82 FR 45438 - Establishment of TRICARE Select and Other TRICARE Reforms
DEPARTMENT OF DEFENSE
Office of the Secretary Federal Register Volume 82, Issue 188 (September 29, 2017)
Office of the Secretary
Federal Register Volume 82, Issue 188 (September 29, 2017)
| Page Range | 45438-45461 | |
| FR Document | 2017-20392 |
[Federal Register Volume 82, Number 188 (Friday, September 29, 2017)] [Rules and Regulations] [Pages 45438-45461] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2017-20392] ======================================================================= ----------------------------------------------------------------------- DEPARTMENT OF DEFENSE Office of the Secretary 32 CFR Part 199 [Docket ID: DOD-2017-HA-0039] RIN 0720-AB70 Establishment of TRICARE Select and Other TRICARE Reforms AGENCY: Office of the Secretary, Department of Defense (DoD). ACTION: Interim final rule. ----------------------------------------------------------------------- SUMMARY: This interim final rule implements the primary features of section 701 and partially implements several other sections of the National Defense Authorization Act for Fiscal Year 2017 (NDAA-17). The law makes significant changes to the TRICARE program, especially to the health maintenance organization (HMO)-like health plan, known as TRICARE Prime; to the preferred provider organization (PPO) health plan, previously called TRICARE Extra which is to be replaced [[Page 45439]] by TRICARE Select; and to the third health care option, known as TRICARE Standard, which will be terminated as of December 31, 2017, and also replaced by TRICARE Select. The statute also adopts a new health plan enrollment system under TRICARE and new provisions for access to care, high value services, preventive care, and healthy lifestyles. In implementing the statutory changes, this interim final rule makes a number of improvements to TRICARE. DATES: This interim final rule is effective October 1, 2017. Comments will be received by November 28, 2017. ADDRESSES: You may submit comments, identified by docket number and title, by any of the following methods:Federal eRulemaking Portal: http://www.regulations.gov. Follow the instructions for submitting comments. Mail: Department of Defense, Office of the Deputy Chief Management Officer, Directorate for Oversight and Compliance, Regulatory and Advisory Committee Division, 4800 Mark Center Drive, Mailbox #24, Suite 08D09B, Alexandria, VA 22350-1700. Instructions: All submissions received must include the agency name, docket number, or title for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the Internet at http://www.regulations.gov as they are received without change, including any personal identifiers or contact information. FOR FURTHER INFORMATION CONTACT: Mr. Mark Ellis, Defense Health Agency, TRICARE Health Plan, (703) 681-0063. SUPPLEMENTARY INFORMATION: I. Executive Summary A. Purpose of the Interim Final Rule In implementing section 701 and partially implementing several other sections of NDAA-17, this interim final rule advances all four components of the Military Health System's quadruple aim of improved readiness, better care, better health, and lower cost. The aim of improved readiness is served by reinforcing the vital role of the TRICARE Prime health plan to refer patients, particularly those needing specialty care, to military medical treatment facilities (MTFs) in order to ensure that military health care providers maintain clinical currency and proficiency in their professional fields. The objective of better care is enhanced by a number of improvements in beneficiary access to health care services, including increased geographical coverage for the TRICARE Select provider network, reduced administrative hurdles for TRICARE Prime enrollees to obtain urgent care services and specialty care referrals, and promotion of high value services and medications. The goal of better health is advanced by expanding TRICARE coverage of preventive care services, treatment of obesity, high-value care, and telehealth. And the aim of lower cost is furthered by refining cost-benefit assessments for TRICARE plan specifications that remain under DoD's discretion and adding flexibilities to incentivize high-value health care services. B. Legal Authority for the Regulatory Action This interim final rule is required to implement or partially implement several sections of NDAA-17, including 701, 706, 715, 718, and 729. The legal authority for this rule also includes chapter 55 of title 10, United States Code. C. Summary of Major Provisions of the Interim Final Rule The major provisions of the interim final rule are: [rtarr8] The establishment of TRICARE Select as a self-managed, PPO option under the TRICARE program. TRICARE Select replaces the TRICARE Extra and Standard programs and adopts a number of improvements, including fixed copayments rather than cost shares for covered benefits provided by a civilian network provider. TRICARE Select beneficiaries can choose any provider for their healthcare; however, they will enjoy lower out-of-pocket costs if they choose preferred providers within the TRICARE civilian network. [rtarr8] The continuation of TRICARE Prime as a managed care, HMO- like option under the TRICARE program. TRICARE Prime adopts a number of changes to conform to specifications in the new law, including categories of health care services applicable to the determination of copayment amounts (such as primary care, specialty care, emergency care). [rtarr8] Improved access to care, including a codified requirement that the TRICARE Select health care plan is available in all locations and at least 85% of the U.S. beneficiary TRICARE Select population is covered by the TRICARE network. Also, for TRICARE Prime enrollees, there are new procedures to ensure timely appointments for health care services and to authorize some or all urgent care visits without the need for referral from a primary care manager. [rtarr8] Promotion of high value services and medications, telehealth services, preventive health care, and healthy lifestyles. [rtarr8] A new design for the health care enrollment system, including mandatory enrollment to maintain TRICARE coverage, an annual open season enrollment period, and hassle-free enrollment procedures. [rtarr8] Other features include preservation of benefits for active duty dependents and TRICARE-for-Life beneficiaries, and changes to the TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), Continued Health Care Benefit Program (CHCBP), and TRICARE Retiree Dental Program (TRDP) to conform with new statutory requirements. II. Provisions of Interim Final Rule A. Establishment of TRICARE Select The rule implements the new law (section 701 of NDAA-17) that establishes TRICARE Select as a self-managed, PPO program. It allows beneficiaries to use the TRICARE civilian provider network, with reduced out-of-pocket costs compared to care from non-network providers, as well as military treatment facilities (when space is available). Similar to the long-operating ``TRICARE Extra'' and ``TRICARE Standard'' plans, which TRICARE Select replaces, a major feature is that enrollees will not have restrictions on their freedom of choice with respect to health care providers. TRICARE Select is based primarily on 10 U.S.C. 1075 (as added by section 701 of NDAA-17) and 10 U.S.C. 1097. With respect to beneficiary cost sharing, the statute introduces a new split of beneficiaries into two groups: One group (which the rule refers to as ``Group A'') consists of sponsors and their family members who first became affiliated with the military through enlistment or appointment before January 1, 2018, and the second group (referred to as ``Group B'') who first became affiliated on or after January 1, 2018. In general, beneficiary out-of-pocket costs for Group B are higher than for Group A. In addition to implementing the statutory specifications, the interim final rule also makes improvements for TRICARE Select Group A enrollees, compared to the features of the old TRICARE Extra plan. One such improvement is to convert the current cost-sharing requirement of 15% for active duty family members and 20% for retirees and their family members of the allowable charge for care from a network provider to a fixed dollar [[Page 45440]] copayment calculated to approximately equal 15% or 20% of the average allowable charge for the category of care involved. Consistent with prevailing private sector health program practices, the fixed dollar copayment is more predictable for the patient and easier for the network health care provider to administer. The breakdown of categories of care (such as outpatient primary care visit, specialty care visit, emergency room visit, etc.) contained in the rule is the same as the categories now specified in the statute for Group B Select enrollees. A second improvement in TRICARE Select (for both Group A and Group B) is that additional preventive care services that previously were only offered to TRICARE Prime beneficiaries will now (under the authority of 10 U.S.C. 1097 and NDAA-17) also be covered for Select enrollees when furnished by a network health care provider. These are services recommended by the United States Preventive Services Task Force and the Health Resources and Services Administration of the Department of Health and Human Services. These improvements are based partly on the statutory provision (10 U.S.C. 1075(c)(2)) that Group A Select enrollee cost-sharing requirements are calculated as if TRICARE Extra were still being carried out by DoD. TRICARE Extra specifications are based on the underlying authority of 10 U.S.C. 1097, which allows DoD to adopt special rules for the PPO plan. This statute was the basis for the original set of rules for TRICARE Extra, which were adopted in 1995, and is the authority for these improved rules for TRICARE Select Group A, adopted as if TRICARE Extra were still being carried out by DoD. Under the interim final rule, the cost sharing rules applicable to TRICARE Select Group B are those specified in 10 U.S.C. 1075. For TRICARE Select Group A, in addition to the copayment rules noted above, consistent with 10 U.S.C. 1075, an enrollment fee of $150 per person or $300 per family will begin January 1, 2021, for most retiree families, with annual updates thereafter based on the cost of living adjustment (COLA) applied to retired pay. At the same time, the catastrophic cap will increase from $3,000 to $3,500 for these retiree families. These changes, however, will not apply to TRICARE Select Group A active duty families, survivors of members who died while on active duty, or disability retiree families; that is, no enrollment fee will be applicable to this group and the applicable catastrophic cap will continue to be $1,000 for active duty families as established under 10 U.S.C. 1079(b) and $3,000 for survivors of members who died while on active duty or disability retiree families as established under 10 U.S.C. 1086(b). B. Continuation of TRICARE Prime A second major feature of this interim final rule, based primarily on 10 U.S.C. 1075a (also added by section 701 of NDAA-17), is the continuation of TRICARE Prime as a managed care, HMO-like program. It generally features use of military treatment facilities (MTFs) and substantially reduced out-of-pocket costs for authorized care provided outside MTFs. Beneficiaries generally agree to use military treatment facilities and designated civilian provider networks and to follow certain managed care rules and procedures. Like with TRICARE Select, with respect to beneficiary cost sharing, the statute introduces a new split of beneficiaries into two groups (again referred to in the rule as Group A and Group B) based on the military sponsor's initial enlistment or appointment before January 1, 2018 (Group A), or on or after that date (Group B). Beneficiary cost sharing for Group B is slightly higher than for Group A. As with TRICARE Select, the cost sharing specifications for TRICARE Prime Group B are set forth in the statute, and those for Group A are calculated in accordance with other health care provisions of title 10 (rather than the new section 1075a). The primary original statutory authority for the TRICARE Prime health plan, established by DoD regulation in 1995, was 10 U.S.C. 1097, and this continues to be relied upon for the continued operation of TRICARE Prime for Group A. Also relevant to the original terms of TRICARE Prime was section 731 of the National Defense Authorization Act for Fiscal Year 1994. That law required DoD to include, to the maximum extent practicable, the HMO- like option under TRICARE. That law also required that the HMO-like option ``shall be administered so that the costs incurred by the Secretary under the TRICARE program are no greater than the costs that would otherwise be incurred'', to provide health care to beneficiaries. The extent to which this ``cost neutrality'' requirement has not been maintained was recently highlighted by the Congressional Budget Office: ``CBO estimates that under current law, a typical retiree household enrolled in TRICARE Prime as a `family' in 2018, and for whom TRICARE is the primary payer of health benefits, will cost DoD about $17,400, and a typical family that uses Standard/Extra will cost DoD about $12,700.'' \1\ --------------------------------------------------------------------------- \1\ Congressional Budget Office Cost Estimate, S. 2943, National Defense Authorization Act for Fiscal Year 2017, June 10, 2016, page 17. --------------------------------------------------------------------------- Based on the TRICARE Prime cost neutrality provision in NDAA-1994, the original 1995 TRICARE Prime regulation included (at 32 CFR 199.18(g)) that cost sharing requirements ``may be updated for subsequent years to the extent necessary to maintain compliance with statutory requirements pertaining to government costs.'' Since NDAA- 1994, Congress took away DoD's discretion for enrollment fee increases, which are now tied by law to the retired pay COLA. However, DoD continues to have discretion to update copayment amounts--which have not changed since 1995--and this discretion is confirmed by the newly enacted 10 U.S.C. 1075a(a)(3). This discretion to update copayment amounts is continued in the interim final rule, but the framework for setting Prime Group A copayment amounts is being revised. Specifically, DoD is adopting for Group A the same structure of categories of care that Congress adopted for Group B. Thus, for example, while the current TRICARE Prime copayment amount makes no distinction between primary care and specialty care services, the new Group B structure under the statute does have a different copayment for primary care and specialty care. Under the rule, copayment amounts for Group A beneficiaries will be set for each of those categories, as well as the other categories of care the statute now specifies for Group B enrollees. The interim final rule does not specify the amount for each category of care. Rather, consistent with DoD's discretion under current statute and regulation, the actual amount will be set each year prior to open season enrollment. The interim final rule does, however, specify that the amount for each category of care for Group A enrollees may not exceed the amount that Congress set for Group B enrollees. In this way, the Prime copay structure would be in alignment with proposed legislative changes recommended by the Department to Congress for enactment this year to eliminate the ``grandfathering'' of Group A retiree families and return to a single TRICARE Prime model for all working-age retiree families. Again, it should be noted that this applies only to per- service copayments; enrollment fee increases for Group A enrollees will continue to be based on the retired pay COLA. [[Page 45441]] The interim final rule also continues the point-of-service provision of the current TRICARE Prime plan. Any health care services obtained by a Prime enrollee not in accordance with the rules and procedures of Prime (e.g. failure to obtain a primary care manager referral when such a referral is required or seeing a non-network provider when a network provider is available) will not be paid for under Prime rules, but may be covered by the point-of-service option. This results in higher cost sharing--specifically, a deductible of $300 per person and $600 per family, and a copayment of 50 percent of the allowable charges after the deductible. Point-of-service charges do not count against the annual catastrophic cap. These point-of-service rules continue for TRICARE Prime Group A and are also applicable to Group B. For Group B, the rules for point-of-service charges are specified in 10 U.S.C. 1075a(c), which clarifies that point-of-service cost sharing is ``notwithstanding'' the usual cost sharing rules of Prime Group B enrollees. One other matter on which the interim final rule preserves DoD discretion, similar to that in the current regulation, is with respect to the locations where TRICARE Prime is offered. This is noted in the current regulation at 32 CFR 199.17(a)(5). Under the interim final rule, the locations where TRICARE Prime will be offered will be determined by the Director, Defense Health Agency (DHA) and announced prior to the annual open season enrollment period. The guiding principle for this decision is that the purpose of TRICARE Prime is to support the medical readiness of the armed forces and the readiness of medical personnel. Codification in regulation of this guiding principle is a corollary to the codification by Congress in statute, specifically sections 703 and 725 of NDAA-17 that MTFs exist to support the medical readiness of the armed forces and the readiness of medical personnel. TRICARE Prime, especially for working age retirees and family members, provides MTFs clinical workload, including for a range of medical specialty areas that permit military health care providers to maintain currency and proficiency in their respective clinical fields. This important support of a ready medical force is what justifies the higher government cost of Prime (which CBO estimates at $17,400 per retiree family), notwithstanding the original statutory requirement of cost neutrality between TRICARE Prime and TRICARE Standard. This cost- benefit assessment supports the conclusion that it is practicable to offer TRICARE Prime in areas where it supports the medical readiness of one or more MTFs. Additionally, where TRICARE Prime is offered, it may be limited to active duty family members if the Director, DHA determines it is not practicable to offer TRICARE Prime to retired beneficiaries as well--a determination that again would take into account the nature of the supported MTF and the range of services it offers. C. Improved Access to Care A third significant change in the interim final rule is a set of improvements in standards for access to care. The TRICARE Select plan replaces TRICARE Standard as the generally applicable plan in all areas. Under TRICARE Select, eligible beneficiaries can choose any provider for their healthcare, and they will enjoy lower out-of-pocket costs if they choose providers within the TRICARE civilian network. The vast majority of TRICARE beneficiaries located in the United States will have access to TRICARE network providers (it is DoD's plan that at least 85% of the U.S. beneficiary population under TRICARE Select will be covered by the network upon implementation), similar to the current TRICARE Extra option, but with the benefit of predictable fixed dollar copayments. In cases in which a network provider is not available to a TRICARE Select enrollee, such as in remote locations where there are very few primary or specialty providers, enrollees will still have access to any TRICARE authorized provider, with cost sharing comparable to the current TRICARE Standard plan (i.e. 25% for retired category beneficiaries). A second interim final rule enhancement for access to care is that if a TRICARE Prime enrollee seeks to obtain an appointment for care from the managed care support contractor but is not offered an appointment within the applicable access time standards from a network provider, the enrollee will be authorized to receive care from any authorized provider without incurring the additional fees associated with point-of-service care. A third access to care improvement under the interim final rule is that the TRICARE Prime referral requirement may be waived for urgent care visits for Prime enrollees other than active duty members. This is similar to the current pilot program, which waives the referral requirement (other than for active duty members) for up to two urgent care visits per year. The specific number of urgent care visits without a referral will be determined annually prior to the beginning of the open season enrollment period. A fourth access to care improvement is adoption of the new statutory provision that a primary care manager who believes a referral to a specialty care network provider is medically necessary and appropriate need not obtain pre-authorization from the managed care support contractor. Managed care support contractor preauthorization is only required with respect to a primary care manager's referral for inpatient hospitalization, inpatient care at a skilled nursing facility, inpatient care at a residential treatment center and inpatient care at a rehabilitation facility. D. Promotion of High Value Services and Medications and Telehealth Services In addition to the expansion noted above concerning preventive care services, the interim final rule makes a number of other improvements in TRICARE Prime and TRICARE Select based on provisions of sections 701(h), 706, 718, and 729 of NDAA-17. Section 701(h), among other things, provides for a four-year pilot program to encourage use by patients of high value services and medications. Section 706, among other things, authorizes special arrangements with provider groups that will improve population-based health outcomes and focus more on preventive care. Section 729 calls for special actions to incentivize medical intervention programs to address chronic diseases and other conditions and healthy lifestyle interventions. Section 718, among other things, requires actions to promote greater use of telehealth services under TRICARE. While these sections of NDAA-17 also require actions outside the scope of this interim final rule (such as contracting actions) they can be partially implemented, consistent with Congressional intent, in this rule. The interim final rule does this in several ways. First, the interim final rule authorizes coverage under TRICARE Prime and TRICARE Select for medically necessary treatment of obesity even if it is the sole or major condition treated. Under 10 U.S.C. 1079(a)(10), this is disallowed under the basic program. However, it is DoD's conclusion that the underlying authority of 10 U.S.C. 1097, together with section 729 of NDAA-17 (which specifically authorizes medical intervention for obesity), allow the Department to cover these services when provided by a network provider [[Page 45442]] for a TRICARE Prime or TRICARE Select enrollee. Second, the interim final rule codifies authority of the Director, DHA to waive or reduce copayment requirements for TRICARE Prime and TRICARE Select enrollees for care received from network providers for certain health care services that provide especially high value in terms of better health outcomes for patients. Authority for this includes section 706 and 729 of NDAA-17. This is also consistent with the four-year pilot program authority of section 701(h), but does not necessarily rely on that time-limited authority. Consistent with the intent of these sections, the Department also intends to use the authority of Sec. 199.21(j)(3) of the TRICARE Pharmacy Benefits Program section of the TRICARE regulations to encourage use of high value medications by reducing or eliminating the copayment of selected medicines. Third, consistent with section 718 of NDAA-17, the interim final rule provides that health care services covered by TRICARE and provided through the use of telehealth modalities are covered services to the same extent as if provided in person at the location of the patient if those services are medically necessary and appropriate for such modalities. The Director, DHA will establish standardized payment methods to reimburse for such services, and shall reduce or eliminate, as appropriate, beneficiary copayments or cost-shares for such services in cases in which a copayment would otherwise apply. This may be done by designating some telehealth services as high value services for which lower copays apply as well as the elimination of any beneficiary cost-sharing related to originating site fees when used to support the provision of telehealth services. E. Changes to Health Plan Enrollment System A fourth major change in the interim final rule is its implementation of the new statutory design for the health care enrollment system. Starting in calendar year 2018, beneficiaries other than active duty members and TRICARE-for-Life beneficiaries must elect to enroll in TRICARE Select or TRICARE Prime in order to be covered by the private sector care portion of TRICARE. While TRICARE-for-Life beneficiaries under the age of 65 are permitted to enroll in TRICARE Prime under limited circumstances, their failure to enroll will not affect their coverage by the private sector care portion of TRICARE. Enrollment will be done during an open season period prior to the beginning of each plan year, which operates with the calendar year. An enrollment choice will be effective for the plan year. As an exception to the open season enrollment rule, enrollment changes can be made during the plan year for certain qualifying events, such as a change in eligibility status, marriage, divorce, birth of a new family member, relocation, loss of other health insurance, or other events. Eligible Prime or Select beneficiaries who do not enroll will no longer have private sector care coverage under the TRICARE program (including the TRICARE retail pharmacy and mail order pharmacy programs) until the next open enrollment season or they have a qualifying event, except that they do not lose any statutory eligibility for space-available care in military medical treatment facilities. There is a limited grace period exception to this enrollment requirement for calendar year 2018, as provided in section 701(d)(3) of NDAA-17, to give beneficiaries another chance to adjust to this new requirement for annual enrollment. For the administrative convenience of beneficiaries, there are also procedures for automatic enrollment in Prime and Select for most active duty family members, and automatic renewal of enrollments of covered beneficiaries, subject to the opportunity to decline or cancel. Due to a compressed implementation schedule that precludes an annual open season enrollment period in calendar year 2017 for existing TRICARE beneficiaries to elect or change their TRICARE coverage, the Department will convert existing TRICARE Standard coverage to TRICARE Select coverage effective January 1, 2018. All other existing TRICARE coverages will be renewed effective January 1, 2018. As noted previously, beneficiaries may elect to change their TRICARE coverage anytime during the limited grace period in calendar year 2018. F. Additional Provisions of Interim Final Rule The interim final rule has several other noteworthy provisions. First, there are no changes in benefits for TRICARE-for-Life beneficiaries, or generally in cost sharing levels for active duty family members. Second, although ``TRICARE Standard'' is terminated as a distinct TRICARE plan as of December 31, 2017, basic program benefits (as established under 32 CFR 199.4) continue under both TRICARE Prime and TRICARE Select. In addition, when a TRICARE Select beneficiary receives services covered by the basic program benefits from an authorized health care provider who is not part of the TRICARE provider network, that care is covered by TRICARE as ``out-of-network'' care under terms that match the old TRICARE Standard plan. Third, in order to transition enrollment fees, deductibles, and catastrophic caps from a fiscal year basis to a calendar year basis, special rules apply for the last quarter of calendar year 2017, including that a Prime enrollee's enrollment fee for the quarter is one-fourth of the enrollment fee for fiscal year 2017, and the deductible amount and the catastrophic cap amount for fiscal year 2017 will be applicable to the 15-month period of October 1, 2016, through December 31, 2017. A similar transition rule will apply to TRICARE for Life, TYA, TRR and TRS to align remaining program deductibles and/or catastrophic caps from a fiscal year to calendar year basis for consistency and ease of administration. Additionally, the interim final rule adopts several changes to regulatory provisions applicable to the TYA, TRS, TRR, and TRDP programs to conform with new statutory requirements. In implementing section 701(a) of NDAA-17, together with section 701(j)(1)(F), the rule conforms the TYA regulation to the statutory language which established the eligibility of TYA under 10 U.S.C. 1110b to enroll in TRICARE Select and provided that the TYA premium shall apply instead of the otherwise applicable TRICARE Prime or Select enrollment fee. In implementing section 701(j)(1)(B), the rule conforms the TRICARE Reserve Select plan regulation to the statutory language which defines ``TRICARE Reserve Select'' as the TRICARE Select self-managed, preferred-provider network option under 10 U.S.C. 1075 made available to beneficiaries under 10 U.S.C. 1076d and requires payment of a premium for coverage instead of the TRICARE Select enrollment fee. In implementing section 701(j)(1)(C), the rule conforms the TRICARE Retired Reserve plan regulation to the statutory language which defines ``TRICARE Retired Reserve'' as the TRICARE Select self-managed, preferred-provider network option under 10 U.S.C. 1075 made available to beneficiaries under 10 U.S.C. 1076e and requires payment of a premium for coverage instead of the TRICARE Select enrollment fee. In implementing section 701(a) and 701(e), the rule conforms the CHCBP regulation to replace TRICARE Standard with TRICARE Select as the continuation health care benefit for Department of Defense and the other uniformed services beneficiaries losing eligibility. [[Page 45443]] In implementing section 715, the rule conforms the TRDP regulation to the statutory language which authorizes an interagency agreement between the Department of Defense and the Office of Personnel Management to allow beneficiaries otherwise eligible for the TRDP to enroll in a dental insurance plan offered under the Federal Employees Dental and Vision Insurance Program. Under the statute, TRDP beneficiaries will have the opportunity to access a dental plan with significantly higher annual maximum benefit and a lower premium cost than available under the current TRDP, while giving the Department an opportunity to eliminate costs associated with procuring and administering a separate TRDP contract. Also, the interim final rule adopts several changes to regulatory provisions applicable to benefit coverage of medically necessary food and vitamins. Section 714 of NDAA-17 confirms long-standing TRICARE policy authorizing benefit coverage of medically necessary vitamins when prescribed for management of a covered disease or condition. In addition, while section 714 confirms long-standing TRICARE policy authorizing medical nutritional therapy coverage of medically necessary food and medical equipment/supplies necessary to administer such food when prescribed for dietary management of a covered disease or condition, the law also allows the medically necessary food benefit to include coverage of low protein modified foods. Consistent with this we also recognize the role of Nutritionists and Registered Dieticians in the appropriate planning for the use of medically necessary foods. Additionally, the interim final rule adopts several conforming changes to regulatory provisions applicable to general TRICARE administration, the TRICARE Pharmacy Benefits Program and the Extended Health Care Option to reflect transition of deductibles, catastrophic caps, and program reimbursement limitations, as applicable, from a fiscal year basis to a calendar year basis for consistency and ease of administration. Simultaneously, technical corrections are being made to the TRICARE Pharmacy Benefits Program to conform regulation provisions to statutory provisions enacted by section 702 of the National Defense Authorization Act for Fiscal Year 2016. Finally, the interim final rule includes authority for the Director, DHA to establish preferred provider networks in areas outside the United States where it is determined to be economically in the best interests of the Department of Defense. As a result of the TRICARE Philippines Demonstration Project, which commenced in January 1, 2013, the Department has determined that the TRICARE contracted preferred provider network established in designated locations in the Philippines provided adequate access to beneficiaries with 97 percent of care delivered by network providers. It also successfully achieved the demonstration goals of reducing aberrant billing activities, reduced out-of-pocket expenses for beneficiaries, and increased overall beneficiary satisfaction while leading to a net savings to the government. Although the demonstration was projected to continue through December 31, 2018, the Philippines preferred provider network is determined to be economically in the interests of the Department of Defense and the demonstration shall terminate effective December 31, 2017, with transition of the demonstration's approved preferred provider network to a TRICARE Select preferred provider network effective January 1, 2018. G. Recap: Cost Sharing Tables The following two tables summarize beneficiary fees (including enrollment fees, deductibles, cost sharing amounts, and catastrophic loss protection limits) under TRICARE Select and TRICARE Prime for calendar year 2018. For future calendar years, all fees are subject to review and annual updating in accordance with sections 1075, 1075a, and 1097 of title 10, United States Code. Table 1 is for active duty family members (ADFMs); Table 2 is for retiree families. As a guide for understanding the tables: [rtarr8] For services listed as ``to be determined (TBD)'', the Director, DHA will ensure the applicable fee for calendar year 2018 will be available at www.health.mil/rates before December 1, 2017. [rtarr8] For services not specifically addressed in these tables, applicable cost-sharing requirements shall be established by the Director, DHA and published annually. [rtarr8] For services designated as ``IN'', the listed fee is for covered services or supplies obtained ``in-network,'' meaning received from TRICARE authorized network providers. [rtarr8] For TRICARE Prime beneficiaries, if covered services or supplies are not obtained in accordance with the rules and procedures of Prime (e.g., failure to obtain a required referral or unauthorized use of a non-network provider), the services or supplies will be reimbursed under a point-of-service option for which there is a deductible of $300 per person or $600 per family and a cost share of 50 percent of the allowable charges after the deductible. [rtarr8] For services designated as ``OON'', the listed fee for TRICARE Select beneficiaries is for covered services or supplies obtained ``out-of-network'', meaning received from non-network TRICARE authorized providers. [rtarr8] Certain preventive services have no cost sharing whether received from network or non-network providers. However, certain preventive services are not covered services for TRICARE Prime or Select beneficiaries unless obtained from network providers. Additionally, TRICARE Prime beneficiaries are required to obtain services in accordance with the rules and procedures of Prime to avoid point-of-service charges. [rtarr8] Enrollment fees and deductibles are listed in the tables as individual/family, indicating the dollar amounts applicable per individual or per family. [rtarr8] The criteria for fees associated with High Value Primary Care Outpatient Care and High Value Specialty Outpatient Care are under development but will be designed to encourage beneficiaries to receive health care services from high-value providers as highlighted in the contractor's network provider directory. When finalized, the fees will be made available at www.health.mil/rates. [rtarr8] Inpatient subsistence refers to the rate charged for inpatient care obtained in a military treatment facility. [rtarr8] ``COLA'' is the cost-of-living adjustment for retired pay under 10 U.S.C. 1401a by which certain fees are required to be annually indexed. [rtarr8] ``<'' means less than; <= means less than or equal to. [[Page 45444]] Table 1--TRICARE Select and TRICARE Prime Cost Sharing for Active Duty Family Members for Calendar Year 2018 ---------------------------------------------------------------------------------------------------------------- Select Group A Select Group B Prime Group A Prime Group B ADFMs ADFMs ADFMs ADFMs ---------------------------------------------------------------------------------------------------------------- Annual Enrollment............... $0................ $0................ $0................ $0 Annual Deductible............... E1-E4: $50/$100; E1-E4: $50/$100; 0................. 0 E5 & above: $150/ E5 & above: $150/ $300. $300. Annual Catastrophic Cap......... $1,000............ $1,000............ 1,000............. 1,000 Preventive Care Outpatient Visit $0................ $0................ 0................. 0 Primary Care Outpatient Visit... Fixed fee to = 15% $15 primary care 0................. 0 of average IN; 20% OON. allowable amount IN; 20% OON. Specialty Care Outpatient Visit. Fixed fee to = 15% $25 specialty care 0................. 0 of average IN; 20% OON. allowable amount IN; 20% OON. High-Value Primary Care Under Development; Under Development; 0................. 0 Outpatient Visit. Less than normal Less than normal primary care primary care amount. amount. High-Value Specialty Care Under Development; Under Development; 0................. 0 Outpatient Visit. Less than normal Less than normal primary care primary care amount. amount. Emergency Room Visit............ Fixed fee to = 15% $40 IN; 20% OON... 0................. 0 of average allowable amount IN; 20% OON. Urgent Care Center.............. Same as primary $20 IN; 20% OON... 0................. 0 care outpatient amount IN; 20% OON. Ambulatory Surgery.............. $25............... $25 IN; 20% OON... 0................. 0 Ambulance Service (not including Fixed fee to = 15% $15 IN; 20% OON... 0................. 0 air). of average allowable amount IN; 20% OON. Durable Medical Equipment....... 15% IN; 20% OON... 10% IN; 20% OON... 0................. 0 Inpatient Hospital Admission.... Subsistence charge/ $60/admission IN; 0................. 0 day, minimum $25/ 20% OON. admission. Inpatient Skilled Nursing/Rehab Subsistence charge/ $25/day IN; $50/ 0................. 0 Facility. day, minimum $25/ day OON. admission. ---------------------------------------------------------------------------------------------------------------- Table 2--TRICARE Select and TRICARE Prime Cost Sharing for Retiree Families for Calendar Year 2018 ---------------------------------------------------------------------------------------------------------------- Select Group A Select Group B Prime Group A Prime Group B Retirees Retirees Retirees Retirees ---------------------------------------------------------------------------------------------------------------- Annual Enrollment............... $0 until 2021; $450/$900......... FY17 amount $350/$700. $150/$300 in 2021 ($282.60/$565.20) +COLA? +COLA. Annual Deductible............... $150/$300......... $150/$300 IN; $300/ $0................ $0. $600 OON. Annual Catastrophic Cap......... $3,000 until 2021; $3,500............ $3,000............ $3,500. $3,500 in 2021. Preventive Care Visit........... $0................ $0................ $0................ $0. Primary Care Outpatient Visit... Fixed fee that = $25 primary IN; TBD, <=$20 primary $20 primary. 20% of average 25% OON. allowable amount IN; 25% OON. Specialty Care Outpatient Visit. Fixed fee that = $40 specialty IN; TBD, <=$30 $30 specialty. 20% of average 25% OON. specialty. allowable amount IN; 25% OON. High Value Primary Care OP Visit Under Development; Under Development; Under Development; Under Development;
Document Created: 2017-09-29 03:26:57
Document Modified: 2017-09-29 03:26:57
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 Interim final rule. Dates This interim final rule is effective October 1, 2017. Comments will be received by November 28, 2017. Contact Mr. Mark Ellis, Defense Health Agency, TRICARE Health Plan, (703) 681-0063. FR Citation 82 FR 45438 RIN Number 0720-AB70 CFR Associated Claims; Dental Health; Health Care; Health Insurance; Individuals with Disabilities; Mental Health; Mental Health Parity and Military Personnel
![45438 Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations
power and responsibilities between the While the DEA does not have a basis List of Subjects in 21 CFR Part 1308
Federal Government and Indian tribes. to estimate the number of affected Administrative practice and
entities, the DEA estimates that the procedure, Drug traffic control,
Regulatory Flexibility Act
maximum number of affected entities is Reporting and recordkeeping
The Administrator, in accordance 436,761 of which 425,856 are estimated requirements.
with the Regulatory Flexibility Act (5 to be small entities. Since the affected
entities are expected to handle other For the reasons set out above, 21 CFR
U.S.C. 601–612) (RFA), has reviewed
controlled substances and maintain part 1308 is amended as follows:
this rule and by approving it certifies
that it will not have a significant security and recordkeeping facilities PART 1308—SCHEDULES OF
economic impact on a substantial and processes consistent with CONTROLLED SUBSTANCES
number of small entities. The purpose of controlled substances, the DEA
this rule is to remove naldemedine from estimates any economic impact will be ■ 1. The authority citation for 21 CFR
the list of schedules of the CSA. This minimal. Because of these facts, this part 1308 continues to read as follows:
action removes regulatory controls and rule will not have a significant
Authority: 21 U.S.C. 811, 812, 871(b),
administrative, civil, and criminal economic impact on a substantial 956(b), unless otherwise noted.
sanctions applicable to controlled number of small entities.
substances for handlers and proposed ■ 2. In § 1308.12, revise the introductory
Unfunded Mandates Reform Act of 1995 text of paragraph (b)(1) to read as
handlers of naldemedine. Accordingly,
it has the potential for some economic In accordance with the Unfunded follows:
impact in the form of cost savings. Mandates Reform Act (UMRA) of 1995,
§ 1308.12 Schedule II.
2 U.S.C. 1501 et seq., the DEA has
This rule will affect all persons who * * * * *
determined and certifies that this action
handle, or propose to handle, (b) * * *
would not result in any Federal
naldemedine. Due to the wide variety of (1) Opium and opiate, and any salt,
mandate that may result ‘‘in the
unidentifiable and unquantifiable compound, derivative, or preparation of
expenditure by State, local, and tribal
variables that potentially could opium or opiate excluding
governments, in the aggregate, or by the
influence handling of naldemedine, the apomorphine, thebaine-derived
private sector, of $100,000,000 or more
DEA is unable to determine the number butorphanol, dextrorphan, nalbuphine,
(adjusted for inflation) in any one year
of entities and small entities which naldemedine, nalmefene, naloxegol,
* * *.’’ Therefore, neither a Small
might handle naldemedine. However, naloxone, and naltrexone, and their
Government Agency Plan nor any other
the DEA estimates that all persons who respective salts, but including the
action is required under UMRA of 1995.
handle, or propose to handle following:
naldemedine, are currently registered Paperwork Reduction Act * * * * *
with the DEA to handle controlled This action does not impose a new
substances. Therefore, the 1.7 million Dated: September 22, 2017.
collection of information requirement
(1,683,023 as of April 2017) controlled Chuck Rosenberg,
under the Paperwork Reduction Act, 44
substance registrations, representing U.S.C. 3501–3521. This action would Acting Administrator.
approximately 436,761 entities, would not impose recordkeeping or reporting [FR Doc. 2017–20919 Filed 9–28–17; 8:45 am]
be the maximum number of entities requirements on State or local BILLING CODE 4410–09–P
affected by this rule. The DEA estimates governments, individuals, businesses, or
that 425,856 (97.5%) of 436,761 affected organizations. An agency may not
entities are ‘‘small entities’’ in conduct or sponsor, and a person is not DEPARTMENT OF DEFENSE
accordance with the RFA and Small required to respond to, a collection of
Business Administration size standards. information unless it displays a Office of the Secretary
The DEA estimates all controlled currently valid OMB control number.
substance registrants handle both 32 CFR Part 199
controlled and non-controlled Congressional Review Act
[Docket ID: DOD–2017–HA–0039]
substances and these registrants are This rule is not a major rule as
expected to continue to handle defined by section 804 of the Small RIN 0720–AB70
naldemedine. Additionally, since Business Regulatory Enforcement
prospective naldemedine handlers are Fairness Act of 1996 (Congressional Establishment of TRICARE Select and
likely to handle other controlled Review Act (CRA)). This rule will not Other TRICARE Reforms
substances, the cost benefits they would result in: An annual effect on the AGENCY: Office of the Secretary,
receive as a result of the de-control of economy of $100,000,000 or more; a Department of Defense (DoD).
naldemedine is minimal. As major increase in costs or prices for ACTION: Interim final rule.
naldemedine handlers continue to consumers, individual industries,
handle other controlled substances, they Federal, State, or local government SUMMARY: This interim final rule
will need to maintain their DEA agencies, or geographic regions; or implements the primary features of
registration and keep the same security significant adverse effects on section 701 and partially implements
and recordkeeping processes, competition, employment, investment, several other sections of the National
equipment, and facilities in place and productivity, innovation, or on the Defense Authorization Act for Fiscal
asabaliauskas on DSKBBXCHB2PROD with RULES
would experience only minimal ability of United States-based Year 2017 (NDAA–17). The law makes
reduction in security, inventory, enterprises to compete with foreign significant changes to the TRICARE
recordkeeping, and labeling costs. based enterprises in domestic and program, especially to the health
Physical security control requirements export markets. However, pursuant to maintenance organization (HMO)-like
are the same for controlled substances the CRA, the DEA has submitted a copy health plan, known as TRICARE Prime;
listed in schedules II, III, IV, and V for of this final rule to both Houses of to the preferred provider organization
the vast majority of registrants Congress and to the Comptroller (PPO) health plan, previously called
(practitioners). General. TRICARE Extra which is to be replaced
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![Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 45447
(iii) Food marketed for the amount specified in paragraph (f) of this supervision of a physician who is
management of diabetes; or section will be applicable to the 15- overseeing the episode of treatment or
(iv) Such other products as the month period of October 1, 2016 the covered program of services.
Director, Defense Health Agency through December 31, 2017. (M) Registered dietician. The dietician
determines appropriate. (g) * * * must be licensed by the State in which
(3) Covered disease or condition (39) Counseling. Educational, the care is provided and must be under
under paragraph (d)(3)(iii)(B) of this vocational, non-medical nutritional the supervision of a physician who is
section means: counseling, counseling for overseeing the episode of treatment or
(i) Inborn errors of metabolism; socioeconomic purposes, stress the covered program of services.
(ii) Medical conditions of management, and/or lifestyle * * * * *
malabsorption; modification purposes, except the
(iii) Pathologies of the alimentary tract following are not excluded: § 199.7 [Amended]
or the gastrointestinal tract; * * * * * ■ 6. Section 199.7(a)(6) is amended by
(iv) A neurological or physiological (v) Medical nutritional therapy (also removing the words ‘‘fiscal year’’
condition; and referred to as medical nutritional everywhere they appear and adding in
(v) Such other diseases or conditions counseling) required in the their place the words ‘‘calendar year’’.
the Director, Defense Health Agency administration of the medically
determines appropriate. necessary foods, services and supplies § 199.8 [Amended]
* * * * * authorized in paragraph (d)(3)(iii)(B) of ■ 7. Section 199.8(d)(1)(v) is amended
(vi) * * * this section, medically necessary by removing ‘‘Sec. 199.4(f)(10)’’ and
(D) Medically necessary vitamins vitamins authorized in paragraph adding in its place ‘‘§ 199.4(f)(10)’’ and
used for the management of a covered (d)(3)(vi)(D) of this section, or when removing the words ‘‘fiscal year’’ and
disease or condition pursuant to a medically necessary for other adding in their place the words
prescription, order, or recommendation authorized covered services. ‘‘calendar year’’.
of a TRICARE authorized provider * * * * * ■ 8. Section 199.11 is amended by
acting within the provider’s scope of (57) Food, food substitutes. Food, food revising paragraph (a) to read as follows:
license/certificate of practice. For substitutes, vitamins, or other
purposes of this paragraph (d)(3)(vi)(D), nutritional supplements, including § 199.11 Overpayments recovery.
the term ‘‘covered disease or condition’’ those related to prenatal care, except as (a) General. Actions to recover
means: authorized in paragraphs (d)(3)(iii)(B) overpayments arise when the
(1) Inborn errors of metabolism; and (d)(3)(vi)(D) of this section. government has a right to recover
(2) Medical conditions of money, funds, or property from any
* * * * *
malabsorption; person, partnership, association,
■ 4. Section 199.5 is amended by:
(3) Pathologies of the alimentary tract corporation, governmental body or other
■ a. Removing the words ‘‘fiscal year’’
or the gastrointestinal tract; legal entity, foreign or domestic, except
(4) A neurological or physiological everywhere they appear and adding in
their place the words ‘‘program year’’ in another Federal agency, because of an
condition; erroneous payment of benefits under
(5) Pregnancy in relation to prenatal paragraphs (c)(7)(iii), (f)(3), (g)(2)(i), and
(h)(3)(v)(A); and both CHAMPUS and the TRICARE
vitamins, with the limitation the program under this part. The term
■ b. Adding paragraph (a)(3).
prenatal vitamins that require a ‘‘Civilian Health and Medical Program
prescription in the United States may be The addition reads as follows:
of the Uniformed Services’’ (CHAMPUS)
covered for prenatal care only; § 199.5 TRICARE Extended Health Care is defined in 10 U.S.C. 1072(2), referred
(6) Such other disease or conditions Option (ECHO). to as the CHAMPUS basic program.
the Director, Defense Health Agency (a) * * * Prior to January 1, 2018, the term
determines appropriate. (3) The Government’s cost-share for ‘‘TRICARE program’’ referred to the
* * * * * ECHO or ECHO home health benefits triple-option of health benefits known
(e) * * * during any program year is limited as as TRICARE Prime, TRICARE Extra, and
(28) * * * stated in this section. In order to TRICARE Standard. Specifically,
(iv) Health promotion and disease transition the program year from a fiscal TRICARE Standard was the TRICARE
prevention visits (which may include all year to a calendar year basis, the program under which the basic program
of the services provided pursuant to Government’s annual cost-share of health care benefits generally referred
§ 199.17(f)(2)) for beneficiaries 6 years of limitation specified in paragraph (f) of to as CHAMPUS was made available to
age or older may be provided in this section shall be prorated for the last eligible beneficiaries under this Part
connection with immunizations and quarter of calendar year 2018 as 199. Effective January 1, 2018, the term
cancer screening examinations authorized by 10 U.S.C. 1079(f)(2)(A). ‘‘TRICARE program’’ is defined in 10
authorized by paragraphs (e)(28)(i) and * * * * * U.S.C. 1072(2) and includes TRICARE
(ii) of this section). Prime, TRICARE Select and TRICARE
■ 5. Section 199.6 is amended by
(v) Breastfeeding support, supplies for Life. It is the purpose of this section
revising paragraphs (c)(3)(iii)(L) and (M)
(including breast pumps and associated to prescribe procedures for
to read as follows:
equipment), and counseling. investigation, determination, assertion,
asabaliauskas on DSKBBXCHB2PROD with RULES
* * * * * § 199.6 TRICARE-authorized providers. collection, compromise, waiver and
(f) * * * * * * * * termination of claims in favor of the
(13) Special transition rule for the last (c) * * * United States for erroneous benefit
quarter of calendar year 2017. In order (3) * * * payments arising out of the
to transition deductibles and (iii) * * * administration CHAMPUS and the
catastrophic caps from a fiscal year basis (L) Nutritionist. The nutritionist must TRICARE program. For the purpose of
to a calendar year basis, the deductible be licensed by the State in which the this section, references herein to
amount and the catastrophic cap care is provided and must be under the TRICARE beneficiaries, claims, benefits,
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![45456 Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations
referral procedures established pursuant (ii) The wait time for an appointment (i) The provider must meet all
to this section, to make available to for a well-patient visit or a specialty applicable requirements in paragraph
designated DoD utilization management care referral shall not exceed four (p)(4) of this section.
or quality monitoring contractors weeks; for a routine visit, the wait time (ii) The provider must agree to follow
medical records and other pertinent for an appointment shall not exceed one all quality assurance and utilization
records, and to authorize the release of week; and for an urgent care visit the management procedures established
information to MTF Commanders wait time for an appointment shall pursuant to this section.
regarding such quality assurance and generally not exceed 24 hours. (iii) The provider must be a
utilization management activities. (iii) Emergency services shall be participating provider under TRICARE
(iv) All preferred network providers available and accessible to handle for all claims.
must be Medicare participating emergencies (and urgent care visits if (iv) The provider must meet all other
providers, unless this requirement is not available from other primary care qualification requirements, and agree to
waived based on extraordinary providers pursuant to paragraph all other rules and procedures, that are
circumstances. This requirement that a (p)(5)(ii) of this section), within the established, publicly announced, and
provider be a Medicare participating service area 24 hours a day, seven days uniformly applies by the Director (or
provider does not apply to providers a week. other authorized official).
who not eligible to be participating (iv) The network shall include a (v) The provider must sign a preferred
providers under Medicare. sufficient number and mix of board provider network agreement covering all
(v) The network provider must be certified specialists to meet reasonably applicable requirements. Such
available to all TRICARE beneficiaries. the anticipated needs of enrollees. agreements will be for a duration of one
(vi) The provider must agree to accept Travel time for specialty care shall not year, are renewable, and may be
the same payment rates negotiated for exceed one hour under normal canceled by the provider or the Director
Prime enrollees for any person whose circumstances, unless a longer time is (or other authorized official) upon
care is reimbursable by the Department necessary because of the absence of appropriate notice to the other party.
of Defense, including, for example, providers (including providers not part The Director shall establish an
Select participants, supplemental care of the network) in the area. This agreement model or other guidelines to
cases, and beneficiaries from outside the requirement does not apply under the promote uniformity in the agreements.
area. Specialized Treatment Services (2) In addition to the above
(vii) All preferred providers must Program. requirements, the Director, or designee,
meet all other qualification (v) Office waiting times in may establish additional categories of
requirements, and agree to comply with nonemergency circumstances shall not preferred providers of high quality/high
all other rules and procedures exceed 30 minutes, except when value that require additional
established for the preferred provider emergency care is being provided to qualifications.
network. patients, and the normal schedule is (r) General fraud, abuse, and conflict
(viii) In locations where TRICARE disrupted. of interest requirements under TRICARE
Prime is not available, a TRICARE (6) Special reimbursement methods program. All fraud, abuse, and conflict
provider network will, to the extent for network providers. The Director, of interest requirements for the basic
practicable, be available for TRICARE may establish, for preferred provider CHAMPUS program, as set forth in this
Select enrollees. In these locations, the networks, reimbursement rates and part (see especially applicable
minimal requirements for network methods different from those provisions of § 199.9) are applicable to
participation are those set forth in established pursuant to § 199.14. Such the TRICARE program.
paragraph (p)(4)(i) of this section. Other provisions may be expressed in terms of (s) [Reserved]
requirements of this paragraph (p) will percentage discounts off CHAMPUS (t) Inclusion of Department of
apply unless waived by the Director. allowable amounts, or in other terms. In Veterans Affairs Medical Centers in
(5) Access standards. Preferred circumstances in which payments are TRICARE networks. TRICARE preferred
provider networks will have attributes based on hospital-specific rates (or other provider networks may include
of size, composition, mix of providers rates specific to particular institutional Department of Veterans Affairs health
and geographical distribution so that the providers), special reimbursement facilities pursuant to arrangements,
networks, coupled with the MTF methods may permit payments based on made with the approval of the Assistant
capabilities (when applicable), can discounts off national or regional Secretary of Defense (Health Affairs),
adequately address the health care prevailing payment levels, even if between those centers and the Director,
needs of the enrollees. In the event that higher than particular institution- or designated TRICARE contractor.
a Prime enrollee seeks to obtain from specific payment rates. (u) Care provided outside the United
the managed care support contractor an (q) Preferred provider network States. The TRICARE program is not
appointment for care but is not offered establishment. (1) The any qualified automatically implemented in all
an appointment within the access time provider method may be used to respects outside the United States. This
standards from a network provider, the establish a civilian preferred provider paragraph (u) sets forth the provisions of
enrollee will be authorized to receive network. Under this method, any this section applicable to care received
care from a non-network provider TRICARE-authorized provider that outside the United States under the
without incurring the additional fees meets the qualification standards following TRICARE health plans.
associated with point-of-service care. established by the Director, or designee, (1) TRICARE Prime. The Director may,
asabaliauskas on DSKBBXCHB2PROD with RULES
The following are the access standards: may become a part of the preferred in conjunction with implementation of
(i) Under normal circumstances, provider network. Such standards must the TRICARE program, authorize a
enrollee travel time may not exceed 30 be publicly announced and uniformly special Prime program for command
minutes from home to primary care applied. Also under this method, any sponsored dependents of active duty
delivery site unless a longer time is provider who meets all applicable members who accompany the members
necessary because of the absence of qualification standards may not be in their assignments in foreign
providers (including providers not part excluded from the preferred provider countries. Under this special program, a
of the network) in the area. network. Qualifications include: preferred provider network may be
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![Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 45457
established through contracts or information will include a description ■ g. Removing the semicolon at the end
agreements with selected health care of the preferred provider network of paragraph (p)(2)(iii) and adding ‘‘;
providers. Under the network, Prime program and other pertinent and’’ in its place;
covered services will be provided to the information. The Director shall also ■ h. Revising paragraph (p)(2)(iv); and
enrolled covered dependents subject to issue policies, instructions, and ■ i. Removing paragraph (p)(2)(v).
applicable Prime deductibles, guidelines necessary to implement this The revisions and additions read as
copayments, and point-of-service special program. follows:
charges. To the extent practicable, rules (3) TRICARE for Life. The TRICARE
§ 199.20 Continued Health Care Benefit
and procedures applicable to TRICARE for Life (TFL) option shall be available
Program (CHCBP).
Prime under this section shall apply outside the United States. Eligible TFL
unless specific exemptions are granted beneficiaries may receive covered (a) Purpose. The CHCBP is a
in writing by the Director. The use of services and supplies authorized under premium-based temporary health care
this authority by the Director for any § 199.4, subject to the applicable coverage program, authorized by 10
particular geographical area will be catastrophic cap, deductibles and cost- U.S.C. 1078a, and available to
published on the primary publicly shares under § 199.4, whether received individuals who meet the eligibility and
available Internet Web site of the from a network provider or any enrollment criteria as set forth in
Department and on the publicly authorized TRICARE provider not in a paragraph (d)(1) of this section. The
available Internet Web site of the preferred provider network. However, if CHCBP is not part of the TRICARE
managed care support contractor that a TFL beneficiary receives covered program. However, as set forth in this
has established the provider network services from a PPN provider, the section, it functions under similar rules
under the TRICARE program. Published beneficiary’s out-of-pocket costs will and procedures to the TRICARE Select
information will include a description generally be lower. program. Because the purpose of the
of the preferred provider network (v) Administration of the TRICARE CHCBP is to provide a continuation
program and other pertinent program in the state of Alaska. In view health care benefit for Department of
information. The Director shall also of the unique geographical and Defense and the other uniformed
issue policies, instructions, and environmental characteristics impacting services beneficiaries losing eligibility,
guidelines necessary to implement this the delivery of health care in the state it will be administered so that it
special program. of Alaska, administration of the appears, to the maximum extent
TRICARE program in the state of Alaska practicable, to be part of the TRICARE
(2) TRICARE Select. The TRICARE
will not include financial underwriting Select program. Medical coverage under
Select option shall be available outside
of the delivery of health care by a this program will be the same as the
the United States except that a preferred
TRICARE contractor. All other benefits payable under the TRICARE
provider network of providers shall only
provisions of this section shall apply to Select program. There is a cost for
be established in areas where the
administration of the TRICARE program enrollment to the CHCBP and these
Director determines that it is
in the state of Alaska as they apply to premium costs must be paid by CHCBP
economically in the best interest of the
the other 49 states and the District of enrollees before any care may be cost
Department of Defense. In such a case,
Columbia. shared.
the Director shall establish a preferred
provider network through contracts or (w) Administrative procedures. The * * * * *
agreements with selected health care Assistant Secretary of Defense (Health (d) * * *
providers for eligible beneficiaries to Affairs), the Director, and MTF (7) * * *
receive covered benefits subject to the Commanders (or other authorized (i) * * *
enrollment and cost-sharing amounts officials) are authorized to establish (D) In the case of a former spouse of
applicable to the specific category of administrative requirements and a member or former member (other than
beneficiary. When an eligible procedures, consistent with this section, the former spouse whose marriage was
beneficiary, other than a TRICARE for this part, and other applicable DoD dissolved after the separation of the
Life beneficiary, receives covered Directives or Instructions, for the member from the service unless such
services from an authorized TRICARE implementation and operation of the separation was by retirement), the
non-network provider, including in TRICARE program. period of coverage under the CHCBP is
areas where a preferred provider unlimited, if former spouse:
§ 199.18 [Removed and Reserved] (1) Has not remarried before age of 55
network has not been established by the
Director, the beneficiary shall be subject ■ 10. Section 199.18 is removed and after the marriage to the member or
to cost-sharing amounts applicable to reserved. former member was dissolved; and
out-of-network care. To the extent ■ 11. Section 199.20 is amended by:
(2) Was eligible for TRICARE as a
practicable, rules and procedures ■ a. Revising paragraph (a);
dependent or enrolled in CHCBP at any
applicable to TRICARE Select under this ■ b. Removing the words ‘‘TRICARE
time during the 18 month period before
section shall apply unless specific Standard program’’ and adding in their the date of the divorce, dissolution, or
exemptions are granted in writing by the place the words ‘‘TRICARE Select annulment; and
Director. The use of this authority by the program’’ in paragraph (c); * * * * *
Director to establish a TRICARE ■ c. Revising paragraphs (d)(7)(i)(D) (e) * * *
preferred provider network for any introductory text, (d)(7)(i)(D)(1) and (2), (1) In general. Except as provided in
asabaliauskas on DSKBBXCHB2PROD with RULES
particular geographical area will be and (e)(1) and (3); paragraph (e)(2) of this section, the
published on the primary publicly ■ d. Removing the words ‘‘TRICARE provisions of § 199.4 shall apply to the
available Internet Web site of the Standard’’ and adding in their place the CHCBP as they do to TRICARE Select
Department and on the publicly words ‘‘TRICARE Select program’’ in under § 199.17.
available Internet Web site of the paragraphs (f) through (n); * * * * *
managed care support contractor that ■ e. Removing and reserving paragraph (3) Beneficiary liability. For purposes
has established the provider network (o); of CHCBP coverage, the beneficiary
under the TRICARE program. Published ■ f. Revising paragraph (p)(1); deductible, catastrophic cap and cost
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request in the appropriate format in email Lieutenant Commander John this collapse, portions of the adjacent
accordance with established procedures. Bannon, Waterways Management sea cliff fell into the ocean, producing
(vi) In accordance with the provisions Division, Coast Guard; telephone: 808– localized waves, and showers of debris.
of § 199.17(o)(2), coverage terminates for 541–4359, email: John.E.Bannon@ As of March 2017, a new delta has
young adult dependents who fail to uscg.mil. begun to form at the Kamokuna ocean
make premium payments in accordance SUPPLEMENTARY INFORMATION: entry point. This lava delta continues to
with established procedures. grow and collapse, and cracks parallel
(vii) Absent a new qualifying event, I. Table of Abbreviations to the sea cliff surrounding it persist,
young adults are not eligible to re-enroll BLS Bureau of Labor Statistics indicating further collapses may occur
in TYA until the next annual open COTP Captain of the Port with little or no warning.
season. DHS Department of Homeland Security On March 28, 2017, the Coast Guard
* * * * * FR Federal Register established a temporary final rule (TFR)
(f) Administration. The Director may NPRM Notice of proposed rulemaking
and put into place a safety zone for
establish other processes, policies and § Section symbol
OMB Office of Management and Budget mariners near lava entry points to
procedures for the effective address the hazards of the lava entering
RFA Regulatory Flexibility Act
administration of the TYA Program and SNPRM Supplemental notice of proposed the ocean. The TFR discussed Sector
may authorize exceptions to rulemaking Honolulu’s review of nearly 30 years of
requirements of this section, if TFR Temporary final rule delta collapse and ejecta distance
permitted. U.S.C. United States Code observations from the Hawaii Volcano
Dated: September 20, 2017. II. Background Information and Observatory records. The TFR was
Aaron Siegel, Regulatory History published in the April 3, 2017 Federal
Alternate OSD Federal Register Liaison Register (82 FR 16109).
The Coast Guard is extending, for an
Officer, Department of Defense. On April 3, 2017, the Coast Guard
additional six months, an existing
[FR Doc. 2017–20392 Filed 9–28–17; 8:45 am] also published a notice of proposed
temporary safety zone for the navigable
BILLING CODE 5001–06–P waters surrounding the entry of lava rulemaking (NPRM) to establish a
from the Kilauea Volcano into the permanent safety zone that would
Pacific Ocean on the southeast side of encompass all waters extending 300
DEPARTMENT OF HOMELAND the Island of Hawaii, HI. Extending this meters (984 feet) in every direction
SECURITY safety zone ensures mariners remain around all entry points of lava flow into
safe from the potential hazards the navigable waters surrounding the
Coast Guard associated with molten lava entering the entry of lava from the Kilauea Volcano
ocean while the proposed rule is being into the Pacific Ocean on the southeast
33 CFR Part 165 reviewed. This safety zone will continue side of the Island of Hawaii, HI (82 FR
[Docket Number USCG–2017–0172] to encompass all waters within 300 16142). We determined that a radius of
meters (984 feet) of all entry points of 300 meters was a reasonable, minimum
RIN 1625–AA00 high-hazard zone around a point of
lava flow into the ocean. Because the
entry points of the lava vary, the safety active lava flow entering the ocean. The
Safety Zone; Pacific Ocean, Kilauea safety zone allows the Coast Guard to
Lava Flow Ocean Entry on Southeast zone location will also vary. Entry of
persons or vessels into this safety zone impose and enforce restrictions on
Side of Island of Hawaii, HI vessels operating closely to the lava
remains prohibited, unless specifically
AGENCY: Coast Guard, DHS. authorized by the Captain of the Port entry area, which protects persons and
ACTION: Temporary final rule. (COTP) Honolulu, or his designated vessels from the potential hazards
representative. associated with molten lava entering the
SUMMARY: The Coast Guard is extending, Lava flow that enters the ocean can be ocean. The NPRM addressed this
for an additional six months, the potentially hazardous to anyone near it, concern and invited the public to
existing temporary safety zone particularly when lava deltas collapse. comment on the safety zone. The
surrounding the entry of lava from the A lava delta is new land that forms comment period, which ended on June
Kilauea volcano into the navigable when lava accumulates above sea level, 2, 2017, received 67 comments. On May
waters of the Pacific Ocean on the and extends from the existing base of a 8, 2017, at a public meeting held in
southeast side of the Island of Hawaii, sea cliff. Persons near active lava flow Hilo, HI, meeting participants discussed
HI. The extension of this safety zone is entry sites incur potential hazards, the proposed rule and NPRM’s public
necessary to protect persons and vessels particularly when lava deltas collapse. comments.
from hazards associated with molten These hazards include, but are not During the period of the TFR, four
lava entering the ocean while the limited to, plumes of hot, corrosive tour operators and one photographer
proposed rule is reviewed. seawater laden with hydrochloric acid, with economic ties to lava tourism
DATES: This rule is effective from and fine volcanic particles that can petitioned the COTP Honolulu for entry
September 28, 2017 through March 28, irritate the skin, eyes, and lungs; within 300 meters of the high-hazard
2018. explosions of debris and eruptions of zone. They also requested and
ADDRESSES: To view documents scalding water from hot rock entering petitioned for various levels of entry
mentioned in this preamble as being the ocean; sudden lava delta collapses; distances—ranging from a close, safe
asabaliauskas on DSKBBXCHB2PROD with RULES
available in the docket, go to https:// and waves associated with these distance to 50 meters—based on sea
www.regulations.gov, type USCG–2017– explosions and collapses. conditions resulting from the lava entry.
0172 in the ‘‘SEARCH’’ box and click Lava has been entering the ocean at The COTP Honolulu granted express
‘‘SEARCH.’’ Click on Open Docket the Kamokuna lava delta on Kilauea authorization for entry within 300
Folder on the line associated with this Volcano’s south coast since July 2016. meters to the five operators. The
rule. On December 31, 2016, a large portion authorization included operational
FOR FURTHER INFORMATION CONTACT: If of lava delta collapsed into the ocean at restrictions and other vessel safety
you have questions on this rule, call or the Kamokuna entry point. Following criteria requirements considered by the
VerDate Sep<11>2014 16:55 Sep 28, 2017 Jkt 241001 PO 00000 Frm 00041 Fmt 4700 Sfmt 4700 E:\FR\FM\29SER1.SGM 29SER1](https://thefederalregister.org/doc/82_FR_45626/page/24.svg)
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