1.0 DESCRIPTION
Changes in TRICARE coverage
and payment necessitated by the COVID-19 pandemic.
1.1 The Assistant Secretary of Defense
(Health Affairs) (ASD(HA)) issued an Interim Final Rule (IFR) with comment
in the Federal Register on May 12, 2020, temporarily
amending the TRICARE regulation to encourage social distancing and
prevent the spread of COVID-19 by incentivizing the use of telemedicine
services.
1.2 The ASD(HA)
issued a second IFR with comment in the Federal Register on
September 3, 2020, temporarily amending the TRICARE regulation to
expand the COVID-19 therapies available to TRICARE beneficiaries while
doing so in settings that ensure informed consent of the beneficiary,
and that the benefits of treatment outweigh the potential risks.
This IFR also expands TRICARE coverage of acute care facilities
during the COVID-19 pandemic.
1.3 The ASD(HA)
issued a third IFR with comment in the
Federal Register on
October 30, 2020, temporarily amending the TRICARE regulation to
cover National Institute of Allergy and Infectious Disease (NIAID)-sponsored clinical
trials when for the treatment or prevention of COVID-19. See
Chapter 7, Section 24.2.
1.4 The ASD(HA) issued a Final Rule
in the
Federal Register on June 1, 2022, finalizing
certain temporary provisions of the IFRs published in 2020 in response
to the COVID-19 pandemic. The Final Rule finalized without change
the temporary relaxation of state professional licensing requirements
(see
paragraph 2.2). The Final Rule finalized coverage
of temporary hospitals, with modifications (see
paragraph 2.7).
The Final Rule made permanent coverage of audio-only telephone services
(renamed telephonic office visits) (see
Chapter 7, Section 22.1).
2.0 POLICY
2.1 Temporary Coverage of Audio-Only
Telephone Services
Existing
regulations exclude TRICARE coverage of telephone services (audio-only)
except for biotelemetry. Given the CDC guidelines for social distancing
and some states governors’ orders for residents to stay at home,
the ASD(HA) is permitting an exception to the regulatory exclusion.
TRICARE-authorized providers are allowed to render medically necessary
care and treatment to beneficiaries over the telephone, when face-to-face,
hands-on treatment is not medically necessary.
2.1.1 Telephone services (audio-only)
are not excluded when otherwise covered TRICARE services are provided
to a beneficiary through this modality, if the services are medically
or psychologically necessary and appropriate.
2.1.2 The contractor shall ensure
the provider reports telephone services involving evaluation and management
visits using Current Procedural Terminology (CPT) codes 99441-99443;
98966-98968; Healthcare Common Procedure Coding System (HCPCS) code
G2012.
2.1.3 The contractor
shall ensure the provider reports other authorized telephone services
(e.g., psychotherapy services) with the appropriate CPT or HCPCS
code and with the appropriate modifier and Place of Service Code
(e.g.,
02) to report that the care was delivered via
telephone. During the COVID-19 pandemic the Government does not
require Place of Service Code
02 for telehealth claims
if a more appropriate Place of Service Code is necessary for correct
billing. See
Chapter 7, Section 22.1.
2.1.4 The contractor shall ensure
the provider does not provide audio-only care where a visual connection
is required to ensure appropriate medical care; e.g., evaluation
of a skin lesion by a dermatologist or intensive outpatient programs.
2.2 Temporary
Relaxation of State Professional Licensing Requirements
2.2.1 In the United States (US),
if applicable federal or state law permits providers to operate
within a jurisdiction without obtaining a license in that state,
the contractor may cost-share services provided to beneficiaries
by an otherwise authorized TRICARE provider if that provider holds
an equivalent license from any state in the US, complies with provisions
for interstate practice in the state where the beneficiary is receiving
care, and is not affirmatively barred or restricted from practicing
in any state in the US. This temporary change does not supplant
state authority to regulate licensure, but assures that if licensure
requirements are relaxed by any state or the Federal Government
during the period of the COVID-19 pandemic, that providers caring
for TRICARE beneficiaries in compliance with applicable state or
federal law will be eligible for reimbursement under TRICARE.
2.2.2 For overseas locations, if
the host-nation permits providers to operate within that nation
without obtaining a license in that nation, the TRICARE Overseas
Program (TOP) contractor may cost-share services provided to beneficiaries
by a TRICARE-authorized provider if the provider holds an equivalent
license in the nation in which they normally practice and meets
all requirements for practice under the host nation.
2.2.3 Providers listed on the Department
of Health and Human Services (HHS) sanction list remain ineligible to
provide care under TRICARE.
2.3 Coverage of Treatment Use of
Investigational Drugs Under Expanded Access
2.3.1 The contractor shall cost-share
treatment use of investigational drugs under expanded access under the
medical program under the following circumstances:
2.3.1.1 The investigational drug is
for the treatment of a serious or life-threatening case of COVID-19
or its associated sequelae.
2.3.1.2 The US Food and Drug Administration
(FDA) has approved the investigational drug for treatment use under
expanded access.
2.3.1.3 The investigational drug is
administered in a setting approved by the FDA (i.e., individual
patient access, emergency individual patient access, intermediate
access, and widespread access).
2.3.2 For care provided overseas, the
TOP contractor shall cost-share drugs without formal marketing approval
in a nation when the following conditions in that nation are met:
2.3.2.1 Use of the investigational
drug is permitted in that nation.
2.3.2.2 The investigational drug is
intended to treat a serious or life-threatening case of COVID-19
or its associated sequelae.
2.3.2.3 There is no satisfactory or
comparable alternative available.
2.3.2.4 The potential patient benefit
justifies the potential risks of treatment use.
2.3.2.5 The investigational drug will
not compromise the potential development or interfere with clinical investigations
that could support marketing approval of the investigational drug
for the use.
2.3.3 The contractor
shall not cost-share investigational drugs when provided as part
of a clinical trial.
2.3.4 Coverage
of investigational drugs in this section supersedes the exclusion
of treatment investigational new drugs under
Chapter 8, Section 9.1.
2.3.5 Coverage of investigational
drugs in this section does not apply to drugs administered under
the TRICARE Pharmacy (TPharm) Program.
2.4 Temporary Waiver of
Certain Critical Access Hospital (CAH) Participation RequirementsUnder 32 CFR 199.6(b)(4)(xvi),
CAHs must meet all conditions of participation under 42 CFR 485.601
through 485.645 in relation to TRICARE beneficiaries in order to
receive payment under the TRICARE Program. If Medicare temporarily
waives a condition of participation for CAHs, TRICARE has the legal
authority to continue to authorize the CAH as a TRICARE provider
as long as Medicare does not revoke the CAH’s status as a Medicare
provider. TRICARE has exercised this legal authority to recognize
Medicare’s emergency waiver issued under Section 1135(b) of the
Social Security Act (42 United States Code (USC) § 1320b-5), for
the following requirements for CAH participation:
• The requirement that
CAHs make available 24-hour emergency care services and provide
not more than 25 beds for acute (hospital-level) inpatient care
or swing beds used for Skilled Nursing Facility-Level care.
• The requirement that
CAHs maintain a length-of-stay, as determined on an annual average
basis, of no longer than 96 hours.
2.5 Temporary Waiver of
Certain Hospice Participation RequirementsUnder 32 CFR 199.6(b)(4)(xiii),
Hospice programs must be Medicare approved and meet all Medicare
conditions of participation under (42 CFR part 418) in relation
to TRICARE patients in order to receive payment under the TRICARE
Program. A hospice program may be found to be out of compliance
with a particular Medicare condition of participation and still
participate in the TRICARE Program as long as the hospice is allowed
continued participation in Medicare. TRICARE has exercised this
legal authority to recognize Medicare’s emergency waiver issued
under Section 1135(b) of the Social Security Act (42 USC § 1320b-5),
for the following requirements for Hospice participation:
• The requirement to provide
non-core services such as Physical Therapy (PT), Occupational Therapy
(OT), and Speech Language Pathology (SLP).
• The requirement to conduct
on-site nurse visits every two weeks.
2.6 Temporary Waiver of
the Referral Requirement for TRICARE Prime Enrollees, Not Including
Active Duty Service Members (ADSMs)ADSMs may receive COVID-19
vaccines from any TRICARE authorized non-network provider without
incurring Point-of-Service (POS) charges where applicable.
2.6.1 Due to widespread need
for COVID-19 vaccines and the possibility that one day these vaccines
may not be free-of-charge, on February 23, 2021, a notice was published
in the Federal Register (86
FR 10942) advising TRICARE Prime enrollees, not including ADSMs,
of a waiver to the referral requirement so they may receive COVID-19
vaccines, a clinical prevention service, from any TRICARE Basic
(medical) program authorized non-network provider without incurring
POS charges where applicable.
2.6.2 Although there is no
separate copayment/cost-share for clinical preventive services,
there may be a copayment/cost-share or POS charge if the vaccine
is administered as part of a primary or specialty care visit for
a reason other than preventive care or for other services received
during the office visit.
2.6.4 This waiver does not
apply to ADSMs as they are governed by the requirements of the Supplemental Health
Care Program (SHCP) which allows for payment of claims for civilian
services rendered pursuant to a referral by a provider in a Market/Military
Medical Treatment Facility (MTF) as well as for civilian health
care. For information on the SCHP, see the TRICARE Operations Manual
(TOM), Chapter
17.
2.7 Temporary Hospital Expansion
Sites
Temporary
hospitals, freestanding Ambulatory Surgical Centers (ASCs), and
other entities that enroll with Medicare as hospitals for the duration
of Medicare’s “Hospitals without Walls” initiative are exempt from
certain institutional requirements for acute care hospitals listed
in
32 CFR 199.6(b)(4)(i). The contractor shall
temporarily change the status of these providers to a hospital status
when the following provisions are met.
2.7.1 The contractor shall ensure
temporary hospitals, including temporary hospital expansion locations such
as the patient’s home, meet the following requirements:
2.7.1.1 The Centers for Medicare and
Medicaid Services (CMS) has approved the location or site to receive payment
for Medicare services.
2.7.1.2 The location or site meets
all criteria required by CMS for Medicare coverage of inpatient
or outpatient hospital services.
2.7.2 The contractor shall ensure
freestanding ASCs meet the following requirements:
2.7.2.1 CMS has approved the location
or site to receive payment for Medicare services. The contractor
shall obtain a copy of the facility’s approval letter before reimbursing
services and supplies.
2.7.2.2 If a freestanding ASC temporarily
enrolls as a hospital, but later changes or loses its enrollment
status back to an ASC with Medicare, then the contractor shall not
reimburse that ASC as a hospital, effective on the date of the enrollment
status change under Medicare.
2.7.3 Other entities (not including temporary
hospitals and freestanding ASCs) shall meet the following requirements:
2.7.3.1 Enrollment with and approval by
CMS as a hospital. The contractor shall obtain a copy of the facility’s approval
letter before reimbursing services and supplies.
2.7.3.2 If an entity other than a temporary
hospital or freestanding ASC temporarily enrolls as a hospital,
but later changes or loses its hospital enrollment status with Medicare,
then the contractor shall not reimburse that entity as a hospital,
effective on the date of the enrollment status change under Medicare.
2.7.4 The contractor shall ensure
that services and supplies provided in these facilities are otherwise
covered under the TRICARE Program.
2.7.5 The contractor shall reimburse
otherwise covered services and supplies (provided in facilities
that meet the requirements in
paragraph 2.7) using the existing applicable
TRICARE reimbursement methodologies for hospitals.
3.0 EFFECTIVE
DATES
3.1 May 12, 2020, for temporary
exception to the prohibition on telephone services in the US.
3.2 May 12,
2020, for the provision relaxing professional licensing requirements
to allow interstate and international licensing.
3.3 September 3, 2020, for treatment
use of investigational drugs under expanded access.
3.4 September 3, 2020, for temporary
hospitals and freestanding ASCs enrolled with Medicare as hospitals.
3.5 June 1, 2022,
for other entities (not including temporary hospitals and freestanding
ASCs) enrolled with Medicare as hospitals.
3.6 For overseas, the effective
date is March 10, 2020 for the provisions identified above.
3.7 March 1, 2020, for the
temporary waiver of the CAH participation requirements.
3.8 March 1, 2020, for the
temporary waiver of the Hospice participation requirements.
3.9 December 13, 2020, for
the temporary waiver of the TRICARE Prime referral requirements
for COVID-19 vaccines.
4.0 EXPIRATION
4.1 Unless
otherwise specified in this section, services provided in the US,
these provisions expire upon expiration of the President’s national
emergency for the COVID-19 outbreak.
4.2 Unless
otherwise specified in this section, services provided outside the
50 US, District of Columbia, and US Territories including the Commonwealth
of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth
of the Northern Mariana Islands, these provisions expire upon conclusion
of the COVID-19 pandemic, as determined by the ASD(HA).
4.3 Coverage of temporary hospitals,
freestanding ASCs, and other entities enrolled with Medicare as hospitals
expires upon expiration of Medicare’s “Hospitals without Walls”
initiative.
4.4 Under section 3.19 of
the Public Health Service (PHS) Act, a Public Health Emergency (PHE)
declaration lasts until the Secretary of HHS declares the PHE no
longer exists, or upon the expiration of the 90-day period beginning
on the date the Secretary declared a PHE exists, whichever occurs
first. The Secretary may extend the PHE declaration for subsequent
90-day periods for as long as the PHE continues to exist, and may
terminate the declaration whenever he determines the PHE has ceased
to exist. The manual provisions related to the waiver of the CAH
and hospice participation requirements terminate upon expiration
of the COVID-19 PHE declared by the Secretary of HHS.