(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]