Coordination of military health system and IDEA programs

>From the web page
http://www.fed-icc.org/policy/index.htm

TRICARE and IDEA Part C: A Guide to Services

This guide was developed to address questions
about the interface between the military health system and the 
Infants and Toddlers with Disabilities Program (Part C) of the 
Individuals with Disabilities Education Act.  The guide has been 
approved for distribution by both the Departments of Defense and 
Education. Specific questions regarding coverage in particular 
situations should be address to the respective Departments.

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>From the Microsoft Word document
http://www.fed-icc.org/policy/Joint-Document-091900.doc

INTRODUCTION

This guide was developed by the Federal Interagency Coordinating
Council (FICC), which advises the Secretaries of Education,
Defense, and other federal agencies, on coordinating federal
programs and policies affecting services to children ages birth
to three with disabilities.  At the request of the FICC, the
Department of Defense (DoD) task force developed this document to
address questions about the interface between the DoD military
health system and the Infants and Toddlers with Disabilities
program (Part C) of the Individuals with Disabilities Education
Act (IDEA).

Prior to the 1997 Amendments of IDEA, there was a question
between the IDEA and TRICARE/CHAMPUS related to which program was
the "payor of last resort" for young children with disabilities
and their families.  In 1997, Congress amended Part C to state
that IDEA Part C is payor of last resort "for services that would
have been paid for from another public or private funding source,
including any medical program administered by the Secretary of
Defense...".  Congress thus clarified that TRICARE "pays first"
for services that are otherwise eligible for reimbursement by
TRICARE.  This guide is intended to provide general information
primarily for administrators of these two programs and families
of infants and toddlers with disabilities.

This guide includes: 
(1) a brief description of Part C; 
(2) a chart indicating the availability of TRICARE coverage for
early intervention services; 
(3) frequently asked questions about TRICARE programs; and 
(4) references.


DISCLAIMER

The information presented in this document is based upon relevant
United States statutes and material obtained from the respective
Department regulations and policies.  The respective Departments
are solely responsible for its content.

This document contains a general summary of complex coverage
rules.  Specific questions regarding coverage in particular
situations should be addressed to the respective Departments.

Further, while this document has been approved for distribution
by both Departments, it does not provide a factual determination
regarding benefits in individual cases and does not supersede
official TRICARE regulations and policies.

This document is subject to change only with prior authorization
of the Departments of Defense and Education.

FEDERAL INTERAGENCY COORDINATING COUNCIL

The Federal Interagency Coordinating Council (FICC) was created
in the 1991 Amendments to the Individuals with Disabilities
Education Act (IDEA).  Congress intended for the FICC to be a
model for States with respect to coordination of policies,
development of technical assistance initiatives, and performance
of other functions necessary to achieve the objectives of Part C
(birth through 2 year olds and their families) and section 619 (3
through 5 year olds) of the IDEA.  Both of these programs provide
financial support to States for the implementation of services
for young children with disabilities.

The FICC was originally established to advise and assist the
Secretary of Education on matters related to services for infants
and toddlers with disabilities and their families.  Later, the
scope of the FICC's purview was expanded to include
preschool-aged children.  The purposes of the FICC are:  
(1) minimizing duplication across public agencies which provide
services to infants and toddlers with disabilities and their
families; (2) ensuring coordination of technical assistance; 
(2) ensuring coordination of early intervention and preschool
services; 
(3) identification of gaps in program and services across
agencies; and 
(4) identifying barriers to cross-agency coordination of services
for these children and their families. 

The FICC is charged with the following tasks:  
(1) advise and assist the respective Secretaries in the
performance of their responsibilities related to children from
birth through age 5 who are eligible for services under the IDEA;

(2) conduct policy analyses of Federal programs related to this
age group in order to determine areas of conflict, overlap,
duplication, or inappropriate omission; 
(3) identify strategies to address these issues; 
(4) develop and recommend joint policy memoranda concerning
interagency collaboration, including modifications to
regulations, and elimination of barriers to interagency programs
and activities; 
(5) coordinate technical assistance and dissemination of
information on best practices, effective coordination strategies,
and recommendations for improved services to young children, and 
(6) facilitate activities in support of State's interagency
coordination efforts.

The 1993 Amendments to IDEA broadened the FICC's advisory
responsibilities to include the Secretaries of Health and Human
Services, Agriculture, Defense and Interior and the Commission on
Social Security.  Additionally, the specific FICC membership
categories were also expanded in statute, and include
representation from Federal agencies, State and local service
providers, and family member consumers.  These individuals serve
at the pleasure of the Secretary of Education. The FICC is
chaired by the Assistant Secretary of the Office of Special
Education and Rehabilitative Services and co-chaired by a family
member.

CONTENTS

Overview of Programs

Individual with Disabilities 
Education Act (IDEA)     - Infants and Toddlers with Disabilities
(Part C)

Department of Defense    - TRICARE

Department of Defense    - Program for Persons with Disabilities
(PFPWD)

Department of Defense    - Early Intervention Programs

Department of Defense    - Exceptional Family Member Program
(EFMP)

Overview of TRICARE and PFPWD Coverage for Part C Services

Frequently Asked Questions about the Military Health System

Process for Accessing the Military Health System 

References

September 20, 1999 letter from Dr. H. James T. Sears to Judith E.
Heumann regarding TRICARE services for children with autism.


OVERVIEW OF PROGRAMS

PART C OF INDIVIDUALS WITH DISABILITIES EDUCATION ACT*
* 20 USC 1431-1445; 34 CFR Part 303.
Purpose: 
Enhance the infant's or toddler's development and the family's
capacity to meet their child's developmental needs.

Eligible Group: 
Children from birth through age two who - 
* have diagnosed mental or physical condition that has a high
probability of resulting in a developmental delay, or
*  are experiencing developmental delays, as defined by the
State, in one or more  developmental areas ( cognitive; physical,
including vision and hearing; communication; social; emotional,
adaptive), or
* at State discretion, are at risk of having substantial
developmental delays if early intervention services are not
provided

Eligibility:  
Varies by state due to unique state definition of developmental
delay.  See               
http://www.nectas.unc.edu/pubs/pubslist1.html#state

Requirements:   
State agency must:
(  have a child find system to seek-out children in need of
services,
(  provide an assessment of the child and family at no cost to
the family,
(  complete assessments and develop an Individual Family Service
Plan (IFSP) to
                address family needs as well as child's needs
within 45 days of referral of a child, and 
(  provide services in natural environments.

Services:   
Pages 5 through 13 provide a description of early intervention
services

Availability:  
All states receive Part C funds and have statewide services.  For
a listing of state contacts, see
http://www.nectas.unc.edu/contact/ptccoord.html

Financing of Services:
(  combined state and federal funding
(  states required to coordinate sources of funding
(  Part C is payor of last resort against TRICARE, Medicaid,
private insurance and other
    sources

TRICARE
The Department of Defense provides a Military Health System (MHS)
known as TRICARE.  It is a regionally managed health care program
that combines the military's direct health care system of
hospitals and clinics with a network of civilian health care
professionals to provide improved access and high quality health
care services.  TRICARE consists of three options:

(  TRICARE Prime    a Health Maintenance Organization-like option
(  TRICARE Extra    a fee-for-service option with reduced
cost-shares
(  TRICARE Standard a fee-for-service option with deductibles and
cost-shares; was formerly known as the Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS)

PROGRAM FOR PERSONS WITH DISABILITIES 
The Military Health System also provides the Program for Persons
with Disabilities (PFPWD), which was formerly known as the
Program for the Handicapped (PFTH).  Congress established this
program for active duty family member(s) with a qualifying
disability.  The PFPWD provides financial assistance and another
mechanism to receive services, equipment, and supplies necessary
for diagnosis, treatment, habilitation, and rehabilitation.  The
PFPWD is not a stand-alone benefit; family members receiving
services through the PFPWD may also participate in the TRICARE
options.

DEPARTMENT OF DEFENSE EARLY INTERVENTION SERVICES
The DoD provides early intervention services consistent with Part
C of the Individuals with Disabilities Education Act (IDEA) for
infants and toddlers who, but for their age, would be eligible to
attend a DoD school. The Military Departments (Army, Navy and Air
Force) provide early intervention services through programs
called Educational and Developmental Intervention Services
(EDIS).  In the United States, the Military Departments provide
early intervention to children who reside on installations with
DoD Schools.  Overseas, the Military Departments provide early
intervention services in assigned geographic areas of
responsibility  (e.g., the Navy is responsible for providing
early intervention services to all eligible children in Japan and
Okinawa).  The Reference section at the back of this guide
contains locations of programs in the United States, Europe, and
Asia.

Eligibility:   
Infants and toddlers from birth through two year of age are
eligible for early intervention services if they meet one of the
following criteria:

* The child is experiencing a developmental delay as measured by
diagnostic instruments and procedures of 2 standard deviations
below the mean in at least one area, or by a 25 percent delay in
at least one area on assessment instruments that yield scores in
months, or a developmental delay of 1.5 standard deviations below
the mean in two or more areas, or by a 20 percent delay on
assessment instruments that yield scores in months in two or more
of the following areas of development: cognitive, physical,
communication, social or emotional, or adaptive.

* The child has a diagnosed physical or mental condition which
has a high probability of resulting in developmental delay; e.g.,
chromosomal disorders or genetic syndromes.

Referral Process:  
Each Military Department develops and implements a comprehensive
child-find public awareness program in its assigned geographic
area of responsibility.  These efforts focus on the early
identification of children who may be eligible to receive early
intervention services.  The public awareness program provides
information to military communities about the early intervention
program and he child find system.  The program includes
information about the purpose and scope of the system, how to
make referrals, and how to gain access to services.  Each
military community maintains a central directory with information
about early intervention services and other community support
services.  EDIS prepares and disseminates materials for parents
on the availability of early intervention services to all primary
referral sources, especially hospitals, physicians and child
development centers.

Unique features:
DoD does not receive funding for its early intervention programs
from the Department of Education, or any other Federal, state or
local agency.

DEPARTMENT OF DEFENSE 
EXCEPTIONAL FAMILY MEMBER PROGRAM
NOTE:  Each Military Service's Exceptional Family Member Program
(EFMP) is unique. EFMP is used by all of the Services to identify
family members with special needs.  The information is used
primarily by the Personnel components when assigning service
members to new duty locations..  The Army also uses the term to
describe its overall  community support program for family
members with special needs. .  

Description:  
The Exceptional Family Member Program is a mandatory
enrollment/identification program for active duty personnel who
have family members with exceptional medical, psychological,
developmental, or educational needs.  The program assists in
assigning an active duty member to an area where his/her
exceptional family member's special needs can be met.

Required Enrollment:  
Family members with any long-term special medical, physical,
developmental, or educational need.

Referral Process:  
The referral process differs by Military Service.  Basically, a
service member self-identifies or is referred by a physician or
other medical provider to an EFMP Coordinator/Officer (terms
differ by Military Service).  Paperwork is completed (DD  Form
2792, The Exceptional Family Member Medical and Educational
Summary), by a medical provider/designee or by school personnel
(in the case of an educational need) documenting the family
member's needs.  In all Services but the Air Force, the family
member is enrolled in the EFMP.  (In the Air Force, the sponsor's
record is flagged to indicate that there is something that should
be considered when making assignments.)



TRICARE AND PROGRAM FOR PERSON WITH DISABILITIES 
COVERAGE FOR PART C SERVICES
Unless otherwise noted, the definitions for services are those
found in the IDEA Part C Federal Regulations.  All services
cost-shared by TRICARE must be "medically or psychologically
necessary".1  TRICARE cost-sharing determinations are on a
case-by-case basis; this information is intended to help
determine what may be cost-shared by TRICARE.

Assistive Technology
DEFINITION (34 CFR 303.12(d)(1)):  
Assistive technology device means any item, piece of equipment,
or product system, whether acquired commercially off the shelf,
modified, or customized, that is used to increase, maintain, or
improve the functional capabilities of children with
disabilities. Assistive technology service means a service that
directly assists a child with a disability in the selection,
acquisition, or use of an assistive technology device. Assistive
technology services include--
(i) The evaluation of the needs of a child with a disability,
including a functional evaluation of the child in the child's
customary environment;
(ii) Purchasing, leasing, or otherwise providing for the
acquisition of assistive technology devices by children with
disabilities;
(iii) Selecting, designing, fitting, customizing, adapting,
applying, maintaining, repairing, or replacing assistive
technology devices;
(iv) Coordinating and using other therapies, interventions, or
services with assistive technology devices, such as those
associated with existing education and rehabilitation plans and
programs;
(v) Training or technical assistance for a child with
disabilities or, if appropriate, that child's family; and
(vi) Training or technical assistance for professionals
(including individuals providing early intervention services) or
other individuals who provide services to or are otherwise
substantially involved in the major life functions of individuals
with disabilities.

TRICARE:  
Cost-shared if the item meets the definition of durable medical
equipment (DME) under 32 CFR 199.2.  Excludes hearing aids,
glasses, and communication devices.  Training would be
cost-shared under therapy rather than DME.

PFPWD:  
Cost-shared if medically necessary for the treatment of
qualifying conditions.  Will cost-share standard equipment, but
not deluxe models.  With respect to computers, and assistive
software, the PFPWD will not cover the basic computer, but will
cover adaptations (special keyboards, etc).  Training for the
assistive technology device would be cost-shared. Under PFPWD
only one similar type of device can be cost shared at one time. 
The item can be replaced due to normal wear and tear or when the
device is no longer useful to the beneficiary.

Audiology
DEFINITION (34 CFR 303.12(d)(2)): includes--
(i) Identification of children with auditory impairment, using at
risk criteria and appropriate audiologic screening techniques;
(ii) Determination of the range, nature, and degree of hearing
loss and communication functions, by use of audiological
evaluation procedures;
(iii) Referral for medical and other services necessary for the
habilitation or rehabilitation of children with auditory
impairment;
(iv) Provision of auditory training, aural rehabilitation, speech
reading and listening device orientation and training, and other
services;
(v) Provision of services for prevention of hearing loss; and
(vi) Determination of the child's need for individual
amplification, including selecting, fitting, and dispensing
appropriate listening and vibrotactile devices, and evaluating
the effectiveness of those devices.

TRICARE:  
Audiology services are available for medical diagnostic purposes. 
Physician referral is required.  TRICARE cannot cost-share for
hearing aids, and services related to hearing aids, such as
fitting and adjusting.  Aural rehabilitation may be cost-shared
to the same extent as other allowed medical services.

PFPWD:  
Audiology services may be cost-shared as under TRICARE. 
Physician referral is required.  Hearing aids may be cost-shared
when the hearing loss is, or is part of, the qualifying
condition.  The cost of hearing aids may be prorated over several
months to avoid the $1,000 monthly cap.

Family Training, Counseling, and Home Visits
DEFINITION (34 CFR 303.12(d)(3)): 
means services provided, as appropriate, by social workers,
psychologists, and other qualified personnel to assist the family
of a child eligible under this part in understanding the special
needs of the child and enhancing the child's development.

TRICARE:  
May be cost-shared as mental health services for a diagnosed
mental health condition.  Physician referral required.

PFPWD:  
Same as for TRICARE.  In addition, family training may be
cost-shared for family members of a PFPWD beneficiary when
required as an integral part of the management of the qualifying
condition.

Health Services
DEFINITION (34 CFR 303.13): 
means services necessary to enable a child to benefit from the
other early intervention services under Part C during the time
that the child is receiving the other early intervention
services.
(b) The term includes--
(1) Such services as clean intermittent catheterization,
tracheostomy care, tube feeding, the changing of dressings or
colostomy collection bags, and other health services; and
(2) Consultation by physicians with other service providers
concerning the special health care needs of eligible children
that will need to be addressed in the course of providing other
early intervention services.
(c) The term does not include the following:
(1) Services that are--
(i) Surgical in nature (such as cleft palate surgery, surgery for
club foot, or the shunting of hydrocephalus); or
(ii) Purely medical in nature (such as hospitalization for
management of congenital heart ailments, or the prescribing of
medicine or drugs for any purpose).
(2) Devices necessary to control or treat a medical condition.
(3) Medical-health services (such as immunizations and regular
"well-baby'' care) that are routinely recommended for all
children.

TRICARE:  
May be cost-shared when services are a covered benefit and
provided by a TRICARE-authorized provider.

PFPWD:  
Generally, PFPWD covers services for treatment of the qualifying
condition not available under TRICARE.

Medical Services
DEFINITION (34 CFR 303.12(d)(5)):  
"Medical services only for diagnostic or evaluation purposes
means services provided by a licensed physician to determine a
child's developmental status and need for early intervention
services."

TRICARE:  
May be cost-shared when services are a covered benefit and
provided by a TRICARE-authorized provider.

PFPWD:  
Generally, PFPWD covers services for treatment of the qualifying
condition not available under TRICARE.

Nursing Services
DEFINITION (34 CFR 303.12(d)(6)):
includes--
(i) The assessment of health status for the purpose of providing
nursing care, including the identification of patterns of human
response to actual or potential health problems;
(ii) Provision of nursing care to prevent health problems,
restore or improve functioning, and promote optimal health and
development; and
(iii) Administration of medications, treatments, and regimens
prescribed by a licensed physician.

TRICARE:  
Only medically necessary services may be cost-shared. 
Determination is made on individual basis.  

PFPWD:  
Generally, PFPWD covers services for treatment of the qualifying
condition not available under TRICARE.

Nutrition Services

DEFINITION: (34 CFR 303.12(d)(7)): includes--
    (i) Conducting individual assessments in--
    (A) Nutritional history and dietary intake;
    (B) Anthropometric, biochemical, and clinical variables;
    (C) Feeding skills and feeding problems; and
    (D) Food habits and food preferences;
    (ii) Developing and monitoring appropriate plans to address
the nutritional needs of children eligible under this part, based
on the findings in paragraph (d)(7)(i) of this section; and
    (iii) Making referrals to appropriate community resources to
carry out nutrition goals.

TRICARE:  
Nutritional counseling is excluded by regulation.  Medically
necessary nutritional diagnostic and treatment services may be
cost-shared if done in conjunction with otherwise allowed
service.  Determination is made on individual basis.

PFPWD:  
Generally, PFPWD covers services for treatment of the qualifying
condition not available under TRICARE.

Occupational Therapy 
DEFINITION: (34 CFR 303.12(d)(8)): 
includes services to address the functional needs of a child
related to adaptive development, adaptive behavior and play, and
sensory, motor, and postural development. These services are
designed to improve the child's functional ability to perform
tasks in home, school, and community settings, and include-
(i) Identification, assessment, and intervention;
(ii) Adaptation of the environment, and selection, design, and
fabrication of assistive and orthotic devices to facilitate
development and promote the acquisition of functional skills; and
(iii) Prevention or minimization of the impact of initial or
future impairment, delay in development, or loss of functional
ability.

TRICARE:  
Medically necessary services may be cost-shared.  Must be
referred and monitored by a physician.  No limits on frequency or
duration

PFPWD:  
Medically necessary services may be cost-shared for the treatment
of a qualifying condition.  Must be referred and monitored by a
physician.  No limits on frequency/duration.

Physical Therapy
DEFINITION: (34 CFR 303.12(d)(9)): 
includes services to address the promotion of sensorimotor
function through enhancement of musculoskeletal status,
neurobehavioral organization, perceptual and motor development,
cardiopulmonary status, and effective environmental adaptation.
These services include--
(i) Screening, evaluation, and assessment of infants and toddlers
to identify movement dysfunction;
(ii) Obtaining, interpreting, and integrating information
appropriate to program planning to prevent, alleviate, or
compensate for movement dysfunction and related functional
problems; and
(iii) Providing individual and group services or treatment to
prevent, alleviate, or compensate for movement dysfunction and
related functional problems.

TRICARE:  
Medically necessary services may be cost-shared.  Must be
referred and monitored by a physician.  No limits on frequency or
duration

PFPWD:  
Medically necessary services may be cost-shared for the treatment
of a qualifying condition.  Must be referred and monitored by a
physician.  No limits on frequency/duration.

Psychological Services
DEFINITION: (34 CFR 303.12(d)(10)): 
includes--
(i) Administering psychological and developmental tests and other
assessment procedures;
(ii) Interpreting assessment results;
(iii) Obtaining, integrating, and interpreting information about
child behavior, and child and family conditions related to
learning, mental health, and development; and
(iv) Planning and managing a program of psychological services,
including psychological counseling for children and parents,
family counseling, consultation on child development, parent
training, and education programs.

TRICARE:  
Cost-shared when provided for the diagnosis or treatment of a
cost-shared mental disorder.

PFPWD:  
Cost-shared when necessary for treatment of the qualifying
condition.

Service Coordination
DEFINITION: (34 CFR 303.12(d)(11)): 
means assistance and services provided by a service coordinator
to a child eligible under Part C and the child's family that are
in addition to the functions and activities included under 34 CFR
303.23.  

Service coordination in 34 CFR 303.23 means the activities
carried out by a service coordinator to assist and enable a child
eligible under Part C and the child's family to receive the
rights, procedural safeguards, and services that are authorized
to be provided under the State's early intervention program.
(2) Each child eligible under Part C and the child's family must
be provided with one service coordinator who is responsible for--
(i) Coordinating all services across agency lines; and
(ii) Serving as the single point of contact in helping parents to
obtain the services and assistance they need.
(3) Service coordination is an active, ongoing process that
involves--
(i) Assisting parents of eligible children in gaining access to
the early intervention services and other services identified in
the individualized family service plan;
(ii) Coordinating the provision of early intervention services
and other services (such as medical services for other than
diagnostic and evaluation purposes) that the child needs or is
being provided;
(iii) Facilitating the timely delivery of available services; and
(iv) Continuously seeking the appropriate services and situations
necessary to benefit the development of each child being served
for the duration of the child's eligibility.
    (b) Specific service coordination activities. Service
coordination activities include--
(1) Coordinating the performance of evaluations and assessments;
(2) Facilitating and participating in the development, review,
and evaluation of individualized family service plans;
(3) Assisting families in identifying available service
providers;
(4) Coordinating and monitoring the delivery of available
services;
(5) Informing families of the availability of advocacy services;
(6) Coordinating with medical and health providers; and
(7) Facilitating the development of a transition plan to
preschool services, if appropriate.

TRICARE: 
Cannot be cost-shared.  Case management is provided as an
administrative service by TRICARE.

PFPWD:  
Cannot be cost-shared.  Case Management is provided as an
administrative service by TRICARE.

Social Work Services
DEFINITION: (34 CFR 303.12(d)(12)): 
includes--
(i) Making home visits to evaluate a child's living conditions
and patterns of parent-child interaction;
(ii) Preparing a social or emotional developmental assessment of
the child within the family context;
(iii) Providing individual and family-group counseling with
parents and other family members, and appropriate social
skill-building activities with the child and parents;
(iv) Working with those problems in a child's and family's living
situation (home, community, and any center where early
intervention services are provided) that affect the child's
maximum utilization of early intervention services; and
(v) Identifying, mobilizing, and coordinating community resources
and services to enable the child and family to receive maximum
benefit from early intervention services.

TRICARE:  
Cost-shared if provided by a TRICARE-authorized licensed clinical
social worker as a mental health service for a covered mental
disorder.

PFPWD: 
Cannot be cost-shared.

Special Instruction
DEFINITION: (34 CFR 303.12(d)(13)): 
includes--
(i) The design of learning environments and activities that
promote the child's acquisition of skills in a variety of
developmental areas, including cognitive processes and social
interaction;
(ii) Curriculum planning, including the planned interaction of
personnel, materials, and time and space, that leads to achieving
the outcomes in the child's individualized family service plan;
(iii) Providing families with information, skills, and support
related to enhancing the skill development of the child; and
(iv) Working with the child to enhance the child's development.

TRICARE:  
Cannot be cost-shared.

PFPWD:  
Special education instruction and training may be cost-shared.

Speech-Language Pathology
DEFINITION: (34 CFR 303.12(d)(14)): 
includes--
(i) Identification of children with communicative or
oropharyngeal disorders and delays in development of
communication skills, including the diagnosis and appraisal of
specific disorders and delays in those skills;
(ii) Referral for medical or other professional services
necessary for the habilitation or rehabilitation of children with
communicative or oropharyngeal disorders and delays in
development of communication skills; and
(iii) Provision of services for the habilitation, rehabilitation,
or prevention of communicative or oropharyngeal disorders and
delays in development of communication skills.

TRICARE:  
Cost-shared only when rendered as a part of treatment addressing
conditions that are not due to educational or occupational
deficits.

PFPWD:  
Cost-shared to treat the qualifying condition or a
speech-language disorder caused by a qualifying condition.

Transportation and related costs
DEFINITION: (34 CFR 303.12(d)(15)): 
includes the cost of travel (e.g., mileage, or travel by taxi,
common carrier, or other means) and other costs (e.g., tolls and
parking expenses) that are necessary to enable a child eligible
under this part and the child's family to receive early
intervention services.

TRICARE:  
Cannot be cost-shared.

PFPWD:  
May be cost-shared when provided in conjunction with receipt of
other authorized PFPWD services.  Parent/guardian may be
reimbursed for eligible transportation.

Vision Services
DEFINITION: (34 CFR 303.12(d)(16)): 
means--
(i) Evaluation and assessment of visual functioning, including
the diagnosis and appraisal of specific visual disorders, delays,
and abilities;
(ii) Referral for medical or other professional services
necessary for the habilitation or rehabilitation of visual
functioning disorders, or both; and
(iii) Communication skills training, orientation and mobility
training for all environments, visual training, independent
living skills training, and additional training necessary to
activate visual motor abilities.

TRICARE:  
Diagnostic services may be cost-shared.  Mobility training cannot
be cost-shared.

PFPWD:  
Diagnostic and treatment services may be cost-shared.

FREQUENTLY ASKED QUESTIONS REGARDING DOD HEALTH CARE PROGRAMS AND
PAYMENT FOR 
IDEA PART C SERVICES

1. What are the eligibility requirements for TRICARE's  programs?
Generally, the TRICARE program is available to active duty
members of the United States Uniformed Services and their family
members, retirees and their family members, and survivors of all
uniformed services who are under 65 years of age.  Those over age
65 who are eligible for Medicare may seek care at military
treatment facilities on a space-available basis.

Eligibility for services through the PFPWD is limited to
dependents of active duty military personnel who are moderately
or severely mentally retarded or has/have a serious physical
disability.  Beneficiaries under the age of three with a
neuromuscular developmental condition or other condition that is
likely to precede a diagnosis of moderate or severe mental
retardation or be characterized as a serious physical disability
by the age of seven may also be eligible for the PFPWD.

Prior approval by TRICARE is required for all services and
supplies through the PFPWD.  All local resources must be
considered and those determined as adequate must be utilized
before a request for coverage through the PFPWD will be acted
upon.  Each case is considered and evaluated individually.

2. Can a child/family hold dual enrollment in more than one of
these programs concurrently?
Yes.  Active duty family members can take advantage of the
TRICARE options and the PFPWD concurrently.  However, services
authorized for receipt through the PFPWD may not be concurrently
furnished through the TRICARE options.

3. If so, are there stipulations about which program's benefits
would supercede other program's benefits? 
No.  However, coverage of many PFPWD services is not authorized
through the other TRICARE options.

4. What are the advantages and disadvantages of each program?
Advantages of TRICARE Prime
* no enrollment fee for active duty and families
* lowest cost among the three options
* small fee per visit to civilian providers
* no balance billing
* priority access to care at military treatment facilities
* a variety of preventive and wellness services at no additional
charge
* primary care manager supervision and care coordination
* away-from-home emergency coverage
* Point-of-Service option to go outside of the network

Disadvantages of TRICARE Prime
* beneficiaries generally must use providers in the TRICARE
network
* primary care manager or Plan must authorize care
* available near military hospitals and in a few other locations
(in other areas,       beneficiaries use TRICARE Standard)
* specialty care by referral only
* may not disenroll within a 12-month period, unless moved from
area or lose                   eligibility
* Point-of-Service option requires greater beneficiary
cost-sharing

Advantages of TRICARE Extra and Standard (formerly CHAMPUS)
* no enrollment fee 
* no balance billing (Extra only).  For Standard, patient pays
deductible, co-payment, and balance, if bill exceeds the
allowable charge and provider is non-participating, but only up
to 15% additional.
* no deductible when using retail pharmacy network (Extra only)
* non-availability statement may be required for civilian
inpatient care for areas surrounding military treatment
facilities
* the TRICARE Extra co-payment is 5% less than Standard
* no primary care manager required
* Standard has broadest choice of providers but is the most
expensive option

Disadvantages of TRICARE Extra and Standard 
* Higher out-of-pocket costs
* Exposure to balance billing, subject to the 15% additional, by
TRICARE Standard providers if they choose not to accept TRICARE
allowed amounts as full payment
* Added administrative burden of filing claims if provider will
not submit them

Advantages of the Program for Persons with Disabilities (PFPWD)
* provides a source of financial relief, and another mechanism
through which to receive needed services/equipment/supplies
* the cost-share for services in any month is a fixed amount
based on the active duty member's rank, ranging from $25 to 250
per month
* no deductibles
* the family may determine and select the most cost beneficial
program through which to receive services
* high cost items may be prorated over several months such that
the prorated amount does not exceed the maximum monthly benefit  
* PFPWD also shares in the cost of some additional benefits not
available through TRICARE.  Some of these are:
* equipment that does not qualify as Durable Medical Equipment
* unique adaptive training
* special education/instruction program and tutor
* adjunct services, such as a reader for a blind beneficiary
* medical attendant during transport to receive PFPWD services
* transportation

Disadvantages of the Program for Persons with Disabilities
* PFPWD is available only for active duty family beneficiaries
and children who meet specific diagnostic categories
* There is a maximum allowable monthly benefit of $1,000 -
regardless of disability. 
Amounts for services that exceed the limit may not be cost-shared
through the other TRICARE options and are the responsibility of
the family, except that, if more than one family member receives
services through the PFPWD in any given month, the $1,000 cap
applies only to the one with the lowest reimbursable.
* Pre-authorization is required.  Authorizations are valid for a
period of up to six months.  At the beneficiary's request,
services through the PFPWD may be reauthorized every six months.
* To the extent adequate and available, services from other
public resources must be utilized first.  NOTE:  the one
exception to this is IDEA which in 1997 was amended to clarify
that the Department of Defense health care system pay first for
otherwise allowable Part C services.

5. Is there a presumptive eligibility for any of the above
programs?  If so, what services or supports are provided during
the period of presumptive eligibility?
No.  Eligibility for TRICARE is based solely on a beneficiary's
relationship to an active duty or retired member of the U.S.
Uniformed Services.  Those individuals under 65 who are eligible
for Medicare because of disability or end-stage kidney disease
may also participate.  Beneficiaries over age 65 are only
entitled to care in a military treatment facility on a
space-available basis.

Identification for the PFPWD program is typically made by the
beneficiary's Primary Care Manager, or other TRICARE-authorized
provider, who determines that the beneficiary has a PFPWD
qualifying condition.  Eligibility is a prerequisite to
authorization and payment of any PFPWD benefits.

PFPWD eligibility must be determined and services authorized
prior to claims processing.  This requirement may be waived for
services or items that would be allowed, except for the absence
of the prior authorization.  In those situations where a deferral
or denied application for coverage through the PFPWD subsequently
is approved, such subsequent approval may be applied
retroactively to the date coverage would have been effective had
adequate information been provided.

6. What is the process for a potentially eligible family to apply
for benefits under any of these programs?
Contact the local military treatment facility's Health Benefits
Advisor, or the Managed Care Support Contractor's TRICARE Service
Center.  They can assist in establishing enrollment in TRICARE
Prime, assignment of a Primary Care Manager, and determining
eligibility for other options, including the PFPWD.

7. Do the enrollees in each of these programs have an opportunity
to participate in different enrollment options?  If so, how do
the programs and services differ among these options?
Eligible beneficiaries may enroll in TRICARE Prime, or choose
among the other two options: TRICARE Extra or TRICARE Standard. 
Detailed services and benefit information may be found on the
World Wide Web at http://www.tricare.osd.mil or obtained through
the regional contractor's TRICARE Service Center.

Enrollment in TRICARE Prime, Extra or Standard does not affect a
person's eligibility to receive services through PFPWD.  The
PFPWD is not intended to be a stand-alone benefit. All services
received through the PFPWD program must be in connection with the
qualifying condition and be preauthorized to ensure that
requested benefits are necessary and appropriate. All providers
must be TRICARE-authorized.

8. What specific services or supports are provided by each of the
programs? Are there specific stipulations regarding the provision
of services and/or supports?
The TRICARE benefits are established at 32 CFR 199.4.  They
include medically and psychologically necessary diagnostic
testing and treatment.  The services are provided by military
treatment facilities and a network of credentialed healthcare
professionals from military and civilian networks.  TRICARE Prime
provides some preventive services not available through TRICARE
Standard and TRICARE Extra.  TRICARE Prime and TRICARE Extra
offer reduced cost shares.

The PFPWD benefits are established at 32 CFR 199.5.  They
include items and services that TRICARE has determined capable of
confirming, arresting, or reducing the severity of the disabling
effects of a qualifying condition.  These include:

* 
diagnostic procedures to establish a qualifying condition
diagnosis or to measure the extent of functional loss
* treatment through the use of such medical, habilitative, or
rehabilitative methods, techniques, therapies, and equipment such
as certain prosthetic devices, orthopedic braces, orthopedic
appliances; in-home, inpatient or outpatient care as appropriate
* training when required to allow the use of an assistive
technology device or to acquire skills which are expected to
assist the beneficiary to reduce the disabling effects of a
qualifying condition, and for parents (or guardian) and siblings
of a PFPWD beneficiary when required as an integral part of the
management of the qualifying condition
* special education/instruction, other than training specifically
designed to accommodate the disabling effects of a qualifying
condition
* institutional care within a State, when the severity of the
qualifying condition requires protective custody or training in a
residential environment
* transportation when required to convey the PFPWD beneficiary to
or from a facility or institution to receive otherwise allowable
services or items
* adjunct services such as an interpreter/translator for the
deaf, readers for the blind, and equipment adaptation and
maintenance

9. Is there a difference between the services provided for
on-base families and for families who live off base?
Differences in availability and provision of medical services for
families are based on the type of managed care option, not
location. TRICARE Prime enrollees have the highest priority
access to available care in a military treatment facility.  Other
beneficiaries are entitled to space available care in a military
treatment facility or referral to the civilian network.

However, the delivery of early intervention services differs for
military families depending upon where they live.  DoD provides
early intervention services through military treatment facilities
to families in the United States who reside on a military
installation served by a DoD school.  (32 CFR 80.2).  Families
who reside off an installation in the U.S. would receive their
services from the State Part C system.  DoD provides early
intervention services to all eligible military families who
reside in overseas locations.

10. Are there any restrictions on the location (including natural
environments) where services can be provided through any of these
programs?
Early intervention services which qualify as medical services may
be provided in an inpatient, outpatient, or natural environment
settings (e.g., home, school, child care center).  Medical
institutions must be a TRICARE-authorized facility and
TRICARE-authorized providers must perform all services.

11. 
What prior authorizations must be met in order for a family to
receive services through each program?
For members enrolled in TRICARE Prime, the Primary Care Manager
is the only provider who may render services without prior
authorization.  All services provided through the PFPWD require
prior authorization.

12. Is there a "medical necessity" requirement associated with
the above programs?  If so, what is the definition for each
program? How does this differ from the "medical necessity"
definition used by Medicaid?
All claims for medical services are subject to review for medical
necessity.  As specified in 32 CFR 199.2(b), medically or
psychologically necessary is defined as "the frequency, extent,
and types of medical services or supplies which represent
appropriate medical care and that are generally accepted by
qualified professionals to be reasonable and adequate for the
diagnosis and treatment of illness, injury, pregnancy, and mental
disorders or that are reasonable and adequate for well-baby
care." 

Appropriate medical care is defined at 32 CFR 199.2(b) as "(i)
Services performed in connection with the diagnosis or treatment
of disease or injury, pregnancy, mental disorder, or well-baby
care which Are in keeping with the generally accepted norms for
medical practice in the United States; (ii) The authorized
individual professional provider rendering the medical care is
qualified to perform such medical services by reason of his or
her training and education and is licensed or certified by the
state where the serviced is rendered or appropriate national
organization otherwise meets CHAMPUS standards; and (iii) The
services are furnished economically.  For purposes of this part,
"economically" means that the services are furnished in the least
expensive level of care or medical environment adequate to
provide the required medical care regardless of whether or not
that level of care is covered by CHAMPUS.

As noted in the response to question 9, the PFPWD includes
defined benefits for certain non-medical services and items.

The TRICARE and PFPWD definitions are applied consistently across
the country, and differ from Medicaid medical necessity
definitions, which are established at the State level.

13. What, if any, case management services are provided as part
of these programs?
In the FY 1993 Defense Authorization Act, Congress provided for
establishment of a comprehensive individual case management
program through TRICARE.  TRICARE already includes a
comprehensive plan for quality and utilization management.  The
Individual Case Management Rule is in the process of being
revised to incorporate new legislative changes.  Through this
program, waiver of benefit limits or exclusions to the basic
TRICARE program for high cost or custodial patients may be
authorized for beneficiaries when the provision of such services
or supplies is cost effective and clinically appropriate.  The
case management program is designed to provide a cost-effective
plan of care by targeting appropriate resources to meet the
individual needs of the beneficiary.

14. Do any of the available programs require the use of specific
providers?  If so, is there any mechanism whereby a family could
use an eligible provider that is associated with another program
(State's early intervention program, Medicaid, State's Title V
program, etc)?
Members enrolled in the TRICARE Prime option are required to
utilize their Primary Care Manager, military providers in
military treatment facilities, and the managed care support
contractor's network of providers for their medical care. 
Through the TRICARE Extra option, the preferred provider network
may be used on a case-by-case basis.  Through TRICARE Standard,
families may select providers in and out of the network.  All
providers must be TRICARE-authorized for payment of claims.

15. How could a provider from another program for which the
child/family is eligible become an eligible provider under a
program through the Department of Defense?
All individual professional and institutional providers and
vendors who meet TRICARE's requirements for authorization may
become TRICARE-authorized providers. There are no additional or
special requirements for providers of early intervention
services.  If a provider is already TRICARE-authorized, no
additional action is required.  Application to be a TRICARE
authorized provider may be made to the Managed Care Support
Contractor where the provider is located.

For information on the appropriate point of contact for a
specific location, consult the Internet site
http://www.tricare.osd.mil and select the "Regional Web Sites"
link from the "A-to-Z Site List" window.

16. Does the use of any of these programs mandate the billing of
other programs?
TRICARE does not bill other programs.  When TRICARE is second
payer to other primary insurance, TRICARE waits for the other
payer to process a claim before making its payment determination.

17. How do these programs interface with other medical assistance
programs in which the child may be participating (i.e., Title V,
Medicaid, private insurance)?
TRICARE coverage is subject to the rules of double coverage. 
That is, TRICARE, including the PFPWD, is second payer to all
other plans except Medicaid, IDEA Part C, benefits through the
State Victims of Crime Compensation Program, and certain other
insurance policies that are specifically designated as TRICARE
supplements.

TRICARE will only share in the costs of medically necessary
services.  TRICARE will assist a sponsor to obtain information
from those agencies that are possible sources of assistance for
the specific condition.

PROCESS FOR ACCESSING THE MILITARY HEALTH SYSTEM


TRICARE:
There is no general requirement for prior authorization. 
However, under TRICARE Prime, specialty services must be referred
by the beneficiary's Primary Care Manager.  Any TRICARE
-authorized provider can refer for specialty services under
TRICARE Standard and Extra.

To locate a provider, there are TRICARE Service Centers, with an
800 number, in each TRICARE region.  The regional contractor
employs health care finders to assist people with referrals and
locating a provider.


PROGRAM FOR PERSONS WITH DISABILITIES:
All services require prior authorization.  Authorizations are
obtained from the TRICARE Service Center.


REFERENCES

Part C State Coordinators     
http://www.nectas.unc.edu/contact/ptccoord.html

Part C State eligibility definitions    
http://www.nectas.unc.edu/pubs/pubslist1.html#state

Office of Special Education Programs    
http://www.ed.gov/offices/OSERS/OSEP/index.html

Local TRICARE Service Centers      
http://www.tricare.osd.mil/tricare/trimap2.html

Department of Defense Early Intervention Sites    
http://www.odedodea.edu/pa/sch_loc.html


OTHER RELEVANT WEBSITES: 

Parent Training Information Centers     http://www.taalliance.org

National Information Center for Children and Youth with
Disabilities (NICHY)     http:// nichy.org

National Early Childhood Technical Assistance System (NECTAS)    
http://www.nectas.unc.edu

FICC http://www.fed-icc.org

FICC correspondence on autism attached



1    Medically or psychologically necessary is defined as "the
frequency, extent, and types of medical services or supplies
which represent appropriate medical care and that are generally
accepted by qualified professionals to be reasonable and adequate
for the diagnosis and treatment of illness, injury, pregnancy,
and mental disorders or that are reasonable and adequate for
well-baby care."  32 CFR 199.2(b)


TRICARE AND IDEA PART C: A GUIDE TO SERVICES 10

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