(a) Purpose.
This part prescribes guidelines and policies
for the administration of the Civilian Health and Medical Program
of the Uniformed Services (CHAMPUS) for the Army, the Navy, the
Air Force, the Marine Corps, the Coast Guard, the Commissioned Corps
of the U.S. Public Health Service (USPHS) and the Commissioned Corps
of the National Oceanic and Atmospheric Administration (NOAA).
(b)
Applicability--
(1) Geographic.
This part is
applicable geographically within the 50 States of the United States,
the District of Columbia, the Commonwealth of Puerto Rico, and the
United States possessions and territories, and in all foreign countries,
unless specific exemptions are granted in writing by the Director,
OCHAMPUS, or a designee.
(2) Agency.
The provisions of this part apply throughout
the Department of Defense (DoD), the Coast Guard, the Commissioned
Corps of the USPHS, and the Commissioned Corps of the NOAA.
(c) Authority and responsibility--
(1) Legislative
authority--
(i) Joint
regulations.
10
U.S.C. chapter 55 authorizes the Secretary of Defense, the Secretary
of Health and Human Services, and the Secretary of Transportation
jointly to prescribe regulations for the administration of CHAMPUS.
(ii) Administration.
10 U.S.C. chapter
55 also authorizes the Secretary of Defense to administer CHAMPUS
for the Army, Navy, Air Force, and Marine Corps under DoD jurisdiction,
the Secretary of Transportation to administer CHAMPUS for the Coast
Guard, when the Coast Guard is not operating as a service in the
Navy, and the Secretary of Health and Human Services to administer
CHAMPUS for the Commissioned Corps of the NOAA and the USPHS.
(2) Organizational
delegations and assignments--
(i) Assistant Secretary of Defense (Health Affairs) (ASD(HA)).
The Secretary
of Defense, by 32 CFR part 367, delegated authority to the ASD(HA)
to provide policy guidance, management control and coordination
as required for CHAMPUS, and to develop, issue, and maintain regulations
with the coordination of the Military Departments and consistent
with DoD 5025.1-M.
Additional
implementing authority is contained in DoD Directive 5105.46.
(ii) Department of
Health and Human Services.
The Secretary of Health and Human Services
has delegated authority to the Assistant Secretary for Health, DHHS,
to consult with the Secretary of Defense or a designee and to approve
and issue joint regulations implementing 10 U.S.C. chapter 55. This
delegation was effective April 19, 1976 (41 FR 18698, May 6, 1976).
(iii) Department
of Transportation.
The Secretary of Transportation has delegated
authority to the Commandant, United States Coast Guard, to consult
with the Secretary of Defense or a designee and to approve an issue
joint regulations implementing 10 U.S.C., chapter 55.
(iv) Office of CHAMPUS
(OCHAMPUS).
By
DoD Directive 5105.46, OCHAMPUS was established as an OSD field
activity under the policy guidance and direction of the ASD(HA).
The Director, OCHAMPUS, is directed to execute the following responsibilities
and functions:
(A) Supervise and administer
the programs and missions to:
(1) Provide technical
direction and guidance on organizational, administrative, and operational matters.
(2) Conduct studies and research activities
in the health care area to assist in formulating policy required
to guide OCHAMPUS in carrying out its programs.
(3) Enter into agreements through the Department
of Defense with respect to the Military Departments or other U.S.
Government entities, as required, for the effective performance
of CHAMPUS.
(4) Supervise
and administer OCHAMPUS financial management activities to include:
(i) Formulating budget estimates and justifications
to be submitted to the Deputy Assistant Secretary of Defense (Administration)
(DASD(A)) for inclusion in the overall budget for the Office of
the Secretary of Defense.
(ii) Ensuring
the establishment and maintenance of necessary accounting records
and submission of required financial reports to the DASD(A).
(iii) Ensuring the effective execution of approved
budgets.
(5) Contract
for claims processing services, studies and research, supplies,
equipment, an other services necessary to carry out the CHAMPUS
programs.
(6) Monitor claims
adjudication and processing contracts to ensure that CHAMPUS fiscal intermediaries
are fulfilling their obligations.
(7) Convey appropriate
CHAMPUS information to providers of care, practitioners, professional societies,
health industry organizations, fiscal agents, hospital contractors,
and others who have need of such information.
(8) Collect, maintain, and analyze program
cost and utilization data appropriate for preparation of budgets,
fiscal planning, and as otherwise needed to carry out CHAMPUS programs
and missions.
(9) Arrange for
the facilities logistical and administrative support to be provided
by the Military Departments.
(10) Execute
such other functions as appropriate to administer the programs and
missions assigned.
(11) Direct and
control of the office, activities, and functions of OCHAMPUS Europe
(OCHAMPUSEUR).
Note: The Director, OCHAMPUS, may also
establish similar offices for OCHAMPUS Southern Hemisphere (OCHAMPUSSO)
and OCHAMPUS Pacific (OCHAMPUSPAC).
(B) Develop
for issuance, subject to approval by the ASD(HA), such policies
or regulations as required to administer and manage CHAMPUS effectively.
(v) Evidence of eligibility.
The Department
of Defense, through the Defense Enrollment Eligibility Reporting
System (DEERS), is responsible for establishing and maintaining
a listing of persons eligible to receive benefits under CHAMPUS.
Identification cards or devices bearing information necessary for preliminary
evidence of eligibility, subject to verification through the DEERS,
shall be issued to eligible persons by the appropriate Uniformed
Services (DoD 1341.1-M, “Defense Enrollment Eligibility Reporting
System (DEERS) Program Manual”).
(d) Medical benefits
program.
The
CHAMPUS is a program of medical benefits provided by the U.S. Government
under public law to specified categories of individuals who are
qualified for these benefits by virtue of their relationship to
one of the seven Uniformed Services. Although similar in structure
in many of its aspects, CHAMPUS is not an insurance program in that
it does not involve a contract guaranteeing the indemnification
of an insured party against a specified loss in return for a premium
paid. Further, CHAMPUS is not subject to those state regulatory
bodies or agencies that control the insurance business generally.
(e) Program funds.
The funds used
by CHAMPUS are appropriated funds furnished by the Congress through
the annual appropriation acts for the Department of Defense and
the DHHS. These funds are further disbursed by agents of the government
under contracts negotiated by the Director, OCHAMPUS, or a designee,
under the provisions of the Federal Acquisition Regulation (FAR).
These agents (referred to in this part as CHAMPUS fiscal intermediaries)
receive claims against CHAMPUS and adjudicate the claims under this
part and in accordance with administrative procedures and instructions
prescribed in their contracts. The funds expended for CHAMPUS benefits
are federal funds provided CHAMPUS fiscal intermediaries solely
to pay CHAMPUS claims, and are not a part of or obtained from the
CHAMPUS fiscal intermediary’s funds related to other programs or
insurance coverage. CHAMPUS fiscal intermediaries are reimbursed
for the adjudication and payment of CHAMPUS claims at a rate (generally
fixed-price) prescribed in their contracts.
(f)
Claims
adjudication and processing.
The Director, OCHAMPUS, is responsible for
making such arrangements as are necessary to adjudicate and process
CHAMPUS claims worldwide.
(1) The United States--
(i) Contracting out.
The primary method of processing
CHAMPUS claims in the United States is through competitively procured,
fixed-price contracts. The Director, OCHAMPUS, or a designee, is
responsible for negotiating, under the provisions of the FAR, contracts
for the purpose of adjudicating and processing CHAMPUS claims (and
related supporting activities).
(ii) In-house.
The Director,
OCHAMPUS, or a designee, is authorized to adjudicate and process certain
CHAMPUS claims in-house at OCHAMPUS, when it is determined to be
in the best interests of CHAMPUS subject to applicable considerations
set forth in OMB Circular A-76. Such in-house claims processing
may involve special or unique claims, or all claims for a specific
geographic area.
(2) Outside the United States--
(i) Special subsidiary office or contracting out.
For adjudicating
and processing CHAMPUS claims for services or supplies provided
outside the United States, the Director, OCHAMPUS, or a designee,
has the option of either setting up a special subsidiary claims
paying operation (such as OCHAMPUSEUR) or contracting out as described
in paragraph (f)(1)(i) of this section. Such claims paying operations
are reviewed periodically to determine whether current arrangements continue
to be appropriate and the most effective.
(ii) Support agreements.
In those situations
outside the United States that demand special arrangements, the
Director, OCHAMPUS, may enter into support agreements through the
Department of Defense with any of the Military Departments or other
government agency to process CHAMPUS claims in specific geographic
locations. Such agreements may be negotiated for such period of
time as the Director, OCHAMPUS, or designee, may determine to be
necessary to meet identified special demands.
(g) Recommendations
for change to part.
The Director, OCHAMPUS, or a designee, shall
establish procedures for receiving and processing recommendations
for changes to this part from interested parties.
(h) CHAMPUS, claims
forms.
The
Director, OCHAMPUS, or a designee, is responsible for the development
and updating of all CHAMPUS claim forms and any other forms necessary
in the administration of CHAMPUS.
(i) The CHAMPUS handbook.
The Director,
OCHAMPUS, or a designee, shall develop the CHAMPUS, Handbook. The
CHAMPUS Handbook is a general program guide for the use of CHAMPUS beneficiaries
and providers and shall be updated, as required.
(j) Program integrity.
The Director,
OCHAMPUS, or a designee, shall oversee all CHAMPUS personnel, fiscal
intermediaries, providers, and beneficiaries to ensure compliance
with this part. The Director, OCHAMPUS, or a designee, shall accomplish
this by means of proper delegation of authority, separation of responsibilities,
establishment of reports, performance evaluations, internal and
external management and fiscal audits, personal or delegated reviews
of CHAMPUS responsibilities, taking affidavits, exchange of information
among state and Federal governmental agencies, insurers, providers
and associations of providers, and such other means as may be appropriate.
Compliance with law and this part shall include compliance with
specific contracts and agreements, regardless of form, and general
instructions, such as CHAMPUS policies, instructions, procedures,
and criteria relating to CHAMPUS operation.
(k) Role of CHAMPUS
Health Benefits Advisor (HBA).
The CHAMPUS HBA is appointed (generally by
the commander of a Uniformed Services medical treatment facility)
to serve as an advisor to patients and staff in matters involving
CHAMPUS. The CHAMPUS HBA may assist beneficiaries or sponsors in applying
for CHAMPUS benefits, in the preparation of claims, and in their
relations with OCHAMPUS and CHAMPUS fiscal intermediaries. However,
the CHAMPUS HBA is not responsible for CHAMPUS policies and procedures
and has no authority to make benefit determinations or obligate
Government funds. Advice given to beneficiaries as to determination
of benefits or level of payment is not binding on OCHAMPUS or CHAMPUS
fiscal intermediaries.
(l) Cooperation and
exchange of information with other Federal programs.
The Director, OCHAMPUS,
or a designee, shall disclose to appropriate officers or employees
of the DHHS:
(1) Investigation
for fraud.
The
name and address of any physician or other individual actively being investigated
for possible fraud in connection with CHAMPUS, and the nature of
such suspected fraud. An active investigation exists when there
is significant evidence supporting an initial complaint but there
is need for further investigation.
(2) Unnecessary services.
The name and
address of any provider of medical services, organization, or other
person found, after consultation with an appropriate professional
association or appropriate peer review body, to have provided unnecessary
services. Such information will be released only for the purpose
of conducting an investigation or prosecution, or for the administration
of titles XVIII and XIX of the Social Security Act, provided that
the information will be released only to the agency’s enforcement
branch and that the agency will preserve the confidentiality of
the information received and will not disclose such information
for other than program purposes.
(m) Disclosure of information
to the public.
Records
and information acquired in the administration of CHAMPUS are records
of the Department of Defense and may be disclosed in accordance
with DoD Directive 5400.7
, DoD 5400.7-R
,
and DoD 5400.11-R
(codified
in 32 CFR parts 286 and 286a), constituting the applicable DoD Directives
and DoD Regulations implementing the Freedom of Information and
the Privacy Acts.
(n) Discretionary authority.
When it is determined
to be in the best interest of CHAMPUS, the Director, OCHAMPUS, or
a designee, is granted discretionary authority to waive any requirements
of this part, except that any requirement specifically set forth
in 10 U.S.C. chapter 55, or otherwise imposed by law, may not be
waived. It is the intent that such discretionary authority be used
only under very unusual and limited circumstances and not to deny
any individual any right, benefit, or privilege provided to him
or her by statute or this part. Any such exception granted by the
Director, OCHAMPUS, or a designee, shall apply only to the individual
circumstance or case involved and will in no way be construed to
be precedent-setting.
(o) Demonstration projects.
(1) Authority.
The Director,
OCHAMPUS may waive or alter any requirements of this regulation
in connection with the conduct of a demonstration project required
or authorized by law except for any requirement that may not be
waived or altered pursuant to 10 U.S.C. chapter 55, or other applicable
law.
(2) Procedures.
At least 30
days prior to taking effect, OCHAMPUS shall publish a notice describing the
demonstration project, the requirements of this regulation being
waived or altered under paragraph (o)(1) of this section and the
duration of the waiver or alteration. Consistent with the purpose
and nature of demonstration projects, these notices are not covered
by public comment practices under DoD Directive 5400.9 (32 CFR part
296) or DoD Instruction 6010.8.
(3) Definition.
For purposes
of this section, a “demonstration project” is a project of limited
duration designed to test a different method for the finance, delivery
or administration of health care activities for the uniformed services.
Demonstration projects may be required or authorized by 10 U.S.C.
1092, any other statutory provision requiring or authorizing a demonstration
project or any other provision of law that authorizes the activity
involved in the demonstration project.
(p) Military-Civilian
Health Services Partnership Program.
The Secretary of Defense,
or designee, may enter into an agreement (external or internal)
providing for the sharing of resources between facilities of the
uniformed services and facilities of a civilian health care provider
or providers if the Secretary determines that such an agreement
would result in the delivery of health care in a more effective,
efficient or economical manner. This partnership allows CHAMPUS
beneficiaries to receive inpatient and outpatient services through
CHAMPUS from civilian personnel providing health care services in
military treatment facilities and from uniformed service professional
providers in civilian facilities. The policies and procedures by
which partnership agreements may be executed are set forth in Department
of Defense Instruction (DoDI) 6010.12, “Military-Civilian Health
Services Partnership Program.” The Director, OCHAMPUS, or a designee,
shall issue policies, instructions, procedures, guidelines, standards,
or criteria as may be necessary to provide support for implementation
of DoDI 6010.12, to promulgate and manage benefit and financial
policy issues, and to develop a program evaluation process to ensure
the Partnership Program accomplishes the purpose for which it was developed.
(1) Partnership agreements.
Military treatment
facility commanders, based upon the authority provided by their
representative Surgeons General of the military departments, are
responsible for entering into individual partnership agreements
only when they have determined specifically that use of the Partnership
Program is more economical overall to the Government than referring
the need for health care services to the civilian community under
the normal operation of the CHAMPUS Program. All such agreements
are subject to the review and approval of the Director, OCHAMPUS,
or designee, and the appropriate Surgeon General.
(i) External Partnership
Agreements.
The
external partnership agreement is an agreement between a military
treatment facility Commander and a CHAMPUS-authorized institutional
provider, enabling Uniformed Services health care personnel to provide
otherwise covered medical care to CHAMPUS beneficiaries in a civilian
facility. Authorized costs associated with the use of the facility
will be financed through CHAMPUS under normal cost-sharing and reimbursement
procedures currently applicable under the basic CHAMPUS. Savings
will be realized under this type of agreement by using available military
health care personnel to avoid the civilian professional provider
charges which would otherwise be billed to CHAMPUS.
(ii) Internal Partnership
Agreements.
The
internal partnership agreement is an agreement between a military
treatment facility commander and a CHAMPUS-authorized civilian health
care provider which enables the use of civilian health care personnel
or other resources to provide medical care to CHAMPUS beneficiaries
on the premises of a military treatment facility. These internal
agreements may be established when a military treatment facility
is unable to provide sufficient health care services for CHAMPUS
beneficiaries due to shortages of personnel and other required resources.
In addition to allowing the military treatment facility to achieve
maximum use of available facility space, the internal agreement
will result in savings to the Government by using civilian medical
specialists to provide inpatient care in Government-owned facilities,
thereby avoiding the civilian facility charges which would have
otherwise been billed to CHAMPUS.
(2) Beneficiary Cost-Sharing.
Beneficiary
cost-sharing under the Partnership Program is outlined in Sec. 199.4(f)(5)
of this part.
(3) Reimbursement.
Reimbursement under the Partnership
Program is outlined in Sec. 199.14(f) of this part.
(4) Beneficiary Eligibility
and Authorized Providers.
Existing requirements of this Regulation remain
in effect as concerns beneficiary eligibility and authorized providers.
(5) Range of Benefits.
Health care
services provided CHAMPUS beneficiaries under the terms of the Partnership
Program must be consistent with the CHAMPUS range of benefits outlined
in this Regulation. The services rendered must be otherwise covered.
Charges allowed for professional services provided under the Partnership
Program may include costs of support personnel, equipment, and supplies
when specifically outlined in the partnership agreement, However,
all CHAMPUS coverage and provider requirements must be met.
(q) Equality of benefits.
All claims submitted
for benefits under CHAMPUS shall be adjudicated in a consistent,
fair, and equitable manner, without regard to the rank of the sponsor.
(r) TRICARE program.
Many rules and
procedures established in sections of this part are subject to revision
in areas where the TRICARE program is implemented. The TRICARE program
is the means by which managed care activities designed to improve
the delivery and financing of health care services in the Military
Health Services System (MHSS) are carried out. Rules and procedures
for the TRICARE program are set forth in Sec. 199.17.
[51 FR 24008, Jul 1, 1986, as amended at
52 FR 38754, Oct 19, 1987; 53 FR 27961, Jul 26, 1988; 55 FR 43338,
Oct 29, 1990; 60 FR 52094, Oct 5, 1995]