[Federal Register Volume 62, Number 66 (Monday, April 7, 1997)]
[Proposed Rules]
[Pages 16510-16513]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-8611]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); TRICARE Program; Nonavailability Statement Requirements
AGENCY: Office of the Secretary, DoD.
ACTION: Proposed rule.
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SUMMARY: This proposed rule revises certain requirements and procedures
for the TRICARE Program, the purpose of which is to implement a
comprehensive managed health care delivery system composed of military
medical treatment facilities and CHAMPUS. Issues addressed in this
proposed rule include priority for access to care in military treatment
facilities and requirements for payment of enrollment fees. This
proposed rule also includes provisions revising the requirement that
certain beneficiaries obtain a non-availability statement from a
military treatment facility commander prior to receiving certain health
care services from civilian providers.
DATES: Comments must be received on or before June 6, 1997.
ADDRESSES: Forward comments to Office of the Civilian Health and
Medical Program of the Uniformed Services (OCHAMPUS), Program
Development Branch, Aurora, CO 80045-6900.
FOR FURTHER INFORMATION CONTACT: Steve Lillie, Office of the Assistant
Secretary of Defense (Health Affairs), telephone (703) 695-3350.
Questions regarding payment of specific claims under the CHAMPUS
allowable charge method should be addressed to the appropriate CHAMPUS
contractor.
SUPPLEMENTARY INFORMATION:
I. Introduction and Background
A. Congressional Action
Section 712 of the National Defense Authorization Act for Fiscal
Year 1996 revised 10 U.S.C. 1097(c), regarding the role of military
medical treatment facilities in managed care initiatives, including
TRICARE. Prior to the revision, section 1097(c) read in part,
``However, the Secretary may, as an incentive for enrollment, establish
reasonable preferences for services in facilities of the uniformed
services for covered beneficiaries enrolled in any program established
under, or operating in connection with, any contract under this
section.'' The Authorization Act provision replaced ``may'' with
``shall'', which has the effect of directing priority access for
TRICARE Prime enrollees over persons not enrolled.
Another statutory provision relating to access priority is 10
U.S.C. 1076(a), which establishes a special priority for survivors of
sponsors who died on active duty: they are given the same priority as
family members of active duty members. This special access priority is
not time-limited, as is the special one-year cost sharing protection
given to this category under 10 U.S.C. 1079.
The National Defense Authorization Act for FY 1997, section 734
amended 10 U.S.C. 1080 to establish certain exceptions to requirements
for nonavailability statements in connection with payment of claims for
civilian health care services. First, the Act eliminates authority for
nonavailability statements for outpatient services; NASs have been
required for a limited number of outpatient procedures over the past
several years. Second, the Act eliminates authority for NAS
requirements for enrollees in managed care plans, which has the effect
of eliminating NAS requirements for TRICARE Prime enrollees. Finally,
the Act gives the Secretary authority to waive NAS requirements based
on an
[[Page 16511]]
evaluation of the effectiveness of NAS in optimizing use of military
facilities.
The National Defense Authorization Act for FY 1996, section 713
requires that enrollees in TRICARE Prime be permitted to pay applicable
enrollment fees on a quarterly basis, and prohibits imposition of an
administrative fee related to the quarterly payment option.
B. Provisions of the Proposed Rule
1. Access Priority (proposed revisions to section 199.17(d)). This
paragraph explains that in regions where TRICARE is implemented, the
order of access priority for services in military treatment facilities
is as follows: (1) active duty service members; (2) family members of
active duty service members enrolled in TRICARE Prime; (3) retirees,
their family members and survivors enrolled in TRICARE Prime; (4)
family members of active duty service members who are not enrolled in
TRICARE Prime; and (5) all others based on current access priorities.
For purposes of access priority, but not for cost sharing, survivors of
sponsors who died on active duty are to be given the same priority as
family members of active duty service members. This means that if they
are enrolled in TRICARE Prime, they have the same access priority as
family members of active duty service members, or if not enrolled in
TRICARE Prime, they have the same access priority for military
treatment facility care as family members of active duty service
members who are not enrolled in TRICARE Prime.
The proposed rule also includes a provision explaining that
enrollment status does not affect access priority for some groups and
circumstances. This provision would allow the commander of a military
medical treatment facility to designate for priority access certain
individuals, for specific episodes of health care treatment. Such
individuals may include Secretarial designees, active duty family
members from outside the MTF's service area, foreign military and their
family members authorized care through international agreements, DoD
civilians with authorizing conditions, individuals on the Temporary
Disability Retired List, and Reserve and National Guard members.
Additional exceptions may be granted for other categories of
individuals, eligible for treatment in the MTF, whose access to care is
needed to provide a clinical case mix to support graduate medical
education programs, upon approval by the Assistant Secretary of Defense
(Health Affairs).
2. Enrollment Fees (proposed revisions to section 199.17(o) and
199.18(c)). These revisions would eliminate the requirement for a
TRICARE Prime enrollee to pay an additional maintenance fee of $5.00
per installment for those TRICARE Prime enrollees who elect to pay
their annual enrollment fee on a quarterly basis. Additionally, these
revisions would permit waiver of enrollment fee collection for
retirees, their family members, and survivors who are eligible for
Medicare on the basis of disability. This group is eligible for
TRICARE/CHAMPUS as a secondary payor if they are enrolled in Part B of
Medicare, and pay the applicable monthly premium.
3. Nonavailability Statements (proposed revisions to section
199.4(a)). Revisions to this section modify our exiting requirements
for beneficiaries to obtain nonavailability statements (NASs). The
requirement for beneficiaries to obtain an NAS for selected outpatient
procedures is eliminated. Beneficiaries who choose to obtain outpatient
care, including ambulatory surgery, from civilian sources remain
subject to current TRICARE/CHAMPUS cost sharing rules, but the
requirement that the beneficiary obtain an NAS prior to TRICARE/CHAMPUS
sharing in the civilian health care costs has been removed.
The requirement for beneficiaries enrolled in TRICARE Prime to
obtain an NAS for inpatient care is also eliminated. TRICARE was
designed so that the military treatment facility is the first source of
specialty care, with TRICARE Prime enrollees having access priority
before non-enrolled beneficiaries. In general, TRICARE Prime enrollees
obtain care from civilian network providers only when the military
treatment facility cannot provide the care because it does not have the
capability, or because the enrollee cannot be seen within time frames
required by TRICARE Prime access standards. Since the Health Care
Finder must authorize all non-emergency specialty care obtained from
civilian sources, the NAS requirement for this category of beneficiary
is redundant.
Lastly, the revisions would eliminate the requirement that a non-
enrolled beneficiary must obtain an NAS for inpatient hospital
maternity care before TRICARE/CHAMPUS shares in any costs for related
outpatient maternity care. Some diagnostic tests, procedures, or
consultations from civilian sources may be required during a course of
maternity care and this allows TRICARE/CHAMPUS to share in the costs of
the civilian care without requiring the beneficiary to obtain all
maternity related care in a civilian setting.
4. Revisions to the Uniform HMO Benefit. We are contemplating minor
changes in the copayment structure of the Uniform HMO Benefit, which is
used in TRICARE Prime. The proposed rule includes two revisions, which
would eliminate copayments for preventive services and for ancillary
services. Current provisions include copayments for ancillary services
unless they are provided as part of an office visit. This has resulted
in multiple copayments in cases where beneficiaries are sent to
multiple sites for diagnostic testing pursuant to a visit, which we
regard as unfair.
Suggestions for additional minor changes to the Uniform HMO benefit
will be considered. We will need to maintain compliance with the
statutory requirements of overall budget neutrality and for reduced
beneficiary out-of-pocket costs.
5. Other provisions. The proposed rule also includes new provisions
regarding two issues. The first is the inapplicability of the TRICARE
Prime annual catastrophic cap to out-of-pocket costs incurred under the
TRICARE Prime point-of-service option. This is at section 199.18(f)(2).
Also, a restatement of current policy, at section 199.17(a)(7), records
DoD interpretation of two statutory provisions preempting state laws in
connection with TRICARE contracts.
C. Regulatory Procedures
Executive Order 12866 requires certain regulatory assessments for
any ``significant regulatory action,'' defined as one which would
result in an annual effort on the 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 is not a significant regulatory action under the provisions of
Executive Order 12866, and it would not have a significant impact on a
substantial number of small entities.
This proposed rule will impose no additional information collection
requirements on the public under the Paperwork Reduction Act of 1980
(44 USC 3501-3511).
This is a proposed rule. Public comments are invited. All comments
will be considered. A discussion of the major issues raised by public
comments will be included with issuance of the final rule, anticipated
approximately 60
[[Page 16512]]
days after the end of the comment period.
List of Subjects in 32 CFR Part 199
Claims, Handicapped, Health insurance, and Military personnel.
Accordingly, 32 CFR Part 199 is proposed to be 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 199.2(b) is proposed to be amended by revising the
definition of ``nonavailability statement'' to read as follows:
Sec. 199.2 Definitions.
* * * * *
(b) * * *
Nonavailability statement. A certification by a commander (or a
designee) of a Uniformed Services medical treatment facility, recorded
on DEERS, generally for the reason that the needed medical care being
requested by a non-TRICARE Prime enrolled beneficiary cannot be
provided at the facility concerned because the necessary resources are
not available in the time frame needed.
* * * * *
3. Section 199.4 is proposed to be amended by removing paragraphs
(a)(9)(i)(C) and (a)(9)(v)(B) and the note following paragraph
(a)((9)(vi), by redesignating paragraph (a)(9)(i)(D) as paragraph
(a)(9)(i)(C) and paragraph (a)(9)(v)(A) as paragraph (a)(9)(v), and by
revising paragraphs (a)(9) introductory text, (a)(9)(i)(B), and
(a)(9)(ii) and by adding new paragraph (a)(10)(vi)(E) to read as
follows:
Sec. 199.4 Basic program benefits.
* * * * *
(a) * * *
(9) Nonavailability statements within a 40-mile catchment area. In
some geographic locations, it is necessary for CHAMPUS beneficiaries
not enrolled in TRICARE Prime to determine whether the required
inpatient medical care can be provided through a Uniformed Services
facility. If the required care cannot be provided, the hospital
commander, or designee, will issue a Nonavailability Statement (DD form
1251). Except for emergencies, a Nonavailability Statement should be
issued before medical care is obtained from a civilian source. Failure
to secure such a statement may waive the beneficiary's rights to
benefits under CHAMPUS.
(i) * * *
(B) For CHAMPUS beneficiaries who are not enrolled in TRICARE
Prime, an NAS is required for services in connection with nonemergency
inpatient hospital care if such services are available at a facility of
the Uniformed Services located within a 40-mile radius of the residence
of the beneficiary, except that a NAS is not required for services
otherwise available at a facility of the Uniformed Services located
within a 40-mile radius of the beneficiary's residence when another
insurance plan or program provides the beneficiary primary coverage for
the services. This requirement for an NAS does not apply to
beneficiaries enrolled in TRICARE Prime, even when those beneficiaries
use the point-of-service option under section 199.17(n)(3).
* * * * *
(ii) Beneficiary responsibility. A CHAMPUS beneficiary who is not
enrolled in TRICARE Prime is responsible for securing information
whether or not he or she resides in a geographic area that requires
obtaining a Nonavailability Statement. Information concerning current
rules and regulations may be obtained from the Offices of the Army,
Navy, and Air Force Surgeons General; or a representative of the
TRICARE managed care support contractor's staff, or the Director,
OCHAMPUS.
* * * * *
(10) * * *
(vi) * * *
(E) The beneficiary is enrolled in TRICARE Prime.
3. Section 199.17 is proposed to be amended by adding paragraph
(a)(7) and revising paragraphs (d)(1) and (o)(3) to read as follows:
Sec. 199.17 TRICARE program.
(a) * * *
(7) Preemption of State laws. Pursuant to 10 U.S.C. 1103 and the
fourth proviso of section 8025 of the Department of Defense
Appropriations Act, 1994 (Pub. L. 103-139), any state or local law
relating to a health insurance, prepaid health plans, or other health
care delivery, administration, and financing methods is preempted and
does not apply in connection with TRICARE regional contracts. Any such
law, or regulation pursuant to such law, is without any force or
effect, and State or local governments have no legal authority to
enforce them in relation to the TRICARE regional contracts. (However,
the Department of Defense may, by contract, establish legal obligations
on the part of the TRICARE contractors to conform with requirements
similar or identical to requirements of State or local laws or
regulations.)
* * * * *
(d) * * *
(1) Military treatment facility (MTF) care. (i) In general. All
participants in Prime are eligible to receive care in military
treatment facilities. Participants in Prime will be given priority for
such care over other beneficiaries. Among the following beneficiary
groups, access priority for care in military treatment facilities where
TRICARE is implemented as follows: Active duty service members; active
duty service members' dependents who are enrolled in TRICARE Prime;
Retirees, their dependents and survivors who are enrolled in TRICARE
Prime; Active duty service member's dependents who are not enrolled in
TRICARE Prime; and Retirees, their dependents and survivors who are not
enrolled in TRICARE Prime. For purposes of this paragraph (d)(1),
survivors of members who died while on active duty are considered as
among dependents of active duty service members.
(ii) Special provisions. Enrollment in Prime does not affect access
priority for care in military treatment facilities for several
miscellaneous beneficiary groups and special circumstances. These
include Secretarial designees, NATO and other foreign military
personnel and dependents authorized care through international
agreements, civilian employees under workers' compensation programs or
under safety programs, members on the Temporary Disability Retired List
(for statutorily required periodic medical examinations), members of
the reserve components not on active duty (for covered medical
services), active duty dependents unable to enroll in Prime and
temporarily away from place of residence, and other beneficiary groups
as designated by the ASD(HA). Additional exceptions to the normal Prime
enrollment priority access rules may be granted for other categories of
individuals, eligible for treatment in the MTF, whose access to care is
necessary to provide an adequate clinical case mix to support graduate
medical education programs or readiness-related medical skills
sustainment activities, to the extent approved by the Assistant
Secretary of Defense (Health Affairs).
* * * * *
(o) * * *
(3) Quarterly installment payments of enrollment fee. The
enrollment fee required by Sec. 199.18(c) may be paid in quarterly
installments, each equal to one-fourth of the total amount. For any
beneficiary paying his or her enrollment
[[Page 16513]]
fee in quarterly installments, failure to make a required installment
payment on a timely basis (including a grace period, as determined by
the Director, OCHAMPUS) will result in termination of the beneficiary's
enrollment in Prime and disqualification from future enrollment in
Prime for a period of one year.
* * * * *
4. Section 199.18 is proposed to be amended by revising paragraphs
(d)(2)(i) and (f), and by adding paragraph (c)(3), to read as follows:
Sec. 199.18 Uniform HMO benefit.
* * * * *
(c) * * *
(3) Waiver of enrollment fee for certain beneficiaries. The
Assistant Secretary of Defense (Health Affairs) may waive the
enrollment fee requirements of this section for beneficiaries described
in 10 U.S.C. 1086(d)(2) (i.e., those who are eligible for Medicare on
the basis of disability or end stage renal disease and who maintain
enrollment in Part B of Medicare).
(d) * * *
(2) * * *
(i) For most physician office visits and other routine services,
there is a per visit fee for each of the following groups: dependents
of active duty members in pay grades E-1 through E-4; dependents of
active duty members in pay grades of E-5 and above; and retirees and
their dependents. This fee applies to primary care and specialty care
visits, except as provided elsewhere in this paragraph (d)(2) of this
section. It also applies family health services, home health care
visits, eye examinations, and immunizations. It does not apply to
ancillary health services or to preventive health services described in
paragraph (b)(2) of this section.
* * * * *
(f) Limit on out-of-pocket under the uniform HMO benefit. (1) Total
out-of-pocket costs per family of dependents of active duty members
under the Uniform HMO Benefit may not exceed $1,000 during the one-year
enrollment period. Total out-of-pocket costs per family of retired
members, dependents of retired members and survivors under the Uniform
HMO Benefit may not exceed $3,000 during the one-year enrollment
period. For this purpose, out-of-pocket costs means all payments
required of beneficiaries under paragraphs (c), (d), and (e) of this
section. In any case in which a family reaches this limit, all
remaining payments that would have been required of the beneficiary
under paragraphs (c), (d), and (e) of this section will be made by the
program in which the Uniform HMO Benefit is in effect.
(2) The limits established by paragraph (f)(1) of this section do
not apply to out-of-pocket costs incurred pursuant to paragraphs
(m)(1)(i) or (m)(2)(i) of Sec. 199.7 under the point-of-service option
of TRICARE Prime.
* * * * *
Dated: April 1, 1997.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 97-8611 Filed 4-4-97; 8:45 am]
BILLING CODE 5000-04-M