03-8014. TRICARE Program; Inclusion of Anesthesiologist's Assistants as Authorized Providers; Coverage of Cardiac Rehabilitation in Freestanding Cardiac Rehabilitation Facilities

AGENCY:

Office of the Secretary, Department of Defense.

ACTION:

Proposed rule.

SUMMARY:

This proposed rule establishes a new category of provider as an authorized TRICARE provider, and it increases the settings where cardiac rehabilitation can be covered as a TRICARE benefit. It recognizes anesthesiologist's assistants as authorized providers under certain circumstances. It also authorizes cardiac rehabilitation services, which are already a covered TRICARE benefit when provided by hospitals, to be provided in freestanding cardiac rehabilitation facilities.

DATES:

Public comments must be received by June 2, 2003.

ADDRESSES:

Forward comments to: TRICARE Management Activity (TMA), Medical Benefits and Reimbursements Systems, 16401 East Centretech Parkway, Aurora, CO 80011-9043.

FOR FURTHER INFORMATION CONTACT:

Stephen E. Isaacson, Medical Benefits and Reimbursement Systems, TMA, [phone].

SUPPLEMENTARY INFORMATION:

A. Inclusion of Anesthesiologist's Assistants as Authorized Providers

At present only two types of anesthesia providers may provide services to TRICARE beneficiaries—anesthesiologists and certified registered nurse anesthetists (CRNAs). In some areas of the country, anesthesiologist's assistants, after completing the specified training, being accredited, and being licensed by the state also provide anesthesia services. The Centers for Medicare and Medicaid Services (CMS) already recognizes anesthesiologist's assistants as authorized providers (42 CFR 410.69).

We propose to recognize anesthesiologist's assistants as authorized providers under the same conditions applied by CMS. That is:

(1) They must work only under the direct supervision of an anesthesiologist;

(2) They must comply with all applicable requirements of state law and be licensed, where applicable, by the state in which they practice; and

(3) They must have completed the appropriate educational requirements. This includes graducation from a Master's level medical school-based anesthesiologist's assistant program that is accredited by the Committee on Allied Health Education and Accreditation and includes approximately two years of appropriate specialized basic science and clinical education in anesthesia. This program must build on a premedical undergraduate science background.

Recognition of anesthesiologist's assistants will not increase the costs of anesthesia to the Program. This is, payment for anesthesia services provided by an anesthesiologist and an anesthesiologist's assistant under the anesthesiologist's direct supervision will never exceed what would have been paid if the services were provided only by the anesthesiologist.

Since anesthesiologist's assistants may not practice independently, they also may not bill independently for their services. All claims for their services must be submitted by their employer, whether it is a hospital, a physician, or some other similar entity. Such claims must indicate that the services were provided by an anesthesiologist's assistant.

B. Coverage of Cardiac Rehabilitation in Freestanding Cardiac Rehabilitation Centers

On October 19, 1990, the Office of the Secretary of Defense published a final rule in the Federal Register (55 FR 42366) establishing cardiac rehabilitation as a TRICARE benefit when used in the treatment of certain cardiac events. The following rationale was provided for limiting cariac rehabilitation services to TRICARE authorized hospitals:

As a national program, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) strives for uniformity and equity in benefits to ensure beneficiary safety. Toward this end, CHAMPUS relies on the existing nationwide infrastructure for accreditation and professional regulatory oversight. With the large variety of freestanding cardiac rehabilitation clinics throughout the country, it is incumbent upon CHAMPUS to seek out national standards to provide a clear line of demarcation on CHAMPUS requirements. Currently, there is no organized national accreditation agency for accrediting freestanding cardiac rehabilitation clinics, nor does there appear to be standardized state licensure, or certification procedures in existence which address standards for freestanding cardiac rehabilitation clinics. Since OCHAMPUS does not have the resources to conduct its own accreditation activities, the requirement for national accreditation is at least a minimum assurance that a facility or specialized treatment facility meets some standards of quality.

However, since incorporation of this restriction (i.e., cardiac rehabilitation services being restricted to hospital based facilities/programs) there has been an evolution of alternative freestanding delivery programs whose efficacy and safety have been recognized by the medical community and other third-party payers. Freestanding cardiac rehabilitation programs are examples of this evolutionary trend. With the establishment of standardized licensure and accreditation procedures, many of these freestanding programs have been recognized and approved for participation under TRICARE.

Currently TRICARE provides coverage/payment for inpatient or outpatient services and/or supplies provided in connection with a cardiac rehabilitation program when provided by a TRICARE authorized hospital. Outpatient cardiac rehabilitation treatment programs affiliated with TRICARE authorized hospitals are reimbursed an all-inclusive allowable charge per session that includes all related professional services provided during a rehabilitation session. Inpatient programs are paid based upon the reimbursement system in place for the hospital where the services are provided. Separate cost-sharing is allowed for initial evaluation and testing and related professional services.

Since hospital based cardiac rehabilitation is already an established benefit under TRICARE, its benefit and reimbursement structure can be applied to freestanding cardiac rehabilitation programs. Claims for freestanding outpatient cardiac rehabilitation treatment will be reimbursed in the same manner as outpatient cardiac rehabilitation treatment programs affiliated with TRICARE authorized hospitals. That is, they will be reimbursed based upon an all inclusive allowable charge per session that includes all related professional services provided during the rehabilitation session.

Regulatory Procedures

Executive Order (EO) 12866 requires that a comprehensive regulatory impact analysis be performed on any economically significant regulatory action, defined as one which would result in an annual effect of $100 million or more on the national economy or which would have other substantial impacts.

The Regulatory Flexibility Act requires that each Federal agency prepare, and make available for public comment, a regulatory flexibility analysis when the agency issues a regulation which would have a significant impact on a substantial number of small entities. This rule is not economically significant and will not significantly affect a substantial number of small entities.

“This rule has been designated as significant and has been reviewed by the Office Management and Budget as required under the provisions of E.O. 12866.”

Paperwork Reduction Act

This rule imposes no burden as defined by the Paperwork Reduction Act of 1995.

List of Subjects in 32 CFR Part 199

• Claims
• Handicapped
• Health insurance, and Military personnel

Accordingly, 32 CFR part 199 is proposes to be amended as follows:

PART 199—[AMENDED]

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

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

2. Section 199.4 is proposed to be amended by revising paragraph (e)(18)(iv) as follows:

§ 199.4

Basic program benefits.

(e) * * *

(18) * * *

(iv) Providers. A provider of cardiac rehabilitation services must be a TRICARE authorized hospital (see Section 199.6 paragraph (b)(4)(i)) or a freestanding cardiac rehabilitation facility that meets the requirements of Section 199.6 paragraph (f). All cardiac rehabilitation services must be ordered by a physician.

* * * * *

3. Section 199.6 is proposed to be amended by redesignating paragraph (c)(3)(iii)(I) as paragraph (c)(3)(iii)(J) and adding a new paragraph (c)(3)(iii)(I) as follows:

§ 199.6

Authorized Providers.

(c) * * *

(3) * * *

(iii) * * *

(I) Anesthesiologist's Assistant. An anesthesiologist's assistant may provide covered anesthesia services, if the anesthesiologist's assistant:

(1) Works under the direct supervision of an anesthesiologist, and the anesthesiologist bills for the services;

(2) Is in compliance with all applicable requirements of state law, including any licensure requirements the state imposes on nonphysician anesthetists; and

(3) Is a graduate of a Master's level medical school-based anesthesiologist's assistant educational program that:

(i) Is accredited by the Committee on Allied Health Education and Accreditation; and

(ii) Includes approximately two years of specialized basic science and clinical education in anesthesia at a level that builds on a premedical undergraduate science background.

* * * * *

Dated: March 28, 2003.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.