(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]