Notice2023-16477
Modifications to the Overseas Implementation of the TRICARE Childbirth and Breastfeeding Support Demonstration
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Published
August 2, 2023
Issuing agencies
Defense Department
Abstract
The Assistant Secretary of Defense for Health Affairs (ASD(HA)) is notifying the public that the TRICARE Childbirth and Breastfeeding Support Demonstration (CBSD) will be modified for implementation to the TRICARE Overseas Program (TOP). Additionally, the ASD(HA) is notifying the public that due to current financial constraints, all or part of the evaluation of the CBSD may be conducted by internal DoD analytics staff.
Full Text
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<title>Federal Register, Volume 88 Issue 147 (Wednesday, August 2, 2023)</title>
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[Federal Register Volume 88, Number 147 (Wednesday, August 2, 2023)]
[Notices]
[Pages 50850-50851]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-16477]
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DEPARTMENT OF DEFENSE
Office of the Secretary
Modifications to the Overseas Implementation of the TRICARE
Childbirth and Breastfeeding Support Demonstration
AGENCY: Department of Defense (DoD).
ACTION: Notice of demonstration modifications.
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SUMMARY: The Assistant Secretary of Defense for Health Affairs
(ASD(HA)) is notifying the public that the TRICARE Childbirth and
Breastfeeding Support Demonstration (CBSD) will be modified for
implementation to the TRICARE Overseas Program (TOP). Additionally, the
ASD(HA) is notifying the public that due to current financial
constraints, all or part of the evaluation of the CBSD may be conducted
by internal DoD analytics staff.
DATES: The CBSD will expand overseas with the modifications discussed
in this notice on January 1, 2025.
FOR FURTHER INFORMATION CONTACT: Erica Ferron, 303-676-3626,
<a href="/cdn-cgi/l/email-protection#e782958e8486c984c9818295958889c9848e91a78f82868b938fc98a8e8b"><span class="__cf_email__" data-cfemail="e287908b8183cc81cc848790908d8ccc818b94a28a87838e968acc8f8b8e">[email protected]</span></a>.
SUPPLEMENTARY INFORMATION:
A. Background
Section 746 of the William M. (Mac) Thornberry National Defense
Authorization Act for Fiscal Year 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. On
October 29, 2021, the ASD(HA) published a Federal Register Notice (FRN)
announcing the CBSD (86 Federal Register (FR) 60006), which began
nationwide in the United States (U.S.) on January 1, 2022, and will
expand to include overseas beneficiaries and locations on January 1,
2025.
The FRN announced that the CBSD was designed to evaluate the
following hypotheses:
(1) Access to doulas will have a positive and measurable impact on
maternal and fetal outcomes.
(2) Access to lactation consultants and lactation counselors will
have the same or better impact on maternal and fetal outcomes when
compared to the same services provided by other TRICARE-authorized
providers.
(3) The cost of providing access to such providers is justified by
the impact of the providers on maternal and fetal outcomes.
(4) It is feasible to administer the new provider classes and the
services they provide.
The FRN specified that coverage would be provided under private
sector care and excluded care provided in direct care within Military
Medical Treatment Facilities (MTFs). To participate, beneficiaries were
required to be enrolled in Prime or Select with one of the managed care
support contractors (MCSCs). TRICARE for Life, the Uniformed Services
Family Health Plan, the Continued Health Care Benefit Program
beneficiaries were excluded from participation. Beginning January 1,
2025, beneficiaries in Prime (including Prime Remote) and Select
enrolled to the TOP contractor will be eligible to participate. The
demonstration created a new benefit category (childbirth support
services) and added three new extra-medical maternity care provider
classes (Certified Labor Doulas (CLDs), Certified Lactation
Consultants, and Certified Lactation Counselors). It also created
qualification criteria for the new provider classes, established
benefit limitations, added group breastfeeding counseling sessions to
the existing individual breastfeeding counseling benefit, and
established reimbursement methodologies.
B. Maternity Care Under the TOP
Each year, approximately 60,000 beneficiaries give birth under the
MCSCs in private sector care facilities in the United States. The
number of beneficiaries who give birth overseas under the TOP program
is comparatively very small. Based on claims data for calendar year
(CY) 2022, TRICARE beneficiaries enrolled with the TOP contractor gave
birth 1,093 times in private sector care facilities in 41 countries.
Over half of those deliveries occurred in Germany, with the next most
frequent locations for deliveries being Italy, South Korea, the U.S.
(TOP beneficiaries electing to deliver in one of the 50 states or
District of Columbia), Puerto Rico, and Japan. These six locations
accounted for 87 percent of deliveries under TOP. Of the 34 remaining
countries, 13 had only one delivery, and another nine only had two
deliveries in 2022. In 2021, the top six locations were the same, but
there were 14 countries that had a delivery in 2021 that did not have
one in 2022 while there were births in 15 countries in 2022 for which a
birth was not recorded in 2021. In other words, there is a small group
of countries within which the DoD can reliably expect most TOP
deliveries to occur and a larger number of countries in which a small
number of deliveries may occur. Expansion of the demonstration overseas
accounts for this variability as well as the overall smaller number of
deliveries overseas.
C. CBSD Modifications for Implementation Overseas
This FRN notifies the public that the DoD intends to modify the
CBSD for overseas implementation by way of guidance to be published to
the TRICARE manuals (found at <a href="http://manuals.health.mil">manuals.health.mil</a>). These changes are
expected to impact some or all of the requirements published in the
initial CBSD FRN and are intended to facilitate the DoD's ability to
measure the CBSD hypotheses. The DoD's focus for overseas
implementation will be testing
[[Page 50851]]
the fourth hypothesis, that is, is it feasible to administer the new
provider classes and the services they provide in overseas locations?
The other three hypotheses will be measured primarily using the larger
beneficiary population already receiving services under the CBSD in the
U.S.
As a worldwide benefit, the TRICARE Basic (i.e., medical) benefit
recognizes that cultural differences unique to health care practices
and services in overseas locations necessitate allowances for
variations in care delivery from how the program is administered in the
U.S. in order to ensure a robust benefit (see the TRICARE Policy Manual
(TPM), Chapter 12, Section 1.1). Such uniquities and cultural
differences are expected to impact care provided under the CBSD, such
that deviating from the CBSD requirements will be required. The
requirements for the three classes of providers under the CBSD are
likely to need adjustment in some or all locations to ensure
applicability in the many countries in which TRICARE beneficiaries may
give birth each year. These modifications will be enacted prior to the
start of the CBSD overseas, but additional modifications may occur
during the two-year overseas period. While the DoD selected
certification bodies that had an international component, these bodies
may be less available outside of the U.S. and Western Europe, such that
additional bodies are required. The overseas CBSD modifications will
extend to the extra-medical maternity provider classes approved under
the CBSD in the U.S., but will not include new classes of extra-medical
maternity providers. Additionally, we anticipate modifying
reimbursement rates for CBSD services overseas, commensurate with how
reimbursement is typically modified for overseas delivery of the
TRICARE Basic (i.e., medical) benefit (see the TRICARE Reimbursement
Manual, Chapter 1, Section 34 and 35 for examples of such variances).
Finally, the DoD also anticipates that it may be necessary to add
an enrollment requirement. The lack of an enrollment process in the
U.S. was facilitated by known, uniform provider requirements such that
both beneficiaries and providers could be assured that requirements
were met prior to the receipt of services. Given that the DoD may need
to approve changes to provider requirements consistent with care
delivery in other countries, beneficiaries may not have the same
ability to independently verify the qualifications of a provider
without interacting with the TOP contractor. As such, an enrollment
requirement would ensure beneficiaries understand the requirements for
the CBSD in their location.
These and other modifications necessary to ensure DoD's ability to
evaluate the CBSD hypotheses overseas will be published to the TRICARE
Operations Manual, which is publicly available at <a href="http://manuals.health.mil">http://manuals.health.mil</a>. Additionally, the DoD will continue to publish
information about the CBSD on its website (see <a href="http://tricare.mil/cbsd">tricare.mil/cbsd</a>) and
social media accounts.
D. Modification to the Demonstration Evaluation
Separately, the ASD(HA) is notifying the public of a change to the
evaluation of the CBSD. The DoD stated in the October 29, 2021, FRN
that we intended to use an independent contractor to evaluate the CBSD,
at an estimated cost of $4.3M. Due to a constrained financial
environment, the DoD may use internal DoD staff and resources to
perform some or all of this evaluation. More information on the
evaluation will be reported in the annual reports to Congress.
Dated: July 28, 2023.
Aaron T. Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2023-16477 Filed 8-1-23; 8:45 am]
BILLING CODE 5001-06-P
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