TRICARE, Formerly Known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year 2012 Mental Health Rate Updates, 72911-72912 [2011-30514]
Download as PDF
<![CDATA[
72911
Federal Register / Vol. 76, No. 228 / Monday, November 28, 2011 / Notices
EXEMPTIONS CLAIMED FOR THE SYSTEM:
None.
[FR Doc. 2011–30539 Filed 11–25–11; 8:45 am]
BILLING CODE 5001–06–P
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE, Formerly Known as the
Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS);
Fiscal Year 2012 Mental Health Rate
Updates
Office of the Secretary,
Department of Defense.
ACTION: Notice of updated mental health
rates for Fiscal Year 2012.
AGENCY:
This notice provides the
updated regional per-diem rates for lowvolume mental health providers; the
update factor for hospital-specific perdiems; the updated cap per-diem for
high-volume providers; the beneficiary
per-diem cost-share amount for lowvolume providers; and, the updated perdiem rates for both full-day and half-day
TRICARE Partial Hospitalization
Programs for Fiscal Year 2012.
DATES: Effective Date: The Fiscal Year
2012 rates contained in this notice are
effective for services on or after October
1, 2011.
ADDRESSES: TRICARE Management
Activity (TMA), Medical Benefits and
Reimbursement Branch, 16401 East
Centretech Parkway, Aurora, CO 80011–
9066.
FOR FURTHER INFORMATION CONTACT: Elan
Green, Medical Benefits and
Reimbursement Branch, TMA,
telephone (303) 676–3907.
SUPPLEMENTARY INFORMATION: The final
rule published in the Federal Register
(FR) on September 6, 1988, (53 FR
34285) set forth reimbursement changes
that were effective for all inpatient
hospital admissions in psychiatric
hospitals and exempt psychiatric units
occurring on or after January 1, 1989.
The final rule published in the Federal
Register on July 1, 1993, (58 FR 35400)
set forth maximum per-diem rates for all
partial hospitalization admissions on or
SUMMARY:
after September 29, 1993. Included in
these final rules were provisions for
updating reimbursement rates for each
federal Fiscal Year. As stated in the final
rules, each per-diem shall be updated by
the Medicare update factor for hospitals
and units exempt from the Medicare
Prospective Payment System (i.e., this is
the same update factor used for the
inpatient prospective payment system).
For Fiscal Year 2012, the market basket
rate is 3.0 percent. This year, Medicare
applied two reductions to its market
basket amount: (1) A 1.0 percent
reduction for economy-wide
productivity required by section 3410(a)
of the Patient Protection and Affordable
Care Act (PPACA) which amended
section 1886(b)(3)(B) of the Social
Security Act, and (2) a 0.1 percent point
adjustment as required by section
1886(b)(3)(B)(xii) of the Act as added
and amended by sections 3401 and
10319(a) of the PPACA. These two
reductions do not apply to TRICARE.
Hospitals and units with hospitalspecific rates (hospitals and units with
high TRICARE volume) and regionalspecific rates for psychiatric hospitals
and units with low TRICARE volume
will have their TRICARE rates for Fiscal
Year 2012 updated by 3.0 percent
Partial hospitalization rates for fullday and half-day programs also will be
updated by 3.0 percent for Fiscal Year
2012.
The cap amount for high-volume
hospitals and units also will be updated
by the 3.0 percent for Fiscal Year 2012.
The beneficiary cost share for lowvolume hospitals and units also will be
updated by the 3.0 percent for Fiscal
Year 2012.
Per 32 CFR 199.14, the same area
wage indexes used for the CHAMPUS
Diagnosis-Related Group (DRG)-based
payment system shall be applied to the
wage portion of the applicable regional
per-diem for each day of the admission.
The wage portion shall be the same as
that used for the CHAMPUS DRG-based
payment system. For wage index values
greater than 1.0, the wage portion of the
regional rate subject to the area wage
adjustment is 68.8 percent for Fiscal
Year 2012. For wage index values less
than or equal to 1.0, the wage portion
of the regional rate subject to the area
wage adjustment is 62 percent.
Additionally, 32 CFR 199.14, requires
that hospital specific and regional perdiems shall be updated by the Medicare
update factor for hospitals and units
exempt from the Medicare prospective
payment system.
The following reflect an update of 3.0
percent for Fiscal Year 2012.
REGIONAL-SPECIFIC RATES FOR PSYCHIATRIC HOSPITALS AND UNITS
WITH LOW TRICARE VOLUME FOR
FISCAL YEAR 2012
Regional
rate
United States Census Region
Northeast:
New England .....................
Mid-Atlantic ........................
Midwest:
East North Central .............
West North Central ............
South:
South Atlantic ....................
East South Central ............
West South Central ...........
West:
Mountain ............................
Pacific ................................
Puerto Rico ........................
$787
758
655
618
780
834
711
710
838
53
Beneficiary cost-share: Beneficiary
cost-share (other than dependents of
Active Duty members) for care paid on
the basis of a regional per-diem rate is
the lower of $208 per day or 25 percent
of the hospital billed charges effective
for services rendered on or after October
1, 2011.
Cap Amount: Updated cap amount for
hospitals and units with high TRICARE
volume is $ 989 per day for services on
or after October 1, 2011.
The following reflect an update of 3.0
percent for Fiscal Year 2012 for the
partial hospitalization rates.
PARTIAL HOSPITALIZATION RATES FOR FULL-DAY AND HALF-DAY PROGRAMS
pmangrum on DSK3VPTVN1PROD with NOTICES
[Fiscal year 2012]
Full-day rate
(6 hours or more)
United States Census Region
Northeast:
New England (Maine, N.H., Vt., Mass., R.I., Conn.) ...........................................................................
Mid-Atlantic:
(N.Y., N.J., Penn.) ................................................................................................................................
Midwest:
East North Central (Ohio, Ind., Ill., Mich., Wis.) ...................................................................................
VerDate Mar<15>2010
15:34 Nov 25, 2011
Jkt 226001
PO 00000
Frm 00015
Fmt 4703
Sfmt 4703
E:\FR\FM\28NON1.SGM
Half-day rate
(3–5 hours)
$315
343
258
302
28NON1
$234
225
72912
Federal Register / Vol. 76, No. 228 / Monday, November 28, 2011 / Notices
PARTIAL HOSPITALIZATION RATES FOR FULL-DAY AND HALF-DAY PROGRAMS—Continued
[Fiscal year 2012]
Full-day rate
(6 hours or more)
United States Census Region
West North Central:
(Minn., Iowa, Mo., N.D., S.D., Neb., Kan.) ...........................................................................................
South:
South Atlantic (Del., Md., DC, Va., W.Va., N.C., S.C., Ga., Fla.) .......................................................
East South Central:
(Ky., Tenn., Ala., Miss.) ........................................................................................................................
West South Central:
(Ark., La., Texas, Okla.) .......................................................................................................................
West:
Mountain (Mon., Idaho, Wyo., Col., N.M., Ariz., Utah, Nev.) ...............................................................
Pacific (Wash., Ore., Calif., Alaska, Hawaii) ........................................................................................
Puerto Rico ..................................................................................................................................................
The above rates are effective for
services rendered on or after October 1,
2011.
Dated: November 22, 2011.
Aaron Siegel,
Alternate OSD Federal Register Liaison
Officer,
Department of Defense.
[FR Doc. 2011–30514 Filed 11–25–11; 8:45 am]
BILLING CODE 5001–06–P
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE; Civilian Health and Medical
Program of the Uniformed Services
(CHAMPUS); Fiscal Year 2012
Diagnosis-Related Group (DRG)
Updates
Office of the Secretary,
Department of Defense (DoD).
ACTION: Notice of DRG revised rates.
AGENCY:
This notice describes the
changes made to the TRICARE DRGbased payment system in order to
conform to changes made to the
Medicare Prospective Payment System
(PPS).
It also provides the updated fixed loss
cost outlier threshold, cost-to-charge
ratios and the data necessary to update
the FY 2012 rates.
DATES: Effective Dates: The rates,
weights and Medicare PPS changes
which affect the TRICARE DRG-based
payment system contained in this notice
are effective for admissions occurring on
or after October 1, 2011.
ADDRESSES: TRICARE Management
Activity (TMA), Medical Benefits and
Reimbursement Systems, 16401 East
Centretech Parkway, Aurora, CO 80011–
9066.
FOR FURTHER INFORMATION CONTACT:
Mark A. Jacobs, Medical Benefits and
pmangrum on DSK3VPTVN1PROD with NOTICES
SUMMARY:
VerDate Mar<15>2010
15:34 Nov 25, 2011
Jkt 226001
Reimbursement Systems, TMA,
telephone (303) 676–3802.
Questions regarding payment of
specific claims under the TRICARE
DRG-based payment system should be
addressed to the appropriate contractor.
SUPPLEMENTARY INFORMATION: The final
rule published on September 1, 1987 (52
FR 32992) set forth the basic procedures
used under the CHAMPUS DRG-based
payment system. This was subsequently
amended by final rules published
August 31, 1988 (53 FR 33461), October
21, 1988 (53 FR 41331), December 16,
1988 (53 FR 50515), May 30, 1990 (55
FR 21863), October 22, 1990 (55 FR
42560), and September 10, 1998 (63 FR
48439).
An explicit tenet of these final rules,
and one based on the statute authorizing
the use of DRGs by TRICARE, is that the
TRICARE DRG-based payment system is
modeled on the Medicare PPS, and that,
whenever practicable, the TRICARE
system will follow the same rules that
apply to the Medicare PPS. The Centers
for Medicare and Medicaid Services
(CMS) publishes these changes annually
in the Federal Register and discusses in
detail the impact of the changes.
In addition, this notice updates the
rates and weights in accordance with
our previous final rules. The actual
changes we are making, along with a
description of their relationship to the
Medicare PPS, are detailed below.
I. Medicare PPS Changes Which Affect
the TRICARE DRG-Based Payment
System
Following is a discussion of the
changes CMS has made to the Medicare
PPS that affect the TRICARE DRG-based
payment system.
A. DRG Classifications
Under both the Medicare PPS and the
TRICARE DRG-based payment system,
cases are classified into the appropriate
DRG by a Grouper program. The
PO 00000
Frm 00016
Fmt 4703
Sfmt 4703
Half-day rate
(3–5 hours)
302
225
323
244
350
264
350
264
353
347
225
267
260
170
Grouper classifies each case into a DRG
on the basis of the diagnosis and
procedure codes and demographic
information (that is, sex, age, and
discharge status). The Grouper used for
the TRICARE DRG-based payment
system is the same as the current
Medicare Grouper with two
modifications. The TRICARE system has
replaced Medicare DRG 435 with two
age-based DRGs (900 and 901), and has
implemented thirty-four (34) neonatal
DRGs in place of Medicare DRGs 385
through 390. For admissions occurring
on or after October 1, 2001, DRG 435 has
been replaced by DRG 523. The
TRICARE system has replaced DRG 523
with the two age-based DRGs (900 and
901). For admissions occurring on or
after October 1, 1995, the CHAMPUS
grouper hierarchy logic was changed so
the age split (age <29 days) and
assignments to MDC 15 occur before
assignment of the PreMDC DRGs. This
resulted in all neonate tracheostomies
and organ transplants to be grouped to
MDC 15 and not to DRGs 480–483 or
495. For admissions occurring on or
after October 1, 1998, the CHAMPUS
grouper hierarchy logic was changed to
move DRG 103 to the PreMDC DRGs and
to assign patients to PreMDC DRGs 480,
103 and 495 before assignment to MDC
15 DRGs and the neonatal DRGs. For
admissions occurring on or after
October 1, 2001, DRGs 512 and 513
were added to the PreMDC DRGs,
between DRGs 480 and 103 in the
TRICARE grouper hierarchy logic. For
admissions occurring on or after
October 1, 2004, DRG 483 was deleted
and replaced with DRGs 541 and 542,
splitting the assignment of cases on the
basis of the performance of a major
operating room procedure. The
description for DRG 480 was changed to
‘‘Liver Transplant and/or Intestinal
Transplant’’, and the description for
DRG 103 was changed to ‘‘Heart/Heart
E:\FR\FM\28NON1.SGM
28NON1
]]>Agencies
[Federal Register Volume 76, Number 228 (Monday, November 28, 2011)]
[Notices]
[Pages 72911-72912]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-30514]
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE, Formerly Known as the Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS); Fiscal Year 2012 Mental
Health Rate Updates
AGENCY: Office of the Secretary, Department of Defense.
ACTION: Notice of updated mental health rates for Fiscal Year 2012.
-----------------------------------------------------------------------
SUMMARY: This notice provides the updated regional per-diem rates for
low-volume mental health providers; the update factor for hospital-
specific per-diems; the updated cap per-diem for high-volume providers;
the beneficiary per-diem cost-share amount for low-volume providers;
and, the updated per-diem rates for both full-day and half-day TRICARE
Partial Hospitalization Programs for Fiscal Year 2012.
DATES: Effective Date: The Fiscal Year 2012 rates contained in this
notice are effective for services on or after October 1, 2011.
ADDRESSES: TRICARE Management Activity (TMA), Medical Benefits and
Reimbursement Branch, 16401 East Centretech Parkway, Aurora, CO 80011-
9066.
FOR FURTHER INFORMATION CONTACT: Elan Green, Medical Benefits and
Reimbursement Branch, TMA, telephone (303) 676-3907.
SUPPLEMENTARY INFORMATION: The final rule published in the Federal
Register (FR) on September 6, 1988, (53 FR 34285) set forth
reimbursement changes that were effective for all inpatient hospital
admissions in psychiatric hospitals and exempt psychiatric units
occurring on or after January 1, 1989. The final rule published in the
Federal Register on July 1, 1993, (58 FR 35400) set forth maximum per-
diem rates for all partial hospitalization admissions on or after
September 29, 1993. Included in these final rules were provisions for
updating reimbursement rates for each federal Fiscal Year. As stated in
the final rules, each per-diem shall be updated by the Medicare update
factor for hospitals and units exempt from the Medicare Prospective
Payment System (i.e., this is the same update factor used for the
inpatient prospective payment system). For Fiscal Year 2012, the market
basket rate is 3.0 percent. This year, Medicare applied two reductions
to its market basket amount: (1) A 1.0 percent reduction for economy-
wide productivity required by section 3410(a) of the Patient Protection
and Affordable Care Act (PPACA) which amended section 1886(b)(3)(B) of
the Social Security Act, and (2) a 0.1 percent point adjustment as
required by section 1886(b)(3)(B)(xii) of the Act as added and amended
by sections 3401 and 10319(a) of the PPACA. These two reductions do not
apply to TRICARE. Hospitals and units with hospital-specific rates
(hospitals and units with high TRICARE volume) and regional-specific
rates for psychiatric hospitals and units with low TRICARE volume will
have their TRICARE rates for Fiscal Year 2012 updated by 3.0 percent
Partial hospitalization rates for full-day and half-day programs
also will be updated by 3.0 percent for Fiscal Year 2012.
The cap amount for high-volume hospitals and units also will be
updated by the 3.0 percent for Fiscal Year 2012.
The beneficiary cost share for low-volume hospitals and units also
will be updated by the 3.0 percent for Fiscal Year 2012.
Per 32 CFR 199.14, the same area wage indexes used for the CHAMPUS
Diagnosis-Related Group (DRG)-based payment system shall be applied to
the wage portion of the applicable regional per-diem for each day of
the admission. The wage portion shall be the same as that used for the
CHAMPUS DRG-based payment system. For wage index values greater than
1.0, the wage portion of the regional rate subject to the area wage
adjustment is 68.8 percent for Fiscal Year 2012. For wage index values
less than or equal to 1.0, the wage portion of the regional rate
subject to the area wage adjustment is 62 percent.
Additionally, 32 CFR 199.14, requires that hospital specific and
regional per-diems shall be updated by the Medicare update factor for
hospitals and units exempt from the Medicare prospective payment
system.
The following reflect an update of 3.0 percent for Fiscal Year
2012.
Regional-Specific Rates for Psychiatric Hospitals and Units With Low
Tricare Volume for Fiscal Year 2012
------------------------------------------------------------------------
Regional
United States Census Region rate
------------------------------------------------------------------------
Northeast:
New England............................................ $787
Mid-Atlantic........................................... 758
Midwest:
East North Central..................................... 655
West North Central..................................... 618
South:
South Atlantic......................................... 780
East South Central..................................... 834
West South Central..................................... 711
West:
Mountain............................................... 710
Pacific................................................ 838
Puerto Rico............................................ 53
------------------------------------------------------------------------
Beneficiary cost-share: Beneficiary cost-share (other than
dependents of Active Duty members) for care paid on the basis of a
regional per-diem rate is the lower of $208 per day or 25 percent of
the hospital billed charges effective for services rendered on or after
October 1, 2011.
Cap Amount: Updated cap amount for hospitals and units with high
TRICARE volume is $ 989 per day for services on or after October 1,
2011.
The following reflect an update of 3.0 percent for Fiscal Year 2012
for the partial hospitalization rates.
Partial Hospitalization Rates for Full-Day and Half-Day Programs
[Fiscal year 2012]
------------------------------------------------------------------------
Full-day rate (6 Half-day rate (3-
United States Census Region hours or more) 5 hours)
------------------------------------------------------------------------
Northeast:
New England (Maine, N.H., Vt., $315 $234
Mass., R.I., Conn.)..........
Mid-Atlantic:
(N.Y., N.J., Penn.)........... 343 258
Midwest:
East North Central (Ohio, 302 225
Ind., Ill., Mich., Wis.).....
[[Page 72912]]
West North Central:
(Minn., Iowa, Mo., N.D., S.D., 302 225
Neb., Kan.)..................
South:
South Atlantic (Del., Md., DC, 323 244
Va., W.Va., N.C., S.C., Ga.,
Fla.)........................
East South Central:
(Ky., Tenn., Ala., Miss.)..... 350 264
West South Central:
(Ark., La., Texas, Okla.)..... 350 264
West:
Mountain (Mon., Idaho, Wyo., 353 267
Col., N.M., Ariz., Utah,
Nev.)........................
Pacific (Wash., Ore., Calif., 347 260
Alaska, Hawaii)..............
Puerto Rico....................... 225 170
------------------------------------------------------------------------
The above rates are effective for services rendered on or after
October 1, 2011.
Dated: November 22, 2011.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer,
Department of Defense.
[FR Doc. 2011-30514 Filed 11-25-11; 8:45 am]
BILLING CODE 5001-06-P
