[Federal Register: April 3, 2003 (Volume 68, Number 64)]
[Proposed Rules]
[Page 16247-16249]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr03ap03-28]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
RIN 0720-AA76
TRICARE Program; Inclusion of Anesthesiologist's Assistants as
Authorized Providers; Coverage of Cardiac Rehabilitation in
Freestanding Cardiac Rehabilitation Facilities
AGENCY: Office of the Secretary, Department of Defense.
ACTION: Proposed rule.
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SUMMARY: This proposed rule establishes a new category of provider as
an authorized TRICARE provider, and it increases the settings where
cardiac rehabilitation can be covered as a TRICARE benefit. It
recognizes anesthesiologist's assistants as authorized providers under
certain circumstances. It also authorizes cardiac rehabilitation
services, which are already a covered TRICARE benefit when provided by
hospitals, to be provided in freestanding cardiac rehabilitation
facilities.
DATES: Public comments must be received by June 2, 2003.
ADDRESSES: Forward comments to: TRICARE Management Activity (TMA),
Medical Benefits and Reimbursements Systems, 16401 East Centretech
Parkway, Aurora, CO 80011-9043.
FOR FURTHER INFORMATION CONTACT: Stephen E. Isaacson, Medical Benefits
and Reimbursement Systems, TMA, (303) 676-3572.
SUPPLEMENTARY INFORMATION:
A. Inclusion of Anesthesiologist's Assistants as Authorized Providers
At present only two types of anesthesia providers may provide
services to TRICARE beneficiaries--anesthesiologists and certified
registered nurse anesthetists (CRNAs). In some areas of the country,
anesthesiologist's assistants, after completing the specified training,
being accredited, and being licensed by the state also provide
anesthesia services. The Centers for Medicare and Medicaid Services
(CMS) already recognizes anesthesiologist's assistants as authorized
providers (42 CFR 410.69).
[[Page 16248]]
We propose to recognize anesthesiologist's assistants as authorized
providers under the same conditions applied by CMS. That is:
(1) They must work only under the direct supervision of an
anesthesiologist;
(2) They must comply with all applicable requirements of state law
and be licensed, where applicable, by the state in which they practice;
and
(3) They must have completed the appropriate educational
requirements. This includes graducation from a Master's level medical
school-based anesthesiologist's assistant program that is accredited by
the Committee on Allied Health Education and Accreditation and includes
approximately two years of appropriate specialized basic science and
clinical education in anesthesia. This program must build on a
premedical undergraduate science background.
Recognition of anesthesiologist's assistants will not increase the
costs of anesthesia to the Program. This is, payment for anesthesia
services provided by an anesthesiologist and an anesthesiologist's
assistant under the anesthesiologist's direct supervision will never
exceed what would have been paid if the services were provided only by
the anesthesiologist.
Since anesthesiologist's assistants may not practice independently,
they also may not bill independently for their services. All claims for
their services must be submitted by their employer, whether it is a
hospital, a physician, or some other similar entity. Such claims must
indicate that the services were provided by an anesthesiologist's
assistant.
B. Coverage of Cardiac Rehabilitation in Freestanding Cardiac
Rehabilitation Centers
On October 19, 1990, the Office of the Secretary of Defense
published a final rule in the Federal Register (55 FR 42366)
establishing cardiac rehabilitation as a TRICARE benefit when used in
the treatment of certain cardiac events. The following rationale was
provided for limiting cariac rehabilitation services to TRICARE
authorized hospitals:
As a national program, Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS) strives for uniformity and equity
in benefits to ensure beneficiary safety. Toward this end, CHAMPUS
relies on the existing nationwide infrastructure for accreditation
and professional regulatory oversight. With the large variety of
freestanding cardiac rehabilitation clinics throughout the country,
it is incumbent upon CHAMPUS to seek out national standards to
provide a clear line of demarcation on CHAMPUS requirements.
Currently, there is no organized national accreditation agency for
accrediting freestanding cardiac rehabilitation clinics, nor does
there appear to be standardized state licensure, or certification
procedures in existence which address standards for freestanding
cardiac rehabilitation clinics. Since OCHAMPUS does not have the
resources to conduct its own accreditation activities, the
requirement for national accreditation is at least a minimum
assurance that a facility or specialized treatment facility meets
some standards of quality.
However, since incorporation of this restriction (i.e., cardiac
rehabilitation services being restricted to hospital based facilities/
programs) there has been an evolution of alternative freestanding
delivery programs whose efficacy and safety have been recognized by the
medical community and other third-party payers. Freestanding cardiac
rehabilitation programs are examples of this evolutionary trend. With
the establishment of standardized licensure and accreditation
procedures, many of these freestanding programs have been recognized
and approved for participation under TRICARE.
Currently TRICARE provides coverage/payment for inpatient or
outpatient services and/or supplies provided in connection with a
cardiac rehabilitation program when provided by a TRICARE authorized
hospital. Outpatient cardiac rehabilitation treatment programs
affiliated with TRICARE authorized hospitals are reimbursed an all-
inclusive allowable charge per session that includes all related
professional services provided during a rehabilitation session.
Inpatient programs are paid based upon the reimbursement system in
place for the hospital where the services are provided. Separate cost-
sharing is allowed for initial evaluation and testing and related
professional services.
Since hospital based cardiac rehabilitation is already an
established benefit under TRICARE, its benefit and reimbursement
structure can be applied to freestanding cardiac rehabilitation
programs. Claims for freestanding outpatient cardiac rehabilitation
treatment will be reimbursed in the same manner as outpatient cardiac
rehabilitation treatment programs affiliated with TRICARE authorized
hospitals. That is, they will be reimbursed based upon an all inclusive
allowable charge per session that includes all related professional
services provided during the rehabilitation session.
Regulatory Procedures
Executive Order (EO) 12866 requires that a comprehensive regulatory
impact analysis be performed on any economically significant regulatory
action, defined as one which 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 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 rule is not economically significant and will not significantly
affect a substantial number of small entities.
``This rule has been designated as significant and has been
reviewed by the Office Management and Budget as required under the
provisions of E.O. 12866.''
Paperwork Reduction Act
This rule imposes no burden as defined by the Paperwork Reduction
Act of 1995.
List of Subjects in 32 CFR Part 199
Claims, Handicapped, Health insurance, and Military personnel.
Accordingly, 32 CFR part 199 is proposes to be amended as follows:
PART 199--[AMENDED]
1. The authority citation for part 199 continues to read as
follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
2. Section 199.4 is proposed to be amended by revising paragraph
(e)(18)(iv) as follows:
Sec. 199.4 Basic program benefits.
(e) * * *
(18) * * *
(iv) Providers. A provider of cardiac rehabilitation services must
be a TRICARE authorized hospital (see Section 199.6 paragraph
(b)(4)(i)) or a freestanding cardiac rehabilitation facility that meets
the requirements of Section 199.6 paragraph (f). All cardiac
rehabilitation services must be ordered by a physician.
* * * * *
3. Section 199.6 is proposed to be amended by redesignating
paragraph (c)(3)(iii)(I) as paragraph (c)(3)(iii)(J) and adding a new
paragraph (c)(3)(iii)(I) as follows:
Sec. 199.6 Authorized Providers.
(c) * * *
[[Page 16249]]
(3) * * *
(iii) * * *
(I) Anesthesiologist's Assistant. An anesthesiologist's assistant
may provide covered anesthesia services, if the anesthesiologist's
assistant:
(1) Works under the direct supervision of an anesthesiologist, and
the anesthesiologist bills for the services;
(2) Is in compliance with all applicable requirements of state law,
including any licensure requirements the state imposes on nonphysician
anesthetists; and
(3) Is a graduate of a Master's level medical school-based
anesthesiologist's assistant educational program that:
(i) Is accredited by the Committee on Allied Health Education and
Accreditation; and
(ii) Includes approximately two years of specialized basic science
and clinical education in anesthesia at a level that builds on a
premedical undergraduate science background.
* * * * *
Dated: March 28, 2003.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 03-8014 Filed 4-2-03; 8:45 am]
BILLING CODE 5001-08-M