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[Federal Register Volume 79, Number 137 (Thursday, July 17, 2014)]
[Rules and Regulations]
[Pages 41636-41642]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-16702]

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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DOD-2011-HA-0134]
RIN 0720-AB55

TRICARE Certified Mental Health Counselors

AGENCY: Office of the Secretary, Department of Defense (DoD).

ACTION: Final rule.

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SUMMARY: The Department of Defense is publishing this final rule to 
implement the TRICARE Certified Mental Health Counselor (TCMHC) 
provider type as a qualified mental health provider authorized to 
independently diagnose and treat TRICARE beneficiaries and receive 
reimbursement for services. Additionally, we are extending the time 
frame that was mentioned in the Interim Final Rule for meeting certain 
education, examination, and supervised clinical practice criteria to be 
considered for authorization as a TCMHC. The time frame has been 
changed from prior to January 1, 2015, to prior to January 1, 2017. One 
final set of criteria shall apply for the authorization of the TCMHC 
beginning January 1, 2017. The supervised mental health counselor 
(SMHC) provider type, while previously proposed to be terminated under 
TRICARE, is now continued indefinitely as an extramedical individual 
provider practicing mental health counseling under the supervision of a 
TRICARE-authorized physician.

DATES: Effective Date: This rule is effective August 18, 2014.

FOR FURTHER INFORMATION CONTACT: Dr. Patricia Moseley, Defense Health 
Agency, Clinical Support Division, Behavioral Health Branch, 703-681-
0064.

SUPPLEMENTARY INFORMATION:

I. Executive Summary

A. Purpose of the Final Rule

 1. The Need for the Regulatory Action
    The purpose of this final rule is to prescribe regulations that 
will allow licensed or certified mental health counselors to be able to 
independently provide care to TRICARE beneficiaries and receive payment 
for those services. The final rule incorporates the recommendations of 
the Institute of Medicine (IOM) 2010 report for the independent 
practice of mental health counselors (MHCs) under TRICARE, including 
specific education, licensure,

[[Page 41637]]

examination, and supervised clinical practice experience requirements 
in order to become a TRICARE authorized independent provider. This 
final rule also provides for the continued authorization of Supervised 
Mental Health Counselors (SMHCs) as TRICARE authorized providers when 
practicing under physician referral and supervision. This important 
change to the interim final rule, will maintain continuity of care for 
those beneficiaries who are receiving services from SMHCs under the 
current system and will help to ensure a continued robust, quality 
provider pool for TRICARE beneficiaries to access when seeking 
medically necessary and appropriate mental health counseling services. 
Authorization of TCMHCs and SMHCs is part of a comprehensive quality-
management system implemented by TRICARE for all mental health 
professionals.
2. Legal Authority for the Regulatory Action
    The legal authority for this Final Rule is Section 724 of the 
National Defense Authorization Act (NDAA) for Fiscal Year 2011, Public 
Law 111-383, which required the Department of Defense to prescribe 
regulations to establish the criteria that would allow licensed or 
certified mental health counselors to be able to independently provide 
care to TRICARE beneficiaries and receive payment for those services.

B. Summary of the Major Provisions of the Final Rule

1. Designation of ``TRICARE Certified Mental Health Counselor (TCMHC)'' 
as an Allied Health Professional Under TRICARE
    This final rule establishes a new category of individual 
professional providers of medical care under the TRICARE program 
entitled TRICARE Certified Mental Health Counselors (TCMHC).
2. Under Basic Program Benefits, Services of TCMHCs and SMHCs Are 
Extended to Beneficiaries
    Under this final rule, beneficiaries are able to choose the 
services of a either a TCMHC who independently provides diagnostic and 
therapeutic services or a Supervised Mental Health Counselor (SMHC) who 
is authorized to provide mental health counseling pursuant to physician 
referral and ongoing supervision of the beneficiary's care. This final 
rule rescinds the expiration date published in the IFR for phase-out 
the SMHC provider type. The rule also adds appropriate definitions in 
32 CFR 199.2 for SMHCs and TCMHCs.
3. The Transition Period Is Extended to December 31, 2016, for a MHC To 
Meet the Currently Recognized Quality Standards Required for 
Independent Practice
    The date of the transition period established in the IFR is 
extended in the final rule and is changed accordingly throughout this 
rule. TCMHCs who are authorized during the transition period are not 
required to be reauthorized under the new criteria after January 1, 
2017. Additionally, MHCs who meet all certification requirements prior 
to the end of the transition period can apply for TRICARE authorization 
at any time after the transition period. Such authorization will be 
based on the certification requirements met prior to the end of the 
transition period. Providers who do not meet all of the certification 
requirements prior to the expiration of the transition period will be 
required to meet the quality standards recommended by the IOM and 
adopted by TRICARE, including possession of a master's or higher-level 
degree from a Council for Accreditation of Counseling and Related 
Educational Programs (CACREP) accredited mental health counseling 
program of education and training as well as having passed the National 
Clinical Mental Health Counseling Examination (NCMHCE).
4. Expansion of Providers Authorized To Supervise the Post-Master's 
Clinical Practice for Authorization as a TCMHC
    This final rule modifies the criteria in the IFR to permit 
supervision of a prospective TCMHC's post-master's clinical practice 
experience. Supervision is no longer restricted to a mental health 
counselor licensed for independent practice in mental health counseling 
in the jurisdiction where practicing but may be gained from multiple, 
licensed independent mental health professionals, similar to industry 
standards.

C. Costs and Benefits

    This rule is not anticipated to have an annual effect on the 
economy of $100 million or more; therefore, it is not an economically 
significant rule under Executive Order 12866 and the Congressional 
Review Act. All services and supplies authorized under the TRICARE 
Basic Program must be determined to be medically necessary in the 
treatment of an illness, injury or bodily malfunction before the care 
can be cost shared by TRICARE. For this reason, DoD anticipates that 
TRICARE will have a marginal increase in cost associated with increased 
access to authorized mental health counselors within the TRICARE basic 
program.

II. Discussion of Final Rule

A. Background

    1. The Conference Report (House Report 109-360) to the National 
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2006, requested 
the Department of Defense to report on actions taken to improve the 
efficiency and effectiveness of procedures to facilitate physician 
referral and supervision of MHCs. The report included a description of 
``best practices'' employed throughout the military health system (MHS) 
to ensure access to services provided by MHCs under the TRICARE 
program. The report concluded that there remained significant 
variability among the states in training programs and requirements for 
licensure as a MHC. The report stated that while there is evidence that 
the extent of training variability decreased over time, it continued to 
be evident that professional counselors licensed to practice had quite 
varying exposure to classroom education and supervised clinical 
experiences in the assessment and treatment of persons with mental 
disorders.
    2. Section 717 of the National Defense Authorization Act for Fiscal 
Year 2008, Public Law 111-181, directed the Secretary of Defense to 
conduct an independent study of the credentials, preparation, and 
training of individuals practicing as licensed MHCs and to make 
recommendations for permitting licensed MHCs to practice independently 
under the TRICARE program. In this study, the Institute of Medicine 
(IOM) of the National Academies of Science recommended allowing 
licensed MHCs who meet certain requirements for training, education, 
experience, certification, and licensure to practice independently 
under the TRICARE program. This final rule implements changes to 32 CFR 
Part 199 largely based on those recommendations.
    3. Section 724 of the National Defense Authorization Act for Fiscal 
Year 2011, Public Law 111-383, required the Department of Defense to 
prescribe regulations that establish the criteria for the independent 
practice of mental health counselors, as previously studied by the IOM 
in accordance with Section 717 of FY 2008 NDAA. As a result, the 
published Interim Final Rule--TRICARE: Certified Mental Health 
Counselors (76 Federal Register 80741-80744) requested 60 days of 
public comment from December 27, 2011 until February 27, 2012. In this 
final rule,

[[Page 41638]]

these criteria allow licensed or certified TCMHCs to independently 
provide care to TRICARE beneficiaries and receive payment for those 
services as do other allied health professionals listed in 32 CFR 
199.6(c)(3)(iii).

B. Certification Criteria for TRICARE Certified Mental Health Counselor 
(TCMHC) Independent Practice Under TRICARE

    This final rule establishes certification criteria largely 
consistent with the recommendations of the Institute of Medicine (IOM) 
2010 study, ``Provision of Mental Health Counseling Services under 
TRICARE,'' (http://www.iom.edu/Reports/2010/Provision-of-Mental-Health-Counseling-Services-Under-TRICARE.aspx). The IOM recommendations 
specify that the independent practice of MHCs in TRICARE should occur 
under certain circumstances, to include:

    A master's or higher level degree in counseling from a program 
in mental health counseling or clinical mental health counseling 
that is accredited by the Council for Accreditation of Counseling 
and Related Educational Programs (CACREP); a state license in mental 
health counseling at the `clinical' or the higher or highest level 
available in states that have tiered licensing schemes; the passage 
of the National Clinical Mental Health Counseling Examination; and a 
well-defined scope of practice for practitioners (p. 10).

    TRICARE adopts the quality standards recommended by the IOM. We 
understand the availability of CACREP accredited clinical mental health 
counseling training programs and the use of the NCMHCE examination as 
quality standards are not yet widespread in the field. To support this 
health care provider transition, the new quality standards for the 
independent practice of TCMHCs will not fully replace existing 
criteria, including regional accreditation of institution programs and 
passage of the National Counselor Exam (NCE), until January 1, 2017. 
While the IFR set an expiration date for authorization of SMHCs to 
coincide with the end of the transition period, this final rule 
specifies that TRICARE will continue authorization of SMHCs 
indefinitely to preserve access to care for our beneficiaries during 
and after the transition period. This will preserve patient access to 
an experienced and well-trained mental health professional provider 
group. At the same time, this final rule is designed to encourage 
greater participation of qualified MHCs to become independent TCMHCs 
and thus improve access to quality mental health treatment for our 
beneficiaries.

C. Additional Revisions to the Regulations

    In reviewing the interim final rule, we realized that we 
inadvertently failed to update several other provisions of the 
regulation that reference ``mental health counselors'' to account for 
the expansion of provider types in this field and the different rules 
that apply to each. Consequently, in this final rule, we have deleted 
the definition of ``mental health counselor'' from 32 CFR 199.2 and 
replaced it with definitions of ``Supervised Mental Health Counselor'' 
and ``TRICARE Certified Mental Health Counselor.'' We have also revised 
32 CFR 199.7(e)(3) to clearly indicate that claims for reimbursement 
for services of supervised mental health counselors must include 
certification to the effect that a written communication has been made 
or will be made to the referring physician at the end of treatment, or 
more frequently, as required by the referring physician. There is no 
similar requirement for TCMHCs as they are authorized to practice 
independently

III. Public Comments

    The Interim Final Rule: TRICARE--Certified Mental Health Counselors 
was published in the Federal Register (76 FR 80741-80744) on December 
27, 2011, for a 60-day public comment period. We received 404 public 
comments. Following is a summary of the public comments and our 
responses.
    Comment: A few commenters suggested a change from the title of 
Certified Mental Health Counselor (CMHC) as was the proposed title 
published in the Interim Final Rule, because the acronym, CMHC, is very 
similar to the National Board for Certified Counselor's (NBCC) title 
for Certified Clinical Mental Health Counselor (CCMHC).
    Response: We agree and believe it is necessary to distinguish the 
titles to prevent confusion. Consequently, the final rule will use the 
title, TRICARE Certified Mental Health Counselor (TCMHC).
    Comment: Many commenters recommended independent provider status 
for qualified MHCs. Some commenters requested continuation of physician 
referral and supervision as a condition of authorization.
    Response: TRICARE appreciates the skills and professional 
experience of the MHCs seeking independent status and recognizes the 
depth of expertise represented by the current SMHC provider pool. With 
this final rule, TRICARE maintains a robust selection of extramedical 
provider types for beneficiaries, plus beneficiaries may now choose to 
receive medically necessary and appropriate care from a TCMHC without 
physician referral and supervision. Under the final rule, the criteria 
provider category of an SMHC will remain indefinitely.
    Comment: Multiple national organizations and individuals expressed 
concern about the time required to obtain counseling degrees, 
licensure, and supervised clinical practice hours and to prepare for 
the NCMHCE. These commenters requested additional time for current 
counseling graduate students to complete their degrees, gain supervised 
clinical practice hours, and pass national examinations in order to 
become authorized for independent practice under TRICARE.
    Response: We recognize that the combined education and examination 
criteria for authorization as a TCMHC may present a higher bar to the 
field of mental health counseling in some states. Consequently, the 
transition period has been extended until January 1, 2017, and this 
date is modified throughout the final rule. The final rule balances the 
implementation of quality standards for MHCs with beneficiary access to 
their services. This four year period allows completion of counseling 
degrees, supervised clinical practice hours, and licensure under the 
existing quality standards. MHCs who meet all of the criteria for 
TCMHCs prior to end of the transition period may apply for 
certification after the transition period, and this certification will 
be based on the criteria (c)(3)(iii)(N)(2). This extension also allows 
time for experienced MHCs and currently practicing SMHCs to pass the 
National Clinical Mental Health Counseling Examination (NCMHCE). This 
change aims to ensure the availability of well-qualified, independent 
providers for our beneficiaries.
    Comment: Some commenters suggested that any professional mental 
health discipline or state licensed professional counselors should be 
able to supervise the clinical practice of the MHC for TRICARE 
authorization as a TCMHC. A few commenters recommend supervisors use 
standards other than those of the American Mental Health Counselor 
Association (AMHCA) standards.
    Response: We appreciate these suggestions and have amended the 
Final Rule at 32 CFR 199.6(c)(3)(iii)(N)(1)(iii) and (2)(iii) to expand 
the types of providers authorized to supervise the post-master's 
clinical practice for certification as a TCMHC. Supervision is no 
longer restricted to mental health counselors licensed for independent 
practice but may be gained from

[[Page 41639]]

multiple, licensed independent mental health professionals, including 
psychiatrists, clinical psychologists, certified clinical social 
workers, and certified psychiatric nurse specialists who are licensed 
for independent practice in the jurisdiction where practicing and who 
are practicing within the scope of their licenses. SMHCs and pastoral 
counselors, who require physician referral and supervision, as well as 
marriage and family therapists, do not meet the qualification criteria 
as supervisors for MHCs seeking authorization as TCMHCs. The final rule 
addresses supervised clinical practice that is provided in a manner 
consistent with the AMHCA guidelines specific to the knowledge, skills, 
and practice of mental health counseling. The Department of Defense has 
elected to adopt these standards, consistent with the IOM's 
recommendation, as the AMHCA is the recognized national or professional 
association that sets the standards for the profession.
    Comment: Many commenters request that the licensed professional 
counselors (LPCs) be allowed to practice independently under TRICARE, 
for example, psychotherapists; school, career, substance abuse, and 
rehabilitation counselors; expressive arts therapists; and counseling 
psychologists and licensed psychological associates.
    Response: We appreciate these comments from individuals and 
professional organizations. We are aware that states allow specialty 
counseling areas to practice under the title of ``licensed professional 
counselor'' or similar titles and that educational requirements vary 
from state to state. The 2006 MHS Report to Congress and the 2010 IOM 
report noted that the great majority of the states do not require that 
a LPC graduate from a mental health specialty counseling program in 
order to be licensed to assess and treat persons with mental disorders. 
This final rule responds to the statutory requirement for the 
Department to prescribe criteria for the independent practice of 
licensed and certified mental health counselors. Thus, in the final 
rule TCMHCs are required to have specified education and training in 
order to diagnose and treat mental health conditions as individual 
professional providers of care. This final rule, however, also 
maintains SMHCs as a category of authorized TRICARE providers. 
Consequently, individuals, including some of those specifically 
identified by the commenters, who possess either a master's degree in 
mental health counseling or an allied mental health field and meet all 
other SMHC criteria, may also serve as TRICARE authorized providers 
with physician referral and ongoing supervision.
    Comment: Several commenters recommend that TRICARE use a state 
license for authorization as a TCMHC. One commenter recommended that a 
state license alone should be sufficient as Medicaid and private 
insurance companies consider them sufficient for the practice of MHCs. 
Another commenter raised concerns that the criteria for authorizing 
TCMHCs will result in ``separate regulations for the credentialing of 
mental health counselors'' for Medicaid, Medicare, and TRICARE.
    Response: We appreciate these comments, but have determined that 
the final rule will adhere to the IOM (2010) recommendations that 
incorporate a set of four criteria (licensure, education, certification 
via examination, and clinical supervision), not the state license 
alone, for the independent practice of MHCs under TRICARE. The IOM 
Report discusses at greater length both independent and supervised 
practice under other federal programs. We would note that Medicare does 
not recognize licensed professional counselors as independent 
providers, so they are not directly reimbursed through the program.
    Comment: Some commenters asked whether TRICARE requires 
professional certification of a MHC.
    Response: Yes. Reference to professional licensure and 
certification was unintentionally omitted from the interim final rule. 
We appreciate the comment and have corrected this inadvertent exclusion 
for the final rule by adding relevant provisions at 32 CFR 
199.6(c)(3)(iii)(N)(1)(iv) and (2)(iv). Consistent with TRICARE 
requirements, professional certification is required when a 
jurisdiction does not issue a professional license [32 CFR 
199.6(c)(2)(ii)]. Currently, all states (but not all territories) issue 
professional licensure for MHCs. In 1993, professional certification by 
the National Academy of Certified Mental Health Counselors of the 
American Mental Health Counselors Association was placed in the 
National Board for Certified Counselors' credentialing process. Thus 
the professional certification of Certified Clinical Mental Health 
Counselor is now required for authorization as a TCMHC or SMHC in those 
jurisdictions that do not issue a professional license.
    Comment: Multiple commenters proposed the acceptance of their own 
states' or territories' licensing criteria for the number of hours of 
post-master's supervised clinical practice experience for the TCMHC.
    Response: As recognized by the IOM, state requirements and 
practices can vary considerably. The requirements for all TRICARE 
authorized providers are set forth by federal regulation, specifically 
32 CFR 199.6, including professional licensure, certification, and any 
specific education, training, and experience necessary to promote the 
delivery of services by fully qualified individuals. By establishing 
uniform standards, TRICARE seeks to provide high quality behavioral 
health care delivered by well-trained clinicians. No compelling 
comments were submitted to change the final rule requirement for TCMHCs 
related to the hours of supervised clinical practice.
    Comment: A few commenters ask whether a master's degree from an 
accredited on-line mental health or clinical mental health program met 
the criteria for independent practice under TRICARE.
    Response: The final rule makes no distinction between how a degree 
is earned, whether via distance learning or otherwise, as long as the 
provider has obtained a master's or higher-level degree from an 
appropriately accredited mental health counseling program of education 
and training. We would note, however, at the present time that CACREP 
and other regional accrediting bodies accredit very few institutions' 
programs that provide distance learning for mental health counseling.
    Comment: A few commenters recommended that the National Counselor 
Examination (NCE) should be the ``key to eligibility,'' not program 
accreditation. A few commenters expressed that either the NCE or the 
NCMHCE should be the accepted criteria for certification. Other 
commenters expressed appreciation that passage of the NCMHCE with 
graduation from a non-CACREP accredited program in mental health 
counseling is part of the eligibility criteria.
    Response: We appreciate these comments. TRICARE accepted the 
specific recommendations of the IOM for the independent practice of 
MHCs, to include accredited education as well as examination criteria. 
To ensure the availability of TCMHCs who meet these quality standards 
during the transition period, this final rule pairs the examinations 
with the education criteria. After the transition period, only the more 
rigorous examination of clinical knowledge of patient care, the NCMHCE, 
is accepted for authorization as a TCMHC.

[[Page 41640]]

    Comment: A few commenters suggest that TRICARE certify graduates 
from all universities that the federal government approves and 
allocates federal education funds. Other commenters ask whether 
graduates of the Rehabilitation Services of America (RSA) educational 
programs are allowed to practice independently under TRICARE, since 
their scholarship program provides federal funding for grants.
    Response: The final rule makes no distinction as to which 
universities and educational programs receive federal funding. 
Appropriately accredited programs of education and training for 
clinical mental health counselors, will satisfy the educational 
requirements applicable to TCMHCs and SMHCs regardless of whether or 
not federal funding has been provided. Conversely, federal funding of 
programs that do not meet the specified educational and accreditation 
criteria will not serve to waive the applicable requirements. 
Additionally, we understand that the RSA oversees competitive grant 
programs designed to ensure that skilled personnel are available to 
service the rehabilitation needs of individuals with disabilities and 
that many discretionary grants are provided for master's degrees in 
rehabilitation counseling (http://www2.ed.gov/students/college/aid/rehab/carcouns.html). Congress requested that the DoD prescribe 
criteria for the authorization of MHCs to practice independently under 
TRICARE. The Department does not intend to broaden the scope of this 
final rule to rehabilitation counselors who do not meet the criteria 
specified in the regulation for TCMHCs or SMHCs.
    Comment: Numerous commenters recommended a grandfathering clause to 
exempt a practicing MHC from meeting the criteria of the final rule. 
Others suggested the acceptance of each state's license as the criteria 
for grandfathering. Some commenters specifically recommended 
grandfathering MHCs who have two to five years of supervised experience 
serving the military.
    Response: We believe the changes that have been made to the final 
rule to permit the continued practice of SMHCs under existing 
eligibility criteria, as well as the extension of the transition period 
for a MHC to meet the current quality standards, adequately address 
these comments while still ensuring the provision of high quality 
mental health care for beneficiaries, regardless of their location. 
Specifically, the transition period allows MHCs the time to meet the 
quality standards for independent practice and allows for the 
implementation of uniform criteria that are not gained by 
grandfathering. TRICARE recognizes that many mental health counselors 
and current SMHCs have graduated prior to the establishment of either 
the CACREP accreditation for mental health counseling programs or the 
National Board of Certified Counselor's national examination for 
clinical mental health counselors. This final rule seeks to balance the 
implementation of quality standards for mental health counselors with 
beneficiary access to those services.

IV. Regulatory Impact Analysis

Overall Impact

    The Department has examined the impact of this final rule as 
required by Executive Orders (EOs) 12866 (September 1993, Regulatory 
Planning and Review) and 13563 (January 18, 2011, Improving Regulation 
and Regulatory Review), the Regulatory Flexibility Act (RFA) (September 
19, 1980, Pub. L. 96-354), the Unfunded Mandates Reform Act of 1995 
(Pub. L. 104-4), and the Congressional Review Act [5 U.S.C. 804(2)].
1. Executive Order 12866, ``Regulatory Planning and Review'' and 
Executive Order 13563, ``Improving Regulation and Regulatory Review''
    E.O.s 12866 and 13563 direct agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). E.O. 13563 emphasizes the 
importance of quantifying both costs and benefits, reducing costs, 
harmonizing rules, and promoting flexibility. A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any one year). We estimate 
that this rulemaking is not ``economically significant'' as measured by 
the $100 million threshold and, hence, is not a major rule under the 
Congressional Review Act or the E.O.s.
2. Congressional Review Act, 5 U.S.C. 804(2)
    Under the Congressional Review Act, a major rule may not take 
effect until at least 60 days after submission to Congress of a report 
regarding the rule. A major rule is one that would have an annual 
effect on the economy of $100 million or more or have certain other 
impacts. This Final rule is not a major rule under the Congressional 
Review Act.
3. Public Law 96-354, ``Regulatory Flexibility Act'' (RFA), Title 5, 
U.S.C., Sec. 601
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses if a rule has a significant impact on a substantial 
number of small entities. For purposes of the RFA, small entities 
include small businesses, nonprofit organizations, and small 
governmental jurisdictions. This rule is not an economically 
significant regulatory action, and it has been certified that it will 
not have a significant impact on a substantial number of small 
entities. Therefore, this rule is not subject to the requirements of 
the RFA.
4. Public Law 104-4, Sec. 202, ``Unfunded Mandates Reform Act''
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any one year of 
$100 million in 1995 dollars, updated annually for inflation. That 
threshold level is currently approximately $140 million. This final 
rule will not mandate any requirements for state, local, or tribal 
governments or the private sector.
5. Public Law 96-511, ``Paperwork Reduction Act'' (Title 44, U.S.C., 
Chapter 35)
    This rule will not impose significant additional information 
collection requirements on the public under the Paperwork Reduction Act 
of 1995 (44 U.S.C. 3502-3511). Existing information collection 
requirements of the TRICARE and Medicare programs will be utilized. 
TRICARE authorized and non-network providers will be coding and filing 
claims in the same manner as they currently are with TRICARE.
6. Executive Order 13132, ``Federalism''
    This rule has been examined for its impact under E.O. 13132, and it 
does not contain policies that have federalism implications that would 
have substantial direct effects on the States, on the relationship 
between the national Government and the States, or on the distribution 
of powers and responsibilities among the various levels of Government. 
Therefore, consultation with State and local officials is not required.

List of Subjects in 32 CFR Part 199

    Claims, Dental health, Health care, Health insurance, Individuals 
with disabilities, Military personnel.

    Accordingly, 32 CFR part 199 is amended as follows:

[[Page 41641]]

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.  199.2, paragraph (b) is amended by removing the definition 
of ``Mental health counselor'' and adding the definitions of 
``Supervised mental health counselor'' and ``TRICARE certified mental 
health counselor'' in alphabetical order to read as follows:

Sec.  199.2  Definitions.

* * * * *
    (b) * * *
    Supervised mental health counselor. An extramedical individual 
provider who meets the requirements outlined in Sec.  199.6.
* * * * *
    TRICARE certified mental health counselor. An allied health 
professional who meets the requirements outlined in Sec.  199.6.
* * * * *

0
3. Section 199.4 is amended by revising paragraph (c)(3)(ix)(A) to read 
as follows:

Sec.  199.4  Basic program benefits.

* * * * *
    (c) * * *
    (3) * * *
    (ix) * * *
    (A) Covered diagnostic and therapeutic services. Subject to the 
requirements and limitations stated, CHAMPUS benefits are payable for 
the following services when rendered in the diagnosis or treatment of a 
covered mental disorder by a CHAMPUS-authorized, qualified mental 
health provider practicing within the scope of his or her license. 
Qualified mental health providers are: Psychiatrists or other 
physicians; clinical psychologists, certified psychiatric nurse 
specialists, certified clinical social workers, certified marriage and 
family therapists, TRICARE certified mental health counselors, pastoral 
counselors under a physician's supervision and supervised mental health 
counselors under a physician's supervision. No payment will be made for 
any service listed in paragraph (c)(3)(ix)(A) of this section rendered 
by an individual who does not meet the criteria of Sec.  199.6 for his 
or her respective profession, regardless of whether the provider is an 
independent professional provider or an employee of an authorized 
professional or institutional provider.
* * * * *

0
4. Section 199.6 is amended by revising paragraphs (c)(3)(iii)(N) and 
(c)(3)(iv)(C) to read as follows:

Sec.  199.6  TRICARE--authorized providers.

* * * * *
    (c) * * *
    (3) * * *
    (iii) * * *
    (N) TRICARE certified mental health counselor. For the purposes of 
CHAMPUS, a TRICARE certified mental health counselor (TCMHC) must be 
licensed for independent practice in mental health counseling by the 
jurisdiction where practicing. In jurisdictions with two or more 
licenses allowing for differing scopes of independent practice, the 
licensed mental health counselor may only practice within the scope of 
the license he or she possesses. In addition, a TCMHC must meet the 
requirements of either paragraph (c)(3)(iii)(N)(1) or the requirements 
of paragraph (c)(3)(iii)(N)(2) of this section.
    (1) The requirements of this paragraph are that the TCMHC:
    (i) Must have passed the National Clinical Mental Health Counselor 
Examination (NCMHCE) or its successor as determined by the Director, 
TMA; and
    (ii) Must possess a master's or higher-level degree from a mental 
health counseling program of education and training accredited by the 
Council for Accreditation of Counseling and Related Educational 
Programs (CACREP); and
    (iii) Must have a minimum of two (2) years of post-master's degree 
supervised mental health counseling practice which includes a minimum 
of 3,000 hours of supervised clinical practice and 100 hours of face-
to-face supervision. Supervision must be provided by mental health 
counselors at the highest level of state licensure, psychiatrists, 
clinical psychologists, certified clinical social workers, or certified 
psychiatric nurse specialists who are licensed for independent practice 
in the jurisdiction where practicing and who are practicing within the 
scope of their licenses. Supervised clinical practice must be received 
in a manner that is consistent with the guidelines regarding knowledge, 
skills, and practice standards for supervision of the American Mental 
Health Counselors Association; and
    (iv) Is licensed or certified for independent practice in mental 
health counseling by the jurisdiction where practicing (see paragraph 
(c)(2)(ii) of this section for more specific information).
    (2) The requirements of this paragraph are that the TCMHC, prior to 
January 1, 2017:
    (i) Possess a master's or higher-level degree from a mental health 
counseling program of education and training accredited by CACREP and 
must have passed the National Counselor Examination (NCE); or
    (ii) Possess a master's or higher-level degree from a mental health 
counseling program of education and training from either a CACREP or 
regionally accredited institution and have passed the NCMHCE; and
    (iii) Must have a minimum of two (2) years of post-master's degree 
supervised mental health counseling practice which includes a minimum 
of 3,000 hours of supervised clinical practice and 100 hours of face-
to-face supervision. Supervision must be provided by mental health 
counselors at the highest level of state licensure, psychiatrists, 
clinical psychologists, certified clinical social workers, or certified 
psychiatric nurse specialists who are licensed for independent practice 
in the jurisdiction where practicing and who are practicing within the 
scope of their licenses. Supervised clinical practice must be received 
in a manner that is consistent with the guidelines regarding knowledge, 
skills, and practice standards for supervision of the American Mental 
Health Counselors Association; and
    (iv) Is licensed or certified for independent practice in mental 
health counseling by the jurisdiction where practicing (see paragraph 
(c)(2)(ii) of this section for more specific information).
    (3) The Director, TRICARE Management Activity may amend or modify 
existing or specify additional certification requirements as needed to 
accommodate future practice and licensing standards and to ensure that 
all TCMHCs continue to meet educational, licensing, and clinical 
training requirements considered appropriate.
    (iv) * * *
    (C) Supervised mental health counselor. For the purposes of 
TRICARE, a supervised mental health counselor is an individual who does 
not meet the requirements of a TRICARE certified mental health 
counselor in paragraph (c)(3)(iii)(N) of this section, but meets all of 
the following requirements and conditions of practice:
    (1) Minimum of a master's degree in mental health counseling or 
allied mental health field from a regionally accredited institution; 
and

[[Page 41642]]

    (2) Two years of post-masters experience which includes 3,000 hours 
of clinical work and 100 hours of face-to-face supervision; and
    (3) Is licensed or certified to practice as a mental health 
counselor by the jurisdiction where practicing (see paragraph 
(c)(3)(iv)(D) of this section for more specific information); and
    (4) May only be reimbursed when:
    (i) The TRICARE beneficiary is referred for therapy by a physician; 
and
    (ii) A physician is providing ongoing oversight and supervision of 
the therapy being provided; and
    (iii) The mental health counselor certifies on each claim for 
reimbursement that a written communication has been made or will be 
made to the referring physician of the results of the treatment. Such 
communication will be made at the end of the treatment, or more 
frequently, as required by the referring physician (refer to Sec.  
199.7).
* * * * *

0
5. Section 199.7 is amended by revising paragraphs (e)(3) to read as 
follows:

Sec.  199.7  Claims submission, review, and payment.

* * * * *
    (e) * * *
    (3) Claims involving the services of marriage and family 
counselors, pastoral counselors, and supervised mental health 
counselors. CHAMPUS requires that marriage and family counselors, 
pastoral counselors, and supervised mental health counselors make a 
written report to the referring physician concerning the CHAMPUS 
beneficiary's progress. Therefore, each claim for reimbursement for 
services of marriage and family counselors, pastoral counselors, and 
supervised mental health counselors must include certification to the 
effect that a written communication has been made or will be made to 
the referring physician at the end of treatment, or more frequently, as 
required by the referring physician.
* * * * *

    Dated: July 11, 2014.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2014-16702 Filed 7-16-14; 8:45 am]
BILLING CODE 5001-06-P
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