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Title 32 National Defense
Civilian Health And Medical Program Of The Uniformed Services (CHAMPUS)
Part 199.17
TRICARE Program
Revision:  C-1, September 29, 2017
Rule:  Interim Final Rule/FR Vol 82, No 188
(a)  Establishment.
(1)  Purpose.
(2)  Statutory authority.
(3)  Scope of the program.
(4)  Rules and procedures affected.
(5)  Implementation based on local action.
(6)  Major features of the TRICARE program.
(i)  Beneficiary categories.
(ii)  Health plans available.
(A)  TRICARE Prime.
(B)  TRICARE Select.
(C)  TRICARE for Life.
(D)  TRICARE Standard.
(iii)  Comprehensive enrollment system.
(7)  Preemption of State laws.
(b)  TRICARE Prime and TRICARE Select health plans in general.
(1)  TRICARE Prime.
(2)  TRICARE Select.
(c)  Eligibility for enrollment in TRICARE Prime and TRICARE Select.
(1)  Active duty members.
(2)  Dependents of active duty members.
(3)  Survivors of deceased members.
(4)  Retired, dependents of retirees, and survivors (other than survivors of deceased members covered under paragraph (c)(3) of this section).
(d)  Health benefits under TRICARE Prime--
(1)  Military treatment facility (MTF) care--
(i)  In general.
(ii)  Special provisions.
(2)  Non-MTF care for active duty members.
(3)  Civilian sector Prime benefits.
(e)  Health benefits under the TRICARE extra plan--
(1)  Civilian sector care.
(2)  Military treatment facility (MTF) care.
(f)  Benefits under TRICARE Prime and TRICARE Select--
(1)  In general.
(2)  Preventive care services.
(3)  Treatment of obesity.
(4)  High value services.
(5)  Other services.
(g)  TRICARE Prime Remote for Active Duty Family Members--
(1)  In general.
(2)  Active duty family member.
(3)  Eligibility.
(4)  Enrollment.
(5)  Health care management requirements under TRICARE Prime Remote for Active Duty Family Members.
(6)  Cost sharing.
(h)  Resource sharing agreements.
(i)  General quality assurance, utilization review, and preauthorization requirements under the TRICARE program.
(j)  Pharmacy services.
(k)  Design of cost sharing structures under TRICARE Prime and TRICARE Select--
(1)  In general.
(2)  Categories of health care services.
(i)  Preventive care visits.
(ii)  Primary care outpatient visits.
(iii)  Specialty care outpatient visits.
(iv)  Emergency room visits.
(v)  Urgent care center visits.
(vi)  Ambulance services.
(vii)  Ambulatory surgery.
(viii)  Inpatient hospital admissions.
(ix)  Skilled nursing facility or rehabilitation facility admissions.
(x)  Durable medical equipment, prosthetic devices, and other authorized supplies.
(xi)  Outpatient prescription pharmaceuticals.
(3)  Beneficiary categories further subdivided.
(l)  Enrollment fees and cost sharing (including deductibles and catastrophic cap) amounts.
(1)  Enrollment fee and cost sharing under TRICARE Prime.
(2)  Enrollment fee and cost sharing under TRICARE Select.
(3)  Special cost-sharing rules.
(4)  Special transition rule for the last quarter of calendar year 2017.
(m)  Limit on out-of-pocket costs under TRICARE Prime and TRICARE Select.
(n)  Additional health care management requirements under TRICARE Prime.
(1)  Primary care manager.
(2)  Referral and preauthorization requirements.
(3)  Restrictions on the use of providers.
(4)  Point-of-service option.
(5)  Prime travel benefit.
(o)  TRICARE program enrollment procedures.
(1)  Annual open season enrollment.
(2)  Exceptions to the calendar year enrollment process.
(3)  Installment payments of enrollment fee.
(4)  Effect of failure to enroll.
(5)  Automatic enrollment for certain dependents.
(6)  Grace periods.
(p)  Civilian preferred provider networks.
(1)  Status of network providers.
(2)  Utilization management policies.
(3)  Quality assurance requirements.
(4)  Provider qualifications.
(5)  Access standards.
(6)  Special reimbursement methods for network providers.
(q)  Preferred provider network establishment.
(r)  General fraud, abuse, and conflict of interest requirements under TRICARE program.
(s)  [Reserved]
(t)  Inclusion of Department of Veterans Affairs Medical Centers in TRICARE networks.
(u)  Care provided outside the United States.
(1)  TRICARE Prime.
(2)  TRICARE Select.
(3)  TRICARE for Life.
(v)  Administration of the TRICARE program in the state of Alaska.
(w)  Administrative procedures.
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