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 Access
2.3.1 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
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:
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.
2.5 Temporary Waiver
of Certain Critical Access Hospital (CAH) Participation RequirementsUnder 32 CFR 199.6(b)(4)(xvi), CAHs must meet all
conditions of participation under 42 CFR 485.601 through 485.645
in relation to TRICARE beneficiaries in order to receive payment
under the TRICARE program. If Medicare temporarily waives a condition
of participation for CAHs, TRICARE has the legal authority to continue
to authorize the CAH as a TRICARE provider as long as Medicare does not
revoke the CAH’s status as a Medicare provider. TRICARE has exercised
this legal authority to recognize Medicare’s emergency waiver issued
under Section 1135(b) of the Social Security Act (42 United States
Code (USC) § 1320b-5), for the following requirements for CAH participation:
• The requirement
that CAHs make available 24-hour emergency care services and provide
not more than 25 beds for acute (hospital-level) inpatient care
or swing beds used for Skilled Nursing Facility-Level care.
• The requirement
that CAHs maintain a length-of-stay, as determined on an annual average
basis, of no longer than 96 hours.
2.6 Temporary Waiver
of Certain Hospice Participation RequirementsUnder 32 CFR 199.6(b)(4)(xiii), Hospice programs
must be Medicare approved and meet all Medicare conditions of participation
(42 CFR part 418) in relation to TRICARE patients in order to receive
payment under the TRICARE program. A hospice program may be found
to be out of compliance with a particular Medicare condition of
participation and still participate in the TRICARE program as long
as the hospice is allowed continued participation in Medicare. TRICARE
has exercised this legal authority to recognize Medicare’s emergency
waiver issued under Section 1135(b) of the Social Security Act (42
USC § 1320b-5), for the following requirements for Hospice participation:
• The requirement
to provide non-core services such as Physical Therapy (PT), Occupational
Therapy (OT), and Speech-Language Pathology (SLP).
• The requirement
to conduct on-site nurse visits every two weeks.
2.7 Temporary Waiver
of the Referral Requirement for TRICARE Prime Enrollees, Not Including
Active Duty Service Members (ADSMs), So They May Receive COVID-19 Vaccines
From Any TRICARE Authorized Non-Network Provider Without Incurring
Point-of-Service (POS) Charges Where Applicable2.7.1 Due to the widespread
need for COVID-19 vaccines and the possibility that one day these vaccines
may not be free-of-charge, on February 23, 2021, a notice was published
in the Federal Register (86 FR 10942) advising TRICARE Prime enrollees,
not including ADSMs, of a waiver to the referral requirement so
they may receive COVID-19 vaccines, a clinical preventive service,
from any TRICARE Basic (medical) program authorized non-network
provider without incurring POS charges where applicable.
2.7.2 Although there
is no separate copayment/cost-share for clinical preventive services,
there may be a copayment/cost-share or POS charge if the vaccine
is administered as part of a primary or specialty care visit for
a reason other than preventive care or for other services received
during the office visit.
2.7.4 This waiver does
not apply to ADSMs as they are governed by the requirements of the Supplemental
Health Care Program (SHCP) which allows for payment of claims for
civilian services rendered pursuant to a referral by a provider
in a Market/Military Treatment Facility (MTF) as well as for civilian
health care. For information on the SHCP, see the TRICARE Operations
Manual (TOM), Chapter 17.
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.
3.6 March 1, 2020,
for the temporary waiver of the CAH participation requirements.
3.7 March 1, 2020,
for the temporary waiver of the Hospice participation requirements.
3.8 December 13,
2020, for the temporary waiver of the Prime referral requirement
for COVID-19 vaccines.
4.0 EXPIRATION
4.1 Unless
otherwise specified in this section, for 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, for 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.
4.4 Under section
319 of the Public Health Service (PHS) Act, a Public Health Emergency
(PHE) declaration lasts until the Secretary of HHS declares the
PHE no longer exists, or upon the expiration of the 90-day period
beginning on the date the Secretary declared a PHE exists, whichever
occurs first. The Secretary may extend the PHE declaration for subsequent
90-day periods for as long as the PHE continues to exist, and may
terminate the declaration whenever he determines the PHE has ceased
to exist. The manual provisions related to the waiver of the CAH
and hospice participation requirements terminate upon expiration
of the COVID-19 PHE declared by the Secretary of HHS.