05-14844. TRICARE Formerly Known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year 2005 Puerto Rico Region Specific Mental Health Rates

AGENCY:

Office of the Secretary, DoD.

ACTION:

Notice of rate setting; establishment of region specific Puerto Rico Mental Health rates.

SUMMARY:

This notice provides for the establishment of a Puerto Rico region specific per diem rates for low volume providers; the establishment of region specific per diem rates for both full-day and half-day TRICARE Partial Hospitalization Programs under the TRICARE Mental Health Per Diem Payment System for fiscal year 2005.

EFFECTIVE DATE:

The fiscal year 2005 rates contained in this notice are effective for services occurring on or after September 1, 2005.

FOR FURTHER INFORMATION CONTACT:

Christine Gavlick, Office of Medical Benefits and Reimbursement Systems, TRICARE Management Activity, telephone [phone].

SUPPLEMENTARY INFORMATION:

The final rule published in the Federal Register on September 6, 1988, (53 FR 34285) set forth reimbursement methodologies that were effective for all inpatient hospital admissions in psychiatric hospitals and exempt psychiatric units occurring on or after January 1, 1989. This final rule uses regionally established per diems to pay hospitals that do not have enough CHAMPUS discharges upon which to base a valid hospital-specific rate. Regional rates incorporate adjustments for area wage differences, indirect medical educations costs and pass through payments for direct medical education costs. Mental Health partial hospitalization programs are also reimbursed according to regional per diems. The Mental Health regional per diems are applied utilizing the designated Federal Census regions. By 32 CFR 199.14(a)(2)(viii)(E), the commonwealth of Puerto Rico is subject to TRICARE's mental halth reimbursement methodologies. Since Puerto Rico is not incorporated in a Federal Census Region, this notice establishes a Puerto Rico region specific per diem as well as region specific rates for partial hospitalization programs, both full day and half-day programs. TRICARE additionally published in the Federal Register on July 1, 1993, (58 FR 35-400) final rules that set forth maximum per diem rates for all partial hospitalization admissions on or after September 29, 1993. Included in these final rules were provisions for updating reimbursement rates for each federal fiscal year. As stated in the final rules, each per diem shall be updated by the Medicare update factor for hospitals and units exempt from the Medicare Prospective Payment System. For fiscal year 2005, Medicare has recommended a rate of increase of 3.3 percent for hospitals and units excluded from the prospective payment system. TRICARE has incorporated this update factor for FY 2005 in the determinaion of the region specific Puerto Rico rates. Consistent with Medicare, the wage portion of the regional rate subject to the area wage adjustment is 71.56 percent for FY 2005.

The following reflects the Puerto Rico region specific rates:

Region Specific Rates for Psychiatric Hospitals and Units With Low Tricare Volume

United States region	Rate1
Puerto Rico	$434.00
1 Wage portion of the rate, subject to the area wage adjustment—71.56 percent.

Beneficiary Cost-Share: Beneficiary cost-share (other than dependents of active duty members) for care paid on the basis of a regional per diem rate is the lower of $169 per day or 25 percent of the hospital billed charges effective for services rendered on or after October 1, 2004.

Puerto Rico Region Specific Partial Hospitalization Rates For Full-Time Day and Half-Day Programs FY 2005

United States region	Full-day rate (6 hours or more)	(Half-day rate (3-5 hours)
Puerto Rico	$183	$138

The above rates are effective for services rendered on or after September 1, 2005.

Dated: July 22, 2005.

L.M. Bynum,

Alternate OSD Federal Register, Liaison Officer, Department of Defense.