2024-07705. Modification To Childbirth Support Services Covered Under the TRICARE Childbirth and Breastfeeding Support Demonstration

AGENCY:

Department of Defense.

ACTION:

Notice of demonstration modifications.

SUMMARY:

The Director of the Defense Health Agency (DHA) is notifying the public of adjustments to the reimbursement and provider qualifications for childbirth support services under the Childbirth and Breastfeeding Support Demonstration (CBSD).

DATES:

The Phase 2 changes will be fully implemented by January 1, 2025, with a transition period starting June 10, 2024. The two modifications to the certified labor doulas (CLD) certification requirement are effective April 11, 2024.

FOR FURTHER INFORMATION CONTACT:

Erica Ferron, 303-676-3626, [e-mail].

SUPPLEMENTARY INFORMATION:

A. Background

Section 746 of the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year (FY) 2021 (NDAA FY 2021) directed the Secretary of Defense to establish a five-year demonstration project under TRICARE to evaluate the cost, quality of care, and impact on maternal and fetal outcomes of covering the services of doulas and lactation consultants or counselors not otherwise TRICARE-authorized, and to determine whether it would be appropriate to implement permanent coverage. Section 746 also required the Secretary to conduct a maternity survey.

This demonstration was implemented as the CBSD, with details announced in a Federal Register notice (FRN) published by the Assistant Secretary of Defense for Health Affairs (ASD(HA)) on October 29, 2021 (86 FR 60006). The FRN prescribed the qualifications for the three extra medical maternal health providers (CLDs, certified lactation consultants, and certified lactation counselors), the number and type of services to be reimbursed, and the reimbursement rates for the services. The demonstration began on January 1, 2022, in the United States under the two Managed Care Support Contractors (MCSCs), with overseas expansion planned for January 1, 2025. The ASD(HA) later delegated to the Director, DHA, the authority to modify requirements established in that FRN. The Director, DHA, announces such modifications in this FRN.

B. Childbirth Support Services Phase 2 and Transition Period

This FRN announces a second iteration of certain components of childbirth support services under the CBSD. This new phase will include a new reimbursement methodology, new doula-specific codes, increased flexibility for antepartum and postpartum visits, and a new requirement for CLDs to be participating providers. Phase 2 will be fully implemented by January 1, 2025, with a transition period during which services will be reimbursed under the existing (Phase 1) requirements. Each component of the new phase and the transition are discussed in full in this notice.

1. Establishment of a Reimbursement Methodology for Childbirth Support Services

The first component of the new phase of childbirth support services announced in this FRN is the establishment of a reimbursement methodology that will replace the current reimbursement amounts. The methodology is as follows:

(1) TRICARE will identify state Medicaid rates for states reimbursing for doula services.

(2) TRICARE will identify an appropriate Medicaid-to-Medicare Fee Index for obstetrical services for each state reimbursing for Medicaid services.

(3) The state Medicaid rates will be multiplied by the Fee Index.

(4) A weighted average will be created based on the number of TRICARE reimbursed deliveries that occur in each state with a Medicaid program that reimburses for doula services. This weighted average will be the national reimbursement rate for CLDs under the CBSD.

Using this methodology, the DHA anticipates that the calendar year (CY) 2024 rate for antepartum and postpartum visits (60 minutes) will be approximately $107.00 per visit and $957.00 for continuous labor support. This national rate will then be adjusted by locality using the Medicare Geographic Adjustment Factor. The national rate will be recalculated annually based on Medicaid program rates and current Medicaid-to-Medicare fee indexes along with the CHAMPUS Maximum Allowable Charge (CMAC) update published each year by March 1 (available at https://www.health.mil/​Military-Health-Topics/​Access-Cost-Quality-and-Safety/​TRICARE-Health-Plan/​Rates-and-Reimbursement). The new rates for CY 2024 will be published by the start of the transition for Phase 2. For CY 2024, the national rate for all covered childbirth support services will be about $550.00 more per TRICARE beneficiary than under the current rates. Because this methodology is based on Medicaid rates, it may go up or down each year as new state Medicaid agencies bring doula services online or adjust their reimbursement amounts. The TRICARE rate is designed to be higher than the state Medicaid rates at the national level, though it may be lower in individual states with higher Medicaid reimbursement rates.

2. New Billing Codes

As part of Phase 2, the DHA intends to implement new, doula service-specific codes to replace the current general maternity and home health codes. The new codes, which will be announced in the TRICARE manuals, will be tied to the new reimbursement rates while the existing, Phase 1 codes, will remain linked to the Phase 1 rates until the transition is completed.

3. Increased Flexibility for Antepartum and Postpartum Visits

The third component of the Phase 2 changes is a modification to how antepartum and postpartum support visits will be billed and paid. Currently these visits are untimed, with six visits authorized. This FRN announces that the DHA is switching to timed visits, with visits billed per 15-minute increment, with each beneficiary allowed up to 24 15-minute increments (each 15-minute increment would be reimbursable at about $26.75 in CY 2024). This will allow the beneficiary and their doula to select the most appropriate use of their visit allowance. For example, a beneficiary might choose a 90-minute initial antepartum visit (six increments), a two-and-a-half-hour initial postpartum visit (ten increments), and two 60-minute postpartum visits (eight increments). The new billing codes, discussed above, will be billed per 15-minute increment for visits. The DHA will publish coding guidance for doulas in the implementing instructions in the TRICARE manuals found at manuals.health.mil.

4. Requirement for CLDs To Be Participating Providers

The final adjustment that DHA is making as part of Phase 2 is adding a requirement that all CLDs under the CBSD must be a participating provider under TRICARE. Under this requirement, CLDs will be required to file claims and to accept the TRICARE reimbursement rate as payment in full, as well as meet all other requirements as a TRICARE-participating provider.

5. Transition Period From Phase 1 to Phase 2

The changes above will be fully effective on January 1, 2025, with a transition period from June 10, 2024 until January 1, 2025. During the transition period, CLDs can opt to perform services under Phase 1 or Phase 2. CLDs who are non-participating will be eligible to continue to render services under the CBSD through the end of the transition period using Phase 1 common procedural terminology codes and billing rules, and to receive Phase 1 reimbursement rates. Similarly, during the transition, beneficiaries will be able to file for reimbursement for services received from non-participating providers under Phase 1 requirements. Non-participating providers will be ineligible for reimbursement of services rendered on or after January 1, 2025, even if the non-participating provider has entered into an agreement with a beneficiary, and/or their doula benefit has not yet been exhausted. For example, if a non-participating provider renders antepartum visits in late December 2024, those may be reimbursed; however, if the beneficiary experiences labor on January 2, 2025, the continuous labor support charges will be denied unless the provider becomes a participating provider.

CLDs who are already participating providers (network or non-network) when the transition period begins or who execute a participation agreement before the end of the transition period will be eligible to begin using the new codes and to receive the new reimbursement rates. This eligibility will begin either on the start of the transition period or the date the participation agreement is signed, whichever is later.

Any antepartum or postpartum visits performed under Phase 1 requirements will count as 4 15-minute increments against the beneficiary's 24 visit allowance under Phase 2.

Example: A beneficiary received an initial antepartum visit prior to the start of the transition period, followed by another antepartum visit after the transition period began from a non-participating CLD. The beneficiary's CLD then signs a participation agreement, after which time the beneficiary gives birth. The initial two antepartum visits would be reimbursed under Phase 1 rules and would count as 8 15-minute increments against the beneficiary's 24 increment allowance (4 increments for each visit). The labor support would be reimbursed under Phase 2 rules. After delivery, the beneficiary would have 16 15-minute increments remaining to use in the postpartum period, in any configuration (e.g., one 4-hour visit, two 2-hour visits, four 1-hour visits).

The DHA notes that it will take several months for the TRICARE's contractors to implement the new billing codes, during which time claims processing under Phase 2 may be delayed.

C. Adjustments to CLD Certification Requirements

Separate from the Phase 2 changes discussed above, the Director is also announcing that one new certification body will be accepted for CLDs under the CBSD: the National Black Doula Association (NBDA). The DHA made this decision based on analysis of publicly available information for the approximately 47 certification and training bodies recognized by the state Medicaid programs (not already approved under the CBSD) using the criteria discussed in the FRN that published on October 29, 2021. The criteria we discussed in that FRN required that the bodies selected for inclusion had to have a time-limited certification and be well-established with a wide-ranging footprint ( i.e., national or international); included classroom training and workshops in labor physiology and other childbirth topics; required doulas to have completed at least two deliveries prior to certification; required evaluations from health care professionals for services provided during labor support or a comprehensive examination; and had an established scope of practice, code of ethics, code of conduct, or similar by which the doula is required to agree to abide.

The Director, DHA, also announces in this FRN that the certification requirement for doulas practicing in a state with an active state-wide doula Medicaid benefit will be waived when that doula is actively enrolled in that state Medicaid program and provides evidence of such an enrollment (the doula must be practicing in the state in which they hold a Medicaid enrollment). To be eligible, the Medicaid program must be a state-wide program with requirements set by the state Medicaid agency. Medicaid programs of limited duration (pilot/demonstration programs) and programs where a contractor (for example, a managed care organization or accountable care organization) sets the provider requirements do not meet these criteria. All other TRICARE CLD requirements will continue to be in effect (age, education, experience, cardiopulmonary resuscitation certification, and possession of a national provider identification number). The various statewide programs have different and varying requirements, and so this demonstration is testing the impact of those programs on provider quality and availability. This may impact the DHA's provider requirements if a permanent benefit is established. The TRICARE program is a uniform benefit, but because this is a demonstration, we are allowing some variability between the states so that we can test the impact of these differences on provider quality, availability, and other outcomes.

E. Cost

The modifications in this FRN are not anticipated to increase the overall cost of the CBSD above the $51.16M for health care and administrative costs that were announced in the 2021 FRN.

Dated: April 8, 2024.

Aaron T. Siegel,

Alternate OSD Federal Register Liaison Officer, Department of Defense.