Families of some active-duty Reserve and National Guard members will get a break on paying annual deductibles associated with the military’s health care system, according to a final rule (http://edocket.access.gpo.gov/2008/E8-18597.htm) published 12 AUG in the Federal Register. The rule, which was proposed in AUG 06 and took effect on 12 AUG makes permanent the Defense Department’s authority to waive the annual TRICARE deductibles for eligible dependents of reservists and Guard members who are called to active duty for more than 30 days. It applies to those who choose to participate in TRICARE Standard or Extra, rather than TRICARE Prime. By law, the TRICARE Standard (or Extra) deductible for active-duty family members is $150 per individual and $300 per family each fiscal year. For those at the E-4 level and below, the deductibles are $50 per individual and $100 per family. Dependents are defined as spouses and children. In addition, the final regulation increases the amount that can be billed to out-of-network health care providers. “This helps reserve and Guard family members to be able to continue to see civilian providers with whom they have established relations and promotes access and clinically appropriate continuity of care,” the notice stated. The rule makes permanent authority exercised by Defense through the extension of a demonstration project. The fiscal 2005 National Defense Authorization Act gave the department that authority and waived certain TRICARE deductibles for active-duty members of reserve components. The Federal Register notice stated that an independent government estimate concluded that the annual cost for implementing the rule would be less than $30 million. [Source: GovExec.com Today 13 Aug 08 ++]

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The new form, available in the link below was developed to ease the claim processing in the Philippines for two different situations:

1. When an itemized bill/receipt/statement is needed to go along with a claim, but the provider cannot provide one.

2. When one of our beneficiaries has Other Health Insurance (OHI), but the OHI company does not, cannot or will not provide a statement of coverage and what was paid by the OHI.

This form has been reviewed, vetted and approved through the required HQ TRICARE departments as well as the contracting partner, WPS. It is the hope of Tricare Area Office – Pacific (TAO-P) that this form will help ease the claims processing when the above two situations occur. The form is available for download on the TAO-P website: http://tpaoweb.oki.med.navy.mil/, by clicking the button titled “TRICARE In The Philippines”. For questions call (81) 6117-43-2031/29 Camp Lester, Okinawa or email Tony.Ingram@med.navy.mil. [Source: Lt Col Tony Ingram, Chief, Program Operations, TAO-P msg. 11 Aug 08 ++]

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On 24 JUL the Beneficiary Advisory Panel (BAP) met to provide comments to the Department of Defense (DoD) Pharmacy and Therapeutics Committee’s (P&T Committee) recommendations on formulary status, pre-authorizations, and the effective date for a drug’s change from formulary to non-formulary status. Moving a drug to non-formulary status means it will still be available to beneficiaries, but usually at a higher price. It may also require medication authorization. Current and new drugs were reviewed during this meeting. BAP recommendations for drugs currently on the DoD Uniform Formulary are as follows:

Hydroxytryptamine (Triptans) drugs:

• sumatriptan (Imitrex), sumatriptan/naproxen (Treximet), eletriptan (Relpax), rizatriptan (Maxalt), zolmitriptan (Zomig) will be classified as formulary, and

• almotriptan (Axert), frovatriptan (Frova) and naratriptan (Amerge) will be non-formulary within a 90-day implementation period.

Osteoporosis Agents:

• alendronate (Fosamax), alendronate/vitamin D (Fosamax plus D), risedronate (Actonel), risedronate with calcium (Actonel with calcium), ibandronate (Boniva), raloxifene (Evista), teriparatide (Forteo), recombinant calcitonin (Fortical) will be maintained on the Uniform Formulary, and

• salmon-calcitonin (Miacalcin) will be placed on the non-formulary status within a 90-day implementation period.

Newly approved drugs by the Federal Drug Administration were considered by the BAP. Those recommended to be classified as non-formulary with a 60-day implementation period were:

• nebivolol (Bystolic) is used to treat hypertension,

• levocetirizine (Xyzal) is used to treat seasonal and perennial allergic rhinitis and chronic idiopathic urticaria,

• zileuton extended release (Zyfol CR) is used to treat asthma, and

• olmesartan/amlodipine (Azor) is used to treat hypertension.

New drugs that were recommended for formulary status were:

• fenofibrate meltdose (Fenoglide) is used for the treatment of hyperlipidemia and mixed dyslipidemia,

• simvastatin/niacin extended release (Simcor) is used for the treatment of hyperlipidemia,

• birmonidine/timolol maleate (Combigan) is used to reduce the increase intraocular pressure; aliskiren/H, and

• aliskiren/hysdrochlorothiazide (Tekturna HCT) is used for the treatment of hypertension.

Axert was placed on non-formulary status. For additional information on the recent BAP meeting, refer to www.tricare.mil/pharmacy/bap. [Source: NMFA e-News 29 Jul 08 ++]

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All Hands [7/1/08]

Edmund Chan, the Director of TMO Pacific has sent the following message to all Philippine Tricare users. Attached is the Tricare Philippine pamphlet for your future reference:

Dear Sirs,

I am writing this email to inform you about the establishment of a TRICARE Satellite Office in the Philippines and also to let you know about the newly established TRICARE rates that will go into effect on October 1, 2008. I know that you work with the Retirees on a frequent basis and may have newsletters, forums and other means to communicate with our Retiree beneficiaries and their families. If possible, kindly help us with reaching out to our Retirees with this information. I am attaching a letter that you can post and also our Philippines Retiree TRICARE brochure. Thank you for serving our Retirees and Happy Fourth of July.

Please let me know if you have any questions and also let us know how we can serve you better. V/R Ed Edmund Chan Director, TRICARE Area Office Pacific

Commercial: 011-81-611-743-2057

Voice Commercial: 011-81-611-743-2056

Fax DSN: 315-643-2057

PSC 482 Box 2749 FPO AP 96362

Dear TRICARE Beneficiaries,

I send you greetings from the TRICARE Area Office - Pacific in Okinawa, Japan. We are delighted to announce that we will be establishing a Philippines Satellite Office (hopefully by the end of the year) in Manila. Lt Col Tony Ingram and I are currently meeting with JUSMAGPHIL and the Department of State to negotiate space for our office. Once the office is set up, you will be able to call or visit the Philippines Satellite Office for help with your TRICARE issues and problems. More importantly, the Satellite Office will be my “boots on the ground” to help with improving the TRICARE program for you and our providers.

In the meantime, we will continue to support you from our Okinawa office. Please send us email at TPAO.CSC@med.navy.mil or call us at the numbers below:

Commercial: 81-611.743.2036

DSN: 315.643.2036 DSN FAX: 315.643.2037

Toll Free: 888-777-8343 Menu Option # 4

In the next few weeks, you will be receiving a letter from Wisconsin Physician Services (WPS) to inform you about the new Philippines rates that have been established to pay for inpatient (hospital) and outpatient care. These new rates will begin on October 1, 2008. The new rates were developed by the TRICARE Management Activity (TMA) office to replace the Puerto Rico caps that are currently used for outpatient services and for the inpatient daily rates in the Philippines. TMA used the World Bank International Comparison Program index for the Philippines to establish more reasonable rates to reflect costs in the Philippines.

Generally the new rate caps will be lower than the current caps, so it is important that you know what these rates are in order to avoid significant out of pocket costs. These rates will be published on the TRICARE

website: http://www.tricare.mil/tma/foreignfee/ - inpatient rates

are already listed (next page) and the outpatient rates will be listed soon.

Finally, I want to wish everyone a Happy Fourth of July and Mabuhay! I also want to thank the Retired Activities Offices (RAOs) and other contacts for your continued support with helping the retirees throughout the Philippines.

Sincerely,

Ed Chan

Director, TRICARE Area Office – Pacific

Philippines Inpatient

Per Diem Rates

Group

Number Description Current Allowed October 1, 2008

Amount Per Day

01 Infectious Disease $1,847 $1,144

02 Cancer $2,136 $1,196

03 Endocrine $2,119 $1,141

04 Mental Health $909 $395

05 Nervous System $1,906 $1,027

06 Circulatory $3,044 $1,769

07 Respiratory $1,828 $916

08 Digestive $1,888 $1,009

09 Genitourinary $1,980 $1,152

10 Pregnancy and birth $1,076 $555

11 Musculoskeletal and Skin $3,079 $1,998

12 Congenital anomalies $2,916 $1,657

13 Perinatal $731 $333

14 Symptoms, signs, etc. $1,950 $1,080

15 Injuries $2,246 $1,249

16 Poisoning $1,801 $1,069

17 Complications $2,333 $1,403

18 V-codes $1,640 $966

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A former health care executive was sentenced 17 JUN to five years in prison for helping his Philippines-based company swindle nearly $100 million from the U.S. military health insurance program. Thomas Lutz, 41, said in federal court he took responsibility for the six-year scheme in which Health Visions Corp. bilked $99.9 million from the military’s Tricare program through inflated and fraudulent claims. U.S. District Judge Barbara Crabb said the five-year sentence was modest given the extent of the fraud, but it was the longest she could impose under Lutz’s plea deal. Health Visions and Lutz were initially charged in a 75-count indictment in 2005. He pleaded guilty in 2006 to a single count of conspiracy to pay kickbacks and agreed to cooperate with prosecutors, a deal Crabb called “a huge break” for Lutz. “It’s just horrifying that you were able to take as much money as you did,” Crabb told Lutz. Prosecutors said the company routinely inflated claims by more than 230%, operated a phony insurance program and billed for medical services never delivered.

Read the rest of this entry »

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Most Tricare users are aware that Tricare by law is always the last payer over any other type of medial care insurance (including Medicare) that a user has. However, this does not apply to Medicaid. Medicaid is essentially a welfare program, providing medical benefits for people under various state welfare programs (such as Aid to Families with Dependent Children) or who qualify by reason of being determined to be “medically indigent” based on a means test. Congress enacted P.L. 97-377 with the intent that no class of Tricare beneficiary should have to resort to welfare programs; therefore, Medicaid was exempted from these double coverage provisions. Whenever a Tricare beneficiary is also eligible for Medicaid, Tricare is always the primary payer. Medicaid can supplement Tricare. [Source: Washington Times Sgt Shaft article 19 May 08 ++]

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Budgetary rules forced a House subcommittee to take the unprecedented step of creating a new Tricare preventive health care program that does not apply to 1.5 million Medicare-eligible retirees and their families in the Tricare for Life (TFL) program. Rep. Susan Davis (D-CA), chairwoman of the House Armed Services military personnel panel, said the plan, approved 7 APR as part of the 2009 defense authorization bill, is aimed at cutting the military’s long-term health care costs by providing preventive care. The personnel portion of the defense policy bill, approved by voice vote and with no debate, includes:

• A 3.9 percent military pay raise.

• Increases in Army and Marine Corps active-duty personnel and in Army National Guard and Army Reserve support personnel on full-time active duty.

• A tuition assistance program for military spouses.

• Permission for a Pentagon-proposed experiment under which active-duty members could take a break of up to three years in their military career.

Davis said her subcommittee rejected a Pentagon request for a $1.2 billion increase in Tricare health and pharmacy fees but wants to look for other ways to hold down costs, which is why expanding preventive care is attractive. She called the initiative “preferable” to the Pentagon’s proposed increase in Tricare fees. The preventive care plan would waive co-payments for certain treatments such as vaccinations, smoking cessation help, and breast and colorectal cancer screening. It would apply to Tricare Standard, Tricare Select and Tricare Reserve beneficiaries — but, because of budgetary procedures, not TFL. Aides named two areas in which TFL beneficiaries would be treated differently than other Tricare users: shingle vaccinations and MRIs for mammograms. Younger retirees would receive these services for free, but TFL users would have to pay, either directly or by buying supplemental Medicare insurance, aides said. Rep. John McHugh of New York, the subcommittee’ s ranking Republican, said this would be the first instance of differences in what is covered under Tricare, and also promised to work to try to find funding to offset that action.

There are two kinds of spending in the defense budget: discretionary, which applies to personnel, operating and acquisitions costs and construction programs; and mandatory, also known as direct spending, for programs such as retired pay, GI Bill benefits for reservists, and some health care expenses, including TFL. Davis said only congressional leaders can resolve the funding problem because direct spending involves programs such as Social Security, Medicare, Medicaid and federal civilian retired pay that fall outside the jurisdiction of the armed services committee. Congressional leaders could agree to an offset by cutting other direct spending or could find another way to fund preventive care, subcommittee aides said. Steve Strobridge, government relations director for the Military Officers Association of America, said he understands the dilemma facing the subcommittee and agrees that what they did “is certainly preferable to not doing anything.” “We have been very supportive of preventive care programs,” he said. “It only makes common sense that if you come up with programs like smoking cessation that it is going to save money in the long run.” [Source: NavyTimes Rick Maze article Posted 7 May 08 ++]

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Every year, the federal government tweaks the elaborate system that determines the amount doctors get paid for care and procedures, known as “reimbursement rates”. Those changes, in turn, translate into changes in cost shares, or co-pays, for Tricare beneficiaries. Payment for inpatient hospital stays in specified locations outside the 50 United States and the District of Columbia, are made utilizing the lesser of (a) billed charges or (b) the prospectively determined per diems adjusted by a country specific index (CSI). The per diem rates are developed into reimbursement groupings by utilizing diagnosis codes as contained in the International Classification of Diseases, 9th Revision, and Clinical Modification (ICD-9-CM). The per diem rates are the maximum allowable amounts that Tricare shall reimburse and the amount on which patient cost-shares are calculated. The National U.S. per diem rate is multiplied by a unique CSI factor which adjusts the National U.S. per diems for the applicable country. The country specific hospital per diem, for those specified locations outside the 50 United States and the District of Columbia is the product of the National U.S. per diem and the CSI. This payment system applies to all hospitals providing hospital inpatient services and professional provider reimbursements in the Philippines, Panama, and other overseas areas as designated by the Government.

The CSI is a factor obtained from the World Bank’s International Comparison Program. The index factor is based on a large array of goods and services or market basket within the specific country which is then standardized and weighted to a U.S. standard and currency. The use of the CSI enables a conversion and therefore creates parity between the U.S. and the specific country in the purchasing of the same amount and type of medical services. Tricare is utilizing a two year phase in approach for the implementation of the World Bank’s International Comparison Program CSI. Per change 77 dated 7 APR 08 to the Tricare Reimbursement Manuel for the Philippines and Panama, the first year of the CSI phase in has been set at 0.52 and 0.70 through 28 FEB 08. The second year of the CSI phase in has been set at 0.229 for the Philippines and 0.60 for Panama effective 1 MAR 09. However, their is a requirement that all providers that submit bills to Tricare and are effected by the changes must be given at least 100 days notice so it is likely that the changes will not take effect until AUG 08 and AUG 09 respectively. The change equates to a 27.1point index reduction (52%) for the Philippines and a 10 point index reduction (15%) for Panama assuming nothing is done to reverse these reductions. For additional info refer to http://manuals.tricare.osd.mil. [Source: Tricare Reimbursement Manual 6010.55-M w/Change 77 Chap 1 Sect 34 & 35dtd 7 Apr 08 ++]

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Coming soon to TRICARE4u.com

In July, 2008, Wisconsin Physicians Service (WPS) and TRICARE4u.com is proud to present to our valued TDEFIC and Foreign Providers a new feature that will provide claims processing information on a weekly basis to you as a registered Provider.

Every Monday morning you will receive an e-mail reminding you to check the web site for your claims information along with a link to the TRICARE4u web site for your convenience. Simply log-in to your account with your username and password. Once you log-in, you will have access to all of the claims processing information for the previous week on an easy to read report. For your convenience, you will have the ability to download this report into an Excel format. The report will not only provide you with the previous week s claims information, but also access to up to three weeks prior.

The new web service will provide you with the following advantages:

No need to call TRICARE Customer Service to find the status of claims. This information will be provided in the report Save time, money, and resources
Receive timely and accurate claims processing information without any effort on your end.

Ability to print off up to 4 weeks worth of claims information for your records. The report will provide you with the following TRICARE for Life and Foreign claims processing information:

In-processing Claims Information
Processed Claims with information showing if a check has been generated
Denied Claims with a link to the claim detail so you can find out why the claim was denied

We invite you to take advantage of this new free service being provided by WPS and TRICARE4u.com at a computer near you in July, 2008. We look forward to hearing your feedback as we strive to provide you with excellent service in return for the service that you provide to our beneficiaries.

Thank you for your time and we look forward to working with you in the future!

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