[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
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Non-preventive
primary care and Mental health (%) Government cost
urgent care (%) increase
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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
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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
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3-month 6-month 9-month
scenario scenario scenario
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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
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Total Government Cost increase.......................... 27,016,110 49,227,937 66,351,451
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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
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Total estimated value to beneficiaries...................... 43,916,839 80,014,567 107,315,107
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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