[Federal Register Volume 68, Number 64 (Thursday, April 3, 2003)]
[Proposed Rules]
[Pages 16247-16249]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-8014]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720-AA76


TRICARE Program; Inclusion of Anesthesiologist's Assistants as 
Authorized Providers; Coverage of Cardiac Rehabilitation in 
Freestanding Cardiac Rehabilitation Facilities

AGENCY: Office of the Secretary, Department of Defense.

ACTION: Proposed rule.

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SUMMARY: This proposed rule establishes a new category of provider as 
an authorized TRICARE provider, and it increases the settings where 
cardiac rehabilitation can be covered as a TRICARE benefit. It 
recognizes anesthesiologist's assistants as authorized providers under 
certain circumstances. It also authorizes cardiac rehabilitation 
services, which are already a covered TRICARE benefit when provided by 
hospitals, to be provided in freestanding cardiac rehabilitation 
facilities.

DATES: Public comments must be received by June 2, 2003.

ADDRESSES: Forward comments to: TRICARE Management Activity (TMA), 
Medical Benefits and Reimbursements Systems, 16401 East Centretech 
Parkway, Aurora, CO 80011-9043.

FOR FURTHER INFORMATION CONTACT: Stephen E. Isaacson, Medical Benefits 
and Reimbursement Systems, TMA, (303) 676-3572.

SUPPLEMENTARY INFORMATION: 

A. Inclusion of Anesthesiologist's Assistants as Authorized Providers

    At present only two types of anesthesia providers may provide 
services to TRICARE beneficiaries--anesthesiologists and certified 
registered nurse anesthetists (CRNAs). In some areas of the country, 
anesthesiologist's assistants, after completing the specified training, 
being accredited, and being licensed by the state also provide 
anesthesia services. The Centers for Medicare and Medicaid Services 
(CMS) already recognizes anesthesiologist's assistants as authorized 
providers (42 CFR 410.69).

[[Page 16248]]

    We propose to recognize anesthesiologist's assistants as authorized 
providers under the same conditions applied by CMS. That is:
    (1) They must work only under the direct supervision of an 
anesthesiologist;
    (2) They must comply with all applicable requirements of state law 
and be licensed, where applicable, by the state in which they practice; 
and
    (3) They must have completed the appropriate educational 
requirements. This includes graducation from a Master's level medical 
school-based anesthesiologist's assistant program that is accredited by 
the Committee on Allied Health Education and Accreditation and includes 
approximately two years of appropriate specialized basic science and 
clinical education in anesthesia. This program must build on a 
premedical undergraduate science background.
    Recognition of anesthesiologist's assistants will not increase the 
costs of anesthesia to the Program. This is, payment for anesthesia 
services provided by an anesthesiologist and an anesthesiologist's 
assistant under the anesthesiologist's direct supervision will never 
exceed what would have been paid if the services were provided only by 
the anesthesiologist.
    Since anesthesiologist's assistants may not practice independently, 
they also may not bill independently for their services. All claims for 
their services must be submitted by their employer, whether it is a 
hospital, a physician, or some other similar entity. Such claims must 
indicate that the services were provided by an anesthesiologist's 
assistant.

B. Coverage of Cardiac Rehabilitation in Freestanding Cardiac 
Rehabilitation Centers

    On October 19, 1990, the Office of the Secretary of Defense 
published a final rule in the Federal Register (55 FR 42366) 
establishing cardiac rehabilitation as a TRICARE benefit when used in 
the treatment of certain cardiac events. The following rationale was 
provided for limiting cariac rehabilitation services to TRICARE 
authorized hospitals:

    As a national program, Civilian Health and Medical Program of 
the Uniformed Services (CHAMPUS) strives for uniformity and equity 
in benefits to ensure beneficiary safety. Toward this end, CHAMPUS 
relies on the existing nationwide infrastructure for accreditation 
and professional regulatory oversight. With the large variety of 
freestanding cardiac rehabilitation clinics throughout the country, 
it is incumbent upon CHAMPUS to seek out national standards to 
provide a clear line of demarcation on CHAMPUS requirements. 
Currently, there is no organized national accreditation agency for 
accrediting freestanding cardiac rehabilitation clinics, nor does 
there appear to be standardized state licensure, or certification 
procedures in existence which address standards for freestanding 
cardiac rehabilitation clinics. Since OCHAMPUS does not have the 
resources to conduct its own accreditation activities, the 
requirement for national accreditation is at least a minimum 
assurance that a facility or specialized treatment facility meets 
some standards of quality.

    However, since incorporation of this restriction (i.e., cardiac 
rehabilitation services being restricted to hospital based facilities/
programs) there has been an evolution of alternative freestanding 
delivery programs whose efficacy and safety have been recognized by the 
medical community and other third-party payers. Freestanding cardiac 
rehabilitation programs are examples of this evolutionary trend. With 
the establishment of standardized licensure and accreditation 
procedures, many of these freestanding programs have been recognized 
and approved for participation under TRICARE.
    Currently TRICARE provides coverage/payment for inpatient or 
outpatient services and/or supplies provided in connection with a 
cardiac rehabilitation program when provided by a TRICARE authorized 
hospital. Outpatient cardiac rehabilitation treatment programs 
affiliated with TRICARE authorized hospitals are reimbursed an all-
inclusive allowable charge per session that includes all related 
professional services provided during a rehabilitation session. 
Inpatient programs are paid based upon the reimbursement system in 
place for the hospital where the services are provided. Separate cost-
sharing is allowed for initial evaluation and testing and related 
professional services.
    Since hospital based cardiac rehabilitation is already an 
established benefit under TRICARE, its benefit and reimbursement 
structure can be applied to freestanding cardiac rehabilitation 
programs. Claims for freestanding outpatient cardiac rehabilitation 
treatment will be reimbursed in the same manner as outpatient cardiac 
rehabilitation treatment programs affiliated with TRICARE authorized 
hospitals. That is, they will be reimbursed based upon an all inclusive 
allowable charge per session that includes all related professional 
services provided during the rehabilitation session.

Regulatory Procedures

    Executive Order (EO) 12866 requires that a comprehensive regulatory 
impact analysis be performed on any economically significant regulatory 
action, defined as one which would result in an annual effect of $100 
million or more on the national economy or which would have other 
substantial impacts.
    The Regulatory Flexibility Act 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. 
This rule is not economically significant and will not significantly 
affect a substantial number of small entities.
    ``This rule has been designated as significant and has been 
reviewed by the Office Management and Budget as required under the 
provisions of E.O. 12866.''

Paperwork Reduction Act

    This rule imposes no burden as defined by the Paperwork Reduction 
Act of 1995.

List of Subjects in 32 CFR Part 199

    Claims, Handicapped, Health insurance, and Military personnel.

    Accordingly, 32 CFR part 199 is proposes to be amended as follows:

PART 199--[AMENDED]

    1. The authority citation for part 199 continues to read as 
follows:

    Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.

    2. Section 199.4 is proposed to be amended by revising paragraph 
(e)(18)(iv) as follows:


Sec.  199.4  Basic program benefits.

    (e) * * *
    (18) * * *
    (iv) Providers. A provider of cardiac rehabilitation services must 
be a TRICARE authorized hospital (see Section 199.6 paragraph 
(b)(4)(i)) or a freestanding cardiac rehabilitation facility that meets 
the requirements of Section 199.6 paragraph (f). All cardiac 
rehabilitation services must be ordered by a physician.
* * * * *
    3. Section 199.6 is proposed to be amended by redesignating 
paragraph (c)(3)(iii)(I) as paragraph (c)(3)(iii)(J) and adding a new 
paragraph (c)(3)(iii)(I) as follows:


Sec.  199.6  Authorized Providers.

    (c) * * *

[[Page 16249]]

    (3) * * *
    (iii) * * *
    (I) Anesthesiologist's Assistant. An anesthesiologist's assistant 
may provide covered anesthesia services, if the anesthesiologist's 
assistant:
    (1) Works under the direct supervision of an anesthesiologist, and 
the anesthesiologist bills for the services;
    (2) Is in compliance with all applicable requirements of state law, 
including any licensure requirements the state imposes on nonphysician 
anesthetists; and
    (3) Is a graduate of a Master's level medical school-based 
anesthesiologist's assistant educational program that:
    (i) Is accredited by the Committee on Allied Health Education and 
Accreditation; and
    (ii) Includes approximately two years of specialized basic science 
and clinical education in anesthesia at a level that builds on a 
premedical undergraduate science background.
* * * * *

    Dated: March 28, 2003.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 03-8014 Filed 4-2-03; 8:45 am]
BILLING CODE 5001-08-M