(a) Purpose and applicability.
(1) The
purpose of this section is to implement, with respect to health
care services provided under the supplemental health care program
for active duty members of the uniformed services, the provision
of 10 U.S.C. 1074(c). This section of law authorizes DoD to establish
for the supplemental care program the same payment rules, subject
to appropriate modifications, as apply under CHAMPUS.
(2) This
section applies to the program, known as the supplemental care program,
which provides for the payment by the uniformed services to private
sector health care providers for health care services provided to
active duty members of the uniformed services. Although not part
of CHAMPUS, the supplemental care program is similar to CHAMPUS
in that it is a program for the uniformed services to purchase civilian
health care services for active duty members. For this reason, the
Director, OCHAMPUS assists the uniformed services in the administration
of the supplemental care program.
(3) This
section applies to all health care services covered by the CHAMPUS.
For purposes of this section, health care services ordered by a
military treatment facility (MTF) provider for an MTF patient (who
is not an active duty member) for whom the MTF provider maintains
responsibility are also covered by the supplemental care program
and subject to the requirements of this section.
(b) Obligation of providers
concerning payment for supplemental health care for active duty members--
(1) Hospitals covered
by DRG-based payment system.
For a hospital covered by the CHAMPUS DRG-based
payment system to maintain its status as an authorized provider
for CHAMPUS pursuant to Sec. 199.6, that hospital must also be a
participating provider for purposes of the supplemental care program.
As a participating provider, each hospital must accept the DRG-based payment
system amount determined pursuant to Sec. 199.14 as payment in full
for the hospital services covered by the system. The failure of
any hospital to comply with this obligation subjects that hospital
to exclusion as a CHAMPUS-authorized provider.
(2) Other participating
providers.
For
any institutional or individual provider, other than those described
in paragraph (b)(1) of this section that is a participating provider,
the provider must also be a participating provider for purposes
of the supplemental care program. The provider must accept the CHAMPUS
allowable amount determined pursuant to Sec. 199.14 as payment in
full for the hospital services covered by the system. The failure
of any provider to comply with this obligation subjects the provider
to exclusion as a participating provider.
(c) General rule for
payment and administration.
Subject to the special rules and procedures
in paragraph (d) of this section and the waiver authority in paragraph
(e) of this section, as a general rule the provisions of Sec. 199.14
shall govern payment and administration of claims under the supplemental
care program as they do claims under CHAMPUS. To the extent necessary
to interpret or implement the provisions of Sec. 199.14, related
provisions of this part shall also be applicable.
(d) Special rules and
procedure.
As
exceptions to the general rule in paragraph (c) of this section, the
special rules and procedures in this section shall govern payment
and administration of claims under the supplemental care program.
These special rules and procedures are subject to the TRICARE Prime
Remote program for active duty service members set forth in paragraph
(e) of this section and the waiver authority of paragraph (f) of
this section.
(1) There is no patient
cost sharing under the supplemental care program. All amounts due
to be paid to the provider shall be paid by the program.
(2) Preauthorization
by the Uniformed Services of each service is required for the supplemental
care program except for services in cases of medical emergency (for
which the definition in Sec. 199.2 shall apply) or in cases governed
by the TRICARE Prime Remote program for active duty service members
set forth in paragraph (e) of this section. It is the responsibility
of the active duty members to obtain preauthorization for each service.
With respect to each emergency inpatient admission, after such time as
the emergency condition is addressed, authorization for any proposed
continued stay must be obtained within two working days of admission.
(3) With
respect to the filing of claims and similar administrative matters
for which this part refers to activities of the CHAMPUS fiscal intermediaries,
for purposes of the supplemental care program, responsibilities
for claims processing, payment and some other administrative matters
may be assigned by the Director, OCHAMPUS to the same fiscal intermediaries,
other contractor, or to the nearest military medical treatment facility
or medical claims office.
(4) The annual cost
pass-throughs for capital and direct medical education costs that
are available under the CHAMPUS DRG-based payment system are also
available, upon request, under the supplemental care program. To
obtain payment include the number of active duty bed days as a separate
line item on the annual request to the CHAMPUS fiscal intermediaries.
(5) For
providers other than participating providers, the Director, OCHAMPUS
may authorize payment in excess of CHAMPUS allowable amounts. No
provider may bill an active duty member any amount in excess of
the CHAMPUS allowable amount.
(e) TRICARE Prime Remote
for Active Duty Members.
(1) General.
The TRICARE
Prime Remote (TPR) program is available for certain active duty
members of the Uniformed Services assigned to remote locations in
the United States and the District of Columbia who are entitled
to coverage of medical care, and the standards for timely access
to such care, outside a military treatment facility that are comparable
to coverage for medical care and standards for timely access to
such care as exist under TRICARE Prime under Sec. 199.17. Those
active duty members who are eligible under the provisions of 10
U.S.C. 1074(c)(3) and who enroll in the TRICARE Prime Remote program,
may not be required to receive routine primary medical care at a
military medical treatment facility.
(2) Eligibility.
To receive health
care services under the TRICARE Prime Remote program, an individual
must be an active duty member of the Uniformed Services on orders
for more than thirty consecutive days who meet the following requirements:
(i) Has
a permanent duty assignment that is greater than fifty miles or
approximately one hour drive from a military treatment facility
or military clinic designated as adequate to provide the needed primary
care services to the active duty service member; and
(ii) Pursuant
to the assignment of such duty, resides at a location that is greater
than fifty miles or approximately one hour from a military medical
treatment facility or military clinic designated as adequate to
provide the needed primary care services to the active duty service
member.
(3) Enrollment.
An active duty
service member eligible for the TRICARE Prime Remote program must enroll
in the program. If an eligible active duty member does not enroll
in the TRICARE Prime Remote program, the member shall receive health
care services provide under the supplemental health program subject
to all requirements of this section without application of the provisions
of paragraph (e) of this section.
(4) Preauthorization.
If a TRICARE
Prime network under Sec. 199.17 exists in the remote location, the TRICARE
Prime Remote enrolled active duty member will select or be assigned
a primary care manager. In the absence of a TRICARE primary care
manager in the remote location and if the active duty member is
not assigned to a military primary care manager based on fitness
for duty requirements, the TRICARE Prime Remote enrolled active
duty member may use a local TRICARE authorized provider for primary
health care services without preauthorization. Any referral for
specialty care will require the TRICARE Prime Remote enrolled active
duty member to obtain preauthorization for such services.
(f) Waiver authority.
With the exception
of statutory requirements, any restrictions or limitations pursuant
to the general rule in paragraph (c) of this section, and special
rules and procedures in paragraph (d) of this section, may be waived
by the Director, OCHAMPUS, at the request of an authorized official
of the uniformed service concerned, based on a determination that
such waiver is necessary to assure adequate availability of health
care services to active duty members.
(g) Authorities.
(1) The
Uniformed Services may establish additional procedures, consistent
with this part, for the effective administration of the supplemental
care program in their respective services.
(2) The
Assistant Secretary of Defense for Health Affairs is responsible
for the overall policy direction of the supplemental care program
and the administration of this part.
(3) The Director, OCHAMPUS
shall issue procedural requirements for the implementation of this section,
including requirement for claims submission similar to those established
by Sec. 199.7.
[56 FR 23801, May 24, 1991, as amended at
58 FR 58963, Nov 5, 1993; 67 FR 5479, Feb 6, 2002; 71 FR 50348,
Aug 25, 2006]