[Federal Register Volume 64, Number 29 (Friday, February 12, 1999)]
[Rules and Regulations]
[Pages 7084-7089]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-3441]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DoD 6010.8-R]
RIN 0720-AA30
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); Individual Case Management
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: This final rule implements provisions of the 1993 National
Defense Authorization Act which allows the Secretary of Defense to
establish a case management program for CHAMPUS beneficiaries with
extraordinary medical or psychological disorders and to allow such
beneficiaries medical or psychological services, supplies, or durable
medical equipment excluded by law or regulation as a TRICARE/CHAMPUS
benefit. Under this program, waiver of benefit limits or exclusions to
the basic TRICARE/CHAMPUS program may be authorized for beneficiaries
when the provision of such services or supplies is cost effective and
clinically appropriate, as compared to historical or projected TRICARE/
CHAMPUS utilization of health care services. Such waivers will also
provide families in crisis time for transition to other sources of
support when TRICARE/CHAMPUS benefits have been exhausted. This case
management program is designed to provide a cost-effective plan of care
by targeting appropriate resources to meet the individual needs of the
beneficiary.
DATED: March 15, 1999.
FOR FURTHER INFORMATION CONTACT: CDR Tracy Malone, TRICARE Management
Activity, (703) 681-1745.
SUPPLEMENTARY INFORMATION: The Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS) supplements the availability of health
care in military hospitals and clinics.
Statutory Authority
The case management program is based on the authority of 10 U.S.C.
1079(a)(17), which provides:
The Secretary of Defense may establish a program for the
individual case management of a person covered by this section or
section 1086 of this title who has extraordinary medical or
psychological disorders and, under such a program, may waive benefit
limitations contained in paragraph (5) and (13) of this subsection
or section 1077(b)(1) of this title and authorize the payment for
comprehensive home health care services, supplies, and equipment if
the Secretary determines that such a waiver is cost effective and
appropriate.
Statutory and Legislative History
This provision was enacted in 1992 by Congress as section 704 of
the National Defense Authorization Act for Fiscal Year 1993, Pub. L.
102-484, Oct. 23, 1992. It is substantively identical to a provision
recommended by the Department of Defense in a report to Congress
submitted a few months earlier by the Assistant Secretary of Defense
(Health Affairs) and entitled, ``Report to Congress: Comprehensive Home
Health Care as a CHAMPUS Benefit.'' The 1992 Report to Congress and
statutory
[[Page 7085]]
enactment were the outgrowth of a series of legislative provisions
dating back to 1985, when Congress directed the Department of Defense
to ``conduct a pilot test project of providing home health care'' to
certain CHAMPUS beneficiaries. Department of Defense Appropriations
Act, 1986, PUb. L. 99-190, Section 8084. A similar provision was
enacted a year later. Department of Defense Appropriations Act, 1987,
Pub. L. 99-591, Section 9074.
In 1987, Congress directed the Department of Defense to establish a
second, expanded demonstration project. The statute required DoD to
``conduct an expanded pilot project of providing home Health care as
part of an individualized case-managed range of benefits that may
reasonably deviate from otherwise payable types, amounts and levels of
care'' for patients ``with exceptionally serious, long-range, costly
and incapacitating physical or mental conditions.'' Department of
Defense Appropriations Act, 1988, Pub. L. 100-202, Section 8071. A
similar provision was enacted the following year. Department of Defense
Appropriations act, 1989, Pub. L. 100-463, Section 8058. Based on these
two demonstration projects, in 1991, the House and Senate
Appropriations Committees directed the Department of Defense to
investigate the possibility of including comprehensive home health care
as a CHAMPUS benefit and report to Congress on its findings. H. Rept.
No. 102-95, p. 89; S. Rept. No. 102-154, p. 37. The resulting report to
Congress led to enactment of section 1079(a)(17), which is being
implemented by this final rule.
In enacting this provision, Congress took another major step to
direct and allow DoD to, in the words of the previous statute,
``reasonably deviate from'' the normal, restrictive statutory coverage
for health services for patients with ``exceptionally serious, long-
range, costly and incapacitating'' conditions. Pub. L. 100-202, Section
8071. A dominant statutory restriction affecting health care for such
patients is the statutory exclusion of ``domiciliary or custodial
care.'' 10 U.S.C. Section 1077(b)(1). This exclusion is made applicable
to CHAMPUS by the introductory text of 10 U.S.C. Section 1079(a) and is
implemented in its most important respect for CHAMPUS by regulations at
32 CFR sections 199.2 and 199.4(e)(12).
These regulations are well known and have been the subject of
litigation from time to time in recent years, including a widely
circulated, adverse District of Columbia Court of Appeals decision in
1987. Barnett v. Weinberger, 818 F.2d 953 (D.C. Cir. 1987); see also
Fiduk v. Montgomery, No. 3:96-CV-409 RM (N.D. Ind., Mar. 27, 1998). The
regulations are also well known to Congress, which has moved to create
reasonable exceptions to the statutory and regulatory exclusion of
custodial care.
This was, in fact, a primary reason Congress established the case
management program by enacting section 1079(a)(17), and why the statute
expressly authorizes a waiver of the custodial care exclusion section
of 1077(b)(1) under the case management program when ``the Secretary
determines that such a waiver is cost-effective and appropriate.'' This
congressional purpose was explicitly stated in the explanation of the
members of the Conference Committee that agreed to the final version of
the section 1079(a)(17). The Conference Report explains:
The conferees believe the case management program is the best
approach to address the need of beneficiaries for whom regular
CHAMPUS benefits are limited by the custodial care exclusion and
other restrictions contained in the Law and CHAMPUS regulations.
H. Conf. Rept. 102-966, 102d Cong., 2d Sess., 719. The Department of
Defense agrees with Congress that the case management program is the
best approach to address the custodial care issue. Culminating a series
of statutory enactments dating back to 1985, the case management
program will allow CHAMPUS to assist beneficiaries who need long-term
custodial care to transition to programs, which, unlike CHAMPUS,
provide long-term custodial care. This was a principal objective of
Congress in enacting the case management program and is a principal
focus of the regulatory implementation of the program.
Case Management
Case management is used in many TRICARE/CHAMPUS settings to
organize acute and outpatient health care services. This final rule
focuses specifically on the use of case management to address complex
health care needs of catastrophically ill or injured beneficiaries, It
offers a system for organizing multidisciplinary services often
required for management of extraordinary medical or psychological
disorders and provides a bridge between acute and long term care
services generally excluded under TRICARE/CHAMPUS. It is designed to
improve quality of care, control costs, and support patients and
families through catastrophic medical events.
The TRICARE/CHAMPUS individual case management program seeks to
achieve cost effective quality health care by considering alternatives
to current TRICARE/CHAMPUS benefit limitations or exclusions that, when
provided, are cost effective and clinically appropriate. Section 199.4
provides, as a case management related benefit, authority for services
or supplies that would otherwise be excluded as non-medical or
duplicate durable equipment, custodial care, or domiciliary care.
Waivers of benefit limits will be approved and coordinated by case
managers and may include, but are not limited to, services or supplies
such as home healthcare, medical supplies, back-up durable medical
equipment, extended skilled nursing care and home health aides.
Services or supplies provided in the home by other than already
recognized providers of care must fall under the auspices of a home
health care agency which has been either authorized by Medicare or
licensed by the State in which it operates. Providers of other services
as a result of such waivers must be licensed or certified by the
prevailing authority for that service. Section 199.2 revises the
definition of ``treatment plan'' to include inpatient and outpatient
care and adds definitions for waiver of benefit limits, case
management, case manager, case management multidisciplinary team,
extraordinary condition, and primary caregiver.
Eligibility
Although participation in the TRICARE/CHAMPUS case management
program is voluntary, certain conditions must exist for a beneficiary
to be eligible for participation. These conditions are: (1) The
presence of an extraordinary medical condition which has resulted in
high utilization of TRICARE/CHAMPUS resources, (2) the cost
effectiveness of providing the alternative services or supplies, (3)
the willingness of the beneficiary to participate, and (4) a competent
patient or the presence of a primary caregiver in the home when the
services provided include home health care.
Custodial Care
We expect patients and their families will require varying levels
of support and time to stabilize following a catastrophic illness. Case
managers will determine on a case-by-case basis the need and
appropriate amount of time for temporary waivers to custodial care
exclusions. Waivers to custodial care exclusions will be subject to a
lifetime maximum of 365 days and must be cost effective when compared
to available covered services. Such waivers are
[[Page 7086]]
designed to allow families sufficient opportunity for transition to
alternative funding sources and services.
Prior Authorization
Prior authorization from case managers will be required before the
delivery of any case managed benefits. Because eligibility for a waiver
of benefit limits/exclusions is based on an in depth assessment of
medical needs, as well as the cost effectiveness and clinical
appropriateness of alternate services, any services provided absent
prior authorization will not be covered by TRICARE/CHAMPUS.
Retrospective requests for coverage under this program will not be
authorized.
Military Health System Resource Management
To ensure cost efficient as well as cost-effective use of
resources, the Department of Defense requires establishment of case
management programs, as described in this rule, in all TRICARE/CHAMPUS
managed care support contracts. Managed care support contractors will
be authorized to make available case management services to Military
Medical Treatment Facilities (MTFs). MTFs will be provided the
opportunity to refer potential candidates to the appropriate TRICARE/
CHAMPUS case manager. Where possible, MTFs will provide care and
services or supplies in support of regional case management programs.
Beneficiary Acknowledgment
Case management is a collaborative process involving the case
manager, beneficiary, primary caregiver, and professional health care
providers. For case management to be successful, the beneficiary and
primary caregiver must participate in the process and be aware of and
agree with the requirements of the program. To document the
understanding of their roles, rights and responsibilities, a standard
acknowledgment, signed by the beneficiary (or representative) and the
primary caregiver, will be required prior to the start of case
management services.
Denial/Appeals Process
Beneficiaries and/or providers who dispute a determination
regarding medical appropriateness or necessity of proposed services or
treatment under the case management program might appeal those
decisions. The existing Appeal and Hearing Procedures outlined in 32
CFR section 199.10 will be used for these cases.
CHAMPUS HHC/HHC-CM Demonstration
The 1986 Home Health Care and 1988 Home Health Care-Case Management
Demonstration projects were developed to test whether case management,
coupled with home healthcare benefits, could reduce medical costs and
improve services to CHAMPUS beneficiaries. Under the 1986
demonstration, case management services were limited to beneficiaries
who, in the absence of case managed home health care, would have
remained hospitalized. The 1988 program was less restrictive and no
longer required case management services only as a substitute for
continued hospitalization. The General Accounting Office (GAO)
addressed the effectiveness of methods for identifying potentially
eligible beneficiaries and establishing the clinical appropriateness
and cost-effectiveness of services provided. In its report, ``DEFENSE
HEALTH CARE: Further Testing and Evaluation of Case Managed Home Care
Is Needed,'' the GAO identified a need for stronger cost controls and
improved targeting of potential candidates before implementation of a
permanent case management program under CHAMPUS. With the GAO's
recommendations and observations in mind, the Department is
establishing this TRICARE/CHAMPUS case management program which
provides clinically appropriate, cost effective alternatives to covered
services, organizes complex or multidisciplinary services, and allows
families a transition period to arrange for long term care not provided
under TRICARE/CHAMPUS. The organized delivery of services for these
patients is designed to improve continuity and quality of care, lower
overall costs to the Department, and result in better quality of life.
Public Comments
The proposed rule was published in the Federal Register Thursday,
January 4, 1996, (61 FR 339). Significant effort has been undetaken in
the ensuing months to resolve several difficult issues, primarily
relating to long term care. Providing a reasonable safety net for
beneficiaries who require custodial or long-term services continues to
be a difficult challenge for the health care industry. With this
management program, the Department is attempting to strike a delicate
balance between its primary mission of medical readiness and
appropriate support for medical system beneficiaries when they are most
vulnerable.
We received seven comment letters, all of which were from providers
and provider associations. Several commentors were quite detailed,
providing helpful insights and the benefit of many years' experience.
We thank those who took the time to provide suggestions, many of which
have been incorporated into this final rule. Significant items raised
by commentors and our analysis of the comments are summarized below.
1. Access to Case Management Benefits
Several commentors expressed concern that the proposed rule limited
case management services to catastrophically ill or injured patients
and placed undue emphasis on the use of inpatient acute services as a
prerequisite for this program. They point out that case management is
widely used in private sector health plans to enhance the cost
effective delivery of quality care for a wide range of patients, not
just those facing catastrophic events. We are aware that case
management has many applications, some of which are already required
and used by the Department in both military medical treatment
facilities and by TRICARE Managed Care Support contractors. The broad
application of case management in these settings requires no new
regulatory authority. This final rule specifically addresses the unique
circumstances of catastrophic illness and provides new authority to
waive benefit limitations/exclusions when there are more cost
effective, clinically appropriate alternatives to higher intensity
covered services. We agree that use of impatient services as a
prerequisite for participation in this case management program
inappropriately excludes opportunities for better management of certain
complex of catastrophic illnesses. We have clarified eligibility
requirements to extend case management benefits to individuals who have
demonstrated extraordinarily high TRICARE/CHAMPUS resource utilization,
regardless of whether or not treatment has included an acute inpatient
stay.
2. Quality and Outcomes
One provider expressed concern that there was insufficient emphasis
on quality of care, quality of life, and outcomes in the proposed rule.
While cost effectiveness is an important requirement for application of
the new waiver authority described in this rule, it does not take
precedence over quality of care. Proposed treatment provided as part of
this program must be clinically appropriate, high quality and cost
effective. In addition to outcome measures already used by DoD,
specific
[[Page 7087]]
performance measures for this program will be developed and included in
more detailed operational guidance.
3. Primary Cargiver
We received many comments on our requirement for the presence of a
primary caregiver as a condition for participation in this program.
This requirement was based on the idea that individuals who required a
monitored or controlled environment could not safely move outside
institutional care without the presence of a primary caregiver, most
likely a family member. We reasoned that primary caregivers would be
essential components in this transfer, not only to assure the patient's
safety, but also to participate in the effective implementation of a
case management treatment plan. Commentors presented several scenarios
in which individuals who would benefit from this program may not have a
primary caregiver as described in the proposed rule. We agree with
these comments and have modified the eligibility requirement to state
there must be a patient capable of self-support or be assisted by a
primary caregiver. We have retained the requirement for presence of a
primary caregiver when the program includes a waiver for provision of
custodial care services in the home.
4. Program Operation
We received numerous detailed comments and suggestions about
specific operation of the proposed case management program, including
requirements and contents for treatment plans, reporting requirements
and methods for transition from case management services, These are
detailed program elements, which will be included in operational
policies following publication of this rule.
5. Case Management for Extraordinary Psychological Illnesses
Several commentors expressed concern that the proposed rule did not
seem to allow exceptions to benefit exclusions for treatment of
catastrophic physiological illness. This is not the case. The rule
proposes case management services and associated appropriate relief
from otherwise excluded services for both medical and psychological
disorders. Exceptions to benefit limitations must be medically and/or
psychologically appropriate and must be cost effective when compared to
available covered services.
6. Qualifications of Case Managers
We received comments from a provider association regarding our
requirement that case managers be either registered nurses or licensed
social workers with at least two-year case management experience. The
commentor believed this requirement should be broadened to allow other
professional specialties, such as physicians or psychologists, to act
as case managers. Although it is not typical practice for health plans
to employ physicians, psychologists, or other similarly trained
professionals as case managers; we have no objection to their acting in
this capacity. Accordingly, we have modified the case manager
definition to allow physicians and psychologists with at least two
years experience in case management to act as case managers for TRICARE
programs. This rule focuses on care of catastrophic illness or injury
that requires both basic knowledge of medical and psychological
disorders and experience in coordinating services for seriously ill
beneficiaries. Because of this, we do not believe it appropriate to
reduce professional qualifications from those proposed.
Regulatory Procedures
Executive Order (EO) 12866 requires that a comprehensive regulatory
impact analysis be performed on any economically significant regulatory
action, defined as one which would result in an annual effect of $100
million or more on the national economy or which would 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 rule is has been reviewed and approved by OMB and under EO
12866. In addition, we certify that this rule will not significantly
affect a substantial number of small entities.
Paperwork Reduction Act
This rule, as written, imposes no burden as defined by the
Paperwork Reduction Act of 1995. If however, any program implemented
under this rule causes such a burden to be imposed, approval therefore
will be sought of the Office of Management and Budget in accordance
with the Act, prior to implementation.
List of Subjects in 32 CFR Part 199
Claims, handicapped, health insurance, and military personnel.
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 199.2(b) is amended by adding new definitions in
alphabetical order:
Sec. 199.2 Definitions.
* * * * *
Case management. Case management is a collaborative process which
assesses, plans, implements, coordinates, monitors, and evaluates the
options and services required to meet an individual's health needs,
using communication and available resources to promote quality, cost
effective outcomes.
Case managers. A licensed registered nurse, licensed clinical
social worker, licensed psychologist or licensed physician who has a
minimum of two (2) years case management experience.
Extraordinary condition. A complex clinical condition, which
resulted, or is expected to result, in extraordinary TRICARE/CHAMPUS
costs or utilization, based on thresholds established by the Director,
OCHAMPUS, or designee.
Primary caregiver. An individual who renders to a beneficiary
services to support the essentials of daily living (as defined in
Sec. 199.2) and specific services essential to the safe management of
the beneficiary's condition.
Waiver of benefit limits. Extension of current benefit limitations
under the Case Management Program, of medical care, services, and/or
equipment, not otherwise a benefit under the TRICARE/CHAMPUS program.
3. Section 199.4 is amended by adding new paragraphs (e)(20) and
(i) as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(e) Special benefit information.
* * *
(20) Case management services. As part of case management for
beneficiaries with complex medical or psychological conditions, payment
for services or supplies not otherwise covered by the basic CHAMPUS/
TRICARE program may be authorized when they are provided in accordance
with Sec. 199.4(i). Waiver of benefit limits/exclusions to the basic
CHAMPUS/TRICARE program may be cost shared where it is demonstrated
that the absence of such services would result in the exacerbation of
an existing extraordinary condition, as defined in Sec. 199.2, to the
extent that frequent or
[[Page 7088]]
extensive services are required; and such services are a cost effective
alternative to the Basic CHAMPUS program.
* * * * *
(i) Case management program. (1) In general. Case management, as it
applies to this program, provides a collaborative process among the
case manager, beneficiary, primary caregiver, professional health care
providers and funding sources to meet the medical needs of an
individual with an extraordinary condition. It is designed to promote
quality and cost-effective outcomes through assessment, planning,
implementing, monitoring and evaluating the options and services
required. Payment for services or supplies limited or not otherwise
covered by the basic TRICARE/CHAMPUS program may be authorized when
they are provided in accordance with paragraph (i) of this section.
Waiver of benefit limits/exclusions may be cost-shared where it is
demonstrated that the absence of such services would result in the
exacerbation of an existing extraordinary condition, as defined in
Sec. 199.2, to the extent that such services are a cost-effective
alternative to the basic TRICARE/CHAMPUS program.
(2) Applicability of case management program. A CHAMPUS eligible
beneficiary may participate in the case management program if he/she
has an extraordinary condition, which is disabling and requires
extensive utilization of TRICARE resources. The medical or
psychological condition must also:
(i) Be contained in the latest revision of the International
Classification of Diseases Clinical Modification, or the Diagnostic and
Statistical Manual of Mental Disorders;
(ii) Meet at least one of the following:
(A) Demonstrate a prior history of high CHAMPUS costs in the year
immediately preceding eligibility for the case management program; or
(B) Require clinically appropriate services or supplies from
multiple providers to address an extraordinary condition; and
(iii) Can be treated more appropriately and cost effectively at a
less intensive level of care.
(3) Prior authorization required. Services or supplies allowable as
a benefit exception under this Section shall be cost-shared only when a
beneficiary's entire treatment has received prior authorization through
an individual case management program.
(4) Cost effective requirement. Treatment must be determined to be
cost effective by comparison to alternative treatment that would
otherwise be required or when compared to existing reimbursement
methodology. Treatment must meet the requirements of appropriate
medical care as defined in Sec. 199.2.
(5) Limited waiver of exclusions and limitations. Limited waivers
of exclusions and limitations normally applicable to the basic program
may be granted for specific services or supplies only when a
beneficiary's entire treatment has received prior authorization through
the individual case management program described in paragraph (i) of
this section. The Director, OCHAMPUS may grant a patient-specific
waiver of benefit limits for services or supplies in the following
categories, subject to the waiver requirements of this section.
(i) Durable equipment. The cost of a device or apparatus which does
not qualify as Durable Medical Equipment (as defined in Sec. 199.2) or
back-up durable medical equipment may be shared when determined by the
Director, OCHAMPUS to be cost-effective and clinically appropriate.
(ii) Custodial care. The cost of services or supplies rendered to a
beneficiary that would otherwise be excluded as custodial care (as
defined in Sec. 199.2) may be cost-shared for a maximum lifetime period
of 365 days when determined by the Director, OCHAMPUS, to be cost
effective and clinically appropriate. To qualify for a waiver of
benefit limits of custodial care, the patient must meet all eligibility
requirements of paragraph (i) of this section, including that the
absence of the waived services would result in the exacerbation of an
existing extraordinary condition. In addition:
(A) The proposed treatment must be cost effective and clinically
appropriate as determined by the individual case manager. For example,
the treatment would be determined to be cost effective by comparison to
alternative care that would otherwise be required or when compared to
existing reimbursement methodology.
(B) For patients receiving care at home, there must be a primary
caregiver or the patient is capable of self-support.
(iii) Domiciliary care. The cost of services or supplies rendered
to be a beneficiary what would otherwise be excluded as domiciliary
care (as defined in Sec. 199.2) may be shared when determined by the
Director, OCHAMPUS to be cost effective and clinically appropriate.
Waivers for domiciliary care are subject to the same requirements as
paragraphs (i)(5)(ii) of this section.
(iv) In home services. The cost of the following in-home services
may be shared when determined by the Director, OCHAMPUS to be cost
effective and clinically appropriate: nursing care, physical,
occupational, speech therapy, medical social services, intermittent or
part-time services of a home health aide, beneficiary transportation
required for treatment plan implementation, and training for the
beneficiary and primary caregiver sufficient to allow them to assume
all feasible responsibility for the care of the beneficiary that will
facilitate movement of the beneficiary to the least resource-intensive,
clinically appropriate setting. (Qualifications for home health aides
shall be based on the standards at 42 CFR 848.36.)
(6) Case management acknowledgment. The beneficiary, or
representative, and the primary caregiver shall sign a case management
acknowledgment as a prerequisite to prior authorization of case
management services. The acknowledgment shall include, in part, all of
the following provisions:
(i) The right to participate fully in the development and ongoing
assessment of the treatment;
(ii) That all health care services for which TRICARE/CHAMPUS cost
sharing is sought shall be authorized by the case manager prior to
their delivery;
(iii) That there are limitations in scope and duration of the
planned case management treatment, including provisions to transition
to other arrangements; and
(iv) The conditions under which case management services are
provided, including the requirement that the services must be cost
effective and clinically appropriate;
(v) That a beneficiary's participation in the case management
program shall be discontinued for any of the following reasons:
(A) The loss of TRICARE/CHAMPUS eligibility;
(B) A determination that the services or supplies provided are not
cost effective or clinically appropriate;
(C) The beneficiary, or representative, and/or primary caregiver,
terminates participation in writing;
(D) The beneficiary and/or primary caregiver's failure to comply
with requirements in this paragraph (i); or
(E) A determination that the beneficiary's condition no longer
meets the requirements of participation as described in paragraph (i)
of this section.
(7) Other administrative requirements. (i) Qualified providers of
services or items not covered under the basic
[[Page 7089]]
program, or who are not otherwise eligible for TRICARE/CHAMPUS
authorized status, may be authorized for a time-limited period when
such authorization is essential to implement the planned treatment
under case management. Such providers must not be excluded or suspended
as a CHAMPUS provider, must hold Medicare or state certification or
licensure appropriate to the service, and must agree to participate on
all claims related to the case management treatment.
(ii) Retrospective requests for authorization of waiver of benefit
limits/exclusions will not be considered. Authorization of waiver of
benefit limits/exclusions is allowed only after all other options for
services or supplies have been considered and either appropriately
utilized or determined to be clinically inappropriate and/or not cost-
effective.
(iii) Experimental or investigational treatment or procedures shall
not be cost-shared as an exception to standard benefits under this
part.
(iv) TRICARE/CHAMPUS case management services may be provided by
contractors designated by the Director, OCHAMPUS.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 99-3441 Filed 2-11-99; 8:45 am]
BILLING CODE 5000-04-M
