[Federal Register Volume 89, Number 71 (Thursday, April 11, 2024)]
[Notices]
[Pages 25617-25619]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-07705]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Modification To Childbirth Support Services Covered Under the 
TRICARE Childbirth and Breastfeeding Support Demonstration

AGENCY: Department of Defense.

ACTION: Notice of demonstration modifications.

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SUMMARY: The Director of the Defense Health Agency (DHA) is notifying 
the public of adjustments to the reimbursement and provider 
qualifications for childbirth support services under the Childbirth and 
Breastfeeding Support Demonstration (CBSD).

DATES: The Phase 2 changes will be fully implemented by January 1, 
2025, with a transition period starting June 10, 2024. The two 
modifications to the certified labor doulas (CLD) certification 
requirement are effective April 11, 2024.

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 (FY) 2021 (NDAA FY 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. Section 746 also required the Secretary to conduct a 
maternity survey.
    This demonstration was implemented as the CBSD, with details 
announced in a Federal Register notice (FRN)

[[Page 25618]]

published by the Assistant Secretary of Defense for Health Affairs 
(ASD(HA)) on October 29, 2021 (86 FR 60006). The FRN prescribed the 
qualifications for the three extra medical maternal health providers 
(CLDs, certified lactation consultants, and certified lactation 
counselors), the number and type of services to be reimbursed, and the 
reimbursement rates for the services. The demonstration began on 
January 1, 2022, in the United States under the two Managed Care 
Support Contractors (MCSCs), with overseas expansion planned for 
January 1, 2025. The ASD(HA) later delegated to the Director, DHA, the 
authority to modify requirements established in that FRN. The Director, 
DHA, announces such modifications in this FRN.

B. Childbirth Support Services Phase 2 and Transition Period

    This FRN announces a second iteration of certain components of 
childbirth support services under the CBSD. This new phase will include 
a new reimbursement methodology, new doula-specific codes, increased 
flexibility for antepartum and postpartum visits, and a new requirement 
for CLDs to be participating providers. Phase 2 will be fully 
implemented by January 1, 2025, with a transition period during which 
services will be reimbursed under the existing (Phase 1) requirements. 
Each component of the new phase and the transition are discussed in 
full in this notice.

1. Establishment of a Reimbursement Methodology for Childbirth Support 
Services

    The first component of the new phase of childbirth support services 
announced in this FRN is the establishment of a reimbursement 
methodology that will replace the current reimbursement amounts. The 
methodology is as follows:
    (1) TRICARE will identify state Medicaid rates for states 
reimbursing for doula services.
    (2) TRICARE will identify an appropriate Medicaid-to-Medicare Fee 
Index for obstetrical services for each state reimbursing for Medicaid 
services.
    (3) The state Medicaid rates will be multiplied by the Fee Index.
    (4) A weighted average will be created based on the number of 
TRICARE reimbursed deliveries that occur in each state with a Medicaid 
program that reimburses for doula services. This weighted average will 
be the national reimbursement rate for CLDs under the CBSD.
    Using this methodology, the DHA anticipates that the calendar year 
(CY) 2024 rate for antepartum and postpartum visits (60 minutes) will 
be approximately $107.00 per visit and $957.00 for continuous labor 
support. This national rate will then be adjusted by locality using the 
Medicare Geographic Adjustment Factor. The national rate will be 
recalculated annually based on Medicaid program rates and current 
Medicaid-to-Medicare fee indexes along with the CHAMPUS Maximum 
Allowable Charge (CMAC) update published each year by March 1 
(available at https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement). 
The new rates for CY 2024 will be published by the start of the 
transition for Phase 2. For CY 2024, the national rate for all covered 
childbirth support services will be about $550.00 more per TRICARE 
beneficiary than under the current rates. Because this methodology is 
based on Medicaid rates, it may go up or down each year as new state 
Medicaid agencies bring doula services online or adjust their 
reimbursement amounts. The TRICARE rate is designed to be higher than 
the state Medicaid rates at the national level, though it may be lower 
in individual states with higher Medicaid reimbursement rates.

2. New Billing Codes

    As part of Phase 2, the DHA intends to implement new, doula 
service-specific codes to replace the current general maternity and 
home health codes. The new codes, which will be announced in the 
TRICARE manuals, will be tied to the new reimbursement rates while the 
existing, Phase 1 codes, will remain linked to the Phase 1 rates until 
the transition is completed.

3. Increased Flexibility for Antepartum and Postpartum Visits

    The third component of the Phase 2 changes is a modification to how 
antepartum and postpartum support visits will be billed and paid. 
Currently these visits are untimed, with six visits authorized. This 
FRN announces that the DHA is switching to timed visits, with visits 
billed per 15-minute increment, with each beneficiary allowed up to 24 
15-minute increments (each 15-minute increment would be reimbursable at 
about $26.75 in CY 2024). This will allow the beneficiary and their 
doula to select the most appropriate use of their visit allowance. For 
example, a beneficiary might choose a 90-minute initial antepartum 
visit (six increments), a two-and-a-half-hour initial postpartum visit 
(ten increments), and two 60-minute postpartum visits (eight 
increments). The new billing codes, discussed above, will be billed per 
15-minute increment for visits. The DHA will publish coding guidance 
for doulas in the implementing instructions in the TRICARE manuals 
found at manuals.health.mil.

4. Requirement for CLDs To Be Participating Providers

    The final adjustment that DHA is making as part of Phase 2 is 
adding a requirement that all CLDs under the CBSD must be a 
participating provider under TRICARE. Under this requirement, CLDs will 
be required to file claims and to accept the TRICARE reimbursement rate 
as payment in full, as well as meet all other requirements as a 
TRICARE-participating provider.

5. Transition Period From Phase 1 to Phase 2

    The changes above will be fully effective on January 1, 2025, with 
a transition period from June 10, 2024 until January 1, 2025. During 
the transition period, CLDs can opt to perform services under Phase 1 
or Phase 2. CLDs who are non-participating will be eligible to continue 
to render services under the CBSD through the end of the transition 
period using Phase 1 common procedural terminology codes and billing 
rules, and to receive Phase 1 reimbursement rates. Similarly, during 
the transition, beneficiaries will be able to file for reimbursement 
for services received from non-participating providers under Phase 1 
requirements. Non-participating providers will be ineligible for 
reimbursement of services rendered on or after January 1, 2025, even if 
the non-participating provider has entered into an agreement with a 
beneficiary, and/or their doula benefit has not yet been exhausted. For 
example, if a non-participating provider renders antepartum visits in 
late December 2024, those may be reimbursed; however, if the 
beneficiary experiences labor on January 2, 2025, the continuous labor 
support charges will be denied unless the provider becomes a 
participating provider.
    CLDs who are already participating providers (network or non-
network) when the transition period begins or who execute a 
participation agreement before the end of the transition period will be 
eligible to begin using the new codes and to receive the new 
reimbursement rates. This eligibility will begin either on the start of 
the transition period or the date the participation agreement is 
signed, whichever is later.

[[Page 25619]]

    Any antepartum or postpartum visits performed under Phase 1 
requirements will count as 4 15-minute increments against the 
beneficiary's 24 visit allowance under Phase 2.
    Example: A beneficiary received an initial antepartum visit prior 
to the start of the transition period, followed by another antepartum 
visit after the transition period began from a non-participating CLD. 
The beneficiary's CLD then signs a participation agreement, after which 
time the beneficiary gives birth. The initial two antepartum visits 
would be reimbursed under Phase 1 rules and would count as 8 15-minute 
increments against the beneficiary's 24 increment allowance (4 
increments for each visit). The labor support would be reimbursed under 
Phase 2 rules. After delivery, the beneficiary would have 16 15-minute 
increments remaining to use in the postpartum period, in any 
configuration (e.g., one 4-hour visit, two 2-hour visits, four 1-hour 
visits).
    The DHA notes that it will take several months for the TRICARE's 
contractors to implement the new billing codes, during which time 
claims processing under Phase 2 may be delayed.

C. Adjustments to CLD Certification Requirements

    Separate from the Phase 2 changes discussed above, the Director is 
also announcing that one new certification body will be accepted for 
CLDs under the CBSD: the National Black Doula Association (NBDA). The 
DHA made this decision based on analysis of publicly available 
information for the approximately 47 certification and training bodies 
recognized by the state Medicaid programs (not already approved under 
the CBSD) using the criteria discussed in the FRN that published on 
October 29, 2021. The criteria we discussed in that FRN required that 
the bodies selected for inclusion had to have a time-limited 
certification and be well-established with a wide-ranging footprint 
(i.e., national or international); included classroom training and 
workshops in labor physiology and other childbirth topics; required 
doulas to have completed at least two deliveries prior to 
certification; required evaluations from health care professionals for 
services provided during labor support or a comprehensive examination; 
and had an established scope of practice, code of ethics, code of 
conduct, or similar by which the doula is required to agree to abide.
    The Director, DHA, also announces in this FRN that the 
certification requirement for doulas practicing in a state with an 
active state-wide doula Medicaid benefit will be waived when that doula 
is actively enrolled in that state Medicaid program and provides 
evidence of such an enrollment (the doula must be practicing in the 
state in which they hold a Medicaid enrollment). To be eligible, the 
Medicaid program must be a state-wide program with requirements set by 
the state Medicaid agency. Medicaid programs of limited duration 
(pilot/demonstration programs) and programs where a contractor (for 
example, a managed care organization or accountable care organization) 
sets the provider requirements do not meet these criteria. All other 
TRICARE CLD requirements will continue to be in effect (age, education, 
experience, cardiopulmonary resuscitation certification, and possession 
of a national provider identification number). The various statewide 
programs have different and varying requirements, and so this 
demonstration is testing the impact of those programs on provider 
quality and availability. This may impact the DHA's provider 
requirements if a permanent benefit is established. The TRICARE program 
is a uniform benefit, but because this is a demonstration, we are 
allowing some variability between the states so that we can test the 
impact of these differences on provider quality, availability, and 
other outcomes.

E. Cost

    The modifications in this FRN are not anticipated to increase the 
overall cost of the CBSD above the $51.16M for health care and 
administrative costs that were announced in the 2021 FRN.

    Dated: April 8, 2024.
Aaron T. Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2024-07705 Filed 4-10-24; 8:45 am]
BILLING CODE 6001-FR-P