[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