to enroll or not.
- No enrollment fee.
- Lock out rules apply for family members. 1
Costs
- You do not pay co-pays for outpatient or inpatient care.
- As costs change annually (fiscal or calendar year), go to the TRICARE Web site for up-to-date information.
- Your catastrophic cap is $1000 per fiscal year per family.
- If you use Prime network providers, your claims are filed for you.
- Medicare eligible family members with an Active Duty sponsor DO NOT have to have Medicare Part B. 4
Benefits
- Family members are eligible for the Extended Care Health Option (ECHO) benefit.
- Family members are entitled to free eye exams annually.
Enrollment
- You must submit a new enrollment form upon your retirement.
- You must now pay enrollment fees.
- The 20th of the month rule applies. 2
- Lock out rules
- apply. 1
- You may not be assigned to the same provider you had when on active duty.
Costs
- You now pay co-pays for outpatient or inpatient care, unless you are enrolled in Prime at an MTF.
- As costs change annually (fiscal or calendar year), go to the TRICARE Web site for up-to-date information.
- Your catastrophic cap increases to $3000 per fiscal year per family.
- If you use Prime network providers, your claims are filed for you.
- Medicare eligible retirees and family members MUST have Medicare Part B to retain TRICARE eligibility. 4
Benefits
- Family members no longer qualify for ECHO benefits.
- You and your family are only entitled to an eye exam once every two years.
Enrollment
- Is Prime available where I am going to retire?
- Is the doctor I want to see a Prime network provider?
- Have I submitted my completed Prime enrollment form, with payment, by the 20th of the month before my official retirement date to avoid a break in coverage? 2
- Have I decided on and set up a process to pay my enrollment fees (check, credit card, electronic fund transfer, allotment)? [You are always responsible for making payments, even if the bill doesn't arrive on time]
Costs
- If I seek specialty care without a referral, can I afford to pay the higher cost of Point of Service? 3
- Do I have a TRICARE Explanation of Benefits for any care I have received? If not, have I called my provider and the contractor to make sure my claims are being processed correctly?
Benefits
- Have I researched what other programs/providers are available to meet my family's members needs now that ECHO is no longer available to me?
- If I or my family members are entitled to Medicare Part A, have I correctly purchased Part B in order to retain TRICARE eligibility? 4
TRICARE Prime Web sites and Resources:
Plan
When You Are On Active Duty
When You Retire
Things To Consider
TRICARE PRIME REMOTE (TPR)
Enrollment
- Active Duty members are required to be Prime or Prime Remote.
- No enrollment fee.
- You must use a network provider if there is one available in your area.
- Lock out rules apply for family members. 1
Costs
- You do not pay co-pays for outpatient or inpatient care.
- As costs change annually (fiscal or calendar year), go to the TRICARE Web site for up-to-date information.
- Your catastrophic cap is $1000 per fiscal year per family.
- If you use Prime network providers, your claims are filed for you.
- Medicare eligible family members with an Active Duty sponsor DO NOT have to have Medicare Part B. 4
Benefits
- Family members are eligible for the Extended Care Health Option (ECHO) benefit.
- Family members are entitled to free eye exams annually.
Enrollment
- You are no longer eligible for TRICARE Prime Remote-TPR is only for active duty and their family members.
- You will be disenrolled from TPR at the end of your active duty time; you and your family are then covered under TRICARE Standard/Extra.
Enrollment
- Is Prime available where I am going to retire?
- Is the doctor I want to see a Prime network provider?
- Have I submitted my completed Prime enrollment form, with payment, by the 20th of the month before my official retirement date to avoid a break in coverage? 1
- Have I decided on and set up a process to pay my enrollment fees (check, credit card, electronic fund transfer, allotment)? [You are always responsible for making payments, even if the bill doesn't arrive on time]
Costs
- If I seek specialty care without a referral, can I afford to pay the higher cost of Point of Service? 3
- Do I have a TRICARE Explanation of Benefits for any care I have received? If not, have I called my provider and the contractor to make sure my claims are being processed correctly?
Benefits
- Have I researched what other programs/providers are available to meet my family's members needs now that ECHO is no longer available to me?
- If I have Medicare eligible family members have I correctly purchased Part B? 4
TRICARE Prime Remote Web sites and Resources:
Plan
When You Are On Active Duty
When You Retire
Things To Consider
TRICARE STANDARD and EXTRA
Enrollment
- For other than active duty members and their family members not enrolled in Prime, TPR and Overseas programs.
- No enrollment required.
Costs
- You must use an authorized TRICARE provider. 5
- Certain procedures require prior authorization (see link below), otherwise the claim will be denied.
- There is an annual outpatient deductible and inpatient/outpatient cost shares; since many costs change annually (fiscal or calendar year), go to the TRICARE Web site for up-to-date information.
- You may be required to file your own claims.
- Your catastrophic cap is $1000 per fiscal year per family.
Benefits
- Family members are eligible for the Extended Care Health Option (ECHO) benefit.
- Medicare eligible family members with an Active Duty sponsor DO NOT have to have Medicare Part B. 4
Enrollment
- Unless you reenroll in Prime, you will be disenrolled from Prime and will be covered by Standard or Extra.
- No enrollment required.
Costs
- You must use a TRICARE-authorized provider. 5
- Certain procedures require prior authorization (see link below), otherwise the claim will be denied.
- There is an annual outpatient deductible and inpatient/outpatient cost shares; as many costs change annually (fiscal or calendar year), go to the TRICARE Web site for up-to-date information.
- You may be required to file your own claims.
- Your catastrophic cap is $3000 per fiscal year per family.
Benefits
- Family members no longer qualify for ECHO benefits.
- Medicare eligible retirees and family members MUST have Medicare Part B to retain TRICARE eligibility. 4
- Have I found the TRICARE-authorized (Standard/Extra) providers in the area where I am retiring?
- Before having any procedure done, did I check to see if I need a prior authorization? Did I ensure I had an authorization in place before scheduling my appointment?
- Do I have all the necessary paperwork to file my claim, including the proper claim form and supporting documents?
- If I or my family members are entitled to Medicare Part A, have I correctly purchased Part B in order to retain TRICARE eligibility? 4
TRICARE STANDARD and EXTRA Web sites and Resources:
Plan
When You Are On Active Duty
When You Retire
Things To Consider
TRICARE for Life/ Entitled to Medicare
[based on age, disability or end-stage renal disease (ESRD)]
- In general active duty family members do not use TRICARE for Life (TFL), because TFL requires enrollment in Medicare Part B regardless of the sponsor's status. 4
- Medicare Part B is not required for other TRICARE programs when the beneficiary has an Active Duty sponsor.
- Available to dual-eligible beneficiaries with Medicare Part A and Part B, regardless of age. 4
- Medicare eligible family members can enroll in Medicare Part B anytime while their sponsor is on active duty or in the first eight months following retirement without having to pay a surcharge for late enrollment.
- If the Part B coverage is not effective upon retirement of the sponsor, the Medicare eligible family member is not eligible for any TRICARE coverage.
- If you do not enroll in Medicare Part B during the 8 month Special Enrollment Period, you may enroll during the General Enrollment Period which occurs each year January through March, however, your Part B coverage will not be effective until July of the year you enroll and you will pay a 10 percent surcharge for each 12 month period that you were eligible to enroll, but didn't.
- Three months before your 65th birthday you will receive a letter from the Defense Manpower Data Center which will explain the requirements for maintaining your TRICARE benefits beyond age 65.
- There is no enrollment in TRICARE for Life, however, your DEERS record must be updated to reflect your entitlement to Medicare Part A and Part B. Take the letter you receive from the Social Security Administration, which contains the effective dates of Medicare Part A and Part B to an ID card facility to have your DEERS record updated. You do not need to wait to receive your Medicare card to update DEERS.
Entitled to Medicare (TRICARE for Life) Web sites and Resources:
Plan
When You Are On Active Duty
When You Retire
Things To Consider
TRICARE PHARMACY SERVICES
- Active Duty members have no pharmacy co-pays.
- Your family members pay for medications filled through the TRICARE Mail Order Pharmacy (TMOP), a TRICARE retail pharmacy, or a non-network pharmacy.
- You and your family members will pay for medications filled through TMOP, a TRICARE retail pharmacy, or a non-network pharmacy.
- Costs vary depending on the medication and where you get the prescription filled.
- Some medications require prior-authorization or have quantity limits.
- If you have other health insurance (OHI) with a pharmacy benefit, you cannot use TMOP unless you have exhausted your other pharmacy benefit or your OHI does not cover a particular medication.
- Have I registered to get my routine medications through the TRICARE Mail Order Pharmacy?
- Did I get an extra prescription, with refills from my provider, to send to the TMOP when I started on a new long-term medication(s)?
- Do I know what local pharmacies are TRICARE Network pharmacies for short term medications?
- Do I know if my medications are covered; have any special rules and how much they will cost?
TRICARE Pharmacy Web sites and Resources:
TRICARE DENTAL PROGRAM (TDP) and TRICARE RETIREE DENTAL PROGRAM (TRDP)
- You are covered as an active duty member with care through the military dental treatment facility or as authorized by Military Medical Support Office (MMSO).
- Family coverage is available for purchase through the TRICARE Dental Program.
- You and your family can now purchase coverage through the TRICARE Retiree Dental Program (TRDP).
- Premiums vary from location to location.
- You may have higher cost shares for covered services.
- The sponsor has to enroll for the family to enroll, unless certain requirements are met.
- Using a TRDP provider reduces your out-of-pocket costs.
- Retirees who enroll within 120 days of their retirement from active duty may be eligible to skip the 12-month waiting period for additional services.
- Do I know which dentists accept the TRICARE Retiree Dental Program insurance?
TRICARE Dental Program Web sites and Resources:
Footnotes
1 If enrolled in TRICARE Prime, you are enrolled for a period of up to 12-months and remain enrolled unless you take an action to disenroll, lose your eligibility status, or, if retired, are disenrolled for failure to pay the required enrollment fees. If disenrolled, you may be subject to the 12-month lock out period. This means that you may not be eligible to re-enroll in Prime for a 12-month period from the effective date of disenrollment.
2 If your application and payment are received by the 20th of the month, your Prime enrollment is effective on the first day of the next month. If it is received after the 20th of the month, your enrollment in Prime is not effective on the first day of the next month, but on the first day of the month after the next month (i.e, submit Jan 3, effective Feb 1; submit Jan 22, effective Mar 1).
3 Point of Service is an option under TRICARE Prime that allows enrollees the freedom to seek and receive non-emergent health care services from any TRICARE authorized civilian provider, in or out of the network, without requesting a referral from their primary care manager (PCM) or the health care finder (HCF). POS claims are subject to a deductible of $300 for an individual or $600 for a family, plus 50 percent cost-shares for outpatient and inpatient claims, and excess charges up 15% over the allowed amount. The 50 percent cost-share continues to be applied even after you meet the enrollment year catastrophic cap.
4 Medicare eligible family members can enroll in Medicare Part B anytime while their sponsor is on active duty or in the first eight months following retirement without having to pay a surcharge for late enrollment. If you do not enroll in Medicare Part B during the 8 month Special Enrollment Period, you may enroll during the General Enrollment Period which occurs each year January through March, however, your Part B coverage will not be effective until July of the year you enroll and you will pay a 10 percent surcharge for each 12 month period that you were eligible to enroll, but didn't.
5 An authorized TRICARE provider is a doctor or other individual providers of care, hospitals or suppliers who have been approved by TRICARE to provide medical care and supplies. Generally, this means the provider is licensed by the state, accredited by a national organization, or meets other standards of the medical community. If a provider is not authorized, they may be considered a non-payable provider and TRICARE cannot help to cost-share the charges.
For more information, contact your local health benefits advisor, beneficiary counseling and assistance coordinator, TRICARE service center or visit the TRICARE Web site at www.tricare.osd.mil .
See also: Retirees Web Site
TRICARE: The Basics Fact Sheet
Choosing TRICARE Standard Fact Sheet
TRICARE For Life Fact Sheet
TRICARE Plus Fact Sheet
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