81 FR 27328 - 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

DEPARTMENT OF DEFENSE
Office of the Secretary

Federal Register Volume 81, Issue 88 (May 6, 2016)

Page Range		27328-27329
FR Document		2016-10265

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.

Federal Register, Volume 81 Issue 88 (Friday, May 6, 2016)

[Federal Register Volume 81, Number 88 (Friday, May 6, 2016)]
[Rules and Regulations]
[Pages 27328-27329]
From the Federal Register Online  [www.thefederalregister.org]
[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.

-----------------------------------------------------------------------

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

27328 Federal Register / Vol. 81, No. 88 / Friday, May 6, 2016 / Rules and Regulations

(3) Revocation. If an organization’s Kirsten B. Wielobob, Federal mandate that may result in the
certification as a CPEO is revoked, the Acting Deputy Commissioner for Services and expenditure by State, local and tribal
organization will not be considered a Enforcement. governments, in aggregate, or by the
CPEO for purposes of section 3511 Approved: April 28, 2016. private sector, of $100 million or more
unless and until it again applies to be Mark J. Mazur, in any one year.
certified as a CPEO in accordance with Assistant Secretary of the Treasury (Tax Public Law 96–354, ‘‘Regulatory
paragraph (a) of this section and is again Policy). Flexibility Act’’ (5 U.S.C. 601)
certified by the IRS as meeting the [FR Doc. 2016–10700 Filed 5–4–16; 4:15 pm]
requirements of this section. An It has been certified that these
BILLING CODE 4830–01–P
organization whose certification as a correcting amendments are subject to
CPEO has been revoked may not re- the Regulatory Flexibility Act (5 U.S.C.
apply to be certified as a CPEO until one 601) because they would not, if
DEPARTMENT OF DEFENSE promulgated, have a significant
year has passed since the effective date
of its revocation. economic impact on a substantial
Office of the Secretary
number of small entities. These are
(4) Disclosure of suspension and correcting amendments to the existing
revocation—(i) Notification by the 32 CFR Part 199
regulation.
CPEO. An organization whose [DOD–2013–HA–0053]
certification as a CPEO has been Public Law 96–511, ‘‘Paperwork
suspended or revoked must notify its RIN 0720–AB59 Reduction Act’’ (44 U.S.C. Chapter 35)
customers of such suspension or TRICARE Program; Clarification of It has been determined that these
revocation in the time and manner Benefit Coverage of Durable correcting amendments do not impose
prescribed by the Commissioner in Equipment and Ordering or reporting or recordkeeping requirements
further guidance. Prescribing Durable Equipment; under the Paperwork Reduction Act of
(ii) Disclosure by the IRS. If the IRS 1995.
Clarification of Benefit Coverage of
suspends or revokes an organization’s Assistive Technology Devices Under Executive Order 13132, Federalism
certification as a CPEO, the IRS will the Extended Care Health Option It has been determined that these
make available to the public the fact of Program correcting amendments do not have
such suspension or revocation in the federalism implications, as set forth in
AGENCY: Office of the Secretary,
time and manner described in further Executive Order 13132. This rule does
Department of Defense (DoD).
guidance. The IRS may also not have substantial direct effects on:
ACTION: Correcting amendments.
individually notify the organization’s (1) The States;
customers of such suspension or SUMMARY: The DoD published a final (2) The relationship between the
revocation. rule on December 31, 2014 (79 FR National Government and the States; or
(o) Effective/applicability date—(1) In 78707–78714). This rule makes (3) The distribution of power and
general. This section applies on and correcting amendments to the responsibilities among the various
after July 1, 2016. previously published final rule to clarify levels of Government.
(2) Expiration date. The applicability that only the replacement of lost or List of Subjects in 32 CFR Part 199
of this section expires on or before May stolen rental durable equipment is
Claims, Dental health, Health care,
3, 2019. excluded from coverage. Additionally,
Health insurance, Individuals with
in the final rule, DoD mistakenly used
disabilities, and Military personnel.
PART 602—OMB CONTROL NUMBERS asterisks in a paragraph it was revising
in its entirety. To correct this mistake Accordingly, 32 CFR part 199 is
UNDER THE PAPERWORK corrected by making the following
REDUCTION ACT and ensure that all revisions are
appropriately codified, these correcting correcting amendments:
■ Par. 3. The authority citation for part amendments set out the full text of the PART 199—[AMENDED]
602 continues to read in part as follows: impacted paragraph.
DATES: This rule is effective May 6, ■ 1. The authority citation for part 199
Authority: 26 U.S.C. 7805 * * * 2016. These correcting amendments are continues to read as follows:
applicable January 30, 2015. Authority: 5 U.S.C. 301; 10 U.S.C. chapter
■ Par. 4. In § 602.101, paragraph (b) is
FOR FURTHER INFORMATION CONTACT: Gail 55.
amended by adding the following
entries in numerical order to the table L. Jones, (303) 676–3401. ■ 2. In § 199.4, paragraph (d)(3)(ii) is
to read as follows: SUPPLEMENTARY INFORMATION: revised to read as follows:
Executive Order 12866, ‘‘Regulatory § 199.4 Basic program benefits.
§ 602.101 OMB Control numbers.
Planning and Review’’ and Executive
* * * * * * * * * *
Order 13563, ‘‘Improving Regulation (d) * * *
(b) * * * and Regulatory Review’’ (3) * * *
It has been determined that these (ii) Durable equipment—(A) Scope of
CFR Part or section where Current OMB correcting amendments are not benefit. (1) Durable equipment, which is
identified and described Control No. for the specific use of the beneficiary
significant regulatory actions. These
correcting amendments do not meet the and is ordered by an authorized
Lhorne on DSK30JT082PROD with RULES

criteria in these Executive Orders. individual professional provider listed
* * * * *
301.7705–1T ......................... 1545–2266
in § 199.6(c)(3)(i), (ii) or (iii), acting
Unfunded Mandates Reform Act (Sec. within his or her scope of licensure
301.7705–2T ......................... 1545–2266 202, Pub. L. 104–4) shall be covered if the durable
* * * * * It has been determined that these equipment meets the definition in
correcting amendments do not contain a § 199.2 and—

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Federal Register / Vol. 81, No. 88 / Friday, May 6, 2016 / Rules and Regulations 27329

(i) Provides the medically appropriate for the proper use of the monitor, may monthly rental charge, a lease-purchase
level of performance and quality for the be cost-shared as durable medical price, and a lump-sum purchase price
medical condition present and equipment when supervised by the and a provision for the time value of
(ii) Is not otherwise excluded by this prescribing physician for in-home use money at the rate determined by the
part. by: U.S. Department of Treasury. If a
(2) Items that may be provided to a (i) An infant beneficiary who has had beneficiary wishes to obtain an item of
beneficiary as durable equipment an apparent life-threatening event, as durable equipment with deluxe, luxury,
include: defined in guidelines issued by the immaterial or non-essential features, the
(i) Durable medical equipment as Director, OCHAMPUS, or a designee, or beneficiary may agree to accept
defined in § 199.2; (ii) An infant beneficiary who is a TRICARE coverage limited to the
(ii) Wheelchairs. A wheelchair, which subsequent or multiple birth biological allowable amount that would have
is medically appropriate to provide sibling of a victim of sudden infant otherwise been authorized for a similar
basic mobility, including reasonable death syndrome (SIDS), or item without those features. In that case,
additional costs for medically (iii) An infant beneficiary whose birth the TRICARE coverage is based upon
appropriate modifications to weight was 1,500 grams or less, or the allowable amount for the kind of
accommodate a particular physiological (iv) An infant beneficiary who is a durable equipment normally used to
or medical need, may be covered as pre-term infant with pathologic apnea, meet the intended purpose (i.e., the
durable equipment. An electric as defined in guidelines issued by the standard item least costly). The provider
wheelchair, or TRICARE approved Director, OCHAMPUS, or a designee, or shall not hold the beneficiary liable for
alternative to an electric wheelchair (v) Any beneficiary who has a deluxe, luxury, immaterial, or non-
(e.g., scooter) may be provided in lieu of condition or suspected condition essential features that cannot be
a manual wheelchair when it is designated in guidelines issued by the considered in determining the TRICARE
medically indicated and appropriate to Director, OCHAMPUS, or a designee, for allowable costs. However, the
provide basic mobility. Luxury or which the in-home use of the beneficiary shall be held liable if the
deluxe wheelchairs, as described in cardiorespiratory monitor otherwise provider has a specific agreement in
paragraph (d)(3)(ii)(A)(3) of this section, meets Basic Program requirements. writing from the beneficiary (or his or
include features beyond those required (2) The following types of services her representative) accepting liability
for basic mobility of a particular and items may be cost-shared when for the itemized difference in costs of
beneficiary are not authorized. provided in conjunction with an the durable equipment with deluxe,
(iii) Iron lungs. otherwise authorized cardiorespiratory luxury, or immaterial features and the
(iv) Hospital beds. monitor: TRICARE allowable costs for an
(v) Cardiorespiratory monitors under (i) Trend-event recorder, including otherwise authorized item without such
conditions specified in paragraph technical support necessary for the features.
(d)(3)(ii)(B) of this section. proper use of the recorder.
(3) Whether a prescribed item of (ii) Analysis of recorded physiological (2) In general, repairs of beneficiary
durable equipment provides the data associated with monitor alarms. owned durable equipment are covered
medically appropriate level of (iii) Professional visits for services when necessary to make the equipment
performance and quality for the otherwise authorized by this part, and serviceable and replacement of durable
beneficiary’s condition must be for family training on how to respond to equipment is allowed when the durable
supported by adequate documentation. an apparent life threatening event. equipment is not serviceable because of
Luxury, deluxe, immaterial, or non- (iv) Diagnostic testing otherwise normal wear, accidental damage or
essential features, which increase the authorized by this part. when necessitated by a change in the
cost of the item relative to a similar item (C) Exclusions. Durable equipment, beneficiary’s condition. However,
without those features, based on which is otherwise qualified as a benefit repairs of durable equipment damaged
industry standards for a particular item is excluded from coverage under the while using the equipment in a manner
at the time the equipment is prescribed following circumstances: inconsistent with its common use, and
or replaced for a beneficiary, are not (1) Durable equipment for a replacement of lost or stolen rental
authorized. Only the ‘‘base’’ or ‘‘basic’’ beneficiary who is a patient in a type of durable equipment are excluded from
model of equipment (or more cost- facility that ordinarily provides the coverage. In addition, repairs of deluxe,
effective alternative equipment) shall be same type of durable equipment item to luxury, or immaterial features of durable
covered, unless customization of the its patients at no additional charge in equipment are excluded from coverage.
equipment, or any accessory or item of the usual course of providing its * * * * *
supply for any durable medical services.
(2) Durable equipment, which is § 199.5 [Amended]
equipment, is essential, as determined
by the Director (or designee), for— available to the beneficiary from a ■ 3. In § 199.5:
(i) Achieving therapeutic benefit for Uniformed Services Medical Treatment ■ a. Paragraph (c)(2)(v) is amended by
the patient; Facility. removing the phrase ‘‘as well as lost or
(ii) Making the equipment serviceable; (D) Basis for reimbursement. (1) stolen devices’’.
or Durable equipment may be provided on ■ b. Paragraph (c)(8)(iii) is amended by
(iii) Otherwise assuring the proper a rental or purchase basis. Coverage of adding the word ‘‘rental’’ after the word
functioning of the equipment. durable equipment will be based on the ‘‘stolen’’, and by removing the second
(B) Cardiorespiratory monitor price most advantageous to the occurrence of ‘‘and/or AT devices’’.
exception. (1) When prescribed by a government taking into consideration
Lhorne on DSK30JT082PROD with RULES

physician who is otherwise eligible as a the anticipated duration of the Dated: April 27, 2016.
CHAMPUS individual professional medically necessary need for the Aaron Siegel,
provider, or who is on active duty with equipment and current price Alternate OSD Federal Register Liaison
a United States Uniformed Service, an information for the type of item. The Officer, Department of Defense.
electronic cardiorespiratory monitor, cost analysis must include a comparison [FR Doc. 2016–10265 Filed 5–5–16; 8:45 am]
including technical support necessary of the total price of the item as a BILLING CODE 5001–06–P

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Document Created: 2016-05-06 00:29:18
Document Modified: 2016-05-06 00:29:18

Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Rules and Regulations
Action		Correcting amendments.
Dates		This rule is effective May 6, 2016. These correcting amendments are applicable January 30, 2015.
Contact		Gail L. Jones, (303) 676-3401.
FR Citation		81 FR 27328
RIN Number		0720-AB59
CFR Associated		Claims; Dental Health; Health Care; Health Insurance; Individuals with Disabilities and Military Personnel

81 FR 27328 - 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

DEPARTMENT OF DEFENSEOffice of the Secretary

Federal Register Volume 81, Issue 88 (May 6, 2016)

DEPARTMENT OF DEFENSE
Office of the Secretary