National Defense Authorization Act NDAA -02 Initiatives

1. 1 National Defense Authorization Act (NDAA) -02 Initiatives TRICARE Management Activity Barbara Gallegos Good morning and welcome to the brief on the National Defense Authorization Act 2002 Initiatives. Before I begin I would like to introduce Mr. Howard Altschwager an Attorney with TMA Office of General Counsel who has work closely with TMA staff on each of these issues. This session is a workshop with questions welcome as I cover each of the topics. Good morning and welcome to the brief on the National Defense Authorization Act 2002 Initiatives. Before I begin I would like to introduce Mr. Howard Altschwager an Attorney with TMA Office of General Counsel who has work closely with TMA staff on each of these issues. This session is a workshop with questions welcome as I cover each of the topics.

2. 2 Overview Home Health Agency - PPS Skilled Nursing Facility - PPS Change in Definition of Custodial Care Extended Care Health Option Elimination of Non-Availability Statements In addition to the topics I am covering I would like to bring your attention additional sessions that cover some of these topics in more detail: Reserve Health Care session on Tuesday from T203 1400-1450 (TAMP) Providing Services to Our Most Vulnerable Beneficiaries W502 1030-1120 (ECHO) and a session on one of the initiatives that I will not be covering which is the Prime Travel/Non-Medical Attendant Benefits W203 1400-1450In addition to the topics I am covering I would like to bring your attention additional sessions that cover some of these topics in more detail: Reserve Health Care session on Tuesday from T203 1400-1450 (TAMP) Providing Services to Our Most Vulnerable Beneficiaries W502 1030-1120 (ECHO) and a session on one of the initiatives that I will not be covering which is the Prime Travel/Non-Medical Attendant Benefits W203 1400-1450

3. 3 Overview Augmentative communication devices Hearing aids Durable medical equipment Rehabilitative therapy Transitional assistance management program

4. 4 Home Health Agency - PPS Scope Mirrored after Medicare’s HHA - PPS Part-time or intermittent skilled nursing care Part-time or intermittent services of home health aide Other services included are medical supplies, PT, OT, ST etc. DME & osteoporosis drugs as well as other drugs are payable outside the PPS Home Health Agency must be Medicare certified and sign a participation agreement Beneficiary must be confined to home Enhances the current benefits in the home by covering home health aides. Makes the home health benefit the same as Medicare limiting DOD’s liability with Tricare for Life beneficiaries. Intermittent is 28 to 35 hours per week. Confined to home is Medicare’s definition, however it has been adapted by Tricare to allow attendance at school which would be analogous to Medicare’s provision to allow attendance at an adult day care program. Also allowed is leave for services that are infrequent or short duration e.g. trip to barber, a drive.Enhances the current benefits in the home by covering home health aides. Makes the home health benefit the same as Medicare limiting DOD’s liability with Tricare for Life beneficiaries. Intermittent is 28 to 35 hours per week. Confined to home is Medicare’s definition, however it has been adapted by Tricare to allow attendance at school which would be analogous to Medicare’s provision to allow attendance at an adult day care program. Also allowed is leave for services that are infrequent or short duration e.g. trip to barber, a drive.

5. 5 Home Health Agency- PPS Reimbursement Case-mix and wage-adjusted 60 day episode of care Derived from the OASIS (Outcome Information Assessment Set) completed by the home health agency 18 & under and/or maternity care require abbreviated assessment, 23 items to generate a HIPPS code for payment Updated each fiscal year Implementation With the T-Nex contracts HIPPS stands for Health Insurance Prospective Payment System. For those interested in more detail, an Interim Final rule was published June 13, 2002, Vol. 67, No. 114 page 40597.HIPPS stands for Health Insurance Prospective Payment System. For those interested in more detail, an Interim Final rule was published June 13, 2002, Vol. 67, No. 114 page 40597.

6. 6 Skilled Nursing Facility - PPS Scope Mirrored after Medicare, exception benefit is not limited to 100 days Requires a 3 day consecutive day prior hospitalization Must be admitted within 30 days after discharge from hospital Skilled services must be for a medical condition that was treated during the 3 day hospitalization This legislation moved the SNF benefit from billed charges to Medicare’s prospective payment system which makes it easier to process Tricare for Life claims on a secondary basis. Because we have not limited the Tricare benefit to 100 days, once the Medicare limit is exhausted, Medicare/Tricare eligibles would be eligible to receive additional SNF care. Please note this is not long term care or assisted living.This legislation moved the SNF benefit from billed charges to Medicare’s prospective payment system which makes it easier to process Tricare for Life claims on a secondary basis. Because we have not limited the Tricare benefit to 100 days, once the Medicare limit is exhausted, Medicare/Tricare eligibles would be eligible to receive additional SNF care. Please note this is not long term care or assisted living.

7. 7 Skilled Nursing Facility - PPS Scope (cont’d) Skilled nursing facility must be Medicare certified and sign a participation agreement Reimbursement Adopting Medicare’s SNF - PPS per diem covering all routine, ancillary and capital costs Based on a resident assessment using the standardized Minimum Data Set (MDS) Signing a participation agreement prevents balance billing of our beneficiaries. Decision has been made to accept Medicaid certification for pediatric SNFs. Signing a participation agreement prevents balance billing of our beneficiaries. Decision has been made to accept Medicaid certification for pediatric SNFs.

8. 8 Skilled Nursing Facility - PPS Reimbursement (cont’d) RUG grouper converts the resident specific data into a case-mix classification 44 RUGs (Resource Utilization Groups) Each RUG for the per diem payment is the sum of 3 parts - nursing, therapy and non-case-mix PPS does not apply to children under 10 (pay as billed or negotiated rate) Status Implementation is scheduled for August 2003 For those interested in more detail, the SNF-PPS was also published in the Interim Final rule of June 13, 2002, Vol. 67, No. 114 page 40597. Implementation is on schedule. For those interested in more detail, the SNF-PPS was also published in the Interim Final rule of June 13, 2002, Vol. 67, No. 114 page 40597. Implementation is on schedule.

9. 9 Change in the Definition of Custodial Care Prior to change Definition focused on the condition of the patient, limiting medically necessary services After change Definition focuses on the treatment or services that can be rendered safely and reasonably by a person who is not medically skilled; or Is or are designed mainly to help the patient with the activities of daily living Prior to the change, if the beneficiary was determined to be custodial, the benefit was limited to one hour per day of skilled nursing care, and up to 12 physician visits per calendar year. This change in definition was a result of Tricare’s experience under the Individual Case Management Program for Persons with Extraordinary Conditions, commonly referred to as the ICMP-PEC program. The purpose of this program was to provider a waiver process to cover medically necessary skilled services when the beneficiaries condition met the custodial care definition. It was soon recognized that if the definition of custodial care was changed there would be no need for the waiver program. New definition in line with industry definition.Prior to the change, if the beneficiary was determined to be custodial, the benefit was limited to one hour per day of skilled nursing care, and up to 12 physician visits per calendar year. This change in definition was a result of Tricare’s experience under the Individual Case Management Program for Persons with Extraordinary Conditions, commonly referred to as the ICMP-PEC program. The purpose of this program was to provider a waiver process to cover medically necessary skilled services when the beneficiaries condition met the custodial care definition. It was soon recognized that if the definition of custodial care was changed there would be no need for the waiver program. New definition in line with industry definition.

10. 10 Implementation Custodial care transitional policy effective December 28, 2001 (MCSCs not–at–risk) Implemented July 31, 2002 Change in definition (MCSCs at-risk) With implementation of SNF - PPS in August of 2003 With implementation of HHA - PPS (T-NEX contracts) Change in the Definition of Custodial Care To quickly implement we changed our contracts with the Managed Care Support Contractors to reimburse the additional medically necessary skilled care on a not-at-risk basis (pass through costs). To quickly implement we changed our contracts with the Managed Care Support Contractors to reimburse the additional medically necessary skilled care on a not-at-risk basis (pass through costs).

11. 11 Extended Care Health Option (ECHO) Scope Name change and enhancement of the Program for Persons with Disabilities Discretion to Increase the monthly government cost share to $2,500 Create a comprehensive home health care benefit not subject to the $2,500 CAP which includes coverage of respite and custodial care Add a respite care benefit Only available to dependents of active duty with a qualifying condition Legislation was provided to enhance the current Program for Persons with Disabilities. We are proposing to change the name to Extended Care Health Option (ECHO). Benefit is currently limited to $1,000 per month. To enhance readiness we are proposing the comprehensive home health care benefit under ECHO. Respite care is short-term care for a patient in order to provide rest and change for those who have been caring for the patient at home, usually the patient’s family. There is no change in eligibility for program, it is only available to active duty family members.Legislation was provided to enhance the current Program for Persons with Disabilities. We are proposing to change the name to Extended Care Health Option (ECHO). Benefit is currently limited to $1,000 per month. To enhance readiness we are proposing the comprehensive home health care benefit under ECHO. Respite care is short-term care for a patient in order to provide rest and change for those who have been caring for the patient at home, usually the patient’s family. There is no change in eligibility for program, it is only available to active duty family members.

12. 12 Implementation A proposed rule is being drafted Benefits available sometime after the implementation of the T-NEX contracts Extended Care Health Option (ECHO)

13. 13 Elimination of Non-Availability Statements Scope Requires the elimination of non-availability statements by December 28, 2003, with the exception of mental health Except for maternity, the Secretary has the authority to waive the NAS elimination requirement if Significant cost would be avoided by performing specific procedures at the affected MTFs

14. 14 A specific procedure must be provided at the affected MTFs to ensure the proficiency levels of the practitioners; or The lack of NAS data would significantly interfere with TRICARE contract administration Status Maternity NASs will be eliminated on December 28, 2003 unless DOD is given a legislative relief Med/Surg NASs will be eliminated on December 28, unless a waiver is granted until T-NEX Elimination of Non-Availability Statements Does require an Interim Final rule to be published to eliminate the NAS requirements.Does require an Interim Final rule to be published to eliminate the NAS requirements.

15. 15 Augmentative Communication Devices Scope Provides coverage for ACDs as voice prostheses ACDs are commonly known as speech generating devices TRICARE benefit will be similar to Medicare Implementation After T-NEX award Proposed rule currently in coordination Speech generating devices are characterized by: Being a dedicated speech device, used solely by the individual who has a severe speech impairment; May have digitized speech output, using pre-recorded messages, less than or equal to 8 minutes recording time; May have synthesized speech output, which requires message formulation by spelling and device access by physical contact with the device-direct selection techniques; May have synthesized speech output, which permits multiple methods of message formulation and multiple methods of device access; or May be software that allows a laptop computer, desktop computer or personal digital assistant (PDA) to function as a speech generating device. Examples of devices that do not meet the above definition and are excluded are: Devices that are not dedicated speech devices, can run a word processing package, an accounting program or perform other non-medical functions. Laptop computers, desktop computers, or PDAs, which may be programmed to perform the same function as a speech generating device, not primarily medical in nature and would not meet coverage requirements. A device that is useful to someone without severe speech impairment is not considered an SGD. Speech generating devices are characterized by: Being a dedicated speech device, used solely by the individual who has a severe speech impairment; May have digitized speech output, using pre-recorded messages, less than or equal to 8 minutes recording time; May have synthesized speech output, which requires message formulation by spelling and device access by physical contact with the device-direct selection techniques; May have synthesized speech output, which permits multiple methods of message formulation and multiple methods of device access; or May be software that allows a laptop computer, desktop computer or personal digital assistant (PDA) to function as a speech generating device. Examples of devices that do not meet the above definition and are excluded are: Devices that are not dedicated speech devices, can run a word processing package, an accounting program or perform other non-medical functions. Laptop computers, desktop computers, or PDAs, which may be programmed to perform the same function as a speech generating device, not primarily medical in nature and would not meet coverage requirements. A device that is useful to someone without severe speech impairment is not considered an SGD.

16. 16 Hearing Aids Scope For active duty family members only Coverage shifted to the Basic Program Profound hearing loss Separate thresholds for children and adults Implementation After T-NEX award Proposed rule currently in coordination Child as defined in 32 CFR 199.3 unmarried etc. No industry standard for profound hearing loss, so Tricare has developed a definition which will be subject to comment in our proposed rule. Child threshold 26dB HL or greater hearing threshold level in one or both ears when tested in the frequency range at 500, 1,000, 2,000, 3,000 or 4,000 Hz Adult threshold 40 dB HL or greater in one or both ears when tested at 500, 1,000, 1,500, 2,000, 3,000, or 4,000Hz or 26 dB HL or greater in one or both ears at any three or more of those frequencies; or a speech recognition score less than 94% dB HL stands for decibel hearing loss Child as defined in 32 CFR 199.3 unmarried etc. No industry standard for profound hearing loss, so Tricare has developed a definition which will be subject to comment in our proposed rule. Child threshold 26dB HL or greater hearing threshold level in one or both ears when tested in the frequency range at 500, 1,000, 2,000, 3,000 or 4,000 Hz Adult threshold 40 dB HL or greater in one or both ears when tested at 500, 1,000, 1,500, 2,000, 3,000, or 4,000Hz or 26 dB HL or greater in one or both ears at any three or more of those frequencies; or a speech recognition score less than 94% dB HL stands for decibel hearing loss

17. 17 Durable Medical Equipment (DME) Scope Provides a definition for DME Currently provide coverage in accordance with the definition Implementation After T-NEX award Proposed rule currently in coordination Definition is any durable medical equipment that can improve, restore, or maintain the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient’s function or condition. Coverage includes customization of the beneficiary owned equipment. Must be ordered by a physician and meet the definition of DME.Definition is any durable medical equipment that can improve, restore, or maintain the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient’s function or condition. Coverage includes customization of the beneficiary owned equipment. Must be ordered by a physician and meet the definition of DME.

18. 18 Rehabilitative Therapy Scope TRICARE considers rehabilitative therapy as physical therapy, occupational therapy and speech therapy Coverage is all medically necessary and appropriate therapy in connection with a specific medical condition which is not custodial Program is currently in compliance with this coverage Custodial meaning that the services could safely and reasonably be provided by person who is not medically skilled or the services are not activities of daily living.Custodial meaning that the services could safely and reasonably be provided by person who is not medically skilled or the services are not activities of daily living.

19. 19 Implementation After T-NEX award Proposed rule currently in coordination Rehabilitative Therapy

20. 20 Transitional AssistanceManagement Program Scope Makes permanent the authority for transitional health care Deleted coverage for dependents of those eligible for transitional coverage (Department created a Demonstration so coverage was not lost) Extended coverage to 60 days for those with less than six years of active service

21. 21 Scope (Cont’d) Extended coverage to 120 days for those with six years or more of active service Implementation DEERS has updated their system to reflect the correct eligibility time frames Proposed rule in coordination to add the new provisions and the NDAA03 technical language adding the dependents eligibility TRICARE Manuals will be updated with T-NEX Transitional AssistanceManagement Program As I mentioned Reservists health care issues are being discussed in a separate track. As you can see from this presentation, Tricare is a dynamic program, constantly changing to meet the needs of our military families.As I mentioned Reservists health care issues are being discussed in a separate track. As you can see from this presentation, Tricare is a dynamic program, constantly changing to meet the needs of our military families.