[Federal Register Volume 74, Number 167 (Monday, August 31, 2009)]
[Proposed Rules]
[Pages 44798-44800]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-20684]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD-2009-HA-0094]
RIN 0720-AB32


TRICARE; Diabetic Education

AGENCY: Office of the Secretary, Department of Defense.

ACTION: Proposed rule.

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SUMMARY: The Department of Defense is publishing this proposed rule to 
clarify TRICARE coverage for diabetic education. This rule introduces 
new definitions and addresses revisions or omissions in policy or 
procedure inadvertently missed in previous regulatory changes 
pertaining to diabetic education.

DATES: Written comments received at the address indicated below by 
October 30, 2009 will be accepted.

ADDRESSES: You may submit comments, identified by docket number or 
Regulatory Information Number (RIN) and title, by either of the 
following methods:
    The Web site: http://www.regulations.gov. Follow the instructions 
for submitting comments.
    Mail: Federal Docket Management System Office, Room 3C843 Pentagon, 
1160 Defense Pentagon, Washington, DC 20301-1160.
    Instructions: All submissions received must include the agency name 
and docket number or RIN 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: Joy Saly, Medical Benefits and 
Reimbursement Branch, TRICARE Management Activity, telephone (303) 676-
3742. Questions regarding payment of specific claims should be 
addressed to the appropriate TRICARE contractor.

SUPPLEMENTARY INFORMATION: This proposed rule introduces new 
definitions and addresses revisions or omissions in policy or procedure 
inadvertently missed in previous regulatory changes pertaining to 
diabetic education.
    Diabetes self-management training is an interactive, collaborative 
process involving beneficiaries with diabetes, their physician(s) and 
their educators. The educational process should provide the beneficiary 
with the knowledge and skills needed to perform self-care, manage 
crises, and make lifestyle changes required to manage the diabetes 
successfully.
    TRICARE had previously classified diabetes self-management training 
as a counseling service that was not medically necessary. Since all 
services provided under the TRICARE program must be medically necessary 
and appropriate, diabetes self-management training was excluded from 
coverage. In developing the TRICARE policy on self-management, however, 
it was determined that diabetes educational services are consistent 
with the medically necessary and appropriate provision and it was 
decided to conform with Medicare's policy on diabetes self-management 
training. As such, TRICARE removed ``diabetic self-

[[Page 44799]]

management training'' programs as an excluded benefit effective July 1, 
1998. Although the policy change conflicted with existing regulation 
language, TRICARE determined to move forward with the policy change 
because TRICARE was expanding and not restricting a benefit, and the 
change was in line with Medicare's benefit. This proposed rule corrects 
the failure to amend the language of the regulation and brings the 
regulation into conformance with the current policy.
    Sec. 199.4 provides basic program benefits.
    Sec. 199.4(d)(3)(xiv) Diabetic Self-Management Training (DSMT) is 
added as a benefit under other covered services and supplies. This 
addition brings the regulation into conformance with the current 
policy.
    Sec. 199.4(g)(39) is revised to remove diabetic self-education 
programs as an exclusion.
    Sec. 199.6 addresses authorized providers.
    Sec. 199.6(c)(3)(iii)(L) adds Nutritionist to the list of 
individual professional providers of medical care authorized to provide 
services to CHAMPUS beneficiaries.
    Sec.199.6(c)(3)(iii)(M) adds Registered Dietitian to the list of 
individual professional providers of medical care authorized to provide 
services to CHAMPUS beneficiaries.
    Regulatory Procedures.

Executive Order 12866, ``Regulatory Planning and Review''

    Section 801 of title 5, United States Code, and Executive Order 
12866 require certain regulatory assessments and procedures for any 
major rule or significant regulatory action, defined as one that would 
result in an annual effect of $100 million or more on the national 
economy or which would have other substantial impacts. It has been 
certified that this rule is not a significant regulatory action.

Public Law 96-354, ``Regulatory Flexibility Act'' (RFA) (5 U.S.C. 601)

    Public Law 96-354, ``Regulatory Flexibility Act'' (RFA) (5 U.S.C. 
601), requires that each Federal agency prepare a regulatory 
flexibility analysis when the agency issues a regulation which would 
have a significant impact on a substantial number of small entities. 
This proposed rule will not have a significant impact on a substantial 
number of small entities. Therefore, this proposed rule is not subject 
to the requirements of the RFA.

Public Law 96-511, ``Paperwork Reduction Act'' (44 U.S.C. Chapter 35)

    This rule does not contain a ``collection of information'' 
requirement, and will not impose additional information collection 
requirements on the public under Public Law 96-511, ``Paperwork 
Reduction Act'' (44 U.S.C. Chapter 35).

Public Law 104-4, Section 202, ``Unfunded Mandates Reform Act''

    Section 202 of Public Law 104-4, ``Unfunded Mandates Reform Act,'' 
requires that an analysis be performed to determine whether any federal 
mandate may result in the expenditure by State, local and tribal 
governments, in the aggregate, or by the private sector of $100 million 
in any one year. It has been certified that this proposed rule does not 
contain a Federal mandate that may result in the expenditure by State, 
local and tribal governments, in aggregate, or by the private sector, 
of $100 million or more in any one year, and thus this proposed rule is 
not subject to this requirement.

Executive Order 13132, ``Federalism''

    Executive Order 13132, ``Federalism,'' requires that an impact 
analysis be performed to determine whether the rule has 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 power and responsibilities among the various 
levels of government. It has been certified that this proposed rule 
does not have federalism implications, as set forth in Executive Order 
13132.

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 proposed to be amended as follows:

PART 199--[AMENDED]

    1. The authority citation for part 199 continues to read as 
follows:


    Authority: 5 U.S.C. 301; 10 U.S.C. Chapter 55.

    2. Section 199.4 is amended by adding paragraph (d)(3)(ix), and 
revising paragraph (g)(39) to read as follows:


Sec.  199.4  Basic program benefits.

* * * * *
    (d) * * *
    (3) * * *
    (ix) Diabetes Self-Management Training (DSMT). A training service 
or program that educates diabetic patients about the successful self-
management of diabetes. It includes the following criteria: education 
about self-monitoring of blood glucose, diet, and exercise; an insulin 
treatment plan developed specifically for the patient who is insulin-
dependent; and motivates the patient to use the skills for self-
management. The DSMT service or program must be accredited by the 
American Diabetes Association. Coverage limitations on the provision of 
this benefit will be as determined by the Director, TRICARE Management 
Activity, or designee.
* * * * *
    (g) * * *
    (39) Counseling. Counseling services that are not medically 
necessary in the treatment of a diagnosed medical condition: For 
example, educational counseling, vocational counseling, nutritional 
counseling, and counseling for socioeconomic purposes, stress 
management, lifestyle modification, etc. Services provided by a 
certified marriage and family therapist, pastoral or mental health 
counselor in the treatment of a mental disorder are covered only as 
specifically provided in Sec.  199.6. Services provided by alcoholism 
rehabilitation counselors are covered only when rendered in a CHAMPUS-
authorized treatment setting and only when the cost of those services 
is included in the facility's CHAMPUS-determined allowable cost rate.
* * * * *
    3. Section 199.6 is amended by adding paragraphs (c)(3)(iii)(L) and 
(M).


Sec.  199.6  TRICARE--authorized providers.

* * * * *
    (c) * * *
    (3) * * *
    (iii) * * *
    (L) Nutritionist. A nutritionist may provide diabetes self-
management training (DSMT) via an accredited DSMT program. The 
nutritionist must be licensed by the State in which the care is 
provided, and must be under the supervision of a physician who is 
overseeing the DSMT program.
    (M) Registered Dietitian. A dietitian may provide diabetes self-
management training (DSMT) via an accredited DSMT program. The 
dietitian must be licensed by the State in which the care is provided, 
and must be under the supervision of a physician who is overseeing the 
DSMT program.
* * * * *


[[Page 44800]]


    Dated: August 21, 2009.
Patricia L. Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. E9-20684 Filed 8-28-09; 8:45 am]
BILLING CODE 5001-06-P