[Federal Register Volume 63, Number 30 (Friday, February 13, 1998)]
[Rules and Regulations]
[Pages 7287-7288]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-3502]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720-AA46


Civilian Health and Medical Program of the Uniformed Services 
(CHAMPUS); TRICARE Prime Balance Billing

AGENCY: Office of the Secretary, DOD.

ACTION: Interim final rule.

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SUMMARY: This interim final rule establishes financial protections for 
TRICARE Prime enrollees in limited circumstances when they receive 
covered services from a non-network provider. This rule is being 
published to provide protection for TRICARE Prime enrollees.

DATES: This rule is effective March 16, 1998. Public comments must be 
received by April 14, 1998.

ADDRESSES: TRICARE Support Office (TSO), Program Development Branch, 
Aurora, CO 80045-6900.

FOR FURTHER INFORMATION CONTACT:
Kathleen Larkin, 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 TRICARE/
CHAMPUS contractor.

SUPPLEMENTARY INFORMATION:

I. Overview of the Rule

    This interim final rule implements section 731 of the FY 1996 
National Defense Authorization Act and section 711 of the FY 1997 
National Defense Authorization Act which modified 10 U.S.C. 1079(h) to 
provide protections for TRICARE Prime enrollees from balance billing 
situations in limited circumstances. Each regional TRICARE managed care 
support contractor is required to establish a network of civilian 
providers in areas where TRICARE Prime (the enrollment option) is 
offered. As is standard for Health Maintenance Organizations, enrollees 
in TRICARE Prime receive care from network providers. But on occasion, 
such as when a network provider is not available, or in emergencies, 
they may receive covered services from non-network providers. This rule 
provides protection in these situations; TRICARE Prime enrollees will 
be responsible for their copayments, but not for balance billing by 
non-participating providers.

II. Rulemaking Procedures

    Executive order 12866 requires certain regulatory assessments for 
any significant regulatory action, defined as one which would result in 
an annual effect 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.
    It has determined that this is not a significant regulatory action.
    The interim final rule will not impose additional information 
collection requirements on the public under the Paperwork Reduction Act 
of 1995 (44 U.S.C. Chapter 55).
    This rule is being issued as an interim final rule, with comment 
period, as an exception to our standard practice of soliciting pubic 
comments prior to issuance. The Assistant Secretary of Defense (Health 
Affairs) has determined that following the standard practice in this 
case would be impracticable, unnecessary, and contrary to the pubic 
interest. This determination is based on several factors. First, this 
change directly implements a statutory amendment enacted by Congress 
expressly for this purpose. (See House Conference Report 104-724, p. 
762, and House Report 104-563, p. 318) Second, this rule implements the 
statutory policy without embellishment. The rule simply implements the 
unambiguous Congressional policy of adjusting TRICARE/CHAMPUS payment 
rates to protect Prime enrollees when receiving authorized care for 
nonparticipating providers. Third, implementation of the statutory 
amendment, enacted September 23, 1996, has already been substantially 
delayed because of a separate statutory provision (section 8008 of the 
Department of Defense Appropriations Act), which expired September 30, 
1997, and a further delay is unwarranted. Fourth, TRICARE Prime is a 
major ``quality of life'' program of the Department of Defense. Its 
success is of great importance to maintaining adequate retention rates 
of military personnel and, thus, the conduct of the military affairs 
function of the United States. Fifth, the unexpected imposition of 
balance billing requirements on TRICARE prime enrollees receiving 
authorized care has been voiced as a major complaint, undermining 
beneficiary trust in commitments made to Prime enrollees and ultimately 
the success of the TRICARE initiative. Public comments are invited. All 
comments will be carefully considered. A discussion of the major issues 
received by public comments will be included with the issuance of the 
permanent final rule, anticipated approximately 60 days after the end 
of the comment period.

List of Subjects in 32 CFR Part 199

    Claims, Health insurance, Individuals with disabilities, Military 
personnel, Reporting and recordkeeping requirements.

    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 199.14 is amended by adding paragraph (h)(1)(i)(D) to 
read as follows:


Sec. 199.14   Provider reimbursement methods.

* * * * *
    (h) Reimbursement of Individual Health Care Professionals and Other 
Non-Institutional Health-Care Providers. * * *
    (1) Allowable charge method. * * *

[[Page 7288]]

    (1) Introduction. * * *
    (D) Special rule for TRICARE Prime Enrollees. In the case of a 
TRICARE Prime enrollee (see Sec. 199.17) who receives authorized care 
from a non-participating provider, the CHAMPUS determined reasonable 
charge will be the CMAC level as established in paragraph (h)(1)(i)(B) 
of this section plus any balance billing amount up to the balance 
billing limit as referred to in paragraph (h)(1)(i)(C) of this section. 
The authorization for such care shall be pursuant to the procedures 
established by the Director, OCHAMPUS (also referred to as the TRICARE 
Support Office).
* * * * *
    Dated: February 6, 1998.
L.M. Bynum,
Alternate Federal Register Liaison Officer, Department of Defense.
[FR Doc. 98-3502 Filed 2-12-98; 8:45 am]
BILLING CODE 5000-04-M