[Federal Register Volume 59, Number 35 (Tuesday, February 22, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-2921]
[[Page Unknown]]
[Federal Register: February 22, 1994]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DoD 6010.8-R]
RINS-0720-AA08-0720-AA10-0720-AA13
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); Coverage of Screening Mammography and Papanicolaou (PAP)
Tests, Certified Marriage and Family Therapists, and Requirements for
Coverage and Reimbursement of Services of Physicians in Teaching
Settings
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: This final rule revises the exclusions and limitations of the
CHAMPUS regulation pertaining to preventive care and unnecessary
diagnostic tests not related to a specific illness, injury, or
definitive set of symptoms, to allow coverage for screening mammography
and PAP tests on a preventive basis initially following the recommended
guidelines of the American Cancer Society as a basis for coverage. The
final rule also removes the requirement for physician supervision and
referral for certified marriage and family therapists; requires all
certified marriage and family therapists to accept CHAMPUS payment as
payment in full; ensures that the relationship of certified marriage
and family therapists is consistent with other mental health
practitioners with comparable education and training; protects the
CHAMPUS beneficiary from incurring added out-of-pocket costs for care
rendered that is not part of the current CHAMPUS mental health benefits
package; and better defines the specific requirements of existing
CHAMPUS policies for coverage and reimbursement of services of teaching
physicians and physicians in training.
EFFECTIVE DATE: This part is effective February 22, 1994. The effective
date for changes in Sec. 199.4, paragraphs (g)(1), (g)(2), (g)(37)(vii)
and (g)(37)(viii) and (g)(39), and section 199.6, paragraph (d)(6),
related to screening PAP tests and mammography on a preventive basis is
November 5, 1990; the effective date for changes in Sec. 199.2(b),
``marriage and family therapist, certified,'' ``pastoral counselors,''
``mental health counselor,'' Sec. 199.4, paragraph (c)(3)(ix)(A), and
Sec. 199.6, paragraphs (c) (1)(iv) and (3)(iv), related to certified
marriage and family therapists is May 23, 1994; and the effective date
for changes in Sec. 199.2(b), ``approved teaching programs,''
``attending physician,'' ``physician in training'' and ``teaching
physician,'' Sec. 199.4, paragraphs (b)(1)(i), (c)(1)(i), (c)(3)(xiii),
and 199.6, paragraph (c)(1), related to services of teaching physicians
and physicians in training is March 24, 1994.
ADDRESSES: Office of the Civilian Health and Medical Program of the
Uniformed Services (OCHAMPUS), Program Development Branch, Aurora, CO
80045-6900.
FOR FURTHER INFORMATION CONTACT:
Judy Carroll, Program Development Branch, OCHAMPUS, telephone (303)
361-1089.
SUPPLEMENTARY INFORMATION: On August 21, 1991 (56 FR 41498), and
November 12, 1991 (56 FR 57501), the Office of Secretary of Defense
published for public comment notices of proposed rulemaking to comply
with sections 701 and 702 of the National Defense Authorization Act for
Fiscal Year 1991. These statutory provisions are codified at 10 U.S.C.
1079 (a) (2), (8), and (13). This final rule consolidates the comments
and the changes based on comments of three proposed rule amendments to
implement sections 701 and 702 of the Defense Authorization Act for
Fiscal Year (FY) 1991 (Pub. L. 101-510), and to revise requirements for
coverage and reimbursement of services of physicians in teaching
settings. The publication of the final rule amendments was delayed as a
result of the Presidential moratorium on regulation changes. This final
rule completes the action required to amend this part as outlined in
the three previously published proposed rules. The proposed rules
provided specific coverage requirements, screening frequencies, payment
limitations and provider certification requirements, for mammography
and PAP tests, removed the requirement for physician supervision and
referral for certified marriage and family therapists and required all
certified marriage and family therapists to accept CHAMPUS payment as
payment in full. Additionally, in FR Doc. 91-28934, appearing in the
Federal Register on December 10, 1991 (56 FR 64491), the Office of
Secretary of Defense also published for public comment a notice of
proposed rulemaking to revise the comprehensive CHAMPUS regulation, DoD
6010.8-R, pertaining to basic CHAMPUS benefits to better define the
specific requirements for coverage and reimbursement of services of
teaching physicians and physicians in training. We refer the reader to
the proposed rules for a more detailed explanation of this change. We
provided a 30-day comment period on each of the proposed amendments to
the CHAMPUS regulation. The following summarizes the comments received
following publication of each proposed rule amendment, and the actions
taken based on these comments.
Discussion of Comments for
1. Screening Mammographies and PAP Smears
We received two (2) public comments and one (1) comment from the
government agencies which by law we are required to consult with during
the rulemaking process in response to the proposed rule regarding
CHAMPUS coverage for screening mammography and papanicolaou (PAP) tests
related to the proposed screening frequencies for mammography and PAP
testing. A summary of the comments and our responses to them are listed
below.
Comment: The coverage limitations for screening mammography set out
in section II of the proposed rule are virtually identical to the
Medicare requirement. However, we wish to point out that the American
College of Radiology and other groups including the National Cancer
Institute, American Cancer Society, American Medical Association, and
other physician organizations recommend that women 65 years of age or
older have mammograms on an annual basis. We recommend adopting the
position of national professional organizations over Medicare current
coverage policy.
Response: We have found your argument persuasive and have amended
the language in the Final Rule to follow the expert opinion and
recommendation of national professional organizations. The amended
language will allow annual screening for women 65 years of age or
older.
Comment: The Department of Defense has proposed adopting current
Medicare regulations for use in the CHAMPUS program. Under these
regulations, screening mammography would be allowed only once every two
years for ``asymptomatic women over the age of 65.'' Mammography is the
only screening device currently available that detects breast cancers
before they become palpable. Diagnosed in the early stages, breast
cancer is more amenable to less invasive medical therapies. This
translates into money saved as a result of fewer and shorter
hospitalizations, less radical and more inexpensive treatments, and a
lower recurrence rate. This organization believes that all women over
the age of 50 should undergo annual screening mammography and clinical
breast examination as part of their overall preventive health-care
plan.
Response: In order to remain in keeping with nationally recognized
breast cancer screening frequencies which recommend that annual
mammograms should be allowed for all women age 50 and over, we have
added clarifying language to the final rule. The new language allows
women between the ages of 50 and 64 years of age to have annual
mammography screening.
Comment: Because of greater risk, annual screening mammography is
important for women 65 and over. Additionally, the proposed rule which
allowed coverage for screening PAP tests on an annual basis is
inconsistent with the consensus of the scientific community, which
suggests that following three consecutive annual PAP tests with
negative findings, and in the absence of risk factors, screening may
safely be decreased to every two (2) to (3) years.
Response: We have amended language in the final rule to allow
coverage of screening PAP tests every two (2) years after three
consecutive annual exams with normal findings and in the absence of
risk factors.
2. Certified Marriage and Family Therapists
We received twelve (12) public comments from five (5) interested
professional organizations and three (3) comments from the Government
agencies which by law we are required to consult with during the
rulemaking process in response to the proposed rule to remove the
requirement for physician supervision and referral for certified
marriage and family therapists and require all certified marriage and
family therapists to accept CHAMPUS payment as payment in full. Three
(3) of the professional organizations provided similar comments. A
summary of the comments and our responses to them are listed below:
Comment: One commentor expressed great concern that the proposed
rule contained no provision to address the need for either medical
differential diagnosis by a physician or evaluation by a mental health
professional of the level of clinical psychologist or clinical social
worker. The commenter strongly urged that OCHAMPUS require that
patients being seen by any of these various categories of nonphysician
mental health practitioners be evaluated by physicians, including
psychiatrists, to assure that appropriate medical care will be
provided.
Response: We, too, share the concerns of this professional
organization. However, based upon the provisions of the FY 1991 Defense
Authorization Act, as cited above, we can no longer require physician
referral and supervision. We have added language which states that
patients with medical conditions must receive appropriate concurrent
management by a physician. Additionally, claims for services by
certified marriage and family therapists shall continue to be reviewed
in accord with appropriate medical concepts.
Comment: One commenter questioned by OCHAMPUS would forward with
this proposal, knowing assuredly that costs will inevitably increase.
Even with the ``payment in full'' requirements for this proposed
regulation, the expansion to independent practice and billing will be
costly.
Response: As previously stated, this change was mandated by
Congress. Program costs associated with this final amendment are not
expected to be substantial, since this amendment will eliminate
administrative requirements for CHAMPUS, the beneficiary, and the
provider population.
Comment: The proposed rule would also permit mental health
counselors and pastoral counselors to be certified and removed from
physician supervision and referral requirements. There certainly is no
legislative authority for the proposed expansion for others than
marriage and family therapists, and we think this effort is misguided.
Response: Neither the proposed nor final rules permit mental health
or pastoral counselors to practice without physician supervision and
referral. Both rules keep the requirement for physician supervision and
referral for mental health and pastoral counselors.
Comment: We believe it inappropriate that OCHAMPUS has gone ahead
and promulgated federal criteria that would recognize independent
practice and payment under CHAMPUS for practitioners that are not
permitted such legal right under state law. We do not believe that
OCHAMPUS should be usurping the traditional state role and
responsibility to regulate individual professions. This permits
unregulated practice without any quality assurance to protect patients.
Response: CHAMPUS requires all providers comply with state
licensure and certification requirements, and to practice within the
parameters of their scope of licensure. This means that if a state
requires a certified marriage and family therapist to practice with
physician involvement, OCHAMPUS would also require the provider to
practice within the state standard.
Comment: We strongly request that you add mental health counselors
as mental health providers not needing physician referral.
Response: The legislation which mandated the removal of physician
supervision and referral only authorized removal of the requirement for
one category of provider, that is, certified marriage and family
therapists. By law, the physician supervision and referral requirement
is still required for services rendered by pastoral counselors and
mental health counselors under CHAMPUS.
Comment: We recommend correcting the national organization which
offers clinical membership for marriage and family therapists to the
American Association for Marriage and Family Therapy rather than the
American Association of Marriage and Family Counselors which was listed
in proposed paragraph (c)(3)(iv)(D)(2).
Response: We have revised the regulatory language to reflect the
correct name of the national organization which offers clinical
membership for marriage and family therapists.
Comment: The experience requirements delineated in
Sec. 199.6(c)(3)(iv)(A)(2) are outdated and cumbersome to administer
given the many specific requirements detailed. We recommend that
CHAMPUS change the experience requirement to reflect current American
Association of Marriage and Family Therapy clinical membership
criteria. Such a change would be consistent not only with the current
standards established by the nationally recognized credentialing
organization for marriage and family therapy, but it would also
establish criteria consistent with other independent CHAMPUS providers.
Response: We do not find this argument persuasive. A comparison of
the requirements shows that the hours of training for marriage and
family therapists are identical. However, the American Association of
Marriage and Family Therapy standards do not include the requirement
for psychotherapy experience even though psychotherapy is one of the
major services certified marriage and family therapists provide. Since
the CHAMPUS benefit does not include counseling services and certified
marriage and family therapists will primarily be providing
psychotherapy services to CHAMPUS beneficiaries, we feel a requirement
for psychotherapy experience is critical.
Comment: We recommend that certified marriage and family therapists
be removed from the ``extramedical'' provider category
(Sec. 199.6(c)(3)(iv)(A)) and be listed under ``Other allied health
professionals'' as Sec. 199.6(c)(3)(iii)(H)(3). The American
Association of Marriage and Family Therapy is concerned that the
extramedical designation may lead beneficiaries and providers to
believe that a certified marriage and family therapist still requires a
physician's supervision and referral.
Response: CHAMPUS beneficiaries will be advised of the elimination
of the physician supervision and referral requirement for certified
marriage and family therapists through changes in the beneficiary's
handbook and other public news releases. This should eliminate any
confusion.
Comment: In paragraph (c)(3) to Sec. 199.6(c)(3)(iv), the proposed
rule refers to ``paragraph (c)(3)(iv) of this section for more specific
information regarding licensure.'' We assume that this paragraph refers
to paragraph (c)(3)(iv)(D) of the proposed rule which discusses
additional information applicable to each of the extramedical
providers.
Response: Your assumption is correct.
Comment: For the sake of clarity, we believe that paragraph (c)(3)
to Sec. 199.6(c)(3)(iv) should explicitly state that ``In jurisdictions
that do not provide for licensure or certification, the provider must
be certified by or eligible for full clinical membership in the
appropriate national professional association that sets standards for
the specific profession.'' Currently, the proposed rule could be
mistakenly interpreted to mean that if providers live in a state that
does not regulate marriage and family therapy, they cannot be CHAMPUS
authorized providers.
Response: We have incorporated the above technical revision.
Comment: Paragraph (c)(3) to Sec. 199.6(c)(3)(iv) also does not
address the professional status of marriage and family therapists
licensed or certified in California, Michigan, and New Jersey. Although
marriage and family therapists in each of these jurisdictions meet
CHAMPUS' educational and experience requirements, they are technically
regulated as marriage, family and child counselors or marriage and
family counselors. We fear that California, Michigan, and New Jersey's
marriage and family therapists may be denied CHAMPUS provider status
based on the semantics of a professional title, despite the fact that
the credentials and scope of practice are the same in these states as
they are for marriage and family therapists in other regulated
jurisdictions.
Response: CHAMPUS denial of provider status is not based solely on
professional title. Licensing is but one part of the marriage and
family certification and review process. Authorization as a certified
marriage and family therapist under CHAMPUS includes licensure,
graduation from a regionally accredited school, a degree in an
appropriate field, and post-graduate clinical training.
Comment: We assume and would like to clarify that CHAMPUS providers
who currently qualify as marriage and family counselors will qualify as
certified marriage and family therapists without having to redocument
their credentials. We understand that they must agree to accept the
CHAMPUS allowable charge as payment in full as stipulated by proposed
paragraph 4 (now paragraph 5) of Sec. 199.6(c)(3)(iv)(A)(4), (now
paragraph (5)), but we do not understand the change to be a requirement
for the resubmission of credential materials. We feel it would be an
administrative burden to both OCHAMPUS and individual providers to
require such redocumentation of professional qualifications. We
recommend language be incorporated within the final rule to circumvent
the possibility for such an administrative nightmare.
Response: The legislation required that all marriage and family
therapists be certified. We have interpreted this to mean that only
providers who meet the very minimum level of requirements should remain
authorized under CHAMPUS. Additionally, the legislation did not provide
grandfathering provisions for marriage and family counselors already
authorized under CHAMPUS. We feel recertification will ensure CHAMPUS
beneficiaries receive care provided by both certified and qualified
providers.
Comment: Will certified marriage and family therapists who have
signed a participation agreement with OCHAMPUS be able to terminate the
agreement.
Response: Certified marriage and family therapists who have signed
a participation agreement with OCHAMPUS may terminate the agreement
upon notification to OCHAMPUS. The participation agreement will
stipulate the number of days required for notification to terminate.
Comment: Will certified marriage and family therapists who have
terminated their participation agreement be eligible to qualify as
another category of provider under CHAMPUS? If this allowed, we foresee
a number of problems in the adjudication of claims, particularly if
they choose to switch to a category of provider which still requires
physician supervision and referral and continue to treat the same
patients.
Response: Upon application to OCHAMPUS, a provider must indicate
under which category of provider he/she wishes to be authorized. Once a
determination by OCHAMPUS is made that the applicant meets the
qualifications of the provider category for which he/she is applying,
switching from one group to another seldom occurs. Switching could be
allowed if the provider has continued his/her education and such
additional education qualifies him/her for a different provider
category (i.e., nurse to M.D., clinical psychologist to psychiatrist,
or M.D. to psychiatrist). Such upward or changed speciality movement
generally does not create an adjudication problem. However, we agree
that the new legislative provisions regarding certified marriage and
family therapists may create adjudication problems, since the
provisions of the law allow certified marriage and family therapists to
practice without physician supervision and referral. Switching and
movement within any other extramedical provider category where
physician supervision and referral is required would result in CHAMPUS
beneficiaries incurring costs for denied care. Care denied for lack of
physician supervision and referral would not be subject to the hold
harmless provisions of the new legislation since these provisions only
apply to the certified marriage and family therapists provider
category. We feel it would be inappropriate to require retroactive
physician supervision and referral for care that has already been
rendered, or for continuing care. To prevent CHAMPUS beneficiaries from
incurring costs Congress did not intend them to incur with this change,
we have added language to the final rule which precludes marriage and
family therapists from switching within the extramedical provider
category. As of the effective date of termination, the certified
marriage and family therapist will no longer be recognized as an
authorized provider under CHAMPUS. Subsequent to termination, the
certified marriage and family therapist may only be reinstated as an
authorized CHAMPUS extramedical provider by entering into a new
participation agreement as a certified marriage and family therapist.
3. Services of Physicians in Teaching Settings
We received one (1) public comment from a national physician
organization and one (1) comment from one of the government agencies
which by law we are required to consult with during the rulemaking
process.
Comment: It is not uncommon for physicians to have a contract with
an academic hospital to provide individual, personal services to
hospital patients and for the contract to provide for the physicians to
bill the patient or their insurer directly for those services. In these
cases, the hospital does not bill patients/insurers and makes no
payment to the physician for the services. To require hospitals to
change such billing arrangements serves no useful purpose.
Response: We agree, and it was not our intent to require hospitals
to change their billing arrangements. The CHAMPUS regulation has always
had the requirement that physicians who are employed by or under
contract to the hospital cannot bill for their services. This, however,
is intended to apply only to those contracts which incorporate payment
to the physicians. It does not include contracts which only provide
physicians with normal privileges to admit patients and to render
services in the hospital on a fee-for-service basis. In order to
reflects this intent, we have modified the language in Sec. 199.4
(c)(3)(xiii)(A)(4) as well as in Sec. 199.6 (c)(1).
Comment: In addition to interns and residents, fellows in certain
subspecialties are also ``physicians in training.'' It is unclear from
the document whether or not a fellow in a subspecialty would be
considered a ``physician in training.''
Response: We consider fellows to be physicians in training, and we
have added them to the definition in Sec. 199.2.
Section 605(b) of the Regulatory Flexibility Act (RFA) of 1980
(Pub. L. 96-354) requires that each federal agency prepare and make
available for public comment a regulatory flexibility analysis when the
agency issues a regulation which would have a significant impact on a
substantial number of small entities. The Department of Defense
certifies, pursuant to section 605(b) of title 5, United States Code,
enacted by the Regulatory Flexibility Act (Pub. L. 96-354), that this
final amendment will not have a significant impact on a substantial
number of small businesses, organizations, or government jurisdictions.
For purposes of the RFA, we consider small entities to include all
hospitals and third-party payers.
We have determined that this final amendment is a routine amendment
necessary to provide specific requirements for existing policies and to
implement legislation which authorized expanded CHAMPUS benefits, and
relieved administrative requirements for the CHAMPUS beneficiary and
provider community. It is not, therefore, a ``major rule'' under
Executive Order 12291. This final rule only provides specific
requirements for existing policies; expands benefits; and ensures
equitable administration of CHAMPUS requirements among mental health
providers with comparable education and training while also protecting
CHAMPUS beneficiaries from incurring added costs for mental health care
not normally covered under the CHAMPUS program. It will not involve any
significant burden on CHAMPUS beneficiaries or providers.
Although this change does not qualify as a ``major rule'' under
Executive Order 12291, a cost analysis for costs associated with
implementing screening mammogram and Pap tests was provided in the
proposed rule amendment on screening mammogram and PAP tests.
Additionally, an increase in program costs related to implementation of
this final amendment for the issues related to certified marriage and
family therapists and physicians in teaching settings are not expected
to be substantial, since this amendment will eliminate administrative
requirements for certified marriage and family therapists for CHAMPUS,
the beneficiary and the provider population and only better defines the
specific requirements for coverage of existing policies related to
physicians in teaching settings.
This final rule does not impose information collection
requirements. Therefore, it does not need to be reviewed by the
Executive Office of Management and Budget under authority of the
Paperwork Reduction Act of 1980 (44 U.S.C. 3501-3511).
List of Subjects in 32 CFR Part 199
Claims, Handicapped, Health insurance, Military personnel.
Accordingly, 32 CFR part 199 is amended as follows:
1. The authority citation for part 199 continues to read as
follows:
Authority: 5 U.S.C. 301; 10 U.S.C. 1079, 1086.
2. Section 199.2(b) is amended by adding the new definitions,
``approved teaching programs,'' ``pastoral counselors,'' ``physician in
training,'' and ``teaching physician,'' by removing the definition for
``marriage and family counselor or pastoral counselor,'' by adding the
definition ``marriage and family therapist, certified,'' in
alphabetical order, and by revising the definitions for ``attending
physician,'' and ``mental health counselor'' to read as follows:
Sec. 199.2 Definitions.
* * * * *
(b) * * *
Approved teaching programs. For purposes of CHAMPUS, an approved
teaching program is a program of graduate medical education which has
been duly approved in its respective specialty or subspecialty by the
Accreditation Council for Graduate Medical Education of the American
Medical Association, by the Committee on Hospitals of the Bureau of
Professional Education of the American Osteopathic Association, by the
Council on Dental Education of the American Dental Association, or by
the Council on Podiatry Education of the American Podiatry Association.
* * * * *
Attending physician. The physician who has the primary
responsibility for the medical diagnosis and treatment of the patient.
A consultant or an assistant surgeon, for example, would not be an
attending physician. Under very extraordinary circumstances, because of
the presence of complex, serious, and multiple, but unrelated, medical
conditions, a patient may have more than one attending physician
concurrently rendering medical treatment during a single period of
time. An attending physician also may be a teaching physician.
* * * * *
Marriage and family therapist, certified. An extramedical
individual provider who meets the requirements outlined in Sec. 199.6.
* * * * *
Mental health counselor. An extramedical individual provider who
meets the requirements outlined in Sec. 199.6
* * * * *
Pastoral counselor. An extramedical individual provider who meets
the requirements outlined in Sec. 199.6.
* * * * *
Physician in training. Interns, residents, and fellows
participating in approved postgraduate training programs and physicians
who are not in approved programs but who are authorized to practice
only in a hospital or other institutional provider setting, e.g.,
individuals with temporary or restricted licenses, or unlicensed
graduates of foreign medical schools.
* * * * *
Teaching physician. A teaching physician is any physician whose
duties include providing medical training to physicians in training
within a hospital or other institutional provider setting.
* * * * *
3. Section 199.4 is amended by revising paragraphs (b)(1)(i),
(c)(1)(i), (c)(3)(ix)(A), by adding a new paragraph (c)(3)(xiii) after
the Note, (g)(37)(vii), and (g)(37)(viii), and by revising paragraphs
(g)(1), (g)(2), and (g)(39) to read as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(b) * * *
(1) * * *
(i) Billing practices. To be considered for benefits under
Sec. 199.4(b), covered services and supplies must be provided and
billed for by a hospital or other authorized institutional provider.
Such billings must be fully itemized and sufficiently descriptive to
permit CHAMPUS to determine whether benefits are authorized by this
part. Depending on the individual circumstances, teaching physician
services may be considered an institutional benefit in accordance with
Sec. 199.4(b) or a professional benefit under Sec. 199.4(c). See
paragraph (c)(3)(xiii) of this section for the CHAMPUS requirements
regarding teaching physicians. In the case of continuous care, claims
shall be submitted to the appropriate CHAMPUS fiscal intermediary at
least every 30 days either by the beneficiary or sponsor or, on a
participating basis, directly by the facility on behalf of the
beneficiary (refer to Sec. 199.7).
* * * * *
(c) * * *
(1) * * *
(i) Billing practices. To be considered for benefits under
paragraph (c) of this section, covered professional services must be
performed personally by the physician or other authorized individual
professional provider, who is other than a salaried or contractual
staff member of a hospital or other authorized institution, and who
ordinarily and customarily bills on a fee-for-service basis for
professional services rendered. Such billings must be itemized fully
and be sufficiently descriptive to permit CHAMPUS to determine whether
benefits are authorized by this part. See paragraph (c)(3)(xiii) of
this section for the requirements regarding the special circumstances
for teaching physicians. For continuing professional care, claims
should be submitted to the appropriate CHAMPUS fiscal intermediary at
least every 30 days either by the beneficiary or sponsor, or directly
by the physician or other authorized individual professional provider
on behalf of a beneficiary (refer to Sec. 199.7).
* * * * *
(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, clinical social workers, and certified marriage and family
therapists; and pastoral and 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.
* * * * *
(xiii) Physicians in a teaching setting.
(A) Teaching physicians.
(1) General. The services of teaching physicians may be reimbursed
on an allowable charge basis only when the teaching physician has
established an attending physician relationship between the teaching
physician and the patient or when the teaching physician provides
distinct, identifiable, personal services (e.g., services rendered as a
consultant, assistant surgeon, etc.). Attending physician services may
include both direct patient care services or direct supervision of care
provided by a physician in training. In order to be considered an
attending physician, the teaching physician must:
(i) Review the patient's history and the record of examinations and
tests in the institution, and make frequent reviews of the patient's
progress; and
(ii) Personally examine the patient; and
(iiii) Confirm or revise the diagnosis and determine the course of
treatment to be followed; and
(iv) Either perform the physician's services required by the
patient or supervise the treatment so as to assure that appropriate
services are provided by physicians in training and that the care meets
a proper quality level; and
(v) Be present and ready to perform any service performed by an
attending physician in a nonteaching setting when a major surgical
procedure or a complex or dangerous medical procedure is performed; and
(vi) Be personally responsible for the patient's care, at least
throughout the period of hospitalization.
(2) Direct supervision by an attending physician of care provided
by physicians in training. Payment on the basis of allowable charges
may be made for the professional services rendered to a beneficiary by
his/her attending physician when the attending physician provides
personal and identifiable direction to physicians in training who are
participating in the care of the patient. It is not necessary that the
attending physician be personally present for all services, but the
attending physician must be on the provider's premises and available to
provide immediate personal assistance and direction if needed.
(3) Individual, personal services. A teaching physician may be
reimbursed on an allowable charge basis for any individual,
identifiable service rendered to a CHAMPUS beneficiary, so long as the
service is a covered service and is normally reimbursed separately, and
so long as the patient records substantiate the service.
(4) Who may bill. The services of a teaching physician must be
billed by the institutional provider when the physician is employed by
the provider or a related entity or under a contract which provides for
payment to the physician by the provider or a related entity. Where the
teaching physician has no relationship with the provider (except for
standard physician privileges to admit patients) and generally treats
patients on a fee-for-service basis in the private sector, the teaching
physician may submit claims under his/her own provider number.
(B) Physicians in training. Physicians in training in an approved
teaching program are considered to be ``students'' and may not be
reimbursed directly by CHAMPUS for services rendered to a beneficiary
when their services are provided as part of their employment (either
salaried or contractual) by a hospital or other institutional provider.
Services of physicians in training may be reimbursed on an allowable
charge basis only if:
(1) The physician in training is fully licensed to practice
medicine by the state in which the services are performed, and
(2) The services are rendered outside the scope and requirements of
the approved training program to which the physician in training is
assigned.
* * * * *
(g) * * *
(1) Not medically or psychologically necessary. Services and
supplies that are not medically or psychologically necessary for the
diagnosis or treatment of a covered illness (including mental disorder)
or injury, for the diagnosis and treatment of pregnancy or well-baby
care except as provided in the following paragraph.
(2) Unnecessary diagnostic tests. X-ray, laboratory, and
pathological services and machine diagnostic tests not related to a
specific illness or injury or a definitive set of symptoms except for
cancer screening mammography and cancer screening papanicolaou (PAP)
tests provided under the terms and conditions contained in the
guidelines adopted by the Director, OCHAMPUS.
* * * * *
(37) * * *
(vii) Screening mammography for asymptomatic women 35 years of age
and older when provided under the terms and conditions contained in the
guidelines adopted by the Director, OCHAMPUS.
(viii) Cancer screening papanicolaou (PAP) test for women who are
or have been sexually active, and women 18 years of age and older when
provided under the terms and conditions contained in the guidelines
adopted by the Director, OCHAMPUS.
* * * * *
(39) Counseling. Counseling services that are not medically
necessary in the treatment of a diagnosed medical condition: For
example, educational counseling, vocational counseling, nutritional
counseling, and counseling for socioeconomic purposes, diabetic self-
education programs, stress management, lifestyle modification, etc.
Services provided by a certified marriage and family therapist,
pastoral or mental health counselor in the treatment of a mental
disorder are covered only as specifically provided in Sec. 199.6.
Services provided by alcoholism rehabilitation counselors are covered
only when rendered in a CHAMPUS-authorized treatment setting and only
when the cost of those services is included in the facility's CHAMPUS-
determined allowable cost rate.
* * * * *
4. Section 199.6 is amended by revising the introductory text of
paragraphs (c)(1), (c)(1)(iv) and (3)(iv), and by adding a new
paragraph (d)(6), to read as follows:
Sec. 199.6 Authorized providers.
* * * * *
(c) * * *
(1) General. Individual professional providers of care are those
providers who bill for their services on a fee-for-service basis and
who are not employed by an institutional provider or under a contract
which provides for payment to the individual professional provider by
an institutional provider. This category also includes those
individuals who have formed professional corporations or associations
qualifying as a domestic corporation under 26 CFR 301.7701-5. Such
individual professional providers must be licensed or certified by the
local licensing or certifying agency for the jurisdiction in which the
care is provided; or in the absence of state licensure/certification,
be a member of, or demonstrate eligibility for full clinical membership
in, the appropriate national or professional certifying association
that sets standards for the profession of which the provider is a
member. Services provided must be in accordance with good medical
practice and prevailing standards of quality of care and within
recognized utilization norms.
* * * * *
(iv) Physician referral and supervision. Physician referral and
supervision is required for the services of paramedical providers as
listed in paragraph (c)(3)(iii)(H) of this section and for pastoral
counselors and mental health counselors. Physician referral means that
the physician must actually see the patient, perform an evaluation, and
arrive at an initial diagnostic impression prior to referring the
patient. Documentation is required of the physician's examination,
diagnostic impression, and referral. Physician supervision means that
the physician provides overall medical management of the case. The
physician does not have to be physically located on the premises of the
provider to whom the referral is made. Communication back to the
referring physician is an indication of medical management.
* * * * *
(3) * * *
(iv) Extramedical individual providers. Extramedical individual
providers are those who do counseling or nonmedical therapy and whose
training and therapeutic concepts are outside the medical field. The
services of extramedical individual professionals are coverable
following the CHAMPUS determined allowable charge methodology provided
such services are otherwise authorized in this or other sections of the
regulation.
(A) Certified marriage and family therapists. For the purposes of
CHAMPUS, a certified marriage and family therapist is an individual who
meets the following requirements:
(1) Recognized graduate professional education with the minimum of
an earned master's degree from a regionally accredited educational
institution in an appropriate behavioral science field, mental health
discipline; and
(2) The following experience:
(i) Either 200 hours of approved supervision in the practice of
marriage and family counseling, ordinarily to be completed in a 2- to
3-year period, of which at least 100 hours must be in individual
supervision. This supervision will occur preferably with more than one
supervisor and should include a continuous process of supervision with
at least three cases; and
(ii) 1,000 hours of clinical experience in the practice of marriage
and family counseling under approved supervision, involving at least 50
different cases; or
(iii) 150 hours of approved supervision in the practice of
psychotherapy, ordinarily to be completed in a 2- to 3-year period, of
which at least 50 hours must be individual supervision; plus at least
50 hours of approved individual supervision in the practice of marriage
and family counseling, ordinarily to be completed within a period of
not less than 1 nor more than 2 years; and
(iv) 750 hours of clinical experience in the practice of
psychotherapy under approved supervision involving at least 30 cases;
plus at least 250 hours of clinical practice in marriage and family
counseling under approved supervision, involving at least 20 cases; and
(3) Is licensed or certified to practice as a marriage and family
therapist by the jurisdiction where practicing (see paragraph
(c)(3)(iv)(D) of this section for more specific information regarding
licensure); and
(4) Agrees that a patients' organic medical problems must receive
appropriate concurrent management by a physician.
(5) Agrees to accept the CHAMPUS determined allowable charge as
payment in full, except for applicable deductibles and cost-shares, and
hold CHAMPUS beneficiaries harmless for noncovered care (i.e., may not
bill a beneficiary for noncovered care, and may not balance bill a
beneficiary for amounts above the allowable charge). The certified
marriage and family therapist must enter into a participation agreement
with the Office of CHAMPUS within which the certified marriage and
family therapist agrees to all provisions specified above.
(6) As of the effective date of termination, the certified marriage
and family therapist will no longer be recognized as an authorized
provider under CHAMPUS. Subsequent to termination, the certified
marriage and family therapist may only be reinstated as an authorized
CHAMPUS extramedical provider by entering into a new participation
agreement as a certified marriage and family therapist.
(B) Pastoral counselors. For the purposes of CHAMPUS, a pastoral
counselor is an individual who meets the following requirements:
(1) Recognized graduate professional education with the minimum of
an earned master's degree from a regionally accredited educational
institution in an appropriate behavioral science field, mental health
discipline; and
(2) The following experience:
(i) Either 200 hours of approved supervision in the practice of
pastoral counseling, ordinarily to be completed in a 2- to 3-year
period, of which at least 100 hours must be in individual supervision.
This supervision will occur preferably with more than one supervisor
and should include a continuous process of supervision with at least
three cases; and
(ii) 1,000 hours of clinical experience in the practice of pastoral
counseling under approved supervision, involving at least 50 different
cases; or
(iii) 150 hours of approved supervision in the practice of
psychotherapy, ordinarily to be completed in a 2- to 3-year period, of
which at least 50 hours must be individual supervision; plus at least
50 hours of approved individual supervision in the practice of pastoral
counseling, ordinarily to be completed within a period of not less than
1 nor more than 2 years; and
(iv) 750 hours of clinical experience in the practice of
psychotherapy under approved supervision involving at least 30 cases;
plus at least 250 hours of clinical practice in pastoral counseling
under approved supervision, involving at least 20 cases; and
(3) Is licensed or certified to practice as a pastoral counselor by
the jurisdiction where practicing (see paragraph (c)(3)(iv)(D) of this
section for more specific information regarding licensure); and
(4) The services of a pastoral counselor meeting the above
requirements are coverable following the CHAMPUS determined allowable
charge methdology, under the following specified conditions:
(i) The CHAMPUS beneficiary must be referred for therapy by a
physician; and
(ii) A physician is providing ongoing oversight and supervision of
the therapy being provided; and
(iii) The pastoral counselor must certify 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).
(5) Because of the similarity of the requirements for licensure,
certification, experience, and education, a pastoral counselor may
elect to be authorized under CHAMPUS as a certified marriage and family
therapist, and as such, be subject to all previously defined criteria
for the certified marriage and family therapist category, to include
acceptance of the CHAMPUS determined allowable charge as payment in
full, except for applicable deductibles and cost-shares (i.e., balance
billing of a beneficiary above the allowable charge is prohibited; may
not bill beneficiary for noncovered care). The pastoral counselor must
also agree to enter into the same participation agreement as a
certified marriage and family therapist with the Office of CHAMPUS
within which the pastoral counselor agrees to all provisions including
licensure, national association membership and conditions upon
termination, outlined above for certified marriage and family
therapist.
Note: No dual status will be recognized by the Office of
CHAMPUS. Pastoral counselors must elect to become one of the
categories of extramedical CHAMPUS provides specified above. Once
authorized as either a pastoral counselor, or a certified marriage
and family therapist, claims review and reimbursement will be in
accordance with the criteria established for the elected provider
category.
(C) Mental health counselor. For the purposes of CHAMPUS, a mental
health counselor is an individual who meets the following requirements:
(1) Minimum of a master's degree in mental health counseling or
allied mental health field from a regionally accredited institution;
and
(2) Two years of post-masters experience which includes 3000 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 CHAMPUS 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).
(D) The following additional information applies to each of the
above categories of extramedical individual providers:
(1) These providers must also be licensed or certified to practice
as a certified marriage and family therapist, pastoral counselor or
mental health counselor by the jurisdiction where practicing. In
jurisdictions that do not provide for licensure or certification, the
provider must be certified by or eligible for full clinical membership
in the appropriate national professional association that sets
standards for the specific profession.
(2) Grace period for therapists or counselors in states where
licensure/certification is optional. CHAMPUS is providing a grace
period for those therapists or counselors who did not obtain optional
licensure/certification in their jurisdiction, not realizing it was a
CHAMPUS requirement for authorization. The exemption by state law for
pastoral counselors may have misled this group into thinking licensure
was not required. The same situation may have occurred with the other
therapist or counselor categories where licensure was either not
mandated by the state or was provided under a more general category
such as ``professional counselors.'' This grace period pertains only to
the licensure/certification requirement, applies only to therapists or
counselors who are already approved as of October 29, 1990, and only in
those areas where the licensure/certification is optional. Any
therapist or counselor who is not licensed/certified in the state in
which he/she is practicing by August 1, 1991, will be terminated under
the provisions of Sec. 199.9. This grace period does not change any of
the other existing requirements which remain in effect. During this
grace period, membership or proof of eligibility for full clinical
membership in a recognized professional association is required for
those therapists or counselors who are not licensed or certified by the
state. The following organizations are recognized for therapists or
counselors at the level indicated: Full clinical member of the American
Association of Marriage and Family Therapy; membership at the fellow or
diplomate level of the American Association of Pastoral Counselors; and
membership in the National Academy of Certified Clinical Mental Health
Counselors. Acceptable proof of eligibility for membership is a letter
from the appropriate certifying organization. This opportunity for
delayed certification/licensure is limited to the counselor or
therapist category only as the language in all of the other provider
categories has been consistent and unmodified from the time each of the
other provider categories were added. The grace period does not apply
in those states where licensure is mandatory.
(E) Christian Science practitioners and Christian Science nurses.
CHAMPUS cost-shares the services of Christian Science practitioners and
nurses. In order to bill as such, practitioners or nurses must be
listed or be eligible for listing in the Christian Science Journal\1\
at the time the service is provided.
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\1\Copies of this journal can be obtained through the Christian
Science Publishing Company, 1 Norway Street, Boston, MA 02115-3122
or the Christian Science Publishing Society, P.O. Box 11369, Des
Moines, IA 50340.
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* * * * *
(d) * * *
(6) Mammography suppliers. Mammography services may be cost-shared
only if the supplier is certified by Medicare for participation as a
mammography supplier, or is certified by the American College of
Radiology as having met its mammography supplier standards.
* * * * *
Dated: February 4, 1994.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 94-2921 Filed 2-18-94; 8:45 am]
BILLING CODE 5000-04-M