(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]