[Federal Register Volume 63, Number 203 (Wednesday, October 21, 1998)]
[Rules and Regulations]
[Pages 56081-56082]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-28140]


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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: Final rule.

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SUMMARY: This final rule establishes financial protections for TRICARE 
Prime enrollees in limited circumstances when they receive covered 
services from a non-network provider.

DATES: This rule is effective March 16, 1998.

ADDRESSES: TRICARE Management Activity, Program Development Branch, 
Aurora, CO 80045-6900.

FOR FURTHER INFORMATION CONTACT:
Kathleen Larkin, Office of the Assistant Secretary of Defense (Health 
Affairs)/TRICARE Management Activity, telephone (703) 681-1745.
    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 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. Balance billing can otherwise occur when a 
provider bills a TRICARE Prime enrollee an actual charge in excess of 
the allowable amount. 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 and they are referred to a 
non-network provider, 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.
    Public Comments. The interim final rule was published in the 
Federal Register on February 13, 1998. We received one comment letter. 
We thank the commenter who approved of the Department's steps taken to 
further protect TRICARE Prime beneficiaries from the uncertainties of 
balance billing by non-network providers. The commenter also suggested 
that we more clearly define balance billing protections for ``out-of-
network referrals'' and more specifically state our definition of 
``providers'' with respect to references to non-participating 
providers.
    Response. The rule is designed to limit TRICARE Prime beneficiary 
liability when properly referred by the primary care manager or Health 
Care Finder for authorized care outside of the TRICARE network in 
limited instances where there is a lack of network providers, or there 
is a mistaken referral to an out-of-network provider. Emergency care 
requires no prior authorization; however, balance billing protections 
also apply to TRICARE Prime beneficiaries who receive care in an 
emergency setting from non-network providers. With respect to the 
request to further define the term ``providers,'' the definition is 
contained in 199.2 of this part and is generally considered to be a 
hospital, or other institutional provider, a physician, or other 
individual professional provider, or other provider of services or 
supplies.
    Provisions of Final Rule. The final rule is consistent with the 
interim final rule.

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

[[Page 56082]]

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.
    The final rule will not impose additional information collection 
requirements on the public under the Paperwork Reduction Act of 1995 
(44 U.S.C. Chapter 35).

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. * * *
    (i) Introduction. * * *
    (D) Special rule for TRICARE Prime Enrollees. In the case of a 
TRICARE Prime enrollee (see section 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: October 15, 1998.
L.M. Bynum,
Alternate Federal Register Liaison Officer, Department of Defense.
[FR Doc. 98-28140 Filed 10-20-98; 8:45 am]
BILLING CODE 5000-04-M