1.0 Purpose
1.1 The purpose of this demonstration
is to meet the requirements set forth in the National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 2021, Section 746. The Defense Health
Agency (DHA) will determine if health outcomes are improved by allowing
doulas and lactation consultants or counselors, not otherwise authorized
under TRICARE, to provide care. DHA will evaluate the demonstration
results and may propose future benefit structure changes including
permanent coverage of childbirth and/or breastfeeding support from
doulas and lactation consultants or counselors. A Federal
Register notice announcing the start of the demonstration
was published in the Federal Register on October 29,
2021.
1.2 A Federal
Register notice announcing that
the demonstration would be modified for overseas implementation
was published in the Federal
Register on August 2, 2023.
Special policies for overseas implementation of the demonstration
are in Section 12.
All requirements in this section apply to care rendered overseas
unless specifically modified by Section 12.
2.0 Background
2.1 The NDAA
FY 2015, Section 706, expanded coverage of breastfeeding counseling
by adding breastfeeding support, supplies, and counseling as a covered
benefit to Title 10, Section 1079(a)(17). Beginning December 19,
2014, beneficiaries were eligible for up to six outpatient breastfeeding/lactation
counseling sessions per birth event. These sessions were authorized
in addition to any breastfeeding/lactation counseling services received
as part of an inpatient maternity stay or outpatient obstetrical
or well-child visit. DHA required these services to be performed
by an already authorized TRICARE provider, such as a physician,
physician assistant (PA), nurse practitioner (NP), certified nurse
midwife (CNM), registered nurse (RN), outpatient hospital, or clinic.
See the TRICARE Policy Manual (TPM),
Chapter 8, Section 2.6.
2.2 Lactation
consultants and lactation counselors are extramedical individual
providers who have received specialized training to aid in breastfeeding
and infant nutrition from breastmilk. Lactation consultants have
the highest level of breastfeeding training and are able to provide
a full range of breastfeeding care, and lactation consultant services
may be necessary when complex problems surrounding breastfeeding
arise. Lactation counselors are trained to provide breastfeeding
counseling to support normal lactation and breastfeeding parents
of healthy, full-term infants.
2.3 Labor
doulas, sometimes referred to as birth doulas, are extramedical
individual providers who aid a birthing parent during the birthing
process. They provide support for the birthing parent during labor,
and may also meet with the birthing parent a few times prior to
or after labor. Labor doulas are not medical personnel and do not
provide medical services, such as examination of the cervix or prescription
of medications, and do not give medical advice. Rather, the labor
doula provides physical, emotional, and informational support for
the birthing parent during the labor process, supporting the birthing
parent during vaginal birth or a cesarean section (C-section).
3.0 Demonstration
Goals And Evaluation
3.1 The demonstration is designed
to evaluate the following hypotheses:
3.1.1 Access
to doulas will have a positive and measurable impact on maternal
and fetal outcomes.
3.1.2 Access to lactation consultants
and lactation counselors will have the same or better impact on
maternal and fetal outcomes when compared to the same services provided
by other TRICARE-authorized providers.
3.1.3 The cost
of providing access to such providers is justified by the impact
of the providers on maternal and fetal outcomes.
3.1.4 It is
feasible to administer the new provider classes and the services
they provide.
3.2 DHA will evaluate the demonstration
and provide updates in reports to Congress per NDAA FY 2021. DHA’s
evaluation will include analysis of both claims data and beneficiary
survey responses. In order to measure maternal and fetal outcomes,
DHA will compare outcomes and use of services: (1) with historical
data; (2) between those who choose not to use a service and those
who do; and (3) with nationwide statistics. Additionally, DHA will
ask questions on the beneficiary survey to assist in evaluating
the quality of care received. The effectiveness of the demonstration
will be evaluated by the impact of the demonstration on outcomes,
the availability of providers under the demonstration, and beneficiary
satisfaction with the providers. Cost will be evaluated by reviewing
the overall cost of the demonstration, but also by capturing cost-savings
due to improvements in maternal and fetal outcomes (for example,
the cost savings associated with avoiding C-sections).
3.3 DHA will
perform a survey not later than one year after the enactment of
the NDAA and annually thereafter for the duration of the demonstration
project per NDAA FY 2021.
4.0 Policy And Eligibility
4.1 TRICARE
Prime and TRICARE Select enrollees are eligible to participate in
the demonstration if they otherwise meet requirements for the demonstration.
However, beneficiaries enrolled in TRICARE Prime and TRICARE Select
outside the 50 United States
(U.S.) and
the District of Columbia (OCONUS) are not eligible to participate
in the demonstration until the demonstration expands overseas, even
if they receive care in the 50
U.S. or
the District of Columbia (CONUS). See
paragraph 9.1 for beneficiaries excluded
from participation in the demonstration.
4.2 The contractor
shall automatically enroll beneficiaries in the demonstration when
they or their provider (i.e., doula, lactation consultant, or lactation
counselor) file a claim for services under the demonstration. The
contractor shall verify the beneficiary and provider meet eligibility
criteria in this section and shall record the beneficiary’s enrollment
by using the appropriate Special Processing Code (SPC).
4.3 The benefit
includes breastfeeding counseling from a lactation consultant or
counselor who meets the demonstration requirements for beneficiaries
that are eligible under TPM,
Chapter 8, Section 2.6.
4.4 The benefit includes Certified
Labor Doula (CLD) services for pregnant beneficiaries with a gestational
age over 20 weeks when the beneficiary is under the care of a TRICARE-authorized
provider (e.g., an obstetrician, a certified nurse midwife, etc.)
for the maternity episode-of-care.
4.5 The benefit
does not include CLD services for beneficiaries who give birth in
direct care/at Markets/Military Treatment Facilities (MTFs). The
contractor may, on a case-by-case basis, reimburse doula services
provided prior to the birth for a beneficiary if the contractor
finds the beneficiary, at the time of service, did not intend to
give birth in direct care/at a Market/MTF.
4.6 The benefit
does not include CLD services for deliveries performed or planned
to be performed by a provider that is not TRICARE-authorized (e.g.,
a lay midwife or a planned unattended childbirth), except in emergency
circumstances. The contractor may identify this care, for example,
when the contractor receives a doula claim but does not receive
an accompanying claim for prenatal care from TRICARE-authorized
providers during the same period.
5.0 Breastfeeding
Support
5.1 Lactation Consultant Qualifications.
A lactation consultant shall be at least 18 years old and meet all
of the requirements below.
5.1.1 Certification Requirement.
The lactation consultant shall hold a current certification as a lactation
consultant by one of the following organizations:
• International Board of Lactation
Consultant Examiners. Certification as an International Board Certified
Lactation Consultant (IBCLC) qualifies.
• Academy of Lactation Policy
and Practice, Inc. (ALPP). Certification as an Advanced Lactation Consultant
or an Advanced Nurse Lactation Consultant qualifies.
5.1.2 License
requirement. If a state or local jurisdiction offers a lactation
consultant licensure or certification, the contractor shall require
such a license or certification, even if it is optional in the state or
local jurisdiction.
5.1.3 Cardiopulmonary Resuscitation
(CPR) certification. The lactation consultant shall maintain a current
adult, child, and infant CPR certification.
5.1.4 National
Provider Identification (NPI) Number. The contractor shall require
the lactation consultant to submit claims under their own NPI number.
Overseas providers are exempt from this requirement.
5.2 Lactation Counselor Qualifications.
A lactation counselor shall be at least 18 years old and meet all
of the requirements below.
5.2.1 Certification Requirement.
The lactation counselor shall hold a current certification by ALPP as
a Certified Lactation Counselor.
5.2.2 License
Requirement. If a state or local jurisdiction offers a lactation
counselor licensure or certification, the contractor shall require
such a license or certification, even if it is optional in the state or
local jurisdiction.
5.2.3 CPR Certification. The lactation
counselor shall maintain a current adult, child, and infant CPR
certification.
5.2.4 NPI Number. The contractor
shall require the lactation counselor to submit claims under their
own NPI number. Overseas providers are exempt from this requirement.
5.3 Breastfeeding
Support Covered Services
5.3.1 The benefit includes breastfeeding
support services that meet the requirements of TPM,
Chapter 8, Section 2.6 without requiring services
to be rendered by a TRICARE-authorized individual professional provider.
The benefit includes up to six breastfeeding counseling services,
either individual or group. The breastfeeding parent is entitled
to a total of six sessions irrespective of whether these sessions
are provided by a TRICARE-authorized provider under the existing
breastfeeding counseling benefit, a provider authorized under this
demonstration, or a combination of both. Only the breastfeeding
parent is eligible for breastfeeding counseling. The infant or infants,
if multiples, are not eligible for separate counseling services.
The six visit limitation applies to the breastfeeding dyad.
5.3.2 Covered
services are:
5.3.2.1 In person or remote individual
breastfeeding counseling sessions.
5.3.2.2 In Person or Remote Group Breastfeeding
Counseling. This demonstration adds coverage for group breastfeeding
counseling, which includes group prenatal breastfeeding education.
The benefit includes group breastfeeding counseling when performed
by a lactation consultant, lactation counselor, or other TRICARE-authorized
provider (i.e., coverage of group breastfeeding counseling shall not
be limited to providers under the demonstration).
5.3.2.3 The contractor shall ensure
services performed via telehealth use a two-way visual component
and comply with all relevant TRICARE telemedicine/telehealth requirements
(TPM,
Chapter 7, Section 22.1).
5.4 Reimbursement.
The contractor shall reimburse services under the breastfeeding
support portion of the demonstration as listed below. The contractor
shall not reimburse any other services performed by a lactation
consultant or lactation counselor.
5.4.1 The contractor shall reimburse
individual lactation counseling sessions under the existing TRICARE
breastfeeding support benefit, at the non-physician, non-facility
CHAMPUS Maximum Allowable Charge (CMAC) under the existing Current
Procedural Terminology (CPT) codes 99401 to 99404 (see TPM,
Chapter 8, Section 2.6).
5.4.2 The contractor
shall reimburse group lactation counseling CPT codes 99411 or 99412. These
are established CPT codes and the contractor shall reimburse them
by using the existing CMAC. Use of either CPT code counts as one
session towards the six session limit.
• CPT code 99411 for 30 minutes
of lactation counseling or education in a group setting.
• CPT code 99412 for 60 minutes
of lactation counseling or education in a group setting.
5.4.3 Application
of Health Insurance Portability and Accountability Act (HIPAA) taxonomy designation.
The contractor shall verify that all claims for breastfeeding support
services under the demonstration include the HIPAA taxonomy designation
of each provider type. Each provider on a claim form must be identified
by the correct HIPAA taxonomy designation. The designations to be
used are:
• 163WL0100X Lactation Consultant
(if an RN)
• 174N00000X Lactation Consultant
(if not an RN)
• 174400000X Lactation Counselor
(if the National Uniform Claims Committee creates a taxonomy designation
specific to lactation counselors, that taxonomy designation shall
be used)
• Other appropriate HIPAA taxonomy
based on license/certification
6.0 Childbirth
Support
6.1 CLD Qualifications
A CLD shall be at least 18
years old and meet all of the requirements below. The contractor
shall ensure the education and experience components are not obtained
during the CLD’s own childbirth or the childbirth of an immediate
family member. For example, the contractor shall not count the birth
of the CLD’s own child toward the requirement under
paragraph 6.1.2.1. The contractor shall not
count childbirth course attendance in the course of their own pregnancy/pregnancy
of a partner toward the requirement under
paragraph 6.1.1.
6.1.1 Education. The contractor shall
ensure the CLD has:
• Attended a minimum of 24 education
hours to include:
• The physiology
of labor;
• Labor doula training;
• Antepartum
doula training; and
• Postpartum
doula training.
Note: The contractor shall not count
self-paced learning such as reading a book or writing an essay;
however, the contractor shall count remote synchronous or asynchronous
online courses or in-person courses.
• Attended one or more breastfeeding
courses.
• Attended one or more childbirth
classes.
6.1.2 Experience.
The contractor shall ensure the CLD has, within the last three years:
6.1.2.1 Provided continuous in-person
childbirth support for at least three childbirths as the primary
labor doula supporting the birthing parent, with a minimum of 15
hours over the three childbirths. The contractor shall ensure at
least two of the three births were a vaginal birth.
6.1.2.2 Provided antepartum and postpartum
support for at least one birth.
6.1.3 Certification Requirement.
The contractor shall ensure the CLD holds a current certification as
a CLD, certified doula, or similar perinatal certification (postpartum
doula certification by itself does not qualify), obtained within
the last three years from one of the following organizations:
• BirthWorks International
• Childbirth and Postpartum Professional
Association
• Doulas of North America (DONA)
International
• International Childbirth Education
Association
• to Labor
6.1.4 License
Requirement. If a state or local jurisdiction offers a doula, childbirth
support, or similar licensure or certification, the contractor shall
require such a license or certification, even if it is optional
in the state or local jurisdiction.
6.1.5 CPR Certification.
The contractor shall ensure the CLD maintains a current adult, child,
and infant CPR certification.
6.1.6 NPI Number.
The contractor shall require the CLD to submit claims under their
own NPI number. Overseas providers are exempt from this requirement.
6.2 Childbirth
Support Covered Services
6.2.1 In person antepartum and Postpartum
Care Visits. The benefit includes up to a combined total of six
visits by a CLD before and after birth.
6.2.2 In person
continuous Labor Support. The benefit includes continuous labor
support from a CLD during labor and delivery once per birth event.
6.3 Reimbursement
6.3.1 The contractor
shall require a completed claim for reimbursement. Beneficiaries
may submit claims and receive reimbursement. The contractor shall
limit reimbursement to 100% of the allowable charge.
6.3.2 The contractor
shall not reimburse claims from a CLD for services not personally
performed. For example, if the CLD performs all antepartum and postpartum
visits, but has a substitute CLD attend the labor due to the CLD
having multiple patients in labor at one time, the contractor shall
not reimburse the CLD for the continuous labor support. Instead,
the contractor shall reimburse the substitute CLD for the continuous
labor support if they met all requirements of the demonstration.
6.3.3 Antepartum
and Postpartum Support Visits. Antepartum and postpartum support
visits are untimed and the contractor shall reimburse using CPT
code 99509. The contractor shall reimburse each visit at a rate
equal to $46 in Calendar Year (CY) 2022, locality adjusted and updated
annually. The contractor shall reimburse a maximum of six combined
antepartum and postpartum visits per birth event, with no more than
one visit per day.
6.3.4 Continuous Labor Support. The
continuous labor support visit is untimed and the contractor shall
reimburse using CPT code 59899. The contractor shall reimburse only
one continuous labor support visit per birth event. The contractor
shall use a reimbursement rate equal to a multiplier of 15 times
the rate for CPT code 99509 to establish the rate for CPT code 59899.
CPT code 59899 will not be listed in the CMAC file and it is the
responsibility of the contractor to do the calculation. This is approximately
$690 in CY 2022. The contractor shall use this rate regardless of
the length of labor, and regardless of whether the delivery is vaginal
or C-section or whether the labor results in a live birth. The contractor
shall not reimburse additional amounts for travel to the delivery
location or travel to move with the patient from an initial location
(the home or birthing center) to another location (a hospital), for
long or difficult deliveries, or for false labor. The contractor
shall reimburse continuous labor support separately from the inpatient
or outpatient hospitalization for the childbirth.
6.3.5 Billed
Charges. The contractor shall reimburse CLDs the lower of the billed
charge or the rates listed above. A CLD who advertises their rate
at a rate lower than the TRICARE reimbursement amount but bills
TRICARE for the reimbursement rate listed above (i.e., charges TRICARE
beneficiaries more than they charge other clients) may be subject
to the administrative remedies for fraud, waste, and abuse, pursuant
to
32 CFR 199.9.
The contractor shall refer these cases to the appropriate program integrity
authority.
6.3.6 Cost-Shares. The contractor
shall consider services provided under this demonstration as part
of the maternity episode, and shall not charge separate cost-shares.
For example, for enrollees in TRICARE Select Group A, their cost-share
for a maternity episode ending in a childbirth in a network hospital
is: $20.15/day ($25 minimum) in CY 2021. The contractor shall cost-share
CLD services whether the labor is completed via vaginal birth or
C-section, and whether or not the labor results in a live birth.
6.3.7 Application
of HIPAA taxonomy designation. The contractor shall verify that
all claims for childbirth support services under the demonstration
include the HIPAA taxonomy designation of each provider type. Each
provider on a claim form must be identified by the correct HIPAA
taxonomy designation. The designation to be used for CLDs is 374J00000X.
6.3.8 Referrals.
The contractor shall not require a referral for childbirth support
services except for a TRICARE Prime beneficiary receiving services
from an out-of-network provider. If a TRICARE Prime beneficiary
receives childbirth support services from an out-of-network CLD
without a referral, Point of Service charges may apply.
• The contractor shall consider
a referral authorizing a TRICARE Prime beneficiary to receive their maternity
episode-of-care outside of direct care/Markets/MTFs to include childbirth
support services under this demonstration and no separate referral
shall be required.
7.0 Additional
Contractor Responsibilities
7.1 Contractor requirements shall
apply to the
U.S. Managed Care Support
Contractors (MCSCs) beginning January 1, 2022. Beginning January
1, 2025, the contractor requirements shall also apply to the TRICARE
Overseas Program (TOP) contractor
(see Section 12 for special policies
for overseas implementation). The requirement in
paragraph 7.4 may
apply to TRICARE contractors other than the
U.S. MCSCs
and the TOP contractor, as determined by Section J of the contract.
7.2 The contractor
shall verify providers under the demonstration meet all requirements
for eligibility in accordance with
Chapter 4, Section 1.
In cases where the doula certification body listed in
paragraph 6.1.3 has
requirements that overlap with other demonstration requirements
(for example, if a certification body requires the CLD to perform
support at three deliveries and the demonstration requires support
at three deliveries) then the contractor shall consider certification
sufficient to meet that requirement. However, in cases where demonstration
criteria are more stringent than the certification body’s requirement
(for example, the certification body only requires support at two deliveries),
the contractor shall verify the demonstration requirements are met
consistent with existing requirements for determining provider eligibility.
7.3 The contractor shall create
“Doula” and “Lactation Consultant/Counselor” searchable specialty types
of TRICARE-authorized providers as part of the online TRICARE provider
search tool required in
Chapter 11, Section 4.
The searchable specialty type shall include all providers meeting
the requirements of this demonstration, even if an otherwise authorized
TRICARE provider (e.g., an RN who is also a lactation consultant).
7.4 The contractor shall provide
reports as described in the Contract Data Requirements List (CDRL).
Details for reporting are identified in DD Form 1423, CDRL, located
in Section J of the applicable contract.
7.5 The contractor
shall assign all claims processed under the demonstration a SPC.
The contractor shall process claims for individual and group breastfeeding
counseling provided by a lactation consultant or lactation counselor
who is not an otherwise TRICARE authorized provider and group breastfeeding
counseling provided by any TRICARE authorized provider with SPC
BF (Breastfeeding Support
Demonstration). The contractor shall process CLD claims for CLDs
using SPC
CB (Childbirth Support Demonstration). See
the TRICARE Systems Manual (TSM),
Chapter
2.
7.6 The contractor shall manage
and resolve all inquiries related to the demonstration.
7.7 The contractor
shall offer provider education to the new classes of providers on
claims submission and demonstration participation.
7.9 The contractor
shall provide education to beneficiaries and providers on the demonstration throughout
the demonstration.
7.9.1 The contractor
shall inform the beneficiary that the beneficiary is participating
in the demonstration after the contractor has adjudicated at least
one claim for a service under the demonstration. The contractor
shall include in the notification that the beneficiary may be given
the opportunity to participate in a survey about their demonstration
participation, and request a valid email address from the beneficiary.
The contractor shall notify the beneficiary in the method of their choosing
(a statement on the explanation of benefits, an email, etc.) using
their best business practice.
7.9.2 The contractor
shall include in educational material that a correct email address
is required in order for the beneficiary to be eligible to participate
in the survey. The contractor is not required to include the email
request in every piece of educational material, but only where appropriate.
7.9.3 The contractor
shall request or confirm the beneficiary’s email address during
any beneficiary-initiated encounter related to the demonstration.
The contractor shall tell the beneficiary:
• They have the option to provide
the email address or not without impacting their eligibility for
the demonstration; and
• They can only participate in
the survey if they provide an email address.
7.9.4 The contractors
are not required under the demonstration to actively pursue an email address
beyond the requirements under
paragraph 7.9. Requirements for this demonstration
do not eliminate or otherwise alter the contractor’s obligations
to maintain correct beneficiary contact information elsewhere in
the manuals or contract.
8.0 DHA
Responsibilities
DHA will
perform evaluations of the demonstration, develop annual reports
to Congress, and will administer the survey as mandated by NDAA
FY 2021, Section 746.
9.0 Exclusions
9.1 The contractor shall not cover/process
claims under this demonstration for the following beneficiaries:
Uniformed Services Family Health Plan (USFHP), Continued Health
Care Benefits Program (CHCBP), and those with TRICARE and Medicare
coverage.
9.2 Services, other than childbirth
support services, performed by a CLD unless the CLD also meets the
requirements for a class of provider authorized to provide those
services (e.g., a CLD cannot bill separately for lactation services
unless the provider also meets the requirements for a lactation consultant
or lactation counselor under this demonstration).
9.3 CLD charges
other than those allowed by
paragraph 6.3, including additional reimbursement for
a long or challenging birth, non-singleton births (e.g., two continuous
labor support charges for twins), travel, for false labor, or any
charges beyond those explicitly covered under this demonstration.
9.4 Additional
charges for non-covered, non-medical services. If the CLD charges
for non-covered or non-medical services beyond those services reimbursed
under the demonstration (e.g., aroma therapy), the CLD shall notify
the beneficiary in writing (signed by the beneficiary) regarding
any additional charges prior to administration of the non-covered
service (see TPM,
Chapter 1, Section 4.1). The CLD shall not
mandate the use of any non-covered services if accepting reimbursement
under this demonstration. The contractor shall evaluate evidence
of CLDs providing medical services, when they are not otherwise-authorized
providers (for example, if a CLD bills for an evaluation and management visit
(E&M)), and refer cases as appropriate to DHA Program Integrity
or law enforcement.
9.6 Services
performed by a certified lactation consultant or certified lactation
counselor other than breastfeeding counseling services unless the
certified lactation consultant or certified lactation counselor
also meets the requirements for a class of provider authorized to
provide those services (e.g., a lactation consultant/counselor cannot
provide E&M services unless the provider also meets the requirements
for an individual professional provider under TRICARE statute, regulation,
and policy).
9.7 Postpartum childbirth support
visit and a breastfeeding support visit at the same encounter, even
if the provider is both a CLD and a certified lactation consultant
or certified lactation counselor.
9.8 Services
by breastfeeding peer counselors, lactation educators, or other
lactation specialists not meeting the qualification requirements
under this demonstration for a certified lactation consultant or
certified lactation counselor.
9.9 Services
of a CLD, certified lactation consultant, or certified lactation
counselor that is an immediate family member of the beneficiary.
9.10 Services of a certified lactation
consultant or certified lactation counselor performed via audio-only
telehealth.
9.11 Services
of a CLD performed via telehealth.
9.12 International
telehealth services (i.e., telehealth services performed by a provider
in one country to beneficiaries in another country, to include providers
and beneficiaries located in the U.S.). Telehealth services permitted
in this section may only be provided internal to a country and only
if otherwise meeting all TRICARE and demonstration requirements
and the telehealth requirements of the host nation (includes those
established by any entity responsible for regulating the provision
of telehealth services where furnished and where the beneficiary
resides, whether at the local, regional, or national level).
10.0 Effective
Date And Duration
10.1 January 1, 2022, through December
31, 2026, for the 50 U.S. and District
of Columbia.
10.2 January 1, 2025, through December
31, 2026, for overseas locations.
10.3 Effective July 25, 2023, audio-only
telehealth for breastfeeding counseling and all telehealth for childbirth
support services are excluded.