[Federal Register Volume 88, Number 147 (Wednesday, August 2, 2023)]
[Notices]
[Pages 50850-50851]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-16477]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Modifications to the Overseas Implementation of the TRICARE 
Childbirth and Breastfeeding Support Demonstration

AGENCY: Department of Defense (DoD).

ACTION: Notice of demonstration modifications.

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SUMMARY: The Assistant Secretary of Defense for Health Affairs 
(ASD(HA)) is notifying the public that the TRICARE Childbirth and 
Breastfeeding Support Demonstration (CBSD) will be modified for 
implementation to the TRICARE Overseas Program (TOP). Additionally, the 
ASD(HA) is notifying the public that due to current financial 
constraints, all or part of the evaluation of the CBSD may be conducted 
by internal DoD analytics staff.

DATES: The CBSD will expand overseas with the modifications discussed 
in this notice on January 1, 2025.

FOR FURTHER INFORMATION CONTACT: Erica Ferron, 303-676-3626, 
[email protected].

SUPPLEMENTARY INFORMATION: 

A. Background

    Section 746 of the William M. (Mac) Thornberry National Defense 
Authorization Act for Fiscal Year 2021 directed the Secretary of 
Defense to establish a five-year demonstration project under TRICARE to 
evaluate the cost, quality of care, and impact on maternal and fetal 
outcomes of covering the services of doulas and lactation consultants 
or counselors not otherwise TRICARE-authorized, and to determine 
whether it would be appropriate to implement permanent coverage. On 
October 29, 2021, the ASD(HA) published a Federal Register Notice (FRN) 
announcing the CBSD (86 Federal Register (FR) 60006), which began 
nationwide in the United States (U.S.) on January 1, 2022, and will 
expand to include overseas beneficiaries and locations on January 1, 
2025.
    The FRN announced that the CBSD was designed to evaluate the 
following hypotheses:
    (1) Access to doulas will have a positive and measurable impact on 
maternal and fetal outcomes.
    (2) Access to lactation consultants and lactation counselors will 
have the same or better impact on maternal and fetal outcomes when 
compared to the same services provided by other TRICARE-authorized 
providers.
    (3) The cost of providing access to such providers is justified by 
the impact of the providers on maternal and fetal outcomes.
    (4) It is feasible to administer the new provider classes and the 
services they provide.
    The FRN specified that coverage would be provided under private 
sector care and excluded care provided in direct care within Military 
Medical Treatment Facilities (MTFs). To participate, beneficiaries were 
required to be enrolled in Prime or Select with one of the managed care 
support contractors (MCSCs). TRICARE for Life, the Uniformed Services 
Family Health Plan, the Continued Health Care Benefit Program 
beneficiaries were excluded from participation. Beginning January 1, 
2025, beneficiaries in Prime (including Prime Remote) and Select 
enrolled to the TOP contractor will be eligible to participate. The 
demonstration created a new benefit category (childbirth support 
services) and added three new extra-medical maternity care provider 
classes (Certified Labor Doulas (CLDs), Certified Lactation 
Consultants, and Certified Lactation Counselors). It also created 
qualification criteria for the new provider classes, established 
benefit limitations, added group breastfeeding counseling sessions to 
the existing individual breastfeeding counseling benefit, and 
established reimbursement methodologies.

B. Maternity Care Under the TOP

    Each year, approximately 60,000 beneficiaries give birth under the 
MCSCs in private sector care facilities in the United States. The 
number of beneficiaries who give birth overseas under the TOP program 
is comparatively very small. Based on claims data for calendar year 
(CY) 2022, TRICARE beneficiaries enrolled with the TOP contractor gave 
birth 1,093 times in private sector care facilities in 41 countries. 
Over half of those deliveries occurred in Germany, with the next most 
frequent locations for deliveries being Italy, South Korea, the U.S. 
(TOP beneficiaries electing to deliver in one of the 50 states or 
District of Columbia), Puerto Rico, and Japan. These six locations 
accounted for 87 percent of deliveries under TOP. Of the 34 remaining 
countries, 13 had only one delivery, and another nine only had two 
deliveries in 2022. In 2021, the top six locations were the same, but 
there were 14 countries that had a delivery in 2021 that did not have 
one in 2022 while there were births in 15 countries in 2022 for which a 
birth was not recorded in 2021. In other words, there is a small group 
of countries within which the DoD can reliably expect most TOP 
deliveries to occur and a larger number of countries in which a small 
number of deliveries may occur. Expansion of the demonstration overseas 
accounts for this variability as well as the overall smaller number of 
deliveries overseas.

C. CBSD Modifications for Implementation Overseas

    This FRN notifies the public that the DoD intends to modify the 
CBSD for overseas implementation by way of guidance to be published to 
the TRICARE manuals (found at manuals.health.mil). These changes are 
expected to impact some or all of the requirements published in the 
initial CBSD FRN and are intended to facilitate the DoD's ability to 
measure the CBSD hypotheses. The DoD's focus for overseas 
implementation will be testing

[[Page 50851]]

the fourth hypothesis, that is, is it feasible to administer the new 
provider classes and the services they provide in overseas locations? 
The other three hypotheses will be measured primarily using the larger 
beneficiary population already receiving services under the CBSD in the 
U.S.
    As a worldwide benefit, the TRICARE Basic (i.e., medical) benefit 
recognizes that cultural differences unique to health care practices 
and services in overseas locations necessitate allowances for 
variations in care delivery from how the program is administered in the 
U.S. in order to ensure a robust benefit (see the TRICARE Policy Manual 
(TPM), Chapter 12, Section 1.1). Such uniquities and cultural 
differences are expected to impact care provided under the CBSD, such 
that deviating from the CBSD requirements will be required. The 
requirements for the three classes of providers under the CBSD are 
likely to need adjustment in some or all locations to ensure 
applicability in the many countries in which TRICARE beneficiaries may 
give birth each year. These modifications will be enacted prior to the 
start of the CBSD overseas, but additional modifications may occur 
during the two-year overseas period. While the DoD selected 
certification bodies that had an international component, these bodies 
may be less available outside of the U.S. and Western Europe, such that 
additional bodies are required. The overseas CBSD modifications will 
extend to the extra-medical maternity provider classes approved under 
the CBSD in the U.S., but will not include new classes of extra-medical 
maternity providers. Additionally, we anticipate modifying 
reimbursement rates for CBSD services overseas, commensurate with how 
reimbursement is typically modified for overseas delivery of the 
TRICARE Basic (i.e., medical) benefit (see the TRICARE Reimbursement 
Manual, Chapter 1, Section 34 and 35 for examples of such variances).
    Finally, the DoD also anticipates that it may be necessary to add 
an enrollment requirement. The lack of an enrollment process in the 
U.S. was facilitated by known, uniform provider requirements such that 
both beneficiaries and providers could be assured that requirements 
were met prior to the receipt of services. Given that the DoD may need 
to approve changes to provider requirements consistent with care 
delivery in other countries, beneficiaries may not have the same 
ability to independently verify the qualifications of a provider 
without interacting with the TOP contractor. As such, an enrollment 
requirement would ensure beneficiaries understand the requirements for 
the CBSD in their location.
    These and other modifications necessary to ensure DoD's ability to 
evaluate the CBSD hypotheses overseas will be published to the TRICARE 
Operations Manual, which is publicly available at http://manuals.health.mil. Additionally, the DoD will continue to publish 
information about the CBSD on its website (see tricare.mil/cbsd) and 
social media accounts.

D. Modification to the Demonstration Evaluation

    Separately, the ASD(HA) is notifying the public of a change to the 
evaluation of the CBSD. The DoD stated in the October 29, 2021, FRN 
that we intended to use an independent contractor to evaluate the CBSD, 
at an estimated cost of $4.3M. Due to a constrained financial 
environment, the DoD may use internal DoD staff and resources to 
perform some or all of this evaluation. More information on the 
evaluation will be reported in the annual reports to Congress.

    Dated: July 28, 2023.
Aaron T. Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2023-16477 Filed 8-1-23; 8:45 am]
BILLING CODE 5001-06-P