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 11.
All requirements in this section apply to care rendered overseas
unless specifically modified by Section 11.
1.3 A Federal
Register notice 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 CNM, 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 Medical 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.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.CPR
Certification. The lactation counselor shall maintain a current
adult, child, and infant CPR certification.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.
5.4.2.1 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:
6.1.1.1 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.
6.1.1.2 Attended one or more breastfeeding
courses.
6.1.1.3 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 Certification6.1.4.1 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 state Medicaid program enrollment
for the CLD to qualify under this provision.6.1.4.2.1 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.
6.1.4.2.2 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.
The contractor shall take this action 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.
6.1.4.2.3 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.6.1.8.1 Participation agreements
are effective the date signed and shall not be backdated to allow retroactive
eligibility for reimbursement.
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 16.3.1 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.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.
6.3.8.1 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
(POS) charges may apply.
6.3.8.2 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.
6.3.9 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 26.4.1 The contractor shall
require all CLDs who deliver care in the 50 U.S. and the District
of Columbia to be participating providers who agree to file claims
and accept TRICARE reimbursement as payment in full effective for dates
of service on or after January 1, 2025.
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 Government will
post the reimbursement rates to the DHA website by March 1st 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 Government 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 Charges6.4.6.1 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 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 Referrals6.4.9.1 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, POS 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 18.10-1 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
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Note: When a TRICARE Prime-enrolled
beneficiary uses a non-network provider (participating or non-participating)
without a referral, they are responsible for a POS charge of 50%
of the allowed amount. When a POS charge is applied, TRICARE only
reimburses 50% of the allowed amount. The POS 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).
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ANTEPARTUM/POST-PARTUM
VISIT ALLOWANCES
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Six untimed visits billed
under CPT code 99509.
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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.
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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.
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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 11 for
special policies for overseas implementation). The requirement
in
paragraph 7.4 may apply to TRICARE contractors
other than the 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; andThey 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.
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.