[Federal Register Volume 62, Number 125 (Monday, June 30, 1997)]
[Rules and Regulations]
[Pages 35086-35097]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-17001]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DoD 6010.8-R]
RIN 0720-AA32
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); Program for Persons with Disabilities; Basic Program
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: This final rule simplifies the administration of benefits
under the CHAMPUS Program for the Handicapped (PFTH) and changes the
name of this benefit to Program for Persons with Disabilities (PFPWD);
adds occupational therapists in independent practice to the list of
authorized individual professional providers; provides criteria for
cost-sharing certain procedures when data is transferred electronically
from the patient's home to a medical practitioner; defines and limits
plans recognized as supplemental insurance under CHAMPUS; and adopts
the Federal Claims Collection Act and the Federal Claims Collection
Standards by reference.
DATES: This rule is effective October 28, 1997, except
Sec. 199.11(g)(1) which is effective November 15, 1990.
ADDRESSES: Office of the Civilian Health and Medical Program of the
Uniformed Services (OCHAMPUS), Program Development Branch, Aurora, CO
80045-6900.
FOR FURTHER INFORMATION CONTACT:
Michael Kottyan, telephone (303) 361-1120.
SUPPLEMENTARY INFORMATION: The CHAMPUS supplements the availability of
health care resources for Military Health Services System (MHSS)
beneficiaries. The MHSS consists of military hospitals and the CHAMPUS.
CHAMPUS consists of basic general medical and surgical benefits, and
non-medical benefits through the Program for Persons with Disabilities
(PFPWD).
A summary of written comments received, the CHAMPUS response, and
the amendments being made by this final rule follow.
I. Program for Persons With Disabilities (PFPWD)
On June 10, 1991, a proposed rule was published in the Federal
Register (56 FR 26635) regarding administrative revisions to the
CHAMPUS Program for the Handicapped (PFTH), which included renaming
these benefits the Program for Persons with Disabilities (PFPWD).
By law, PFPWD benefits are limited to spouses or children with
diagnosed moderate or severe mental retardation, or serious physical
disability, who have an active duty Uniformed Service Member sponsor,
or who are determined to be an abused dependent of certain former
Members. Unlike the basic benefit, the PFPWD applies a fixed, pay-grade
based cost-share amount regardless of the amount of expense allowable
as a benefit (basic benefit beneficiary cost-share is a percentage of
the allowed amount), has no annual deductible amount, includes certain
necessary services and items that are not medical in nature, and has a
$1,000 per month benefit limit for most beneficiaries.
A distinctive aspect of the PFPWD is the statutory requirement that
ties eligibility for benefits to the use of public facilities to the
extent that such facilities are available and adequate to meet a
specific disability related need.
CHAMPUS PFPWD benefits do not alter the obligations which Section
504 of the Rehabilitation Act, as amended, and the Americans with
Disabilities Act, as amended, places upon CHAMPUS providers, nor are
CHAMPUS benefits a substitute for special education and related
services associated with a free appropriate public education which the
Individuals with Disabilities Education Act, as amended, makes
available.
Comment: Two comments noted that this rule should use the type of
language currently preferred by the disability community. The terms
``handicap'' and ``the handicapped'' are no longer acceptable. The
preferred forms are ``disability'' and ``persons with disabilities.''
Response: We have renamed the Program for the Handicapped (PFTH)
the Program for Persons with Disabilities (PFPWD). This name change
recognizes that the term ``handicapped'' presumes an unavoidable
consequence of illness or injury that unnecessarily discounts the
capabilities of every CHAMPUS beneficiary with a disability. Editorial
changes throughout the final rule are responsive to current terminology
preferences.
Comment: The statement that PFPWD beneficiaries reside, with few
exceptions, within Military Treatment Facility catchment areas, and
that the proposed change will facilitate beneficiary access to needed
services and items is not true for the other three Uniformed Services
and could adversely affect the Coast Guard, the Public Health Service,
and the National Oceanic and Atmospheric Administration.
Response: We are aware that MHSS beneficiaries with sponsors in
these Uniformed Services are not usually within a military hospital's
catchment area. PFPWD eligibility determination, benefit authorization,
and related support, will continue to be available through the network
of regional CHAMPUS contractors.
Comment: A PFPWD qualifying condition is required to be certified
again at least every 36 months. For certain conditions (i.e. severe
mental retardation, cerebral palsy with paralysis, muscular dystrophy,
missing essential body parts, etc.) there will never be a change in
PFPWD clinical eligibility. A list of conditions which do not require
frequent certification should be used.
Response: We have removed the 36 month review requirement. Rather
than a list, reviews will now be based upon the prognosis for a change
in the qualifying condition.
Comment: One comment recommended extending PFPWD benefits to
retired members because, in many cases, beneficiaries will never lose
their dependence on the sponsor. Special needs beneficiaries may force
sponsors to remain on active duty longer than they desire merely to
remain eligible for PFPWD.
Response: The limitation of PFPWD benefits to dependents of active
duty uniformed service members is a requirement of the law that
authorizes PFPWD benefits.
Comment: Two comments noted that the provisions for transportation
should allow movement from one State to another when necessary to
obtain care.
Response: We have clarified the transportation exclusion to assure
that transportation between any of the United States, and certain other
areas defined as a state by the Regulation, is not excluded.
Comment: The current edition of the Diagnostic and Statistical
Manual of Mental Disorders is the Third Edition, Revised; Down Syndrome
is generally preferred to Down's Syndrome; the phrase ``. . . are
eligible for payment under a State plan for medical assistance under
Title XIX of the Social Security Act (Medicaid) . . .'' should be used
throughout when referring to Medicaid benefits; and Medicaid
[[Page 35087]]
Intermediate Care Facilities are now termed Medicaid Nursing
Facilities.
Response: We will specify the most current edition of the
Diagnostic and Statistical Manual of Mental Disorders in administrative
instruction. All other technical changes have been incorporated into
this final rule.
Comment: The proposed changes appear to place the active duty
sponsor at a higher financial risk under the PFPWD than those active
duty sponsors using basic benefits. There is presently a $1,000
catastrophic cap for basic benefits and the governments would then
assume a payment obligation of the cost-share over that cap. Any
additional cost for care under the PFPWD beyond the $1,000/month
benefit limit remains the responsibility of the active duty sponsor.
Response: The catastrophic loss protection provision of law does
not allow PFPWD cost-share amounts, or amounts in excess of the $1,000/
month PFPWD benefit limit paid by a beneficiary, to be counted toward
the catastrophic loss active duty family threshold of $1,000/fiscal
year. Only basic benefit deductible and cost-share amounts can be
applied to this threshold. PFPWD beneficiaries obtain most of their
medical care as a basic benefit. These changes to the PFPWD provide the
active duty sponsor with more control over financial risk by allowing a
choice between PFPWD or basic benefits where no choice previously
existed. PFPWD allowable services and items which are excluded as basic
benefits include institutional care for protective custody or training,
training, special education, nonmedical equipment, transportation, and
certain prosthetic devices. A key consideration when a choice between
PFPWD or basic benefits is available is catastrophic loss protection.
We have addressed the issue of informed choice between basic and PFPWD
benefits in two ways. First, we will provide written guidance and
training for Health Benefits Advisors at Military Treatment Facilities
regarding the beneficiary cost-share liability implications of using
PFPWD benefits, rather than basic benefits, whenever such a choice
exists. Second, we have added a provision to this final rule that will
assure that a family that finds they inadvertently have a liability for
PFPWD benefits, that would otherwise not have existed after activation
of the basic benefit catastrophic loss protection, will have a way to
request relief.
Comment: The proposed rule would define rehabilitation as ``the
restoration of physical functioning lost due to illness or injury.'' By
focusing narrowly on physical functioning, we fear that this definition
would serve to limit the range of services available to address the
rehabilitation needs of the physically handicapped. Rehabilitation
restores not only the physical functioning of an individual, but also
the individual's physiological, social, vocational, educational, and
economic adjustment to the handicap. The proposed rule lists categories
of services available under the PFPWD benefit and addresses some
nonphysical aspects of rehabilitation, such as training and special
education. We are encouraged that CHAMPUS does not intend to limit
rehabilitation services to those related strictly to physical
functioning. However this list does not explicitly mention services
related to the individual's psychosocial needs. We suggest a clearer
and more explicit treatment of the scope of rehabilitative services
available under the PFPWD. Fist we recommend defining rehabilitation as
the restoration of physical, psychological, social, vocational, and
educational functioning lost due to illness or injury. Second, we would
add explicit recognition of the broad range of rehabilitative services
that may be necessary to restore or improve functioning for the
physically handicapped.
Response: We agree that physical rehabilitation is but one facet of
restoring an individual's ability to function. We have rewritten this
definition to accommodate the extensive scope of providers and
processes which pursue restorative outcomes for a growing range of
dysfunctions. The revised definition focuses upon functional limitation
reduction as the critical outcome produced by rehabilitative processes.
The widest scope of individual need, with allowance for the dynamic
nature of the rehabilitative process, is subsumed within this
definition. Rather than simply restating well established elements of
rehabilitative focus and treatment at the regulatory level, we have
chosen to create an outcome standard for these benefits which allows
maximum flexibility for identifying services and items that confirm,
arrest, or reduce disabling effects of a qualifying condition. This
approach allows responsiveness to the success of traditional, evolving,
and emerging rehabilitative and habilitative resources in providing
functional gains to CHAMPUS beneficiaries.
Comment: The ``in whole or in part'' phrase should be deleted from
the definition of public facility adequacy. This phrase suggests the
possibility that care could be fragmented among several providers, a
result we do not believe CHAMPUS intended. For example, a public
facility may be funded only to provide for a specific number of
physical therapy sessions per week, but based on the medical opinion of
the practitioner, the patient requires more frequent services. Under
the proposed definition the individual's needs could be met ``in part''
by this facility, so it would be considered adequate and the individual
would be required to use it. The additional services, beyond what the
public facility can provide, would have to be obtained from another
provider or paid for out-of-pocket.
Response: We have deleted this phrase and have rewritten the
provision to avoid such conflicts.
Comment: Although we support the changes being proposed, we have
concern that the CHAMPUS program itself, for which changes are not
being proposed, is also in need of revision. We would encourage you to
propose recommendations to change the basic CHAMPUS legislation so that
children with less severe disabilities would also be eligible for
services, and that the $1,000 per month limitation on services be
expanded.
Response: The $1,000/month PFPWD benefit limit and related
eligibility criteria are provisions of law. Beneficiaries with less
than serious disability have access to basic benefits which provide a
wide range of medical and allied health services. Long-term use of the
entire $1,000/month PFPWD is rare. Such maximum benefit use is
predominantly associated with declining use of long term residential
care.
Comment: Although some limitations are statutory, it appears that
it would be possible to revise the proposed regulation so that persons
with disabilities have access to CHAMPUS benefits more in line with the
intent of Section 504 of the Rehabilitation Act (29 U.S.C. 794). This
law is implemented within the Department of Defense by DoD Directive
1020.1, ``Nondiscrimination on the Basis of Handicap in Programs and
Activities Assisted or Conducted by the Department of Defense,'' dated
March 31, 1982. It seems unfair that the proposed regulation requires
persons with disabilities to make choices about benefits that could
result in their losing money. In some situations, beneficiaries could
be forced to trade one type of benefit for another. In other
situations, they could lose benefits because of an ill-advised choice.
By contrast, benefits are straightforward for beneficiaries who are not
disabled and therefore have no need for the special program. CHAMPUS
beneficiaries, whether they are disabled or not, should receive the
[[Page 35088]]
maximum benefits to which they are entitled in any particular
situation. Proposed language states in effect, that the wrong decision
about benefits is irreversible. This language should be deleted and
replaced with provisions that make CHAMPUS staff responsible for
assuring that beneficiaries with disabilities receive all the benefits
for which they are eligible.
Response: Assisting beneficiaries make prudent health care choices
is a responsibility shared by many Military Health Services System
(MHSS) entities. CHAMPUS will provide Policy Manual guidance and
CHAMPUS Handbook and pamphlet information to assist beneficiaries to
determine the best election of benefits in a given family's situation.
Ongoing public information efforts can be responsive to demonstrated
beneficiary understanding of the choices among MHSS benefit options. We
have also provided administrative means to minimize any adverse
economic effect upon the beneficiary or family of PFPWD use because of
basic benefit catastrophic loss protection.
Comment: The definition of the term serious physical handicap
imposes a ``substantial productive activity'' limitation on persons who
have qualifying disabilities. Does this mean that a dependent teenager
who uses a wheelchair and has a part-time job would not be covered? It
would be preferable to use a functional definition, such as the one in
DoD Directive 1020.1, instead of linking the definition to
productivity.
Response: Employability has never been a PFPWD eligibility
criterion. However, we have rewritten the definition of ``Serious
Physical Handicap'' (as ``Serious Physical Disabilities'') and added
complementary definitions for ``Major Life Activity'' and ``Handicap''
to focus upon the underlying loss of function rather than the
productivity of the beneficiary.
Comment: Proposed language suggests that services that should be
provided for pupils with disabilities through public schools, or
through DoD operated schools, are to be funded through this CHAMPUS
cost-sharing program. There should be clarification of the relationship
of this program to requirements under DoD Directive 1342.16,
``Provision of Free Public Education for Eligible Dependent Children
pursuant to section 6, Pub. L. 81-874, as amended.''
Response: CHAMPUS will treat DoD Directive 1342.16 schools the same
as any other local educational agency within the state in which the DoD
school is located. The Individuals with Disabilities Education Act
requires persons with disabilities be provided a free public education.
Accordingly, special education services that are within the State Plan
required by the Act, and are a part of a beneficiary's Individual
Educational Plan, are excluded as a PFPWD benefit. Such exclusion is
because of the Act's requirements upon public schools, and because
CHAMPUS statutory authority requires that to qualify for PFPWD
benefits, public facilities, such as public schools, must be used to
the extent available and adequate. Because CHAMPUS benefits have
legally imposed beneficiary cost-share requirements (and benefit amount
limits for PFPWD benefits) the Act's requirement that the student or
parents not be charged for such services cannot be met.
Comment: This regulation should include a statement that all
CHAMPUS services are provided in accordance with DoD Directive 1020.1
[Nondiscrimination on the Basis of Handicap in Programs and Activities
Assisted or Conducted by the Department of Defense]. Complaints under
Section 504 [of the rehabilitation Act] indicate the need for special
attention to certain requirements. For example, there would be specific
references to telecommunication devices and certified sign language
interpreters for persons who are deaf, as well as special signs and
readers for persons who are blind and architectural accessibility and
personal assistants for individuals with other types of disabilities.
Response: We have made explicit in this final rule that the
services of an interpreter, reader, or personal assistant is an
allowable PFPWD benefit when the service is not an adjunct to receipt
of a PFPWD allowable service or item. PFPWD cost-share of these types
of services for beneficiaries with serious disabilities does not
relieve CHAMPUS providers of their obligation to provide CHAMPUS
beneficiaries with disabilities equal access, to include the provision
of communication resources and architectural accessibility.
Overview of PFTH/PFPWD Changes
Editorial changes have been made throughout this final rule,
including the addition and reorganization of material for clarity. The
following provides an overview of the changes to those sections in this
final rule pertaining to the PFPWD. Substantial changes between the
proposed and final documents are noted.
Section 199.2, Definitions
The proposed definitions for rehabilitation and habilitation have
been rewritten to focus upon the reduction of inability to function
rather than upon the underlying cause of the disability. We have
rewritten the definition of ``serious physical disability'' for clarity
and have added supporting definitions for ``handicap'' and ``major life
activity.'' We have moved the definitions for ``public facility
availability'' and ``public facility adequacy'' from Sec. 199.5 to
Sec. 199.2. Other definitions are unchanged.
Section 199.5(a), General
The name Program for the Handicapped (PFTH) has been changed to
Program for Persons with Disabilities (PFPWD).
We have shortened the proposed statement of purpose to focus upon
reducing disabling effects.
We have allowed the beneficiary the choice of using PFPWD or basic
benefits whenever possible. This changes the PFTH policy that resulted
in loss of access to basic benefits for outpatient services directly
related to the disability.
We have continued to exclude the use of basic benefits to cover
otherwise allowable PFPWD benefit cost which is not payable because the
monthly PFPWD benefit limit has been reached. The law authorizing PFPWD
benefits prohibits the government from paying, in any month, an amount
which exceeds the maximum allowable PFPWD benefit; consequently, basic
benefits cannot be used to pay for any PFPWD benefit residual expense
once the PFPWD monthly benefit limit is reached.
We have added a provision for readjudication of claims when the
PFPWD created a cost-share liability for services or items which would
not otherwise have been incurred due to basic benefit catastrophic loss
protection.
We have separated the determination of PFPWD eligibility from the
adjudication of benefit requests. PFTH eligibility previously had to be
established each time a benefit was requested. This change will
significantly reduce the paperwork required for a beneficiary to access
PFPWD benefits.
We have continued to require information about how a requested
benefit will contribute to confirming, arresting, or reducing the
disabling effects of a qualifying condition.
We have removed the absolute requirement for PFPWD benefit
preauthorization by allowing those services or items requiring
[[Page 35089]]
preauthorization to be specified in administrative policy.
Preauthorization serves to safeguard the beneficiary from benefit
denials.
We have limited the maximum length of a benefit authorization to
six months.
We have provided for retrospective waiver of a required
preauthorization on a case-by-case basis.
We have rewritten public facility use requirements to promote
continuity of care.
We have allowed the Commander of a Military Treatment Facility to
certify the lack of public facility availability or adequacy.
We have provided for benefit approval when a public official
refuses to provide a public facility use certification so as not to
disadvantage a beneficiary due to circumstances beyond the
beneficiary's control.
We have provided that repair or maintenance for owned equipment
does not require public facility use certification. This type of
service is rarely available through a public facility and timely access
to such services is usually critical to the beneficiary with a
disability.
We have provided that more than one item of the same type of
equipment for the same beneficiary may not be authorized concurrently.
We have eliminated the requirement that public facility
availability be determined for both the beneficiary's domicile and the
sponsor's domicile when beneficiary and sponsor are separated following
a Service Member's permanent change of duty station.
We have removed the absolute 36 month review cycle for qualifying
conditions in recognition that certain conditions will not change over
time.
We have added a provision to assure that no beneficiary receiving
PFPWD benefits loses eligibility solely as an unintended consequence of
these administrative changes.
Section 199.5(b), Eligibility
We have added certain abused dependents as a new PFPWD eligibility
category as required by law.
We have explicitly accommodated latent qualifying conditions which
cannot usually be definitively diagnosed in infancy, but for which
early clinical intervention is considered appropriate to minimize
disabling effects.
We have removed the detailed criteria and discussion of mental
retardation in favor of the diagnostic criteria in the ``Diagnostic and
Statistical Manual of Mental Disorders'' published by the American
Psychiatric Association. The Third edition, Revised, will apply
immediately, and newer additions will apply as they are published.
We have removed the examples of conditions that may cause serious
physical disability. This material was only informational. Such
screening criteria can be more responsive to changing technology and
standards of care when issued as administrative guidance.
We have removed the provision that extended PFTH benefits beyond
the date of eligibility for benefits.
Section 199.5(c), Benefits
Statutory benefit categories have been defined and types of derived
benefits have been described.
A standard of necessity has been established to permit services and
items to be allowed which are not explicit in this rule (derived PFPWD
benefits).
Section 199.5(d), Exclusions
We have excluded inpatient acute care as it is fully available as a
basic benefit and such care is likely to usually exceed the $1,000/
month PFPWD benefit limit.
We have excluded structural alterations to buildings as a type of
service outside the scope of authorized benefits.
We have excluded homemaker, sitter, or companion services as
custodial care.
We have defined certain adjunct services as benefits because they
are directly related to the efficiency and purpose of the PFPWD, and
are consistent with Department of Defense Directive 1020.1 regarding
``Nondiscrimination on the Basis of Handicap in Programs and Activities
Assisted or Conducted by the Department of Defense.''
We have excluded dental care and orthodontic treatment since dental
care is not included in the statutory authority for PFPWD benefits.
We have excluded nondomestic travel for care and treatment. Active
duty dependents officially residing with an active duty Service Member
outside of the United States are the responsibility of the Sponsor's
Military Command which will provide medical evacuation to the United
States for medical treatment when necessary.
We have excluded the cost differential for deluxe accommodations
for allowable travel when not necessary to the safety of the
beneficiary.
We have rewritten and shortened transportation related exclusions
to improve clarity.
We have excluded payment for services or items when the beneficiary
has no legal obligation to pay.
We have excluded services or items furnished by a public facility.
CHAMPUS benefits are, by law, last pay to other health care benefits
for which the beneficiary is eligible (Medicaid excepted).
We have excluded study, grant, or research programs as services or
items not rendered in accordance with accepted standards as
investigational or experimental in nature.
We have excluded services or items provided by immediate family or
household to minimize conflict of interest.
We have excluded court ordered care, unless such care would
otherwise be a PFPWD benefit.
We have excluded excursions as beyond the scope of the PFPWD travel
benefit.
We have excluded therapeutic absences.
We have clarified that drugs and medicines must meet basic benefit
criteria.
We have added an exclusion of medical devices which are not
approved for commercial distribution by the U.S. Food and Drug
Administration.
Section 199.5(e), Cost-share Liability
Minor editorial changes were made for improved clarity.
Section 199.5(f), Benefit Payment
We have added this paragraph to consolidate payment related
requirements that were scattered throughout the proposed rule.
Section 199.6(e), Providers
We have established PFPWD-unique providers as a separate class of
CHAMPUS providers due to the extra medical nature of PFPWD-unique
benefits.
We have added a provision that allows exclusion or suspension of a
provider of PFPWD services or items due to a pattern of discrimination
on the basis of disability.
Section 199.7(f), Preauthorization
We have removed the detailed documentation requirements for PFPWD
claims as this level of detail is more flexibly addressed in
administrative guidance.
Section 199.8(d), Special Considerations
We have established that Medicaid (services and items eligible for
payment under a State plan for medical assistance under Title XIX of
the Social Security Act) is not to be considered a public facility
resource in PFPWD adjudication. Medicaid is not considered to be
``other insurance'' for CHAMPUS coordination of benefits.
[[Page 35090]]
II. Occupational Therapists
On March 8, 1995, a proposed rule was published in the Federal
Register (60 FR 12717) regarding several issues including the addition
of occupational therapists in independent practice to the list of
authorized individual professional providers recognized by CHAMPUS.
This will allow qualified self-employed occupational therapists to be
authorized for direct CHAMPUS payment for allowable services.
We received four comments regarding this proposed change.
One comment from a national association voiced strong support for
the proposal and recommended that this change be implemented
retroactively. Unless there is a statutorily-established effective date
or some compelling reason for making a change retroactive, we do not
normally implement benefit changes retroactively. We do not believe any
such compelling reason exists for this change.
One comment from another national association suggested that
CHAMPUS modify its reimbursement policy to include coverage for the
services of physical therapy assistants who are employed by
independently authorized physical therapists. We will look into this
possibility, but such a change would require publication of a proposed
rule. Therefore, we are not including it in this final rule.
Two comments were received from occupational therapy providers who
strongly supported this change.
III. Procedures Involving the Electronic Transfer of Data
On September 24, 1991, a proposed rule was published in the Federal
Register (56 FR 48134) regarding criteria for allowing clinical
procedures and consultations involving transtelephonic monitoring and
electronic data transfer.
No written comments were received during the public comment period.
The CHAMPUS Basic Program excludes payment for ``services or advice
rendered by telephone or other telephonic device, including remote
monitoring, except for transtelephonic monitoring of cardiac
pacemakers''. This exclusion promotes the quality of care standard that
a substantive service of a diagnostic or treatment nature requires a
face-to-face contact between provider and patient. Transtelephonic
monitoring exception for cardiac pacemakers, added in 1984 [49 FR
35934], recognized that remote monitoring can be an efficient
alternative to certain outpatient visits to a physician's office or
hospital. Coverage of a procedure subsequent to the promulgation of
this final rule requires that both clinical and fiscal advantages be
demonstrated compared to the procedure without the electronic data
transfer element.
IV. Supplemental Insurance
On June 12, 1991, a proposed rule was published in the Federal
Register (56 FR 26946) regarding CHAMPUS-supplemental insurance plans.
In compliance with applicable statutory provisions (10 U.S.C. 1079
(j)(1) and 10 U.S.C. 1086 (d)) on double coverage CHAMPUS pays benefits
only after all other health plans have made payment, with the exception
of Medicaid and certain insurance policies that are specifically
designed to supplement CHAMPUS benefits. This means that if a CHAMPUS
beneficiary has another health plan, the other plan must pay whatever
it covers before CHAMPUS will make any type of payment. The CHAMPUS
beneficiary may have coverage through an employer, an association, or a
private insurer. This also includes any coverage for which students may
qualify through school health plans. In most circumstances, after the
CHAMPUS beneficiary's other plan has paid its maximum benefits, then
CHAMPUS will pay for covered services up to the amount it would have
paid, had there been no other health benefits plan involved.
This provision will assist CHAMPUS beneficiaries, providers, and
other third-party payers by clarifying what is recognized as a
supplemental insurance plan.
The regulation previously provided that coverage specifically
designed to supplement CHAMPUS benefits was not considered a double
coverage plan. This provision lacked the specificity needed in light of
attempts by some insurance plans to achieve second pay status by merely
defining themselves as supplementary plans even though their coverage
may not be limited to CHAMPUS beneficiaries.
To qualify as supplemental insurance, such insurance must meet the
definition and criteria under supplemental insurance plan in
Sec. 199.2(b).
One comment suggested removal of criterion iii from the definition
of Supplemental Insurance Plan assuming that it would limit the extent
of supplemental insurance which CHAMPUS beneficiaries may purchase.
Criterion iii was retained since it is not a limitation on the amount
of insurance which CHAMPUS beneficiaries may purchase. It merely
defines the purpose of supplemental insurance; which is to pay for
services not covered by CHAMPUS.
Some comments suggested that criterion v defeated the purpose of
supplemental insurance because it was interpreted to mean that the
supplemental insurance could not pay the deductible and cost-share on
behalf of the subscribers. That was not the intent of criterion v, but
in the interest of clarifying its intent, the wording was revised to
state that the supplemental insurance coverage cannot result in lower
deductibles and cost-shares than those imposed by law. The supplemental
insurance may pay the legally imposed deductibles and cost-shares on
behalf of the subscribers, but cannot impose arbitrarily lower amounts
nor can it waive the deductibles or cost-shares.
Other comments suggested adding a statement to criterion iii, to
the effect that supplemental insurance may also provide coverage for
costs in excess of the CHAMPUS allowable charges. That suggestion was
accepted and the wording was added under criterion iii.
A Health Maintenance Organization (HMO) suggested adding wording
that would permit the HMO to offer supplementary insurance through one
of its affiliates since the HMO is not an indemnity insurance plan. We
have added wording that will accept supplemental insurance plans
offered by HMOs.
V. Federal Claims Collection Act
On September 24, 1991, a proposed rule was published in the Federal
Register (56 FR 48135) regarding CHAMPUS use of the Federal Claims
Collection Act and the Federal Claims Collection Standards and former
spouse eligibility. The former spouse portion of the proposed rule is
not being published as a final rule at this time and will be included
in a future complete update of the eligibility section of the CHAMPUS
regulation (Sec. 199.3). No written comments were received during the
public comment period.
The amendment of both the Federal Claims Collection Act, 31 U.S.C.
3711(a)(2) and the Federal Claims Collection Standards, 4 CFR 103.1 and
104.1, allows Federal Agencies to compromise, suspend, or terminate
collection actions on claims when the amount, exclusive of interest
costs, does not exceed $100,000. This rule adopts, by reference, the
language of the Federal Claims Collection Act and Federal Claims
Collection Standards so that future amendments to the Act and the
Regulation will not necessitate corresponding amendments to DoD 6010.8-
R.
[[Page 35091]]
This rule will reduce the number of claims which must be referred
to the Department of Justice, facilitate more timely resolution of
CHAMPUS claims, diminish the size of the backlog of claims which, under
the old system, only the Department of Justice was authorized to
review, and enhance the timeliness of reviews.
VI. Regulatory Procedures
Executive Order 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. This is not an economically significant regulatory
action under the provisions of Executive Order 12866 for the following
reasons:
The PFPWD annual government cost has not exceeded $9 million.
We expect the inclusion of qualified self-employed occupational
therapists as CHAMPUS-authorized individual professional providers will
result in no additional costs. Occupational therapist services are
currently available when billed through other sources.
The telephone services exclusion modification is not expected to
increase the volume (or cost) of covered procedures relative to the
volume anticipated to have been acceptably performed in a different
manner in the absence of this change.
The addition of a definition for qualifying CHAMPUS-supplement
insurance plans only provides CHAMPUS beneficiaries with criteria for
identification of plans which CHAMPUS will treat as second-pay
insurance plans.
The CHAMPUS adoption of Federal Claims Collection Act and the
Federal Claims Collection Standards is only a linkage to existing
Federal law and regulation.
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. We
certify that this final rule will not have a significant economic
impact on a substantial number of small entities under the criteria of
the Regulatory Flexibility Act for the following reasons:
The PFPWD simplification of the administrative structure does not
alter the CHAMPUS pricing methods for PFPWD services or items nor the
scope of providers of PFPWD covered services or items.
The inclusion of qualified self-employed occupational therapists as
authorized individual professional providers will not significantly
affect the provision of services by these individuals.
The telephonic services exclusion modification does not add or
remove requirements for providers of services to CHAMPUS beneficiaries
or substantially alter the scope of services which providers have found
to be covered by the CHAMPUS.
The CHAMPUS-supplement insurance definition only provides CHAMPUS
beneficiaries with criteria for identification of plans which CHAMPUS
will treat as second-pay insurance plans.
The CHAMPUS adoption of Federal Claims Collection Act and the
Federal Claims Collection Standards is only a linkage to existing
Federal law and regulation. OMB has reviewed this rule as a significant
rulemaking pursuant to EO12866.
List of Subjects in 32 CFR Part 199
Administrative practice and procedure, Claims, Fraud, Health care,
Health insurance, Individuals with disabilities, 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 removing the definitions for
``Management plan'', ``Mental retardation'', ``Physical handicap'',
``Program for the handicapped (PFTH)'', and ``Special tutoring'', and
by revising the last sentence of the note following the definition of
``Domiciliary care'', and by adding definitions for ``Durable
equipment'', ``Habilitation'', ``Handicap'', ``Major life activity'',
``Not-for-profit entity'', ``Occupational therapist'', ``Program for
Persons with Disabilities (PFPWD)'', ``Public facility'', ``Public
facility adequacy'', ``Public facility availability'',
``Rehabilitation'', ``Serious physical disability'', ``State,'' and
``Supplemental insurance plan'' in alphabetical order to read as
follows:
Sec. 199.2 Definitions.
* * * * *
(b) * * *
Domiciliary care. * * *
Note: * * * Domiciliary care is not covered under either the
CHAMPUS Basic Program or the Program for Persons with Disabilities
(PFPWD).
* * * * *
Durable equipment. A device or apparatus which does not qualify as
Durable Medical Equipment (as defined in this section), and which is
essential to the efficient arrest or reduction of functional loss
resulting from a qualifying condition as provided by Sec. 199.5.
* * * * *
Habilitation. The provision of functional capacity, absent from
birth due to congenital anomaly or developmental disorder, which
facilitates performance of an activity in the manner, or within the
range considered normal, for a human being.
* * * * *
Handicap. For the purposes of this part, the term ``handicap'' is
synonymous with the term ``disability.''
* * * * *
Major life activity. Breathing, cognition, hearing, seeing, and age
appropriate ability essential to bathing, dressing, eating, grooming,
speaking, stair use, toilet use, transferring, and walking.
* * * * *
Not-for-profit entity. An organization or institution owned and
operated by one or more nonprofit corporations or associations formed
pursuant to applicable state laws, no part of the net earnings of which
inures, or may lawfully inure, to the benefit of any private
shareholder or individual.
Occupational therapist. A person who is trained specially in the
skills and techniques of occupational therapy (that is, the use of
purposeful activity with individuals who are limited by physical injury
of illness, psychosocial dysfunction, developmental or learning
disabilities, poverty and cultural differences, or the aging process in
order to maximize independence, prevent disability, and maintain
health) and who is licensed to administer occupational therapy
treatments prescribed by a physician.
* * * * *
Program for Persons with Disabilities PFPWD). The CHAMPUS benefits
described in Sec. 199.5.
* * * * *
Public facility. A public authority or entity legally constituted
within a State (as defined in this section) to administer, control or
perform a service function for public health, education or human
services programs in a city, county, or township, special district, or
other political subdivision, or such combination of political
subdivisions or
[[Page 35092]]
special districts or counties as are recognized as an administrative
agency for a State's public health, education or human services
programs, or any other public institution or agency having
administrative control and direction of a publicly funded health,
education or human services program.
Public facility adequacy. An available public facility shall be
considered adequate when the Director, OCHAMPUS, or designee,
determines that the quality, quantity, and frequency of an available
service or item otherwise allowable as a CHAMPUS benefit is sufficient
to meet the beneficiary's specific disability related need in a timely
manner.
Public facility availability. A public facility shall be considered
available when the public facility usually and customarily provides the
requested service or item to individuals with the same or similar
disability related need as the otherwise equally qualified CHAMPUS
beneficiary.
* * * * *
Rehabilitation. The reduction of an acquired loss of ability to
perform an activity in the manner, or within the range considered
normal, for a human being.
* * * * *
Serious physical disability. Any physiological disorder or
condition or anatomical loss affecting one or more body systems which
has lasted, or with reasonable certainty is expected to last, for a
minimum period of 12 contiguous months, and which precludes the person
with the disorder, condition or anatomical loss from unaided
performance of at least one Major Life Activity as defined in this
section.
* * * * *
State. For purposes of this part, any of the several States, the
District of Columbia, the Commonwealth of Puerto Rico, the Commonwealth
of the Northern Mariana Islands, and each territory and possession of
the United States.
* * * * *
Supplemental insurance plan. A health insurance policy or other
health benefit plan offered by a private entity to a CHAMPUS
beneficiary, that primarily is designed, advertised, marketed, or
otherwise held out as providing payment for expenses incurred for
services and items that are not reimbursed under CHAMPUS due to program
limitations, or beneficiary liabilities imposed by law. CHAMPUS
recognizes two types of supplemental plans, general indemnity plans,
and those offered through a direct service health maintenance
organization (HMO).
(1) An indemnity supplemental insurance plan must meet all of the
following criteria:
(i) It provides insurance coverage, regulated by state insurance
agencies, which is available only to beneficiaries of CHAMPUS.
(ii) It is premium based and all premiums relate only to the
CHAMPUS supplemental coverage.
(iii) Its benefits for all covered CHAMPUS beneficiaries are
predominantly limited to non-covered services, to the deductible and
cost-shared portions of the pre-determined allowable charges, and/or to
amounts exceeding the allowable charges for covered services.
(iv) It provides insurance reimbursement by making payment directly
to the CHAMPUS beneficiary or to the participating provider.
(v) It does not operate in a manner which results in lower
deductibles or cost-shares than those imposed by law, or that waives
the legally imposed deductibles or cost-shares.
(2) A supplemental insurance plan offered by a Health Maintenance
Organization (HMO) must meet all of the following criteria:
(i) The HMO must be authorized and must operate under relevant
provisions of state law.
(ii) The HMO supplemental plan must be premium based and all
premiums must relate only to CHAMPUS supplemental coverage.
(iii) The HMO's benefits, above those which are directly reimbursed
by CHAMPUS, must be limited predominantly to services not covered by
CHAMPUS and CHAMPUS deductible and cost-share amounts.
(iv) The HMO must provide services directly to CHAMPUS
beneficiaries through its affiliated providers who, in turn, are
reimbursed by CHAMPUS.
(v) The HMO's premium structure must be designed so that no overall
reduction in the amount of the beneficiary deductibles or cost-shares
will result.
* * * * *
3. Section 199.3 is amended by revising paragraphs (a),
(c)(2)(i)(D), the note under paragraph (c)(2)(ii), the note under
paragraph (c)(2)(iii), and the last sentence and note of paragraph
(c)(2)(vi) to read as follows:
Sec. 199.3 Eligibility.
(a) General. This section sets forth those persons who, by the
provisions of 10 U.S.C., Chapter 55, and the NATO Status of Forces
Agreement, are eligible for CHAMPUS benefits. For additional statements
concerning the special requirements of the Program for Persons with
Disabilities (PFPWD), refer to Sec. 199.5. A determination that a
person is eligible does not entitle such a person automatically to
CHAMPUS payments. Other sections of this part set forth additional
requirements that must be met before any CHAMPUS benefits may be
extended. Additionally, the use of CHAMPUS may be denied if a Uniformed
Services medical facility capable of providing the needed care is
available.
* * * * *
(c) * * *
(2) * * *
(i) * * *
(D) For benefits under the PFPWD, January 1, 1967.
(ii) * * *
Note: Retirees and their dependents are not eligible for
benefits of the PFPWD.
(iii) * * *
Note: These classes do not have eligibility for benefits of the
PFPWD.
* * * * *
(vi) * * * For benefits under the PFPWD, dependents of an active
duty member only, January 1, 1969.
Note. Retirees or their dependents do not have eligibility for
benefits of the PFPWD.
* * * * *
4. Section 199.4 is amended by revising paragraphs (b)(8)(iii),
(b)(9)(iv), (c)(3)(x), (g)(52) and (g)(73) to read as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(b) * * *
(8) * * *
(iii) RTC day limits do not apply to services provided under the
Program for Persons with Disabilities (Sec. 199.5) or services provided
as partial hospitalization care.
(9) * * *
(iv) Acute care day limits do not apply to services provided under
the Program for Persons with Disabilities (Sec. 199.5) or services
provided as partial hospitalization care.
* * * * *
(c) * * *
(3) * * *
(x) Physical and occupational therapy. Assessment and treatment
services of a CHAMPUS-authorized physical or occupational therapist may
be cost-shared when:
(A) The services are prescribed and monitored by a physician;
(B) The purpose of the prescription is to reduce the disabling
effects of an illness, injury, or neuromuscular disorder; and
[[Page 35093]]
(C) The prescribed treatment increases, stabilizes, or slows the
deterioration of the beneficiary's ability to perform specified
purposeful activity in the manner, or within the range considered
normal, for a human being.
* * * * *
(g) * * *
(52) Telephone services. Services or advice rendered by telephone
are excluded, except that a diagnostic or monitoring procedure which
incorporates electronic transmission of data or remote detection and
measurement of a condition, activity, or function (biotelemetry) is not
excluded when:
(i) The procedure without electronic transmission of data or
biotelemetry is otherwise an explicit or derived benefit of this
section; and
(ii) The addition of electronic transmission of data or
biotelemetry to the procedure is found by the Director, CHAMPUS, or
designee, to be medically necessary and appropriate medical care which
usually improves the efficiency of the management of a clinical
condition in defined circumstances; and
(iii) That each data transmission or biotelemetry device
incorporated into a procedure that is otherwise an explicit or derived
benefit of this section, has been classified by the U.S. Food and Drug
Administration, either separately or as a part of a system, for use
consistent with the defined circumstances in paragraph (g)(52)(ii) of
this section.
* * * * *
(73) Economic interest in connection with mental health admissions.
Inpatient mental health services (including both acute care and RTC
services) are excluded for care received when a patient is referred to
a provider of such services by a physician (or other health care
professional with authority to admit) who has an economic interest in
the facility to which the patient is referred, unless a waiver is
granted. Requests for waiver shall be considered under the same
procedure and based on the same criteria as used for obtaining
preadmission authorization (or continued stay authorization for
emergency admissions), with the only additional requirement being that
the economic interest be disclosed as part of the request. The same
reconsideration and appeals procedures that apply to day limit waivers
shall also apply to decisions regarding requested waivers of the
economic interest exclusion. However, a provider may appeal a
reconsidered determination that an economic relationship constitutes an
economic interest within the scope of the exclusion to the same extent
that a provider may appeal determinations under Sec. 199.15(i)(3). This
exclusion does not apply to services under the Program for Persons with
Disabilities (Sec. 199.5) or provided as partial hospital care. If a
situation arises where a decision is made to exclude CHAMPUS payment
solely on the basis of the provider's economic interest, the normal
CHAMPUS appeals process will be available.
* * * * *
5. Section 199.5 is revised to read as follows:
Sec. 199.5 Program for Persons with Disabilities (PFPWD).
(a) General. This PFPWD provides financial assistance for certain
CHAMPUS beneficiaries who are moderately or severely mentally retarded,
or seriously physically disabled. The PFPWD is not intended to be a
stand alone benefit.
(1) Purpose. The primary purpose of the PFPWD is to assist in
reducing the disabling effects of a PFPWD qualifying condition.
(2) Benefit source election. A PFPWD beneficiary (or sponsor or
guardian acting on behalf of the beneficiary) may elect to use the
provisions of either this section, or the provisions of Sec. 199.4, for
a specific service or item which is allowable by both sections.
(i) Election limitation. No amount for authorized, or otherwise
allowed, PFPWD services or items remaining after the maximum PFPWD
benefit dollar amount has been reached in a given month may be cost-
shared through the provisions of Sec. 199.4.
(ii) Election change. A beneficiary (or sponsor or guardian acting
on behalf of the beneficiary) shall have the right to request the
Director, OCHAMPUS, or designee, to allow PFPWD cost-shared services or
items otherwise allowable as a benefit of Sec. 199.4, and which were
rendered after the catastrophic loss protection provision applicable to
Sec. 199.4 was in effect for a given PFPWD beneficiary's sponsor, to be
readjudicated according to the provisions of Sec. 199.4. The Director,
OCHAMPUS, or designee, shall allow readjudication when the sponsor's
family's CHAMPUS benefit year cost-share liability would be reduced by
such readjudication. Such requests are subject to the claims filing
deadline provisions of Sec. 199.7. The determination regarding
readjudication is conclusive and may not be appealed.
(3) Application required. A beneficiary shall establish PFPWD
eligibility as a prerequisite to authorization or payment of any PFPWD
benefits. Subsequent review of the PFPWD qualifying condition to
confirm continued eligibility shall be made in accordance with the
prognosis for a change in severity such that the condition would not
likely continue to be a PFPWD qualifying condition.
(4) Benefit authorization. To establish whether a requested service
or item is a PFPWD benefit, the beneficiary (or sponsor or guardian
acting on the behalf of the beneficiary) shall provide such information
about how the requested benefit will contribute to confirming,
arresting, or reducing the disabling effects of the qualifying
condition as the Director, OCHAMPUS, or designee, determines necessary
for benefit adjudication.
(i) Written authorization. The Director, OCHAMPUS, or designee, may
require written authorization for any PFPWD category or type of service
or item as a prerequisite for adjudication of related claims.
(ii) Format. An authorization issued by the Director, OCHAMPUS, or
designee, shall specify, such description, dates, amounts,
requirements, limitations or information as necessary for exact
identification of approved benefits and efficient adjudication of
resulting claims.
(iii) Valid period. An authorization for a particular PFPWD service
or item shall not exceed six consecutive months.
(iv) Authorization waiver. The Director, OCHAMPUS, or designee,
shall waive the requirement for a written CHAMPUS authorization for
rendered PFPWD services or items that, except for the absence of the
written CHAMPUS authorization, would be allowable as a PFPWD benefit.
(v) Public facility use. A PFPWD beneficiary residing within a
State, as defined in Sec. 199.2, must demonstrate that a public
facility, as defined in Sec. 199.2, funds, except funds administered
under a State plan for medical assistance under Title XIX of the Social
Security Act (Medicaid) is not available or adequate, as defined in
Sec. 199.2, to meet the qualifying condition related need.
(A) Equipment repair or maintenance for beneficiary owned equipment
shall be considered not available when the equipment is a type
allowable as a benefit.
(B) A beneficiary shall not be required to change the provider of
public facility funded therapy when public facility funding is depleted
during that beneficiary's course of therapy and when such a change is
determined by the Director, OCHAMPUS, or designee, to be clinically
contraindicated. When contraindicated, other public facilities
[[Page 35094]]
for the therapy shall not be considered adequate for the beneficiary.
(5) Public facility use certification. Written certification, in
accord with information requirements, formats, and procedures
established by the Director, OCHAMPUS, or designee that requested PFPWD
services or items cannot be obtained from public facilities because the
services or items are not available, or if available, are not adequate,
is a prerequisite for PFPWD benefit payment.
(i) A Military Treatment Facility (MTF) Commander, or designee, may
make such certification for a beneficiary residing within a defined
geographic area.
(ii) An administrator of a public facility, or designee, may make
such certification for a beneficiary residing within the service area
of that public facility.
(iii) The domicile of the beneficiary shall be the basis for the
determination of public facility availability when the sponsor and
beneficiary are separately domiciled due to the sponsor's move to a new
permanent duty station or due to legal custody requirements.
(iv) The Director, OCHAMPUS, or designee, may determine, on a case-
by-case basis, that apparent public facility availability for a
requested type of service or item can not be substantiated for a
specific beneficiary's request for PFPWD benefits and is not available.
(A) A case-specific determination shall be shall be based upon a
written statement by the beneficiary (or sponsor or guardian acting on
behalf of the beneficiary) which details the circumstances wherein a
specific individual representing a specific public facility refused to
provide a public facility use certification, and such other information
as the Director, OCHAMPUS, or designee determines to be material to the
determination.
(B) A case-specific determination of public facility availability
by the Director, OCHAMPUS, or designee, is conclusive, and is not
appealable.
(6) Equipment. (i) An item of equipment shall not be authorized
when such authorization would allow concurrent PFPWD cost-sharing of
more than one item of the same type of equipment for the same
beneficiary.
(ii) Reasonable repairs and maintenance shall be allowable for any
beneficiary owned equipment otherwise allowable by this section.
(7) Implementing instructions. The Director, OCHAMPUS, or designee
shall issue policies, instructions, procedures, guidelines, standards,
and criteria necessary to assure the quality and efficiency of services
and items furnished as a PFPWD benefit and to otherwise accomplish the
purpose of the PFPWD.
(i) Other requirements. All provisions of this part, except the
provisions of Sec. 199.4, apply to the PFPWD unless otherwise provided
by this section.
(ii) Continuity of eligibility. A CHAMPUS beneficiary who has an
outstanding Program for the Handicapped (PFTH) benefit authorization
during the 30 calendar day period immediately prior to the effective
date of the Program for Persons with Disabilities (PFPWD) shall be
deemed to have a PFPWD qualifying condition for the duration of the
period during which the beneficiary is otherwise eligible for PFPWD and
the beneficiary continues to meet the applicable PFTH qualifying
condition criteria.
(b) Eligibility--(1) Spouse or child. PFPWD benefits are limited to
a CHAMPUS eligible child or spouse, but not a former spouse, except as
provided in paragraph (b)(1)(ii) of this section, of:
(i) Active duty sponsor. An active duty member of one of the
Uniformed Services as determined in accordance with the provisions of
Sec. 199.3; or
(ii) Former member sponsor. After November 13, 1986, a former
member of a Uniformed Service, when the qualifying condition is the
result of, or has been exacerbated by, an injury or illness resulting
from physical or emotional abuse; or
(iii) Deceased sponsor. A CHAMPUS beneficiary who is receiving
PFPWD benefits at the time of the death of the sponsoring active duty
Uniformed Service member remains eligible for PFPWD benefits through
midnight of the beneficiary's twenty-first birthday when the sponsor
died after January 1, 1997, and the sponsor was, at the time of death,
eligible for receipt of hostile-fire pay or died as a result of disease
or injury incurred while eligible for such pay.
(2) Loss of PFPWD eligibility. Eligibility for PFPWD benefits
ceases as of 12.:01 a.m. of the day following the day that:
(i) The sponsor ceases to be an active duty member for any reason
other than death; or
(ii) Eligibility based upon the abused dependent provisions of
paragraph (b)(1) of this section expires; or
(iii) Eligibility based upon the deceased sponsor provisions of
paragraph (b)(1) of this section expires; or
(iv) The Director, OCHAMPUS, or designee, determines that the
beneficiary no longer has a qualifying condition.
(3) Qualifying condition--(i) Mental retardation. A diagnosis of
moderate or severe mental retardation made in accordance with the
criteria of the current edition of the ``Diagnostic and Statistical
Manual of Mental Disorders'' published by the American Psychiatric
Association is a PFPWD qualifying condition.
(ii)Serious physical disability. A serious physical disability as
defined in Sec. 199.2, is a PFPWD qualifying condition.
(iii) Infant/toddler. For CHAMPUS beneficiaries under the age of
three years with a diagnosed neuromuscular developmental condition or
Down syndrome, or other condition that can to a reasonable medical
probability be expected to precede a diagnosis of moderate or severe
mental retardation or be characterized as a serious physical disability
before the age of seven, the Director, OCHAMPUS, or designee, shall
establish criteria for PFPWD eligibility in lieu of the requirements of
paragraph (b)(3)(i) or paragraph (b)(3)(ii) of this section.
(iv) Multiple disabilities. The cumulative disabling effect shall
be used in the adjudication of a qualifying condition determination
when an applicant has two or more disabilities involving separate body
systems.
(c) Benefit. Items or services which the Director, OCHAMPUS, or
designee, has determined to be intrinsic to the following benefit
categories and has determined to be capable of confirming, arresting,
or reducing the severity of the disabling effects of a qualifying
condition, generally or in a specific case, and which are not otherwise
excluded by this PFPWD, may be allowed.
(1) Diagnostic procedures to establish a qualifying condition
diagnosis or to measure the extent of functional loss.
(2) Treatment through the use of such medical, habilitative, or
rehabilitative methods, techniques, therapies and equipment which
otherwise meet the requirements of this PFPWD. Treatment includes, but
is not limited to, prosthetic devices, orthopedic braces, and
orthopedic appliances. Otherwise allowable treatment may be rendered
in-home, or as inpatient or outpatient care as appropriate.
(3) Training when required to allow the use of an assistive
technology device or to acquire skills which are expected to assist the
beneficiary to reduce the disabling effects of a qualifying condition
and for parents (or guardian) and siblings of a PFPWD beneficiary when
required as an integral part of the management of the qualifying
condition.
[[Page 35095]]
(4) Special education instruction, other than training specifically
designed to accommodate the disabling effects of a qualifying
condition.
(5) Institutional care within a State, as defined in Sec. 199.2,
when the severity of the qualifying condition requires protective
custody or training in a residential environment.
(6) Transportation when required to convey the PFPWD beneficiary to
or from a facility or institution to receive otherwise allowable
services or items. Transportation for a medical attendant may be
approved when medically necessary for the safe transport of the PFPWD
eligible beneficiary.
(7) Adjunct services--(i) Assistive services. Services of a
qualified interpreter or translator for PFPWD beneficiaries who are
deaf, readers for PFPWD beneficiaries who are blind, and personal
assistants for PFPWD beneficiaries with other types of qualifying
conditions, when such services are not directly related to the
rendering or delivery of service or item otherwise an allowable PFPWD
benefit.
(ii) Equipment adaptation. The allowable equipment purchase shall
encompass such services and structural modification to the equipment as
necessary to make the equipment serviceable for a particular
disability.
(iii) Equipment maintenance. Reasonable repairs and maintenance for
that portion of the useful life of beneficiary owned equipment that is
concurrent with the beneficiary's PFPWD eligibility.
(d) Exclusions--(1) Inpatient acute care for medical or surgical
treatment of an acute illness, or of an acute exacerbation of the
qualifying condition, is excluded.
(2) Structural alterations to living space and permanent fixtures
attached thereto, including alterations necessary to accommodate
installation of equipment, or to facilitate entrance or exit, are
excluded.
(3) Homemaker, sitter, or companion services, except as
institutional care of adjunct services, which predominantly provide
assistance with daily living activities or accomplish household chores
or provide companionship or provide supervision or observation, or any
combination of these functions, are excluded.
(4) Dental care or orthodontic treatment is excluded.
(5) Nondomestic travel which originates or terminates outside of a
State, as defined in Sec. 199.2, is excluded.
(6) Deluxe travel accommodation price differential between the
price for a type of accommodation which provides services or features
which exceed the requirements of the beneficiary's condition for safe
transport and the price for a type of accommodation without those
deluxe features, is excluded.
(7) Equipment. Exclusions for durable medical equipment at
Sec. 199.4(d)(3)(ii)(D) apply to all PFPWD allowable equipment.
(8) Medical devices. Prosthetic devices and medical equipment which
do not meet the benefit requirements of Sec. 199.4 are excluded.
(9) No obligation to pay. Services or items for which the
beneficiary or sponsor has no legal obligation to pay, or for which no
charge would be made if the beneficiary was not eligible for the
CHAMPUS, are excluded.
(10) Public facility or Federal government. Services or items paid
for, or eligible for payment, directly or indirectly by a Public
Facility, as defined in Sec. 199.2, or by the Federal government, other
than the Department of Defense, are excluded, except when such services
or items are eligible for payment under a State plan for medical
assistance under Title XIX of the Social Security Act (Medicaid).
(11) Study, grant, or research programs. Services and items
provided as a part of a scientific clinical study, grant, or research
program are excluded.
(12) Unproven drugs, devices, and medical treatments or procedures.
Services and items whose safety and efficacy have not been established
as described in Sec. 199.4 are unproven and cannot be cost-shared by
CHAMPUS.
(13) Immediate family or household. Services or items provided or
prescribed by a member of the beneficiary's immediate family, or a
person living in the beneficiary's or sponsor's household, are
excluded.
(14) Court or agency ordered care. Services or items ordered by a
court or other government agency that are not otherwise a legitimate
PFPWD benefit are excluded.
(15) Excursions. Additional or special charges for excursions,
other than otherwise allowable transportation, are excluded even though
part of a program offered by an approved provider.
(16) Drugs and medicines. Drugs and medicines which do not meet the
benefit requirements of Sec. 199.4 are excluded.
(17) Therapeutic absences. Therapeutic absences from an inpatient
facility are excluded.
(e) Cost-share liability--(1) No deductible. PFPWD benefits are
not subject to a deductible amount.
(2) Sponsor/beneficiary cost-share liability. The total sponsor
cost-share for allowed PFPWD benefits in a given month may not exceed
the amount for the sponsor's pay grade as specified below, regardless
of the number of dependents of that same sponsor receiving PFPWD
benefits in a given month:
------------------------------------------------------------------------
Monthly
Member's pay grade share
------------------------------------------------------------------------
E-1 through E-5................................................ $25
E-6............................................................ 30
E-7 and O-1.................................................... 35
E-8 and O-2.................................................... 40
E-9, W-1, W-2, and O-3......................................... 45
W-3, W-4, and O-4.............................................. 50
O-5............................................................ 65
O-6............................................................ 75
O-7............................................................ 100
O-8............................................................ 150
O-9............................................................ 200
O-10........................................................... 250
------------------------------------------------------------------------
(3) Government cost-share liability: member who sponsors one PFPWD
beneficiary. The government share of the cost of any PFPWD benefit
provided in a given month to a beneficiary who is the sponsor's only
PFPWD eligible dependent may not exceed $1,000 in a given month, after
application of allowable payment methodology.
(4) Government cost-share liability: member who sponsors two or
more PFPWD beneficiaries. The government share of the cost of any PFPWD
benefits provided in a given month, after October 1, 1966, to a
beneficiary who is one of two or more PFPWD eligible dependents of the
same sponsor shall be determined as follows:
(i) Maximum benefit limit determination. The $1,000 maximum monthly
government PFPWD benefit amount shall apply to the beneficiary
incurring the least amount of allowable PFPWD expense in a given month,
after application of allowable payment methodology. When two or more
PFPWD eligible beneficiaries have exactly the same amount of allowable
PFPWD expense in a given month, and that amount is determined to be the
least amount for the sponsor's family group, the $1,000 maximum monthly
benefit in that month shall apply to only one of the PFPWD eligible
beneficiaries in the family group.
(ii) Maximum benefit limit exception. For all other PFPWD
dependents of the same sponsor with allowable PFPWD expense in a given
month, the $1,000 maximum monthly benefit does not apply, and the
government shall cost-share the entire amount for otherwise allowable
services or items received in that month.
(f) Benefit payment--(1) Equipment. The allowable amount for
equipment shall be calculated in the same manner
[[Page 35096]]
as durable medical equipment allowable through Sec. 199.4.
(2) Transportation. The allowable amount for transportation is
limited to the actual cost of the standard published fare plus any
standard surcharge made to accommodate any person with a similar
disability or to the actual cost of specialized medical transportation
when nonspecialized transport cannot accommodate the beneficiary's
disability related needs, or when specialized transport is more
economical than nonspecialized transport. When transport is by private
vehicle, the allowable amount is limited to the Federal government
employee mileage reimbursement rate in effect on the trip date.
(3) Proration of equipment expense. The PFPWD beneficiary (or
sponsor or guardian acting on the beneficiary's behalf) may, only at
the time of the request for authorization of equipment, specify that
the allowable cost of the equipment be prorated. Equipment expense
proration permits the allowable cost of an item of PFPWD authorized
equipment to be apportioned so that no portion of the allowable cost
exceeds the monthly benefit limit and allows each apportioned amount to
be separately authorized as a benefit during subsequent contiguous
months.
(i) Maximum period. The maximum number of contiguous months during
which a prorated amount may be authorized for cost-share shall be the
lesser of:
(A) The number of months calculated by dividing the initial
allowable cost for the item of equipment by $1,000 and doubling the
resulting quotient; or
(B) The number of months of useful equipment life for the
requesting beneficiary, as determined by the Director, OCHAMPUS, or
designee.
(ii) Cost-share. A cost-share is applicable in any month in which a
prorated amount is authorized, subject to the cost-share provisions for
a sponsor with two or more PFPWD eligible beneficiaries.
(iii) Termination. Prorated payments shall be terminated as of the
first day of the month following the death of a beneficiary or as of
the effective date of a beneficiary's loss of PFPWD eligibility for any
other reason.
(4) For-profit institutional care provider. Institutional care
provided by a for-profit entity may be allowed only when the care for a
specific PFPWD beneficiary:
(i) Is contracted for by a public facility, as defined in
Sec. 199.2, as a part of a publicly funded long-term inpatient care
program; and
(ii) Is provided based upon the PFPWD beneficiary's being eligible
for the publicly funded program which has contracted for the care; and
(iii) Is authorized by the public facility as a part of a publicly
funded program; and
(iv) Would cause a cost-share liability in the absence of CHAMPUS
eligibility; and
(v) Produces a PFPWD beneficiary cost-share liability that does not
exceed the maximum charge by the provider to the public facility for
the contracted level of care.
(g) Implementing instructions. The Director, OCHAMPUS, or a
designee, shall issue CHAMPUS policies, instructions, procedures,
guidelines, standards, and criteria as may be necessary to implement
the intent of this section.
6. Section 199.6 is amended by removing and reserving paragraphs
(a)(4) and (b)(4)(x)(B)(2), revising paragraph (c)(3)(iii)(I)(3),
redesignating paragraphs (e) and (f) as paragraphs (f) and (g) and by
adding a new paragraph (e) to read as follows:
Sec. 199.6 Authorized providers.
(a) * * *
(4) [Reserved]
* * * * *
(b) * * *
(4) * * *
(x) * * *
(B) * * *
(2) [Reserved]
* * * * *
(c) * * *
(3) * * *
(iii) * * *
(I) * * *
(3) Licensed registered physical therapists and occupational
therapists.
* * * * *
(e) Program for Persons with Disabilities Providers.--(1) General.
(i) Services and items cost-shared through Sec. 199.5 must be rendered
by a CHAMPUS-authorized provider.
(ii) A Program for the Handicapped (PFTH) provider with CHAMPUS-
authorized status on the effective date for the Program for Persons
with Disabilities (PFPWD) shall be deemed to be a CHAMPUS-authorized
PFPWD provider until all outstanding PFTH benefit authorizations for
services or items being rendered by the provider expire.
(2) PFPWD provider categories.--(i) PFPWD inpatient care provider.
A provider of residential institutional care which is otherwise a PFPWD
benefit shall be:
(A) A not-for-profit entity or a public facility, as defined in
Sec. 199.2; and
(B) Located within a State, as defined in Sec. 199.2; and
(C) Be certified as eligible for Medicaid payment in accordance
with a State plan for medical assistance under Title XIX of the Social
Security Act (Medicaid) as a Medicaid Nursing Facility, or Intermediate
Care Facility for the Mentally Retarded, or be a CHAMPUS-authorized
Institutional Provider as defined in paragraph (b) of this section, or
be approved by a State educational agency as a training institution.
(ii) PFPWD outpatient care provider. A provider of PFPWD
outpatient, ambulatory, or in-home services shall be:
(A) A CHAMPUS-authorized provider of services as defined in this
section; or
(B) An individual, corporation, foundation, or public entity that
predominantly renders services of a type uniquely allowable as a PFPWD
benefit and not otherwise allowable as a benefit of Sec. 199.4, that
meets all applicable licensing or other regulatory requirements that
are extant in the state, county, municipality, or other political
jurisdiction in which the PFPWD service is rendered.
(iii) PFPWD vendor. A provider of an allowable PFPWD item, supply,
equipment, orthotic, or device shall be deemed to be a CHAMPUS-
authorized vendor for the provision of the specific item, supply,
equipment, orthotic, or device when the vendor supplies such
information as the Director, OCHAMPUS, or designee, determines
necessary to adjudicate a specific claim.
(3) PFPWD provider exclusion or suspension. A provider of PFPWD
services or items may be excluded or suspended for a pattern of
discrimination on the basis of disability. Such exclusion or suspension
shall be accomplished according to the provisions of Sec. 199.9.
* * * * *
7. Section 199.7 is amended by revising paragraphs (a)(2),
(b)(2)(xii) and (f)(2), removing paragraph (f)(3), redesignating
paragraph (f)(4) as paragraph (f)(3), and adding a new paragraph (f)(4)
to read as follows:
Sec. 199.7 Claims submission, review, and payment.
(a) * * *
(2) Claim required. No benefit may be extended under the Basic
Program or Program for Persons with Disabilities (PFPWD) without the
submission of a complete and properly executed appropriate claim form.
* * * * *
(b) * * *
(2) * * *
[[Page 35097]]
(xii) Other authorized providers. For items from other authorized
providers (such as medical supplies), an explanation as to the medical
need must be attached to the appropriate claim form. For purchases of
durable equipment under the PFPWD, it is necessary also to attach a
copy of the preauthorization.
* * * * *
(f) * * *
(2) Treatment plan. Each preauthorization request shall be
accompanied by a proposed medical treatment plan (for inpatient stays
under the Basic Program) which shall include generally a diagnosis; a
detailed summary of complete history and physical; a detailed statement
of the problem; the proposed treatment modality, including anticipated
length of time the proposed modality will be required; any available
test results; consultant's reports; and the prognosis. When the
preauthorization request involves transfer from a hospital to another
inpatient facility, medical records related to the inpatient stay also
must be provided.
* * * * *
(4) Advance payment prohibited. No CHAMPUS payment shall be made
for otherwise authorized services or items not yet rendered or
delivered to the beneficiary.
* * * * *
8. Section 199.8 is amended by revising paragraphs (b)(3)(ii) and
(d)(4) to read as follows:
Sec. 199.8 Double coverage.
* * * * *
(b) * * *
(3) * * *
(ii) Coverage specifically designed to supplement CHAMPUS benefits
(a health insurance policy or other health benefit plan that meets the
definition and criteria under supplemental insurance plan as set forth
in Sec. 199.2(b));
* * * * *
(d) * * *
(4) Program for persons with disabilities (PFPWD). A PFPWD eligible
beneficiary (or sponsor or guardian acting on behalf of the
beneficiary) does not have the option of waiving the full use of public
facilities which are determined by the Director, OCHAMPUS, or designee,
to be available and adequate to meet a disability related need for
which a PFPWD benefit was requested. Benefits eligible for payment
under a State plan for medical assistance under Title XIX of the Social
Security Act (Medicaid) are never considered to be available in the
adjudication of PFPWD benefits.
* * * * *
9. Section 199.11 is amended by revising paragraph (g)(1) to read
as follows:
Sec. 199.11 Overpayments recovery.
* * * * *
(g) * * *
(1) Basic considerations. Federal claims against the debtor and in
favor of the United States arising out of the administration of the
CHAMPUS may be compromised or collection action taken thereon may be
suspended or terminated in compliance with the Federal Claims
Collection Act, 31 U.S.C. 3711(a)(2) as implemented by the Federal
Claims Collection Standards, 4 CFR parts 101 through 105.
* * * * *
10. Section 199.20 is amended by revising paragraph (p)(2)(i) to
read as follows:
Sec. 199.20 Continued Health Care Benefit Program (CHCBP).
* * * * *
(p) * * *
(2) * * *
(i) The Program for Persons with Disabilities under Sec. 199.5;
* * * * *
Appendix A to Part 199--[Amended]
11. Appendix A to Part 199 is amended by revising ``PFTH--Program
for the Handicapped'' to read ``PFPWD--Program for Persons with
Disabilities''.
Dated: June 24, 1997.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 97-17001 Filed 6-27-97; 8:45 am]
BILLING CODE 5000-04-M
