2.3 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 (NIAID)-sponsored clinical
trials when for the treatment or prevention of COVID-19. See
Chapter 7, Section 24.2.
2.3.1 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,
the ASD(HA) permits an exception to the regulatory exclusion. 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.
2.3.1.1 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.
2.3.1.2 The contractor shall ensure
the provider reports telephone services involving evaluation and management
visits using Current Procedural Terminology (CPT) codes 99441-99443;
98966-98968; Healthcare Common Procedure Coding System (HCPCS) code
G2012.
2.3.1.3 The contractor shall ensure
the provider reports other authorized telephone services (e.g., psychotherapy
services) with the appropriate CPT or HCPCS code and with the appropriate
modifier and Place of Service Code (e.g.,
02) to report
that the care was delivered via telephone. During the COVID-19 pandemic
the Government does not require Place of Service Code
02 for
telehealth claims if a more appropriate Place of Service Code is
necessary for correct billing. See
Chapter 7, Section 22.1.
2.3.1.4 The contractor shall ensure
the provider does not provide audio-only care where a visual connection is
required to ensure appropriate medical care; e.g., evaluation of
a skin lesion by a dermatologist or intensive outpatient programs.
2.3.2 Temporary Relaxation of State
Professional Licensing Requirements
2.3.2.1 In the United States (US),
if applicable federal or state law permits providers to operate
within a jurisdiction without obtaining a license in that state,
the contractor may cost-share services provided to beneficiaries
by an otherwise authorized TRICARE provider if that provider holds
an equivalent license from any state in the US, 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 US. 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.
2.3.2.2 For overseas locations, if
the host-nation permits providers to operate within that nation
without obtaining a license in that nation, the contractor may cost-share
services provided to beneficiaries by a TRICARE-authorized provider
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.
2.3.2.3 Providers listed on the Department
of Health and Human Services (HHS) sanction list remain ineligible
to provide care under TRICARE.
2.3.3 Coverage of Treatment Use of
Investigational Drugs Under Expanded Access
2.3.3.1 The contractor shall cost-share
treatment use of investigational drugs under expanded access shall under
the medical program under the following circumstances:
2.3.3.1.1 The investigational drug is
for the treatment of a serious or life-threatening case of COVID-19
or its associated sequelae.
2.3.3.1.2 The US Food and Drug Administration
(FDA) has approved the investigational drug for treatment use under
expanded access.
2.3.3.1.3 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).
2.3.3.2 For care provided overseas,
the contractor shall cost-share drugs without formal marketing approval in
a nation in that nation when the following conditions in that nation
are met:
2.3.3.2.1 Use of the investigational
drug is permitted in that nation.
2.3.3.2.2 The investigational drug is
intended to treat a serious or life-threatening case of COVID-19
or its associated sequelae.
2.3.3.2.3 There is no satisfactory or
comparable alternative available.
2.3.3.2.4 The potential patient benefit
justifies the potential risks of treatment use.
2.3.3.2.5 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.
2.3.3.3 The contractor shall not cost-share
investigational drugs when provided as part of a clinical trial.
2.3.3.4 Coverage of investigational
drugs in this section supersedes the exclusion of treatment investigational
new drugs under
Chapter 8, Section 9.1.
2.3.3.5 Coverage of investigational
drugs in this section does not apply to drugs administered under
the TRICARE Pharmacy (TPharm) Program.
2.3.4 Temporary
Hospital Expansion Sites
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 following provisions are met.
2.3.4.1 The contractor shall ensure
temporary hospitals, including temporary hospital expansion locations such
as the patient’s home meet the following requirements:
2.3.4.1.1 Centers for Medicare and Medicaid
Services (CMS) has approved the location or site to receive payment
for Medicare services.
2.3.4.1.2 The location meets all criteria
required by CMS for Medicare coverage of inpatient or outpatient hospital
services.
2.3.4.2 The contractor shall ensure
freestanding ASCs meet the following requirements:
2.3.4.2.1 CMS has approved the location
or site to receive payment for Medicare services. The contractor shall
obtain a copy of the facility’s approval letter before reimbursing
services and supplies.
2.3.4.2.2 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.
2.3.4.3 The contractor shall ensure
that services and supplies provided in these facilities are otherwise covered
under the TRICARE Program.
2.3.4.4 The contractor shall reimburse
otherwise covered services and supplies (provided in facilities
that meet the requirements in
paragraph 2.3.4) using the existing applicable
TRICARE reimbursement methodologies for hospitals.