[Federal Register Volume 85, Number 92 (Tuesday, May 12, 2020)]
[Rules and Regulations]
[Pages 27921-27927]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-10042]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[Docket ID: DOD-2020-HA-0040]
RIN 0720-AB81


TRICARE Coverage and Payment for Certain Services in Response to 
the COVID-19 Pandemic

AGENCY:  Office of the Secretary, Department of Defense.

ACTION:  Interim final rule with request for comments.

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SUMMARY:  The Assistant Secretary of Defense for Health Affairs 
(ASD(HA)) issues this interim final rule with comment to: Provide an 
exception to the prohibition on telephone, audio-only telehealth 
services; to authorize reimbursement for interstate or international 
practice by TRICARE-authorized providers when such authority is 
consistent with governing state, federal, or host nation licensing 
requirements; and to eliminate copayments and cost-shares for 
telehealth services. The changes in this rule will be effective for the 
period of the coronavirus 2019 (COVID-19) pandemic. These changes will 
reduce the spread of COVID-19 among TRICARE beneficiaries by 
incentivizing use of telehealth services, and will aid providers in 
caring for TRICARE beneficiaries by temporarily waiving some licensure 
requirements.

DATES: Effective date: This interim final rule is effective on May 12, 
2020 through the end of the President's national emergency 
(Proclamation 9994 of March 13, 2020 (85 FR 15337)) . ASD(HA) will 
publish a document announcing the expiration date. See the 
SUPPLEMENTARY INFORMATION section for more information.
    Comment date: Comments are invited and must be submitted on or 
before June 11, 2020.

ADDRESSES: You may submit comments, identified by docket number and/or 
Regulation Identification Number (RIN) number and title, by any of the 
following methods:
     Federal Rulemaking Portal: http://www.regulations.gov. 
Follow the instructions for submitting comments.
     Mail: DoD cannot receive written comments at this time due 
to the COVID-19 pandemic. Comments should be sent electronically to the 
docket listed above.
    Instructions: All submissions received must include the agency name 
and docket number or RIN for this Federal Register document. The 
general policy for comments and other submissions from members of the 
public is to make these submissions available for public viewing on the 
internet at http://www.regulations.gov as they are received without 
change, including any personal identifiers or contact information.

FOR FURTHER INFORMATION CONTACT: Major Zachary Rumery, Defense Health 
Agency, 703-681-0053, zachary.r.rumery.mil@mail.mil">zachary.r.rumery.mil@mail.mil; Amber Butterfield, 
Defense Health Agency, 303-676-3565,

[[Page 27922]]

[email protected]; Erica Ferron, Defense Health Agency, 
303-676-3626, [email protected].

SUPPLEMENTARY INFORMATION: 

Expiration Date of the Interim Final Rule

    Unless extended after consideration of submitted comments, this 
interim final rule will cease to be in effect upon termination of the 
President's declared national emergency, in accordance with applicable 
law and regulation (e.g., 50 U.S.C. 1622(a)). Because TRICARE operates 
both in the United States and in overseas locations, the ASD(HA), or 
designee, may determine that it is appropriate to continue exemptions 
to permanent regulation provisions for some or all of TRICARE's 
overseas locations serviced by the TRICARE Overseas Program contractor 
under 32 CFR 199.1(b) beyond termination of the President's declared 
national emergency based on the status of COVID-19 community spread in 
those locations. Such continuation of these provisions for overseas 
locations will be published in TRICARE's implementing instructions 
(TRICARE manuals), available at http://manuals.health.mil.
    If the ASD(HA) determines it would be appropriate to make these 
changes permanent, the ASD(HA) will follow-up with final rulemaking.

I. Executive Summary

A. Purpose of the Interim Final Rule

    A novel coronavirus (SARS-CoV-2), which causes Coronavirus Disease 
2019 (COVID-19), was first detected in December 2019 and has spread 
rapidly throughout the world. On January 31, 2020, the Secretary of 
Health and Human Services determined that a public health emergency 
existed since 27 January, 2020.\1\ On March 13, 2020, the President 
declared a national emergency due to COVID-19. Proclamation 9994 of 
March 13, 2020, titled ``Declaring a National Emergency Concerning the 
Novel Coronavirus Disease (COVID-19) Outbreak'' published in the 
Federal Register on March 18, 2020 (85 FR 15337-15338). This 
proclamation is available at https://www.govinfo.gov/content/pkg/FR-2020-03-18/pdf/2020-05794.pdf. According to WHO data on March 25, 2020, 
there were 416,686 cases of COVID-19 worldwide (18,589 deaths), with 
51,914 in the United States (673 deaths), with the number of cases 
rapidly expanding each day. Medical experts from the National Institute 
of Allergy and Infectious Disease anticipate more cases in the United 
States and overseas in the coming months.\2\
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    \1\ https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx.
    \2\ https://www.niaid.nih.gov/news-events/covid-19-reminder-challenge-emerging-infectious-diseases.
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    In light of the rapid spread of COVID-19, the Centers for Disease 
Control and Prevention (CDC) has urged Americans to work and engage in 
schooling from home whenever possible as well as to avoid congregating 
in groups. Various States (e.g., Washington, New York) and various 
cities (e.g., Los Angeles) have imposed more rigid restrictions on 
gatherings requiring many businesses to restrict or close their 
operations, all to prevent further spread of the disease.
    Pursuant to the President's emergency declaration and as a result 
of the worldwide COVID-19 pandemic, the ASD(HA) hereby modifies the 
following regulations, but in each case, only to the extent necessary, 
as determined by the Director, Defense Health Agency (DHA), to 
encourage social distancing and prevent the spread of COVID-19 by 
incentivizing the use of telehealth services, and to allow TRICARE-
authorized providers to care for TRICARE beneficiaries wherever there 
is need as a result of the consequences of the COVID-19 pandemic. The 
following regulations are temporarily modified:
    a. 32 CFR 199.4(g)(52) Telephone Services: Existing regulations 
exclude TRICARE coverage of telephone services (audio-only) except for 
biotelemetry. Given the current CDC guidelines for social distancing 
and some states' governors' orders for residents to stay at home, it is 
imperative that an exception to the regulatory exclusion be permitted 
to allow TRICARE-authorized providers to render medically necessary 
care and treatment to beneficiaries over the telephone, when in-person 
treatment is not required. Telephone calls of an administrative nature 
(e.g., appointment scheduling) are not medical services and are not 
reimbursable. The exception to the exclusion is warranted now during 
the COVID-19 pandemic and the DoD may follow up with final rulemaking 
to make the removal of the exclusion a permanent change in Program 
regulations, if appropriate, after a thorough review of costs, 
benefits, risks, patient privacy, and other considerations. However, 
while the DoD conducts this review, it is prudent to permit telephone 
services more expansively during this emergency period. This change 
will apply to all geographic areas where TRICARE beneficiaries reside.
    b. 32 CFR 199.6(c)(2) Conditions of authorization--(i) Professional 
license requirement: Existing regulations require TRICARE-authorized 
providers to be licensed in the state where practicing, even if such a 
license is optional. Anticipating that practitioners may be asked to 
surge to areas of high medical need, the federal government (through 
the Department of Health and Human Services (HHS)) and some states 
(e.g., California, Florida, Louisiana) have proposed suspending 
interstate license requirements or otherwise making it easier for 
providers to treat patients beyond the state where the provider holds a 
license. If the federal or state government permits providers to 
operate within a jurisdiction without obtaining a license in that 
state, TRICARE would be unable to cost-share services provided to in-
state beneficiaries by out-of-state licensed providers due to the 
existing regulatory licensure requirements. For telehealth, the 
provider license requirement has long been interpreted to mean that the 
provider must be licensed in the state where practicing and in the 
state where the beneficiary resides. This regulation change would allow 
for reimbursement of an otherwise-authorized TRICARE provider if, under 
applicable federal or state law, that individual holds an equivalent 
license from any state in the United States, complies with any 
provisions for interstate practice in that state, and is not 
affirmatively barred or restricted from practicing in any state in the 
United States. This change does not supplant state authority to 
regulate licensure, but assures that if licensure requirements are 
relaxed by any state or the federal government during the period of the 
COVID-19 pandemic, that providers caring for TRICARE beneficiaries in 
compliance with state or federal law will be eligible for reimbursement 
under TRICARE.
    Implementing this regulatory change resolves an issue of particular 
concern where TRICARE has military installations near the border 
between states and patients may have their primary care or other 
regular provider based in another state (e.g., the patient lives in 
Kentucky but sees a mental health professional in Virginia). Without 
this change, the provider would not be able to be reimbursed for 
services provided to that beneficiary via telehealth unless the 
provider was also licensed in the adjoining state.
    Services provided to TRICARE beneficiaries overseas would be 
eligible for reimbursement when performed by a provider outside of the 
nation in which they are licensed and normally practice if allowed by 
the host country in which

[[Page 27923]]

they are practicing and so long as they hold an equivalent licensure in 
the nation in which they normally provide services. The provider would 
be required to meet all requirements for practice under the host 
nation.
    Providers listed on the HHS sanction list are ineligible to receive 
reimbursement under the TRICARE program, and would remain ineligible 
under this provision.
    c. 32 CFR 199.17(l)(3) Special cost-sharing rules: Existing 
regulations require copayments and cost-sharing for telehealth services 
to be the same as if the service was provided in person. TRICARE's 
cost-shares and copayments are set by law. However, Section 718(d) of 
the National Defense Authorization Act of 2017 authorized the Secretary 
of Defense to reduce or eliminate copayments or cost-shares when deemed 
appropriate for covered beneficiaries in connection with the receipt of 
telehealth services under TRICARE. Given the current environment where 
community-spread of COVID-19 is evident and the CDC has recommended 
social distancing, we find it appropriate to remove copayments and 
cost-shares for TRICARE Prime and Select beneficiaries utilizing 
telehealth services provided by network providers as a necessary 
incentive to prevent further spread of COVID-19 during this emergency. 
The waiving of copayments and cost-shares (including deductibles) for 
in-network telehealth services will apply to all otherwise-covered 
services delivered via telehealth, not just those related to COVID-19, 
and will apply to all TRICARE beneficiaries in all geographic regions 
for the duration of this emergency. TRICARE program rules still apply, 
for example, TRICARE Prime beneficiaries must have a referral from 
their Primary Care Manager (PCM) for a specialty care visit, however, 
under this rule modification, both the PCM visit and the specialty care 
visit (if performed via in-network telehealth) have no cost-share or 
copay. There are no changes to cost-shares and copays for ancillary 
services, durable medical equipment, prescriptions, or other referrals 
or care that are ordered due to or result from the telehealth service.
    d. Dates: These modifications will become effective on May 12, 2020 
and will cease to be in effect upon termination of the President's 
declared national emergency. With TRICARE beneficiaries located 
worldwide, the ASD(HA), or designee, may allow the provisions of this 
interim final rule (IFR) to continue after termination of the 
President's national emergency for some or all of TRICARE's overseas 
locations based on the status of COVID-19 community transmission in 
those locations. Such continuation of these provisions for overseas 
locations will be published in TRICARE's implementing instructions 
(TRICARE manuals), available at http://manuals.health.mil.
    Certain provisions of this IFR may be made permanent (e.g., the 
elimination of the audio-only telehealth exclusion) while others are 
anticipated to be removed when the COVID-19 pandemic has concluded 
(e.g., waiver of telehealth cost-shares and licensure of authorized 
providers). The DoD may issue a final rule to make permanent changes.

B. Interim Final Rule Justification

    Agency rulemaking is governed by section 553 of the Administrative 
Procedure Act (APA), 5 U.S.C. 551 et seq.. Section 553(b) requires 
that, unless the rule falls within one of the enumerated exemptions, 
the DoD must publish a notice of proposed rulemaking in the Federal 
Register that provides interested persons an opportunity to submit 
written data, views, or arguments, prior to finalization of regulatory 
requirements. Section 553(b)(B) of the APA authorizes a department or 
agency to dispense with the prior notice and opportunity for public 
comment requirement when the agency, for ``good cause,'' finds that 
notice and public comment thereon are impracticable, unnecessary, or 
contrary to the public interest. Section 553(d)(3) requires that an 
agency must include an explanation of such good cause with the 
publication of the new rule.
    As noted in this preamble, the United States, as well as numerous 
other countries, have taken unprecedented measures to try to contain or 
slow the spread of COVID-19. The CDC has recommended that individuals 
remain at home unless their occupations are essential, e.g., health 
care workers, and various states and locales have instituted more 
stringent requirements discouraging travel. As a result, ensuring that 
patients receive testing and care as warranted will require robust 
telehealth (including audio-only services) and coverage of providers 
rendering services in different locations from where they are licensed.
    Given the national emergency caused by COVID-19, it would be 
impracticable and contrary to the public health--and, by extension, the 
public interest--to delay these implementing regulations until a full 
public notice-and-comment process is completed.
    Pursuant to 5 U.S.C. 553(b)(B), and for the reasons stated in this 
preamble, the ASD(HA), therefore, concludes that there is good cause to 
dispense with prior public notice and the opportunity to comment on 
this rule before finalizing this rule. For the same reasons, the 
ASD(HA) has determined, consistent with section 553(d) of the APA, that 
there is good cause to make this IFR effective immediately upon 
publication in the Federal Register.

C. Summary of Major Provisions of the Interim Final Rule

    This provision, 32 CFR 199.4(g)(52) currently excludes telephone 
services when they are audio-only. However, biotelemetry for patient 
monitoring and synchronous two-way audio interactions that are enhanced 
with video or similar kinds of data transmissions are covered under the 
TRICARE Program. This IFR temporarily revises the regulation to provide 
an exception to the prohibition for telephonic services (audio-only) 
for the duration of the COVID-19 pandemic. The exception to the 
prohibition is warranted now during the pandemic to permit 
beneficiaries to have their symptoms (which include COVID-19 symptoms, 
or symptoms of other covered illness or injury) evaluated by a provider 
over the telephone before, or in lieu of, obtaining an in-person 
appointment; which may ultimately not be necessary. This practice 
supports containment of the disease and decreases the opportunity for 
exposing others.
    Consistent with existing TRICARE policy, all audio-only telehealth 
encounters must be medically necessary, appropriate, and be rendered by 
a TRICARE-authorized provider acting within the scope of their 
licensure, as defined by TRICARE statute, regulation, and policy. This 
regulatory modification does not expand the services available to 
TRICARE beneficiaries; instead, it makes otherwise-covered services, 
when rendered via telephone (audio-only), eligible for reimbursement 
and cost-sharing when care is medically necessary and appropriate, and 
meets all other provisions of TRICARE policy. While existing telehealth 
platforms that incorporate both audio and video/visual two-way 
communication is preferred, there may be instances when this is not 
possible within the context of this public health emergency. For 
example, a rural provider may not have access to broadband capability, 
or a beneficiary may not have in-home technology to support two-way 
audio/video communication. For the purposes of this public health 
emergency, and to support clinical guidelines regarding social 
distancing, audio-only visits (if appropriate) are an acceptable

[[Page 27924]]

alternative to other, preferred, telehealth platforms. The rendering 
provider will be expected to utilize their judgment of clinical 
necessity, within their licensure and scope of practice, to 
differentiate services provided via audio and video (traditional 
telehealth platforms) or audio-only services. The use of audio-only 
telehealth should be for the purpose of providing assessment, 
diagnosis, clinical care, or formal patient education from an 
authorized provider to a patient, or for providing clinical 
consultation between providers that directly impacts upon a particular 
patient's care. The authorized provider should determine that a phone 
call is appropriate for accomplishing the clinical goals of the 
encounter and document appropriately. If the decision to provide care 
via a traditional audio/visual method is chosen, the reasons for that 
decision should be documented as well. For recurring care, the 
rationale for choosing audio-only or audio and visual should be 
documented only at the initiation of remote care, or upon any change in 
modality.
    Care that normally requires a physical examination (including a 
remote physical examination requiring a tele-presenter such as a nurse) 
is not appropriate for audio-only telehealth encounters. Administrative 
services (for example, making appointments or verifying prescriptions) 
are not separately reimbursed services. Following publication of this 
IFR, the agency will provide additional parameters and policy regarding 
audio-only telehealth encounters in the implementing instructions 
consistent with this IFR and other provisions of TRICARE policy.
    The Agency may follow up with final rulemaking to make the removal 
of the exclusion for telephonic services (audio-only) a permanent 
change in Program regulation, if appropriate, after a thorough review 
of costs, benefits, risks, patient privacy, and other considerations. 
However, while the agency conducts this review, it is prudent to permit 
telephone services more expansively during this emergency period. This 
temporary change will apply to all geographic areas where TRICARE 
beneficiaries reside.
    This provision, 32 CFR 199.6(c)(2)(i), requires providers to be 
licensed in the state in which they practice when such a license is 
offered, even if such a license is not required. The requirement has 
not changed over the years; however, the global pandemic has created a 
situation where flexibility is required in order to allow providers to 
(1) deliver care in areas of need without the additional time and cost 
of re-licensure, when permitted by state and federal law, and (2) 
provide services via telehealth to beneficiaries wherever they are 
located. This temporary rule change will make it easier for TRICARE 
beneficiaries to access telehealth services, and will ensure providers 
are able to treat beneficiaries in areas of high need without worrying 
about not being reimbursed for doing so. Nothing in TRICARE's provision 
supplants the authority of states to manage the licensing of providers 
in their jurisdictions, and this modification would only apply in those 
areas that have opted to relax interstate licensing requirements or 
where the Federal Government has preempted state licensing 
requirements. In doing so, it would ensure that providers continue to 
be reimbursed during the highly-fluid global pandemic. It will still 
require providers to have an equivalent license in any state, to meet 
the requirements for the state where they are practicing, and forbid 
reimbursement of services by a provider who is affirmatively barred or 
restricted from practice in any state.
    This modification would also apply to providers treating 
beneficiaries outside of the United States by allowing the provider to 
practice in a nation other than the one in which they are licensed and 
normally provide services so long as the host nation permits such 
practice and the provider is not on the HHS sanctions list. The ability 
of the provider to practice in the host nation remains the province of 
the host nation; this modification would ensure that services provided 
within the licensure requirements of the host nation would be 
reimbursable under TRICARE.
    This provision, 32 CFR 199.17(l)(3), delineates requirements for 
cost-shares and copayments under the TRICARE program. This IFR would 
amend the regulation to add a new provision waiving cost-shares and 
copayments (including deductibles) for all in-network authorized 
telehealth services for the duration of the COVID-19 pandemic (ending 
when the President's state of emergency declaration is suspended or 
terminated, in accordance with applicable law and regulation). This 
will incentivize TRICARE beneficiaries to utilize telehealth services 
and avoid unnecessary in-person TRICARE-authorized provider visits, 
which could potentially bring them into contact with or inadvertently 
aid in the spread of COVID-19. This will apply to TRICARE Prime and 
Select beneficiaries in all geographic areas.

D. Legal Authority for This Program

    This rule is issued under 10 U.S.C. 1073(a)(2) giving authority and 
responsibility to the Secretary of Defense to administer the TRICARE 
program. The text of 10 U.S.C. chapter 55 can be found at https://manuals.health.mil/.

II. Regulatory History

    Each of the sections being modified by this rule are revised every 
few years to ensure requirements continue to align with the evolving 
health care field. Title 32 CFR Section 199.4 was most recently updated 
on September 29, 2017, with an IFR (82 Federal Register (FR) 45438) 
that implemented the Congressionally-mandated TRICARE Select benefit 
plan. Its revision to 32 CFR 199.4 included the addition of medically 
necessary foods as a benefit under the TRICARE Basic Program. No 
revisions have been made to the telehealth services paragraph being 
revised by this IFR, Sec.  199.4(g)(52), in at least 20 years.
    The most recent update to 32 CFR 199.6 was on March 17, 2020 (85 FR 
15061), which added physical therapist assistants and occupational 
therapy assistants as TRICARE-authorized providers. Six hundred eighty-
one comments, none of which were substantial, were received on the 
proposed rule associated with that change, and all were resolved in the 
final rule. The particular provision being modified by this IFR 
regarding provider licensure, Section 199.6(c)(2)(i) is a long-standing 
requirement of the TRICARE program, and has not been revised in over 20 
years.
    Title 32 CFR Section 199.17 was last revised on February 15, 2019 
(84 FR 4333), as part of the final rule implementing the TRICARE Select 
benefit plan. The revisions to Section 199.17 included adding high-
value services as a benefit under the TRICARE program, as well as 
copayment requirements for Group B beneficiaries. The 32 CFR 199.17(l) 
paragraph being modified by this IFR was created as part of the IFR 
that established the TRICARE Select benefit (82 FR 45438) during which 
a comprehensive revision of Section 199.17 occurred. This paragraph did 
not exist prior to that revision and has not been modified since.

III. Regulatory Analysis

A. Regulatory Planning and Review

a. Executive Orders
Executive Order 12866, ``Regulatory Planning and Review'' and Executive 
Order 13563, ``Improving Regulation and Regulatory Review''
    Executive Orders 13563 and 12866 direct agencies to assess all 
costs and benefits of available regulatory

[[Page 27925]]

alternatives and, if regulation is necessary, to select regulatory 
approaches that maximize net benefits (including potential economic, 
environmental, public health and safety effects, distributive impacts, 
and equity). Executive Order 13563 emphasizes the importance of 
quantifying both costs and benefits, of reducing costs, of harmonizing 
rules, and of promoting flexibility. Accordingly, the rule has been 
reviewed by the Office of Management and Budget (OMB) under the 
requirements of these Executive Orders. This rule has been designated a 
``significant regulatory action,'' and determined to be not 
economically significant, under section 3(f) of Executive Order 12866. 
This rule is not expected to have a significant impact on the economy; 
however, the urgency of the change due to the global pandemic makes it 
a significant regulatory action.
b. Summary
    The modifications to Section 199.4(g)(52) in this IFR will allow 
TRICARE beneficiaries to obtain telephonic (audio) office visits with 
TRICARE-authorized providers for otherwise-covered, medically necessary 
care and treatment and allow reimbursement to those providers during 
the COVID-19 pandemic. It provides an exception to the regulatory 
exclusion prohibiting audio-only telephone services.
    The modifications to Section 199.6(c)(2)(i) in this IFR will allow 
providers to be reimbursed for interstate practice, both in person and 
via telehealth, during the global pandemic so long as the provider 
meets the requirements for practicing in that state or under federal 
law. It removes the requirement that the provider must be licensed in 
the state where practicing, even if that license is optional. For 
providers overseas, this will allow providers, both in person and via 
telehealth, to practice outside of the nation where licensed when 
permitted by the host nation.
    The modifications to Section 199.17(l)(3) will remove cost-shares 
and copayments for telehealth services for TRICARE Prime and Select 
beneficiaries utilizing telehealth services with an in-network, 
TRICARE-authorized provider during the global pandemic. It adds in-
network telehealth services as a special cost-sharing rule to waive the 
beneficiary copay.
c. Affected Population
    This rule impacts all 9.5 million TRICARE beneficiaries, TRICARE-
authorized providers, the TRICARE Program, and its contractors, both in 
the United States and overseas. TRICARE beneficiaries will be impacted 
through increased access to telehealth services and to providers who 
might surge to help with areas of high medical need. Providers will be 
impacted by being able to provide services in any state or nation that 
allows them to do so without risking loss of reimbursement for those 
services. TRICARE's health care contractors will be impacted by being 
required to implement the provisions of this regulatory change. While 
states will not be directly impacted by this change, this change will 
support efforts by states to ensure enough providers are available to 
provide services to TRICARE beneficiaries within their jurisdictions 
when those states relax licensing requirements for interstate practice.
d. Costs
    The cost estimates related to the changes discussed in this IFR 
include health care and administrative costs to the government and 
beneficiary cost impact. The duration of the COVID-19 emergency is 
uncertain, therefore estimated three-, six-, and nine-month scenarios 
for the impact of this IFR are presented.
Health Care Costs Associated With Removing Copays for Telehealth
    There are three factors that would increase DoD health care costs 
due to this rule. First, the government would lose cost-sharing revenue 
paid by beneficiaries on the existing level of telehealth visits. 
Second, there would be induced demand costs, as removal of patient 
costs will increase patient demand for these services. Finally, there 
would be a substitution effect, as the COVID-19 pandemic and removal of 
telehealth cost-shares would encourage a shift from in-person visits, 
for which beneficiaries would pay a copay, to telehealth visits, which 
would be free to beneficiaries. The estimated direct loss of copay 
revenue is estimated at: $156,949.00 for three-month waiver; 
$313,897.00 for six months; and $470,846.00 for nine months. The 
projected induced demand due to zero cost-sharing for telehealth 
visits, (relative to existing utilization) per 3 months is estimated at 
$117,772.00. Regarding the estimated cost associated with the 
substitution effect, see Table 1. Assumed Shifts of Historical Visits 
from In-Person to Telehealth.

                    Table 1--Assumed Shifts of Historical Visits From In-Person to Telehealth
----------------------------------------------------------------------------------------------------------------
                                                           Non-preventive
                                                          primary care and  Mental health (%)   Government cost
                                                          urgent care (%)                           increase
----------------------------------------------------------------------------------------------------------------
During months 1-3......................................                 25                 90        $26,673,895
During months 4-6......................................                 20                 75         21,937,107
During months 7-9......................................                 10                 67         16,848,793
    3-month scenario overall...........................                 25                 90         26,673,895
    6-month scenario overall...........................                 23                 83         48,611,002
    9-month scenario overall...........................                 18                 77         65,459,795
----------------------------------------------------------------------------------------------------------------

Administrative Costs
    The estimated total contractor start-up administrative costs to 
implement this change is approximately $67,000. This includes a one-
time change to the contractors' claims processing systems and education 
of network providers.
Combined Health Care and Administrative Costs
    Table 2 provides a summary of the combined government health care 
and administrative costs of the IFR.

[[Page 27926]]



                  Table 2--Summary of Government Costs of the Proposed COVID-19 Telehealth IFR
----------------------------------------------------------------------------------------------------------------
                                                                      3-month         6-month         9-month
                                                                     scenario        scenario        scenario
----------------------------------------------------------------------------------------------------------------
Government Health care Cost (HC):
    Loss of copays on existing telehealth.......................        $156,949        $313,897        $470,846
    Induced demand..............................................         117,772         235,544         353,316
    Loss of copays on in-person shifting to Telehealth..........      26,673,895      48,611,002      65,459,795
    Subtotal, Government HC cost................................      26,948,616      49,160,443      66,283,957
Start-up administrative cost....................................          67,494          67,494          67,494
                                                                 -----------------------------------------------
        Total Government Cost increase..........................      27,016,110      49,227,937      66,351,451
----------------------------------------------------------------------------------------------------------------

Beneficiary Cost Impact
    There are two types of savings for beneficiaries estimated here. 
First, beneficiaries would avoid the cost-sharing they otherwise would 
have paid on existing telehealth visits and on in-person visits that 
would shift to telehealth. It is estimated the cost-sharing savings to 
beneficiaries would be: $26,830,844.00 for a three-month scenario; 
$48,924,899.00 for a six-month scenario; and $65,930,641.00 for a nine-
month scenario. Second, for the share of historical visits that is 
estimated would shift from in-person to telehealth, beneficiaries would 
avoid travel time and time spent in the provider's waiting room. Two 
parameters were considered in developing the estimate of the value of 
time saved for TRICARE beneficiaries: (1) The average amount of time 
saved per visit, and (2) a monetized estimate of the value of the time 
saved, based on the opportunity cost of that time. We estimated that 
beneficiaries would save an average of 60 minutes per visit for avoided 
travel and time waiting at the provider's office. We converted this 
average time saved per visit to a monetized value to the beneficiary at 
$20 per hour as the average after-tax wage rate. See Table 3 Estimated 
Value to Beneficiaries for the combined results of avoided cost-sharing 
and dollar value of saved time.

                                    Table 3--Estimated Value to Beneficiaries
----------------------------------------------------------------------------------------------------------------
                                                                      3-month         6-month         9-month
                                                                     scenario        scenario        scenario
----------------------------------------------------------------------------------------------------------------
Avoided cost-sharing............................................     $26,830,844     $48,924,899     $65,930,641
Dollar value of time saved......................................      17,085,995      31,089,668      41,384,466
                                                                 -----------------------------------------------
    Total estimated value to beneficiaries......................      43,916,839      80,014,567     107,315,107
----------------------------------------------------------------------------------------------------------------

    Another important value to beneficiaries that is not feasible to 
estimate but worth noting is the possibility that shifting visits from 
in-person to telehealth might reduce the risk of COVID-19 exposure, 
with all the potential benefits that could accompany that reduced 
exposure risk. This reduced risk of COVID-19 exposure will likely 
result in downstream reductions in costs to the TRICARE Program in 
avoided COVID-19 diagnostics and treatment, although it is also not 
feasible to estimate these cost savings.
e. Benefits
    This change will have a positive impact on beneficiaries by 
incentivizing the use of telehealth while reducing their cost to do so. 
This change will have a positive impact on providers, who will be able 
to serve TRICARE beneficiaries where they are and increase their 
ability to reach beneficiaries through telehealth. Further, this change 
will have a positive societal impact by inducing demand for telehealth 
services and reducing the number of TRICARE beneficiaries seeking in-
person health care services and potentially reducing the spread of 
COVID-19. Finally, though we are unable to quantify, the Department may 
have some reduced costs due to reduced spread and exposure of TRICARE 
beneficiaries to COVID-19, partially offsetting some of the costs 
associated with expansion of benefits and copayment waivers.
f. Alternatives
    The DoD considered several alternatives to this IFR. The first 
alternative involved taking no action. Although this alternative would 
be the most cost neutral for DHA, it was rejected as not addressing the 
urgent medical needs of the beneficiary population in response to the 
COVID-19 pandemic.
    The second alternative DoD considered was to only apply the 
regulatory modifications to COVID-19-related diagnoses. This was 
rejected because the effects of the COVID-19 pandemic are causing 
stress on the entire health care system. The regulatory modifications 
in this IFR will take the pressure off of the health care system by: 
(1) Covering telephonic office visits with a TRICARE-authorized 
provider and thereby supporting social distancing recommendations; (2) 
covering TRICARE-authorized providers practicing across state lines, 
thereby increasing the overall access to medical care and treatment; 
and (3) waiving all copayments for in-network telehealth services for 
TRICARE Prime and Select beneficiaries, thereby removing the potential 
cost barrier to obtaining medical services remotely and inducing demand 
for these services, reducing potential person-to-person transmission of 
COVID-19 during medical appointments.

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

    The Department of Defense certifies that this IFR is not subject to 
the Regulatory Flexibility Act (5 U.S.C. 601) because it would not, if 
promulgated, have a significant economic impact on a substantial number 
of small entities. Therefore, the Regulatory Flexibility Act, as 
amended, does not require us to prepare a regulatory flexibility 
analysis.

C. Congressional Review Act

    Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), 
the Office of Information and Regulatory Affairs

[[Page 27927]]

designated this rule as not a major rule, as defined by 5 U.S.C. 
804(2).

D. Sec. 202, Public Law 104-4, ``Unfunded Mandates Reform Act''

    Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) (2 
U.S.C. 1532) requires agencies to assess anticipated costs and benefits 
before issuing any rule whose mandates require spending in any one year 
of $100 million in 1995 dollars, updated annually for inflation. This 
IFR will not mandate any requirements for State, local, or tribal 
governments, nor will it affect private sector costs.

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

    It has been determined that 32 CFR part 199 does not impose 
reporting or recordkeeping requirements under the Paperwork Reduction 
Act of 1995.

F. Executive Order 13132, ``Federalism''

    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. This IFR will not have a substantial effect on State and 
local governments.

List of Subjects in 32 CFR Part 199

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

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

PART 199--CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED 
SERVICES (CHAMPUS)

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 (g)(52) to read as 
follows:


Sec.  199.4   Basic program benefits.

* * * * *
    (g) * * *
    (52) Telephone services. Services or advice rendered by telephone 
are excluded, except that: (i) Telephone services (audio-only) are not 
excluded when otherwise covered TRICARE services are provided to a 
beneficiary through this modality during the coronavirus 2019 (COVID-
19) public health national emergency, if the services are medically 
necessary and appropriate, and
    (ii) A diagnostic or monitoring procedure which incorporates 
electronic transmission of data or remote detection and measurement of 
a condition, activity, or function (biotelemetry) is not excluded when:
    (A) The procedure without electronic transmission of data or 
biotelemetry is otherwise an explicit or derived benefit of this 
section;
    (B) The addition of electronic transmission of data or biotelemetry 
to the procedure is found by the Director, CHAMPUS, or designee, to be 
medically necessary and appropriate medical care which usually improves 
the efficiency of the management of a clinical condition in defined 
circumstances; and
    (C) The each data transmission or biotelemetry devices incorporated 
into a procedure that is otherwise an explicit or derived benefit of 
this section, has been classified by the U.S. Food and Drug 
Administration, either separately or as a part of a system, for 
consistent use with the defined circumstances in paragraph (g)(52)(ii) 
of this section.
* * * * *

0
3. Section 199.6 is amended by revising paragraph (c)(2)(i) to read as 
follows:


Sec.  199.6   TRICARE-authorized providers.

* * * * *
    (c) * * *
    (2) * * *
    (i) Professional license requirement. The individual must be 
currently licensed to render professional health care services in each 
state in which the individual renders services to CHAMPUS 
beneficiaries. Such license is required when a specific state provides, 
but does not require, license for a specific category of individual 
professional provider. The license must be at full clinical practice 
level to meet this requirement. A temporary license at the full 
clinical practice level is acceptable. During the period of national 
emergency for the global coronavirus 2019 (COVID-19) pandemic, a 
license is not required in the United States for each state in which 
the provider practices, so long as the provider holds an equivalent 
license in another state, the state in which the provider is practicing 
permits such practice under its interstate licensing requirements or 
the state licensing requirements have been preempted by Federal law, 
and the provider is not affirmatively barred or restricted from 
practicing in any state. During the COVID-19 pandemic, providers 
overseas are not required to be licensed in each nation in which the 
provider operates, so long as the provider holds an equivalent license 
in another nation, the host nation permits such practice under its 
licensing requirements, and the provider is not on the Department of 
Health and Human Services sanction list.
* * * * *

0
4. Amend Sec.  199.17 by:
0
a. Redesignating paragraph (l)(3)(A) and (B) as (l)(3)(i) and (ii).
0
b. Adding paragraph (l)(3)(iii).
0
c. Redesignating paragraphs (l)(4)(A) and (B) as (l)(4)(i) and (ii).
    The addition reads as follows:


Sec.  199.17   TRICARE program.

* * * * *
    (l) * * *
    (3) * * *
    (iii) Cost-sharing and copayments (including deductibles) shall be 
waived for in-network telehealth services during the national emergency 
for the global coronavirus 2019 (COVID-19) pandemic.
* * * * *

    Dated: May 6, 2020.
Morgan E. Park,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2020-10042 Filed 5-8-20; 4:15 pm]
 BILLING CODE 5001-06-P