TRICARE; Addition of Physical Therapist Assistants and Occupational Therapy Assistants as TRICARE-Authorized Providers, 15061-15066 [2020-04957]

Agencies

• DEPARTMENT OF DEFENSE
• Office of the Secretary

[Federal Register Volume 85, Number 52 (Tuesday, March 17, 2020)]
[Rules and Regulations]
[Pages 15061-15066]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-04957]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[Docket ID: DOD-2018-HA-0028]
RIN 0720-AB72


TRICARE; Addition of Physical Therapist Assistants and 
Occupational Therapy Assistants as TRICARE-Authorized Providers

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

ACTION: Final rule.

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SUMMARY: The Department of Defense is publishing this final rule to add 
licensed or certified physical therapist assistants (PTAs) and 
occupational therapy assistants (OTAs) as TRICARE-authorized providers 
to engage in physical therapy or occupational therapy under the 
supervision of a TRICARE-authorized licensed registered physical 
therapist or occupational therapist in accordance with Medicare's rules 
for supervision and qualification. This rule aligns TRICARE with 
Medicare's policy, which permits PTAs or OTAs to provide physical or 
occupational therapy when supervised by a licensed registered physical 
therapist or occupational therapist.

DATES: This rule is effective April 16, 2020.

FOR FURTHER INFORMATION CONTACT: Erica Ferron, Defense Health Agency, 
Medical Benefits and Reimbursement Section, 303-676-3626 or 
[email protected].

SUPPLEMENTARY INFORMATION:

I. Executive Summary and Overview

A. Purpose of the Final Rule

    This final rule implements section 721 of the National Defense 
Authorization Act for Fiscal Year 2018 (NDAA-18), and advances two of 
the components of the Military Health System's quadruple aim of 
improved readiness and better health. The TRICARE Basic benefit 
currently includes physical therapy (PT) and occupational therapy (OT) 
services rendered by TRICARE-authorized providers within the scope of 
their license when prescribed and monitored by a physician, certified 
physician assistant, or certified nurse practitioner. Allowing licensed 
registered physical therapists and occupational therapists to include 
those services of qualified assistants performing under their 
supervision as covered services may increase access to PT and OT 
services, and increase beneficiary choice in provider selection. Adding 
coverage of services by authorized therapy assistants may increase 
access at the same time the Agency anticipates that an active and aging 
beneficiary population will increasingly use these services.

B. Summary of the Major Provisions of the Final Rule

    The major provisions of the final rule are:
     The addition of licensed or certified PTAs as TRICARE-
authorized providers, operating under the same qualifications 
established by Medicare (42 Code of Federal Regulations (CFR) 484.115 
or successor regulation). Services must be furnished under the 
supervision of a TRICARE-authorized licensed registered physical 
therapist.
     The addition of licensed or certified OTAs as TRICARE-
authorized providers, operating under the same qualifications 
established by Medicare (42 CFR 484.115 or successor regulation). 
Services must be furnished under the supervision of a TRICARE-
authorized licensed registered occupational therapist.

C. Costs and Benefits

    PT and OT services are covered benefits of the TRICARE program, 
authorized at 32 CFR 199.4. We estimate

[[Page 15062]]

that as a result of this rule, there will be a one-percent increase in 
the use of PT and OT services. The cost of increased utilization, along 
with first-year implementation costs of $350,000, is estimated at $20 
million over five years.
    The financial effect of this rule is not in the nature of economic 
costs or imposition of private expenditures to comply with Federal 
regulations. Rather, the rule involves fairly modest changes in federal 
health benefits payments. Consistent with OMB Circular A-4, such 
economic effects are considered ``transfer payments'' caused by Federal 
budget action, rather than regulatory benefits or costs that require 
additional analysis.

II. Discussion of Final Rule

A. Introduction and Background

    Title 32 CFR 199.4(c)(3)(x) states that assessment and treatment 
services of a TRICARE-authorized physical therapist or occupational 
therapist may be cost-shared under certain conditions when prescribed 
and monitored by a physician, certified physician assistant, or 
certified nurse practitioner. In addition, 32 CFR 
199.6(c)(3)(iii)(K)(2) recognizes licensed registered physical 
therapists and occupational therapists as TRICARE-authorized providers 
when PT and OT services meet the conditions and are prescribed and 
monitored as described in the previous sentence. This rule extends 
coverage of PT and OT services, as required by NDAA-18, to include 
services provided by licensed or certified PTAs or OTAs operating under 
the supervision of a TRICARE-authorized licensed registered physical 
therapist or occupational therapist.
PTAs--Qualifications
    PTAs typically hold an associate's degree in PT and are licensed by 
the state in which they practice. This rule ties the qualifications of 
PTAs under the TRICARE program to Medicare's requirements as codified 
at 42 CFR 484.115 (or successor regulation).
PTAs--Supervision Requirements
    Under this rule, TRICARE's supervision requirements match, to the 
extent practicable, Medicare's. The Defense Health Agency (DHA) 
intends, in implementing instructions, to follow Medicare's 
requirements as found within Medicare's policy instructions. DHA will 
rely primarily on Medicare Benefit Policy Manual 100-02 Chapter 15, 
Covered Medical and Other Health Services, Sections 220 and 230, but 
will also refer to other related issuances and manuals, including 
facility-specific chapters of the Medicare Benefit Policy Manual.
    Direct supervision will be required in a private practice setting. 
The supervising physical therapist will be required to be in the office 
suite where the PTA is located and immediately available to furnish 
assistance and direction throughout the performance of the procedure. 
The supervising physical therapist will not be required to be in the 
room with the PTA while the procedure is performed.
    General supervision will be required in all settings other than 
private practice. General supervision will require that procedures be 
performed by the PTA under the physical therapist's overall direction 
and control, but the physical therapist's presence will not be required 
during the performance of the procedure. Under general supervision, the 
training of the PTA who actually performs the procedure and maintenance 
of the necessary equipment and supplies will be the continuing 
responsibility of the physical therapist. Medicare's supervision 
requirements vary further by setting and DHA intends, where 
appropriate, to follow these setting-specific requirements.
    In cases where state or local supervision laws are more stringent, 
the DHA will require physical therapists and the PTAs they supervise to 
follow state or local laws. Services provided by PT aides or other 
personnel, even if under the supervision of a TRICARE-authorized 
licensed registered physical therapist or PTA, are not covered. 
Services provided by PTAs incident to services provided by physicians 
or other licensed or qualified providers other than physical therapists 
are not covered, as only physical therapists can supervise PTAs. If 
Medicare makes changes to its supervision requirements, the DHA will 
evaluate the changes and determine whether to make similar changes; any 
changes deemed appropriate shall be added to the implementing 
instructions.
PTAs--Reimbursement Requirements
    TRICARE is required by statute (Title 10 United States Code 
(U.S.C.) chapter 55, Sec.  1079(h)(1)) to reimburse like Medicare, to 
the extent practicable. PT services will continue to be reimbursed 
under existing TRICARE reimbursement methodology, including the CHAMPUS 
Maximum Allowable Charge (CMAC) methodology and applicable diagnosis-
related groups, except that any Medicare reimbursement requirements 
specific to services provided by PTAs will also be adopted, when 
practicable. Services provided by a PTA above the skill-level of a PTA 
shall not be reimbursed. This includes, but is not limited to, 
evaluations and re-evaluations. Services provided by a PTA beyond the 
scope permitted by state or local law shall not be reimbursed.
OTAs--Qualifications
    OTAs typically hold an associate's degree and are licensed by the 
state in which they practice. This rule ties the qualifications of OTAs 
under the TRICARE program to Medicare's requirements as codified at 42 
CFR 484.115 (or successor regulation).
OTAs--Supervision Requirements
    Under this rule, TRICARE's supervision requirements match, to the 
extent practicable, Medicare's. The DHA intends, in implementing 
instructions, to follow Medicare's requirements as found within the 
Medicare's policy instructions. DHA will rely primarily on Medicare 
Benefit Policy Manual 100-02 Chapter 15, Covered Medical and Other 
Health Services, Sections 220 and 230, but will also refer to other 
related issuances and manuals including facility-specific chapters of 
the Medicare Benefit Policy Manual.
    Direct supervision will be required in a private practice setting. 
The supervising occupational therapist will be required to be in the 
office suite where the OTA is located and immediately available to 
furnish assistance and direction throughout the performance of the 
procedure. The supervising occupational therapist will not be required 
to be in the room with the OTA while the procedure is performed.
    General supervision will be required in all settings other than 
private practice. General supervision will require that procedures be 
performed by the OTA under the occupational therapist's overall 
direction and control, but the occupational therapist's presence will 
not be required during the performance of the procedure. Under general 
supervision, the training of the OTA who actually performs the 
procedure and maintenance of the necessary equipment and supplies will 
be the continuing responsibility of the occupational therapist. 
Medicare's supervision requirements vary further by setting and DHA 
intends, where appropriate, to follow those setting-specific 
requirements.
    In cases where state or local supervision laws are more stringent, 
the DHA will require occupational therapists and the OTAs they 
supervise to follow state or local laws. Services provided by OT aides 
or other personnel, even if under the supervision

[[Page 15063]]

of a TRICARE-authorized licensed registered occupational therapist or 
OTA, are not covered. Services provided by OTAs incident to services 
provided by physicians or other licensed or qualified providers other 
than occupational therapists are not covered, as only occupational 
therapists can supervise OTAs. If Medicare makes changes to its 
supervision requirements, the DHA will evaluate the changes and 
determine whether to make similar changes; any changes deemed 
appropriate shall be added to the implementing instructions.
OTAs--Reimbursement Requirements
    TRICARE is required by statute (10 U.S.C. 55, Sec.  1079(h)(1)) to 
reimburse like Medicare, to the extent practicable. OT services will 
continue to be reimbursed under existing TRICARE reimbursement 
methodology, including the CMAC and applicable diagnosis-related 
groups, except that any Medicare reimbursement requirements specific to 
services provided by OTAs will also be adopted, when practicable. 
Services provided by an OTA above the skill-level of an OTA shall not 
be reimbursed. This includes, but is not limited to, evaluations and 
re-evaluations. Services provided by an OTA beyond the scope permitted 
by state or local law shall not be reimbursed.
Updated Referral Definition
    In order to fully implement section 721 of the NDAA for 2018, DHA 
is updating the definition of referrals to remove the limitation that 
only physicians can make referrals and to distinguish between necessary 
referrals for general benefit coverage and referrals required under 
TRICARE Prime for Prime enrollee care. All referral requirements are 
provided in the regulations and in the implementing instructions. No 
new referral authority is granted with this change; rather, it makes 
the referral definition consistent with existing referral authorities 
including that certified nurse practitioners and certified physician 
assistants can make referrals to licensed registered physical 
therapists and occupational therapists.

III. Public Comments

    The TRICARE proposed rule on the addition of PTAs and OTAs as 
TRICARE-authorized providers (83 FR 65323) was published on December 
20, 2018, and provided a 60-day public comment period. As a result of 
publication of the proposed rule, DHA received 681 comments, most of 
which strongly supported adding PTAs and OTAs as authorized providers 
under TRICARE. Following is a summary of the public comments and our 
responses.

1. Provisions of the Proposed Rule

    A. The proposed rule proposed to add licensed or certified PTAs as 
TRICARE-authorized providers, operating under the same qualifications 
established by Medicare (42 Code of Federal Regulations (CFR) 484.4). 
Services were required to be furnished under the supervision of and 
billed by a licensed or certified TRICARE-authorized physical 
therapist.
    B. The proposed rule proposed to add licensed or certified OTAs as 
TRICARE-authorized providers, operating under the same qualifications 
established by Medicare (42 CFR 484.4). Services were required to be 
furnished under the supervision of and billed by a licensed or 
certified TRICARE-authorized occupational therapist.

2. Analysis of Major Public Comments

A. Terminology
    Comment 1: We received many comments requesting DHA refer to 
assistants to physical therapists as physical therapist assistants, not 
physical therapy assistants.
    Response: We concur with this comment and have revised the rule 
using of the term physical therapist assistants throughout. This term 
has been corrected throughout the preamble and in the one place in the 
regulatory text where it occurred (Sec.  199.6(c)(3)(iii)(K)(2)(i)).
    Comment 2: Many commenters requested DHA remove the term 
``certified'' in front of physical therapists.
    Response: The rule has been revised to use licensed registered 
physical therapists throughout, consistent with language in the 
existing regulation. This edit does not appear in the regulatory text 
but has been corrected in the preamble of this final rule.
    Comment 3: Many commenters were supportive of DHA using Medicare's 
requirements for qualifications of PTAs and OTAs. Some commentators 
requested DHA revise the rule to correct the location of Medicare's 
codification for PTA and OTA qualifications, which is 42 CFR 484.115, 
not Sec.  484.4.
    Response: The NDAA-18 mandated DHA follow Medicare's qualifications 
for PTAs and OTAs as found in 42 CFR 484.4 or successor regulation. 
After passage of the NDAA, Medicare revised its regulations, resulting 
in a new citation for the qualifications of PTAs and OTAs. DHA has 
revised the rule and regulation to contain the new regulatory citation 
(Sec.  484.115), and has added verbiage pointing to ``or successor 
regulation'' to avoid future concerns if Medicare revises its 
qualification regulations.
    Comment 4: Two commenters noted that the Medicare Benefit Policy 
Manual Chapter cited in the proposed rule was incorrect. They requested 
this citation be updated to clarify that Medicare Benefit Policy Manual 
Chapter 15 Sections 220 and 230 would be followed.
    Response: DHA acknowledges the error and has corrected the 
reference in the final rule. The Medicare Benefit Policy Manual Chapter 
DHA intends to reference in developing most of its implementing 
instructions on PTAs and OTAs is Medicare Benefit Policy Manual 100-02 
Chapter 15, Covered Medical and Other Health Services, Sections 220 and 
230. In some cases, the DHA will turn to other issuances or manuals for 
clarifying information, including facility-specific chapters of the 
Medicare Benefit Policy Manual. If Medicare revises, renumbers, or 
otherwise relocates its guidance on PTAs and OTAs, DHA will use the new 
policy information, where appropriate.
B. Supervision of PTAs and OTAs
    Comment 5: Many commenters were supportive of matching TRICARE's 
supervision requirements to Medicare's. Many commenters requested DHA 
clarify whether direct supervision would require the supervising 
physical therapist or occupational therapist to be in the room with the 
PTA or OTA, or whether the supervising therapist would only be required 
to be in the office suite.
    Response: DHA intends to use Medicare's definition of direct 
supervision. That is, the physical therapist or occupational therapist 
will be required to be in the office suite where the PTA or OTA is 
located and immediately available to furnish assistance and direction 
throughout performance of the procedure. The supervising physical 
therapist or occupational therapist will not be required to be in the 
room with the PTA or OTA while the procedure is performed.
    Comment 6: Some commenters requested DHA clarify the supervision 
requirements for specific types of facilities (e.g., rehabilitation 
settings).
    Response: Providing specific supervision requirements for each 
facility type that provides PT or OT under the TRICARE program within 
this final rule could negate the DHA's authority to promptly recognize 
by administrative policy, rather than the much longer CFR amendment 
process, changes to supervision requirements

[[Page 15064]]

when enacted by Medicare. The DHA intends to follow Medicare's 
supervision requirements to the extent practicable; those requirements 
are currently available at the Medicare Benefit Policy Manual 100-02 
Chapter 15 sections 220 and 230, along with Medicare Benefit Policy 
Manuals for specific facilities types (home health agencies, combined 
outpatient rehabilitation facilities, etc.).
    Comment 7: Some commenters disagreed with using Medicare's 
supervision requirements because Medicare requires direct supervision 
in private practice, while allowing general supervision in all other 
settings. These commenters requested DHA consider allowing all PTAs 
and/or OTAs to operate under general supervision. They argued that 
requiring direct supervision for private practice in rural areas would 
create long wait lists and otherwise impact patient care.
    Response: The decision to match TRICARE's PTA and OTA supervision 
requirements to Medicare's was made so that providers operating under 
both programs would only have to follow one set of rules (to the extent 
practicable); additionally, Medicare's rules have been in place for 
many years and have the benefit of having been field-tested. It is 
simpler and more appropriate to follow Medicare's requirements. Should 
Medicare revise its supervision requirements for therapists in private 
practice (or other settings), the DHA will evaluate and revise its 
requirements in implementing instructions, where appropriate.
    Comment 8: One commenter expressed concern over adding OTAs as 
authorized providers or reimbursing other than skilled practitioners. 
In particular, this commenter was concerned with giving assistants the 
ability to treat without direct supervision.
    Response: In determining which providers to authorize to provide 
services to TRICARE beneficiaries, DHA weighs a number of factors, 
including the quality of care provided by the provider type and 
beneficiary access to needed care. In adopting Medicare's supervision 
and qualification requirements, beneficiaries will have increased 
access to care that has been quality tested through the many years of 
PTA and OTA authorization under Medicare. If, after implementation, the 
DHA becomes aware of issues with the quality of care provided by PTAs 
or OTAs, the DHA will have the regulatory flexibility to determine that 
it is no longer practicable to mirror Medicare's supervision 
requirements and make changes accordingly.
C. Scope of Practice of PTAs and OTAs
    Comment 9: Two commenters expressed concern over the use of 
examples of services provided by PTAs and OTAs in the proposed rule, 
arguing that these examples could be seen as limiting the services of 
PTAs and OTAs. One commenter expressed concern over limiting OTAs to 
less complex and/or simpler tasks.
    Response: The provided examples were not intended to be a 
comprehensive list of services provided by PTAs and OTAs. However, the 
DHA is sensitive to concerns about inadvertent limiting of the scope of 
practice of the providers under TRICARE and has removed reference to 
specific tasks performed by PTAs and OTAs. PTAs and OTAs will continue 
to be prohibited from performing services outside their scope of 
practice or license.
D. Billing and Reimbursement
    Comment 10: Many commenters requested the DHA clarify when services 
should be billed under the supervising physical therapist or 
occupational therapist's national provider identification (ID) number, 
and when services should be billed under the facility or organization's 
provider ID number. One commenter supported requiring PTAs to be billed 
under the physical therapist's provider ID number.
    Response: DHA's intention in stating within the rule that services 
of therapy assistants would be required to be billed under the 
supervising therapist was intended to apply to professional services 
and to indicate that therapy assistants could not bill under their own 
national provider ID number. In response to concerns raised by the 
commenters, DHA has removed reference to billing requirements under the 
final rule. Billing of therapy services will continue as they have 
under existing TRICARE policy and regulation, with the exception that 
professional services shall not be billed by a PTA or OTA under his or 
her own provider ID, but shall instead be billed under the provider ID 
of the supervising therapist.
    Comment 11: One commenter requested DHA clarify that billing OTA 
services under the occupational therapist's provider ID does not mean 
that OTA services are included in the bill for the occupational 
therapist's services.
    Response: DHA concurs that the existing regulatory language was 
confusing and has removed reference to therapy assistant services being 
included in the services of the supervising therapist. When a therapist 
and therapy assistant separately provide services to a beneficiary 
(i.e., not at the same time), those services are separately 
reimbursable if they would have otherwise been reimbursable should both 
therapy sessions have been provided by the therapist.
    Comment 12: One commenter requested DHA reimburse PTAs at the same 
rate as physical therapists rather than using Medicare's reimbursement 
methodology.
    Response: The DHA is required by statute (10 U.S.C. 1079(h)(1)) to 
reimburse like Medicare where practicable. It is practicable to follow 
Medicare reimbursement for these services. The final rule language has 
been edited to make clear TRICARE's statutory requirement and intent to 
follow Medicare's reimbursement methodologies.
E. Referral Definition
    Comment 13: Several commenters requested clarification on changes 
to the referral definition. One commenter asked how it applied to non-
physician practitioners (NPPs) and asked whether NPPs would now be able 
to make referrals and sign orders. One commenter asked if PTs and OTs 
would now be allowed to give referrals. One commenter requested DHA 
clarify the anticipated impact of updating the referral definition. One 
commenter expressed concern that the proposed language could be 
misinterpreted to require physician referrals in most cases and offered 
alternative language.
    Response: The updated referral definition confers no new referral 
authority, but makes language consistent with existing regulatory 
restrictions regarding referrals. Historically, a physician was 
required to make all referrals under the TRICARE program. However, in 
recent years, changes to the regulation have been made to extend the 
right to make referrals to other provider types. Of note, certified 
nurse practitioners and certified physician assistants were given the 
right to refer patients to licensed registered physical therapists and 
occupational therapists, and licensed registered speech therapists. 
Prior to this final rule, the referral definition continued to limit 
referrals to physicians, which was not consistent with these previously 
approved changes.
    The updated referral definition does not give physical therapists 
or occupational therapists the ability to make referrals, as they do 
not otherwise have referral authority under the regulations. The DHA 
does not expect updating the referral definition to have

[[Page 15065]]

any impact on the TRICARE Program itself, but will remove an existing 
inconsistency within the regulation. One commenter's proposal to change 
the language to ``generally, when a referral is required to qualify 
health care as a covered benefit, a TRICARE-authorized provider may 
make such a referral as allowed within the scope of the provider's 
license'' cannot be adopted as it does not comply with program 
requirements, and could be seen as authorizing providers to make 
referrals inconsistent with other restrictions within the program. A 
separate proposed rule (see 84 FR 13855) proposes to extend those 
providers which can refer to licensed registered physical therapists, 
occupational therapists, and speech therapists.
    Comment 14: One comment expressed concern about DHA regulating who 
can make referrals, and argued this is an encroachment on clinical 
decisions and state licensure/practice acts.
    Response: DHA's enacting statute permits only a specific list of 
providers to treat or diagnose injuries or illnesses under the TRICARE 
program (10 U.S.C. 1079(a)(12)). In order for providers beyond that 
list to perform services under TRICARE, one of the statutorily 
authorized providers must refer to the provider and oversee and manage 
the episode of care. Physical therapists and occupational therapists 
are not listed in 10 U.S.C. 1079(a)(12) and so can only provide care 
when referred to and managed by a physician, certified physician 
assistant, or certified nurse practitioner. Setting referral 
requirements falls within the authority Congress envisioned when it 
gave DHA the authority to create the TRICARE program.
    Comment 15: One commenter requested DHA revisit the remaining 
regulations that require physician referrals and determine if those 
requirements were still appropriate.
    Response: Revision of referral requirements beyond the limited 
revision to the referral definition is beyond the scope of this final 
rulemaking action.
F. Coverage of Other Assistants
    Comment 16: One comment was received that requested DHA analyze 
potential coverage of other assistants.
    Response: Consideration of assistants other than PTAs and OTAs is 
beyond the scope of this final rulemaking action.

3. Provisions of the Final Rule

    This final rule is consistent with the proposed rule. 
Clarifications have been made to terminology and references, the 
definitions of direct and general supervision, and regarding DHA's 
intention to reimburse like Medicare, where practicable.

IV. Regulatory Impact

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, of reducing costs, 
of harmonizing rules, and of promoting flexibility. This rule has been 
designated a non-significant rule under E.O. 12866 and has not been 
reviewed by the Office of Management and Budget.

Executive Order (E.O.) 13771, ``Reducing Regulation and Controlling 
Regulatory Costs''

    E.O. 13771 seeks to control costs associated with the government 
imposition of private expenditures required to comply with Federal 
regulations and to reduce regulations that impose such costs. 
Consistent with the analysis of transfer payments under OMB Circular A-
4, this final rule does not involve regulatory costs subject to E.O. 
13771.

Congressional Review Act (5 U.S.C. 801, et seq.)

    Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), 
the Office of Information and Regulatory Affairs designated this rule 
as not a major rule, as defined by 5 U.S.C. 804(2).

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

    Section 202 of Public Law 104-4, ``Unfunded Mandates Reform Act,'' 
requires that an analysis be performed to determine whether any federal 
mandate may result in the expenditure by State, local and tribal 
governments, in the aggregate, or by the private sector of $100 million 
or more (adjusted annually for inflation) in any one year. The current 
threshold is approximately $140 million. We do not expect this final 
rule to result in any one-year expenditure that would meet or exceed 
this amount.

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

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

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

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

Executive Order 13132, ``Federalism''

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

List of Subjects in 32 CFR Part 199

    Administrative practice and procedure, Claims, Dental health, 
Fraud, Health care, Health insurance, Individuals with disabilities, 
Military personnel.

    Accordingly, 32 CFR part 199 is amended as follows:

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. Section 199.2 is amended by revising the definition of 
``referral.''


Sec.  199.2  Definitions.

* * * * *
    Referral. The act or an instance of referring a TRICARE beneficiary 
to another authorized provider to obtain necessary medical treatment. 
Generally, when a referral is required to qualify health care as a 
covered benefit, only a

[[Page 15066]]

TRICARE-authorized physician may make such a referral unless this 
regulation specifically allows another category of TRICARE-authorized 
provider to make a referral as allowed within the scope of the 
provider's license. In addition to referrals which may be required for 
certain health care to be a covered TRICARE benefit, the TRICARE Prime 
program under Sec.  199.17 generally requires Prime enrollees to obtain 
a referral for care through a primary care manager (PCM) or other 
authorized care coordinator to avoid paying higher deductible and cost-
sharing for otherwise covered TRICARE benefits.
* * * * *

0
3. Section 199.6 is amended by revising paragraph (c)(3)(iii)(K)(2)(i), 
redesignating paragraph (c)(3)(iii)(K)(2)(ii) as paragraph 
(c)(3)(iii)(K)(2)(iii), and adding a new paragraph 
(c)(3)(iii)(K)(2)(ii) to read as follows:


Sec.  199.6  TRICARE-authorized providers.

* * * * *
    (c) * * *
    (3) * * *
    (iii) * * *
    (K) * * *
    (2) * * *
    (i) Licensed registered physical therapist (PT), including a 
licensed or certified physical therapist assistant (PTA) performing 
under the supervision of a TRICARE-authorized PT. PTAs shall meet the 
qualifications specified by Medicare (42 CFR 484.115, or successor 
regulation) and the Director, DHA, shall issue policy adopting, to the 
extent practicable, Medicare's requirements for PTA supervision.
    (ii) Licensed registered occupational therapist (OT), including a 
licensed or certified occupational therapy assistant (OTA) performing 
under the supervision of a TRICARE authorized OT. OTAs shall meet the 
qualifications specified by Medicare (42 CFR 484.115, or successor 
regulation) and the Director, DHA, shall issue policy adopting, to the 
extent practicable, Medicare's requirements for OTA supervision.

    Dated: March 6, 2020.
Aaron T. Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2020-04957 Filed 3-16-20; 8:45 am]
 BILLING CODE 5001-06-P