TRICARE Policy Manual 6010.60-M, April 1, 2015
Administration
Chapter 1
Section 15.1
TRICARECoverage and Payment for Certain Services in Response to the CoronavirusDisease 2019 (COVID-19) Pandemic
Issue Date:December 24, 2020
Authority:10 USC Chapter 55, Section1073 (a)(2)
Copyright:CPT only © 2006 American MedicalAssociation (or such other date of publication of CPT). All RightsReserved.
Revision:C-100, August 3, 2022
1.0DESCRIPTION
Changes in TRICARE coverageand payment necessitated by the COVID-19 pandemic.
2.0POLICY
The Assistant Secretary ofDefense (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 socialdistancing and prevent the spread of COVID-19 by incentivizing theuse of telemedicine services.
The ASD(HA) issued a secondIFR with comment in the Federal Register on September3, 2020, temporarily amending the TRICARE regulation to expand theCOVID-19 therapies available to TRICARE beneficiaries while doingso 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 facilitiesduring the COVID-19 pandemic.
The ASD(HA) issued a thirdIFR with comment in the Federal Register on October30, 2020, temporarily amending the TRICARE regulation to cover NationalInstitute of Allergy and Infectious Disease-sponsored clinical trialswhen for the treatment or prevention of COVID-19. See Chapter 7, Section 24.2.
The ASD(HA) issueda Final Rule in the Federal Register onJune 1, 2022, finalizing certain temporary provisions of the IFRspublished in 2020 in response to the COVID-19 pandemic. The FinalRule finalized without change the temporary relaxation of stateprofessional licensing requirements (see paragraph 2.2).The Final Rule finalized coverage of temporary hospitals, with modifications(see paragraph 2.4). The Final Rulemade permanent coverage of audio-only telephone services (renamedtelephonic office visits) (see Chapter 7, Section 22.1).
2.1TemporaryCoverage of Audio-Only Telephone Services
Existing regulations excludeTRICARE 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-authorizedproviders are allowed to render medically necessary care and treatmentto beneficiaries over the telephone, when face-to-face, hands-ontreatment is not medically necessary.
2.1.1Telephoneservices (audio-only) are not excluded when otherwise covered TRICARE servicesare provided to a beneficiary through this modality, if the servicesare medically or psychologically necessary and appropriate.
2.1.2Telephoneservices involving evaluation and management visits shall be reportedutilizing Current Procedural Terminology (CPT) code 99441-3; 98966-8;Healthcare Common Procedure Coding System (HCPCS) code G2012.
2.1.3Otherauthorized telephone services (e.g., psychotherapy services) shallbe reported with the appropriate CPT or HCPCS code and with theappropriate modifier or place of service code (e.g., 02) to reportthat the care was delivered via telephone. Place of Service Code02 is not required for telehealth claims if a more appropriate Placeof Service Code is necessary for correct billing.
2.1.4Audio-onlycare is inappropriate where a visual connection would be requiredto ensure appropriate medical care; e.g., evaluation of a skin lesionby a dermatologist or intensive outpatient programs.
2.2Temporary Relaxation of StateProfessional Licensing Requirements
2.2.1In theUnited States, if applicable federal or state law permits providersto operate within a jurisdiction without obtaining a license inthat state, the contractor may cost-share servicesprovided to beneficiaries by an otherwise authorized TRICARE provider ifthat provider holds an equivalent license from any state in theUnited States, complies with provisions for interstate practicein the state where the beneficiary is receiving care, and is notaffirmatively barred or restricted from practicing in any state inthe United States. This temporary change does not supplant stateauthority to regulate licensure, but assures that if licensure requirementsare relaxed by any state or the federal government during the periodof the COVID-19 pandemic, that providers caring for TRICARE beneficiariesin compliance with applicable state or federal law will be eligiblefor reimbursem*nt under TRICARE.
2.2.2For overseaslocations, if the host-nation permits providers to operate withinthat nation without obtaining a license in that nation, theTRICARE Overseas Program (TOP) contractor may cost-share servicesprovided to beneficiaries by a TRICARE-authorized provider ifthe provider holds an equivalent license in the nation in whichthey normally practice and meets all requirements for practice underthe host nation.
2.2.3Providers listed on the Departmentof Health and Human Services (HHS) sanction list remain ineligibleto provide care under TRICARE.
2.3Coverage of Treatment Use ofInvestigational Drugs Under Expanded Access
2.3.1The contractorshall cost-share treatment use of investigationaldrugs under expanded access under themedical program under the following circ*mstances:
2.3.1.1The investigational drug isfor the treatment of a serious or life-threatening case of COVID-19or its associated sequelae.
2.3.1.2The United States Food andDrug Administration (FDA) has approved the investigational drugfor treatment use under expanded access.
2.3.1.3The investigational drug isadministered in a setting approved by the FDA (i.e., individual patientaccess, emergency individual patient access, intermediate access,and widespread access).
2.3.2For care provided overseas, theTOP contractor shall cost-share drugs without formal marketingapproval in a nation when the followingconditions in that nation are met:
2.3.2.1Use of the investigationaldrug is permitted in that nation.
2.3.2.2The investigational drug isintended to treat a serious or life-threatening case of COVID-19 orits associated sequelae.
2.3.2.3There is no satisfactory orcomparable alternative available.
2.3.2.4The potential patient benefitjustifies the potential risks of treatment use.
2.3.2.5Providing the investigationaldrug will not compromise the potential development or interferewith clinical investigations that could support marketing approvalof the investigational drug for the use.
2.3.3The contractorshall not cost-share investigational drugs whenprovided as part of a clinical trial.
2.3.4Coverage of investigationaldrugs in this section supersedes the exclusion of treatment investigationalnew drugs under Chapter 8, Section 9.1.
2.3.5Coverage of investigationaldrugs in this section does not apply to drugs administered underthe TRICARE Pharmacy program.
2.4Temporary Hospital ExpansionSites
2.4.1Temporary hospitals, freestandingAmbulatory Surgical Centers (ASCs), and other entities thatenroll with Medicare as hospitals for the duration of Medicare’s“Hospitals without Walls” initiative are exempt from certain institutionalrequirements for acute care hospitals listed in 32 CFR 199.6(b)(4)(i). The contractor shalltemporarily change the status of these providers to a hospital status whenthe provisions of this paragraph 2.4, are met.
2.4.2The contractorshall ensure temporary hospitals, including temporaryhospital expansion locations such as the patient’s home, meetthe following requirements:
2.4.2.1Centers for Medicareand Medicaid Services (CMS) has approved thelocation or site to receive payment for Medicare services.
2.4.2.2The location or site meets allcriteria required by CMS for Medicare coverage of inpatient or outpatienthospital services.
2.4.3Thecontractor shall ensure freestanding ASCs meetthe following requirements:
2.4.3.1Enrollment with and approvalby CMS as a hospital. The contractor shall obtain a copy of thefacility’s approval letter before reimbursing services and supplies.
2.4.3.2If a freestanding ASC temporarily enrollsas a hospital, but later changes or loses its enrollmentstatus with Medicare, then thecontractor shall no longer reimburse thatASC as a hospital, effective on thedate of the enrollment status change under Medicare.
2.4.4Otherentities (not including temporary hospitals and freestanding ASCs)shall meet the following requirements:
2.4.4.1Enrollment withand approval by CMS as a hospital. The contractor shall obtain acopy of the facility’s approval letter before reimbursing servicesand supplies.
2.4.4.2If an entityother than a temporary hospital or freestanding ASC temporarilyenrolls as a hospital, but later changes or loses its hospital enrollmentstatus with Medicare, then the contractor shall no longer reimbursethat entity as a hospital, effective on the date of the enrollmentstatus change under Medicare.
2.4.5The contractor shall ensurethat services and supplies provided in these facilities are otherwisecovered under the TRICARE program.
2.4.6The contractor shall reimburseotherwise covered services and supplies (provided in facilitiesthat meet the requirements in paragraph 2.4) using the existing applicableTRICARE reimbursem*nt methodologies for hospitals.
2.5Temporary Waiver of CertainCritical Access Hospital (CAH) Participation Requirements
Under 32 CFR 199.6(b)(4)(xvi), CAHs must meet allconditions of participation under 42 CFR 485.601 through 485.645in relation to TRICARE beneficiaries in order to receive paymentunder the TRICARE program. If Medicare temporarily waives a conditionof participation for CAHs, TRICARE has the legal authority to continueto authorize the CAH as a TRICARE provider as long as Medicare doesnot revoke the CAH’s status as a Medicare provider. TRICARE hasexercised this legal authority to recognize Medicare’s emergencywaiver issued under Section 1135(b) of the Social Security Act (42United States Code (USC) § 1320b-5), for the following requirementsfor CAH participation:
•The requirement that CAHs makeavailable 24-hour emergency care services and provide not more than25 beds for acute (hospital-level) inpatient care or swing bedsused for Skilled Nursing Facility-Level care.
•The requirement that CAHs maintaina length-of-stay, as determined on an annual average basis, of nolonger than 96 hours.
2.6Temporary Waiver of CertainHospice Participation Requirements
Under 32 CFR 199.6(b)(4)(xiii), Hospice programsmust be Medicare approved and meet all Medicare conditions of participation(42 CFR part 418) in relation to TRICARE patients in order to receivepayment under the TRICARE program. A hospice program may be foundto be out of compliance with a particular Medicare condition ofparticipation and still participate in the TRICARE program as longas the hospice is allowed continued participation in Medicare. TRICAREhas exercised this legal authority to recognize Medicare’s emergencywaiver issued under Section 1135(b) of the Social Security Act (42 USC§ 1320b-5), for the following requirements for Hospice participation:
•The requirement to providenon-core services such as Physical Therapy (PT), Occupational Therapy (OT),and Speech-Language Pathology (SLP).
•The requirement to conducton-site nurse visits every two weeks.
2.7Temporary Waiver of the ReferralRequirement for TRICARE Prime Enrollees, Not Including Active DutyService Members (ADSMs), So They May Receive COVID-19 Vaccines FromAny TRICARE Authorized Non-Network Provider Without Incurring Point-of-Service(POS) Charges Where Applicable
2.7.1Due tothe widespread need for COVID-19 vaccines and the possibility thatone 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 waiverto the referral requirement so they may receive COVID-19 vaccines,a clinical preventive service, from any TRICARE Basic (medical)program authorized non-network provider without incurring POS charges whereapplicable.
2.7.2Althoughthere is no separate copayment/cost-share for clinical preventiveservices, there may be a copayment/cost-share or POS charge if thevaccine is administered as part of a primary or specialty care visitfor a reason other than preventive care or for other services receivedduring the office visit.
2.7.3For informationon TRICARE coverage of vaccines as clinical preventive services,see Chapter 7, Sections 2.1 and 2.2.
2.7.4This waiverdoes not apply to ADSMs as they are governed by the requirementsof the Supplemental Health Care Program (SHCP) which allows forpayment of claims for civilian services rendered pursuant to a referralby a provider in a Market/Military Treatment Facility (MTF) as wellas for civilian health care. For information on the SHCP, see theTRICARE Operations Manual (TOM), Chapter 17.
3.0EFFECTIVEDATES
3.1May 12, 2020, fortemporary exception to the prohibition on telephone services inthe United States.
3.2May 12, 2020, forthe provision relaxing professional licensing requirements to allowinterstate and international licensing.
3.3September3, 2020, for treatment use of investigational drugs under expandedaccess.
3.4September3, 2020, for temporary hospitals and freestanding ASCs enrolledwith Medicare as Hospitals.
3.5June1, 2022, for other entities (not including temporary hospitals andfreestanding ASCs) enrolled with Medicare as hospitals.
3.6For overseas, the effectivedate is March 10, 2020, for the provisionsidentified above.
3.7March 1, 2020, for the temporarywaiver of the CAH participation requirements.
3.8March 1, 2020, for the temporarywaiver of the Hospice participation requirements.
3.9December 13, 2020, for thetemporary waiver of the TRICARE Primereferral requirement for COVID-19 vaccines.
4.0EXPIRATION
4.1Unlessotherwise specified in this section, for services provided in theUnited States, these provisions expire upon expiration of the President’snational emergency for the COVID-19 outbreak.
4.2Unlessotherwise specified in this section, for services provided outsidethe 50 United States, District of Columbia, and U.S. Territoriesincluding 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).
4.3Coverageof temporary hospitals, freestandingASCs, and other entities enrolled withMedicare as hospitals expires upon expiration of Medicare’s “Hospitalswithout Walls” initiative.
4.4Undersection 319 of the Public Health Service (PHS) Act, a Public HealthEmergency (PHE) declaration lasts until the Secretary of HHS declaresthe PHE no longer exists, or upon the expiration of the 90-day periodbeginning on the date the Secretary declared a PHE exists, whicheveroccurs first. The Secretary may extend the PHE declaration for subsequent90-day periods for as long as the PHE continues to exist, and mayterminate the declaration whenever he determines the PHE has ceasedto exist. The manual provisions related to the waiver of the CAHand hospice participation requirements terminate upon expirationof the COVID-19 PHE declared by the Secretary of HHS.
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