[Federal Register Volume 61, Number 227 (Friday, November 22, 1996)]
[Rules and Regulations]
[Pages 59337-59339]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-29571]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]
RIN-0720-AA26


Civilian Health and Medical Program of the Uniformed Services 
(CHAMPUS); Five Separate Changes

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

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SUMMARY: This final rule addresses five separate changes to comply with 
provisions affecting CHAMPUS. These changes will update this part to 
include as a benefit, a screen to check for the level of lead in the 
blood of an infant; to eliminate the implied statement that ambulance 
services are covered only to, from, and between hospitals; to include 
other forms of prescribed contraceptives by eliminating the reference 
that limits prescribed contraceptives only to those taken orally; to 
identify three additional Gulf Conflict groups eligible for the delay 
in the increased deductible; and to establish lower limits on the 
fiscal year catastrophic cap from $10,000 to $7,500 for all eligibles 
except dependents of active duty personnel, whose limit remains at 
$1,000.

EFFECTIVE DATE: This final rule is effective February 20, 1997 except 
for the changes in section 199.4 which are listed below:
    1. Paragraph (c)(3)(xi)(A)(7) is effective December 5, 1991;
    2. Paragraph (e)(3)(i)(A)(3) is effective October 29, 1992;
    3. Paragraph (f)(2)(i)(G) is effective on October 1, 1991; and
    4. Paragraph (f)(10) is effective on October 1, 1992.

ADDRESSES: Office of the Civilian Health and Medical Program of the 
Uniformed Services (OCHAMPUS), Program Development Branch, Aurora, CO 
80045-6900.

FOR FURTHER INFORMATION CONTACT:
Margaret Brown, Program Development Branch, OCHAMPUS, telephone (303) 
361-1181.

SUPPLEMENTARY INFORMATION: A proposed rule regarding these changes was 
published in the Federal Register on March 21, 1995 (60 FR 14920). Our 
responses to those comments received regarding the proposed rule may be 
found in the review of comments section of this final rule.
    32 CFR 199.4 lists Basic Program benefits including exclusions and 
limitations. Paragraph (c) defines, in general terms, the scope of 
reimbursable services provided by physicians and other authorized 
individual professional providers; paragraph (e) extends benefits under 
certain circumstances, to conditions and limitations that are subject 
to applicable definitions, conditions, or exclusions that are set forth 
in this or other sections of this part; and paragraph (f) identifies 
the liabilities, in the form of cost-shares and deductibles, to be paid 
by beneficiaries or sponsors.
    Well-baby care: Paragraph (c)(3)(xi), provides for certain well-
baby care services for infants up to the age of two years. A paragraph 
(c)(3)(xi)(A)(7) is added to list blood lead test as a benefit for 
infants. This change is effective for services provided on or after 
December 5, 1991.
    Ambulance service: Ambulance services are covered between points 
deemed to be medically necessary for the covered medical condition, 
therefore, the restrictive language, ``to, from, and between 
hospitals'' is removed from paragraph (d)(3)(v).
    Family planning: Paragraph (e)(3) provides for a family planning 
benefit. Paragraph (e)(3)(i)(A)(3) of this section allows benefits for 
prescribed oral contraceptives. With the development of new methods of 
contraception, prescribed contraceptives are no longer limited to those 
taken orally. We have, therefore, amended that paragraph by removing 
the word ``oral'' to expand the coverage accordingly.
    Financial liability-deductibles: Under paragraph (f) of this 
section, CHAMPUS beneficiaries and sponsors have some financial 
responsibility when medical care is received from civilian sources. 
Financial liability is imposed in order to encourage use of the 
Uniformed Services direct medical care system whenever facilities and 
services are available. Beneficiaries are responsible for payment of 
certain deductibles and cost-sharing amounts in connection with 
otherwise covered services and supplies. The cost-share and deductible

[[Page 59338]]

amounts are controlled by statute and subject to change by 
congressional action. Previous legislation had deferred a statutory 
increase in the deductible amount from April 1, 1991 to October 1, 
1991, for dependents of active duty members who served in the Gulf 
Conflict. The National Defense Authorization Act for Fiscal Year 1993 
contains language which prompts a revision of paragraph (f)(2)(i)(G) of 
this section to identify three new groups of Gulf Conflict 
beneficiaries, besides the dependents of active duty members, eligible 
for the delay in the increased deductibles, and to allow credit or 
reimbursement of excess amounts inadvertently paid by those groups 
subject to availability of appropriated funds.
    Catastrophic loss: The National Defense Authorization Act for 
Fiscal Years 1988 and 1989 (Pub. L. 100-180) amended Title 10, United 
States Code and established catastrophic loss protection for CHAMPUS 
beneficiaries on a government fiscal year basis. The law placed fiscal 
year limits or catastrophic caps on beneficiary liability for cost-
shares and deductibles under the CHAMPUS Basic Program. After the 
fiscal year cap is met by the beneficiary, the CHAMPUS-determined 
allowable amounts for all covered services or supplies received under 
the Basic Program are to be paid in full by CHAMPUS.
    For dependents of active duty members, the maximum family liability 
is $1,000 for deductibles and cost-shares based on allowed charges for 
the Basic Program services and supplies received in a fiscal year. For 
all other categories of beneficiary families, the previous fiscal year 
cap of $10,000 under Public Law 100-180 has been reduced under the 1993 
Defense Authorization Act (Pub. L. 102-484) to $7,500. This final rule 
implements the law which reduces the fiscal year catastrophic loss 
protection cap for all categories of beneficiaries other than those of 
active duty dependents, effective for Basic Program services and 
supplies received on or after October 1, 1992.

Review of Comments

    As a result of the proposed rule, the following comments were 
received from interested associations and agencies.
    Comment: The Air Force Consultant for Pediatrics recommended that 
the blood lead level screening should be extended to siblings above the 
age of two years in cases where an infant tested positive on the 
initial lead level screen.
    Response: The inclusion of a lead level screening in the absence of 
symptoms was promulgated by statute in 10 U.S.C. chapter 55, section 
1077(a)(8), and covers only infants. Other necessary laboratory 
services for all CHAMPUS eligibles are available through Chapter 4 of 
DoD 6010.8-R, to confirm or establish suspected symptoms.
    Comment: One comment suggested that we reconsider removing the 
long-standing exclusion of aversion therapy for the treatment of 
alcoholism as CHAMPUS currently reimburses less intrusive therapies.
    Response: We based our intent to remove the long-standing exclusion 
of aversion therapy on an assessment performed by the Agency for Health 
Care Policy and Research. The assessment concluded that chemical 
aversion conditioning is no less effective than other therapies for 
alcoholism when it is provided following the failure of less intrusive 
therapies. To be certain that the removal of the exclusionary language 
was in the best interest of our beneficiaries, we performed a 
literature search looking for well-controlled studies of clinically 
meaningful endpoints, published in the referred medical literature that 
would support that chemical aversion therapy was safe, effective and 
comparable to current therapies. Failing to find such well-controlled 
studies, we agree that the exclusion of chemical aversion therapy 
should remain.

Summary of Regulatory Modifications

    The following modifications were made as a result of suggestions 
received during the public comment period:
    (1) Paragraph (e)(3)(i)(A)(3) was amended to read, ``Prescription 
contraceptives.''
    (2) Several editorial comments were received. All of these comments 
were adopted and incorporated into the final rule.
    Regulatory Procedures: Executive Order 12866 requires that a 
regulatory impact analysis be performed on any major rule. A ``major 
rule'' is defined as one which would result in an annual effect on the 
national economy of $100 million or more or have other substantial 
impacts.
    The Regulatory Flexibility Act (RFA) requires that each federal 
agency prepare, and make available for public comment, a regulatory 
flexibility analysis when the agency issues a regulation which would 
have a significant impact on a substantial number of small entities.
    This final rule is not a major rule under Executive Order 12866, 
and it would not have a significant impact on a substantial number of 
small entities. The changes set forth in this final rule are minor 
revisions to the existing part. This rule does not impose information 
collection requirements. Therefore, it does not need to be reviewed by 
the Executive Office of Management and Budget under authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520).

List of Subjects in 32 CFR Part 199

    Claims, Handicapped, Health insurance, and Military personnel.

    Accordingly, 32 CFR part 199 is amended as follows:

PART 199--[AMENDED]

    1. The authority citation for part 199 continues to read as 
follows:

    Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.

    2. Section 199.4 is amended by adding paragraph (c)(3)(xi)(A)(7); 
by revising paragraph (e)(3)(i)(A)(3) and the first sentence of both 
paragraphs (d)(3)(v) and (f)(2)(i)(G); and by adding paragraph (f)(10) 
to read as follows:


Sec. 199.4  Basic program benefits.

* * * * *
    (c) * * *
    (3) * * *
    (xi) * * *
    (A) * * *
    (7) Blood lead test. (Effective date December 5, 1991.)
* * * * *
    (d) * * *
    (3) * * *
    (v) Ambulance. Civilian ambulance service is covered when medically 
necessary in connection with otherwise covered services and supplies 
and a covered medical condition.
* * * * *
    (e) * * *
    (3) * * *
    (i) * * *
    (A) * * *
    (3) Prescription contraceptives.
* * * * *
    (f) * * *
    (2) * * *
    (i) * * *
    (G) Notwithstanding the dates specified in paragraphs (f)(2)(i)(A) 
and (f)(B)(2)(i) of this section in the case of dependents of active 
duty members of rank E-5 or above with Persian Gulf Conflict service, 
dependents of service members who were killed in the Gulf, or who died 
subsequent to Gulf service, and of members who retired prior to October 
1, 1991, after having served in the Gulf War, the deductible shall be 
the amount specified in paragraph (f)(2)(i)(A) of this section for care

[[Page 59339]]

rendered prior to October 1, 1991, and the amount specified in 
paragraph (f)(2)(i)(B) of this section for care rendered on or after 
October 1, 1991.
* * * * *
    (10) Catastrophic loss protection for basic program benefits. 
Fiscal year limits, or catastrophic caps, on the amounts beneficiaries 
are required to pay are established as follows:
    (i) Dependents of active duty members. The maximum family liability 
is $1,000 for deductibles and cost-shares based on allowable charges 
for Basic Program services and supplies received in a fiscal year.
    (ii) All other beneficiaries. For all other categories of 
beneficiary families (including those eligible under CHAMPVA) the 
fiscal year cap is $10,000.
    (iii) Payment after cap is met. After a family has paid the maximum 
cost-share and deductible amounts (dependents of active duty members 
$1,000 and all others $10,000), for a fiscal year, CHAMPUS will pay 
allowable amounts for remaining covered services through the end of 
that fiscal year.

    Note to paragraph (f)(10): Under the Defense Authorization Act 
for Fiscal Year 1993, the cap for beneficiaries other than 
dependents of active duty members was reduced from $10,000 to $7,500 
on October 1, 1992. The cap remains at $1,000 for dependents of 
active duty members.
* * * * *
    Dated: November 14, 1996.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 96-29571 Filed 11-21-96; 8:45 am]
BILLING CODE 5000-04-M