2.0 POLICY
The Assistant
Secretary of Defense (Health Affairs) (ASD(HA)) issued an Interim
Final Rule (IFR) with comment in the Federal Register on
May 12, 2020, temporarily amending the TRICARE regulation to encourage
social distancing and prevent the spread of COVID-19 by incentivizing
the use of telemedicine services.
The
ASD(HA) issued a second IFR with comment in the Federal Register on
September 3, 2020, temporarily amending the TRICARE regulation to
expand the COVID-19 therapies available to TRICARE beneficiaries
while doing so in settings that ensure informed consent of the beneficiary,
and that the benefits of treatment outweigh the potential risks.
This IFR also expands TRICARE coverage of acute care facilities
during the COVID-19 pandemic.
The
ASD(HA) issued a third IFR with comment in the Federal Register on
October 30, 2020, temporarily amending the TRICARE regulation to
cover National Institute of Allergy and Infectious Disease-sponsored
clinical trials when for the treatment or prevention of COVID-19.
See Chapter 7, Section 24.2.
2.1 Temporary Coverage of Audio-Only Telephone
Services
Existing regulations exclude TRICARE coverage
of telephone services (audio-only) except for biotelemetry. Given
the CDC guidelines for social distancing and some states governors’
orders for residents to stay at home, an exception to the regulatory
exclusion is permitted. TRICARE-authorized providers are allowed
to render medically necessary care and treatment to beneficiaries
over the telephone, when face-to-face, hands-on treatment is not
medically necessary.
2.1.1 Telephone
services (audio-only) are not excluded when otherwise covered TRICARE services
are provided to a beneficiary through this modality, if the services
are medically or psychologically necessary and appropriate.
2.1.2 Telephone services involving evaluation
and management visits shall be reported utilizing Current Procedural
Terminology (CPT) code 99441-3; 98966-8; Healthcare Common Procedure
Coding System (HCPCS) code G2012.
2.1.3 Other authorized telephone services
(e.g., psychotherapy services) shall be reported with the appropriate
CPT or HCPCS code and with the appropriate modifier or place of
service code (e.g., 02) to report that the care was delivered via
telephone. Place of Service Code 02 is not required for telehealth
claims if a more appropriate Place of Service Code is necessary
for correct billing.
2.1.4 Audio-only
care is inappropriate where a visual connection would be required
to ensure appropriate medical care; e.g., evaluation of a skin lesion
by a dermatologist or intensive outpatient programs.
2.2 Temporary Relaxation of State Professional
Licensing Requirements
2.2.1 In the United States, if applicable
federal or state law permits providers to operate within a jurisdiction
without obtaining a license in that state, services provided to
beneficiaries by an otherwise authorized TRICARE provider may be
cost-shared if that provider holds an equivalent license from any state
in the United States, complies with provisions for interstate practice
in the state where the beneficiary is receiving care, and is not
affirmatively barred or restricted from practicing in any state
in the United States. This temporary 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 applicable state or federal law will be eligible
for reimbursement under TRICARE.
2.2.2 For overseas locations, if the host-nation
permits providers to operate within that nation without obtaining
a license in that nation, services provided to beneficiaries by
a TRICARE-authorized provider may be cost-shared if the provider
holds an equivalent license in the nation in which they normally
practice and meets all requirements for practice under the host
nation.
2.2.3 Providers
listed on the Department of Health and Human Services (HHS) sanction
list remain ineligible to provide care under TRICARE.
2.3 Coverage of Treatment
Use of Investigational Drugs Under Expanded Access2.3.1 Treatment use of investigational
drugs under expanded access shall be cost-shared under the medical
program under the following circumstances:2.3.1.1 The
investigational drug is for the treatment of a serious or life-threatening
case of COVID-19 or its associated sequelae.
2.3.1.2 The
United States Food and Drug Administration (FDA) has approved the
investigational drug for treatment use under expanded access.
2.3.1.3 The
investigational drug is administered in a setting approved by the
FDA (i.e., individual patient access, emergency individual patient
access, intermediate access, and widespread access).
2.3.2 For care provided overseas,
drugs without formal marketing approval in a nation are permitted
to be cost-shared in that nation when the following conditions are
met:2.3.2.1 Use
of the investigational drug is permitted in that nation.
2.3.2.2 The
investigational drug is intended to treat a serious or life-threatening
case of COVID-19 or its associated sequelae.
2.3.2.3 There
is no satisfactory or comparable alternative available.
2.3.2.4 The
potential patient benefit justifies the potential risks of treatment
use.
2.3.2.5 Providing
the investigational drug will not compromise the potential development
or interfere with clinical investigations that could support marketing
approval of the investigational drug for the use.
2.3.3 Investigational drugs
shall not be cost-shared when provided as part of a clinical trial.
2.3.4 Coverage
of investigational drugs in this section supersedes the exclusion
of treatment investigational new drugs under Chapter 8, Section 9.1.
2.3.5 Coverage
of investigational drugs in this section does not apply to drugs
administered under the TRICARE Pharmacy program.
2.4 Temporary
Hospital Expansion Sites2.4.1 Temporary hospitals
and freestanding Ambulatory Surgical Centers (ASCs) that enroll
with Medicare as hospitals for the duration of Medicare’s “Hospitals
without Walls” initiative are exempt from institutional requirements
for acute care hospitals listed in 32 CFR 199.6(b)(4)(i). The contractor shall temporarily
change the status of these providers to a hospital status when the
provisions of this paragraph 2.4, are met.
2.4.2 Temporary hospitals,
including temporary hospital expansion locations such as the patient’s
home, shall meet the following requirements:2.4.2.1 CMS
must approve the location or site to receive payment for Medicare
services.
2.4.2.2 The
location or site must meet all criteria required by CMS for Medicare
coverage of inpatient or outpatient hospital services.
2.4.3 Freestanding ASCs
shall meet the following requirements:2.4.3.1 Enrollment with and
approval by CMS as a hospital. The contractor shall obtain a copy
of the facility’s approval letter before reimbursing services and
supplies.
2.4.3.2 If
a freestanding ASC initially enrolls as a hospital, but later changes
its enrollment status back to an ASC with Medicare, or if Medicare
terminates the ASC’s hospital status, then TRICARE will no longer
recognize that ASC as being a hospital, effective the date of the
enrollment status change.
2.4.4 The contractor shall
ensure that services and supplies provided in these facilities are otherwise
covered under the TRICARE program.
2.4.5 The contractor shall
reimburse otherwise covered services and supplies (provided in facilities
that meet the requirements in paragraph 2.4) using the existing applicable
TRICARE reimbursement methodologies for hospitals.
3.0 EFFECTIVE DATES
3.1 May 12, 2020 for temporary exception to
the prohibition on telephone services in the United States.
3.2 May 12, 2020 for the provision relaxing
professional licensing requirements to allow interstate and international
licensing.
3.3 September
3, 2020, for treatment use of investigational drugs under expanded
access.
3.4 September
3, 2020, for temporary hospitals and freestanding ASCs enrolled
with Medicare as Hospitals.
3.5 For
overseas, the effective date is March 10, 2020 for the provisions
identified above.
4.0 EXPIRATION
4.1 Unless otherwise specified
in this section, services provided in the United
States, these provisions expire upon expiration of the President’s
national emergency for the COVID-19 outbreak.
4.2 Unless otherwise specified
in this section, services provided outside the 50
United States, District of Columbia, and U.S. Territories including
the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American
Samoa, and the Commonwealth of the Northern Mariana Islands, these
provisions expire upon conclusion of the COVID-19 pandemic, as determined
by the ASD(HA).
4.3 Coverage
of temporary hospitals and freestanding ASCs enrolled with Medicare
as hospitals expires upon expiration of Medicare’s “Hospitals without
Walls” initiative.