Subtitle A. Health Care Services

Extend for one year the authorization for the Chiropractic demonstration

Directs DoD to terminate demonstration phase of the Chiropractic Demonstration Program (but continue same chiropractic care furnished during FY 2000), complete data collection and analysis, and submit the report to Congress by 1/31/00.

Directs SecDef to submit, by 3/31/00, a plan to implement chiropractic health services throughout the military health care system beginning in FY 2001 if recommended in the final report.

Incorporates House provision which allows SecDef to continue to provide domiciliary or custodial care to approximately 25 beneficiaries who have been receiving custodial care services through demonstration programs which are due to expire, and who would not be eligible for that care under DoD’s case management program. DoD will continue to pay for the cost of this care for these individuals.

Also adds Senate amendment that authorizes SecDef to continue to provide payment under CHAMPUS for domiciliary or custodial care to an eligible beneficiary that would otherwise be excluded from such coverage, and would prohibit SecDef from placing a time limit on the period during which the custodial care exclusions may be waived as part of the case management program. The amendment requires SecDef to conduct a survey of federally funded and state funded programs for the medical care and management of persons whose care is considered custodial in nature. Results are to be reported to Congress by March 31, 2000.

Benefit Levels: TRICARE is to provide "to the maximum extent practicable" benefits similar to the health care coverage available under similar health benefits plans offered under the FEHBP

Portability: Any covered beneficiary enrolled in the TRICARE program may receive benefits under that program at facilities that provide benefits under that program throughout the various TRICARE Regions (portability)

To take effect one year after date of enactment.

Requires SecDef to compare health care available through the TRICARE program with coverage available under similar plans offered under FEHBP. This report to be submitted to Congress NTL March 31, 2000.

Pre-Authorization Requirements: Authorization or certification requirements under TRICARE that impede access to benefits should be minimized "to the maximum extent practicable"

To take effect one year after date of enactment.

Under all new managed care contracts, SecDef shall eliminate requirements under TRICARE Prime that network primary care managers pre-authorize enrollees' preventive health care services within the managed care support network. These cases include: the receipt of preventive obstetric or gynecological services by a network provider;

mammograms performed by a network provider if the beneficiary is female over the age of 35;

preventive specialty urology care from a network urologist if the beneficiary is a male over the age of 60. SecDef is to develop these instructions by May 1, 2000 and implement them by Oct. 1, 2000.

Sect. 716. Improvement of Access to Health Care under TRICARE: Prohibits SecDef from requiring beneficiaries not enrolled in Prime to obtain a non-availability statement (NAS) or pre-authorization from an MTF to receive services from a civilian provider (unless SecDef demonstrates significant cost-avoidance for specific procedures at the affected MTFs, or determines maintaining a procedure at the MTF is needed to ensure health care providers' proficiency, or lack of NAS data would significantly interfere with TRICARE contract administration), or for care in specialized treatment facilities outside 200-mile radius of MTF.

(SecDef may require the beneficiary to provide appropriate notice to his/her primary care manager)

Both House provisions incorporated with Senate amendment directing SecDef to maximum extent practicable, minimize authorization and certification requirements for TRICARE beneficiaries and to require only one NAS to cover all health care services related to outpatient, pre-natal, delivery and postpartum subsequent to the visit that confirms the pregnancy.

Claims Processing Improvements: DoD should implement best business practices in claims processing, including electronic processing of claims "to the maximum extent practicable"

To take effect one year after date of enactment.

Within 6 months after enactment, SecDef must report to Congress assessing the effects of the implementation and whether implementation will result in compliance with best industry practices.

This provision directs SecDef to implement changes to the TRICARE claims processing system recommended by GAO to include:

-95% of all mistake-free claims must be processed NLT 30 days after submission to claims processor;

-100% of all mistake-free claims must be processed within 100 days of submission.

-SecDef may require that interest be paid on claims not processed within 30 days.

-These changes to be implemented within 6 months

-Allows a new managed care support contractor 9 mos after award before services must start.

-SecDef must submit a report w/in 6 months on:

status of claims processing backlogs; estimated time frame for backlog resolution; efforts to reduce the number of change orders for managed care contracts; extent of success in simplifying claims processing procedures; application of best industry practices on claims processing to include electronic processing; any other initiatives by DoD to improve processing.

This provision requires SecDef to allow TRICARE managed care contractors to provide financial incentives to health care providers who file claims electronically.

House provisions incorporated with Senate amendment that defines clean claim and requires SecDef to implement a system for processing TRICARE claims under which 95% of all clean claims must be processed within 30 days of receipt, and 100% processed within 100 days of receipt. Amendment also extends transition time for new TRICARE contracts from six months to nine months; and allows future TRICARE managed care contracts to provide financial incentives to health care providers to file claims electronically.

Reimbursement Rates: TRICARE providers may be reimbursed more than CHAMPUS Maximum Allowable Charge (CMAC) if necessary to ensure the availability of qualified health care providers –may not pay more than 115% of CMAC or the local usual and customary charge, whichever is less.

To take effect one year after date of enactment.

Third-Party Payer Collections: Allows MTFs as well as the US Government to collect third party payments and allows the method on which the recovery rates are to be determined to include amounts similar to TRICARE rates.

To take effect one year after date of enactment.

This provision allows DoD treatment facilities to bill third party payers on reasonable charges, based on current payment rates under CHAMPUS. Also expands the definition of "third-party payer" to match the definition of "any other insurance" under CHAMPUS double coverage program.

House provisions incorporated with Senate amendment that permits SecDef to reimburse TRICARE health care providers above CMAC if higher rates are necessary to assure availability of an adequate providers. MTFs may collect reasonable charges for care incurred on behalf of a covered beneficiary. Requires report to Congress NLT six months after enactment, that assesses the effects of the implementation of these requirements.

Expands the current Reserve Dental Program to make it a full service program like the Active Duty Dependents Plan; allows Individual Ready Reserve members not currently able to enroll in the Reserve Dental Program and dependents of all reservists to enroll in the Reserve Dental Program by paying the entire premium.

Allows SecDef to establish dental insurance plans for eligible members and dependents residing outside of the United States.

Extends the survivors benefit (one year of premium-free care) to the families of reservists if the family member is enrolled in the plan at the time of the member’s death.

Anyone currently enrolled in Prime who becomes Medicare eligible should be able to enroll in Senior Prime if they reside in a demonstration area (current rules only allow those enrolled in Prime at the MTF to "age-in")

Requires that each lead agent establish a full time beneficiary advocate with a toll free telephone line and each MTF establish such an advocate as at least a collateral duty. Positions to be established by January 15, 2000. Report language requires these positions and the telephone numbers to be aggressively marketed.

Senate provision incorporated with House amendment that changes designation of beneficiary advocate to beneficiary counseling and assistance coordinator.

Requires SecDef to institute a continuous enrollment demonstration program for the Uniformed Services Family Health Plans – SecDef may choose the designated providers and the areas covered. Plan is to commence on October 1, 1999 and end Sept. 30, 2001.

Senate provision incorporated, with House amendment that if fewer than all 7 of the USFHP sites were selected, selection of sites should be done randomly.

Allows SecDef to waive the TRICARE Standard deductible for the families of Guardsmen and Reservists recalled to active duty for over 30 days but less than one year.

All new managed care contracts must require TRICARE Prime network to provide health care concurrently to members of the Armed Forces in geographically separated units and their dependents in areas outside the catchment area of an MTF.

SecDef is to submit a report to Congress by May 1, 2000 on the extent and success of implementation of this requirement including reasons and circumstances that have prohibited implementation.

Greater weight shall be accorded to technical and performance-related factors than to cost and price related factors in determining best value for health care contracts in excess of $5,000,000.

Requires periodic DoD reports on efforts to improve management of military pharmacy system.

Requires DoD to:

-Establish uniform formulary by 10/1/00

-Require prior authorization for certain categories of drugs (e.g. high-cost injectable agents, high-cost biotech agents, agents with potential for inappropriate use, and others per SecDef;

-Establish procedures for beneficiaries to receive pharmaceuticals not on the uniform formulary, either by determination of clinical necessity, or by cost-sharing (if not justified by medical necessity).

(Grandfathers drugs provided to eligible beneficiaries before enactment, if the drugs are not on the list of preferred drugs.)

-Establish a Pharmaceutical and Therapeutics Committee to develop uniform formulary and oversee additions to the formulary. Committee to submit a proposed formulary within 90 days.

-Establish a Uniform Formulary Beneficiary Advisory Panel (including association reps) to review and comment on the development of the uniform formulary. SecDef must consider the panel’s comments before final implementation or revisions to formulary.

-Align financial resources so prescription cost is borne by the MTF or contractor responsible for the beneficiary's care.

-Implement Pharmacy Data Transaction Service in all pharmacy programs by April 1, 2000.

-Report to Congress by April 1 and Oct 1, 2001.

*** By April 15, 2001, submit to Congress a plan for expansion of the pharmacy benefit to Medicare-eligible uniformed services beneficiaries.

House provision incorporated with Senate amendment that allows SecDef to use a bid price modification in current managed care contracts to ensure equitable and timely reimbursement to managed care contractors for pharmaceuticals delivered in TRICARE retail pharmacies.

Requires inclusion of a drug in the uniform formulary unless the Pharmacy and Therapeutics Committee decides the drug is not needed (i.e. inclusion of all drugs with specific steps required to drop a drug, rather than exclusion of all drugs with specific steps required to include them). Also requires the Pharmacy and Therapeutics Committee to meet at least quarterly and consider for inclusion on the Uniform Formulary any drugs newly approved by the FDA.

Authorizes members to be ordered to active duty or retained on active duty for a period of more than 30 days to be treated for (or recover from) an injury, illness or disease incurred or aggravated in the line of duty. Also authorizes regular medical and dental care for the member and for the family members if the orders to active duty are for 30 days or more.

SecDef to establish a Department of Defense Center for Medical Informatics to develop ways to assess quality of health care information and to develop a capability for conducting research on quality of health care.

SecDef is also to establish a Medical Informatics Council to coordinate the development, deployment and maintenance of health care informatics systems.

$2 million is authorized for this purpose.

Senate provision incorporated with House amendment that requires DoD establish a program for medical informatics and data to accelerate efforts to automate, capture and exchange clinical data and present providers with clinical guidance using a personal identification carrier, clinical lexicon or digital patient record. SecDef is to establish a Medical Informatics Advisory Committee to advise SecDef on the development, deployment and maintenance of health care informatics systems for DoD. An annual report is to be submitted.