May 2, 2016

 On April 12, the Defense Health Agency (DHA) released details of a congressionally mandated three year pilot program that will determine if the requirement to obtain a referral influences where TRICARE beneficiaries seek care for non-emergency conditions. Specifically, the law directs the DHA to implement a pilot that allows TRICARE beneficiaries to access urgent care centers without pre-authorization.

Currently, DHA requires that TRICARE Prime enrollees obtain a referral for primary or urgent care if they seek that care from someone other than their primary care manager. Because seeking emergency care in an emergency department does not require authorization and because access to primary health care for acute episodic primary care continues to be in high demand, TRICARE enrollees often seek care in the emergency department for non-emergent reasons at a higher cost to the system.

Under the pilot:

  • TRICARE Prime enrollees within the 50 United States or the District of Columbia and TRICARE Overseas Program (TOP) enrollees traveling/seeking stateside care will be allowed to self-refer, without an authorization, to a TRICARE network provider or TRICARE-authorized UCC provider, for urgent care.
  • TRICARE Prime enrollees will be allowed two unauthorized urgent care visits per fiscal year, per individual, including services provided when the enrollee is out of their enrollment area. Overseas enrollees seeking stateside urgent care will not be held to the two visit cap.
  • For these unauthorized urgent care visits, no point of service deductibles and cost shares shall apply.
  • Urgent care accessed via a nurse advice line recommendation that leads to a primary care manager referral shall not be counted against the two allowable self-referred visits.

UCAOA is in the process of acquiring details on how DHA will authorize urgent care center providers under the pilot. However, what is known is that for referral authorizations to be waived, providers from which the TRICARE beneficiary seeks care must have one of the following primary specialty designations:

  • Family Practice;
  • Internal Medicine;
  • General Practice;
  • Pediatrician; and
  • Urgent Care Clinics or Convenience Clinics

Obstetricians/gynecologists, physician assistants, nurse practitioners, and certified nurse midwives can be considered primary care providers and may be designated primary care managers.

The pilot will begin May 23, 2016, and will continue until May 23, 2019.

Last year,  UCAOA lobbied Congress in support of the urgent care pilot and met with DHA officials in January. To read about it, see the original post on the UCAOA website.