[Federal Register: September 14, 2004 (Volume 69, Number 177)]
[Rules and Regulations]
[Page 55358-55360]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr14se04-12]
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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: Final rule.
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SUMMARY: This final addresses eliminating the requirement for TRICARE
preauthorization of inpatient mental health care for TRICARE/Medicare
eligible beneficiaries where Medicare is primary payer and has already
authorized the care; approving a physician or other health care
practitioner who is eligible to receive reimbursement for services
provided under Medicare as a TRICARE provider if the provider is also a
TRICARE authorized provider; and, expanding the TRICARE Dental Program
(TDP) eligibility for dependents of deceased members.
DATES: This rule is effective September 14, 2004 except that the
effective date for the amendment to 32 CFR 199.4(a)(12)(ii)(E)(2) is
October 1, 2004, and the effective date for the amendment to 32 CFR
199.13(c)(13)(ii)(E)(2) is December 2, 2002. The applicability date for
the amendment to 32 CFR 199.6(c)(2)(v) is for any TRICARE contract
entered into on or after December 2, 2002.
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: In the Federal Register of November 19,
2003, (68 FR 65172), the Office of the Secretary of Defense published
for public comment an interim final rule regarding the following three
changes found in the the Bob Stump NDAA 03 (Pub. L. 107-314). We
received no public comments.
I. Elimination of Mental Health Pre-Authorization
Section 701 of the Bob Stump NDAA-03 states that:
(B) Preadmission authorization for inpatient mental health
services is not required under subparagraph (A) in the following
cases:
(i) In the case of an emergency.
(ii) In a case in which any 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 ot subparagraph (C).
(C) In a case of inpatient mental health services to which
subparagraph (B)(ii) applies, the Secretary shall require advance
authorization for a continuation of the provision of such benefits
after benefits cease to be payable for such services under such part
A.
This language eliminates the preauthorization requirement for
inpatient mental health care where Medicare is primary payer.
Currently, in situations where 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 Bob Stump 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.
Section 701 of the Bob Stump NDAA-03 also 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 Bob Stump NDAA-03 states that:
Subject to subsection (a), 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 this
title) shall be considered approved to provide medical care
authorized under this section and section 1086 of this title 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.
This language provides that 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
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. Approval is limited to those providers who are currently
considered TRICARE authorized providers as outlined in 32 CFR 199.6.
Services and supplies rendered by those providers not currently
considered authorized providers shall be denied.
Our contractors are currently in compliance with this provision,
but this 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
[[Page 55359]]
Medicare, TRICARE, or other Federal health programs. Such providers are
presently specifically excluded as TRICARE providers.
III. TRICARE Dental Program
Section 703 of the Bob Stump NDAA 03 revises eligibility by
stating:
If, on the date of the death of the member, the dependent is
enrolled in a dental benefits plan established under subsection (a)
or is not enrolled in such a plan by reason of a discontinuance of a
former enrollment under subsection (f).
Currently, eligibility in the TDP includes any such dependent of a
member who died while on active duty for a period of 31 days or more or
a member of the Ready Reserve (i.e., Selected Reserve and Individual
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. This 3-year period of continued enrollment
also applies to dependents of active duty members who died on or
between the dates of 1 February 2000 and 31 January 2001 while the
dependents were enrolled in the TRICARE Family Member Dental Program
(TFMDP). 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 31 days or more or a member of the Ready
Reserve if, on the date of the death of the member, the dependent is
enrolled in a 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 require 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, and has been
reviewed by the Office of Management and Budget as required under the
provisions of E.O. 12866. In addition, we certify that this proposed
rule will not significantly affect a substantial number of small
entities.
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 paragraphs (a)(12)(ii)(A) and
(a)(12)(ii)(E) and the first sentence in paragraph (b)(6)(iii)(A) to
read as follows:
Sec. 199.4 Basic program benefits
(a) * * *
(12) * * *
(ii) * * *
(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
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) * * *
(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 revising 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. Approval is limited to
those classes of provider currently considered TRICARE authorized
providers as outlined in 32 CFR 199.6. Services and supplies rendered
by those providers who are not currently considered authorized
providers shall be denied.
* * * * *
0
4. Section 199.13 is amended by revising paragraph (c)(3)(ii)(E)(2) to
read as follows:
Sec. 199.13 TRICARE Dental Program.
(c) * * *
(3) * * *
(ii) * * *
[[Page 55360]]
(E) * * *
(2) Continuation of eligibility for dependents of service members
who die while on active duty or while a member of the Ready Reserve
(i.e., 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 Ready Reserve
(i.e., 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: September 2, 2004.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 04-20366 Filed 9-13-04; 8:45 am]
BILLING CODE 5001-06-M