[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
