TRICARE Manuals - Display Chap 18 Sect 11 (Change 139, Jun 10, 2024)

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.

1.3 A Federal Register notice was published April 11, 2024, announcing that the demonstration would be modified for childbirth support services by creating a new Phase 2 for reimbursement, adding a requirement that certified labor doulas (CLDs) be participating providers, adding one CLD certification body, and permitting Medicaid participation by CLDs in lieu of certification.

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

• Effective April 11, 2024, the National Black Doulas Association

• to Labor

6.1.4 Medicaid Participation in Lieu of Certification

6.1.4.1 Effective April 11, 2024, participation in a Medicaid doula program may be substituted for the certification requirement for CLDs practicing in states with an active statewide doula Medicaid benefit. Participation must be in a permanent statewide Medicaid doula program, excluding geographically or time limited programs and programs with requirements set by affordable care or managed care organizations.

6.1.4.2 The contractor shall verify evidence of the CLD’s active enrollment in that state’s Medicaid program for the CLD to qualify under this provision. The CLD is no longer eligible to provide services under the demonstration beginning on the date the CLD is no longer an active Medicaid provider. If the CLD notifies the contractor that they are no longer enrolled as a provider in the Medicaid doula program, or if the contractor otherwise becomes aware that the CLD is no longer enrolled, the contractor shall terminate, suspend, or otherwise disqualify the CLD as a demonstration provider effective the date the CLD stopped being a provider under the state Medicaid program unless the CLD is able to meet the demonstration requirements by holding a demonstration-approved certification.

6.1.4.3 The contractor shall only accept Medicaid participation in lieu of certification for CLDs performing services in the same state in which they are a Medicaid doula (e.g., a CLD participating as a doula under Oregon’s Medicaid program cannot use that participation to be qualified to perform services for TRICARE beneficiaries located in Florida).

6.1.5 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.

6.1.6 CPR Certification. The contractor shall ensure the CLD maintains a current adult, child, and infant CPR certification.

6.1.7 NPI Number. The contractor shall require the CLD to submit claims under their own NPI number. Overseas providers are exempt from this requirement.

6.1.8 Participation Agreement. To be eligible for reimbursement for dates of service on or after January 1, 2025, CLDs in the 50 U.S. and the District of Columbia must sign a participation agreement. Participation agreements are effective the date signed and shall not be backdated to allow retroactive eligibility for reimbursement. The contractor shall use the requirements for participation agreements in TPM, Chapter 11, Section 12.3.

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 Childbirth Support Services Reimbursement - Phase 1

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.

6.3.9 Childbirth support services reimbursement Phase 1 will terminate at the end of the day on December 31, 2024.

6.4 Childbirth Support Services Reimbursement - Phase 2

6.4.1 Effective for dates of service on or after January 1, 2025, for care delivered in the 50 U.S. and the District of Columbia, the contractor shall require all CLDs to be participating providers who agree to file claims and accept TRICARE reimbursement as payment in full.

6.4.2 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.

6.4.3 The contractor shall reimburse childbirth support services under Phase 2 using the reimbursement rates published to the DHA website.

6.4.3.1 The DHA will post the reimbursement rates to the DHA website by March 1 of each year, except for the CY 2024 rates, which will be published following publication of the Federal Register notice announcing the Phase 2 reimbursement methodology.

6.4.3.2 The DHA will retain three years of reimbursement rates for childbirth support services on the DHA website.

6.4.4 Antepartum and Postpartum Support Visits. Antepartum and postpartum support visits are timed per 15-minute increment.

6.4.4.1 The contractor shall reimburse antepartum and postpartum support visits using CPT code T1032.

6.4.4.2 The contractor shall reimburse each 15-minute increment at the reimbursement rate posted to the DHA website. For locations outside of the 50 U.S. and the District of Columbia, the TOP contractor shall follow reimbursement guidelines outlined in Chapter 24, Section 9, paragraph 12.0.

6.4.4.3 The contractor shall reimburse a maximum of 24, 15-minute increments combined for antepartum and postpartum visits per birth event.

6.4.5 Continuous Labor Support. The continuous labor support visit is untimed.

6.4.5.1 The contractor shall reimburse the continuous labor support visit using CPT code T1033.

6.4.5.2 The contractor shall reimburse only one continuous labor support visit per birth event.

6.4.5.3 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.

6.4.5.4 The contractor shall reimburse continuous labor support at the reimbursement rate posted to the DHA website. For locations outside of the 50 U.S. and the District of Columbia, the TOP contractor shall follow reimbursement guidelines outlined in Chapter 24, Section 9, paragraph 12.0.

6.4.5.5 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.

6.4.5.6 The contractor shall reimburse continuous labor support separately from the inpatient or outpatient hospitalization for the childbirth.

6.4.6 Billed Charges

6.4.6.1 The contractor shall reimburse CLDs the lower of the billed charge or the rates listed above.

6.4.6.2 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.

6.4.6.3 The contractor shall refer suspected cases of waste, fraud, and abuse to the appropriate program integrity authority.

6.4.7 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 reimburse CLD services whether the labor is completed via vaginal birth or C-section, and whether or not the labor results in a live birth.

6.4.8 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.

6.4.9 Referrals

6.4.9.1 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.

6.4.9.2 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.

6.4.10 Transition Period. Childbirth support services reimbursement Phase 2 will be fully implemented by January 1, 2025, with a transition period starting June 10, 2024. The contractor shall apply the following rules to the transition period:

6.4.10.1 In the 50 U.S. and the District of Columbia, CLDs with a signed, valid participation agreement may bill using Phase 2 codes and shall be reimbursed using Phase 2 rates.

6.4.10.2 If a beneficiary receives ante/postpartum visits in both Phases 1 and 2, each Phase 1 visit shall count as four 15-minute increments against the beneficiary’s 24 15-minute increment allowance in Phase 2.

6.4.10.3 The contractor shall reimburse only one continuous labor support visit per birth event, whether billed using the Phase 1 or Phase 2 code.

6.4.10.4 A participating CLD may bill under either Phase 1 or Phase 2 (i.e., use codes for either phase) during the transition period.

6.4.10.4.1 If a participating CLD submits a claim with Phase 1 codes during the transition but later determines they would prefer to be reimbursed under Phase 2, the CLD must resubmit the claim with the correct codes for reprocessing.

6.4.10.4.2 The contractor shall not reimburse a CLD for both Phase 1 and Phase 2 codes for the same date(s) of service.

Example 1: A non-participating, non-network CLD renders continuous labor support on September 1, 2024. This CLD is only eligible for reimbursement under Phase 1, using CPT code 59899.

Example 2: A CLD is non-participating and renders antepartum services on June 30, 2024. On July 1, 2024, they sign a participation agreement with the contractor. The June 30 antepartum service shall be reimbursed under Phase 1, but subsequent services may be reimbursed using Phase 2 rates if billed using Phase 2 codes.

Example 3: A CLD is non-participating, and renders two antepartum visits during the month of December 2024, with the delivery occurring January 2, 2025. The CLD signs a participation agreement on January 15, 2025, and renders a two-hour postpartum visit on January 20, 2025. The CLD is eligible for reimbursement under Phase 1 for the two December antepartum services (both untimed) and is eligible to be reimbursed for eight 15-minute increments under Phase 2 for the January postpartum visit. The CLD may balance bill (charge) the beneficiary 15% of the reimbursed amount for antepartum visits, but must accept TRICARE reimbursement as payment in full for the postpartum visit. The claim for continuous labor support on January 2, 2025, is denied. As there are no benefits for non-participating providers beginning with dates of service on or after January 1, 2025, the beneficiary may be liable for the total billed charge for the continuous labor support by the CLD.

Figure 18.11-1 Summary Of Changes To Childbirth Support Services
	Phase 1 Dates of Service Prior To 06/10/2024	Transition Period Dates of Service From 06/10/2024 To 12/31/2024	Phase 2 dates of service on or after 01/01/2025
Participation Agreement	Not Required.	Not required; however, Phase 2 reimbursement is only available for participating CLDs.	Required.
Reimbursement	Reimbursed the locality adjusted rate for CPT code 59899 (continuous labor support) and CPT code 99509 (ante/postpartum visits).	Non-Participating Providers: Phase 1 reimbursement. Participating Providers: Phase 2 reimbursement.	Phase 2 reimbursement only.
Balance Billing	Non-Network, Non-Participating Providers: Permitted up to 15% above the allowed charges. Participating Providers: Not permitted.	Non-Participating Providers: Permitted up to 15% above allowed charges under Phase 1 reimbursement. Participating Providers: Not permitted	Not permitted.
Beneficiary Costs	$0 when the provider is participating. Up to 15% above the TRICARE allowable charge when provider is non-participating.	$0 when the provider is participating. Up to 15% above the TRICARE allowable charge under Phase 1 reimbursement when provider is non-participating.	$0
Beneficiary Costs	Note: When a TRICARE Prime-enrolled beneficiary uses a non-network provider (participating or non-participating) without a referral, they are responsible for a Point Of Service charge of 50% of the allowed amount. When a Point Of Service charge is applied, TRICARE only reimburses 50% of the allowed amount. The Point Of Service charge is in addition to other amounts owed by the beneficiary (i.e., if a non-participating, non-network provider charges the extra 15% discussed above).
Antepartum/ Post-Partum Visit Allowances	Six untimed visits billed under CPT code 99509.	Participating Provider: Twenty-four 15-minute visit increments billed using CPT code T1032 (Phase 2). Non-Participating Provider: Six untimed visits billed using CPT code 99509 (Phase 1). Each untimed (Phase 1) visit counts as four 15-minute increments against the Phase 2 visit allowance if a beneficiary uses a mix of visits under Phases 1 and 2.	Twenty-four 15-minute visit increments billed using CPT code T1032 (Phase 2). Each untimed (Phase 1) visit counts as four 15-minute increments against the Phase 2 visit allowance if a beneficiary used Phase 1 visits prior to January 1, 2025.

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.

7.8 The contractor shall link to demonstration information hosted on https://tricare.mil/Plans/SpecialPrograms from their beneficiary-focused website.

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.

9.5 CLD services at an elective abortion not otherwise covered by TRICARE (see TPM, Chapter 4, Section 18.3).

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.

10.4 January 1, 2022, to December 31, 2024, for childbirth support services reimbursement Phase 1.

10.5 January 1, 2025, to December 31, 2026, for childbirth support services reimbursement Phase 2 and the requirement that CLDs be participating providers, with a transition period beginning June 10, 2024.

10.6 Effective April 11, 2024, the National Black Doulas Association is accepted as a certifying organization for CLDs and active Medicaid participation may be accepted for CLDs in lieu of certification by an approved certification organization.