[Federal Register Volume 81, Number 88 (Friday, May 6, 2016)]
[Rules and Regulations]
[Pages 27328-27329]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-10265]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DOD-2013-HA-0053]
RIN 0720-AB59
TRICARE Program; Clarification of Benefit Coverage of Durable
Equipment and Ordering or Prescribing Durable Equipment; Clarification
of Benefit Coverage of Assistive Technology Devices Under the Extended
Care Health Option Program
AGENCY: Office of the Secretary, Department of Defense (DoD).
ACTION: Correcting amendments.
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SUMMARY: The DoD published a final rule on December 31, 2014 (79 FR
78707-78714). This rule makes correcting amendments to the previously
published final rule to clarify that only the replacement of lost or
stolen rental durable equipment is excluded from coverage.
Additionally, in the final rule, DoD mistakenly used asterisks in a
paragraph it was revising in its entirety. To correct this mistake and
ensure that all revisions are appropriately codified, these correcting
amendments set out the full text of the impacted paragraph.
DATES: This rule is effective May 6, 2016. These correcting amendments
are applicable January 30, 2015.
FOR FURTHER INFORMATION CONTACT: Gail L. Jones, (303) 676-3401.
SUPPLEMENTARY INFORMATION:
Executive Order 12866, ``Regulatory Planning and Review'' and Executive
Order 13563, ``Improving Regulation and Regulatory Review''
It has been determined that these correcting amendments are not
significant regulatory actions. These correcting amendments do not meet
the criteria in these Executive Orders.
Unfunded Mandates Reform Act (Sec. 202, Pub. L. 104-4)
It has been determined that these correcting amendments do not
contain a Federal mandate that may result in the expenditure by State,
local and tribal governments, in aggregate, or by the private sector,
of $100 million or more in any one year.
Public Law 96-354, ``Regulatory Flexibility Act'' (5 U.S.C. 601)
It has been certified that these correcting amendments are subject
to the Regulatory Flexibility Act (5 U.S.C. 601) because they would
not, if promulgated, have a significant economic impact on a
substantial number of small entities. These are correcting amendments
to the existing regulation.
Public Law 96-511, ``Paperwork Reduction Act'' (44 U.S.C. Chapter 35)
It has been determined that these correcting amendments do not
impose reporting or recordkeeping requirements under the Paperwork
Reduction Act of 1995.
Executive Order 13132, Federalism
It has been determined that these correcting amendments do not have
federalism implications, as set forth in Executive Order 13132. This
rule does not have substantial direct effects on:
(1) The States;
(2) The relationship between the National Government and the
States; or
(3) The distribution of power and responsibilities among the
various levels of Government.
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care, Health insurance, Individuals
with disabilities, and Military personnel.
Accordingly, 32 CFR part 199 is corrected by making the following
correcting amendments:
PART 199--[AMENDED]
0
1. The authority citation for part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
0
2. In Sec. 199.4, paragraph (d)(3)(ii) is revised to read as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(d) * * *
(3) * * *
(ii) Durable equipment--(A) Scope of benefit. (1) Durable
equipment, which is for the specific use of the beneficiary and is
ordered by an authorized individual professional provider listed in
Sec. 199.6(c)(3)(i), (ii) or (iii), acting within his or her scope of
licensure shall be covered if the durable equipment meets the
definition in Sec. 199.2 and--
[[Page 27329]]
(i) Provides the medically appropriate level of performance and
quality for the medical condition present and
(ii) Is not otherwise excluded by this part.
(2) Items that may be provided to a beneficiary as durable
equipment include:
(i) Durable medical equipment as defined in Sec. 199.2;
(ii) Wheelchairs. A wheelchair, which is medically appropriate to
provide basic mobility, including reasonable additional costs for
medically appropriate modifications to accommodate a particular
physiological or medical need, may be covered as durable equipment. An
electric wheelchair, or TRICARE approved alternative to an electric
wheelchair (e.g., scooter) may be provided in lieu of a manual
wheelchair when it is medically indicated and appropriate to provide
basic mobility. Luxury or deluxe wheelchairs, as described in paragraph
(d)(3)(ii)(A)(3) of this section, include features beyond those
required for basic mobility of a particular beneficiary are not
authorized.
(iii) Iron lungs.
(iv) Hospital beds.
(v) Cardiorespiratory monitors under conditions specified in
paragraph (d)(3)(ii)(B) of this section.
(3) Whether a prescribed item of durable equipment provides the
medically appropriate level of performance and quality for the
beneficiary's condition must be supported by adequate documentation.
Luxury, deluxe, immaterial, or non- essential features, which increase
the cost of the item relative to a similar item without those features,
based on industry standards for a particular item at the time the
equipment is prescribed or replaced for a beneficiary, are not
authorized. Only the ``base'' or ``basic'' model of equipment (or more
cost- effective alternative equipment) shall be covered, unless
customization of the equipment, or any accessory or item of supply for
any durable medical equipment, is essential, as determined by the
Director (or designee), for--
(i) Achieving therapeutic benefit for the patient;
(ii) Making the equipment serviceable; or
(iii) Otherwise assuring the proper functioning of the equipment.
(B) Cardiorespiratory monitor exception. (1) When prescribed by a
physician who is otherwise eligible as a CHAMPUS individual
professional provider, or who is on active duty with a United States
Uniformed Service, an electronic cardiorespiratory monitor, including
technical support necessary for the proper use of the monitor, may be
cost-shared as durable medical equipment when supervised by the
prescribing physician for in-home use by:
(i) An infant beneficiary who has had an apparent life-threatening
event, as defined in guidelines issued by the Director, OCHAMPUS, or a
designee, or
(ii) An infant beneficiary who is a subsequent or multiple birth
biological sibling of a victim of sudden infant death syndrome (SIDS),
or
(iii) An infant beneficiary whose birth weight was 1,500 grams or
less, or
(iv) An infant beneficiary who is a pre-term infant with pathologic
apnea, as defined in guidelines issued by the Director, OCHAMPUS, or a
designee, or
(v) Any beneficiary who has a condition or suspected condition
designated in guidelines issued by the Director, OCHAMPUS, or a
designee, for which the in-home use of the cardiorespiratory monitor
otherwise meets Basic Program requirements.
(2) The following types of services and items may be cost-shared
when provided in conjunction with an otherwise authorized
cardiorespiratory monitor:
(i) Trend-event recorder, including technical support necessary for
the proper use of the recorder.
(ii) Analysis of recorded physiological data associated with
monitor alarms.
(iii) Professional visits for services otherwise authorized by this
part, and for family training on how to respond to an apparent life
threatening event.
(iv) Diagnostic testing otherwise authorized by this part.
(C) Exclusions. Durable equipment, which is otherwise qualified as
a benefit is excluded from coverage under the following circumstances:
(1) Durable equipment for a beneficiary who is a patient in a type
of facility that ordinarily provides the same type of durable equipment
item to its patients at no additional charge in the usual course of
providing its services.
(2) Durable equipment, which is available to the beneficiary from a
Uniformed Services Medical Treatment Facility.
(D) Basis for reimbursement. (1) Durable equipment may be provided
on a rental or purchase basis. Coverage of durable equipment will be
based on the price most advantageous to the government taking into
consideration the anticipated duration of the medically necessary need
for the equipment and current price information for the type of item.
The cost analysis must include a comparison of the total price of the
item as a monthly rental charge, a lease-purchase price, and a lump-sum
purchase price and a provision for the time value of money at the rate
determined by the U.S. Department of Treasury. If a beneficiary wishes
to obtain an item of durable equipment with deluxe, luxury, immaterial
or non-essential features, the beneficiary may agree to accept TRICARE
coverage limited to the allowable amount that would have otherwise been
authorized for a similar item without those features. In that case, the
TRICARE coverage is based upon the allowable amount for the kind of
durable equipment normally used to meet the intended purpose (i.e., the
standard item least costly). The provider shall not hold the
beneficiary liable for deluxe, luxury, immaterial, or non- essential
features that cannot be considered in determining the TRICARE allowable
costs. However, the beneficiary shall be held liable if the provider
has a specific agreement in writing from the beneficiary (or his or her
representative) accepting liability for the itemized difference in
costs of the durable equipment with deluxe, luxury, or immaterial
features and the TRICARE allowable costs for an otherwise authorized
item without such features.
(2) In general, repairs of beneficiary owned durable equipment are
covered when necessary to make the equipment serviceable and
replacement of durable equipment is allowed when the durable equipment
is not serviceable because of normal wear, accidental damage or when
necessitated by a change in the beneficiary's condition. However,
repairs of durable equipment damaged while using the equipment in a
manner inconsistent with its common use, and replacement of lost or
stolen rental durable equipment are excluded from coverage. In
addition, repairs of deluxe, luxury, or immaterial features of durable
equipment are excluded from coverage.
* * * * *
Sec. 199.5 [Amended]
0
3. In Sec. 199.5:
0
a. Paragraph (c)(2)(v) is amended by removing the phrase ``as well as
lost or stolen devices''.
0
b. Paragraph (c)(8)(iii) is amended by adding the word ``rental'' after
the word ``stolen'', and by removing the second occurrence of ``and/or
AT devices''.
Dated: April 27, 2016.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2016-10265 Filed 5-5-16; 8:45 am]
BILLING CODE 5001-06-P