Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Coverage of Screening Mammography and Papanicolaou (PAP) Tests, Certified Marriage and Family Therapists, and Requirements for Coverage and Reimbursement of Services of Physicians in Teaching Settings

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]

RINS-0720-AA08-0720-AA10-0720-AA13

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); Coverage of Screening Mammography and Papanicolaou (PAP)

Tests, Certified Marriage and Family Therapists, and Requirements for

Coverage and Reimbursement of Services of Physicians in Teaching

Settings

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

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SUMMARY: This final rule revises the exclusions and limitations of the

CHAMPUS regulation pertaining to preventive care and unnecessary

diagnostic tests not related to a specific illness, injury, or

definitive set of symptoms, to allow coverage for screening mammography

and PAP tests on a preventive basis initially following the recommended

guidelines of the American Cancer Society as a basis for coverage. The

final rule also removes the requirement for physician supervision and

referral for certified marriage and family therapists; requires all

certified marriage and family therapists to accept CHAMPUS payment as

payment in full; ensures that the relationship of certified marriage

and family therapists is consistent with other mental health

practitioners with comparable education and training; protects the

CHAMPUS beneficiary from incurring added out-of-pocket costs for care

rendered that is not part of the current CHAMPUS mental health benefits

package; and better defines the specific requirements of existing

CHAMPUS policies for coverage and reimbursement of services of teaching

physicians and physicians in training.

EFFECTIVE DATE: This part is effective February 22, 1994. The effective

date for changes in Sec. 199.4, paragraphs (g)(1), (g)(2), (g)(37)(vii)

and (g)(37)(viii) and (g)(39), and section 199.6, paragraph (d)(6),

related to screening PAP tests and mammography on a preventive basis is

November 5, 1990; the effective date for changes in Sec. 199.2(b),

``marriage and family therapist, certified,'' ``pastoral counselors,''

``mental health counselor,'' Sec. 199.4, paragraph (c)(3)(ix)(A), and

Sec. 199.6, paragraphs (c) (1)(iv) and (3)(iv), related to certified

marriage and family therapists is May 23, 1994; and the effective date

for changes in Sec. 199.2(b), ``approved teaching programs,''

``attending physician,'' ``physician in training'' and ``teaching

physician,'' Sec. 199.4, paragraphs (b)(1)(i), (c)(1)(i), (c)(3)(xiii),

and 199.6, paragraph (c)(1), related to services of teaching physicians

and physicians in training is March 24, 1994.

ADDRESSES: Office of the Civilian Health and Medical Program of the

Uniformed Services (OCHAMPUS), Program Development Branch, Aurora, CO

80045-6900.

FOR FURTHER INFORMATION CONTACT:

Judy Carroll, Program Development Branch, OCHAMPUS, telephone (303)

361-1089.

SUPPLEMENTARY INFORMATION: On August 21, 1991 (56 FR 41498), and

November 12, 1991 (56 FR 57501), the Office of Secretary of Defense

published for public comment notices of proposed rulemaking to comply

with sections 701 and 702 of the National Defense Authorization Act for

Fiscal Year 1991. These statutory provisions are codified at 10 U.S.C.

1079 (a) (2), (8), and (13). This final rule consolidates the comments

and the changes based on comments of three proposed rule amendments to

implement sections 701 and 702 of the Defense Authorization Act for

Fiscal Year (FY) 1991 (Pub. L. 101-510), and to revise requirements for

coverage and reimbursement of services of physicians in teaching

settings. The publication of the final rule amendments was delayed as a

result of the Presidential moratorium on regulation changes. This final

rule completes the action required to amend this part as outlined in

the three previously published proposed rules. The proposed rules

provided specific coverage requirements, screening frequencies, payment

limitations and provider certification requirements, for mammography

and PAP tests, removed the requirement for physician supervision and

referral for certified marriage and family therapists and required all

certified marriage and family therapists to accept CHAMPUS payment as

payment in full. Additionally, in FR Doc. 91-28934, appearing in the

Federal Register on December 10, 1991 (56 FR 64491), the Office of

Secretary of Defense also published for public comment a notice of

proposed rulemaking to revise the comprehensive CHAMPUS regulation, DoD

6010.8-R, pertaining to basic CHAMPUS benefits to better define the

specific requirements for coverage and reimbursement of services of

teaching physicians and physicians in training. We refer the reader to

the proposed rules for a more detailed explanation of this change. We

provided a 30-day comment period on each of the proposed amendments to

the CHAMPUS regulation. The following summarizes the comments received

following publication of each proposed rule amendment, and the actions

taken based on these comments.

Discussion of Comments for

1. Screening Mammographies and PAP Smears

We received two (2) public comments and one (1) comment from the

government agencies which by law we are required to consult with during

the rulemaking process in response to the proposed rule regarding

CHAMPUS coverage for screening mammography and papanicolaou (PAP) tests

related to the proposed screening frequencies for mammography and PAP

testing. A summary of the comments and our responses to them are listed

below.

Comment: The coverage limitations for screening mammography set out

in section II of the proposed rule are virtually identical to the

Medicare requirement. However, we wish to point out that the American

College of Radiology and other groups including the National Cancer

Institute, American Cancer Society, American Medical Association, and

other physician organizations recommend that women 65 years of age or

older have mammograms on an annual basis. We recommend adopting the

position of national professional organizations over Medicare current

coverage policy.

Response: We have found your argument persuasive and have amended

the language in the Final Rule to follow the expert opinion and

recommendation of national professional organizations. The amended

language will allow annual screening for women 65 years of age or

older.

Comment: The Department of Defense has proposed adopting current

Medicare regulations for use in the CHAMPUS program. Under these

regulations, screening mammography would be allowed only once every two

years for ``asymptomatic women over the age of 65.'' Mammography is the

only screening device currently available that detects breast cancers

before they become palpable. Diagnosed in the early stages, breast

cancer is more amenable to less invasive medical therapies. This

translates into money saved as a result of fewer and shorter

hospitalizations, less radical and more inexpensive treatments, and a

lower recurrence rate. This organization believes that all women over

the age of 50 should undergo annual screening mammography and clinical

breast examination as part of their overall preventive health-care

plan.

Response: In order to remain in keeping with nationally recognized

breast cancer screening frequencies which recommend that annual

mammograms should be allowed for all women age 50 and over, we have

added clarifying language to the final rule. The new language allows

women between the ages of 50 and 64 years of age to have annual

mammography screening.

Comment: Because of greater risk, annual screening mammography is

important for women 65 and over. Additionally, the proposed rule which

allowed coverage for screening PAP tests on an annual basis is

inconsistent with the consensus of the scientific community, which

suggests that following three consecutive annual PAP tests with

negative findings, and in the absence of risk factors, screening may

safely be decreased to every two (2) to (3) years.

Response: We have amended language in the final rule to allow

coverage of screening PAP tests every two (2) years after three

consecutive annual exams with normal findings and in the absence of

risk factors.

2. Certified Marriage and Family Therapists

We received twelve (12) public comments from five (5) interested

professional organizations and three (3) comments from the Government

agencies which by law we are required to consult with during the

rulemaking process in response to the proposed rule to remove the

requirement for physician supervision and referral for certified

marriage and family therapists and require all certified marriage and

family therapists to accept CHAMPUS payment as payment in full. Three

(3) of the professional organizations provided similar comments. A

summary of the comments and our responses to them are listed below:

Comment: One commentor expressed great concern that the proposed

rule contained no provision to address the need for either medical

differential diagnosis by a physician or evaluation by a mental health

professional of the level of clinical psychologist or clinical social

worker. The commenter strongly urged that OCHAMPUS require that

patients being seen by any of these various categories of nonphysician

mental health practitioners be evaluated by physicians, including

psychiatrists, to assure that appropriate medical care will be

provided.

Response: We, too, share the concerns of this professional

organization. However, based upon the provisions of the FY 1991 Defense

Authorization Act, as cited above, we can no longer require physician

referral and supervision. We have added language which states that

patients with medical conditions must receive appropriate concurrent

management by a physician. Additionally, claims for services by

certified marriage and family therapists shall continue to be reviewed

in accord with appropriate medical concepts.

Comment: One commenter questioned by OCHAMPUS would forward with

this proposal, knowing assuredly that costs will inevitably increase.

Even with the ``payment in full'' requirements for this proposed

regulation, the expansion to independent practice and billing will be

costly.

Response: As previously stated, this change was mandated by

Congress. Program costs associated with this final amendment are not

expected to be substantial, since this amendment will eliminate

administrative requirements for CHAMPUS, the beneficiary, and the

provider population.

Comment: The proposed rule would also permit mental health

counselors and pastoral counselors to be certified and removed from

physician supervision and referral requirements. There certainly is no

legislative authority for the proposed expansion for others than

marriage and family therapists, and we think this effort is misguided.

Response: Neither the proposed nor final rules permit mental health

or pastoral counselors to practice without physician supervision and

referral. Both rules keep the requirement for physician supervision and

referral for mental health and pastoral counselors.

Comment: We believe it inappropriate that OCHAMPUS has gone ahead

and promulgated federal criteria that would recognize independent

practice and payment under CHAMPUS for practitioners that are not

permitted such legal right under state law. We do not believe that

OCHAMPUS should be usurping the traditional state role and

responsibility to regulate individual professions. This permits

unregulated practice without any quality assurance to protect patients.

Response: CHAMPUS requires all providers comply with state

licensure and certification requirements, and to practice within the

parameters of their scope of licensure. This means that if a state

requires a certified marriage and family therapist to practice with

physician involvement, OCHAMPUS would also require the provider to

practice within the state standard.

Comment: We strongly request that you add mental health counselors

as mental health providers not needing physician referral.

Response: The legislation which mandated the removal of physician

supervision and referral only authorized removal of the requirement for

one category of provider, that is, certified marriage and family

therapists. By law, the physician supervision and referral requirement

is still required for services rendered by pastoral counselors and

mental health counselors under CHAMPUS.

Comment: We recommend correcting the national organization which

offers clinical membership for marriage and family therapists to the

American Association for Marriage and Family Therapy rather than the

American Association of Marriage and Family Counselors which was listed

in proposed paragraph (c)(3)(iv)(D)(2).

Response: We have revised the regulatory language to reflect the

correct name of the national organization which offers clinical

membership for marriage and family therapists.

Comment: The experience requirements delineated in

Sec. 199.6(c)(3)(iv)(A)(2) are outdated and cumbersome to administer

given the many specific requirements detailed. We recommend that

CHAMPUS change the experience requirement to reflect current American

Association of Marriage and Family Therapy clinical membership

criteria. Such a change would be consistent not only with the current

standards established by the nationally recognized credentialing

organization for marriage and family therapy, but it would also

establish criteria consistent with other independent CHAMPUS providers.

Response: We do not find this argument persuasive. A comparison of

the requirements shows that the hours of training for marriage and

family therapists are identical. However, the American Association of

Marriage and Family Therapy standards do not include the requirement

for psychotherapy experience even though psychotherapy is one of the

major services certified marriage and family therapists provide. Since

the CHAMPUS benefit does not include counseling services and certified

marriage and family therapists will primarily be providing

psychotherapy services to CHAMPUS beneficiaries, we feel a requirement

for psychotherapy experience is critical.

Comment: We recommend that certified marriage and family therapists

be removed from the ``extramedical'' provider category

(Sec. 199.6(c)(3)(iv)(A)) and be listed under ``Other allied health

professionals'' as Sec. 199.6(c)(3)(iii)(H)(3). The American

Association of Marriage and Family Therapy is concerned that the

extramedical designation may lead beneficiaries and providers to

believe that a certified marriage and family therapist still requires a

physician's supervision and referral.

Response: CHAMPUS beneficiaries will be advised of the elimination

of the physician supervision and referral requirement for certified

marriage and family therapists through changes in the beneficiary's

handbook and other public news releases. This should eliminate any

confusion.

Comment: In paragraph (c)(3) to Sec. 199.6(c)(3)(iv), the proposed

rule refers to ``paragraph (c)(3)(iv) of this section for more specific

information regarding licensure.'' We assume that this paragraph refers

to paragraph (c)(3)(iv)(D) of the proposed rule which discusses

additional information applicable to each of the extramedical

providers.

Response: Your assumption is correct.

Comment: For the sake of clarity, we believe that paragraph (c)(3)

to Sec. 199.6(c)(3)(iv) should explicitly state that ``In jurisdictions

that do not provide for licensure or certification, the provider must

be certified by or eligible for full clinical membership in the

appropriate national professional association that sets standards for

the specific profession.'' Currently, the proposed rule could be

mistakenly interpreted to mean that if providers live in a state that

does not regulate marriage and family therapy, they cannot be CHAMPUS

authorized providers.

Response: We have incorporated the above technical revision.

Comment: Paragraph (c)(3) to Sec. 199.6(c)(3)(iv) also does not

address the professional status of marriage and family therapists

licensed or certified in California, Michigan, and New Jersey. Although

marriage and family therapists in each of these jurisdictions meet

CHAMPUS' educational and experience requirements, they are technically

regulated as marriage, family and child counselors or marriage and

family counselors. We fear that California, Michigan, and New Jersey's

marriage and family therapists may be denied CHAMPUS provider status

based on the semantics of a professional title, despite the fact that

the credentials and scope of practice are the same in these states as

they are for marriage and family therapists in other regulated

jurisdictions.

Response: CHAMPUS denial of provider status is not based solely on

professional title. Licensing is but one part of the marriage and

family certification and review process. Authorization as a certified

marriage and family therapist under CHAMPUS includes licensure,

graduation from a regionally accredited school, a degree in an

appropriate field, and post-graduate clinical training.

Comment: We assume and would like to clarify that CHAMPUS providers

who currently qualify as marriage and family counselors will qualify as

certified marriage and family therapists without having to redocument

their credentials. We understand that they must agree to accept the

CHAMPUS allowable charge as payment in full as stipulated by proposed

paragraph 4 (now paragraph 5) of Sec. 199.6(c)(3)(iv)(A)(4), (now

paragraph (5)), but we do not understand the change to be a requirement

for the resubmission of credential materials. We feel it would be an

administrative burden to both OCHAMPUS and individual providers to

require such redocumentation of professional qualifications. We

recommend language be incorporated within the final rule to circumvent

the possibility for such an administrative nightmare.

Response: The legislation required that all marriage and family

therapists be certified. We have interpreted this to mean that only

providers who meet the very minimum level of requirements should remain

authorized under CHAMPUS. Additionally, the legislation did not provide

grandfathering provisions for marriage and family counselors already

authorized under CHAMPUS. We feel recertification will ensure CHAMPUS

beneficiaries receive care provided by both certified and qualified

providers.

Comment: Will certified marriage and family therapists who have

signed a participation agreement with OCHAMPUS be able to terminate the

agreement.

Response: Certified marriage and family therapists who have signed

a participation agreement with OCHAMPUS may terminate the agreement

upon notification to OCHAMPUS. The participation agreement will

stipulate the number of days required for notification to terminate.

Comment: Will certified marriage and family therapists who have

terminated their participation agreement be eligible to qualify as

another category of provider under CHAMPUS? If this allowed, we foresee

a number of problems in the adjudication of claims, particularly if

they choose to switch to a category of provider which still requires

physician supervision and referral and continue to treat the same

patients.

Response: Upon application to OCHAMPUS, a provider must indicate

under which category of provider he/she wishes to be authorized. Once a

determination by OCHAMPUS is made that the applicant meets the

qualifications of the provider category for which he/she is applying,

switching from one group to another seldom occurs. Switching could be

allowed if the provider has continued his/her education and such

additional education qualifies him/her for a different provider

category (i.e., nurse to M.D., clinical psychologist to psychiatrist,

or M.D. to psychiatrist). Such upward or changed speciality movement

generally does not create an adjudication problem. However, we agree

that the new legislative provisions regarding certified marriage and

family therapists may create adjudication problems, since the

provisions of the law allow certified marriage and family therapists to

practice without physician supervision and referral. Switching and

movement within any other extramedical provider category where

physician supervision and referral is required would result in CHAMPUS

beneficiaries incurring costs for denied care. Care denied for lack of

physician supervision and referral would not be subject to the hold

harmless provisions of the new legislation since these provisions only

apply to the certified marriage and family therapists provider

category. We feel it would be inappropriate to require retroactive

physician supervision and referral for care that has already been

rendered, or for continuing care. To prevent CHAMPUS beneficiaries from

incurring costs Congress did not intend them to incur with this change,

we have added language to the final rule which precludes marriage and

family therapists from switching within the extramedical provider

category. As of the effective date of termination, the certified

marriage and family therapist will no longer be recognized as an

authorized provider under CHAMPUS. Subsequent to termination, the

certified marriage and family therapist may only be reinstated as an

authorized CHAMPUS extramedical provider by entering into a new

participation agreement as a certified marriage and family therapist.

3. Services of Physicians in Teaching Settings

We received one (1) public comment from a national physician

organization and one (1) comment from one of the government agencies

which by law we are required to consult with during the rulemaking

process.

Comment: It is not uncommon for physicians to have a contract with

an academic hospital to provide individual, personal services to

hospital patients and for the contract to provide for the physicians to

bill the patient or their insurer directly for those services. In these

cases, the hospital does not bill patients/insurers and makes no

payment to the physician for the services. To require hospitals to

change such billing arrangements serves no useful purpose.

Response: We agree, and it was not our intent to require hospitals

to change their billing arrangements. The CHAMPUS regulation has always

had the requirement that physicians who are employed by or under

contract to the hospital cannot bill for their services. This, however,

is intended to apply only to those contracts which incorporate payment

to the physicians. It does not include contracts which only provide

physicians with normal privileges to admit patients and to render

services in the hospital on a fee-for-service basis. In order to

reflects this intent, we have modified the language in Sec. 199.4

(c)(3)(xiii)(A)(4) as well as in Sec. 199.6 (c)(1).

Comment: In addition to interns and residents, fellows in certain

subspecialties are also ``physicians in training.'' It is unclear from

the document whether or not a fellow in a subspecialty would be

considered a ``physician in training.''

Response: We consider fellows to be physicians in training, and we

have added them to the definition in Sec. 199.2.

Section 605(b) of the Regulatory Flexibility Act (RFA) of 1980

(Pub. L. 96-354) 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. The Department of Defense

certifies, pursuant to section 605(b) of title 5, United States Code,

enacted by the Regulatory Flexibility Act (Pub. L. 96-354), that this

final amendment will not have a significant impact on a substantial

number of small businesses, organizations, or government jurisdictions.

For purposes of the RFA, we consider small entities to include all

hospitals and third-party payers.

We have determined that this final amendment is a routine amendment

necessary to provide specific requirements for existing policies and to

implement legislation which authorized expanded CHAMPUS benefits, and

relieved administrative requirements for the CHAMPUS beneficiary and

provider community. It is not, therefore, a ``major rule'' under

Executive Order 12291. This final rule only provides specific

requirements for existing policies; expands benefits; and ensures

equitable administration of CHAMPUS requirements among mental health

providers with comparable education and training while also protecting

CHAMPUS beneficiaries from incurring added costs for mental health care

not normally covered under the CHAMPUS program. It will not involve any

significant burden on CHAMPUS beneficiaries or providers.

Although this change does not qualify as a ``major rule'' under

Executive Order 12291, a cost analysis for costs associated with

implementing screening mammogram and Pap tests was provided in the

proposed rule amendment on screening mammogram and PAP tests.

Additionally, an increase in program costs related to implementation of

this final amendment for the issues related to certified marriage and

family therapists and physicians in teaching settings are not expected

to be substantial, since this amendment will eliminate administrative

requirements for certified marriage and family therapists for CHAMPUS,

the beneficiary and the provider population and only better defines the

specific requirements for coverage of existing policies related to

physicians in teaching settings.

This final rule does not impose information collection

requirements. Therefore, it does not need to be reviewed by the

Executive Office of Management and Budget under authority of the

Paperwork Reduction Act of 1980 (44 U.S.C. 3501-3511).

List of Subjects in 32 CFR Part 199

Claims, Handicapped, Health insurance, Military personnel.

Accordingly, 32 CFR part 199 is amended as follows:

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

follows:

Authority: 5 U.S.C. 301; 10 U.S.C. 1079, 1086.

2. Section 199.2(b) is amended by adding the new definitions,

``approved teaching programs,'' ``pastoral counselors,'' ``physician in

training,'' and ``teaching physician,'' by removing the definition for

``marriage and family counselor or pastoral counselor,'' by adding the

definition ``marriage and family therapist, certified,'' in

alphabetical order, and by revising the definitions for ``attending

physician,'' and ``mental health counselor'' to read as follows:

Sec. 199.2 Definitions.

* * * * *

(b) * * *

Approved teaching programs. For purposes of CHAMPUS, an approved

teaching program is a program of graduate medical education which has

been duly approved in its respective specialty or subspecialty by the

Accreditation Council for Graduate Medical Education of the American

Medical Association, by the Committee on Hospitals of the Bureau of

Professional Education of the American Osteopathic Association, by the

Council on Dental Education of the American Dental Association, or by

the Council on Podiatry Education of the American Podiatry Association.

* * * * *

Attending physician. The physician who has the primary

responsibility for the medical diagnosis and treatment of the patient.

A consultant or an assistant surgeon, for example, would not be an

attending physician. Under very extraordinary circumstances, because of

the presence of complex, serious, and multiple, but unrelated, medical

conditions, a patient may have more than one attending physician

concurrently rendering medical treatment during a single period of

time. An attending physician also may be a teaching physician.

* * * * *

Marriage and family therapist, certified. An extramedical

individual provider who meets the requirements outlined in Sec. 199.6.

* * * * *

Mental health counselor. An extramedical individual provider who

meets the requirements outlined in Sec. 199.6

* * * * *

Pastoral counselor. An extramedical individual provider who meets

the requirements outlined in Sec. 199.6.

* * * * *

Physician in training. Interns, residents, and fellows

participating in approved postgraduate training programs and physicians

who are not in approved programs but who are authorized to practice

only in a hospital or other institutional provider setting, e.g.,

individuals with temporary or restricted licenses, or unlicensed

graduates of foreign medical schools.

* * * * *

Teaching physician. A teaching physician is any physician whose

duties include providing medical training to physicians in training

within a hospital or other institutional provider setting.

* * * * *

3. Section 199.4 is amended by revising paragraphs (b)(1)(i),

(c)(1)(i), (c)(3)(ix)(A), by adding a new paragraph (c)(3)(xiii) after

the Note, (g)(37)(vii), and (g)(37)(viii), and by revising paragraphs

(g)(1), (g)(2), and (g)(39) to read as follows:

Sec. 199.4 Basic program benefits.

* * * * *

(b) * * *

(1) * * *

(i) Billing practices. To be considered for benefits under

Sec. 199.4(b), covered services and supplies must be provided and

billed for by a hospital or other authorized institutional provider.

Such billings must be fully itemized and sufficiently descriptive to

permit CHAMPUS to determine whether benefits are authorized by this

part. Depending on the individual circumstances, teaching physician

services may be considered an institutional benefit in accordance with

Sec. 199.4(b) or a professional benefit under Sec. 199.4(c). See

paragraph (c)(3)(xiii) of this section for the CHAMPUS requirements

regarding teaching physicians. In the case of continuous care, claims

shall be submitted to the appropriate CHAMPUS fiscal intermediary at

least every 30 days either by the beneficiary or sponsor or, on a

participating basis, directly by the facility on behalf of the

beneficiary (refer to Sec. 199.7).

* * * * *

(c) * * *

(1) * * *

(i) Billing practices. To be considered for benefits under

paragraph (c) of this section, covered professional services must be

performed personally by the physician or other authorized individual

professional provider, who is other than a salaried or contractual

staff member of a hospital or other authorized institution, and who

ordinarily and customarily bills on a fee-for-service basis for

professional services rendered. Such billings must be itemized fully

and be sufficiently descriptive to permit CHAMPUS to determine whether

benefits are authorized by this part. See paragraph (c)(3)(xiii) of

this section for the requirements regarding the special circumstances

for teaching physicians. For continuing professional care, claims

should be submitted to the appropriate CHAMPUS fiscal intermediary at

least every 30 days either by the beneficiary or sponsor, or directly

by the physician or other authorized individual professional provider

on behalf of a beneficiary (refer to Sec. 199.7).

* * * * *

(3) * * *

(ix) * * *

(A) Covered diagnostic and therapeutic services. Subject to the

requirements and limitations stated, CHAMPUS benefits are payable for

the following services when rendered in the diagnosis or treatment of a

covered mental disorder by a CHAMPUS-authorized, qualified mental

health provider practicing within the scope of his or her license.

Qualified mental health providers are: psychiatrists or other

physicians; clinical psychologists, certified psychiatric nurse

specialists, clinical social workers, and certified marriage and family

therapists; and pastoral and mental health counselors under a

physician's supervision. No payment will be made for any service listed

in paragraph (c)(3)(ix)(A) of this section rendered by an individual

who does not meet the criteria of Sec. 199.6 for his or her respective

profession, regardless of whether the provider is an independent

professional provider or an employee of an authorized professional or

institutional provider.

* * * * *

(xiii) Physicians in a teaching setting.

(A) Teaching physicians.

(1) General. The services of teaching physicians may be reimbursed

on an allowable charge basis only when the teaching physician has

established an attending physician relationship between the teaching

physician and the patient or when the teaching physician provides

distinct, identifiable, personal services (e.g., services rendered as a

consultant, assistant surgeon, etc.). Attending physician services may

include both direct patient care services or direct supervision of care

provided by a physician in training. In order to be considered an

attending physician, the teaching physician must:

(i) Review the patient's history and the record of examinations and

tests in the institution, and make frequent reviews of the patient's

progress; and

(ii) Personally examine the patient; and

(iiii) Confirm or revise the diagnosis and determine the course of

treatment to be followed; and

(iv) Either perform the physician's services required by the

patient or supervise the treatment so as to assure that appropriate

services are provided by physicians in training and that the care meets

a proper quality level; and

(v) Be present and ready to perform any service performed by an

attending physician in a nonteaching setting when a major surgical

procedure or a complex or dangerous medical procedure is performed; and

(vi) Be personally responsible for the patient's care, at least

throughout the period of hospitalization.

(2) Direct supervision by an attending physician of care provided

by physicians in training. Payment on the basis of allowable charges

may be made for the professional services rendered to a beneficiary by

his/her attending physician when the attending physician provides

personal and identifiable direction to physicians in training who are

participating in the care of the patient. It is not necessary that the

attending physician be personally present for all services, but the

attending physician must be on the provider's premises and available to

provide immediate personal assistance and direction if needed.

(3) Individual, personal services. A teaching physician may be

reimbursed on an allowable charge basis for any individual,

identifiable service rendered to a CHAMPUS beneficiary, so long as the

service is a covered service and is normally reimbursed separately, and

so long as the patient records substantiate the service.

(4) Who may bill. The services of a teaching physician must be

billed by the institutional provider when the physician is employed by

the provider or a related entity or under a contract which provides for

payment to the physician by the provider or a related entity. Where the

teaching physician has no relationship with the provider (except for

standard physician privileges to admit patients) and generally treats

patients on a fee-for-service basis in the private sector, the teaching

physician may submit claims under his/her own provider number.

(B) Physicians in training. Physicians in training in an approved

teaching program are considered to be ``students'' and may not be

reimbursed directly by CHAMPUS for services rendered to a beneficiary

when their services are provided as part of their employment (either

salaried or contractual) by a hospital or other institutional provider.

Services of physicians in training may be reimbursed on an allowable

charge basis only if:

(1) The physician in training is fully licensed to practice

medicine by the state in which the services are performed, and

(2) The services are rendered outside the scope and requirements of

the approved training program to which the physician in training is

assigned.

* * * * *

(g) * * *

(1) Not medically or psychologically necessary. Services and

supplies that are not medically or psychologically necessary for the

diagnosis or treatment of a covered illness (including mental disorder)

or injury, for the diagnosis and treatment of pregnancy or well-baby

care except as provided in the following paragraph.

(2) Unnecessary diagnostic tests. X-ray, laboratory, and

pathological services and machine diagnostic tests not related to a

specific illness or injury or a definitive set of symptoms except for

cancer screening mammography and cancer screening papanicolaou (PAP)

tests provided under the terms and conditions contained in the

guidelines adopted by the Director, OCHAMPUS.

* * * * *

(37) * * *

(vii) Screening mammography for asymptomatic women 35 years of age

and older when provided under the terms and conditions contained in the

guidelines adopted by the Director, OCHAMPUS.

(viii) Cancer screening papanicolaou (PAP) test for women who are

or have been sexually active, and women 18 years of age and older when

provided under the terms and conditions contained in the guidelines

adopted by the Director, OCHAMPUS.

* * * * *

(39) Counseling. Counseling services that are not medically

necessary in the treatment of a diagnosed medical condition: For

example, educational counseling, vocational counseling, nutritional

counseling, and counseling for socioeconomic purposes, diabetic self-

education programs, stress management, lifestyle modification, etc.

Services provided by a certified marriage and family therapist,

pastoral or mental health counselor in the treatment of a mental

disorder are covered only as specifically provided in Sec. 199.6.

Services provided by alcoholism rehabilitation counselors are covered

only when rendered in a CHAMPUS-authorized treatment setting and only

when the cost of those services is included in the facility's CHAMPUS-

determined allowable cost rate.

* * * * *

4. Section 199.6 is amended by revising the introductory text of

paragraphs (c)(1), (c)(1)(iv) and (3)(iv), and by adding a new

paragraph (d)(6), to read as follows:

Sec. 199.6 Authorized providers.

* * * * *

(c) * * *

(1) General. Individual professional providers of care are those

providers who bill for their services on a fee-for-service basis and

who are not employed by an institutional provider or under a contract

which provides for payment to the individual professional provider by

an institutional provider. This category also includes those

individuals who have formed professional corporations or associations

qualifying as a domestic corporation under 26 CFR 301.7701-5. Such

individual professional providers must be licensed or certified by the

local licensing or certifying agency for the jurisdiction in which the

care is provided; or in the absence of state licensure/certification,

be a member of, or demonstrate eligibility for full clinical membership

in, the appropriate national or professional certifying association

that sets standards for the profession of which the provider is a

member. Services provided must be in accordance with good medical

practice and prevailing standards of quality of care and within

recognized utilization norms.

* * * * *

(iv) Physician referral and supervision. Physician referral and

supervision is required for the services of paramedical providers as

listed in paragraph (c)(3)(iii)(H) of this section and for pastoral

counselors and mental health counselors. Physician referral means that

the physician must actually see the patient, perform an evaluation, and

arrive at an initial diagnostic impression prior to referring the

patient. Documentation is required of the physician's examination,

diagnostic impression, and referral. Physician supervision means that

the physician provides overall medical management of the case. The

physician does not have to be physically located on the premises of the

provider to whom the referral is made. Communication back to the

referring physician is an indication of medical management.

* * * * *

(3) * * *

(iv) Extramedical individual providers. Extramedical individual

providers are those who do counseling or nonmedical therapy and whose

training and therapeutic concepts are outside the medical field. The

services of extramedical individual professionals are coverable

following the CHAMPUS determined allowable charge methodology provided

such services are otherwise authorized in this or other sections of the

regulation.

(A) Certified marriage and family therapists. For the purposes of

CHAMPUS, a certified marriage and family therapist is an individual who

meets the following requirements:

(1) Recognized graduate professional education with the minimum of

an earned master's degree from a regionally accredited educational

institution in an appropriate behavioral science field, mental health

discipline; and

(2) The following experience:

(i) Either 200 hours of approved supervision in the practice of

marriage and family counseling, ordinarily to be completed in a 2- to

3-year period, of which at least 100 hours must be in individual

supervision. This supervision will occur preferably with more than one

supervisor and should include a continuous process of supervision with

at least three cases; and

(ii) 1,000 hours of clinical experience in the practice of marriage

and family counseling under approved supervision, involving at least 50

different cases; or

(iii) 150 hours of approved supervision in the practice of

psychotherapy, ordinarily to be completed in a 2- to 3-year period, of

which at least 50 hours must be individual supervision; plus at least

50 hours of approved individual supervision in the practice of marriage

and family counseling, ordinarily to be completed within a period of

not less than 1 nor more than 2 years; and

(iv) 750 hours of clinical experience in the practice of

psychotherapy under approved supervision involving at least 30 cases;

plus at least 250 hours of clinical practice in marriage and family

counseling under approved supervision, involving at least 20 cases; and

(3) Is licensed or certified to practice as a marriage and family

therapist by the jurisdiction where practicing (see paragraph

(c)(3)(iv)(D) of this section for more specific information regarding

licensure); and

(4) Agrees that a patients' organic medical problems must receive

appropriate concurrent management by a physician.

(5) Agrees to accept the CHAMPUS determined allowable charge as

payment in full, except for applicable deductibles and cost-shares, and

hold CHAMPUS beneficiaries harmless for noncovered care (i.e., may not

bill a beneficiary for noncovered care, and may not balance bill a

beneficiary for amounts above the allowable charge). The certified

marriage and family therapist must enter into a participation agreement

with the Office of CHAMPUS within which the certified marriage and

family therapist agrees to all provisions specified above.

(6) As of the effective date of termination, the certified marriage

and family therapist will no longer be recognized as an authorized

provider under CHAMPUS. Subsequent to termination, the certified

marriage and family therapist may only be reinstated as an authorized

CHAMPUS extramedical provider by entering into a new participation

agreement as a certified marriage and family therapist.

(B) Pastoral counselors. For the purposes of CHAMPUS, a pastoral

counselor is an individual who meets the following requirements:

(1) Recognized graduate professional education with the minimum of

an earned master's degree from a regionally accredited educational

institution in an appropriate behavioral science field, mental health

discipline; and

(2) The following experience:

(i) Either 200 hours of approved supervision in the practice of

pastoral counseling, ordinarily to be completed in a 2- to 3-year

period, of which at least 100 hours must be in individual supervision.

This supervision will occur preferably with more than one supervisor

and should include a continuous process of supervision with at least

three cases; and

(ii) 1,000 hours of clinical experience in the practice of pastoral

counseling under approved supervision, involving at least 50 different

cases; or

(iii) 150 hours of approved supervision in the practice of

psychotherapy, ordinarily to be completed in a 2- to 3-year period, of

which at least 50 hours must be individual supervision; plus at least

50 hours of approved individual supervision in the practice of pastoral

counseling, ordinarily to be completed within a period of not less than

1 nor more than 2 years; and

(iv) 750 hours of clinical experience in the practice of

psychotherapy under approved supervision involving at least 30 cases;

plus at least 250 hours of clinical practice in pastoral counseling

under approved supervision, involving at least 20 cases; and

(3) Is licensed or certified to practice as a pastoral counselor by

the jurisdiction where practicing (see paragraph (c)(3)(iv)(D) of this

section for more specific information regarding licensure); and

(4) The services of a pastoral counselor meeting the above

requirements are coverable following the CHAMPUS determined allowable

charge methdology, under the following specified conditions:

(i) The CHAMPUS beneficiary must be referred for therapy by a

physician; and

(ii) A physician is providing ongoing oversight and supervision of

the therapy being provided; and

(iii) The pastoral counselor must certify on each claim for

reimbursement that a written communication has been made or will be

made to the referring physician of the results of the treatment. Such

communication will be made at the end of the treatment, or more

frequently, as required by the referring physician (refer to

Sec. 199.7).

(5) Because of the similarity of the requirements for licensure,

certification, experience, and education, a pastoral counselor may

elect to be authorized under CHAMPUS as a certified marriage and family

therapist, and as such, be subject to all previously defined criteria

for the certified marriage and family therapist category, to include

acceptance of the CHAMPUS determined allowable charge as payment in

full, except for applicable deductibles and cost-shares (i.e., balance

billing of a beneficiary above the allowable charge is prohibited; may

not bill beneficiary for noncovered care). The pastoral counselor must

also agree to enter into the same participation agreement as a

certified marriage and family therapist with the Office of CHAMPUS

within which the pastoral counselor agrees to all provisions including

licensure, national association membership and conditions upon

termination, outlined above for certified marriage and family

therapist.

Note: No dual status will be recognized by the Office of

CHAMPUS. Pastoral counselors must elect to become one of the

categories of extramedical CHAMPUS provides specified above. Once

authorized as either a pastoral counselor, or a certified marriage

and family therapist, claims review and reimbursement will be in

accordance with the criteria established for the elected provider

category.

(C) Mental health counselor. For the purposes of CHAMPUS, a mental

health counselor is an individual who meets the following requirements:

(1) Minimum of a master's degree in mental health counseling or

allied mental health field from a regionally accredited institution;

and

(2) Two years of post-masters experience which includes 3000 hours

of clinical work and 100 hours of face-to-face supervision; and

(3) Is licensed or certified to practice as a mental health

counselor by the jurisdiction where practicing (see paragraph

(c)(3)(iv)(D) of this section for more specific information); and

(4) May only be reimbursed when:

(i) The CHAMPUS beneficiary is referred for therapy by a physician;

and

(ii) A physician is providing ongoing oversight and supervision of

the therapy being provided; and

(iii) The mental health counselor certifies on each claim for

reimbursement that a written communication has been made or will be

made to the referring physician of the results of the treatment. Such

communication will be made at the end of the treatment, or more

frequently, as required by the referring physician (refer to

Sec. 199.7).

(D) The following additional information applies to each of the

above categories of extramedical individual providers:

(1) These providers must also be licensed or certified to practice

as a certified marriage and family therapist, pastoral counselor or

mental health counselor by the jurisdiction where practicing. In

jurisdictions that do not provide for licensure or certification, the

provider must be certified by or eligible for full clinical membership

in the appropriate national professional association that sets

standards for the specific profession.

(2) Grace period for therapists or counselors in states where

licensure/certification is optional. CHAMPUS is providing a grace

period for those therapists or counselors who did not obtain optional

licensure/certification in their jurisdiction, not realizing it was a

CHAMPUS requirement for authorization. The exemption by state law for

pastoral counselors may have misled this group into thinking licensure

was not required. The same situation may have occurred with the other

therapist or counselor categories where licensure was either not

mandated by the state or was provided under a more general category

such as ``professional counselors.'' This grace period pertains only to

the licensure/certification requirement, applies only to therapists or

counselors who are already approved as of October 29, 1990, and only in

those areas where the licensure/certification is optional. Any

therapist or counselor who is not licensed/certified in the state in

which he/she is practicing by August 1, 1991, will be terminated under

the provisions of Sec. 199.9. This grace period does not change any of

the other existing requirements which remain in effect. During this

grace period, membership or proof of eligibility for full clinical

membership in a recognized professional association is required for

those therapists or counselors who are not licensed or certified by the

state. The following organizations are recognized for therapists or

counselors at the level indicated: Full clinical member of the American

Association of Marriage and Family Therapy; membership at the fellow or

diplomate level of the American Association of Pastoral Counselors; and

membership in the National Academy of Certified Clinical Mental Health

Counselors. Acceptable proof of eligibility for membership is a letter

from the appropriate certifying organization. This opportunity for

delayed certification/licensure is limited to the counselor or

therapist category only as the language in all of the other provider

categories has been consistent and unmodified from the time each of the

other provider categories were added. The grace period does not apply

in those states where licensure is mandatory.

(E) Christian Science practitioners and Christian Science nurses.

CHAMPUS cost-shares the services of Christian Science practitioners and

nurses. In order to bill as such, practitioners or nurses must be

listed or be eligible for listing in the Christian Science Journal\1\

at the time the service is provided.

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\1\Copies of this journal can be obtained through the Christian

Science Publishing Company, 1 Norway Street, Boston, MA 02115-3122

or the Christian Science Publishing Society, P.O. Box 11369, Des

Moines, IA 50340.

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* * * * *

(d) * * *

(6) Mammography suppliers. Mammography services may be cost-shared

only if the supplier is certified by Medicare for participation as a

mammography supplier, or is certified by the American College of

Radiology as having met its mammography supplier standards.

* * * * *

Dated: February 4, 1994.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 94-2921 Filed 2-18-94; 8:45 am]

BILLING CODE 5000-04-M