[Federal Register Volume 67, Number 25 (Wednesday, February 6, 2002)]
[Rules and Regulations]
[Pages 5477-5480]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-2676]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[RIN 0720-AA68]


TRICARE Prime Remote for Active Duty Family Members

AGENCY: Office of the Secretary, DoD.

ACTION: Interim final rule.

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SUMMARY: This rule implements 10 U.S.C. 1079(p), as added by section 
722(b) of the Floyd D. Spence National Defense Authorization Act for 
Fiscal Year 2001. The rule provides coverage for medical care for 
active duty family members who reside with an active duty member of the 
Uniformed Services assigned to remote areas and eligible for the 
program known as TRICARE Prime Remote. Active duty family members who 
enroll in TRICARE Prime Remote for Active Duty Family Members (TPRADFM) 
will enjoy benefits generally comparable to TRICARE Prime enrollees 
including access standards, benefit coverage, and cost-shares.

DATES:  This interim final rule is effective April 8, 2002. Written 
comments will be accepted until April 8, 2002.

ADDRESSES: Forward comments to Optimization and Integration Division 
TRICARE Management Activity, Skyline 5, Suite 801, 5111 Leesburg Pike, 
Falls Church, VA 22041-3206.

FOR FURTHER INFORMATION CONTACT: LCDR Robert Styron, Optimization and 
Integration, TRICARE Management Activity, Office of the Secretary of 
Defense (Health Affairs), telephone (703) 681-0064. Questions regarding 
payment of specific TRICARE claims should be addressed to the 
appropriate TRICARE contractor.

SUPPLEMENTARY INFORMATION:

I. Overview of the Rule

    On October 30, 2000, the Floyd D. Spence National Defense 
Authorization Act for Fiscal Year 20012 (NDAA) (Public Law 106-398) was 
signed into law. This interim final rule implements section 722(b) of 
this Act, which amended section 1079 of Title 10, United States Code, 
by adding subsection (p). It requires a TRICARE Prime-like benefit for 
active duty family members residing with their active duty Uniformed 
Services sponsor eligible for TRICARE Prime Remote, as defined by 
section 1074(c)(3) of Title 10, United States Code.

[[Page 5478]]

II. TRICARE Prime Remote for Active Duty Members

    A member of the uniformed services who is on active duty is 
entitled to medical and dental care in any facility of any Uniformed 
Service u8nder 10 U.S.C. 1074(a). Although members on active duty have 
this entitlement, members of the Uniformed Services who qualify for 
TRICARE Prime Remote may not be required to receive routine primary 
medical care at a military treatment facility. TRICARE Prime Remote 
(TPR) was established under 10 U.S.C. 1074(c) to provide a TRICARE 
Prime-like benefit. As defined by 10 U.S.C. 1074(c)(3), the benefit is 
for active duty service members (ADSM) assigned to remote locations, 
who pursuant to that assignment, work and reside at a location more 
than 50 miles, or approximately one hour of driving time, from the 
nearest military treatment facility. ADSM who are TPR-eligible are 
required to enroll in TPR unless another enrollment site designated by 
the services is available.
    The TPR ADSM is required to use the network providers, including 
network Veteran's Affairs facilities, provided the network providers 
have capacity and meet the TRICARE drive time standards of 30 minutes 
for primary care and one hour for specialty care.

III. TRICARE Prime Remote for Active Duty Family Members

    In order to be eligible for TRICARE Prime Remote for Active Duty 
Family Members (TPRADFM), active duty family members (ADFM) must reside 
with a TPR-eligible and enrolled ADSM. For purposes of TPRADFM, ADFM 
include the spouse and children of an active duty member and certain 
unmarried dependents placed in the legal custody of the active duty 
member as a result of a court order for a period of at least 12 months. 
ADFM must enroll in TPRADFM to receive the TPRADFM benefit. ADFM who 
elect not to enroll, or whose sponsor has not enrolled in TPR, may use 
the TRICARE Standard benefit, or enroll in TRICARE Prime where 
available. Under section 722(c) of the Floyd D. Spense National Defense 
Authorization Act for Fiscal Year 2001 (NDAA), the waiver of TRICARE 
Standard cost-shares and deductibles that apply during the interim 
period between the enactment of the NDAA and implementation of TPRADFM 
will expire upon implementation of this rule. TPRADFM eligible 
beneficiaries may elect not to enroll in TPRADFM, and instead receive 
benefits under the Standard program, but will be required to pay the 
associated TRICARE Standard cost-shares and deductibles.
    Section 1079(p) of Title 10, subject to such exceptions as the 
Secretary considers necessary, requires coverage for medical care under 
this section for dependents and standards with respect to timely access 
to such care to be comparable to coverage and standards under the 
managed care option of the TRICARE program known as TRICARE Prime. 
Therefore, the requirements and benefits of TPRADFM shall be similar to 
TRICARE Prime under Section 199.17 to the maximum extent practicable.
    For primary care, family members enrolled in TPRADFM will be 
assigned or be allowed to select a primary care manager when available 
through the TRICARE civilian provider network. The primary care manager 
may be an individual physician, a group practice, a clinic, a treatment 
site or other designation. If a network provider is not available to 
serve as their primary care provider, the TPRADFM enrollee will be able 
to utilize any local TRICARE authorized provider for primary care 
services.
    Family members enrolled in TPRADFM will have the same cost-shares 
and deductibles as those enrolled in TRICARE Prime. If a TRICARE 
network primary care provider is available to serve as their primary 
care manager (PCM); TPRADFM enrollees must select or be assigned to the 
PCM. Enrollment with the network PCM and compliance with the program 
requirements will result in the TPRADFM enrollee having no cost-shares 
or deductibles for the care provided. A TPRADFM enrollee who does not 
enroll with a network provider when one is available to serve as their 
primary care manager is subject to higher point-of-service deductible 
and cost sharing requirements under Section 199.17. Similarly, when a 
TPRADFM is enrolled with a TRICARE network PCM and receives health care 
services for a provider other than their PCM, he/she will be 
responsible for the point-of-service cost-shares and deductibles under 
Section 199.17. If a network provider is not available to serve as 
their primary care manager, a TPRADFM enrollee may use any local 
TRICARE authorized provider for their primary care, and will have no 
cost-shares or deductibles for the care provided.
    TPRADFM enrolled members will be able to access their primary care 
provider without pre-authorization. Referrals to specialists will 
require a pre-authorization by the regional managed care support 
contractor for medical appropriateness and necessity. To the greatest 
extent possible, contractors will assist in finding a TRICARE network 
or authorized provider within the TRICARE Prime drive time access 
standards of one hour for specialty care. Contractors will not be 
required to establish new network relationships for TPRADFM enrollees, 
except where contractually required or deemed economically feasible. 
TPRADFM members are required to use TRICARE network providers for 
specialty-care where available within TRICARE access standards or pay 
the point-of-service deductible and cost-shares under Section 199.17. 
They may use any TRICARE authorized provider to obtain specialty-care 
where a network provider is not available with access standards, once 
they have received authorization and assistance in finding a provider 
by the contractor.

IV. Rulemaking Procedures

    Executive Order 12866 requires that a comprehensive regulatory 
impact analysis be performed on any economically significant regulatory 
action, defined as one that would result in an annual effect on the 
economy of $100 million or more, or have other substantial impacts. 
This rule is not an economically significant regulatory action and it 
will not significantly affect a substantial number of small entities. 
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 entities.
    This rule imposes no burden as defined by the Paperwork Reduction 
Act of 1995 (44 U.S.C. 3501-3511).
    This rule is being implemented as an interim final rule, with 
comment period, as an exception to our normal practice of soliciting 
public comment prior to issuance. The Acting Assistant Secretary of 
Defense (Health Affairs) has determined that following the standard 
practice in this case would be impracticable, unnecessary, and contrary 
to the public interest. This rule implements statutory requirements 
that became effective October 30, 2000, for a program Congress intended 
to become operational one year later. This rule implements the new 
statutory program without significant embellishment of the legislative 
requirements. Public comments are welcome and will be considered for 
possible revisions in the rule.
    This rule has been designated as significant and has been reviewed 
by the Office Management and Budget as

[[Page 5479]]

required under the provisions of Executive Order 12866.

List of Subjects in 32 CFR Part 199

    Claims, Health care, Health insurance, Military personnel, TRICARE 
Prime.

    For the reasons set forth in the preamble, 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 199.16 is amended by revising paragraphs (d) 
introductory text and (d)(2), redesignating paragraphs (e) and (f) as 
paragraphs (f) and (g), respectively, and adding a new paragraph (e) to 
read as follows:


Sec. 199.16  Supplemental Health Care Program for active duty members.

* * * * *
    (d) Special rules and procedures. 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.
* * * * *
    (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.
* * * * *
    (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.
* * * * *

    3. Section 199.17 is amended by revising paragraph (g) to read as 
follows:


Sec. 199.17  TRICARE program.

* * * * *
    (g) TRICARE Prime Remote for Active Duty Family Members. (1) In 
general. In geographic areas in which TRICARE Prime is not offered and 
in which eligible family members reside, there is offered under 10 
U.S.C. 1079(p) TRICARE Prime Remote for Active Duty Family Members as 
an enrollment option. TRICARE Prime Remote for Active Duty Family 
Members (TPRADFM) will generally follow the rules and procedures of 
TRICARE Prime, except as provided in this paragraph (g) and otherwise 
except to the extent the Director, TRICARE Management Activity 
determines them to be infeasible because of the remote area.
    (2) Active duty family member. For purposes of this paragraph (g), 
the term ``active duty family member'' means one of the following 
dependents of an active duty member of the Uniformed Services: spouse, 
child, or unmarried child placed in the legal custody of the active 
duty member as a result of an order of a court of competent 
jurisdiction for a period of at least 12 consecutive months.
    (3) Eligibility. An active duty family member is eligible for 
TRICARE Prime Remote for Active Duty Family Members if he or she is 
eligible for CHAMPUS and meets all of the following additional 
criteria:
    (i) The family member's active duty sponsor has been assigned 
permanent duty as a recruiter; as an instructor at an educational 
institution, an administrator of a program, or to provide 
administrative services in support of a program of instruction for the 
Reserve Officers' Training Corps; as a full-time adviser to a unit of a 
reserve component; or any other permanent duty more than 50 miles, or 
approximately one hour driving time, from the nearest military 
treatment facility that the Executive Director, TRICARE Management 
Activity determines is adequate to provide care.
    (ii) The family member's active duty sponsor, pursuant to the 
assignment of duty described in paragraph (g)(3)(i) of this section, 
resides at a location that is more than 50 miles, or approximately one 
hour of driving time, from the nearest military medical treatment 
facility that the Director, TRICARE Management Activity determines is 
adequate to provide care.
    (iii) The family member resides with the active duty sponsor.
    (4) Enrollment.  TRICARE Prime Remote for Active Duty Family 
Members requires enrollment under procedures set forth in paragraph (o) 
of

[[Page 5480]]

this section or as otherwise established by the Executive Director, 
TRICARE Management Activity.
    (5) Health care management requirements under TRICARE Prime Remote 
for Active Duty Family Members. The additional health care management 
requirements applicable to Prime enrollees under paragraph (n) of this 
section are applicable under TRICARE Prime Remote for Active Duty 
Family Members unless the Executive Director, TRICARE Management 
Activity determines they are infeasible because of the particular 
remote location. Enrollees will be given notice of the applicable 
management requirements in their remote location.
    (6) Cost sharing. Beneficiary cost sharing requirements under 
TRICARE Prime Remote for Active Duty Family Members are the same as 
those under TRICARE Prime under paragraph (m) of this section, except 
that the higher point-of-service option cost sharing and deductible 
shall not apply to routine primary health care services in cases in 
which, because of the remote location, the beneficiary is not assigned 
a primary care manager or the Executive Director, TRICARE Management 
Activity determines that care from a TRICARE network provider is not 
available within the TRICARE access standards under paragraph (p)(5) of 
this section. The higher point-of-service option cost sharing and 
deductible shall apply to specialty health care services received by 
any TRICARE Prime Remote for Active Duty Family Members enrollee unless 
an appropriate referral/preauthorization is obtained as required by 
section (n) under TRICARE Prime. In the case of pharmacy services under 
Sec. 199.21, where the Director, TRICARE Management Activity determines 
that no TRICARE network retail pharmacy has been established within a 
reasonable distance of the residence of the TRICARE Prime Remote for 
Active Duty Family Members enrollee, cost sharing applicable to TRICARE 
network retail pharmacies will be applicable to all CHAMPUS eligible 
pharmacies in the remote area.
* * * * *

    Dated: January 29, 2002.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 02-2676 Filed 2-5-02; 8:45 am]
BILLING CODE 5001-08-M