Federal Register / Vol. 87, No. 105 / Wednesday, June 1, 2022 / Rules and Regulations 33001 

Office of Foreign Assets Control 

Russian Harmful Foreign Activities 

Sanctions Regulations 

31 CFR Part 587 

General License No. 32 

Authorizing the Wind Down of 

Transactions Involving Amsterdam 

Trade Bank NV 

(a) Except as provided in paragraph 

(b) of this general license, all 

transactions ordinarily incident and 

necessary to the wind down of 

transactions involving Amsterdam 

Trade Bank NV, or any entity in which 

Amsterdam Trade Bank NV owns, 

directly or indirectly, a 50 percent or 

greater interest, that are prohibited by 

Executive Order (E.O.) 14024 are 

authorized through 12:01 a.m. eastern 

daylight time, July 12, 2022. 

(b) This general license does not 

authorize: 

(1) Any transactions prohibited by 

Directive 2 under E.O. 14024, 

Prohibitions Related to Correspondent 

or Payable-Through Accounts and 

Processing of Transactions Involving 

Certain Foreign Financial Institutions; 

(2) Any transactions prohibited by 

Directive 4 under E.O. 14024, 

Prohibitions Related to Transactions 

Involving the Central Bank of the 

Russian Federation, the National 

Wealth Fund of the Russian Federation, 

and the Ministry of Finance of the 

Russian Federation; or 

(3) Any transactions otherwise 

prohibited by the Russian Harmful 

Foreign Activities Sanctions 

Regulations, 31 CFR part 587 (RuHSR), 

including transactions involving any 

person blocked pursuant to the RuHSR 

other than the blocked persons 

described in paragraph (a) of this 

general license, unless separately 

authorized. 

Bradley T. Smith, 

Deputy Director, Office of Foreign Assets 

Control. 

Dated: May 5, 2022. 

Andrea M. Gacki, 

Director, Office of Foreign Assets Control. 

[FR Doc. 2022–11760 Filed 5–31–22; 8:45 am] 

BILLING CODE P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

32 CFR Part 199 

[Docket ID: DoD–2020–HA–0040; and DoD– 

2020–HA–0050] 

RIN 0720–AB81; 0720–AB82; and 0720– 

AB83 

TRICARE Coverage and 

Reimbursement of Certain Services 

Resulting From Temporary Program 

Changes in Response to the COVID–19 

Pandemic 

AGENCY: Office of the Assistant 

Secretary of Defense for Health Affairs, 

Department of Defense (DoD). 

ACTION: Final rule. 

SUMMARY: The Assistant Secretary of 

Defense for Health Affairs (ASD(HA)) 

issues this final rule related to certain 

provisions of three TRICARE interim 

final rules (IFRs) with request for 

comments issued in 2020 in response to 

the novel coronavirus disease 2019 

(COVID–19) public health emergency 

(PHE). Temporary coverage of 

telephonic office visits is made 

permanent in this final rule, with its 

adoption expanded beyond the 

pandemic; the temporary telehealth 

cost-share waiver is terminated; and the 

temporary waiver of certain acute care 

hospital requirements and permanent 

adoption of Medicare New Technology 

Add-on Payments for new medical 

items and services are modified, as 

further discussed in the SUPPLEMENTARY

INFORMATION section of this rule 

DATES: This rule is effective July 1, 

2022, except for instruction 4 (the 

provision modifying temporary 

hospitals) which is effective on June 1, 

2022. Effective July 1, 2022 the interim 

final rules amending 32 CFR part 199, 

which were published at 85 FR 27921, 

May 12, 2020, and 85 FR 54914, 

September 3, 2020, are adopted as final 

with changes, except for the note to 

paragraph 199.4(g)(15)(i)(A), published 

at 85 FR 54923, September 3, 2020, 

which remains interim. 

FOR FURTHER INFORMATION CONTACT: 

Erica Ferron, Defense Health Agency, 

Medical Benefits and Reimbursement 

Section, 303–676–3626 or 

erica.c.ferron.civ@mail.mil. Sharon 

Seelmeyer, Defense Health Agency, 

Medical Benefits and Reimbursement 

Section, 303–676–3690 or 

Sharon.l.seelmeyer.civ@mail.mil, 

Diagnosis Related Groups, Hospital 

Value Based Purchasing, Long Term 

Care Hospitals, and New Technology 

Add-On Payments. 

SUPPLEMENTARY INFORMATION: 

I. Executive Summary 

A. Purpose of the Rule 

In response to the novel coronavirus 

(SARS–CoV–2), which causes COVID– 

19, and the President’s declared 

national emergency for the resulting 

pandemic (Proclamation 9994, 85 FR 

15337 (March 18, 2020)), the ASD(HA) 

issued three IFRs in 2020 to make 

temporary modifications to TRICARE 

regulations in order to better respond to 

the pandemic. The first IFR, published 

in the FR on May 12, 2020 (85 FR 

27921), temporarily: (1) Modified the 

TRICARE regulations to allow for 

coverage of medically necessary 

telephonic (audio-only) office visits; (2) 

permitted interstate and international 

practice by TRICARE providers when 

such practice was permitted by state, 

federal, or host-nation law; and (3) 

waived cost-shares and copayments for 

covered telehealth services for the 

duration of the COVID–19 pandemic. 

The second IFR, published in the FR 

on September 3, 2020 (85 FR 54914) 

temporarily: (1) Waived the three-day 

prior hospital qualifying stay 

requirement for skilled nursing facilities 

(SNFs); (2) added coverage for the 

treatment use of investigational drugs 

under expanded access authorized by 

the U.S. Food and Drug Administration 

(FDA) when indicated for the treatment 

of COVID–19; (3) waived certain 

provisions for acute care hospitals in 

order to permit TRICARE authorization 

of temporary hospital facilities and 

freestanding ambulatory surgical centers 

(ASCs) providing inpatient and 

outpatient services to be reimbursed; (4) 

revised the diagnosis related group 

reimbursement (DRG) at a 20 percent 

higher rate for COVID–19 patients; and 

(5) waived certain requirements for long 

term care hospitals (LTCHs). The second 

IFR also included two permanent 

provisions adopting Medicare’s NTAPs 

adjustment to DRGs for new medical 

services and technologies and adopting 

Medicare’s Hospital Value Based 

Purchasing (HVBP) Program. 

The third IFR, published in the FR on 

October 30, 2020 (85 FR 68753) added 

coverage of National Institute of Allergy 

and Infectious Disease (NIAID)- 

sponsored clinical trials when for the 

prevention or treatment of COVID–19 or 

its associated sequelae. 

After publication of each IFR, DoD 

evaluated the appropriateness of each 

temporary measure for continued use 

throughout the national emergency for 

COVID–19, as well as to determine if it 

would be appropriate to make any of the 

provisions permanent within the 


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TRICARE program. After analysis of the 

risks, benefits, and costs of each 

provision, as well as a review of 

comments, the ASD(HA) issues this 

final rule to make the following 

changes: 

a. 32 CFR 199.4(g)(52) Telephone 

Services: The IFR temporarily modified 

this regulation provision which 

excluded telephone services (audioonly) except for biotelemetry. This final 

rule revises this regulatory exclusion 

and permanently modifies 32 CFR 

199.4(c)(1)(iii) Telehealth Services to 

add coverage for medically necessary 

telephonic office visits, in all geographic 

areas where TRICARE beneficiaries 

reside. A telephonic office visit is a 

reimbursable telephone call between a 

beneficiary, who is an established 

patient, and a TRICARE-authorized 

provider. This is considered a type of 

telehealth modality under the TRICARE 

program. Specifically, this change will 

allow providers to be reimbursed for 

medically necessary care and treatment 

provided to beneficiaries over the 

telephone, when a face-to-face, handson visit is not required, and a two-way 

audio and video telehealth visit is not 

possible. The telephonic office visit 

should be a valid medical visit in that 

there is an examination of the patient’s 

history and chief complaint along with 

clinical decision making performed by a 

provider. Telephonic provider-toprovider consults which are audio-only, 

but otherwise meet the definition of a 

covered consultation service are also 

covered under this final rule. Telephone 

calls of an administrative nature (e.g., 

appointment scheduling), routine 

answering of questions, prescription 

refills, or obtaining test results are not 

medical services and are not 

reimbursable. 

DoD implemented temporary coverage 

of telephonic office visits effective May 

12, 2020, in order to provide 

beneficiaries the option to obtain some 

medical services safely from home, 

reducing their exposure to COVID–19 

and to minimize potential spread of the 

illness. In order to determine if 

telephonic office visits should be 

converted to a permanent telehealth 

benefit, DoD analyzed claims data from 

TRICARE private sector care and 

reviewed published industry 

information from: Medicare; health 

insurance plans; and physicians’ 

professional organizations regarding 

telephonic office visits. The TRICARE 

claims data between mid-March and 

mid-September 2020 indicates 

beneficiary utilization of telephonic 

office visits is a small portion of all 

telehealth claims. Medicare and health 

insurance plans reported data indicating 

substantial utilization of telephonic 

office visits. Physicians’ professional 

organizations including the American 

College of Physicians (ACP) and the 

American Medical Association (AMA) 

issued statements reporting physicians’ 

favorable experiences with telephonic 

office visits. Furthermore, the DoD 

received positive public comments 

regarding telephonic office visits 

including multiple requests for the 

agency to consider it as a permanent 

benefit. After thoughtful consideration 

of these facts, and through this final rule 

revising the regulatory exclusion 

prohibiting reimbursement of 

telephonic (audio-only) office visits, the 

DoD will revise the exclusion of audioonly telephonic services and add 

medically necessary telephonic office 

visits as a covered telehealth service 

under the TRICARE Basic Benefit. In 

addition, 32 CFR 199.2 Definitions will 

be amended by this final rule to include 

definitions of ‘‘Biotelemetry,’’ 

‘‘Telephonic consultations,’’ and 

‘‘Telephonic office visits’’ as related to 

the modified telehealth service 

regulation provision. 

b. 32 CFR 199.6(b)(4)(i)(I): The 

temporary waiver of certain acute care 

hospital requirements for temporary 

hospitals and freestanding ambulatory 

surgery centers during the COVID–19 

pandemic from the second COVID IFR 

remains in effect, with modifications. 

The modification temporarily allows 

any entity that enrolled with Medicare 

as a hospital through Medicare’s 

Hospitals Without Walls initiative to 

become a TRICARE-authorized hospital 

that may be considered to meet the 

requirements for an acute care hospital 

listed under paragraph 199.6(b)(4)(i). 

These entities may provide any 

inpatient or outpatient hospital services, 

when consistent with the State’s 

emergency preparedness or COVID–19 

pandemic plan and when they meet the 

Medicare hospital Conditions of 

Participation (CoP), to the extent not 

waived. Under Medicare’s Hospitals 

Without Walls initiative, Centers for 

Medicaid and Medicare Services (CMS) 

relaxed certain requirements to allow 

ASCs and other interested entities, such 

as licensed independent emergency 

departments, to temporarily enroll as 

Medicare-certified hospitals and receive 

reimbursement for hospital inpatient 

and outpatient services. Although CMS 

ceased accepting new enrollments into 

the Hospitals Without Walls initiative, 

effective December 1, 2021, those 

entities that were previously enrolled 

under the initiative continue to be 

enrolled and receive reimbursement for 

hospital inpatient and outpatient 

services. The CMS memorandum 

eliminating future enrollments into the 

Hospitals Without Walls initiative, does 

not impact any of the changes from the 

initial IFR or in this final rule, as both 

require a provider to first be enrolled 

with CMS as a hospital under the 

initiative to register with TRICARE as a 

hospital and receive reimbursement as a 

hospital. 

The ASD(HA) also recognizes the 

need for increased access to inpatient 

and outpatient care during the COVID– 

19 pandemic. In the IFR, we temporarily 

permitted temporary hospitals and 

freestanding ASCs that registered with 

Medicare as hospitals to be reimbursed 

as acute care hospitals (85 FR 54914). 

We are modifying this expanded 

coverage of inpatient and outpatient 

care by allowing any entity enrolled 

with Medicare as a hospital on a 

temporary basis to also be considered a 

TRICARE-authorized hospital and 

receive reimbursement for inpatient and 

outpatient institutional charges under 

the TRICARE DRG payment system, 

Outpatient Prospective Payment System 

(OPPS), or other applicable hospital 

payment system allowed under 

Medicare’s Hospitals Without Walls 

initiative, to the extent practicable. In 

order to reduce burden on these 

providers during the pandemic, we are 

not developing any regulatory 

requirements for participation in 

TRICARE and will instead permit any 

entity that registers with Medicare as a 

hospital under their Hospitals Without 

Walls initiative to be considered a 

TRICARE-authorized hospital. To 

further reduce the burden on providers 

and the TRICARE program, this final 

rule will allow the Defense Health 

Agency (DHA) to adopt any requirement 

related to Medicare’s Hospital without 

Walls initiative through administrative 

policy, when determined practicable, 

without going through the lengthy 

regulatory process. This provision will 

be effective the date published in the FR 

through the expiration of Medicare’s 

Hospitals Without Walls initiative. 

Upon conclusion of Medicare’s 

initiative or when a facility loses its 

hospital status with Medicare, 

whichever occurs earlier, the entity will 

no longer be considered an authorized 

hospital under TRICARE and will not be 

reimbursed for institutional charges 

unless it otherwise qualifies as an 

authorized institutional provider under 

paragraph 199.6(b)(4). While 

vaccination has slowed the spread of 

COVID–19 in many areas of the U.S., the 

virus remains a deadly threat for those 

patients who do contract it and require 

acute care treatment. Additionally, 


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access to acute care treatment for other 

injury and illnesses in areas where there 

is a COVID–19 resurgence remains 

essential. The ASD(HA) finds it 

necessary to make this provision of the 

final rule effective upon publication of 

the final rule. 

c. 32 CFR 199.14(a)(1)(iv): Special 

Programs and Incentive Payments. This 

final rule creates new paragraph 

199.14(a)(1)(iv) to more appropriately 

categorize the NTAP and HVBP 

payments. It moves the NTAP 

provisions from paragraph 

199.14(a)(1)(iii)(E)(5) to 

199.14(a)(1)(iv)(A), and moves the 

HVBP provision from paragraph 

199.14(a)(iii)(E)(6) to 199.14(a)(1)(iv)(B). 

For the NTAP provisions, TRICARE: (1) 

Shall apply Medicare NTAP 

adjustments to TRICARE covered 

services and supplies, except for 

pediatric (defined for NTAPs as 

pertaining to patients under the age of 

18, or who are treated in a children’s 

hospital or in a pediatric ward) services 

and supplies; (2) shall modify NTAP 

reimbursement adjustment rates for 

NTAPs at 100 percent of the average 

cost of the technology or 100 percent of 

the costs in excess of the Medicare 

Severity-Diagnosis Related Group (MS– 

DRG) payment for the case for pediatric 

beneficiaries; and (3) may create a 

reimbursement adjustment for TRICARE 

NTAPs, specific to the TRICARE 

beneficiary population under age 65 in 

the absence of a Medicare NTAP 

adjustment, using criteria similar to 

Medicare criteria for eligible new 

technologies outlined in 42 CFR 412.87 

and the Medicare reimbursement 

criteria outlined in 42 CFR 412.88. 

Under the statutory authority to pay like 

Medicare for like services and items 

when practicable in 10 U.S.C. 1079(i)(2), 

the ASD(HA) has determined that, 

generally, the NTAP reimbursement 

methodology is practicable for TRICARE 

to adopt for any otherwise covered 

services and supplies with a Medicare 

NTAP, under the same conditions as 

approved by Medicare. However, the 

ASD(HA) finds it impracticable to use 

Medicare’s NTAPs for TRICARE’s 

pediatric patients due to the lack of a 

significant pediatric population within 

Medicare. To address the unique 

TRICARE beneficiary population of 

pediatric patients, this rule establishes 

reimbursement of pediatric NTAPs at 

100 percent of the costs in excess of the 

MS–DRG payment. Lastly, when 

TRICARE covers new technologies that 

are not covered by Medicare or do not 

have a Medicare NTAP due to differing 

populations (e.g., biologics used solely 

by pediatric patients), the ASD(HA) 

finds it practicable to establish a 

TRICARE NTAP category and 

methodology whenever necessary. In 

these instances, the Director, DHA, may 

issue implementation instructions 

listing the specific TRICARE NTAPs on 

the website: www.health.mil/ntap. 

d. 32 CFR 199.17(l)(3): The cost-share 

and copayment waiver for telehealth 

services during the COVID–19 

pandemic was implemented in 

TRICARE’s first COVID–19 IFR in 

response to efforts by federal, state, and 

local governments to encourage 

individuals to stay at home, avoid 

exposure, and to reduce possible 

transmission of the virus. When the rule 

was published, there was a high degree 

of uncertainty surrounding the potential 

availability of a vaccine. With the 

approval or emergency use 

authorization of several vaccines by the 

U.S. Food and Drug Administration, the 

widespread availability of such vaccines 

throughout the United States, and the 

elimination of stay-at-home orders by 

most States and localities, this provision 

is no longer necessary. As such, the 

ASD(HA) is terminating the waiver of 

cost-shares and copayments for 

telehealth services on the effective date 

of this final rule, or upon expiration of 

the President’s national emergency for 

COVID–19, whichever occurs earlier. 

e. The DoD continues to evaluate 

potential permanent adoption of the 

treatment use of investigational drugs 

under expanded access and NIAIDsponsored clinical trials and will 

publish a final rule at a future date; 

until such publication, the two benefits 

remain in effect without modification as 

temporarily implemented in the second 

and third IFRs. These two benefits 

remain in effect through the end of the 

President’s national emergency for 

COVID–19, unless modified by future 

rulemaking. Comments received on 

those two provisions during the IFR 

comment periods will be addressed in 

that final rule. 

f. All temporary regulation changes 

made by the three COVID–19-related 

IFRs not otherwise addressed in this 

final rule remain in effect as stated in 

the IFR under which they were 

implemented until such time as the 

conditions for their expiration are met. 

g. The HVBP Program is permanently 

adopted and is moved from 32 CFR 

199.14(a)(1)(iii)(E)(6) to 32 CFR 

199.14(a)(1)(iv)(B); there are otherwise 

no modifications from the second IFR. 

B. Summary of Major Provisions 

a. Changes to the TRICARE Benefit 

Telephonic Office Visits 

A telephonic office visit is an easy-touse telehealth modality that has many 

benefits. A telephonic office visit 

consists of a beneficiary, who is an 

established patient, calling his/her 

provider to discuss an illness (including 

mental illness), injury, or medical 

condition. During the conversation the 

provider will ask questions regarding 

the symptoms and determine if they can 

proceed with the telephonic office visit 

or if based on the information he/she 

reported, a face-to-face, hands-on visit is 

in fact medically necessary. If they 

proceed with the telephonic office visit, 

typically the provider will have the 

beneficiary’s medical record open for 

review during the call, offer medical 

advice, and may place an order for a 

prescription or lab tests. During the 

COVID–19 pandemic, telephonic office 

visits have been instrumental in keeping 

beneficiaries safer at home with less risk 

of exposure to COVID–19 for conditions 

which a face-to-face and hands-on visit 

is not medically necessary. Telephonic 

office visits are also highly desirable for 

beneficiaries who reside in rural areas 

and/or areas where health care services 

are scarce. Likewise, beneficiaries 

without access to the internet and/or 

computers, smartphones, or tablets to 

conduct two-way audio-video telehealth 

visits also greatly benefit from coverage 

of telephonic office visits. DoD will 

continue to offer coverage of telephonic 

office visits through the end of the 

pandemic and with this final rule DoD 

will revise the telephone services 

(audio-only) regulatory exclusion in 

order to make this a permanent 

telehealth benefit available to 

beneficiaries in all geographic locations, 

when such care is medically necessary 

and appropriate. 

To understand the use of telephonic 

office visits during the COVID–19 

pandemic, the DoD analyzed claims 

data from TRICARE private sector care 

and reviewed published industry 

information from: Medicare; health 

insurance plans; and physicians’ 

professional organizations regarding 

telephonic office visits. TRICARE 

private sector claims data from midMarch 2020 through mid-September 

2020 indicates there were a total of 

80,541 telephonic office visits 

conducted. Telephonic office visits were 

an average 2.1 percent of all telehealth 

services provided. Telehealth services 

were 5.7 percent of all outpatient 

professional visits. In August 2020, a 

Medicare Advantage Issue Brief 


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1 ‘‘Issue Brief: Audio-only Telehealth Visits 

Essential for Use in Medicare Advantage Risk 

Adjustment’’, Better Medicare Alliance. August 

2020. Web. Accessed 15 Dec. 2020. 

2 Ibid. 

3 ‘‘Amid pandemic, CMS should level field for 

phone E/M visits’’, Kevin B. O’Reilly, AMA Digital, 

April 20, 2020. Web. Accessed 15 Dec. 2020 

4 ‘‘CMS Announcement of Pay Parity for 

Telephone Calls Answers a TOP ACP Priority’’ 

American College of Physicians. Statement 

attributable to Jacqueline Fincher, President, 

American College of Physicians. April 30, 2020. 

Web. Accessed 15 Dec. 2020. 

reported, ‘‘Three million telehealth 

visits with Medicare beneficiaries 

between mid-March and mid-June were 

conducted via telephone indicating the 

preference for [telephonic office 

visits].’’ 1 Health insurance plans 

including Security Health Plan and 

Kaiser Permanente reported 75 percent 

and 85 percent respectively of their 

telehealth visits as telephonic office 

visits.2 The AMA stated, ‘‘Doctors have 

reported that they have been able to 

conduct successful [telephonic office 

visits] with patients, in lieu of in-person 

or telehealth visits, obtaining about 90 

percent of the information they would 

collect using audio and video capable 

equipment.’’ 3 In March 2020, the ACP 

began writing letters to CMS requesting 

pay parity for telephonic office visits. 

On April 30, 2020, CMS responded to 

the ACP’s requests announcing that it 

was increasing payments for telephonic 

office visits to match payments of 

similar office and outpatient visits.4

TRICARE routinely updates its 

reimbursement rates in accordance with 

CMS updates, consistent with existing 

statutory requirements, when 

practicable. Note that CMS intends to 

only temporarily offer coverage for 

telephonic office visits for certain 

services during the public health 

emergency. However, although 

TRICARE is required to reimburse like 

Medicare to the extent practicable under 

the statute, TRICARE is not required to 

provide the exact same benefits as 

Medicare given the differences in 

populations served. Prior to the 

pandemic, DoD had a telehealth benefit 

that was more generous than what was 

offered under Medicare. Considering all 

of the data and industry information 

discussed, the DoD is finalizing its 

approach to permanently revise the 

telephone services (audio-only) 

regulatory exclusion and allow coverage 

of medically necessary and appropriate 

telephonic office visits for beneficiaries 

in all geographic locations. 

In converting medically necessary 

telephonic office visits to a permanent 

benefit, the DoD will issue policy 

guidance describing coverage of 

medically necessary and appropriate 

telephonic office visits to ensure best 

practices and protect against fraud. 

Entities Temporarily Enrolling as 

Hospitals 

This final rule modifies the temporary 

waiver of certain acute care hospital 

requirements for TRICARE authorized 

hospitals in the IFR to allow any entity 

that has temporarily enrolled with 

Medicare as a hospital through their 

Hospitals Without Walls initiative (or 

enrolls in the future, should Medicare 

resume such enrollments) to 

temporarily become a TRICAREauthorized hospital under paragraph 

199.6(b)(4)(i). These entities may 

provide any inpatient or outpatient 

hospital services, when consistent with 

the State’s emergency preparedness or 

COVID–19 pandemic plan and when 

they meet the Medicare hospital CoP, to 

the extent not waived. While there are 

no direct corollaries in TRICARE 

regulation to the CoP being waived 

under Medicare, there do exist in 

TRICARE regulation certain 

requirements that would prevent 

allowing some facilities to be 

considered as acute care hospitals for 

the purposes of payment. Title 32 CFR 

199.6(b)(3) and (4) list the requirements 

for providers to be considered 

TRICARE-authorized hospitals. It may 

not be possible for some entities to meet 

all of these requirements, such as 

providing primarily inpatient care or 

having Joint Commission (previously 

known as the Joint Commission on 

Accreditation of Hospitals) accreditation 

status or surveying of new facilities. 

We continue to assert, as we did in 

the IFR, that these institutional 

requirements are necessary for 

TRICARE-authorized acute care 

hospitals. We also note there is no 

requirement to have a TRICARE benefit 

that matches Medicare’s benefit, or for 

TRICARE to authorize all providers that 

are providers under Medicare. Both 

TRICARE’s statutory authority and 

population differ from Medicare’s, so it 

is appropriate for TRICARE to continue 

to manage its authorized provider 

program separately from Medicare’s. 

During the COVID–19 pandemic, 

however, it is important for TRICARE to 

ensure swift access to inpatient and 

outpatient care, to include leveraging 

Medicare’s flexibilities for acute care 

facilities. Under Medicare’s Hospitals 

Without Walls initiative, CMS relaxed 

certain requirements to allow ASCs and 

other interested entities, such as 

licensed independent freestanding 

emergency departments, to temporarily 

enroll as Medicare-certified hospitals 

and to receive reimbursement for 

hospital inpatient and outpatient 

services. In the previously-published 

IFR, we extended coverage of acute care 

hospitals to include temporary hospitals 

and freestanding ASCs that registered 

with Medicare as hospitals to be 

reimbursed as hospitals under 

TRICARE. This final rule expands the 

original temporary hospital waiver by 

temporarily permitting any entity to 

qualify as an acute care hospital under 

TRICARE so long as it had enrolled with 

Medicare as a hospital under the 

Hospitals Without Walls initiative prior 

to the December 1, 2021 memorandum 

by which CMS terminated further 

enrollments (or enrolls in the future, 

should CMS resume enrollments). 

In the IFR, it was not our intent to 

maintain a regulatory list of qualifying 

providers in § 199.6 that are eligible to 

enroll with Medicare under their 

Hospitals Without Walls initiative or to 

adopt such changes through the 

regulatory process, which imposes an 

unnecessary administrative burden on 

the DHA and delays coverage for 

providers and patients, as paragraph 

199.6(b)(4)(i) may need to be 

continually updated to keep current 

with Medicare changes during the 

pandemic. Therefore, this final rule 

modifies the temporary regulation 

change from the IFR at paragraph 

199.6(b)(4)(i) to allow any entity 

enrolled with Medicare as a hospital to 

temporarily become a TRICAREauthorized acute care hospital, and 

receive reimbursement for inpatient and 

outpatient institutional charges under 

the TRICARE DRG payment system, 

OPPS, or other applicable hospital 

payment system allowed under 

Medicare’s Hospitals Without Walls 

initiative (when determined 

practicable). The ASD(HA) will 

implement Medicare’s requirements for 

such entities through administrative 

guidance (e.g., the TRICARE manuals) to 

ensure TRICARE requirements for such 

facilities are consistent with the most 

current Medicare requirements under 

the Hospitals Without Walls initiative. 

Under this provision, facilities that 

convert into hospitals and are Medicarecertified hospitals through an 

emergency waiver authority under 

Section 1135 of the Social Security Act 

and are operating in a manner 

consistent with their State’s emergency 

plan in effect during the COVID–19 

pandemic will be eligible for 

reimbursement by TRICARE for covered 

inpatient and outpatient services under 

the applicable hospital payment system. 

Once an entity ends, terminates, or loses 

its hospital status under Medicare, the 

facility will no longer be considered a 

TRICARE-authorized acute care hospital 

effective the date when Medicare 


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deactivated the entity’s hospital billing 

privileges. While we are temporarily 

amending the institutional provider 

requirements under paragraph 

199.6(b)(4)(i), we are still requiring that 

these facilities meet Medicare’s CoP (to 

the extent not waived) established for 

this Presidential national emergency. 

This change will improve beneficiary 

access to medically necessary care and 

may mitigate hospitals’ lack of capacity 

and shortages of resources during the 

pandemic. This change is temporary for 

the duration of Medicare’s ‘‘Hospitals 

Without Walls’’ initiative. 

b. Reimbursement Modifications 

Consistent With Medicare Requirements 

NTAPs 

NTAP Reimbursement 

As stated in the second IFR (85 FR 

54914), for care rendered in an inpatient 

setting, TRICARE shall reimburse 

services and supplies with Medicare 

NTAPs using Medicare’s NTAP 

payment adjustments for only those 

services and supplies that are an 

approved benefit under the TRICARE 

Program. Title 10 U.S.C. 1079(i)(2) 

requires TRICARE to reimburse covered 

services and supplies using the same 

reimbursement rules as Medicare, when 

practicable. However, this provision is 

not self-executing, so this FR 

permanently adopts the Medicare NTAP 

methodology. TRICARE shall also adopt 

future NTAP modifications published 

by CMS, including modifications to the 

NTAP methodology and the list of new 

technologies to which NTAPs are 

applied. 

Pediatric Reimbursement 

Per the authority provided in 10 

U.S.C. 1079(i)(2), the ASD(HA) may 

determine that the Medicare NTAP 

methodology is not practicable for 

certain populations. One such 

population is TRICARE’s pediatric 

population, which, as used in relation to 

the NTAP provisions in this final rule, 

is defined as individuals under the age 

of 18, or who are being treated in a 

children’s hospital or in a pediatric 

ward. Since Medicare does not have a 

pediatric population to consider when 

establishing alternative reimbursements 

for new high-dollar technologies, the 

ASD(HA) has therefore determined it is 

not practicable to use Medicare’s NTAPs 

for pediatric patients; instead, the NTAP 

adjustment should be modified to 

address the unique TRICARE 

beneficiary population of pediatric 

patients. Under this modification, 

TRICARE shall reimburse pediatric 

NTAP claims at 100 percent of the costs 

in excess of the MS–DRG. Paying these 

claims at 100 percent of the costs in 

excess of the MS–DRG increases the 

likelihood that all pediatric 

beneficiaries will receive medically 

necessary and appropriate treatment, 

especially pediatric beneficiaries with 

serious, life-threatening, and costly 

diseases. 

High-Cost Treatments Without an NTAP 

Some new, high-cost treatments are 

not identified as requiring an NTAP by 

CMS. This primarily occurs when a 

treatment for a rare, fatal disease may be 

appropriate for a beneficiary in 

TRICARE’s population but is not 

appropriate for Medicare’s population, 

which is typically age 65 and above. For 

example, Spinraza is a treatment for 

Spinal Muscular Atrophy, a rare genetic 

neuromuscular disease that primarily 

impacts infants and young children. 

Spinraza has a high-cost per treatment, 

but is reimbursed at substantially lower 

cost when administered in a hospital 

because it is included in the DRG 

reimbursement. CMS does not include 

Spinraza in its list of new technologies 

receiving an NTAP. 

The ASD(HA) therefore finds it 

impracticable to reimburse such 

technologies using existing 

reimbursement methodologies, which 

do not allow sufficient rates for new, 

high-cost technologies during the first 

two or three years following FDA 

approval, after which, they are absorbed 

into the core DRG through the annual 

DRG update and calibration process. 

The ASD(HA) finds it practicable to 

establish a category of TRICARE NTAPs. 

This category may include services and 

supplies that are otherwise covered by 

TRICARE and that meet certain CMS 

eligibility criteria under 42 CFR 412.87. 

These eligibility criteria will ensure that 

DHA consistently and comprehensively 

evaluates new treatments when 

selecting which treatments may be 

approved for a TRICARE NTAP. 

Likewise, the reimbursement 

methodology for these TRICARE NTAPs 

shall follow the CMS reimbursement 

methodologies for Medicare NTAPs 

outlined in 42 CFR 412.88. 

For these high-cost, new, life-saving 

treatments that do not qualify or 

otherwise have an NTAP designation 

from CMS but for which the existing 

Medicare reimbursement is not 

practicable for the TRICARE population, 

the Director, DHA, shall establish 

internal guidelines and policy for 

approving TRICARE NTAPs and 

adopting such adjustments together 

with any variations deemed necessary to 

address unique issues involving the 

beneficiary population or program 

administration. These include, but are 

not limited to the exact reimbursement 

methodology, the eligibility criteria, and 

the method for approving or denying a 

TRICARE specific NTAP. The approved 

TRICARE NTAPs shall be published at 

least annually on the website: 

www.health.mil/ntap. 

c. Beneficiary Cost-Shares and 

Copayments 

Termination of Cost-Share and 

Copayment Waivers for Telehealth 

During the COVID–19 Pandemic 

The first IFR implemented a waiver of 

cost-shares and copayments (including 

deductibles) for all in-network 

authorized telehealth services for the 

duration of the COVID–19 pandemic 

(ending when the President’s national 

emergency for COVID–19 is suspended 

or terminated, in accordance with 

applicable law and regulation). The 

purpose was to incentivize TRICARE 

beneficiaries to use telehealth services 

and avoid unnecessary in-person 

TRICARE-authorized provider visits, 

which could potentially bring them into 

contact with or aid the spread of 

COVID–19. The implementation of this 

provision was highly successful, with a 

significant number of beneficiaries 

shifting to the use of telehealth visits. 

Since this provision was enacted, 

however, several vaccines have been 

approved or granted emergency use 

authorization by the FDA and are now 

widely available throughout the United 

States. While concerns remain 

surrounding variants of the SARS–CoV– 

2 virus and herd immunity may not yet 

have been reached, states and localities 

are no longer enacting strict stay-athome orders. 

TRICARE spent approximately 

$20.6M on waived telehealth cost-shares 

and copayments in FY20 and another 

$71.4M through the end of September 

2021. Due in part to flexibilities 

introduced in the IFRs discussed in this 

rule, and other program changes 

implemented via policy, the Defense 

Health Plan faces significant budget 

shortfalls. Termination of this provision 

will save the DoD $4.8M for every 

month it expires prior to the end of the 

national emergency, allowing DoD to 

focus resources on testing, vaccination 

efforts, and treatment for COVID–19- 

positive patients. We do not expect 

termination of this provision to have 

any impact on access to care, as 

beneficiaries will continue to have 

access to telehealth services and will be 

able to choose to continue using such 

services, or to visit their provider inperson, with the same cost-share 

applied to the service regardless of the 


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modality through which it was 

delivered. 

Given the availability of vaccines, the 

reduction of stay-at-home orders, and 

the cost of waiving telehealth costsharing, the ASD(HA) finds it 

appropriate to expire the waiver on the 

effective date of this rule or the date of 

expiration of the President’s national 

emergency for COVID–19, whichever is 

earlier. Telehealth services remain a 

covered benefit for TRICARE 

beneficiaries after the expiration of the 

cost-share/copayment waiver. 

C. Legal Authority for This Program 

This rule is issued under 10 U.S.C. 

1073(a)(2) giving authority and 

responsibility to the Secretary of 

Defense to administer the TRICARE 

program. The text of 10 U.S.C. chapter 

55 can be found at https://

manuals.health.mil/. 

II. Regulatory History 

Each of the sections under which 

TRICARE is administered are revised 

every few years to ensure requirements 

continue to align with the evolving 

health care field. Title 32 CFR 199.4 was 

most recently updated on November 17, 

2020 (85 FR 73193) by a final rule that 

added coverage of physical therapy and 

occupational services prescribed by a 

podiatrist. 

The telephone services paragraph 

being modified by this final rule, 

paragraph 199.4(g)(52), was last 

temporarily modified with publication 

of the COVID–19-related IFR published 

on May 12, 2020 (85 FR 27921–27927), 

which temporarily permitted coverage 

of telephonic office visits for the 

duration of the President’s national 

emergency for the COVID–19 pandemic. 

The telephone services regulatory 

exclusion was first published in the FR 

on April 4, 1977, with the 

comprehensive regulations 

implementing the ‘‘Civilian Health and 

Medical Program of the Uniformed 

Services’’ (42 FR 17972). Then, in 1984, 

the final rule, ‘‘Civilian Health and 

Medical Program of the Uniformed 

Services (CHAMPUS); Cardiac 

Pacemaker Telephonic Monitoring’’ (49 

FR 35934) revised the exclusion to 

allow coverage of transtelephonic 

monitoring (a type of biotelemetry) of 

cardiac pacemakers. No other 

permanent revisions have been made to 

the telephone services paragraph. 

Title 32 CFR 199.6 was last modified 

November 17, 2020 (85 FR 73196). This 

change updated terminology from 

doctors of podiatry or surgical 

chiropody to doctors of podiatric 

medicine or podiatrists and added 

podiatrists to the list of providers 

authorized to prescribe and refer 

beneficiaries to physical therapists and 

occupational therapists. 

Title 32 CFR 199.14 was last 

permanently revised on September 3, 

2020 (85 FR 54914–54924) with the 

addition of NTAPs and the HVBP 

Program under paragraph 

199.14(a)(1)(iii)(E), which are being 

modified by this final rule. 

Title 32 CFR 199.17 was last 

temporarily modified on May 12, 2020 

(85 FR 27921–27927), with publication 

of the telehealth cost-share and 

copayment waiver being terminated by 

this final rule. This section was last 

permanently modified on February 15, 

2019 (84 FR 4333), as part of the final 

rule implementing the TRICARE Select 

benefit plan. The revisions to § 199.17 

included adding high-value services as 

a benefit under the TRICARE program, 

as well as copayment requirements for 

Group B beneficiaries. The 32 CFR 

199.17(l) paragraph being modified by 

this IFR was created as part of the IFR 

that established the TRICARE Select 

benefit (82 FR 45438) during which a 

comprehensive revision of § 199.17 

occurred. This paragraph did not exist 

prior to that revision and has only been 

modified once, with the addition of 

temporary telehealth cost-shares and 

copayment waivers. 

III. Discussion of Comments & Changes 

DoD sincerely appreciates all 

comments received on the IFRs 

published in response to the COVID–19 

pandemic. We respond to comments for 

two of the IFRs below, separated by rule 

and impacted provision, except for 

comments on the treatment use of 

investigational new drugs, which will 

be discussed in a future final rule. We 

will also respond to comments related 

to TRICARE’s third IFR published in 

2020 in a future final rule. Except where 

otherwise modified in this final rule, we 

reaffirm the policies and procedures 

incorporated in the IFRs and 

incorporate the rationale presented in 

the preambles of the IFRs into this final 

rule. 

A. IFR—TRICARE Coverage and 

Payment for Certain Services in 

Response to the COVID–19 Pandemic 

This IFR was published in the FR (85 

FR 27921) on May 12, 2020. Comments 

were accepted for 30 days until June 11, 

2020. A total of 16 comments were 

received. Below is a summary of the 

comments and the Department’s 

responses. Some commenters provided 

detailed feedback concerning the overall 

telehealth program, including its 

applicability to autism services, partial 

hospitalization programs, and 

behavioral health services, or regarding 

benefits outside of the scope of this rule, 

such as care provided in patients’ 

homes. We thank the commenters for 

their feedback however, because these 

comments did not relate to telephonic 

office visits, provider licensing, or 

telehealth copays, we are unable to 

respond in detail to these comments. 

One commenter expressed concern 

about the use of nine months in the cost 

estimate and that provisions would 

expire after nine months. We note that 

the timeframe used for the cost 

estimates was based on early estimates 

for the pandemic and that each 

provision of the IFR only expires when 

the President’s national emergency 

expires, except where modified by this 

final rule. There was no automatic 

expiration at nine months. 

a. Telephonic Office Visits 

1. Provisions of the IFR 

The IFR allowed TRICARE 

beneficiaries to obtain telephonic office 

visits with providers for otherwisecovered, medically necessary care and 

treatment and allowed reimbursement 

to those providers during the COVID–19 

pandemic. It provided a temporary 

exception to the regulatory exclusion 

prohibiting telephone services. 

2. Analysis of Public Comments 

The public comments regarding the 

temporary exception to the regulatory 

exclusion prohibiting telephone services 

were minimal. Commenters requested 

that DoD continue coverage of 

telephonic office visits after the COVID– 

19 pandemic and commenters requested 

telephonic office visits be expanded to 

a range of providers. This final rule 

includes regulatory text revising the 

prohibition on telephone services 

thereby allowing coverage of telephonic 

office visits permanently. This will 

include mental health and addiction 

treatment services when medically 

necessary and appropriate. Regarding 

the request to expand the range of 

providers who can provide telephonic 

office visits, there is nothing in 

TRICARE regulation or policy excluding 

specific provider types such as physical 

therapists, occupational therapists, 

registered dieticians, or diabetes 

counselors (note: Diabetes counselors 

must be registered dieticians to be 

TRICARE-authorized providers) from 

providing their services via telehealth, 

including telephonic office visits, so 

long as they otherwise meet program 

requirements, including that all care be 

medically necessary and appropriate. 

Two commenters requested DoD make 

implementation of the telephonic office 


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visits retroactive, to either January 1, 

2020, or March 1, 2020. The 

commenters noted that CMS adopted 

their allowance of telephonic office 

visits with a retroactive date. While DoD 

acknowledges that some providers may 

have provided telephonic office visits 

prior to the effective date of the IFR, 

DoD lacks the statutory authority to 

make the implementation retroactive. 

One commenter suggested DoD evaluate 

provider and patient satisfaction and 

health outcomes in determining 

whether to permanently adopt 

telephonic office visits. We agree that 

this information would be valuable but 

ultimately determined there was 

sufficient information from other 

sources to make a decision without it. 

3. Provisions of Final Rule 

No changes were made in response to 

public comments; however, this 

provision has been revised for the final 

rule (see next section for details). 

b. Interstate and International Licensing 

of TRICARE-Authorized Providers 

1. Provisions of the IFR 

The IFR allowed providers to be 

reimbursed for interstate practice, both 

in person and via telehealth, during the 

global pandemic so long as the provider 

met the requirements for practicing in 

that State or under Federal law. It 

removed the requirement that the 

provider must be licensed in the state 

where practicing, even if that license is 

optional. For providers overseas, this 

allowed providers, both in person and 

via telehealth, to practice outside of the 

nation where licensed when permitted 

by the host nation. 

2. Analysis of Public Comments 

Comments received on the relaxation 

of licensing requirements for providers 

during the pandemic were generally 

supportive, with no comments received 

opposed. Several commenters suggested 

implementing the relaxed licensing 

requirement permanently for telehealth. 

DoD notes that licensing remains the 

purview of the States and that States 

generally require licensure in each State 

where practicing. DoD will continue to 

evaluate trends in licensing 

requirements for telehealth following 

the COVID–19 pandemic but will not be 

permanently adopting this provision at 

this time. We note that we continue to 

recognize (and recognized prior to the 

COVID–19 pandemic) interstate 

licensing agreements and reciprocal 

license agreements between states 

where a state considers a provider to be 

licensed at the full clinical practice 

level based on such an agreement. 

3. Provisions of Final Rule 

The final rule is consistent with the 

IFR. 

c. Waiver of Copayments and CostSharing for Telehealth Services 

1. Provisions of the IFR 

The IFR waived cost-shares and 

copayments for telehealth services for 

TRICARE Prime and Select beneficiaries 

utilizing telehealth services with an innetwork, TRICARE-authorized provider 

during the President’s declared national 

emergency for COVID–19. 

2. Analysis of Public Comments 

We received four comments regarding 

the waiving of telehealth cost-shares 

and copays, all of them supportive of 

the waiver, with one commenter also 

noting the negative effect of loss copay 

revenue for the DoD. Of the comments 

we received, three of them encouraged 

the DoD to continue to evaluate costsharing policies, and one comment also 

encouraged the DoD to make the 

telehealth copay and cost-share waiver 

permanent. One commenter 

recommended we apply the waiver of 

telehealth copays to copays associated 

with remote physiologic monitoring 

(RPM). RPM services of physiologic 

parameters including, but not limited to, 

monitoring of weight, blood pressure, 

pulse oximetry and respiratory flow rate 

shall be covered. RPM is considered an 

ancillary service and therefore ancillary 

copays and cost-shares shall apply. 

We thank all the commenters for their 

support and feedback. TRICARE’s 

temporary waiving of cost-shares and 

copays for all telehealth services was in 

line with initiatives by commercial 

insurers to incentivize telehealth care to 

help prevent the spread of COVID–19 

and to reduce financial burdens on 

patients. TRICARE’s cost-shares and 

copayments are set by law and require 

copayments and cost-sharing for 

telehealth services to be the same as if 

the service was provided in person. 

Section 718(d) of the National Defense 

Authorization Act of 2017 authorized 

the Secretary of Defense to reduce or 

eliminate copayments or cost-shares 

when deemed appropriate for covered 

beneficiaries in connection with the 

receipt of telehealth services under 

TRICARE. Given the national emergency 

caused by the COVID–19 pandemic, it 

was deemed appropriate to remove costshares and copayments for telehealth 

services during the pandemic, until 

there was no longer an urgent need to 

incentivize telehealth visits. 

3. Provisions of Final Rule 

The final rule is consistent with the 

IFR, except that this provision may 

terminate early. This provision of the 

final rule is being terminated early due 

to both the cost of waiving cost-shares 

and because there remain few, if any, 

stay-at-home orders for this provision to 

support. Defense Health Program dollars 

are better spent on testing, vaccination, 

and treatment for COVID–19, including 

a waiver of cost-shares for medically 

necessary COVID–19 testing, which 

remains in effect as a result of the 

CARES Act. 

B. IFR—TRICARE Coverage of Certain 

Medical Benefits in Response to the 

COVID–19 Pandemic 

This IFR was published in the FR on 

September 3, 2020 (85 FR 54914). 

Comments were accepted for 60 days 

until November 2, 2020. A total of four 

comments were received. Two were 

generally supportive of the provisions 

implemented in the IFR; we are grateful 

to the public for their support. Please 

see a summary of the comments and the 

DoD’s responses below. Comments 

related to the treatment use of 

investigational drugs under expanded 

access will be discussed in a future final 

rule. 

a. SNF 3-Day Prior Stay Waiver 

1. Provisions of the IFR 

The IFR temporarily waived the 

regulatory requirement that an 

individual be an inpatient of a hospital 

for not less than three consecutive 

calendar days before discharge from the 

hospital (three-day prior hospital stay) 

for coverage of a SNF admission for the 

duration of the COVID–19 public health 

emergency, consistent with a similar 

waiver under Medicare and TRICARE’s 

statutory requirement to have a SNF 

benefit like Medicare’s. The waiver will 

terminate when the Health and Human 

Services (HHS) PHE terminates. 

2. Analysis of Public Comments 

We received one comment on this 

provision of the IFR that was supportive 

of the waiver, but requested the DoD 

adopt another Medicare waiver; that is, 

the waiver of a 60-day wellness period. 

We thank the commenter for their 

support and feedback. TRICARE is 

primary payer for Medicare/TRICARE 

dual eligible beneficiaries that have 

exhausted the Medicare 100-day SNF 

benefit (meeting TRICARE coverage 

requirements without any other forms of 

other health insurance (OHI)), and 

TRICARE is also primary payer for nonMedicare TRICARE beneficiaries who 

have no OHI and who meet the 


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TRICARE SNF coverage requirements. 

Because TRICARE covers patients 

immediately after benefits are 

exhausted, there is no current 

requirement for a 60-day wellness 

period under TRICARE. 

3. Provisions of Final Rule 

The final rule is consistent with the 

IFR. 

b. Waiving of Acute Care Hospital 

Requirements for Temporary Hospital 

Facilities and Freestanding ASCs 

1. Provisions of the IFR 

The IFR temporarily exempted 

temporary hospital facilities and 

freestanding ASCs that enrolled as 

hospitals with Medicare from the 

institutional provider requirements for 

acute care hospitals described in 

paragraph 199.6(b)(4)(i). This allowed 

these facilities to provide inpatient and 

outpatient hospital services to improve 

the access of beneficiaries to medically 

necessary care. This change was 

consistent with 10 U.S.C. 1079(i)(2) to 

reimburse hospitals and other 

institutional providers in accordance 

with the same reimbursement 

methodology as Medicare, when 

practicable. This waiver remains in 

effect through the end of Medicare’s 

‘‘Hospitals Without Walls’’ initiative. 

2. Analysis of Public Comments 

No public comments were received on 

this provision. 

3. Provisions of Final Rule 

No changes were made in response to 

public comments; however, this 

provision has been modified for the 

final rule (see next section for details). 

c. 20 Percent Increase in DRG Rates for 

COVID–19 Patients 

1. Provisions of the IFR 

The IFR temporarily adopted the 

Medicare Hospital Inpatient Prospective 

Payment Add-On Payment for COVID– 

19 patients during the COVID–19 PHE 

period. The add-on payment for 

COVID–19 patients increased the 

weighting factor that would otherwise 

apply to the DRG to which the discharge 

is assigned by 20 percent. 

2. Analysis of Public Comments 

We received one comment regarding 

this provision of the IFR. The 

commenter noted that sole community 

hospitals (SCHs) are not subject to 

reimbursement under the DRG system 

and, as such, would not be eligible for 

the 20 percent increased reimbursement 

rate in the IFR. The commenter 

requested TRICARE modify 

reimbursement for SCHs to make them 

eligible for the 20 percent increased 

payment. 

We appreciate the feedback from the 

commenter regarding a 20 percent 

increase for acute inpatient 

reimbursement for SCHs treating 

COVID–19 patients. We would note that 

while SCHs are not eligible for the 20 

percent increased DRG reimbursement, 

we do an aggregate comparison of SCH 

claims paid with what we would have 

paid under the DRG methodology 

(which would include the 20 percent 

DRG increase) and if the SCH payments 

are lower than what would have been 

paid under the DRG methodology, we 

then pay the SCH the difference. So, 

while we are not adding 20 percent to 

the SCH calculation, it is added to the 

DRG and then used in the annual 

adjustment payment calculation. 

3. Provisions of Final Rule 

The final rule is consistent with the 

IFR. 

d. LTCH Reimbursement at the Federal 

Rate 

1. Provisions of the IFR 

The IFR adopted the Medicare waiver 

of site neutral payment provisions for 

LTCHs during the COVID–19 PHE 

period, waiving the site neutral payment 

provisions and reimbursing all LTCH 

cases at the LTCH PPS standard Federal 

rate for claims within the COVID–19 

PHE period. 

2. Analysis of Public Comments 

No public comments were received on 

this provision. 

3. Provisions of Final Rule 

The final rule is consistent with the 

IFR. 

e. Adoption of Medicare’s NTAPs for 

New Medical Services 

1. Provisions of the IFR 

The IFR permanently added coverage 

of Medicare’s NTAP payments for new 

medical services, adding an additional 

payment to the DRG payment for new 

and emerging technologies approved by 

Medicare. 

2. Analysis of Public Comments 

No public comments were received on 

this provision. 

3. Provisions of Final Rule 

No changes were made in response to 

public comments; however, this 

provision has been revised in the final 

rule (see next section for details). 

f. Adoption of Medicare’s HVBP 

Program 

1. Provisions of the IFR 

The IFR permanently added coverage 

of Medicare’s HVBP Program. The 

HVBP Program provides incentives to 

hospitals that show improvement in 

areas of health care delivery, process 

improvement, and increased patient 

satisfaction. 

2. Analysis of Public Comments 

No comments were received on this 

provision. 

3. Provisions of Final Rule 

The final rule content is consistent 

with the IFR content; however the 

HVBP provision has been moved from 

199.14(a)(1)(iii)(E)(6) to 

199.14(a)(1)(iv)(B) to account for the 

changes to the NTAP provisions. 

IV. Summary of Changes From IFRs 

A. Telephonic Office Visits 

Telephonic office visits temporarily 

adopted in the IFR are permanently 

adopted in this final rule. The Director, 

DHA shall issue subsequent policy 

guidance of medically necessary and 

appropriate telephonic office visits to 

ensure best practices and protect against 

fraud. 

B. Temporary Hospitals 

The final rule modifies the waiver of 

acute care hospital requirements at 

paragraph 199.6(b)(4)(i) by expanding 

the waiver to include any facility 

registered with Medicare under its 

Hospitals Without Walls initiative, not 

just temporary hospitals and 

freestanding ASCs as were authorized 

by the IFR. 

C. NTAPs 

This final rule permanently adopts 

the Medicare NTAP methodology and 

future NTAP modifications published 

by CMS, for those otherwise approved 

benefits under the TRICARE Program. 

This rule also creates a pediatric NTAP 

reimbursement methodology based on 

100 percent of the costs in excess of the 

MS–DRG. Finally, this rule provides a 

mechanism to establish a TRICAREspecific NTAP for those high-cost 

treatments that do not have an NTAP 

designation because the population 

affected and treated by these new 

technologies are outside of Medicare’s 

beneficiary population. 

D. Adoption of Medicare’s HVBP 

Program 

This final rule moves the HVBP 

provision from 32 CFR 

199.14(a)(1)(iii)(E)(6) to 32 CFR 


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5Most costs associated with this final rule are 

technically considered to be transfers, i.e., an 

income transfer between taxpayers and program 

beneficiaries. The only true ‘‘costs’’ of this rule are 

administrative costs, and all other costs should be 

considered to be transfer payments. 

199.14(a)(1)(iv)(B) to account for the 

changes to the NTAP provisions; there 

are no changes to the content of the 

HVBP provision. 

E. Telehealth Cost-Share/Copayment 

Waiver 

This final rule finalizes the costshare/copayment waiver provision as 

written in the IFR, except that it now 

terminates on the effective date of this 

rule, or the date of termination of the 

President’s national emergency for 

COVID–19, whichever is earlier. 

V. Regulatory Analysis 

A. Regulatory Planning and Review 

a. Executive Orders 

Executive Order 12866, ‘‘Regulatory 

Planning and Review’’ and Executive 

Order 13563, ‘‘Improving Regulation 

and Regulatory Review’’ 

Executive Orders 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, distribute impacts, and equity). 

Executive Order 13563 emphasizes the 

importance of quantifying both costs 

and benefits, of reducing costs, of 

harmonizing rules, and of promoting 

flexibility. Accordingly, the rule has 

been reviewed by the Office of 

Management and Budget (OMB) under 

the requirements of these Executive 

Orders. This rule has been designated a 

significant regulatory action, although, 

not determined to be economically 

significant, under section 3(f) of 

Executive Order 12866. 

b. Summary 

The modifications to paragraph 

199.4(g)(52) in this FR will revise the 

regulatory exclusion prohibiting 

coverage of telephone services and 

thereby allow permanent coverage of 

medical necessary and appropriate 

telephonic office visits for all TRICARE 

beneficiaries in all geographic locations. 

The modification to paragraph 

199.6(b)(4)(i) in this FR will allow any 

entity that temporarily enrolled with 

Medicare as a hospital through the 

Hospitals Without Walls initiative to be 

deemed to meet the requirements for 

acute care hospitals established under 

TRICARE for the duration of the 

COVID–19 pandemic. This will allow 

more entities to provide inpatient and 

outpatient hospital services, increasing 

access to medically necessary care for 

beneficiaries. 

The modifications to paragraph 

199.14(a)(1)(iv)(A) (previously 

199.14(a)(1)(iii)(E)(5) in the IFR and redesignated in this final rule) will: (1) 

Adopt the Medicare NTAP methodology 

and future NTAP modifications 

published by CMS, (2) create a pediatric 

NTAP reimbursement methodology 

based on 100 percent of the costs in 

excess of the MS–DRG, and (3) provide 

a mechanism to reimburse high-cost 

treatments that do not have a Medicare 

NTAP designation (due to beneficiary 

population differences). 

The modifications to paragraph 

199.17(l)(3) in this rule will provide for 

an earlier termination of the temporary 

waiver of cost-sharing and copayments 

for telehealth. 

c. Affected Population 

The modifications in this rule impact 

all TRICARE beneficiaries, TRICAREauthorized providers, the TRICARE 

program staff and contractors. 

Beneficiaries will be impacted by the 

permanent addition of telephonic office 

visits, the elimination of the telehealth 

cost-share/copayment waivers, 

increased access to new technologies 

afforded by the pediatric NTAPs 

reimbursement methodology, and 

increased access to acute care in 

temporary hospitals. TRICAREauthorized providers will be minimally 

impacted in that telephonic office visit 

will give them a new means to provide 

care and treatment to beneficiaries and 

generate revenue. TRICARE-authorized 

providers who administer Medicare 

approved NTAPs to pediatric patients 

will be reimbursed at a higher rate. 

Acute care facilities that qualify under 

Medicare’s Hospitals Without Walls 

initiative will benefit by automatically 

qualifying as a TRICARE-authorized 

provider for the duration of the 

pandemic. TRICARE program staff and 

contractors who administer the 

TRICARE benefit will be minimally 

impacted as this change will require 

them to update their systems to 

accommodate the change. 

d. Costs 5

The new incremental costs associated 

with this final rule are $20.88M through 

FY24, not including savings resulting 

from early termination of the telehealth 

cost-share/copayment waiver 

(approximately $4.8M savings per 

month). For context, this section also 

provides updated cost estimates for 

temporary benefit and reimbursement 

changes implemented in prior IFRs that 

are finalized in this FR ($278.0M 

through September 30, 2022), including 

the telehealth cost-share/copayment 

waiver being terminated by the FR 

(estimated cost $149.7M through 

September 30, 2022), and updated cost 

estimates associated with permanent 

reimbursement changes implemented in 

prior IFRs that are finalized in this FR 

($13.0M through FY24). Administrative 

costs to implement all provisions are 

$0.67M in one-time costs for both 

previously implemented provisions and 

modifications in this final rule. 

This estimate assumes the President’s 

national emergency for COVID–19 

would expire by September 2022. The 

number and severity of COVID–19 cases 

for TRICARE patients, along with the 

length of the President’s declared 

national emergency for COVID–19 and 

the associated HHS PHE would impact 

the estimates provided in this section. 

1. New Incremental Costs 

The incremental health care impact of 

new permanent benefit and 

reimbursement changes implemented in 

the final rule is $20.88M through FY24, 

and includes coverage of telephonic 

office visits, expanded coverage of 

temporary hospitals, the reimbursement 

methodology for pediatric NTAP cases, 

and the addition of TRICARE NTAPs. 

These amounts are the only new costs 

associated with the FR (i.e., costs for 

benefits and reimbursement changes 

that have not already been 

implemented). 

TABLE 1—NEW COSTS DUE TO MODIFICATIONS IN THE FINAL RULE

Provision Through FY2024 

Paragraph 199.4(g)(52)—Permanent Coverage of Telephonic Office Visits .................................................................................. $19.6M 

Paragraph 199.6(b)(4)(i)—Expanded Coverage for Temporary Hospitals ..................................................................................... 0M 

Paragraph 199.14(a)(1)(iv)(A)(2)—Methodology for Pediatric NTAPs Cases ................................................................................ 0.04M 


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TABLE 1—NEW COSTS DUE TO MODIFICATIONS IN THE FINAL RULE—Continued 

Provision Through FY2024 

Paragraph 199.14(a)(1)(iv)(A)(3)—Addition of TRICARE NTAPs ................................................................................................... 1.2M 

Total .......................................................................................................................................................................................... 20.88M 

Telephonic Office Visits. Government 

expenditures for TRICARE first-pay and 

second pay claims for identifiable 

telephonic office visits amounted to 

approximately $7.6 million in Fiscal 

Year (FY) 2020 and $15.4 million in 

FY21. Also, the average government cost 

per service for telephonic office visits 

was $56, which is 19 percent less than 

the overall telehealth average of $81. 

This estimate assumes telephonic office 

visits will decrease after the pandemic, 

as beneficiaries become more 

comfortable or even prefer in-person 

visits. Additionally, the elimination of 

the telehealth cost-share/copayment 

waiver may shift some visits that could 

have been performed virtually to inperson as there will no longer be a 

financial incentive to obtain services 

virtually. After the drop in visits 

following the pandemic, we assume a 

modest (5 percent) increase in cost for 

telephonic office visits each subsequent 

FY. Lastly, as this provision was 

originally set to expire upon the 

expiration of the national emergency, 

and this estimate assumes that the 

national emergency declaration will 

terminate September 30, 2022, the 

incremental costs of this provision 

include only the costs in FY23 and 

FY24. 

Expanded Coverage of Temporary 

Hospitals. This estimate assumes that 

care received at facilities that register 

with Medicare as hospitals would have 

been provided in other TRICAREauthorized hospitals but for the 

regulation change. We do not anticipate 

any induced demand for hospital care 

due to the authorization of new 

facilities. As such, there are no 

incremental costs associated with 

expanding coverage of temporary 

hospitals. 

NTAP Pediatric Reimbursement 

Methodology. An analysis of claims data 

for FY20 and FY21 found 23 pediatric 

cases which would have qualified under 

this methodology. This estimate is based 

on an average of what would have been 

paid for those cases, along with 

calculations for increases in health care 

costs each year. This estimate includes 

only the difference between the 

standard NTAP rate (65 percent of the 

cost of treatment) and the NTAP 

Pediatric reimbursement rate (100 

percent). This estimate is highly 

uncertain as the number of pediatric 

patients receiving an NTAP each year 

will vary (we assumed 15 cases or fewer 

per year), the costs of those NTAPs are 

unknown, and because the number of 

NTAPs approved by Medicare increases 

each year. 

TRICARE NTAP Approval Process 

and Reimbursement Methodology. The 

costs of this provision were estimated 

by identifying one drug without a 

Medicare NTAP due to their use by the 

64 and younger population, calculating 

the treatment costs for that drug, 

applying the TRICARE NTAP 

adjustment methodology, and 

identifying how many TRICARE 

beneficiaries were treated with that drug 

each year. This estimate is highly 

uncertain and is dependent on the 

number of TRICARE NTAPs approved 

each year by the Director, DHA, the cost 

of each of those technologies, and the 

number of TRICARE beneficiaries 

receiving each technology. 

2. Costs Associated With PreviouslyImplemented Temporary Regulatory 

Provisions 

Provisions under this portion of the 

estimate have already been 

implemented; cost estimates provided 

here are updates from estimates 

published in the associated IFR under 

which they were implemented. These 

amounts are estimated through the end 

of September 2022, when we assume the 

President’s national emergency and the 

HHS PHE will end. An earlier or later 

termination of the national emergency 

or HHS PHE will impact the estimates 

for this portion of the final rule. 

TABLE 2—COSTS DUE TO TEMPORARY PROVISIONS IMPLEMENTED IN PRIOR IFRS

Provision 

Through 

September 30, 

2022 

(million) 

Implementation 

date Planned expiration 

Paragraph 199.4(b)(3)(xiv)—SNF Three-Day Prior Stay 

Waiver.

$1.9 March 1, 2020 ............. Termination of President’s national 

emergency for COVID–19. 

Paragraph 199.4(g)(52)—Temporary Waiver of the Exclusion on Audio-only Telehealth.32.1 May 12, 2020 ............... Termination of President’s national 

emergency for COVID–19. 

Paragraph 199.6(b)(4)(i)—Temporary Hospitals and Freestanding ASCs Registering as Hospitals (as implemented 

in the IFR).

0 September 3, 2020 ...... Expiration of Medicare’s Hospitals 

Without Walls Initiative. 

Paragraph 199.6(c)(2) Waiver of provider licensing requirements for interstate and international practice.0 May 12, 2020 ............... Termination of President’s national 

emergency for COVID–19. 

Paragraph 199.14(a)(1)(iii)(E)(2)—20 Percent DRG Increase for COVID–19 Patients.76.5 January 27, 2020 ......... Termination HHS PHE. 

Paragraph 199.14(a)(9)—LTCH Site Neutral Payments ....... 17.8 January 27, 2020 ......... Termination HHS PHE. 

Paragraph 199.17(l)(3) Temporary Telehealth Cost-Share/ 

Copayment Waiver.

149.7 May 12, 2020 ............... Effective date of this final rule or termination of President’s national emergency for COVID–19, whichever is 

earlier. 

Total ................................................................................ 278.0 ......................................


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SNF Three-Day Prior Stay Waiver. 

The nominal cost associated with this 

provision is due to an assumption that, 

as a result of the waiver, SNF 

admissions will increase by three 

percent. This estimate is consistent with 

the estimate in the IFR. 

Temporary Waiver of the Exclusion of 

Audio-only Telehealth Visits. This 

estimate accounts for amounts related to 

the temporary waiver of the exclusion of 

audio-only telehealth visits from the 

first IFR, and is consistent with the 

factors discussed above for telephonic 

office visits. Included are amounts for 

FY20 through the end of FY22. These 

amounts reflect the costs had the 

ASD(HA) not made telephonic office 

visits permanent, but continued to let 

them expire at the end of the national 

emergency. If the President’s national 

emergency expires prior to the end of 

September 2022, these amounts will 

shift to the above permanent coverage of 

telephonic office visits. 

Temporary Hospitals and 

Freestanding ASCs. This zero cost 

estimate assumes that inpatient care 

provided in these alternate sites is care 

that would have been reimbursed under 

TRICARE but for a lack of acute care 

hospital facility space (i.e., we do not 

estimate that there would be any 

induced demand because of an increase 

in facilities). Additionally, it assumes 

that while reimbursement for outpatient 

procedures in freestanding ASCs would 

be higher than had those procedures 

been reimbursed under the traditional 

reimbursement rates for freestanding 

ASCs, the number of facilities choosing 

to register as hospitals is likely to be 

small enough to have a negligible 

impact on the budget. This estimate is 

consistent with the estimate in the IFR. 

Waiver of Interstate and International 

Licensing for Providers. The zero cost 

estimate assumes patients who are 

seeing providers under relaxed licensing 

requirements would have either seen a 

different provider or the same provider 

in a different setting (i.e., in-person as 

opposed to via telehealth) were it not for 

the waiver. This estimate is consistent 

with the estimate in the IFR. 

20 Percent DRG Increase. In the 

second IFR, we estimated that in an 

eighteen-month period, we would spend 

$37.1M to 51.4M on the 20 percent DRG 

increase. Actual spending through the 

end of FY21 was $41.5M, consistent 

with and on the low end of that 

estimate. This is primarily due to a 

lower average hospitalization cost for 

COVID–19 patients. This estimate 

extends actual costs through the end of 

September 30, 2022. Additional costs 

would be incurred beyond that date if 

the HHS PHE continues to be in effect. 

This estimate is consistent with the 

lower end of the estimate in the IFR. 

LTCH Site Neutral Payments. 

TRICARE is in the process of phasing in 

Medicare’s site-neutral payment rates. 

The phase-in has been halted as a result 

of the IFR; this estimate assumes 

TRICARE LTCH claims will be paid at 

the full LTCH PPS rate through the end 

of the HHS PHE. This estimate is 

consistent with the estimate in the IFR. 

Temporary Waiver of Cost-Shares and 

Copayments for Telehealth Services. 

The largest cost-driver for provisions in 

the previously published IFRs is the 

temporary waiver of cost-shares and 

copayments for telehealth, which is 

expected to cost $149.7M from 

implementation on May 12, 2020, 

through September 30, 2022. These 

costs are associated with the benefit as 

implemented in the previous IFR; 

because we are terminating the benefit 

early in the final rule, we expect to 

realize a cost savings of approximately 

$4.8M per month prior to the end of the 

President’s national emergency for 

COVID–19. The IFR only estimated a 9- 

month cost ($66M). The estimate in this 

IFR is largely consistent with the 

original estimate (approximately $7.3M 

per month), with an expected decrease 

in per-month spend further from the 

initial days of the pandemic and the 

stay-at-home orders that prompted this 

provision. 

3. Costs Associated With PreviouslyImplemented Permanent Regulatory 

Provisions 

The second COVID–19 IFR 

implemented two permanent 

provisions, NTAPs and HVBP. Both are 

finalized in this FR. The costs 

associated with the changes to NTAPs 

implemented in this FR are provided in 

the first section of the cost estimate. 

This section provides costs associated 

with NTAPs as implemented in the IFR, 

as well as costs associated with the 

HVBP Program. 

TABLE 3—COSTS DUE TO PERMANENT REIMBURSEMENT CHANGES IMPLEMENTED IN THE SECOND IFR 

Provision Through FY2024 

Paragraph 199.14(a)(1)(iv)(A)—NTAPs (not including the new pediatric reimbursement methodology provided in table 1) ....... $9.1M

Paragraph 199.14(a)(1)(iv)(B)—HVBP Program ............................................................................................................................. 3.9M 

Total .......................................................................................................................................................................................... 13.0M 

NTAPs. The IFR included the cost 

estimate through September 30, 2021 (a 

range of $5.7M to $11.6M), while this 

estimate provides an updated five-year 

costing using actual TRICARE claims 

data for utilization and reimbursement 

of NTAPS. In creating this estimate, we 

identified TRICARE claims containing a 

treatment with a Medicare NTAP in 

either FY2020 or FY2021 and identified 

the total estimated add-on payment 

amounts and the total estimated 

Medicare cases each year, as published 

in the Federal Register. In FY2020, 

there were 18 treatments with NTAPs 

and 78 TRICARE claims containing one 

of these treatments; in FY2021, there 

were 23 NTAP treatments and 145 

TRICARE claims with NTAPs, although 

the average NTAP maximum add-on 

amount decreased dramatically from 

FY2020 to FY2021 due to the average 

costs of the respective treatments. 

For FY2022, there are a total of 38 

Medicare treatments with NTAPs, 15 of 

which are new and represent a new 

traditional technology, Qualified 

Infectious Disease Products, or 

breakthrough technology. Consistent 

with the IFR, this estimate assumes 

TRICARE NTAPs would continue to be 

a similar percentage of inpatient 

spending to Medicare’s NTAP usage and 

that TRICARE would adopt all of 

Medicare’s NTAPs. This amount will 

vary depending on the number of new 

NTAPs adopted by Medicare each year, 

the extent to which Medicare-identified 

emerging technologies are covered 

under TRICARE’s statutory and 

regulatory requirements, and the extent 

to which TRICARE’s population utilizes 

these technologies. The costs for this 

provision may overestimate the 

incremental costs of this regulatory 

change, because many of these claims 

were being approved on a case-by-case 

basis by the Director, DHA, under 

waiver authority. In those cases, 

adopting NTAPs was likely to reflect a 

cost savings compared to the estimated 

costs, as waivers are typically paid at 

billed charges. 


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HVBP Program. The HVBP Program 

was implemented retroactive to January 

1, 2020; we anticipated that those 

hospitals qualifying for a positive 

adjustment for prior claims would do 

so, while those with negative 

adjustments or adjustments close to zero 

dollars would not. This would result in 

a cost in the first year, with claims in 

following years assumed to be budget 

neutral. This cost estimate is higher 

than the cost estimate published in the 

IFR ($2.5M), as there was more realworld data available to us on hospitals 

eligible for a positive adjustment for the 

initial implementation year. 

e. Benefits 

The addition of telephonic office 

visits as a permanent benefit will 

positively impact beneficiaries, 

particularly beneficiaries with limited 

access to broadband and other 

technology required for video telehealth 

visits, as this change will provide them 

better access to the existing telehealth 

benefit. This will result in avoided 

travel time and time spent in the 

provider’s waiting room (a benefit of 

approximately one hour per beneficiary 

per visit, at a monetized value to the 

beneficiary of $20.00 per hour). 

Providers will benefit from telephonic 

office visits by being able to better treat 

their patients, particularly patients who 

might not come into the office for 

regular office visits. The 

implementation of a distinct pediatric 

reimbursement methodology for 

pediatric NTAPs will positively impact 

beneficiaries and providers, as providers 

will be able to offer beneficiaries access 

to new treatments knowing full 

reimbursement will be provided. 

Expansion of coverage of temporary 

hospitals will benefit beneficiaries, who 

will have access to more acute care 

facilities during the pandemic. 

f. Alternatives 

DoD considered several alternatives to 

this rulemaking. The first option 

considered not publishing a final rule or 

publishing a final rule finalizing the IFR 

provisions listed without any changes. 

The temporary changes would have 

expired as planned without 

modification. Under this option: 

Telephonic office visits would not have 

become a permanent benefit, the 

coverage of hospitals under Medicare’s 

Hospitals Without Walls initiative 

benefit would have remained as 

published in the IFR (meaning facilities 

other than temporary hospitals and 

freestanding ambulatory surgical 

centers, such as freestanding emergency 

rooms, would have continued to be 

ineligible for temporary status as an 

acute care facility), a new pediatric 

reimbursement methodology for NTAPs 

would not have been implemented, and 

the temporary waiver of telehealth costshares and copayments would not have 

been potentially terminated early (at a 

potential cost of around $4.8M per 

month). Each of the modifications in 

this final rule addresses a concern or 

further develops the benefit based on 

information we have gathered since the 

IFRs were published. This option was 

determined to be insufficient to meet 

the needs of the TRICARE Program. 

DoD also considered publishing this 

final rule as is, but restricting telephonic 

office visits to only those TRICARE 

beneficiaries without access to 

conventional two-way audio-video 

equipment. We determined such a 

restriction would be impractical, 

unnecessary, and difficult and costly to 

administer. This option would have 

been inconsistent with modern practices 

in the health care field and would have 

placed an unnecessary burden on 

providers and beneficiaries. This option 

was not selected because its benefits did 

not outweigh the administrative burden 

on DHA, providers, and the potential 

cost of reduced access on beneficiaries. 

Public Law 96–354, ‘‘Regulatory 

Flexibility Act’’ (5 U.S.C. 601) 

The Assistant Secretary of Defense for 

Health Affairs certifies that this final 

rule is not subject to the Regulatory 

Flexibility Act (5 U.S.C. 601) because it 

would not, if promulgated, have a 

significant economic impact on a 

substantial number of small entities. 

Therefore, the Regulatory Flexibility 

Act, as amended, does not require us to 

prepare a regulatory flexibility analysis. 

DoD anticipates that permanent 

coverage of telephonic office visits will 

impact approximately 133,000 

individual professional providers. The 

provisions impacting inpatient facilities 

(the 20 percent DRG increase for 

COVID–19 patients, NTAPs, and the 

HVBP Program) will impact between 

3,400 and 3,800 hospitals. The number 

of LTCHs impacted by site neutral 

payments will be between 200 and 300. 

1,300 SNFs will be impacted by the 

three-day prior hospital stay waiver. We 

are unable to estimate the number of 

providers impacted by the interstate and 

international licensing waiver, but 

expect it will be fairly small as a 

percentage of total TRICARE providers. 

We are similarly unable to estimate how 

many facilities will be eligible as 

TRICARE-authorized acute care 

facilities by registering with Medicare’s 

Hospitals Without Walls initiative who 

would not have been otherwise eligible 

under TRICARE, but expect this to be a 

small number as well. 

The provisions of this IFR that are 

most likely to have an economic impact 

on hospitals and other health care 

providers are the reimbursement 

provisions adopted to meet the statutory 

requirement that TRICARE reimburse 

like Medicare. As its measure of 

significant economic impact on a 

substantial number of small entities, 

HHS uses an adverse change in revenue 

of more than 3 to 5 percent. While 

TRICARE is not required to follow this 

guidance in the issuance of our rules, 

we provide this metric for context, given 

that these temporary and permanent 

changes align with similar changes 

made by Medicare. 

Given that the temporary 

reimbursement provisions of this IFR 

increase reimbursement for hospitals 

and LTCHs, we find that these 

provisions would not have an adverse 

impact on revenue for hospitals and, 

therefore, would not have a significant 

impact on these hospitals and other 

providers meeting the definition of 

small businesses. We also find that 

NTAPs, given that they increase revenue 

under the DRG system, would not have 

an adverse impact on hospitals and 

providers. The HVBP program would 

not reduce revenue for a hospital being 

penalized under the system beyond the 

HHS threshold. Lastly, coverage of 

telephonic office visits and temporary 

hospitals are not expected to result in 

any adverse economic impact on 

hospitals or other health care providers. 

C. Congressional Review Act 

Pursuant to the Congressional Review 

Act (5 U.S.C. 801 et seq.), the Office of 

Information and Regulatory Affairs 

designated this rule as not a major rule, 

as defined by 5 U.S.C. 804(2). 

D. Sec. 202, Public Law 104–4, 

‘‘Unfunded Mandates Reform Act’’ 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

(2 U.S.C. 1532) requires agencies to 

assess anticipated costs and benefits 

before issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. This final rule 

will not mandate any requirements for 

State, local, or tribal governments, nor 

will it affect private sector costs. 

E. Public Law 96–511, ‘‘Paperwork 

Reduction Act’’ (44 U.S.C. Chapter 35) 

It has been determined that 32 CFR 

part 199 does not impose reporting or 

recordkeeping requirements under the 

Paperwork Reduction Act of 1995. 


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F. Executive Order 13132, ‘‘Federalism’’ 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on State and local 

governments, preempts State law, or 

otherwise has Federalism implications. 

This final rule will not have a 

substantial effect on State and local 

governments. 

G. Executive Order 13175, 

‘‘Consultation and Coordination With 

Indian Tribal Governments’’ 

It has been determined that this rule 

does not have a substantial effect on 

Indian tribal governments. This rule 

does not impose substantial direct 

compliance costs on one or more Indian 

tribes, preempt tribal law, or effect the 

distribution of power and 

responsibilities between the federal 

government and Indian tribes. 

List of Subjects in 32 CFR Part 199 

Administrative practice and 

procedure, Claims, Dental, Fraud, 

Health care, Health insurance, 

Individuals with disabilities, Mental 

health programs, and Military 

personnel. 

For the reasons stated in the 

preamble, the interim final rules 

amending 32 CFR part 199, which were 

published at 85 FR 27921–27927, May 

12, 2020, and 85 FR 54914–54924, 

September 3, 2020, are adopted as final 

with changes, except for the note to 

paragraph 199.4(g)(15)(i)(A), published 

at 85 FR 54923, September 3, 2020, 

which remains interim, and DoD further 

amends 32 CFR part 199 as follows: 

PART 199—CIVILIAN HEALTH AND 

MEDICAL PROGRAM OF THE 

UNIFORMED SERVICES (CHAMPUS) 

■ 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. Amend § 199.2 by adding 

definitions for ‘‘Biotelemetry,’’ 

‘‘Telephonic consultations’’ and 

‘‘Telephonic office visits’’ in 

alphabetical order to read as follows: 

§ 199.2 Definitions. 

* * * * * 

Biotelemetry. A diagnostic or 

monitoring procedure for the detection 

or measurement of human physiologic 

functions from a distance using a 

biotelemetry device to remotely monitor 

various vital signs of ambulatory 

patients. Biotelemetry may also be 

referred to as remote physiologic 

monitoring of physiologic parameters. 

See § 199.4. 

* * * * * 

Telephonic consultations: A covered 

consultation service conducted via 

telephone call between TRICAREauthorized providers, including a verbal 

and written report to the patient’s 

treating/requesting physician or other 

TRICARE-authorized provider. 

Telephonic office visits. A covered 

service provided via a telephone call 

between a beneficiary who is an 

established patient and a TRICAREauthorized provider. See § 199.4. 

* * * * * 

■ 3. Amend § 199.4 by revising 

paragraphs (c)(1)(iii), (g)(52) 

introductory text and (g)(52)(i) to read as 

follows: 

§ 199.4 Basic program benefits. 

* * * * * 

(c) * * * 

(1) * * * 

(iii) Telehealth services. Health care 

services covered by TRICARE and 

provided through the use of telehealth 

modalities including telephone services 

for: telephonic office visits; telephonic 

consultations; electronic transmission of 

data or biotelemetry or remote 

physiologic monitoring services and 

supplies, 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 will establish special 

procedures for payment for such 

services. Additionally, where 

appropriate, in order to incentive the 

use of telehealth services, the Director 

may modify the otherwise applicable 

beneficiary cost-sharing requirements in 

paragraph (f) of this section which 

otherwise apply. 

* * * * * 

(g)(52) Telephone services. Services or 

advice rendered by telephone are 

excluded. Exceptions: 

(i) Medically necessary and 

appropriate Telephonic office visits are 

covered as authorized in paragraph 

(c)(1)(iii) of this section. 

* * * * * 

■ 4. Effective June 1, 2022 amend 

§ 199.6 by revising the note to paragraph 

(b)(4)(i)(I) to read as follows: 

§ 199.6 TRICARE-authorized providers. 

* * * * * 

(b) * * * 

(4) * * * 

(i) * * * 

(I) * * * 

Note to paragraph (b)(4)(i)(I): For the 

duration of Medicare’s ‘‘Hospitals Without 

Walls’’ initiative for the coronavirus disease 

2019 (COVID–19) outbreak, any entity that 

temporarily enrolls with Medicare as a 

hospital may be temporarily exempt from 

certain institutional requirements for acute 

care hospitals under TRICARE. To the extent 

practicable, the Director, Defense Health 

Agency (DHA), will adopt by administrative 

policy any process requirement related to 

Medicare’s Hospitals Without Walls 

initiative. 

* * * * * 

■ 5. Amend § 199.14 by: 

■ a. Adding a sentence at the end of 

paragraph (a)(1)(iii)(E) introductory text; 

■ b. Adding paragraph (a)(1)(iv); 

■ c. Redesignating paragraph 

(a)(1)(iii)(E)(5) as paragraph (a)(1)(iv)(A) 

and revising newly redesignated 

paragraph (a)(1)(iv)(A); 

■ d. Redesignating paragraph 

(a)(1)(iii)(E)(6) as paragraph (a)(1)(iv)(B). 

The revision and addition read as 

follows: 

§ 199.14 Provider reimbursement 

methods. 

(a) * * * 

(1) * * * 

(iii) * * * 

(E) *** Additional adjustments to 

DRG amounts are included in paragraph 

(a)(1)(iv) of this section. 

* * * * * 

(iv) Special Programs and Incentive 

Payments. (A) Additional payment for 

new medical services and technologies. 

TRICARE will make New Technology 

Add On Payments (NTAPs) adjustments 

to DRGs as provided in paragraphs 

(a)(1)(iv)(A)(1) through (a)(1)(iv)(A)(11) 

of this section. The Director, Defense 

Health Agency (DHA), shall provide 

notice of the issuance of policies and 

guidelines adopting such adjustments 

together with any variations deemed 

necessary to address unique issues 

involving the beneficiary population or 

program administration. 

(1) Adoption of Medicare NTAPs. For 

TRICARE covered services and supplies, 

TRICARE will adopt Medicare NTAPs 

as implemented under 42 CFR 412.87 

under the same conditions as published 

by the Centers for Medicare & Medicaid 

Services, except for pediatric cases. 

(2) Pediatric cases. For pediatric 

NTAP DRGs, the TRICARE NTAP 

adjustment shall be modified to be set 

at 100 percent of the costs in excess of 

the Medicare Severity-Diagnosis Related 

Group (MS–DRG) payment. As used in 

this paragraph, pediatric is defined as 

services and supplies provided to 

individuals under the age of 18, or who 

are being treated in a children’s hospital 

or in a pediatric ward. 


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(3) TRICARE designated NTAP 

adjustments. For categories of TRICARE 

covered services and supplies for which 

Medicare has not established an NTAP 

adjustment for DRGs, the Director, DHA 

may designate a TRICARE NTAP 

adjustment through a process using 

criteria to identify and select such new 

technology services/supplies similar to 

that utilized by Medicare under 42 CFR 

412.87. The Director, DHA may then 

designate a TRICARE NTAP 

reimbursement adjustment through a 

process using a methodology similar to 

the Medicare methodology outlined in 

42 CFR 412.88. This discretionary 

authority to designate TRICARE NTAP 

adjustments shall apply to services and 

supplies typically provided to TRICARE 

beneficiaries age 64 or younger when 

Medicare has not established an NTAP 

adjustment for such services/supplies. 

As with other discretionary authority 

under this part, a decision to designate 

a TRICARE category of services/supplies 

for an NTAP adjustment to DRGs and 

the amount of such an adjustment are 

not subject to the appeal and hearing 

procedures of § 199.10. The Director, 

DHA, shall select which new 

technologies may be designated as 

TRICARE NTAPs and will publish this 

list based on the eligibility criteria and 

reimbursement methodology provided 

in paragraphs (a)(1)(iv)(A)(4) through 

(a)(1)(iv)(A)(11) of this section. 

(4) Eligibility requirements and 

reimbursement methodology for 

TRICARE designated NTAP 

adjustments. A new medical service or 

technology represents an advance that 

substantially improves, relative to 

technologies previously available, the 

diagnosis or treatment of TRICARE 

beneficiaries. The totality of the 

circumstances is considered when 

making a determination that a new 

medical service or technology 

represents an advance that substantially 

improves, relative to services or 

technologies previously available, the 

diagnosis or treatment of TRICARE 

beneficiaries. 

(5) Criteria for improvement. A 

determination that a new medical 

service or technology represents an 

advance that substantially improves, 

relative to services or technologies 

previously available, the diagnosis or 

treatment of TRICARE beneficiaries 

means one or more of the following: 

(i) The new medical service or 

technology offers a treatment option for 

a patient population unresponsive to, or 

ineligible for, currently available 

treatments. 

(ii) The new medical service or 

technology offers the ability to diagnose 

a medical condition in a patient 

population where that medical 

condition is currently undetectable, or 

offers the ability to diagnose a medical 

condition earlier in a patient population 

than allowed by currently available 

methods and there must also be 

evidence that use of the new medical 

service or technology to make a 

diagnosis affects the management of the 

patient. 

(iii) The use of the new medical 

service or technology significantly 

improves clinical outcomes relative to 

services or technologies previously 

available as demonstrated by one or 

more of the following seven outcomes: 

A reduction in at least one clinically 

significant adverse event, including a 

reduction in mortality or a clinically 

significant complication; A decreased 

rate of at least one subsequent 

diagnostic or therapeutic intervention; 

A decreased number of future 

hospitalizations or physician visits; A 

more rapid beneficial resolution of the 

disease process treatment including, but 

not limited to, a reduced length of stay 

or recovery time; An improvement in 

one or more activities of daily living; An 

improved quality of life; or A 

demonstrated greater medication 

adherence or compliance. 

(iv) The totality of the information 

otherwise demonstrates that the new 

medical service or technology 

substantially improves, relative to 

technologies previously available, the 

diagnosis or treatment of TRICARE 

beneficiaries. 

(6) Evidence. Evidence from scientific 

literature may be sufficient to establish 

that a new medical service or 

technology represents an advance that 

substantially improves, relative to 

services or technologies previously 

available, the diagnosis or treatment of 

TRICARE beneficiaries. 

(7) Prevalence. The medical condition 

diagnosed or treated by the new medical 

service or technology may have a low 

prevalence among TRICARE 

beneficiaries. 

(8) Subpopulation. The new medical 

service or technology may represent an 

advance that substantially improves, 

relative to services or technologies 

previously available, the diagnosis or 

treatment of a subpopulation of patients 

with the medical condition diagnosed or 

treated by the new medical service or 

technology. 

(9) Newness criteria. A medical 

service or technology may be considered 

new within 2 or 3 years after the point 

at which data begin to become available 

reflecting the inpatient hospital code 

assigned to the new service or 

technology (depending on when a new 

code is assigned and data on the new 

service or technology becomes available 

for DRG recalibration). After TRICARE 

has recalibrated the DRGs, based on 

available data, to reflect the costs of an 

otherwise new medical service or 

technology, the medical service or 

technology will no longer be considered 

‘‘new’’ under the criterion of this 

section. 

(10) Payment methodology. For 

discharges involving new medical 

services or technologies that meet the 

criteria specified in paragraphs 

(a)(1)(iv)(A)(4) through (a)(1)(iv)(A)(9) 

and that are approved as TRICARE 

NTAPs per paragraph (a)(1)(iv)(A)(11) of 

this section, TRICARE payment will be 

the lesser of: 

(i) The CMS designated percentage of 

the estimated costs of the new 

technology or medical service, as 

published in 42 CFR 412.88; or 

(ii) The CMS designated percentage of 

the difference between the full DRG 

payment and the hospital’s estimated 

cost for the case, as published in 42 CFR 

412.88. 

(11) Publication and timing. TRICARE 

may consider whether a new medical 

service or technology meets the 

eligibility criteria specified in 

paragraphs (a)(1)(iv)(A)(4) through 

(a)(1)(iv)(A)(9) of this section and 

announce the results on the NTAP 

website. In doing so, TRICARE only 

considers, for add-on payments for a 

particular fiscal year, an application for 

which the new medical device or 

product has received FDA marketing 

authorization by July 1 prior to the 

particular fiscal year; or the application 

is submitted under an alternative 

pathway to the FDA for which 

conditional NTAP approval for FDA 

marketing authorization is granted 

before July 1 of the fiscal year for which 

the applicant applied for new 

technology add-on payments. 

* * * * * 

■ 6. Amend § 199.17 by adding a second 

sentence at the end of paragraph 

(l)(3)(iii) to read as follows: 

§ 199.17 TRICARE program. 

* * * * * 

(l) * * * 

(3) * * * 

(iii) * * * This temporary waiver 

provision terminates July 1, 2022 or the 

date of termination of the President’s 

declared national emergency for 

COVID–19, whichever is earlier. 

* * * * * 


jspears on DSK121TN23PROD with RULES1
Federal Register / Vol. 87, No. 105 / Wednesday, June 1, 2022 / Rules and Regulations 33015 

1 87 FR 17957. 

Dated: May 12, 2022. 

Aaron T. Siegel, 

Alternate OSD Federal Register Liaison 

Officer, Department of Defense. 

[FR Doc. 2022–10545 Filed 5–31–22; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF HOMELAND 

SECURITY 

Coast Guard 

33 CFR Part 100 

[Docket Number USCG–2022–0171] 

RIN 1625–AA08 

Special Local Regulation; Tampa Bay, 

St. Petersburg, FL 

AGENCY: Coast Guard, DHS. 

ACTION: Final rule. 

SUMMARY: The Coast Guard is revising 

the existing special local regulations 

within the Seventh Coast Guard District 

Captain of the Port (COTP) St. 

Petersburg Zone by removing an event 

that no longer takes place, and by 

updating the location of an existing 

event. These changes are being made 

because one event sponsor halted the 

event for the forseeable future, and the 

other changed the event details. 

DATES: This final rule is effective July 1, 

2022. 

ADDRESSES: To view documents 

mentioned in this preamble as being 

available in the docket, go to https://

www.regulations.gov, type USCG–2022– 

0171 in the search box and click 

‘‘Search.’’ Next, in the Document Type 

column, select ‘‘Supporting & Related 

Material.’’ 

FOR FURTHER INFORMATION CONTACT: If 

you have questions on this rule, call or 

email Marine Science Technician 

Second Class Regina L. Cuevas, Sector 

St. Petersburg Prevention Department, 

Coast Guard; telephone (813) 228–2191, 

email Regina.L.Cuevas@uscg.mil. 

SUPPLEMENTARY INFORMATION: 

I. Table of Abbreviations 

CFR Code of Federal Regulations 

DHS Department of Homeland Security 

FR Federal Register 

NPRM Notice of proposed rulemaking 

§ Section 

U.S.C. United States Code 

II. Background Information and 

Regulatory History 

On March 29, 2022, the Coast Guard 

published a notice of proposed 

rulemaking (NPRM) in the Federal 

Register titled, ‘‘Special Local 

Regulations; Recurring Marine Events, 

Sector St. Petersburg.’’ 1 In the NPRM 

we stated the purpose of the rulemaking 

was to remove one existing recurring 

marine event that is no longer held and 

to change the location and date of an 

existing recurring marine event within 

the Seventh Coast Guard District 

Captain of the Port (COTP) St. 

Petersburg Zone that are listed in 33 

CFR 100.703, Table 1 to § 100.703. With 

the postponement of one event for the 

forseeable future, and the change in date 

and location of another, the changes 

proposed in the NPRM were necessary 

to ensure that Table 1 to § 100.703 

accurately reflected the events taking 

place within the COTP St. Petersburg 

Zone, and in the order the events occur. 

The NPRM invited comments on the 

proposed changes to Table 1 to 

§ 100.703. During the comment period 

that ended April 28, 2022, we received 

no comments. 

III. Legal Authority and Need for Rule 

The Coast Guard is issuing this rule 

under authority in 46 U.S.C. 70041. The 

COTP St. Petersburg has determined it 

necessary to revise the existing 

regulations in order to avoid confusion 

regarding the special local regulations 

(SLR) in the COTP St. Petersburg Zone. 

IV. Discussion of Comments, Changes, 

and the Rule 

As noted above, we received no 

comments on our NPRM published 

April 1, 2022. 

This rule makes the following changes 

in 33 CFR 100.703: 

1. Move the event listed in Table 1 to 

§ 100.703, Line No. 5, ‘‘Sarasota 

Powerboat Grand Prix/Powerboat P–1 

USA, LLC to Line No. 4. We are not 

making any other changes to this event. 

2. Move Table 1 to § 100.703, Line 

No. 4, to Line No. 5, and revise the 

event to reflect a name change, course 

location, and date and time for the 

event. 

3. Delete the event listed in Table 1 

to § 100.703, Line No. 6, ‘‘Battle of the 

Bridges/Sarasota Scullers Youth Rowing 

Program.’’ 

Marine events listed in Table 1 to 

§ 100.703 are listed as recurring over a 

particular time, during each month and 

each year. Exact dates are intentionally 

omitted since calendar dates for specific 

events change from year to year. Once 

dates for a marine event are known, the 

Coast Guard notifies the public it 

intends to enforce the special local 

regulation through various means 

including a notice of enforcement 

published in the Federal Register, Local 

Notice to Mariners, and Broadcast 

Notice to Mariners. 

V. Regulatory Analyses 

We developed this rule after 

considering numerous statutes and 

Executive orders related to rulemaking. 

Below we summarize our analyses 

based on a number of these statutes and 

Executive orders, and we discuss First 

Amendment rights of protestors. 

A. Regulatory Planning and Review 

Executive Orders 12866 and 13563 

direct agencies to assess the costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits. 

This rule has not been designated a 

‘‘significant regulatory action,’’ under 

Executive Order 12866. Accordingly, 

this rule has not been reviewed by the 

Office of Management and Budget 

(OMB). 

This regulatory action determination 

is based on the size, location, and 

duration of the special local regulations. 

These areas are limited in size and 

duration, and usually do not affect high 

vessel traffic areas. Moreover, the Coast 

Guard will provide advance notice of 

the regulated areas to the local maritime 

community via Notice of Enforcement 

published in the Federal Register, by 

Local Notice to Mariners, Broadcast to 

Mariners via VHF–FM marine channel 

16, and the rule will allow vessels to 

seek permission to enter the regulated 

area. 

B. Impact on Small Entities 

The Regulatory Flexibility Act of 

1980, 5 U.S.C. 601–612, as amended, 

requires Federal agencies to consider 

the potential impact of regulations on 

small entities during rulemaking. The 

term ‘‘small entities’’ comprises small 

businesses, not-for-profit organizations 

that are independently owned and 

operated and are not dominant in their 

fields, and governmental jurisdictions 

with populations of less than 50,000. 

The Coast Guard received 0 comments 

from the Small Business Administration 

on this rulemaking. The Coast Guard 

certifies under 5 U.S.C. 605(b) that this 

rule will not have a significant 

economic impact on a substantial 

number of small entities. 

While some owners or operators of 

vessels intending to transit the safety 

zone may be small entities, for the 

reasons stated in section V.A above, this 

rule will not have a significant 

economic impact on any vessel owner 

or operator. 

Under section 213(a) of the Small 

Business Regulatory Enforcement 


jspears on DSK121TN23PROD with RULES1