TRICARE Reimbursement Revisions, 2291-2293 [2011-624]

Agencies

• Office of the Secretary
• DEPARTMENT OF DEFENSE

[Federal Register Volume 76, Number 9 (Thursday, January 13, 2011)]
[Proposed Rules]
[Pages 2291-2293]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-624]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DOD-2011-HA-0007]
RIN 0720-AB43


TRICARE Reimbursement Revisions

AGENCY: Office of the Secretary, DoD.

ACTION: Proposed rule.

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SUMMARY: The rule proposes several revisions to the regulation 
necessary to be consistent with Medicare, to include: hospice periods 
of care; reimbursement of physician assistants and assistant-at-surgery 
claims; and this rule revises the regulation by removing references to 
specific numeric Diagnosis Related Group (DRG) values, and replacing 
them with their narrative description.

DATES: Written comments received at the address indicated below by 
March 14, 2011 will be accepted.

ADDRESSES: You may submit comments, identified by docket number and or 
Regulatory Information Number (RIN) number and title, by either of the 
following methods:
     Federal eRulemaking Portal: https://www.regulations.gov. 
Follow the instructions for submitting comments.
     Mail: Federal Docket Management System Office, 1160 
Defense Pentagon, Washington, DC 20301-1160.
    Instructions: All submissions received must include the agency name 
and docket number or RIN for this Federal Register document. The 
general policy for comments and other submissions from members of the 
public is to make these submissions available for public viewing on the 
Internet at https://www.regulations.gov as they are

[[Page 2292]]

received without change, including any personal identifiers or contact 
information.

FOR FURTHER INFORMATION CONTACT: Ms. Ann N. Fazzini, TRICARE Management 
Activity, Medical Benefits and Reimbursement Systems, telephone (303) 
676-3803.

SUPPLEMENTARY INFORMATION: 

I. Hospice

    This proposed rule revises the regulation for hospice periods of 
care. The Defense Authorization Act for FY 1992-1993, Public Law 102-
190, directed TRICARE to provide hospice care in the manner and under 
the conditions provided in section 1861(dd) of the Social Security Act 
(42 U.S.C. 1395x(dd)). Congress' intent was for TRICARE to establish a 
benefit in the same manner as Medicare. TRICARE originally had the same 
periods of hospice care used by Medicare; however, over time the 
Medicare benefit changed, but TRICARE's regulation has not. The TRICARE 
regulation currently provides for an initial period of 90 days, a 
subsequent period of 90 days, a second subsequent period of 30 days, 
and a final period of unlimited duration. Rather than maintaining this 
level of specificity in the regulation and to ensure that TRICARE and 
Medicare's benefit periods are equal, we are revising the regulation to 
state that the distinct periods of care available under the hospice 
benefit shall be the same as those offered under Medicare's hospice 
program. Currently under Medicare, patients are entitled to two 90-day 
election periods, followed by an unlimited number of 60-day periods. 
The level of specific benefits shall be included in the TRICARE 
Reimbursement Manual, and may be accessed at https://www.tricare.mil.

II. Physician Assistants and Assistant-at-Surgery

    The current regulatory language references specific reimbursement 
percentages for assistant-at-surgery reimbursement. Rather than 
including these specific percentage amounts, which would require a 
regulatory change any time the percentage amounts change, we are making 
a general statement referring to the current percentages used by 
Medicare. Our authority for this is 10 U.S.C. 1079(h) which states: 
Except as provided in paragraphs (2) and (3), payment for a charge for 
services by an individual health care professional (or other 
noninstitutional health care provider) for which a claim is submitted 
under a plan contracted for under subsection (a) shall be equal to an 
amount determined to be appropriate, to the extent practicable, in 
accordance with the same reimbursement rules as apply to payments for 
similar services under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.). The Secretary of Defense shall determine the 
appropriate payment amount under this paragraph in consultation with 
the other administering Secretaries. The specific percentages are more 
appropriately included in the TRICARE Reimbursement Manual, and may be 
accessed at https://www.tricare.mil.

III. DRG

    10 U.S.C. 1079(j)(2) provides that the amount to be paid to a 
provider of services for services provided under a plan covered by this 
section shall be determined under joint regulations to be prescribed by 
the administering Secretaries which provide that the amount of such 
payments shall be determined to the extent practicable in accordance 
with the same reimbursement rules as apply to payments to providers of 
services of the same type under title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.).
    In accordance with the above statute, the TRICARE/CHAMPUS DRG-based 
payment system transitioned to adopting the Medicare Severity-DRG based 
payment system on October 1, 2008. When TRICARE transitioned to the 
severity-based system, it was necessary to renumber the existing DRGs, 
and to assign different narrative descriptions to the DRG numbers. As a 
result, the existing regulatory reference to specific DRG numbers and 
descriptions became obsolete, so we are removing the numeric references 
in the regulation and utilizing only the descriptive terminology.

Regulatory Procedures

Executive Order 12866, ``Regulatory Planning and Review''

    Section 801 of title 5, United States Code, and Executive Order 
(E.O.) 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. It has 
been certified that this rule is not economically significant. It has 
been reviewed by the Office of Management and Budget as required under 
the provisions of E.O. 12866.

Public Law 104-4, Section 202, ``Unfunded Mandates Reform Act''

    Section 202 of Public Law 104-4, ``Unfunded Mandates Reform Act,'' 
requires that an analysis be performed to determine whether any Federal 
mandate may result in the expenditure by State, local and Tribal 
governments, in the aggregate, or by the private sector of $100 million 
in any one year. It has been certified that this proposed rule does not 
contain a Federal mandate that may result in the expenditure by State, 
local and Tribal governments, in aggregate, or by the private sector, 
of $100 million or more in any one year, and thus this proposed rule is 
not subject to this requirement.

Public Law 96-354, ``Regulatory Flexibility Act'' (RFA) (5 U.S.C. 601)

    Public Law 96-354, ``Regulatory Flexibility Act'' (RFA) (5 U.S.C. 
601), requires that each Federal agency prepare a regulatory 
flexibility analysis when the agency issues a regulation which would 
have a significant impact on a substantial number of small entities. 
This proposed rule is not an economically significant regulatory 
action, and it has been certified that it will not have a significant 
impact on a substantial number of small entities. Therefore, this 
proposed rule is not subject to the requirements of the RFA.

Public Law 96-511, ``Paperwork Reduction Act'' (44 U.S.C. Chapter 35)

    This rule does not contain a ``collection of information'' 
requirement, and will not impose additional information collection 
requirements on the public under Public Law 96-511, ``Paperwork 
Reduction Act'' (44 U.S.C. Chapter 35).

Executive Order 13132, ``Federalism''

    E.O. 13132, ``Federalism,'' requires that an impact analysis be 
performed to determine whether the rule has federalism implications 
that would have substantial direct effects on the States, on the 
relationship between the national government and the States, or on the 
distribution of power and responsibilities among the various levels of 
government. It has been certified that this proposed rule does not have 
federalism implications, as set forth in E.O. 13132.

List of Subjects in 32 CFR Part 199

    Claims, Dental health, Health care, Health insurance, Individuals 
with disabilities, Military personnel.

    Accordingly, 32 CFR Part 199 is proposed to be amended as follows:

[[Page 2293]]

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 amended by revising paragraph (e)(19)(v) to 
read as follows:


Sec.  199.4  Basic program benefits

* * * * *
    (e) * * *
    (19) * * *
    (v) Periods of care. Hospice care is divided into distinct periods 
of care. The periods of care that may be elected by the terminally ill 
CHAMPUS beneficiary shall be as the Director, TRICARE determines to be 
appropriate, but shall not be less than those offered under Medicare's 
Hospice Program.
* * * * *
    3. Section 199.14 is amended by revising paragraphs 
(a)(1)(ii)(C)(3), (a)(1)(iii)(A)(2), and (j)(1)(ix) to read as follows:


Sec.  199.14  Provider reimbursement methods

* * * * *
    (a) * * *
    (1) * * *
    (ii) * * *
    (C) * * *
    (3) All services related to heart and liver transplantation for 
admissions prior to October 1, 1998, which would otherwise be paid 
under the respective DRG.
* * * * *
    (iii) * * *
    (A) * * *
    (2) Remove DRGs. Those DRGs that represent discharges with invalid 
data or diagnoses insufficient for DRG assignment purposes are removed 
from the database.
* * * * *
    (j) * * *
    (1) * * *
    (ix) The allowable charge for physician assistant services other 
than assistant-at-surgery shall be at the same percentage, used by 
Medicare, of the allowable charge for a comparable service rendered by 
a physician performing the service in a similar location. For cases in 
which the physician assistant and the physician perform component 
services of a procedure other than assistant-at-surgery (e.g., home, 
office or hospital visit), the combined allowable charge for the 
procedure may not exceed the allowable charge for the procedure 
rendered by a physician alone. The allowable charge for physician 
assistant services performed as an assistant-at-surgery shall be at the 
same percentage, used by Medicare, of the allowable charge for a 
physician serving as an assistant surgeon when authorized as CHAMPUS 
benefits in accordance with the provisions of Sec.  199.4(c)(3)(iii). 
Physician assistant services must be billed through the employing 
physician who must be an authorized CHAMPUS provider.
* * * * *

    Dated: January 5, 2011.
Patricia L. Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2011-624 Filed 1-12-11; 8:45 am]
BILLING CODE 5001-06-P