TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year 2016 Diagnosis Related Group (DRG) Updates, 81295-81296 [2015-32655]
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Federal Register / Vol. 80, No. 249 / Tuesday, December 29, 2015 / Notices
Authority: 16 U.S.C. 1801 et seq.
[FR Doc. 2015–32715 Filed 12–28–15; 8:45 am]
BILLING CODE 3510–22–P
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meeting date.
Dated: December 18, 2015 in Washington,
DC.
Thomas Luebke,
Secretary.
[FR Doc. 2015–32419 Filed 12–28–15; 8:45 am]
BILLING CODE 6330–01–M
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE; Civilian Health and Medical
Program of the Uniformed Services
(CHAMPUS); Fiscal Year 2016
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 2016 rates.
asabaliauskas on DSK5VPTVN1PROD with NOTICES
SUMMARY:
VerDate Sep<11>2014
19:17 Dec 28, 2015
Jkt 238001
Effective Date: The rates,
weights, and Medicare PPS changes
which affect the TRICARE DRG-based
payment system contained in this notice
are effective for discharges occurring on
or after October 1, 2015.
ADDRESSES: Defense Health Agency,
TRICARE, Medical Benefits and
Reimbursement Section, 16401 East
Centretech Parkway, Aurora, CO 80011–
9066.
FOR FURTHER INFORMATION CONTACT:
Sharon L. Seelmeyer, Medical Benefits
and Reimbursement Section, TRICARE,
telephone (303) 676–3690. 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 in this
notice.
DATES:
Dated: December 23, 2015.
Tracey L. Thompson,
Acting Deputy Director, Office of Sustainable
Fisheries, National Marine Fisheries Service.
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
Grouper classifies each case into a DRG
on the basis of the diagnosis and
procedure codes and demographic
information (that is, sex, age, and
PO 00000
Frm 00024
Fmt 4703
Sfmt 4703
81295
discharge status). The Grouper used for
the TRICARE DRG-based payment
system is the same as the current
Medicare Grouper with certain
modifications. For FY 2008, Medicare
implemented their Medicare-Severity
DRG (MS–DRG) based payment system.
TRICARE, however, continued with the
Centers for Medicare and Medicaid
Services DRG-based (CMS–DRG)
payment system for FY 2008. For FY
2009, the TRICARE/CHAMPUS DRGbased payment system shall be modeled
on the MS–DRG system, with the
following modifications.
The MS–DRG system consolidated the
43 pediatric CMS DRGs that were
defined based on age less than or equal
to 17 into the most clinically similar
MS–DRGs. In their Inpatient Prospective
Payment System final rule for MS–
DRGs, Medicare stated for their
population these pediatric CMS DRGs
contained a very low volume of
Medicare patients. At the same time,
Medicare encouraged private insurers
and other non-Medicare payers to make
refinements to MS–DRGs to better suit
the needs of the patients they serve.
Consequently, TRICARE finds it
appropriate to retain the pediatric CMS–
DRGs for our population. TRICARE is
also retaining the TRICARE-specific
DRGs for neonates and substance use.
For FY09, TRICARE will use the MS–
DRG v26.0 pre-MDC hierarchy, with the
exception that MDC 15 is applied after
DRG 011–012 and before MDC 24.
For FY10, there are no additional or
deleted DRGs.
For FY 11, the added DRGs and
deleted DRGs are the same as those
included in CMS’ final rule published
on August 16, 2010. That is, DRG 009
is deleted; DRGs 014 and 015 are being
added.
For FY 12, the added DRGs and
deleted DRGs are the same as those
included in CMS’ final rule published
on August 18, 2011 (76 FR 51476–
51846). That is, DRG 015 is deleted;
DRGs 016 and 017 are being added.
For FY 2013 there are no new,
revised, or deleted DRGs.
For FY 2014 there are no new,
revised, or deleted DRGs.
For FY 2015 the added, deleted, and
revised DRGs are the same as those
included in the CMS’ final rule
published on August 22, 2014 (79 FR
49880) with the exception of
endovascular cardiac valve replacement
for which CMS added DRGs 266/267
and TRICARE added DRGs 317/318
because the TRICARE Grouper already
has DRGs 266/267 assigned to pediatric
procedures.
For FY2016 the added, deleted, and
revised DRGs are the same as those
E:\FR\FM\29DEN1.SGM
29DEN1
81296
Federal Register / Vol. 80, No. 249 / Tuesday, December 29, 2015 / Notices
included in the CMS’ final rule
published on August 17, 2015 (80 FR
49326) with the exception of
cardiovascular procedure for which
CMS added DRGs 268–272 and
TRICARE added DRGs 275–279 because
the TRICARE Grouper already has DRGs
268–271 assigned to pediatric
procedures.
dollar amount. Thus, for FY 2016, in
order for a case to qualify for cost outlier
payments, the costs must exceed the
TRICARE DRG base payment rate (wage
adjusted) for the DRG plus the IDME
payment (if applicable) plus $20,758
(wage adjusted). The marginal cost
factor for cost outliers continues to be
80 percent.
claims with discharge dates of October
1, 2014, or later and reimbursed under
the TRICARE DRG-Based payment
system, are to be priced using the rules,
weights, and rates in effect as of the date
of discharge. Prior to this, all final
claims were priced using the rules,
weights, and rates in effect as of the date
of admission.
B. Wage Index and Medicare
Geographic Classification Review Board
Guidelines
TRICARE will continue to use the
same wage index amounts used for the
Medicare PPS. TRICARE will also
duplicate all changes with regard to the
wage index for specific hospitals that
are redesignated by the Medicare
Geographic Classification Review Board.
In addition, TRICARE will continue to
utilize the out-commuting wage index
adjustment.
F. National Operating Standard Cost as
a Share of Total Costs
The FY 2016 TRICARE National
Operating Standard Cost as a Share of
Total Costs (NOSCASTC) used in
calculating the cost outlier threshold is
0.921. TRICARE uses the same
methodology as CMS for calculating the
NOSCASTC; however, the variables are
different because TRICARE uses
national cost-to-charge ratios while CMS
uses hospital specific cost-to-charge
ratios.
J. Updated Rates and Weights
The updated rates and weights are
accessible through the Internet at
https://www.health.mil/rates. The
implementing regulations for the
TRICARE/CHAMPUS DRG-based
payment system are in 32 CFR part 199.
C. Revision of the Labor-Related Share
of the Wage Index
TRICARE is adopting CMS’
percentage of labor related share of the
standardized amount. For wage index
values greater than 1.0, the labor related
portion of the Adjusted Standardized
Amount (ASA) shall continue to equal
69.6 percent. For wage index values less
than or equal to 1.0 the labor related
portion of the ASA shall continue to
equal 62 percent.
G. Indirect Medical Education (IDME)
Adjustment
Passage of the Medical Modernization
Act of 2003 modified the formula
multipliers to be used in the calculation
of IDME adjustment factor. Since the
IDME formula used by TRICARE does
not include disproportionate share
hospitals (DSHs), the variables in the
formula are different than Medicare’s,
however; the percentage reductions that
will be applied to Medicare’s formula
will also be applied to the TRICARE
IDME formula. The multiplier for the
IDME adjustment factor for TRICARE for
FY 2016 is 1.02.
asabaliauskas on DSK5VPTVN1PROD with NOTICES
D. Hospital Market Basket
TRICARE will update the adjusted
standardized amounts according to the
final updated hospital market basket
used for the Medicare PPS for all
hospitals subject to the TRICARE DRGbased payment system according to
CMS’ August 17, 2015, final rule. For
FY 2016, the market basket is 2.4
percent. Note: Medicare’s FY 2016
market basket index adjusts according to
hospitals’ compliance with quality data
and electronic health record meaningful
use submissions. These adjustments do
not apply to the TRICARE Program.
E. Outlier Payments
Since TRICARE does not include
capital payments in our DRG-based
payments (TRICARE reimburses
hospitals for their capital costs as
reported annually to the contractor on a
pass through basis), we will use the
fixed loss cost outlier threshold
calculated by CMS for paying cost
outliers in the absence of capital
prospective payments. For FY 2016, the
TRICARE fixed loss cost outlier
threshold is based on the sum of the
applicable DRG-based payment rate plus
any amounts payable for Indirect
Medical Education (IDME) plus a fixed
VerDate Sep<11>2014
19:17 Dec 28, 2015
Jkt 238001
H. Cost to Charge Ratio
TRICARE uses a national Medicare
cost-to-charge ratio (CCR). For FY 2016,
the Medicare CCR used for the TRICARE
DRG-based payment system for acute
care hospitals and neonates will be
0.2631. This is based on a weighted
average of the hospital-specific
Medicare CCRs (weighted by the
number of Medicare discharges) after
excluding hospitals not subject to the
TRICARE DRG system (Sole Community
Hospitals, Indian Health Service
hospitals, and hospitals in Maryland).
The Medicare CCR is used to calculate
cost outlier payments, except for
children’s hospitals. The Medicare CCR
has been increased by a factor of 1.0065
to include an additional allowance for
bad debt. The 1.0065 factor reflects the
provisions of the Middle Class Tax
Relief and Job Creation Act of 2012. For
children’s hospital cost outliers, the
CCR used is 0.2840.
I. Pricing of Claims
The final rule published on May 21,
2014 (79 FR 29085) set forth all final
PO 00000
Frm 00025
Fmt 4703
Sfmt 4703
Dated: December 22, 2015.
Aaron Siegel,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
[FR Doc. 2015–32655 Filed 12–28–15; 8:45 am]
BILLING CODE 5001–06–P
DEPARTMENT OF DEFENSE
Office of the Secretary
National Commission on the Future of
the Army; Notice of Federal Advisory
Committee Meeting
Deputy Chief Management
Officer, Department of Defense (DoD).
ACTION: Notice of Federal Advisory
Committee Meeting.
AGENCY:
The DoD is publishing this
notice to announce a meeting of the
National Commission on the Future of
the Army (‘‘the Commission’’). The
meeting will be closed to the public.
DATES: Date of the Closed Meeting:
Wednesday, January 13, 2016, from 8:00
a.m. to 5:00 p.m.
ADDRESSES: Address of Closed Meeting,
January 13, 2016: Rm 12110, 12th Floor,
Zachary Taylor Building, 2530 Crystal
Dr., Arlington, VA 22202.
FOR FURTHER INFORMATION CONTACT: Mr.
Don Tison, Designated Federal Officer,
National Commission on the Future of
the Army, 700 Army Pentagon, Room
3E406, Washington, DC 20310–0700,
Email: dfo.public@ncfa.ncr.gov. Desk
(703) 692–9099. Facsimile (703) 697–
8242.
SUPPLEMENTARY INFORMATION: This
meeting will be held under the
provisions of the Federal Advisory
Committee Act (FACA) of 1972 (5
U.S.C., Appendix, as amended), the
Government in the Sunshine Act of
1976 (5 U.S.C. 552b, as amended), and
41 CFR 102–3.150.
Purpose of Meetings:
During the closed meeting on
Wednesday, January 13, 2016, the
SUMMARY:
E:\FR\FM\29DEN1.SGM
29DEN1
]]>Agencies
[Federal Register Volume 80, Number 249 (Tuesday, December 29, 2015)]
[Notices]
[Pages 81295-81296]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-32655]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
TRICARE; Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS); Fiscal Year 2016 Diagnosis Related Group (DRG)
Updates
AGENCY: Office of the Secretary, Department of Defense, DoD.
ACTION: Notice of DRG revised rates.
-----------------------------------------------------------------------
SUMMARY: This notice describes the changes made to the TRICARE DRG-
based 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 2016
rates.
DATES: Effective Date: The rates, weights, and Medicare PPS changes
which affect the TRICARE DRG-based payment system contained in this
notice are effective for discharges occurring on or after October 1,
2015.
ADDRESSES: Defense Health Agency, TRICARE, Medical Benefits and
Reimbursement Section, 16401 East Centretech Parkway, Aurora, CO 80011-
9066.
FOR FURTHER INFORMATION CONTACT: Sharon L. Seelmeyer, Medical Benefits
and Reimbursement Section, TRICARE, telephone (303) 676-3690. 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 in this notice.
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 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
certain modifications. For FY 2008, Medicare implemented their
Medicare-Severity DRG (MS-DRG) based payment system. TRICARE, however,
continued with the Centers for Medicare and Medicaid Services DRG-based
(CMS-DRG) payment system for FY 2008. For FY 2009, the TRICARE/CHAMPUS
DRG-based payment system shall be modeled on the MS-DRG system, with
the following modifications.
The MS-DRG system consolidated the 43 pediatric CMS DRGs that were
defined based on age less than or equal to 17 into the most clinically
similar MS-DRGs. In their Inpatient Prospective Payment System final
rule for MS-DRGs, Medicare stated for their population these pediatric
CMS DRGs contained a very low volume of Medicare patients. At the same
time, Medicare encouraged private insurers and other non-Medicare
payers to make refinements to MS-DRGs to better suit the needs of the
patients they serve. Consequently, TRICARE finds it appropriate to
retain the pediatric CMS-DRGs for our population. TRICARE is also
retaining the TRICARE-specific DRGs for neonates and substance use.
For FY09, TRICARE will use the MS-DRG v26.0 pre-MDC hierarchy, with
the exception that MDC 15 is applied after DRG 011-012 and before MDC
24.
For FY10, there are no additional or deleted DRGs.
For FY 11, the added DRGs and deleted DRGs are the same as those
included in CMS' final rule published on August 16, 2010. That is, DRG
009 is deleted; DRGs 014 and 015 are being added.
For FY 12, the added DRGs and deleted DRGs are the same as those
included in CMS' final rule published on August 18, 2011 (76 FR 51476-
51846). That is, DRG 015 is deleted; DRGs 016 and 017 are being added.
For FY 2013 there are no new, revised, or deleted DRGs.
For FY 2014 there are no new, revised, or deleted DRGs.
For FY 2015 the added, deleted, and revised DRGs are the same as
those included in the CMS' final rule published on August 22, 2014 (79
FR 49880) with the exception of endovascular cardiac valve replacement
for which CMS added DRGs 266/267 and TRICARE added DRGs 317/318 because
the TRICARE Grouper already has DRGs 266/267 assigned to pediatric
procedures.
For FY2016 the added, deleted, and revised DRGs are the same as
those
[[Page 81296]]
included in the CMS' final rule published on August 17, 2015 (80 FR
49326) with the exception of cardiovascular procedure for which CMS
added DRGs 268-272 and TRICARE added DRGs 275-279 because the TRICARE
Grouper already has DRGs 268-271 assigned to pediatric procedures.
B. Wage Index and Medicare Geographic Classification Review Board
Guidelines
TRICARE will continue to use the same wage index amounts used for
the Medicare PPS. TRICARE will also duplicate all changes with regard
to the wage index for specific hospitals that are redesignated by the
Medicare Geographic Classification Review Board. In addition, TRICARE
will continue to utilize the out-commuting wage index adjustment.
C. Revision of the Labor-Related Share of the Wage Index
TRICARE is adopting CMS' percentage of labor related share of the
standardized amount. For wage index values greater than 1.0, the labor
related portion of the Adjusted Standardized Amount (ASA) shall
continue to equal 69.6 percent. For wage index values less than or
equal to 1.0 the labor related portion of the ASA shall continue to
equal 62 percent.
D. Hospital Market Basket
TRICARE will update the adjusted standardized amounts according to
the final updated hospital market basket used for the Medicare PPS for
all hospitals subject to the TRICARE DRG-based payment system according
to CMS' August 17, 2015, final rule. For FY 2016, the market basket is
2.4 percent. Note: Medicare's FY 2016 market basket index adjusts
according to hospitals' compliance with quality data and electronic
health record meaningful use submissions. These adjustments do not
apply to the TRICARE Program.
E. Outlier Payments
Since TRICARE does not include capital payments in our DRG-based
payments (TRICARE reimburses hospitals for their capital costs as
reported annually to the contractor on a pass through basis), we will
use the fixed loss cost outlier threshold calculated by CMS for paying
cost outliers in the absence of capital prospective payments. For FY
2016, the TRICARE fixed loss cost outlier threshold is based on the sum
of the applicable DRG-based payment rate plus any amounts payable for
Indirect Medical Education (IDME) plus a fixed dollar amount. Thus, for
FY 2016, in order for a case to qualify for cost outlier payments, the
costs must exceed the TRICARE DRG base payment rate (wage adjusted) for
the DRG plus the IDME payment (if applicable) plus $20,758 (wage
adjusted). The marginal cost factor for cost outliers continues to be
80 percent.
F. National Operating Standard Cost as a Share of Total Costs
The FY 2016 TRICARE National Operating Standard Cost as a Share of
Total Costs (NOSCASTC) used in calculating the cost outlier threshold
is 0.921. TRICARE uses the same methodology as CMS for calculating the
NOSCASTC; however, the variables are different because TRICARE uses
national cost-to-charge ratios while CMS uses hospital specific cost-
to-charge ratios.
G. Indirect Medical Education (IDME) Adjustment
Passage of the Medical Modernization Act of 2003 modified the
formula multipliers to be used in the calculation of IDME adjustment
factor. Since the IDME formula used by TRICARE does not include
disproportionate share hospitals (DSHs), the variables in the formula
are different than Medicare's, however; the percentage reductions that
will be applied to Medicare's formula will also be applied to the
TRICARE IDME formula. The multiplier for the IDME adjustment factor for
TRICARE for FY 2016 is 1.02.
H. Cost to Charge Ratio
TRICARE uses a national Medicare cost-to-charge ratio (CCR). For FY
2016, the Medicare CCR used for the TRICARE DRG-based payment system
for acute care hospitals and neonates will be 0.2631. This is based on
a weighted average of the hospital-specific Medicare CCRs (weighted by
the number of Medicare discharges) after excluding hospitals not
subject to the TRICARE DRG system (Sole Community Hospitals, Indian
Health Service hospitals, and hospitals in Maryland). The Medicare CCR
is used to calculate cost outlier payments, except for children's
hospitals. The Medicare CCR has been increased by a factor of 1.0065 to
include an additional allowance for bad debt. The 1.0065 factor
reflects the provisions of the Middle Class Tax Relief and Job Creation
Act of 2012. For children's hospital cost outliers, the CCR used is
0.2840.
I. Pricing of Claims
The final rule published on May 21, 2014 (79 FR 29085) set forth
all final claims with discharge dates of October 1, 2014, or later and
reimbursed under the TRICARE DRG-Based payment system, are to be priced
using the rules, weights, and rates in effect as of the date of
discharge. Prior to this, all final claims were priced using the rules,
weights, and rates in effect as of the date of admission.
J. Updated Rates and Weights
The updated rates and weights are accessible through the Internet
at https://www.health.mil/rates. The implementing regulations for the
TRICARE/CHAMPUS DRG-based payment system are in 32 CFR part 199.
Dated: December 22, 2015.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2015-32655 Filed 12-28-15; 8:45 am]
BILLING CODE 5001-06-P
