(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]