[Federal Register: November 19, 2003 (Volume 68, Number 223)]
[Rules and Regulations]
[Page 65172-65174]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr19no03-12]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
RIN 0720-AA85
TRICARE; Changes Included in the National Defense Authorization
Act for Fiscal Year 2003 (NDAA-03)
AGENCY: Office of the Secretary, DoD.
ACTION: Interim final rule.
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SUMMARY: This interim final rule contains several provisions found in
the NDAA-03, Public Law 107-314, signed on December 2, 2002.
Specifically this rule addresses eliminating the requirement for
TRICARE preauthorization of inpatient mental health care for Medicare-
eligible beneficiaries where Medicare is primary payer and has already
authorized the care using Medicare certification of individual
professional providers as sufficient documentation to also certify
individual professional providers under TRICARE; and expanding the
TRICARE Dental Program (TDP) eligibility for dependents of deceased
members. Public comments are invited and will be considered for
possible revisions to the final rule.
DATES: This rule is effective November 19, 2003. The effective date for
the 32 CFR 199.4(a)(12)(ii)(E)(2) is October 1, 2003. The effective
date for 32 CFR 199.13(c)(3)(ii)(E)(2) is December 2, 2002.
APPLICABILITY: The applicability date for 32 CFR 199.6(c)(2)(v) is for
any TRICARE contract entered into on or after December 2, 2002.
COMMENTS: Comments will be accepted until January 20, 2004.
ADDRESSES: Forward comments to Medical Benefits and Reimbursement
Systems, TRICARE Management Activity, 16401 East Centretech Parkway,
Aurora, Colorado 80011-9066.
FOR FURTHER INFORMATION CONTACT: Ann N. Fazzini, (303) 676-3803 (The
sections of this rule regarding elimination of mental health
preauthorization and Medicare providers as TRICARE providers) or Major
Shannon Lynch, (303) 676-3496 (The section of this rule regarding the
TRICARE Dental Program). Questions regarding payment of specific claims
should be addressed to the appropriate TRICARE contractor.
SUPPLEMENTARY INFORMATION:
[[Page 65173]]
I. Elimination of Mental Health Pre-Authorization
Section 701 of the NDAA-03 eliminates the preauthorization
requirement for inpatient mental health where Medicare is primary payer
and has already authorized the care. Currently, in situations were a
Medicare beneficiary, who is also TRICARE eligible, receives inpatient
mental health care, TRICARE applies its rules for preauthorization even
though TRICARE is not the primary payer. The language found in section
701 of the NDAA-03 changes the way we currently operate. Once this
change is implemented, Medicare beneficiaries who are also TRICARE
eligible, will follow Medicare's rules until their Medicare benefit is
exhausted. Once the Medicare benefit is exhausted, TRICARE's rules
regarding preauthorization will apply. We expect implementation of this
change will reduce providers' administrative burden as they will no
longer have to obtain a preauthorization from TRICARE until the
beneficiary's Medicare benefit is exhausted. It will also reduce the
burden on our contractors as they will be required to obtain
preauthorization only after the patient's Medicare benefits are
exhausted.
Additionally, Section 701 of the NDAA-03 continues our current
policy that pre-authorization is not required in the case of an
emergency.
II. Medicare Provider Certification Applicable to TRICARE Individual
Professional Providers
Section 705 of the NDAA-03 provides that Medicare certification of
individual professional providers shall be considered sufficient
documentation to also certify authorized individual professional
providers under TRICARE. When an individual professional provider has
been certified by Medicare and meets one of the TRICARE individual
professional provider categories, the Medicare certification shall be
considered sufficient documentation to certify the provider under
TRICARE.
Our contractors are currently in compliance with this provision. By
accepting Medicare certification as sufficient documentation, TRICARE
has reduced the administrative burden of separately applying for
certification under two federal health care programs. While our
contractors are currently in compliance with this provision this
interim final rule is necessary to add the statutory language to our
regulation.
Section 705 continues the current TRICARE policy of excluding
providers who are sanctioned or who have program integrity violations
under Medicare, TRICARE, or other Federal health programs. Such
providers are specifically excluded as TRICARE providers.
III. TRICARE Dental Program
Currently, eligibility in the TDP includes any such dependent of a
member who died while on active duty for a period of more than 30 days
or a member of the Ready Reserve if the dependent was enrolled on the
date of the death of the member. The exception to this is that the term
does not include the dependent after the end of the three-year period
beginning on the date of the member's death. Section 703 of the NDAA
FY03 TRICARE changes eligibility in the TDP by including any such
dependent of a member who dies while on active duty for a period of
more than 30 days or a member of the Ready reserve if, on the date of
the death of the member, the dependent is enrolled in dental benefits
plan or is not enrolled in such a plan by reason of a discontinuance of
a former enrollment due to transfer to a duty station where dental care
is provided to the member's eligible dependents under a program other
than that plan. The exception remains that the term does not include
the dependent after the end of the three-year period beginning on the
date of the member's death.
IV. Regulatory Procedures
Section 801 of title 5, United States Code, and Executive Order
12866 requires certain regulatory assessments and procedures for any
major rule or significant regulatory action, defined as one that would
result in an annual effect of $100 million or more on the national
economy or which would have other substantial impacts.
The Regulatory Flexibility Act (RFA) requires that each Federal
agency prepare, and make available for public comment, a regulatory
flexibility analysis when the agency issues a regulation which would
have a significant impact on a substantial number of small entities.
This is not a major rule under 5 U.S.C. 801. It is a significant
regulatory action but not economically significant. In addition, we
certify that this proposed rule will not significantly affect a
substantial number of small entities. This rule has been designated as
significant and has been reviewed by the Office of Management and
Budget as required under the provisions of E.O. 12866.
Paperwork Reduction Act
This rule, as written, imposes no burden as defined by the
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3511). If, however, any
program implemented under this rule causes such a burden to be imposed,
approval thereof will be sought from the Office of Management and
Budget in accordance with the Act, prior to implementation.
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care, Health insurance, Individuals
with disabilities, Military personnel.
0
Accordingly, 32 CFR Part 199 is amended as follows:
PART 199--[AMENDED]
0
1. The authority citation for part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
0
2. Section 199.4 is amended by revising paragraph (a)(12)(ii)(A) and
the first sentence in paragraph (b)(6)(ii)(A) and adding a new
paragraph (a)(12)(ii)(E) to read as follows:
Sec. 199.4 Basic program benefits.
(a) * * *
(12) * * *
(ii) Preadmission authorization. (A) This section generally
requires preadmission authorization for all non-emergency inpatient
mental health services and prompt continued stay authorization after
emergency admissions with the exception noted in paragraph (a)(12)(ii)
of this section. It also requires preadmission authorization for all
admissions to a partial hospitalization program, without exception, as
the concept of an emergency admission does not pertain to a partial
hospitalization level of care. Institutional services for which payment
would otherwise be authorized, but which were provided without
compliance with preadmission authorization requirements, do not qualify
for the same payment that would be provided if the preadmission
requirements had been met.
* * * * *
(E) Preadmission authorization for inpatient mental health services
is not required in the following cases:
(1) In the case of an emergency.
(2) In a case in which benefits are payable for such services under
part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et
seq.) subject to paragraph (a)(12)(iii) of this section.
(3) In a case of inpatient mental health services in which
paragraph (a)(12)(ii) of this section applies, the Secretary shall
[[Page 65174]]
require advance authorization for a continuation of the provision of
such services after benefits cease to be payable for such services
under such part A.
* * * * *
(b) * * *
(6) * * *
(iii) Preauthorization requirements. (A) With the exception noted
in paragraph (a)(12)(ii)(E) of this section, all non-emergency
admissions to an acute inpatient hospital level of care must be
authorized prior to the admission. * * *
* * * * *
0
3. Section 199.6 is amended by adding a new paragraph (c)(2)(v) to read
as follows:
Sec. 199.6 Authorized providers.
* * * * *
(c) * * *
(2) * * *
(v) Subject to section 1079(a) of title 10, U.S.C., chapter 55, a
physician or other health care practitioner who is eligible to receive
reimbursement for services provided under Medicare (as defined in
section 1086(d)(3)(C) of title 10 U.S.C., chapter 55) shall be
considered approved to provide medical care authorized under section
1079 and section 1086 of title 10, U.S.C., chapter 55 unless the
administering Secretaries have information indicating Medicare,
TRICARE, or other Federal health care program integrity violations by
the physician or other health care practitioner. That is, TRICARE shall
accept Medicare certification of providers who have a like class of
providers under TRICARE without further authorization unless that
provider is under sanctions as stated herein. Providers without a like
class (i.e., chiropractors) under TRICARE shall be denied.
* * * * *
0
4. Section 199.13 is amended revising paragraph (c)(3)(ii)(E)(2) to
read as follows:
Sec. 199.13 TRICARE Dental Program.
(c) * * *
(3) * * *
(ii) * * *
(E) * * *
(2) Continuation of eligibility for dependents of service members
who die while on active duty or while a member of the Selected Reserve
or Individual Ready Reserve. Eligible dependents of active duty members
while on active duty for a period of thirty-one (31) days or more and
eligible dependents of Selected Reserve or Individual Ready Reserve
members, as specified in 10 U.S.C. 10143 and 10144(b) respectively, if
on the date of the death of the member, the dependent is enrolled in
the TDP, or if not enrolled by reason of a discontinuance of a former
enrollment under paragraphs (c)(4)(ii) and (c)(4)(iii) of this section
shall be eligible for continued enrollment in the TDP for up to three
(3) years from the date of the member's death. This 3-year period of
continued enrollment also applies to dependents of active duty members
who died within the year prior to the beginning of the TDP while the
dependents were enrolled in the TFMDP. This continued enrollment is not
contingent on the Selected Reserve or Individual Ready Reserve member's
own enrollment in the TDP. During the three-year period of continuous
enrollment, the government will pay both the Government and the
beneficiary's portion of the premium share.
* * * * *
Dated: November 12, 2003.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 03-28756 Filed 11-18-03; 8:45 am]
BILLING CODE 5001-06-M