TRICARE Program; Clarification of Benefit Coverage of Durable Equipment and Ordering or Prescribing Durable Equipment; Clarification of Benefit Coverage of Assistive Technology Devices Under the Extended Care Health Option Program, 27328-27329 [2016-10265]

Agencies

• DEPARTMENT OF DEFENSE
• Office of the Secretary

[Federal Register Volume 81, Number 88 (Friday, May 6, 2016)]
[Rules and Regulations]
[Pages 27328-27329]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-10265]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DOD-2013-HA-0053]
RIN 0720-AB59


TRICARE Program; Clarification of Benefit Coverage of Durable 
Equipment and Ordering or Prescribing Durable Equipment; Clarification 
of Benefit Coverage of Assistive Technology Devices Under the Extended 
Care Health Option Program

AGENCY: Office of the Secretary, Department of Defense (DoD).

ACTION: Correcting amendments.

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SUMMARY: The DoD published a final rule on December 31, 2014 (79 FR 
78707-78714). This rule makes correcting amendments to the previously 
published final rule to clarify that only the replacement of lost or 
stolen rental durable equipment is excluded from coverage. 
Additionally, in the final rule, DoD mistakenly used asterisks in a 
paragraph it was revising in its entirety. To correct this mistake and 
ensure that all revisions are appropriately codified, these correcting 
amendments set out the full text of the impacted paragraph.

DATES: This rule is effective May 6, 2016. These correcting amendments 
are applicable January 30, 2015.

FOR FURTHER INFORMATION CONTACT: Gail L. Jones, (303) 676-3401.

SUPPLEMENTARY INFORMATION: 

Executive Order 12866, ``Regulatory Planning and Review'' and Executive 
Order 13563, ``Improving Regulation and Regulatory Review''

    It has been determined that these correcting amendments are not 
significant regulatory actions. These correcting amendments do not meet 
the criteria in these Executive Orders.

Unfunded Mandates Reform Act (Sec. 202, Pub. L. 104-4)

    It has been determined that these correcting amendments do not 
contain a Federal mandate that may result in the expenditure by State, 
local and tribal governments, in aggregate, or by the private sector, 
of $100 million or more in any one year.

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

    It has been certified that these correcting amendments are subject 
to the Regulatory Flexibility Act (5 U.S.C. 601) because they would 
not, if promulgated, have a significant economic impact on a 
substantial number of small entities. These are correcting amendments 
to the existing regulation.

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

    It has been determined that these correcting amendments do not 
impose reporting or recordkeeping requirements under the Paperwork 
Reduction Act of 1995.

Executive Order 13132, Federalism

    It has been determined that these correcting amendments do not have 
federalism implications, as set forth in Executive Order 13132. This 
rule does not have substantial direct effects on:
    (1) The States;
    (2) The relationship between the National Government and the 
States; or
    (3) The distribution of power and responsibilities among the 
various levels of Government.

List of Subjects in 32 CFR Part 199

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

    Accordingly, 32 CFR part 199 is corrected by making the following 
correcting amendments:

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.  199.4, paragraph (d)(3)(ii) is revised to read as follows:


Sec.  199.4  Basic program benefits.

* * * * *
    (d) * * *
    (3) * * *
    (ii) Durable equipment--(A) Scope of benefit. (1) Durable 
equipment, which is for the specific use of the beneficiary and is 
ordered by an authorized individual professional provider listed in 
Sec.  199.6(c)(3)(i), (ii) or (iii), acting within his or her scope of 
licensure shall be covered if the durable equipment meets the 
definition in Sec.  199.2 and--

[[Page 27329]]

    (i) Provides the medically appropriate level of performance and 
quality for the medical condition present and
    (ii) Is not otherwise excluded by this part.
    (2) Items that may be provided to a beneficiary as durable 
equipment include:
    (i) Durable medical equipment as defined in Sec.  199.2;
    (ii) Wheelchairs. A wheelchair, which is medically appropriate to 
provide basic mobility, including reasonable additional costs for 
medically appropriate modifications to accommodate a particular 
physiological or medical need, may be covered as durable equipment. An 
electric wheelchair, or TRICARE approved alternative to an electric 
wheelchair (e.g., scooter) may be provided in lieu of a manual 
wheelchair when it is medically indicated and appropriate to provide 
basic mobility. Luxury or deluxe wheelchairs, as described in paragraph 
(d)(3)(ii)(A)(3) of this section, include features beyond those 
required for basic mobility of a particular beneficiary are not 
authorized.
    (iii) Iron lungs.
    (iv) Hospital beds.
    (v) Cardiorespiratory monitors under conditions specified in 
paragraph (d)(3)(ii)(B) of this section.
    (3) Whether a prescribed item of durable equipment provides the 
medically appropriate level of performance and quality for the 
beneficiary's condition must be supported by adequate documentation. 
Luxury, deluxe, immaterial, or non- essential features, which increase 
the cost of the item relative to a similar item without those features, 
based on industry standards for a particular item at the time the 
equipment is prescribed or replaced for a beneficiary, are not 
authorized. Only the ``base'' or ``basic'' model of equipment (or more 
cost- effective alternative equipment) shall be covered, unless 
customization of the equipment, or any accessory or item of supply for 
any durable medical equipment, is essential, as determined by the 
Director (or designee), for--
    (i) Achieving therapeutic benefit for the patient;
    (ii) Making the equipment serviceable; or
    (iii) Otherwise assuring the proper functioning of the equipment.
    (B) Cardiorespiratory monitor exception. (1) When prescribed by a 
physician who is otherwise eligible as a CHAMPUS individual 
professional provider, or who is on active duty with a United States 
Uniformed Service, an electronic cardiorespiratory monitor, including 
technical support necessary for the proper use of the monitor, may be 
cost-shared as durable medical equipment when supervised by the 
prescribing physician for in-home use by:
    (i) An infant beneficiary who has had an apparent life-threatening 
event, as defined in guidelines issued by the Director, OCHAMPUS, or a 
designee, or
    (ii) An infant beneficiary who is a subsequent or multiple birth 
biological sibling of a victim of sudden infant death syndrome (SIDS), 
or
    (iii) An infant beneficiary whose birth weight was 1,500 grams or 
less, or
    (iv) An infant beneficiary who is a pre-term infant with pathologic 
apnea, as defined in guidelines issued by the Director, OCHAMPUS, or a 
designee, or
    (v) Any beneficiary who has a condition or suspected condition 
designated in guidelines issued by the Director, OCHAMPUS, or a 
designee, for which the in-home use of the cardiorespiratory monitor 
otherwise meets Basic Program requirements.
    (2) The following types of services and items may be cost-shared 
when provided in conjunction with an otherwise authorized 
cardiorespiratory monitor:
    (i) Trend-event recorder, including technical support necessary for 
the proper use of the recorder.
    (ii) Analysis of recorded physiological data associated with 
monitor alarms.
    (iii) Professional visits for services otherwise authorized by this 
part, and for family training on how to respond to an apparent life 
threatening event.
    (iv) Diagnostic testing otherwise authorized by this part.
    (C) Exclusions. Durable equipment, which is otherwise qualified as 
a benefit is excluded from coverage under the following circumstances:
    (1) Durable equipment for a beneficiary who is a patient in a type 
of facility that ordinarily provides the same type of durable equipment 
item to its patients at no additional charge in the usual course of 
providing its services.
    (2) Durable equipment, which is available to the beneficiary from a 
Uniformed Services Medical Treatment Facility.
    (D) Basis for reimbursement. (1) Durable equipment may be provided 
on a rental or purchase basis. Coverage of durable equipment will be 
based on the price most advantageous to the government taking into 
consideration the anticipated duration of the medically necessary need 
for the equipment and current price information for the type of item. 
The cost analysis must include a comparison of the total price of the 
item as a monthly rental charge, a lease-purchase price, and a lump-sum 
purchase price and a provision for the time value of money at the rate 
determined by the U.S. Department of Treasury. If a beneficiary wishes 
to obtain an item of durable equipment with deluxe, luxury, immaterial 
or non-essential features, the beneficiary may agree to accept TRICARE 
coverage limited to the allowable amount that would have otherwise been 
authorized for a similar item without those features. In that case, the 
TRICARE coverage is based upon the allowable amount for the kind of 
durable equipment normally used to meet the intended purpose (i.e., the 
standard item least costly). The provider shall not hold the 
beneficiary liable for deluxe, luxury, immaterial, or non- essential 
features that cannot be considered in determining the TRICARE allowable 
costs. However, the beneficiary shall be held liable if the provider 
has a specific agreement in writing from the beneficiary (or his or her 
representative) accepting liability for the itemized difference in 
costs of the durable equipment with deluxe, luxury, or immaterial 
features and the TRICARE allowable costs for an otherwise authorized 
item without such features.
    (2) In general, repairs of beneficiary owned durable equipment are 
covered when necessary to make the equipment serviceable and 
replacement of durable equipment is allowed when the durable equipment 
is not serviceable because of normal wear, accidental damage or when 
necessitated by a change in the beneficiary's condition. However, 
repairs of durable equipment damaged while using the equipment in a 
manner inconsistent with its common use, and replacement of lost or 
stolen rental durable equipment are excluded from coverage. In 
addition, repairs of deluxe, luxury, or immaterial features of durable 
equipment are excluded from coverage.
* * * * *


Sec.  199.5  [Amended]

0
3. In Sec.  199.5:
0
a. Paragraph (c)(2)(v) is amended by removing the phrase ``as well as 
lost or stolen devices''.
0
b. Paragraph (c)(8)(iii) is amended by adding the word ``rental'' after 
the word ``stolen'', and by removing the second occurrence of ``and/or 
AT devices''.

    Dated: April 27, 2016.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2016-10265 Filed 5-5-16; 8:45 am]
BILLING CODE 5001-06-P