[Federal Register Volume 68, Number 223 (Wednesday, November 19, 2003)]
[Rules and Regulations]
[Pages 65172-65174]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-28756]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720-AA85


TRICARE; Changes Included in the National Defense Authorization 
Act for Fiscal Year 2003 (NDAA-03)

AGENCY: Office of the Secretary, DoD.

ACTION: Interim final rule.

-----------------------------------------------------------------------

SUMMARY: This interim final rule contains several provisions found in 
the NDAA-03, Public Law 107-314, signed on December 2, 2002. 
Specifically this rule addresses eliminating the requirement for 
TRICARE preauthorization of inpatient mental health care for Medicare-
eligible beneficiaries where Medicare is primary payer and has already 
authorized the care using Medicare certification of individual 
professional providers as sufficient documentation to also certify 
individual professional providers under TRICARE; and expanding the 
TRICARE Dental Program (TDP) eligibility for dependents of deceased 
members. Public comments are invited and will be considered for 
possible revisions to the final rule.

DATES: This rule is effective November 19, 2003. The effective date for 
the 32 CFR 199.4(a)(12)(ii)(E)(2) is October 1, 2003. The effective 
date for 32 CFR 199.13(c)(3)(ii)(E)(2) is December 2, 2002.

APPLICABILITY: The applicability date for 32 CFR 199.6(c)(2)(v) is for 
any TRICARE contract entered into on or after December 2, 2002.

COMMENTS: Comments will be accepted until January 20, 2004.

ADDRESSES: Forward comments to Medical Benefits and Reimbursement 
Systems, TRICARE Management Activity, 16401 East Centretech Parkway, 
Aurora, Colorado 80011-9066.

FOR FURTHER INFORMATION CONTACT: Ann N. Fazzini, (303) 676-3803 (The 
sections of this rule regarding elimination of mental health 
preauthorization and Medicare providers as TRICARE providers) or Major 
Shannon Lynch, (303) 676-3496 (The section of this rule regarding the 
TRICARE Dental Program). Questions regarding payment of specific claims 
should be addressed to the appropriate TRICARE contractor.

SUPPLEMENTARY INFORMATION: 

[[Page 65173]]

I. Elimination of Mental Health Pre-Authorization

    Section 701 of the NDAA-03 eliminates the preauthorization 
requirement for inpatient mental health where Medicare is primary payer 
and has already authorized the care. Currently, in situations were a 
Medicare beneficiary, who is also TRICARE eligible, receives inpatient 
mental health care, TRICARE applies its rules for preauthorization even 
though TRICARE is not the primary payer. The language found in section 
701 of the NDAA-03 changes the way we currently operate. Once this 
change is implemented, Medicare beneficiaries who are also TRICARE 
eligible, will follow Medicare's rules until their Medicare benefit is 
exhausted. Once the Medicare benefit is exhausted, TRICARE's rules 
regarding preauthorization will apply. We expect implementation of this 
change will reduce providers' administrative burden as they will no 
longer have to obtain a preauthorization from TRICARE until the 
beneficiary's Medicare benefit is exhausted. It will also reduce the 
burden on our contractors as they will be required to obtain 
preauthorization only after the patient's Medicare benefits are 
exhausted.
    Additionally, Section 701 of the NDAA-03 continues our current 
policy that pre-authorization is not required in the case of an 
emergency.

II. Medicare Provider Certification Applicable to TRICARE Individual 
Professional Providers

    Section 705 of the NDAA-03 provides that Medicare certification of 
individual professional providers shall be considered sufficient 
documentation to also certify authorized individual professional 
providers under TRICARE. When an individual professional provider has 
been certified by Medicare and meets one of the TRICARE individual 
professional provider categories, the Medicare certification shall be 
considered sufficient documentation to certify the provider under 
TRICARE.
    Our contractors are currently in compliance with this provision. By 
accepting Medicare certification as sufficient documentation, TRICARE 
has reduced the administrative burden of separately applying for 
certification under two federal health care programs. While our 
contractors are currently in compliance with this provision this 
interim final rule is necessary to add the statutory language to our 
regulation.
    Section 705 continues the current TRICARE policy of excluding 
providers who are sanctioned or who have program integrity violations 
under Medicare, TRICARE, or other Federal health programs. Such 
providers are specifically excluded as TRICARE providers.

III. TRICARE Dental Program

    Currently, eligibility in the TDP includes any such dependent of a 
member who died while on active duty for a period of more than 30 days 
or a member of the Ready Reserve if the dependent was enrolled on the 
date of the death of the member. The exception to this is that the term 
does not include the dependent after the end of the three-year period 
beginning on the date of the member's death. Section 703 of the NDAA 
FY03 TRICARE changes eligibility in the TDP by including any such 
dependent of a member who dies while on active duty for a period of 
more than 30 days or a member of the Ready reserve if, on the date of 
the death of the member, the dependent is enrolled in dental benefits 
plan or is not enrolled in such a plan by reason of a discontinuance of 
a former enrollment due to transfer to a duty station where dental care 
is provided to the member's eligible dependents under a program other 
than that plan. The exception remains that the term does not include 
the dependent after the end of the three-year period beginning on the 
date of the member's death.

IV. Regulatory Procedures

    Section 801 of title 5, United States Code, and Executive Order 
12866 requires certain regulatory assessments and procedures for any 
major rule or significant regulatory action, defined as one that 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 (RFA) 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 is not a major rule under 5 U.S.C. 801. It is a significant 
regulatory action but not economically significant. In addition, we 
certify that this proposed rule will not significantly affect a 
substantial number of small entities. This rule has been designated as 
significant and has been reviewed by the Office of Management and 
Budget as required under the provisions of E.O. 12866.

Paperwork Reduction Act

    This rule, as written, imposes no burden as defined by the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3511). If, however, any 
program implemented under this rule causes such a burden to be imposed, 
approval thereof will be sought from the Office of Management and 
Budget in accordance with the Act, prior to implementation.

List of Subjects in 32 CFR Part 199

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

0
Accordingly, 32 CFR Part 199 is amended as follows:

PART 199--[AMENDED]

0
1. The authority citation for part 199 continues to read as follows:

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


0
2. Section 199.4 is amended by revising paragraph (a)(12)(ii)(A) and 
the first sentence in paragraph (b)(6)(ii)(A) and adding a new 
paragraph (a)(12)(ii)(E) to read as follows:


Sec.  199.4  Basic program benefits.

    (a) * * *
    (12) * * *
    (ii) Preadmission authorization. (A) This section generally 
requires preadmission authorization for all non-emergency inpatient 
mental health services and prompt continued stay authorization after 
emergency admissions with the exception noted in paragraph (a)(12)(ii) 
of this section. It also requires preadmission authorization for all 
admissions to a partial hospitalization program, without exception, as 
the concept of an emergency admission does not pertain to a partial 
hospitalization level of care. Institutional services for which payment 
would otherwise be authorized, but which were provided without 
compliance with preadmission authorization requirements, do not qualify 
for the same payment that would be provided if the preadmission 
requirements had been met.
* * * * *
    (E) Preadmission authorization for inpatient mental health services 
is not required in the following cases:
    (1) In the case of an emergency.
    (2) In a case in which benefits are payable for such services under 
part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et 
seq.) subject to paragraph (a)(12)(iii) of this section.
    (3) In a case of inpatient mental health services in which 
paragraph (a)(12)(ii) of this section applies, the Secretary shall

[[Page 65174]]

require advance authorization for a continuation of the provision of 
such services after benefits cease to be payable for such services 
under such part A.
* * * * *
    (b) * * *
    (6) * * *
    (iii) Preauthorization requirements. (A) With the exception noted 
in paragraph (a)(12)(ii)(E) of this section, all non-emergency 
admissions to an acute inpatient hospital level of care must be 
authorized prior to the admission. * * *
* * * * *

0
3. Section 199.6 is amended by adding a new paragraph (c)(2)(v) to read 
as follows:


Sec.  199.6  Authorized providers.

* * * * *
    (c) * * *
    (2) * * *
    (v) Subject to section 1079(a) of title 10, U.S.C., chapter 55, a 
physician or other health care practitioner who is eligible to receive 
reimbursement for services provided under Medicare (as defined in 
section 1086(d)(3)(C) of title 10 U.S.C., chapter 55) shall be 
considered approved to provide medical care authorized under section 
1079 and section 1086 of title 10, U.S.C., chapter 55 unless the 
administering Secretaries have information indicating Medicare, 
TRICARE, or other Federal health care program integrity violations by 
the physician or other health care practitioner. That is, TRICARE shall 
accept Medicare certification of providers who have a like class of 
providers under TRICARE without further authorization unless that 
provider is under sanctions as stated herein. Providers without a like 
class (i.e., chiropractors) under TRICARE shall be denied.
* * * * *

0
4. Section 199.13 is amended revising paragraph (c)(3)(ii)(E)(2) to 
read as follows:


Sec.  199.13  TRICARE Dental Program.

    (c) * * *
    (3) * * *
    (ii) * * *
    (E) * * *
    (2) Continuation of eligibility for dependents of service members 
who die while on active duty or while a member of the Selected Reserve 
or Individual Ready Reserve. Eligible dependents of active duty members 
while on active duty for a period of thirty-one (31) days or more and 
eligible dependents of Selected Reserve or Individual Ready Reserve 
members, as specified in 10 U.S.C. 10143 and 10144(b) respectively, if 
on the date of the death of the member, the dependent is enrolled in 
the TDP, or if not enrolled by reason of a discontinuance of a former 
enrollment under paragraphs (c)(4)(ii) and (c)(4)(iii) of this section 
shall be eligible for continued enrollment in the TDP for up to three 
(3) years from the date of the member's death. This 3-year period of 
continued enrollment also applies to dependents of active duty members 
who died within the year prior to the beginning of the TDP while the 
dependents were enrolled in the TFMDP. This continued enrollment is not 
contingent on the Selected Reserve or Individual Ready Reserve member's 
own enrollment in the TDP. During the three-year period of continuous 
enrollment, the government will pay both the Government and the 
beneficiary's portion of the premium share.
* * * * *

    Dated: November 12, 2003.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 03-28756 Filed 11-18-03; 8:45 am]
BILLING CODE 5001-06-M