[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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

* * * * *
    (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