TRICARE Certified Mental Health Counselors, 41636-41642 [2014-16702]
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41636
Federal Register / Vol. 79, No. 137 / Thursday, July 17, 2014 / Rules and Regulations
Issued in Renton, Washington, on June 19,
2014.
Michael Kaszycki,
Acting Manager, Transport Airplane
Directorate, Aircraft Certification Service.
[FR Doc. 2014–16781 Filed 7–16–14; 8:45 am]
BILLING CODE 4910–13–P
DEPARTMENT OF THE TREASURY
Internal Revenue Service
26 CFR Part 1
[TD 9664]
RIN 1545–BF80
Section 67 Limitations on Estates or
Trusts; Change of Effective Date
Internal Revenue Service (IRS),
Treasury.
ACTION: Final regulations; amendment.
AGENCY:
This document amends final
regulations (TD 9664) that were
published in the Federal Register on
May 9, 2014. The final regulations
provide guidance on which costs
incurred by estates or trusts other than
grantor trusts (non-grantor trusts) are
subject to the 2-percent floor for
miscellaneous itemized deductions
under section 67(a) of the Internal
Revenue Code.
DATES: Effective Date: This amendment
to the final regulations published on
May 9, 2014 (79 FR 90), is effective on
July 17, 2014.
Applicability Date: For date of
applicability, see § 1.67–4(d).
FOR FURTHER INFORMATION CONTACT:
Jennifer N. Keeney, (202) 317–6850 (not
a toll-free number).
SUPPLEMENTARY INFORMATION:
SUMMARY:
Background
The final regulations that are the
subject of these amendments are under
section 67 of the Internal Revenue Code.
The final regulations (TD 9664) were
published in the Federal Register on
Friday, May 9, 2014 (79 FR 90). The
final regulations applied to taxable years
beginning on or after May 9, 2014.
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Need for Amendment
The Treasury Department and the IRS
received a comment raising concerns
about the effective/applicability date of
the regulations. As issued, the final
regulations apply to taxable years
beginning on or after May 9, 2014.
Therefore, fiduciaries of existing trusts
and calendar-year estates would
implement the rules beginning January
1, 2015. However, the rules would apply
immediately to any non-grantor trust
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created after May 8, 2014, the estate of
any decedent who dies after May 8,
2014, and any existing fiscal-year estate
with a taxable year beginning after May
8, 2014. The commentator stated that
the effective/applicability date in the
regulations does not give fiduciaries of
these trusts and estates sufficient time to
implement the changes that are
necessary to comply with the
regulations. Specifically, the
commentator is concerned about
allowing fiduciaries sufficient time to
design and implement the necessary
program changes to determine the
portion of a bundled fee that is
attributable to costs that are subject to
the 2-percent floor versus costs that are
not subject to the 2-percent floor. In
response to these comments, this
document amends § 1.67–4(d) of the
Final Regulations so that the regulations
apply to taxable years beginning on or
after January 1, 2015.
List of Subjects in 26 CFR Part 1
Income taxes, Reporting and
recordkeeping requirements.
Adoption of Amendments to the
Regulations
Accordingly, 26 CFR part 1 is
amended as follows:
PART 1—INCOME TAXES
Paragraph 1. The authority citation
for part 1 continues to read in part as
follows:
■
Authority: 26 U.S.C. 7805 * * *
Par. 2. In § 1.67–4, paragraph (d) is
revised read as follows:
■
§ 1.67–4 Costs paid or incurred by estates
or non-grantor trusts.
*
*
*
*
*
(d) Effective/applicability date. This
section applies to taxable years
beginning after December 31, 2014.
Martin V. Franks,
Branch Chief, Publications & Regulations
Branch, Legal Processing Division, Associate
Chief Counsel, (Procedure & Administration).
[FR Doc. 2014–16834 Filed 7–16–14; 8:45 am]
BILLING CODE 4830–01–P
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DOD–2011–HA–0134]
RIN 0720–AB55
TRICARE Certified Mental Health
Counselors
Office of the Secretary,
Department of Defense (DoD).
ACTION: Final rule.
AGENCY:
The Department of Defense is
publishing this final rule to implement
the TRICARE Certified Mental Health
Counselor (TCMHC) provider type as a
qualified mental health provider
authorized to independently diagnose
and treat TRICARE beneficiaries and
receive reimbursement for services.
Additionally, we are extending the time
frame that was mentioned in the Interim
Final Rule for meeting certain
education, examination, and supervised
clinical practice criteria to be
considered for authorization as a
TCMHC. The time frame has been
changed from prior to January 1, 2015,
to prior to January 1, 2017. One final set
of criteria shall apply for the
authorization of the TCMHC beginning
January 1, 2017. The supervised mental
health counselor (SMHC) provider type,
while previously proposed to be
terminated under TRICARE, is now
continued indefinitely as an
extramedical individual provider
practicing mental health counseling
under the supervision of a TRICAREauthorized physician.
DATES: Effective Date: This rule is
effective August 18, 2014.
FOR FURTHER INFORMATION CONTACT: Dr.
Patricia Moseley, Defense Health
Agency, Clinical Support Division,
Behavioral Health Branch, 703–681–
0064.
SUPPLEMENTARY INFORMATION:
SUMMARY:
I. Executive Summary
A. Purpose of the Final Rule
1. The Need for the Regulatory Action
The purpose of this final rule is to
prescribe regulations that will allow
licensed or certified mental health
counselors to be able to independently
provide care to TRICARE beneficiaries
and receive payment for those services.
The final rule incorporates the
recommendations of the Institute of
Medicine (IOM) 2010 report for the
independent practice of mental health
counselors (MHCs) under TRICARE,
including specific education, licensure,
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examination, and supervised clinical
practice experience requirements in
order to become a TRICARE authorized
independent provider. This final rule
also provides for the continued
authorization of Supervised Mental
Health Counselors (SMHCs) as
TRICARE authorized providers when
practicing under physician referral and
supervision. This important change to
the interim final rule, will maintain
continuity of care for those beneficiaries
who are receiving services from SMHCs
under the current system and will help
to ensure a continued robust, quality
provider pool for TRICARE beneficiaries
to access when seeking medically
necessary and appropriate mental health
counseling services. Authorization of
TCMHCs and SMHCs is part of a
comprehensive quality-management
system implemented by TRICARE for all
mental health professionals.
2. Legal Authority for the Regulatory
Action
The legal authority for this Final Rule
is Section 724 of the National Defense
Authorization Act (NDAA) for Fiscal
Year 2011, Public Law 111–383, which
required the Department of Defense to
prescribe regulations to establish the
criteria that would allow licensed or
certified mental health counselors to be
able to independently provide care to
TRICARE beneficiaries and receive
payment for those services.
B. Summary of the Major Provisions of
the Final Rule
1. Designation of ‘‘TRICARE Certified
Mental Health Counselor (TCMHC)’’ as
an Allied Health Professional Under
TRICARE
This final rule establishes a new
category of individual professional
providers of medical care under the
TRICARE program entitled TRICARE
Certified Mental Health Counselors
(TCMHC).
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2. Under Basic Program Benefits,
Services of TCMHCs and SMHCs Are
Extended to Beneficiaries
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The date of the transition period
established in the IFR is extended in the
final rule and is changed accordingly
throughout this rule. TCMHCs who are
authorized during the transition period
are not required to be reauthorized
under the new criteria after January 1,
2017. Additionally, MHCs who meet all
certification requirements prior to the
end of the transition period can apply
for TRICARE authorization at any time
after the transition period. Such
authorization will be based on the
certification requirements met prior to
the end of the transition period.
Providers who do not meet all of the
certification requirements prior to the
expiration of the transition period will
be required to meet the quality
standards recommended by the IOM
and adopted by TRICARE, including
possession of a master’s or higher-level
degree from a Council for Accreditation
of Counseling and Related Educational
Programs (CACREP) accredited mental
health counseling program of education
and training as well as having passed
the National Clinical Mental Health
Counseling Examination (NCMHCE).
4. Expansion of Providers Authorized
To Supervise the Post-Master’s Clinical
Practice for Authorization as a TCMHC
This final rule modifies the criteria in
the IFR to permit supervision of a
prospective TCMHC’s post-master’s
clinical practice experience.
Supervision is no longer restricted to a
mental health counselor licensed for
independent practice in mental health
counseling in the jurisdiction where
practicing but may be gained from
multiple, licensed independent mental
health professionals, similar to industry
standards.
C. Costs and Benefits
Under this final rule, beneficiaries are
able to choose the services of a either a
TCMHC who independently provides
diagnostic and therapeutic services or a
Supervised Mental Health Counselor
(SMHC) who is authorized to provide
mental health counseling pursuant to
physician referral and ongoing
supervision of the beneficiary’s care.
This final rule rescinds the expiration
date published in the IFR for phase-out
the SMHC provider type. The rule also
adds appropriate definitions in 32 CFR
199.2 for SMHCs and TCMHCs.
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3. The Transition Period Is Extended to
December 31, 2016, for a MHC To Meet
the Currently Recognized Quality
Standards Required for Independent
Practice
This rule is not anticipated to have an
annual effect on the economy of $100
million or more; therefore, it is not an
economically significant rule under
Executive Order 12866 and the
Congressional Review Act. All services
and supplies authorized under the
TRICARE Basic Program must be
determined to be medically necessary in
the treatment of an illness, injury or
bodily malfunction before the care can
be cost shared by TRICARE. For this
reason, DoD anticipates that TRICARE
will have a marginal increase in cost
associated with increased access to
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authorized mental health counselors
within the TRICARE basic program.
II. Discussion of Final Rule
A. Background
1. The Conference Report (House
Report 109–360) to the National Defense
Authorization Act (NDAA) for Fiscal
Year (FY) 2006, requested the
Department of Defense to report on
actions taken to improve the efficiency
and effectiveness of procedures to
facilitate physician referral and
supervision of MHCs. The report
included a description of ‘‘best
practices’’ employed throughout the
military health system (MHS) to ensure
access to services provided by MHCs
under the TRICARE program. The report
concluded that there remained
significant variability among the states
in training programs and requirements
for licensure as a MHC. The report
stated that while there is evidence that
the extent of training variability
decreased over time, it continued to be
evident that professional counselors
licensed to practice had quite varying
exposure to classroom education and
supervised clinical experiences in the
assessment and treatment of persons
with mental disorders.
2. Section 717 of the National Defense
Authorization Act for Fiscal Year 2008,
Public Law 111–181, directed the
Secretary of Defense to conduct an
independent study of the credentials,
preparation, and training of individuals
practicing as licensed MHCs and to
make recommendations for permitting
licensed MHCs to practice
independently under the TRICARE
program. In this study, the Institute of
Medicine (IOM) of the National
Academies of Science recommended
allowing licensed MHCs who meet
certain requirements for training,
education, experience, certification, and
licensure to practice independently
under the TRICARE program. This final
rule implements changes to 32 CFR Part
199 largely based on those
recommendations.
3. Section 724 of the National Defense
Authorization Act for Fiscal Year 2011,
Public Law 111–383, required the
Department of Defense to prescribe
regulations that establish the criteria for
the independent practice of mental
health counselors, as previously studied
by the IOM in accordance with Section
717 of FY 2008 NDAA. As a result, the
published Interim Final Rule—
TRICARE: Certified Mental Health
Counselors (76 Federal Register 80741–
80744) requested 60 days of public
comment from December 27, 2011 until
February 27, 2012. In this final rule,
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these criteria allow licensed or certified
TCMHCs to independently provide care
to TRICARE beneficiaries and receive
payment for those services as do other
allied health professionals listed in 32
CFR 199.6(c)(3)(iii).
B. Certification Criteria for TRICARE
Certified Mental Health Counselor
(TCMHC) Independent Practice Under
TRICARE
This final rule establishes certification
criteria largely consistent with the
recommendations of the Institute of
Medicine (IOM) 2010 study, ‘‘Provision
of Mental Health Counseling Services
under TRICARE,’’ (https://www.iom.edu/
Reports/2010/Provision-of-MentalHealth-Counseling-Services-UnderTRICARE.aspx). The IOM
recommendations specify that the
independent practice of MHCs in
TRICARE should occur under certain
circumstances, to include:
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A master’s or higher level degree in
counseling from a program in mental health
counseling or clinical mental health
counseling that is accredited by the Council
for Accreditation of Counseling and Related
Educational Programs (CACREP); a state
license in mental health counseling at the
‘clinical’ or the higher or highest level
available in states that have tiered licensing
schemes; the passage of the National Clinical
Mental Health Counseling Examination; and
a well-defined scope of practice for
practitioners (p. 10).
TRICARE adopts the quality standards
recommended by the IOM. We
understand the availability of CACREP
accredited clinical mental health
counseling training programs and the
use of the NCMHCE examination as
quality standards are not yet widespread
in the field. To support this health care
provider transition, the new quality
standards for the independent practice
of TCMHCs will not fully replace
existing criteria, including regional
accreditation of institution programs
and passage of the National Counselor
Exam (NCE), until January 1, 2017.
While the IFR set an expiration date for
authorization of SMHCs to coincide
with the end of the transition period,
this final rule specifies that TRICARE
will continue authorization of SMHCs
indefinitely to preserve access to care
for our beneficiaries during and after the
transition period. This will preserve
patient access to an experienced and
well-trained mental health professional
provider group. At the same time, this
final rule is designed to encourage
greater participation of qualified MHCs
to become independent TCMHCs and
thus improve access to quality mental
health treatment for our beneficiaries.
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C. Additional Revisions to the
Regulations
In reviewing the interim final rule, we
realized that we inadvertently failed to
update several other provisions of the
regulation that reference ‘‘mental health
counselors’’ to account for the
expansion of provider types in this field
and the different rules that apply to
each. Consequently, in this final rule,
we have deleted the definition of
‘‘mental health counselor’’ from 32 CFR
199.2 and replaced it with definitions of
‘‘Supervised Mental Health Counselor’’
and ‘‘TRICARE Certified Mental Health
Counselor.’’ We have also revised 32
CFR 199.7(e)(3) to clearly indicate that
claims for reimbursement for services of
supervised mental health counselors
must include certification to the effect
that a written communication has been
made or will be made to the referring
physician at the end of treatment, or
more frequently, as required by the
referring physician. There is no similar
requirement for TCMHCs as they are
authorized to practice independently
III. Public Comments
The Interim Final Rule: TRICARE—
Certified Mental Health Counselors was
published in the Federal Register (76
FR 80741–80744) on December 27,
2011, for a 60-day public comment
period. We received 404 public
comments. Following is a summary of
the public comments and our responses.
Comment: A few commenters
suggested a change from the title of
Certified Mental Health Counselor
(CMHC) as was the proposed title
published in the Interim Final Rule,
because the acronym, CMHC, is very
similar to the National Board for
Certified Counselor’s (NBCC) title for
Certified Clinical Mental Health
Counselor (CCMHC).
Response: We agree and believe it is
necessary to distinguish the titles to
prevent confusion. Consequently, the
final rule will use the title, TRICARE
Certified Mental Health Counselor
(TCMHC).
Comment: Many commenters
recommended independent provider
status for qualified MHCs. Some
commenters requested continuation of
physician referral and supervision as a
condition of authorization.
Response: TRICARE appreciates the
skills and professional experience of the
MHCs seeking independent status and
recognizes the depth of expertise
represented by the current SMHC
provider pool. With this final rule,
TRICARE maintains a robust selection
of extramedical provider types for
beneficiaries, plus beneficiaries may
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now choose to receive medically
necessary and appropriate care from a
TCMHC without physician referral and
supervision. Under the final rule, the
criteria provider category of an SMHC
will remain indefinitely.
Comment: Multiple national
organizations and individuals expressed
concern about the time required to
obtain counseling degrees, licensure,
and supervised clinical practice hours
and to prepare for the NCMHCE. These
commenters requested additional time
for current counseling graduate students
to complete their degrees, gain
supervised clinical practice hours, and
pass national examinations in order to
become authorized for independent
practice under TRICARE.
Response: We recognize that the
combined education and examination
criteria for authorization as a TCMHC
may present a higher bar to the field of
mental health counseling in some states.
Consequently, the transition period has
been extended until January 1, 2017,
and this date is modified throughout the
final rule. The final rule balances the
implementation of quality standards for
MHCs with beneficiary access to their
services. This four year period allows
completion of counseling degrees,
supervised clinical practice hours, and
licensure under the existing quality
standards. MHCs who meet all of the
criteria for TCMHCs prior to end of the
transition period may apply for
certification after the transition period,
and this certification will be based on
the criteria (c)(3)(iii)(N)(2). This
extension also allows time for
experienced MHCs and currently
practicing SMHCs to pass the National
Clinical Mental Health Counseling
Examination (NCMHCE). This change
aims to ensure the availability of wellqualified, independent providers for our
beneficiaries.
Comment: Some commenters
suggested that any professional mental
health discipline or state licensed
professional counselors should be able
to supervise the clinical practice of the
MHC for TRICARE authorization as a
TCMHC. A few commenters recommend
supervisors use standards other than
those of the American Mental Health
Counselor Association (AMHCA)
standards.
Response: We appreciate these
suggestions and have amended the Final
Rule at 32 CFR 199.6(c)(3)(iii)(N)(1)(iii)
and (2)(iii) to expand the types of
providers authorized to supervise the
post-master’s clinical practice for
certification as a TCMHC. Supervision
is no longer restricted to mental health
counselors licensed for independent
practice but may be gained from
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multiple, licensed independent mental
health professionals, including
psychiatrists, clinical psychologists,
certified clinical social workers, and
certified psychiatric nurse specialists
who are licensed for independent
practice in the jurisdiction where
practicing and who are practicing
within the scope of their licenses.
SMHCs and pastoral counselors, who
require physician referral and
supervision, as well as marriage and
family therapists, do not meet the
qualification criteria as supervisors for
MHCs seeking authorization as
TCMHCs. The final rule addresses
supervised clinical practice that is
provided in a manner consistent with
the AMHCA guidelines specific to the
knowledge, skills, and practice of
mental health counseling. The
Department of Defense has elected to
adopt these standards, consistent with
the IOM’s recommendation, as the
AMHCA is the recognized national or
professional association that sets the
standards for the profession.
Comment: Many commenters request
that the licensed professional
counselors (LPCs) be allowed to practice
independently under TRICARE, for
example, psychotherapists; school,
career, substance abuse, and
rehabilitation counselors; expressive
arts therapists; and counseling
psychologists and licensed
psychological associates.
Response: We appreciate these
comments from individuals and
professional organizations. We are
aware that states allow specialty
counseling areas to practice under the
title of ‘‘licensed professional
counselor’’ or similar titles and that
educational requirements vary from
state to state. The 2006 MHS Report to
Congress and the 2010 IOM report noted
that the great majority of the states do
not require that a LPC graduate from a
mental health specialty counseling
program in order to be licensed to assess
and treat persons with mental disorders.
This final rule responds to the statutory
requirement for the Department to
prescribe criteria for the independent
practice of licensed and certified mental
health counselors. Thus, in the final
rule TCMHCs are required to have
specified education and training in
order to diagnose and treat mental
health conditions as individual
professional providers of care. This final
rule, however, also maintains SMHCs as
a category of authorized TRICARE
providers. Consequently, individuals,
including some of those specifically
identified by the commenters, who
possess either a master’s degree in
mental health counseling or an allied
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mental health field and meet all other
SMHC criteria, may also serve as
TRICARE authorized providers with
physician referral and ongoing
supervision.
Comment: Several commenters
recommend that TRICARE use a state
license for authorization as a TCMHC.
One commenter recommended that a
state license alone should be sufficient
as Medicaid and private insurance
companies consider them sufficient for
the practice of MHCs. Another
commenter raised concerns that the
criteria for authorizing TCMHCs will
result in ‘‘separate regulations for the
credentialing of mental health
counselors’’ for Medicaid, Medicare,
and TRICARE.
Response: We appreciate these
comments, but have determined that the
final rule will adhere to the IOM (2010)
recommendations that incorporate a set
of four criteria (licensure, education,
certification via examination, and
clinical supervision), not the state
license alone, for the independent
practice of MHCs under TRICARE. The
IOM Report discusses at greater length
both independent and supervised
practice under other federal programs.
We would note that Medicare does not
recognize licensed professional
counselors as independent providers, so
they are not directly reimbursed through
the program.
Comment: Some commenters asked
whether TRICARE requires professional
certification of a MHC.
Response: Yes. Reference to
professional licensure and certification
was unintentionally omitted from the
interim final rule. We appreciate the
comment and have corrected this
inadvertent exclusion for the final rule
by adding relevant provisions at 32 CFR
199.6(c)(3)(iii)(N)(1)(iv) and (2)(iv).
Consistent with TRICARE requirements,
professional certification is required
when a jurisdiction does not issue a
professional license [32 CFR
199.6(c)(2)(ii)]. Currently, all states (but
not all territories) issue professional
licensure for MHCs. In 1993,
professional certification by the
National Academy of Certified Mental
Health Counselors of the American
Mental Health Counselors Association
was placed in the National Board for
Certified Counselors’ credentialing
process. Thus the professional
certification of Certified Clinical Mental
Health Counselor is now required for
authorization as a TCMHC or SMHC in
those jurisdictions that do not issue a
professional license.
Comment: Multiple commenters
proposed the acceptance of their own
states’ or territories’ licensing criteria for
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41639
the number of hours of post-master’s
supervised clinical practice experience
for the TCMHC.
Response: As recognized by the IOM,
state requirements and practices can
vary considerably. The requirements for
all TRICARE authorized providers are
set forth by federal regulation,
specifically 32 CFR 199.6, including
professional licensure, certification, and
any specific education, training, and
experience necessary to promote the
delivery of services by fully qualified
individuals. By establishing uniform
standards, TRICARE seeks to provide
high quality behavioral health care
delivered by well-trained clinicians. No
compelling comments were submitted
to change the final rule requirement for
TCMHCs related to the hours of
supervised clinical practice.
Comment: A few commenters ask
whether a master’s degree from an
accredited on-line mental health or
clinical mental health program met the
criteria for independent practice under
TRICARE.
Response: The final rule makes no
distinction between how a degree is
earned, whether via distance learning or
otherwise, as long as the provider has
obtained a master’s or higher-level
degree from an appropriately accredited
mental health counseling program of
education and training. We would note,
however, at the present time that
CACREP and other regional accrediting
bodies accredit very few institutions’
programs that provide distance learning
for mental health counseling.
Comment: A few commenters
recommended that the National
Counselor Examination (NCE) should be
the ‘‘key to eligibility,’’ not program
accreditation. A few commenters
expressed that either the NCE or the
NCMHCE should be the accepted
criteria for certification. Other
commenters expressed appreciation that
passage of the NCMHCE with
graduation from a non-CACREP
accredited program in mental health
counseling is part of the eligibility
criteria.
Response: We appreciate these
comments. TRICARE accepted the
specific recommendations of the IOM
for the independent practice of MHCs,
to include accredited education as well
as examination criteria. To ensure the
availability of TCMHCs who meet these
quality standards during the transition
period, this final rule pairs the
examinations with the education
criteria. After the transition period, only
the more rigorous examination of
clinical knowledge of patient care, the
NCMHCE, is accepted for authorization
as a TCMHC.
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Comment: A few commenters suggest
that TRICARE certify graduates from all
universities that the federal government
approves and allocates federal
education funds. Other commenters ask
whether graduates of the Rehabilitation
Services of America (RSA) educational
programs are allowed to practice
independently under TRICARE, since
their scholarship program provides
federal funding for grants.
Response: The final rule makes no
distinction as to which universities and
educational programs receive federal
funding. Appropriately accredited
programs of education and training for
clinical mental health counselors, will
satisfy the educational requirements
applicable to TCMHCs and SMHCs
regardless of whether or not federal
funding has been provided. Conversely,
federal funding of programs that do not
meet the specified educational and
accreditation criteria will not serve to
waive the applicable requirements.
Additionally, we understand that the
RSA oversees competitive grant
programs designed to ensure that skilled
personnel are available to service the
rehabilitation needs of individuals with
disabilities and that many discretionary
grants are provided for master’s degrees
in rehabilitation counseling (https://
www2.ed.gov/students/college/aid/
rehab/carcouns.html). Congress
requested that the DoD prescribe criteria
for the authorization of MHCs to
practice independently under TRICARE.
The Department does not intend to
broaden the scope of this final rule to
rehabilitation counselors who do not
meet the criteria specified in the
regulation for TCMHCs or SMHCs.
Comment: Numerous commenters
recommended a grandfathering clause to
exempt a practicing MHC from meeting
the criteria of the final rule. Others
suggested the acceptance of each state’s
license as the criteria for grandfathering.
Some commenters specifically
recommended grandfathering MHCs
who have two to five years of
supervised experience serving the
military.
Response: We believe the changes that
have been made to the final rule to
permit the continued practice of SMHCs
under existing eligibility criteria, as well
as the extension of the transition period
for a MHC to meet the current quality
standards, adequately address these
comments while still ensuring the
provision of high quality mental health
care for beneficiaries, regardless of their
location. Specifically, the transition
period allows MHCs the time to meet
the quality standards for independent
practice and allows for the
implementation of uniform criteria that
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Jkt 232001
are not gained by grandfathering.
TRICARE recognizes that many mental
health counselors and current SMHCs
have graduated prior to the
establishment of either the CACREP
accreditation for mental health
counseling programs or the National
Board of Certified Counselor’s national
examination for clinical mental health
counselors. This final rule seeks to
balance the implementation of quality
standards for mental health counselors
with beneficiary access to those
services.
IV. Regulatory Impact Analysis
Overall Impact
The Department has examined the
impact of this final rule as required by
Executive Orders (EOs) 12866
(September 1993, Regulatory Planning
and Review) and 13563 (January 18,
2011, Improving Regulation and
Regulatory Review), the Regulatory
Flexibility Act (RFA) (September 19,
1980, Pub. L. 96–354), the Unfunded
Mandates Reform Act of 1995 (Pub. L.
104–4), and the Congressional Review
Act [5 U.S.C. 804(2)].
1. Executive Order 12866, ‘‘Regulatory
Planning and Review’’ and Executive
Order 13563, ‘‘Improving Regulation
and Regulatory Review’’
E.O.s 12866 and 13563 direct agencies
to assess all costs and benefits of
available regulatory alternatives and, if
regulation is necessary, to select
regulatory approaches that maximize
net benefits (including potential
economic, environmental, public health
and safety effects, distributive impacts,
and equity). E.O. 13563 emphasizes the
importance of quantifying both costs
and benefits, reducing costs,
harmonizing rules, and promoting
flexibility. A regulatory impact analysis
(RIA) must be prepared for major rules
with economically significant effects
($100 million or more in any one year).
We estimate that this rulemaking is not
‘‘economically significant’’ as measured
by the $100 million threshold and,
hence, is not a major rule under the
Congressional Review Act or the E.O.s.
2. Congressional Review Act, 5 U.S.C.
804(2)
Under the Congressional Review Act,
a major rule may not take effect until at
least 60 days after submission to
Congress of a report regarding the rule.
A major rule is one that would have an
annual effect on the economy of $100
million or more or have certain other
impacts. This Final rule is not a major
rule under the Congressional Review
Act.
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3. Public Law 96–354, ‘‘Regulatory
Flexibility Act’’ (RFA), Title 5, U.S.C.,
Sec. 601
The RFA requires agencies to analyze
options for regulatory relief of small
businesses if a rule has a significant
impact on a substantial number of small
entities. For purposes of the RFA, small
entities include small businesses,
nonprofit organizations, and small
governmental jurisdictions. This 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
rule is not subject to the requirements
of the RFA.
4. Public Law 104–4, Sec. 202,
‘‘Unfunded Mandates Reform Act’’
Section 202 of the Unfunded
Mandates Reform Act of 1995 also
requires that agencies assess anticipated
costs and benefits before issuing any
rule whose mandates require spending
in any one year of $100 million in 1995
dollars, updated annually for inflation.
That threshold level is currently
approximately $140 million. This final
rule will not mandate any requirements
for state, local, or tribal governments or
the private sector.
5. Public Law 96–511, ‘‘Paperwork
Reduction Act’’ (Title 44, U.S.C.,
Chapter 35)
This rule will not impose significant
additional information collection
requirements on the public under the
Paperwork Reduction Act of 1995 (44
U.S.C. 3502–3511). Existing information
collection requirements of the TRICARE
and Medicare programs will be utilized.
TRICARE authorized and non-network
providers will be coding and filing
claims in the same manner as they
currently are with TRICARE.
6. Executive Order 13132, ‘‘Federalism’’
This rule has been examined for its
impact under E.O. 13132, and it does
not contain policies that have
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 powers and
responsibilities among the various
levels of Government. Therefore,
consultation with State and local
officials is not required.
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
amended as follows:
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Federal Register / Vol. 79, No. 137 / Thursday, July 17, 2014 / Rules and Regulations
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. In § 199.2, paragraph (b) is amended
by removing the definition of ‘‘Mental
health counselor’’ and adding the
definitions of ‘‘Supervised mental
health counselor’’ and ‘‘TRICARE
certified mental health counselor’’ in
alphabetical order to read as follows:
■
§ 199.2
Definitions.
*
*
*
*
*
(b) * * *
Supervised mental health counselor.
An extramedical individual provider
who meets the requirements outlined in
§ 199.6.
*
*
*
*
*
TRICARE certified mental health
counselor. An allied health professional
who meets the requirements outlined in
§ 199.6.
*
*
*
*
*
■ 3. Section 199.4 is amended by
revising paragraph (c)(3)(ix)(A) to read
as follows:
§ 199.4
Basic program benefits.
pmangrum on DSK3VPTVN1PROD with RULES
*
*
*
*
*
(c) * * *
(3) * * *
(ix) * * *
(A) Covered diagnostic and
therapeutic services. Subject to the
requirements and limitations stated,
CHAMPUS benefits are payable for the
following services when rendered in the
diagnosis or treatment of a covered
mental disorder by a CHAMPUSauthorized, qualified mental health
provider practicing within the scope of
his or her license. Qualified mental
health providers are: Psychiatrists or
other physicians; clinical psychologists,
certified psychiatric nurse specialists,
certified clinical social workers,
certified marriage and family therapists,
TRICARE certified mental health
counselors, pastoral counselors under a
physician’s supervision and supervised
mental health counselors under a
physician’s supervision. No payment
will be made for any service listed in
paragraph (c)(3)(ix)(A) of this section
rendered by an individual who does not
meet the criteria of § 199.6 for his or her
respective profession, regardless of
whether the provider is an independent
professional provider or an employee of
an authorized professional or
institutional provider.
*
*
*
*
*
VerDate Mar<15>2010
14:56 Jul 16, 2014
4. Section 199.6 is amended by
revising paragraphs (c)(3)(iii)(N) and
(c)(3)(iv)(C) to read as follows:
■
PART 199—[AMENDED]
Jkt 232001
§ 199.6
TRICARE—authorized providers.
*
*
*
*
*
(c) * * *
(3) * * *
(iii) * * *
(N) TRICARE certified mental health
counselor. For the purposes of
CHAMPUS, a TRICARE certified mental
health counselor (TCMHC) must be
licensed for independent practice in
mental health counseling by the
jurisdiction where practicing. In
jurisdictions with two or more licenses
allowing for differing scopes of
independent practice, the licensed
mental health counselor may only
practice within the scope of the license
he or she possesses. In addition, a
TCMHC must meet the requirements of
either paragraph (c)(3)(iii)(N)(1) or the
requirements of paragraph
(c)(3)(iii)(N)(2) of this section.
(1) The requirements of this paragraph
are that the TCMHC:
(i) Must have passed the National
Clinical Mental Health Counselor
Examination (NCMHCE) or its successor
as determined by the Director, TMA;
and
(ii) Must possess a master’s or higherlevel degree from a mental health
counseling program of education and
training accredited by the Council for
Accreditation of Counseling and Related
Educational Programs (CACREP); and
(iii) Must have a minimum of two (2)
years of post-master’s degree supervised
mental health counseling practice
which includes a minimum of 3,000
hours of supervised clinical practice
and 100 hours of face-to-face
supervision. Supervision must be
provided by mental health counselors at
the highest level of state licensure,
psychiatrists, clinical psychologists,
certified clinical social workers, or
certified psychiatric nurse specialists
who are licensed for independent
practice in the jurisdiction where
practicing and who are practicing
within the scope of their licenses.
Supervised clinical practice must be
received in a manner that is consistent
with the guidelines regarding
knowledge, skills, and practice
standards for supervision of the
American Mental Health Counselors
Association; and
(iv) Is licensed or certified for
independent practice in mental health
counseling by the jurisdiction where
practicing (see paragraph (c)(2)(ii) of
this section for more specific
information).
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41641
(2) The requirements of this paragraph
are that the TCMHC, prior to January 1,
2017:
(i) Possess a master’s or higher-level
degree from a mental health counseling
program of education and training
accredited by CACREP and must have
passed the National Counselor
Examination (NCE); or
(ii) Possess a master’s or higher-level
degree from a mental health counseling
program of education and training from
either a CACREP or regionally
accredited institution and have passed
the NCMHCE; and
(iii) Must have a minimum of two (2)
years of post-master’s degree supervised
mental health counseling practice
which includes a minimum of 3,000
hours of supervised clinical practice
and 100 hours of face-to-face
supervision. Supervision must be
provided by mental health counselors at
the highest level of state licensure,
psychiatrists, clinical psychologists,
certified clinical social workers, or
certified psychiatric nurse specialists
who are licensed for independent
practice in the jurisdiction where
practicing and who are practicing
within the scope of their licenses.
Supervised clinical practice must be
received in a manner that is consistent
with the guidelines regarding
knowledge, skills, and practice
standards for supervision of the
American Mental Health Counselors
Association; and
(iv) Is licensed or certified for
independent practice in mental health
counseling by the jurisdiction where
practicing (see paragraph (c)(2)(ii) of
this section for more specific
information).
(3) The Director, TRICARE
Management Activity may amend or
modify existing or specify additional
certification requirements as needed to
accommodate future practice and
licensing standards and to ensure that
all TCMHCs continue to meet
educational, licensing, and clinical
training requirements considered
appropriate.
(iv) * * *
(C) Supervised mental health
counselor. For the purposes of
TRICARE, a supervised mental health
counselor is an individual who does not
meet the requirements of a TRICARE
certified mental health counselor in
paragraph (c)(3)(iii)(N) of this section,
but meets all of the following
requirements and conditions of practice:
(1) Minimum of a master’s degree in
mental health counseling or allied
mental health field from a regionally
accredited institution; and
E:\FR\FM\17JYR1.SGM
17JYR1
41642
Federal Register / Vol. 79, No. 137 / Thursday, July 17, 2014 / Rules and Regulations
(2) Two years of post-masters
experience which includes 3,000 hours
of clinical work and 100 hours of faceto-face supervision; and
(3) Is licensed or certified to practice
as a mental health counselor by the
jurisdiction where practicing (see
paragraph (c)(3)(iv)(D) of this section for
more specific information); and
(4) May only be reimbursed when:
(i) The TRICARE beneficiary is
referred for therapy by a physician; and
(ii) A physician is providing ongoing
oversight and supervision of the therapy
being provided; and
(iii) The mental health counselor
certifies on each claim for
reimbursement that a written
communication has been made or will
be made to the referring physician of the
results of the treatment. Such
communication will be made at the end
of the treatment, or more frequently, as
required by the referring physician
(refer to § 199.7).
*
*
*
*
*
5. Section 199.7 is amended by
revising paragraphs (e)(3) to read as
follows:
■
§ 199.7 Claims submission, review, and
payment.
*
*
*
*
(e) * * *
(3) Claims involving the services of
marriage and family counselors, pastoral
counselors, and supervised mental
health counselors. CHAMPUS requires
that marriage and family counselors,
pastoral counselors, and supervised
mental health counselors make a written
report to the referring physician
concerning the CHAMPUS beneficiary’s
progress. Therefore, each claim for
reimbursement for services of marriage
and family counselors, pastoral
counselors, and supervised mental
health counselors must include
certification to the effect that a written
communication has been made or will
be made to the referring physician at the
end of treatment, or more frequently, as
required by the referring physician.
*
*
*
*
*
pmangrum on DSK3VPTVN1PROD with RULES
*
Dated: July 11, 2014.
Aaron Siegel,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
[FR Doc. 2014–16702 Filed 7–16–14; 8:45 am]
BILLING CODE 5001–06–P
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14:56 Jul 16, 2014
Jkt 232001
DEPARTMENT OF HOMELAND
SECURITY
Coast Guard
33 CFR Part 117
[Docket No. USCG–2013–0848]
RIN 1625–AA09
Drawbridge Operation Regulations;
Gulf Intracoastal Waterway, Venice, FL
Coast Guard, DHS.
Final rule.
AGENCY:
ACTION:
The Coast Guard is modifying
the operating schedule that governs the
Hatchett Creek (US–41) Twin Bridges,
Gulf Intracoastal Waterway mile 56.9,
Venice, FL. Changing the operational
schedule of the Hatchett Creek (US–41)
Twin Bridges will allow the 8 hour,
Sarasota Iron Man Triathlon to occur
annually without being interrupted.
This event is anticipated to be
scheduled annually on the second
Sunday of November, from 9 a.m. to 5
p.m.
DATES: This rule is effective August 18,
2014.
ADDRESSES: Documents mentioned in
this preamble are part of docket [USCG–
2013–0848]. To view documents
mentioned in this preamble as being
available in the docket, go to https://
www.regulations.gov, type the docket
number in the ‘‘SEARCH’’ box and click
‘‘SEARCH.’’ Click on Open Docket
Folder on the line associated with this
rulemaking. You may also visit the
Docket Management Facility in Room
W12–140 on the ground floor of the
Department of Transportation West
Building, 1200 New Jersey Avenue SE.,
Washington, DC 20590, between 9 a.m.
and 5 p.m., Monday through Friday,
except Federal holidays.
FOR FURTHER INFORMATION CONTACT: If
you have questions about this rule, call
or email Ms. Danielle Mauser, Seventh
Coast Guard District, Bridge Branch,
305–415–6946, email
Danielle.L.Mauser2@uscg.mil. If you
have questions about viewing the
docket, call Cheryl Collins, Program
Manager, Docket Operations, telephone
202–366–9826.
SUPPLEMENTARY INFORMATION:
SUMMARY:
Table of Acronyms
CFR Code of Federal Regulations
DHS Department of Homeland Security
FR Federal Register
NPRM Notice of Proposed Rulemaking
§ Section Symbol
U.S.C. United States Code
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Fmt 4700
Sfmt 4700
A. Regulatory History and Information
On November 21, 2013, we published
a notice of proposed rulemaking
(NPRM) entitled, ‘‘Drawbridge
Operation Regulations; Gulf Intracoastal
Waterway, Venice, FL’’ in the Federal
Register (78 FR 69803). No comments
on the proposed rule were received. No
public meeting was requested or held.
B. Basis and Purpose
The changes will have a minor impact
on vessels transiting the Gulf
Intracoastal Waterway in the vicinity of
Venice, Florida, but will still meet the
reasonable needs to navigation. This
action will accommodate the Sarasota
Iron Man Triathlon held annually on the
second Sunday of November.
C. Discussion of Comments, Changes
and the Final Rule
No comments were received. This
rule will allow the Hatchett Creek
Bridge to remain closed to navigation
for eight hours for an annual event. This
rule will revise paragraph (b) in 33 CFR
117.287 to include this eight hour
closure for the second Sunday in
November annually. The Hatchett Creek
(US–41) Bridge provides a vertical
clearance of 16 feet at mean high water
in the closed position and a horizontal
clearance of 90 feet. Vessels with a
height of less than 16 feet may pass
through the bridge at any time. The Gulf
of Mexico is the only alternative route,
and this route would be unacceptable
for certain classes of vessels such as tugs
and barges.
D. Regulatory Analyses
The rule was developed after
considering numerous statutes and
executive orders related to rulemaking.
Below is a summary of the analysis
based on the aforementioned statutes
and executive orders.
1. Regulatory Planning and Review
This rule is not a significant
regulatory action under section 3(f) of
Executive Order 12866, Regulatory
Planning and Review, as supplemented
by Executive Order 13563, Improving
Regulation and Regulatory Review. It
does not require an assessment of
potential costs and benefits under
section 6(a)(3) of Order 12866 or under
section 1 of Executive Order 13563. The
Office of Management and Budget has
not reviewed it under those Orders.
This rule is not a significant
regulatory action because it will only
have a minor impact on vessels
transiting the Gulf Intracoastal
Waterway in the vicinity of Venice,
Florida and it will still meet the
reasonable needs of navigation.
E:\FR\FM\17JYR1.SGM
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Agencies
[Federal Register Volume 79, Number 137 (Thursday, July 17, 2014)]
[Rules and Regulations]
[Pages 41636-41642]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-16702]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DOD-2011-HA-0134]
RIN 0720-AB55
TRICARE Certified Mental Health Counselors
AGENCY: Office of the Secretary, Department of Defense (DoD).
ACTION: Final rule.
-----------------------------------------------------------------------
SUMMARY: The Department of Defense is publishing this final rule to
implement the TRICARE Certified Mental Health Counselor (TCMHC)
provider type as a qualified mental health provider authorized to
independently diagnose and treat TRICARE beneficiaries and receive
reimbursement for services. Additionally, we are extending the time
frame that was mentioned in the Interim Final Rule for meeting certain
education, examination, and supervised clinical practice criteria to be
considered for authorization as a TCMHC. The time frame has been
changed from prior to January 1, 2015, to prior to January 1, 2017. One
final set of criteria shall apply for the authorization of the TCMHC
beginning January 1, 2017. The supervised mental health counselor
(SMHC) provider type, while previously proposed to be terminated under
TRICARE, is now continued indefinitely as an extramedical individual
provider practicing mental health counseling under the supervision of a
TRICARE-authorized physician.
DATES: Effective Date: This rule is effective August 18, 2014.
FOR FURTHER INFORMATION CONTACT: Dr. Patricia Moseley, Defense Health
Agency, Clinical Support Division, Behavioral Health Branch, 703-681-
0064.
SUPPLEMENTARY INFORMATION:
I. Executive Summary
A. Purpose of the Final Rule
1. The Need for the Regulatory Action
The purpose of this final rule is to prescribe regulations that
will allow licensed or certified mental health counselors to be able to
independently provide care to TRICARE beneficiaries and receive payment
for those services. The final rule incorporates the recommendations of
the Institute of Medicine (IOM) 2010 report for the independent
practice of mental health counselors (MHCs) under TRICARE, including
specific education, licensure,
[[Page 41637]]
examination, and supervised clinical practice experience requirements
in order to become a TRICARE authorized independent provider. This
final rule also provides for the continued authorization of Supervised
Mental Health Counselors (SMHCs) as TRICARE authorized providers when
practicing under physician referral and supervision. This important
change to the interim final rule, will maintain continuity of care for
those beneficiaries who are receiving services from SMHCs under the
current system and will help to ensure a continued robust, quality
provider pool for TRICARE beneficiaries to access when seeking
medically necessary and appropriate mental health counseling services.
Authorization of TCMHCs and SMHCs is part of a comprehensive quality-
management system implemented by TRICARE for all mental health
professionals.
2. Legal Authority for the Regulatory Action
The legal authority for this Final Rule is Section 724 of the
National Defense Authorization Act (NDAA) for Fiscal Year 2011, Public
Law 111-383, which required the Department of Defense to prescribe
regulations to establish the criteria that would allow licensed or
certified mental health counselors to be able to independently provide
care to TRICARE beneficiaries and receive payment for those services.
B. Summary of the Major Provisions of the Final Rule
1. Designation of ``TRICARE Certified Mental Health Counselor (TCMHC)''
as an Allied Health Professional Under TRICARE
This final rule establishes a new category of individual
professional providers of medical care under the TRICARE program
entitled TRICARE Certified Mental Health Counselors (TCMHC).
2. Under Basic Program Benefits, Services of TCMHCs and SMHCs Are
Extended to Beneficiaries
Under this final rule, beneficiaries are able to choose the
services of a either a TCMHC who independently provides diagnostic and
therapeutic services or a Supervised Mental Health Counselor (SMHC) who
is authorized to provide mental health counseling pursuant to physician
referral and ongoing supervision of the beneficiary's care. This final
rule rescinds the expiration date published in the IFR for phase-out
the SMHC provider type. The rule also adds appropriate definitions in
32 CFR 199.2 for SMHCs and TCMHCs.
3. The Transition Period Is Extended to December 31, 2016, for a MHC To
Meet the Currently Recognized Quality Standards Required for
Independent Practice
The date of the transition period established in the IFR is
extended in the final rule and is changed accordingly throughout this
rule. TCMHCs who are authorized during the transition period are not
required to be reauthorized under the new criteria after January 1,
2017. Additionally, MHCs who meet all certification requirements prior
to the end of the transition period can apply for TRICARE authorization
at any time after the transition period. Such authorization will be
based on the certification requirements met prior to the end of the
transition period. Providers who do not meet all of the certification
requirements prior to the expiration of the transition period will be
required to meet the quality standards recommended by the IOM and
adopted by TRICARE, including possession of a master's or higher-level
degree from a Council for Accreditation of Counseling and Related
Educational Programs (CACREP) accredited mental health counseling
program of education and training as well as having passed the National
Clinical Mental Health Counseling Examination (NCMHCE).
4. Expansion of Providers Authorized To Supervise the Post-Master's
Clinical Practice for Authorization as a TCMHC
This final rule modifies the criteria in the IFR to permit
supervision of a prospective TCMHC's post-master's clinical practice
experience. Supervision is no longer restricted to a mental health
counselor licensed for independent practice in mental health counseling
in the jurisdiction where practicing but may be gained from multiple,
licensed independent mental health professionals, similar to industry
standards.
C. Costs and Benefits
This rule is not anticipated to have an annual effect on the
economy of $100 million or more; therefore, it is not an economically
significant rule under Executive Order 12866 and the Congressional
Review Act. All services and supplies authorized under the TRICARE
Basic Program must be determined to be medically necessary in the
treatment of an illness, injury or bodily malfunction before the care
can be cost shared by TRICARE. For this reason, DoD anticipates that
TRICARE will have a marginal increase in cost associated with increased
access to authorized mental health counselors within the TRICARE basic
program.
II. Discussion of Final Rule
A. Background
1. The Conference Report (House Report 109-360) to the National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2006, requested
the Department of Defense to report on actions taken to improve the
efficiency and effectiveness of procedures to facilitate physician
referral and supervision of MHCs. The report included a description of
``best practices'' employed throughout the military health system (MHS)
to ensure access to services provided by MHCs under the TRICARE
program. The report concluded that there remained significant
variability among the states in training programs and requirements for
licensure as a MHC. The report stated that while there is evidence that
the extent of training variability decreased over time, it continued to
be evident that professional counselors licensed to practice had quite
varying exposure to classroom education and supervised clinical
experiences in the assessment and treatment of persons with mental
disorders.
2. Section 717 of the National Defense Authorization Act for Fiscal
Year 2008, Public Law 111-181, directed the Secretary of Defense to
conduct an independent study of the credentials, preparation, and
training of individuals practicing as licensed MHCs and to make
recommendations for permitting licensed MHCs to practice independently
under the TRICARE program. In this study, the Institute of Medicine
(IOM) of the National Academies of Science recommended allowing
licensed MHCs who meet certain requirements for training, education,
experience, certification, and licensure to practice independently
under the TRICARE program. This final rule implements changes to 32 CFR
Part 199 largely based on those recommendations.
3. Section 724 of the National Defense Authorization Act for Fiscal
Year 2011, Public Law 111-383, required the Department of Defense to
prescribe regulations that establish the criteria for the independent
practice of mental health counselors, as previously studied by the IOM
in accordance with Section 717 of FY 2008 NDAA. As a result, the
published Interim Final Rule--TRICARE: Certified Mental Health
Counselors (76 Federal Register 80741-80744) requested 60 days of
public comment from December 27, 2011 until February 27, 2012. In this
final rule,
[[Page 41638]]
these criteria allow licensed or certified TCMHCs to independently
provide care to TRICARE beneficiaries and receive payment for those
services as do other allied health professionals listed in 32 CFR
199.6(c)(3)(iii).
B. Certification Criteria for TRICARE Certified Mental Health Counselor
(TCMHC) Independent Practice Under TRICARE
This final rule establishes certification criteria largely
consistent with the recommendations of the Institute of Medicine (IOM)
2010 study, ``Provision of Mental Health Counseling Services under
TRICARE,'' (https://www.iom.edu/Reports/2010/Provision-of-Mental-Health-Counseling-Services-Under-TRICARE.aspx). The IOM recommendations
specify that the independent practice of MHCs in TRICARE should occur
under certain circumstances, to include:
A master's or higher level degree in counseling from a program
in mental health counseling or clinical mental health counseling
that is accredited by the Council for Accreditation of Counseling
and Related Educational Programs (CACREP); a state license in mental
health counseling at the `clinical' or the higher or highest level
available in states that have tiered licensing schemes; the passage
of the National Clinical Mental Health Counseling Examination; and a
well-defined scope of practice for practitioners (p. 10).
TRICARE adopts the quality standards recommended by the IOM. We
understand the availability of CACREP accredited clinical mental health
counseling training programs and the use of the NCMHCE examination as
quality standards are not yet widespread in the field. To support this
health care provider transition, the new quality standards for the
independent practice of TCMHCs will not fully replace existing
criteria, including regional accreditation of institution programs and
passage of the National Counselor Exam (NCE), until January 1, 2017.
While the IFR set an expiration date for authorization of SMHCs to
coincide with the end of the transition period, this final rule
specifies that TRICARE will continue authorization of SMHCs
indefinitely to preserve access to care for our beneficiaries during
and after the transition period. This will preserve patient access to
an experienced and well-trained mental health professional provider
group. At the same time, this final rule is designed to encourage
greater participation of qualified MHCs to become independent TCMHCs
and thus improve access to quality mental health treatment for our
beneficiaries.
C. Additional Revisions to the Regulations
In reviewing the interim final rule, we realized that we
inadvertently failed to update several other provisions of the
regulation that reference ``mental health counselors'' to account for
the expansion of provider types in this field and the different rules
that apply to each. Consequently, in this final rule, we have deleted
the definition of ``mental health counselor'' from 32 CFR 199.2 and
replaced it with definitions of ``Supervised Mental Health Counselor''
and ``TRICARE Certified Mental Health Counselor.'' We have also revised
32 CFR 199.7(e)(3) to clearly indicate that claims for reimbursement
for services of supervised mental health counselors must include
certification to the effect that a written communication has been made
or will be made to the referring physician at the end of treatment, or
more frequently, as required by the referring physician. There is no
similar requirement for TCMHCs as they are authorized to practice
independently
III. Public Comments
The Interim Final Rule: TRICARE--Certified Mental Health Counselors
was published in the Federal Register (76 FR 80741-80744) on December
27, 2011, for a 60-day public comment period. We received 404 public
comments. Following is a summary of the public comments and our
responses.
Comment: A few commenters suggested a change from the title of
Certified Mental Health Counselor (CMHC) as was the proposed title
published in the Interim Final Rule, because the acronym, CMHC, is very
similar to the National Board for Certified Counselor's (NBCC) title
for Certified Clinical Mental Health Counselor (CCMHC).
Response: We agree and believe it is necessary to distinguish the
titles to prevent confusion. Consequently, the final rule will use the
title, TRICARE Certified Mental Health Counselor (TCMHC).
Comment: Many commenters recommended independent provider status
for qualified MHCs. Some commenters requested continuation of physician
referral and supervision as a condition of authorization.
Response: TRICARE appreciates the skills and professional
experience of the MHCs seeking independent status and recognizes the
depth of expertise represented by the current SMHC provider pool. With
this final rule, TRICARE maintains a robust selection of extramedical
provider types for beneficiaries, plus beneficiaries may now choose to
receive medically necessary and appropriate care from a TCMHC without
physician referral and supervision. Under the final rule, the criteria
provider category of an SMHC will remain indefinitely.
Comment: Multiple national organizations and individuals expressed
concern about the time required to obtain counseling degrees,
licensure, and supervised clinical practice hours and to prepare for
the NCMHCE. These commenters requested additional time for current
counseling graduate students to complete their degrees, gain supervised
clinical practice hours, and pass national examinations in order to
become authorized for independent practice under TRICARE.
Response: We recognize that the combined education and examination
criteria for authorization as a TCMHC may present a higher bar to the
field of mental health counseling in some states. Consequently, the
transition period has been extended until January 1, 2017, and this
date is modified throughout the final rule. The final rule balances the
implementation of quality standards for MHCs with beneficiary access to
their services. This four year period allows completion of counseling
degrees, supervised clinical practice hours, and licensure under the
existing quality standards. MHCs who meet all of the criteria for
TCMHCs prior to end of the transition period may apply for
certification after the transition period, and this certification will
be based on the criteria (c)(3)(iii)(N)(2). This extension also allows
time for experienced MHCs and currently practicing SMHCs to pass the
National Clinical Mental Health Counseling Examination (NCMHCE). This
change aims to ensure the availability of well-qualified, independent
providers for our beneficiaries.
Comment: Some commenters suggested that any professional mental
health discipline or state licensed professional counselors should be
able to supervise the clinical practice of the MHC for TRICARE
authorization as a TCMHC. A few commenters recommend supervisors use
standards other than those of the American Mental Health Counselor
Association (AMHCA) standards.
Response: We appreciate these suggestions and have amended the
Final Rule at 32 CFR 199.6(c)(3)(iii)(N)(1)(iii) and (2)(iii) to expand
the types of providers authorized to supervise the post-master's
clinical practice for certification as a TCMHC. Supervision is no
longer restricted to mental health counselors licensed for independent
practice but may be gained from
[[Page 41639]]
multiple, licensed independent mental health professionals, including
psychiatrists, clinical psychologists, certified clinical social
workers, and certified psychiatric nurse specialists who are licensed
for independent practice in the jurisdiction where practicing and who
are practicing within the scope of their licenses. SMHCs and pastoral
counselors, who require physician referral and supervision, as well as
marriage and family therapists, do not meet the qualification criteria
as supervisors for MHCs seeking authorization as TCMHCs. The final rule
addresses supervised clinical practice that is provided in a manner
consistent with the AMHCA guidelines specific to the knowledge, skills,
and practice of mental health counseling. The Department of Defense has
elected to adopt these standards, consistent with the IOM's
recommendation, as the AMHCA is the recognized national or professional
association that sets the standards for the profession.
Comment: Many commenters request that the licensed professional
counselors (LPCs) be allowed to practice independently under TRICARE,
for example, psychotherapists; school, career, substance abuse, and
rehabilitation counselors; expressive arts therapists; and counseling
psychologists and licensed psychological associates.
Response: We appreciate these comments from individuals and
professional organizations. We are aware that states allow specialty
counseling areas to practice under the title of ``licensed professional
counselor'' or similar titles and that educational requirements vary
from state to state. The 2006 MHS Report to Congress and the 2010 IOM
report noted that the great majority of the states do not require that
a LPC graduate from a mental health specialty counseling program in
order to be licensed to assess and treat persons with mental disorders.
This final rule responds to the statutory requirement for the
Department to prescribe criteria for the independent practice of
licensed and certified mental health counselors. Thus, in the final
rule TCMHCs are required to have specified education and training in
order to diagnose and treat mental health conditions as individual
professional providers of care. This final rule, however, also
maintains SMHCs as a category of authorized TRICARE providers.
Consequently, individuals, including some of those specifically
identified by the commenters, who possess either a master's degree in
mental health counseling or an allied mental health field and meet all
other SMHC criteria, may also serve as TRICARE authorized providers
with physician referral and ongoing supervision.
Comment: Several commenters recommend that TRICARE use a state
license for authorization as a TCMHC. One commenter recommended that a
state license alone should be sufficient as Medicaid and private
insurance companies consider them sufficient for the practice of MHCs.
Another commenter raised concerns that the criteria for authorizing
TCMHCs will result in ``separate regulations for the credentialing of
mental health counselors'' for Medicaid, Medicare, and TRICARE.
Response: We appreciate these comments, but have determined that
the final rule will adhere to the IOM (2010) recommendations that
incorporate a set of four criteria (licensure, education, certification
via examination, and clinical supervision), not the state license
alone, for the independent practice of MHCs under TRICARE. The IOM
Report discusses at greater length both independent and supervised
practice under other federal programs. We would note that Medicare does
not recognize licensed professional counselors as independent
providers, so they are not directly reimbursed through the program.
Comment: Some commenters asked whether TRICARE requires
professional certification of a MHC.
Response: Yes. Reference to professional licensure and
certification was unintentionally omitted from the interim final rule.
We appreciate the comment and have corrected this inadvertent exclusion
for the final rule by adding relevant provisions at 32 CFR
199.6(c)(3)(iii)(N)(1)(iv) and (2)(iv). Consistent with TRICARE
requirements, professional certification is required when a
jurisdiction does not issue a professional license [32 CFR
199.6(c)(2)(ii)]. Currently, all states (but not all territories) issue
professional licensure for MHCs. In 1993, professional certification by
the National Academy of Certified Mental Health Counselors of the
American Mental Health Counselors Association was placed in the
National Board for Certified Counselors' credentialing process. Thus
the professional certification of Certified Clinical Mental Health
Counselor is now required for authorization as a TCMHC or SMHC in those
jurisdictions that do not issue a professional license.
Comment: Multiple commenters proposed the acceptance of their own
states' or territories' licensing criteria for the number of hours of
post-master's supervised clinical practice experience for the TCMHC.
Response: As recognized by the IOM, state requirements and
practices can vary considerably. The requirements for all TRICARE
authorized providers are set forth by federal regulation, specifically
32 CFR 199.6, including professional licensure, certification, and any
specific education, training, and experience necessary to promote the
delivery of services by fully qualified individuals. By establishing
uniform standards, TRICARE seeks to provide high quality behavioral
health care delivered by well-trained clinicians. No compelling
comments were submitted to change the final rule requirement for TCMHCs
related to the hours of supervised clinical practice.
Comment: A few commenters ask whether a master's degree from an
accredited on-line mental health or clinical mental health program met
the criteria for independent practice under TRICARE.
Response: The final rule makes no distinction between how a degree
is earned, whether via distance learning or otherwise, as long as the
provider has obtained a master's or higher-level degree from an
appropriately accredited mental health counseling program of education
and training. We would note, however, at the present time that CACREP
and other regional accrediting bodies accredit very few institutions'
programs that provide distance learning for mental health counseling.
Comment: A few commenters recommended that the National Counselor
Examination (NCE) should be the ``key to eligibility,'' not program
accreditation. A few commenters expressed that either the NCE or the
NCMHCE should be the accepted criteria for certification. Other
commenters expressed appreciation that passage of the NCMHCE with
graduation from a non-CACREP accredited program in mental health
counseling is part of the eligibility criteria.
Response: We appreciate these comments. TRICARE accepted the
specific recommendations of the IOM for the independent practice of
MHCs, to include accredited education as well as examination criteria.
To ensure the availability of TCMHCs who meet these quality standards
during the transition period, this final rule pairs the examinations
with the education criteria. After the transition period, only the more
rigorous examination of clinical knowledge of patient care, the NCMHCE,
is accepted for authorization as a TCMHC.
[[Page 41640]]
Comment: A few commenters suggest that TRICARE certify graduates
from all universities that the federal government approves and
allocates federal education funds. Other commenters ask whether
graduates of the Rehabilitation Services of America (RSA) educational
programs are allowed to practice independently under TRICARE, since
their scholarship program provides federal funding for grants.
Response: The final rule makes no distinction as to which
universities and educational programs receive federal funding.
Appropriately accredited programs of education and training for
clinical mental health counselors, will satisfy the educational
requirements applicable to TCMHCs and SMHCs regardless of whether or
not federal funding has been provided. Conversely, federal funding of
programs that do not meet the specified educational and accreditation
criteria will not serve to waive the applicable requirements.
Additionally, we understand that the RSA oversees competitive grant
programs designed to ensure that skilled personnel are available to
service the rehabilitation needs of individuals with disabilities and
that many discretionary grants are provided for master's degrees in
rehabilitation counseling (https://www2.ed.gov/students/college/aid/rehab/carcouns.html). Congress requested that the DoD prescribe
criteria for the authorization of MHCs to practice independently under
TRICARE. The Department does not intend to broaden the scope of this
final rule to rehabilitation counselors who do not meet the criteria
specified in the regulation for TCMHCs or SMHCs.
Comment: Numerous commenters recommended a grandfathering clause to
exempt a practicing MHC from meeting the criteria of the final rule.
Others suggested the acceptance of each state's license as the criteria
for grandfathering. Some commenters specifically recommended
grandfathering MHCs who have two to five years of supervised experience
serving the military.
Response: We believe the changes that have been made to the final
rule to permit the continued practice of SMHCs under existing
eligibility criteria, as well as the extension of the transition period
for a MHC to meet the current quality standards, adequately address
these comments while still ensuring the provision of high quality
mental health care for beneficiaries, regardless of their location.
Specifically, the transition period allows MHCs the time to meet the
quality standards for independent practice and allows for the
implementation of uniform criteria that are not gained by
grandfathering. TRICARE recognizes that many mental health counselors
and current SMHCs have graduated prior to the establishment of either
the CACREP accreditation for mental health counseling programs or the
National Board of Certified Counselor's national examination for
clinical mental health counselors. This final rule seeks to balance the
implementation of quality standards for mental health counselors with
beneficiary access to those services.
IV. Regulatory Impact Analysis
Overall Impact
The Department has examined the impact of this final rule as
required by Executive Orders (EOs) 12866 (September 1993, Regulatory
Planning and Review) and 13563 (January 18, 2011, Improving Regulation
and Regulatory Review), the Regulatory Flexibility Act (RFA) (September
19, 1980, Pub. L. 96-354), the Unfunded Mandates Reform Act of 1995
(Pub. L. 104-4), and the Congressional Review Act [5 U.S.C. 804(2)].
1. Executive Order 12866, ``Regulatory Planning and Review'' and
Executive Order 13563, ``Improving Regulation and Regulatory Review''
E.O.s 12866 and 13563 direct agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects, distributive impacts, and equity). E.O. 13563 emphasizes the
importance of quantifying both costs and benefits, reducing costs,
harmonizing rules, and promoting flexibility. A regulatory impact
analysis (RIA) must be prepared for major rules with economically
significant effects ($100 million or more in any one year). We estimate
that this rulemaking is not ``economically significant'' as measured by
the $100 million threshold and, hence, is not a major rule under the
Congressional Review Act or the E.O.s.
2. Congressional Review Act, 5 U.S.C. 804(2)
Under the Congressional Review Act, a major rule may not take
effect until at least 60 days after submission to Congress of a report
regarding the rule. A major rule is one that would have an annual
effect on the economy of $100 million or more or have certain other
impacts. This Final rule is not a major rule under the Congressional
Review Act.
3. Public Law 96-354, ``Regulatory Flexibility Act'' (RFA), Title 5,
U.S.C., Sec. 601
The RFA requires agencies to analyze options for regulatory relief
of small businesses if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, small entities
include small businesses, nonprofit organizations, and small
governmental jurisdictions. This 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 rule is not subject to the requirements of
the RFA.
4. Public Law 104-4, Sec. 202, ``Unfunded Mandates Reform Act''
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any one year of
$100 million in 1995 dollars, updated annually for inflation. That
threshold level is currently approximately $140 million. This final
rule will not mandate any requirements for state, local, or tribal
governments or the private sector.
5. Public Law 96-511, ``Paperwork Reduction Act'' (Title 44, U.S.C.,
Chapter 35)
This rule will not impose significant additional information
collection requirements on the public under the Paperwork Reduction Act
of 1995 (44 U.S.C. 3502-3511). Existing information collection
requirements of the TRICARE and Medicare programs will be utilized.
TRICARE authorized and non-network providers will be coding and filing
claims in the same manner as they currently are with TRICARE.
6. Executive Order 13132, ``Federalism''
This rule has been examined for its impact under E.O. 13132, and it
does not contain policies that have 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 powers and responsibilities among the various levels of Government.
Therefore, consultation with State and local officials is not required.
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 amended as follows:
[[Page 41641]]
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. In Sec. 199.2, paragraph (b) is amended by removing the definition
of ``Mental health counselor'' and adding the definitions of
``Supervised mental health counselor'' and ``TRICARE certified mental
health counselor'' in alphabetical order to read as follows:
Sec. 199.2 Definitions.
* * * * *
(b) * * *
Supervised mental health counselor. An extramedical individual
provider who meets the requirements outlined in Sec. 199.6.
* * * * *
TRICARE certified mental health counselor. An allied health
professional who meets the requirements outlined in Sec. 199.6.
* * * * *
0
3. Section 199.4 is amended by revising paragraph (c)(3)(ix)(A) to read
as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(c) * * *
(3) * * *
(ix) * * *
(A) Covered diagnostic and therapeutic services. Subject to the
requirements and limitations stated, CHAMPUS benefits are payable for
the following services when rendered in the diagnosis or treatment of a
covered mental disorder by a CHAMPUS-authorized, qualified mental
health provider practicing within the scope of his or her license.
Qualified mental health providers are: Psychiatrists or other
physicians; clinical psychologists, certified psychiatric nurse
specialists, certified clinical social workers, certified marriage and
family therapists, TRICARE certified mental health counselors, pastoral
counselors under a physician's supervision and supervised mental health
counselors under a physician's supervision. No payment will be made for
any service listed in paragraph (c)(3)(ix)(A) of this section rendered
by an individual who does not meet the criteria of Sec. 199.6 for his
or her respective profession, regardless of whether the provider is an
independent professional provider or an employee of an authorized
professional or institutional provider.
* * * * *
0
4. Section 199.6 is amended by revising paragraphs (c)(3)(iii)(N) and
(c)(3)(iv)(C) to read as follows:
Sec. 199.6 TRICARE--authorized providers.
* * * * *
(c) * * *
(3) * * *
(iii) * * *
(N) TRICARE certified mental health counselor. For the purposes of
CHAMPUS, a TRICARE certified mental health counselor (TCMHC) must be
licensed for independent practice in mental health counseling by the
jurisdiction where practicing. In jurisdictions with two or more
licenses allowing for differing scopes of independent practice, the
licensed mental health counselor may only practice within the scope of
the license he or she possesses. In addition, a TCMHC must meet the
requirements of either paragraph (c)(3)(iii)(N)(1) or the requirements
of paragraph (c)(3)(iii)(N)(2) of this section.
(1) The requirements of this paragraph are that the TCMHC:
(i) Must have passed the National Clinical Mental Health Counselor
Examination (NCMHCE) or its successor as determined by the Director,
TMA; and
(ii) Must possess a master's or higher-level degree from a mental
health counseling program of education and training accredited by the
Council for Accreditation of Counseling and Related Educational
Programs (CACREP); and
(iii) Must have a minimum of two (2) years of post-master's degree
supervised mental health counseling practice which includes a minimum
of 3,000 hours of supervised clinical practice and 100 hours of face-
to-face supervision. Supervision must be provided by mental health
counselors at the highest level of state licensure, psychiatrists,
clinical psychologists, certified clinical social workers, or certified
psychiatric nurse specialists who are licensed for independent practice
in the jurisdiction where practicing and who are practicing within the
scope of their licenses. Supervised clinical practice must be received
in a manner that is consistent with the guidelines regarding knowledge,
skills, and practice standards for supervision of the American Mental
Health Counselors Association; and
(iv) Is licensed or certified for independent practice in mental
health counseling by the jurisdiction where practicing (see paragraph
(c)(2)(ii) of this section for more specific information).
(2) The requirements of this paragraph are that the TCMHC, prior to
January 1, 2017:
(i) Possess a master's or higher-level degree from a mental health
counseling program of education and training accredited by CACREP and
must have passed the National Counselor Examination (NCE); or
(ii) Possess a master's or higher-level degree from a mental health
counseling program of education and training from either a CACREP or
regionally accredited institution and have passed the NCMHCE; and
(iii) Must have a minimum of two (2) years of post-master's degree
supervised mental health counseling practice which includes a minimum
of 3,000 hours of supervised clinical practice and 100 hours of face-
to-face supervision. Supervision must be provided by mental health
counselors at the highest level of state licensure, psychiatrists,
clinical psychologists, certified clinical social workers, or certified
psychiatric nurse specialists who are licensed for independent practice
in the jurisdiction where practicing and who are practicing within the
scope of their licenses. Supervised clinical practice must be received
in a manner that is consistent with the guidelines regarding knowledge,
skills, and practice standards for supervision of the American Mental
Health Counselors Association; and
(iv) Is licensed or certified for independent practice in mental
health counseling by the jurisdiction where practicing (see paragraph
(c)(2)(ii) of this section for more specific information).
(3) The Director, TRICARE Management Activity may amend or modify
existing or specify additional certification requirements as needed to
accommodate future practice and licensing standards and to ensure that
all TCMHCs continue to meet educational, licensing, and clinical
training requirements considered appropriate.
(iv) * * *
(C) Supervised mental health counselor. For the purposes of
TRICARE, a supervised mental health counselor is an individual who does
not meet the requirements of a TRICARE certified mental health
counselor in paragraph (c)(3)(iii)(N) of this section, but meets all of
the following requirements and conditions of practice:
(1) Minimum of a master's degree in mental health counseling or
allied mental health field from a regionally accredited institution;
and
[[Page 41642]]
(2) Two years of post-masters experience which includes 3,000 hours
of clinical work and 100 hours of face-to-face supervision; and
(3) Is licensed or certified to practice as a mental health
counselor by the jurisdiction where practicing (see paragraph
(c)(3)(iv)(D) of this section for more specific information); and
(4) May only be reimbursed when:
(i) The TRICARE beneficiary is referred for therapy by a physician;
and
(ii) A physician is providing ongoing oversight and supervision of
the therapy being provided; and
(iii) The mental health counselor certifies on each claim for
reimbursement that a written communication has been made or will be
made to the referring physician of the results of the treatment. Such
communication will be made at the end of the treatment, or more
frequently, as required by the referring physician (refer to Sec.
199.7).
* * * * *
0
5. Section 199.7 is amended by revising paragraphs (e)(3) to read as
follows:
Sec. 199.7 Claims submission, review, and payment.
* * * * *
(e) * * *
(3) Claims involving the services of marriage and family
counselors, pastoral counselors, and supervised mental health
counselors. CHAMPUS requires that marriage and family counselors,
pastoral counselors, and supervised mental health counselors make a
written report to the referring physician concerning the CHAMPUS
beneficiary's progress. Therefore, each claim for reimbursement for
services of marriage and family counselors, pastoral counselors, and
supervised mental health counselors must include certification to the
effect that a written communication has been made or will be made to
the referring physician at the end of treatment, or more frequently, as
required by the referring physician.
* * * * *
Dated: July 11, 2014.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2014-16702 Filed 7-16-14; 8:45 am]
BILLING CODE 5001-06-P