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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 1
Section 15.1
TRICARE Coverage and Payment for Certain Services in Response to the Coronavirus Disease 2019 (COVID-19) Pandemic
Issue Date:  December 24, 2020
Authority:  10 USC Chapter 55, Section 1073 (a)(2)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-80, April 9, 2021
Changes in TRICARE coverage and payment necessitated by the COVID-19 pandemic.
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 Access
2.3.1  Treatment use of investigational drugs under expanded access shall be cost-shared under the medical program under the following circumstances:  The investigational drug is for the treatment of a serious or life-threatening case of COVID-19 or its associated sequelae.  The United States Food and Drug Administration (FDA) has approved the investigational drug for treatment use under expanded access.  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:  Use of the investigational drug is permitted in that nation.  The investigational drug is intended to treat a serious or life-threatening case of COVID-19 or its associated sequelae.  There is no satisfactory or comparable alternative available.  The potential patient benefit justifies the potential risks of treatment use.  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 Sites
2.4.1  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:  CMS must approve the location or site to receive payment for Medicare services.  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:  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.  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.
3.1  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.
4.1  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.
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