64768 Federal Register / Vol. 83, No. 242 / Tuesday, December 18, 2018 / Proposed Rules 

amount received by a nonqualified 

intermediary that is a participating FFI 

or a registered deemed-compliant FFI if 

the nonqualified intermediary reports 

such amount as having been withheld 

upon under chapter 3 to the extent 

permitted under § 1.1461–1(c)(4)(iv). 

* * * 

* * * * * 

■ Par. 13. Section 1.1474–2 is amended 

by revising the second sentence of 

paragraph (a)(3)(i) introductory text, 

paragraphs (a)(3)(i)(A) through (C), and 

paragraph (a)(4) to read as follows: 

§ 1.1474–2 Adjustments for 

overwithholding or underwithholding of tax. 

(a) * * * 

(3) * * * 

(i) * * * In such a case, the 

withholding agent may reimburse itself 

by reducing, by the amount of tax 

actually repaid to the beneficial owner 

or payee, the amount of any deposit of 

withholding tax otherwise required to 

be made by the withholding agent under 

§ 1.6302–2(a)(1)(iii) for any subsequent 

payment period occurring before the 

end of the calendar year following the 

calendar year of overwithholding. * * * 

(A) The repayment to the beneficial 

owner or payee occurs before the 

earliest of the due date (including 

extensions) for filing the Form 1042–S 

for the calendar year of 

overwithholding, the date the Form 

1042–S is actually filed with the IRS, or 

the date the Form 1042–S is furnished 

to the beneficial owner or payee; 

(B) The withholding agent states on a 

timely filed (including extensions) Form 

1042–S for the calendar year of 

overwithholding the amount of tax 

withheld and the amount of any actual 

repayment; and 

(C) The withholding agent states on a 

timely filed (including extensions) Form 

1042 for the calendar year of 

overwithholding the amount of 

adjustments made to overwithholding 

under paragraph (a)(1) of this section 

and the amount of any credit claimed 

under § 1.6414–1. 

* * * * * 

(4) Set-off. Under the set-off 

procedure, the withholding agent may 

repay the beneficial owner or payee by 

applying the amount overwithheld 

against any amount of tax which 

otherwise would be required under 

chapter 3 or 4 of the Internal Revenue 

Code or the regulations under part 1 of 

this chapter to be withheld from income 

paid by the withholding agent to such 

person. Any such set-off that occurs for 

a payment period in the calendar year 

following the calendar year of 

overwithholding shall be allowed only 

if— 

(i) The repayment to the beneficial 

owner or payee occurs before the 

earliest of the due date (including 

extensions) for filing the Form 1042–S 

for the calendar year of 

overwithholding, the date the Form 

1042–S is actually filed with the IRS, or 

the date the Form 1042–S is furnished 

to the beneficial owner or payee; 

(ii) The withholding agent states on a 

timely filed (including extensions) Form 

1042–S for the calendar year of 

overwithholding the amount of tax 

withheld and the amount of any 

repayment made through set-off; and 

(iii) The withholding agent states on 

a timely filed (including extensions) 

Form 1042 for the calendar year of 

overwithholding the amount of 

adjustments made to overwithholding 

under paragraph (a)(1) of this section 

and the amount of any credit claimed 

under § 1.6414–1. 

* * * * * 

Kirsten Wielobob, 

Deputy Commissioner for Services and 

Enforcement. 

[FR Doc. 2018–27290 Filed 12–13–18; 4:15 pm] 

BILLING CODE 4830–01–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

32 CFR Part 220 

[Docket ID: DOD–2016–HA–0107] 

RIN 0720–AB68 

Collection From Third Party Payers of 

Reasonable Charges for Healthcare 

Services 

AGENCY: Office of the Assistant 

Secretary of Defense (Health Affairs), 

DoD. 

ACTION: Proposed rule. 

SUMMARY: This rule exercises the 

Department of Defense’s (DoD’s) 

authority to update current regulations 

to compute reasonable charges for 

inpatient and ambulatory (outpatient) 

institutional resources and also for 

pharmaceuticals, durable medical 

equipment (DME), supplies, 

immunizations, injections or other 

medications administered or furnished 

by DoD military treatment facilities 

(MTFs) under their three existing 

healthcare cost recovery programs— 

Third Party Collections, Medical 

Services Account, and Medical 

Affirmative Claims. Specifically, the 

rule updates the reasonable charges 

methodologies for inpatient and 

ambulatory institutional billing to allow 

for the use of Itemized Resource 

Utilization (IRU) based rates— 

developed from the cost to provide 

inpatient and ambulatory institutional 

healthcare resources—in addition to 

current bundled prospective 

reimbursement approaches of diagnostic 

related group (DRG), ambulatory 

payment classification (APC), 

ambulatory surgery center (ASC) and 

ambulatory procedure visit (APV) based 

rates. It also revises the reasonable 

charges methodology for 

pharmaceuticals, DME, supplies, 

immunizations, injections or medication 

administered to allow for their 

calculation using either Civilian Health 

and Medical Program of the Uniformed 

Services (CHAMPUS) prevailing rates or 

IRU based rates—developed from the 

cost to provide these healthcare items 

and resources– regardless of whether 

CHAMPUS prevailing rates are 

available. The additional IRU 

methodology implements an itemized 

rate and reasonable charges structure 

that improves collections and operation 

of DoD’s healthcare cost recovery 

programs by ensuring MTFs receive 

appropriate reimbursement for 

institutional healthcare resources as 

well as for pharmaceuticals, DME, 

supplies, immunizations, injections or 

medication provided or administered 

and is more consistent with civilian 

health insurance industry practice. The 

proposed rule also replaces ‘‘hospital’’ 

with ‘‘institutional’’ throughout most of 

the regulation to align it with civilian 

health insurance industry terminology 

and better promote identification and 

separate billing of institutional and 

professional services. 

DATES: Comments must be received by 

February 19, 2019. 

ADDRESSES: You may submit comments, 

identified by docket number and/or 

Regulatory Information Number (RIN) 

and title, by any of the following 

methods: 

• Federal Rulemaking Portal: http://

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: Department of Defense, Office 

of the Deputy Chief Management 

Officer, Directorate for Oversight and 

Compliance, 4800 Mark Center Drive, 

Mailbox #24, Alexandria, VA 22350– 

1700. 

Instructions: All submissions received 

must include the agency name and 

docket number or RIN for this Federal 

Register document. The general policy 

for comments and other submissions 

from members of the public is to make 

these submissions available for public 

viewing on the internet at http://

www.regulations.gov as they are 


amozie on DSK3GDR082PROD with PROPOSALS1
Federal Register / Vol. 83, No. 242 / Tuesday, December 18, 2018 / Proposed Rules 64769 

received without change, including any 

personal identifiers or contact 

information. 

FOR FURTHER INFORMATION CONTACT: Ms. 

DeLisa E. Prater, Program Manager, 

Defense Health Agency Uniform 

Business Office, (703) 275–6380. 

SUPPLEMENTARY INFORMATION: 

A. Executive Summary 

1. Purpose of the Proposed Rule 

The purpose of this proposed rule is 

to incorporate new additional statutory 

authority for calculating reasonable 

institutional facility charges for: (a) 

Inpatient services and resources 

provided at DoD (MTFs in addition to 

the current authorized methodology 

which uses all-inclusive prospective 

Civilian Health and Medical Program of 

the Uniformed Services (CHAMPUS) 

diagnostic related group (DRG) based 

payment rates (including professional 

charges), and (b) ambulatory services 

provided at DoD MTFs in addition to 

the current authorized methodologies 

which use all-inclusive CHAMPUS 

ambulatory procedure classification 

(APC) and ambulatory surgery center 

(ASC) based payment rates and MHS 

ambulatory procedure visit (APV) based 

payment rates. As defined in 32 CFR 

199.2, the term ‘‘facility charges’’ means 

the charges, either inpatient or 

outpatient, made by a MTF to cover the 

overhead costs of providing the service 

(e.g., building costs such as depreciation 

and interest, staffing costs, drugs and 

supplies; overhead costs such as 

utilities, housekeeping, maintenance). It 

also revises the reasonable charges 

methodology for pharmaceuticals, DME, 

supplies, immunizations, injections or 

medication administered or provided to 

allow for their reasonable charges 

calculation using either CHAMPUS 

prevailing or cost based rates regardless 

of whether CHAMPUS prevailing rates 

are available. The legal authority for this 

proposed rule is 10 U.S.C. 1095(f), 

1097b(b) and 1079b. 

2. Summary of the Major Provisions of 

the Proposed Rule 

a. It would create an additional 

exception to the general rule that 

reasonable charges under 32 CFR 

220.8(a), 220.8(b), 220.8(f)(5) and 

220.8(f)(6) for inpatient and ambulatory 

institutional resources as well as for 

pharmaceuticals, DME, supplies, 

immunizations, injections or medication 

administered are based on the rates used 

by CHAMPUS under 32 CFR 199.14 to 

reimburse authorized providers. 

Specifically, it authorizes DoD MTFs to 

use an alternative reasonable charges 

methodology based on Itemized 

Resource Utilization (IRU) rates— 

developed from the cost to provide 

these resources and items—in addition 

to the use of aggregated and prospective 

DRG, APC, ASC and APV and prevailing 

CHAMPUS based encounter rates. 

b. As a ‘‘housekeeping’’ change, it 

would replace ‘‘hospital’’ with 

‘‘institutional’’ throughout most of the 

regulation to align it with civilian health 

insurance industry terminology and 

better promote identification and 

separate billing of institutional and 

professional services as required by 32 

CFR 220.8(b). 

B. Background 

DoD is authorized to collect 

‘‘reasonable charges’’ from third party 

payers for the cost of inpatient and 

ambulatory (outpatient) institutional 

services and also for pharmaceuticals, 

DME, supplies, immunizations, 

injections or medication administered 

or provided at DoD MTFs to military 

retirees, all dependents, and other 

eligible beneficiaries who have private 

health insurance. See 10 U.S.C. 1095 

and 32 CFR 220.2. Also, DoD must 

collect from nonbeneficiaries (or their 

insurers) the cost of trauma or other 

medical care provided to them and from 

other federal agencies, the average cost 

of healthcare provided to their 

beneficiaries at DoD MTFs (10 U.S.C. 

1079b(a) and 1085). Currently, DoD uses 

all-inclusive prospective CHAMPUS 

DRG based payment rates (including 

professional charges) as the reasonable 

charges for inpatient care and allinclusive CHAMPUS APC and ASC 

based and MHS APV charges for 

miscellaneous institutional ambulatory 

care in its healthcare cost recovery 

programs—Third Party Collection, 

Medical Services Account and Medical 

Affirmative Claims. The MHS APV rate 

is authorized by the Assistant Secretary 

of Defense (Health Affairs) (ASD(HA)) 

Policy Memorandum, ‘‘Use of CPT Code 

99199’’ (September 14, 2004) because 

MTFs currently do not have the 

appropriate software to group 

encounters into APCs and ASCs. Also, 

DoD uses the average cost for 

pharmaceutical rates because 

CHAMPUS prevailing rates are not 

available. However, DoD uses 

CHAMPUS based rates for DME, 

supplies, immunizations, injections or 

medication administered. 

C. Expected Costs 

IRU based rates are more 

representative of actual costs specific to 

the institutional resources and also to 

pharmaceuticals, DME, supplies, 

immunizations, injections or medication 

administered or consumed in the 

provision of care to a patient. Also, IRU 

based rates provide DoD the ability it 

does not currently have to bill third 

party payers in an itemized manner that 

they are accustomed to. With the 

availability of this alternative reasonable 

charges methodology, DoD MTFs can 

bill for institutional resources and also 

for pharmaceuticals, DME, supplies, 

immunizations, injections or medication 

administered using charge descriptions 

(i.e., an MTF’s comprehensive list of 

items and services for which it can 

charge) and individual cost-based rates 

associated with those descriptions. As a 

result, institutional bills are much more 

consistent with the actual resources and 

services provided to the patient, third 

party payers who receive MTF claims 

will have the detailed data needed for 

reimbursement, and the potential for 

MTFs to receive appropriate 

reimbursement improves. MTF claims 

are frequently returned for additional 

information or denied because they are 

not in an itemized format consistent 

with standard industry health insurance 

practice. The format of resulting lineitem inpatient charges based on IRU 

rates will more closely resemble the 

format currently used in the health 

insurance industry and promote more 

efficient claim adjudication. This rule 

will not affect any payments by 

TRICARE as this rule does not pertain 

to purchased care. It specifically applies 

to rate development for cost recovery in 

the direct care setting. 

In addition, using only the current 

methodologies for reasonable charges 

based on bundled prospective DRG/ 

APC/ASC/APV based rates methods and 

CHAMPUS prevailing rates methods for 

pharmaceuticals, DME, supplies, 

immunizations, injections or medication 

administered limits MTFs’ flexibility 

and ability to effectively accommodate 

current and new provider 

reimbursement methodologies and is 

likely reducing and resulting in missed 

reimbursement opportunities from third 

party payers. Third party payers do not 

uniformly have nor apply payment 

methods and rates to claims received. 

Rather, they each have their own 

distinct set of rules for and levels of 

payment that are not necessarily DRG/ 

APC/ASC/APV/CHAMPUS rate based. 

For example, there are multiple versions 

of groupers, and a payer’s 

reimbursement policy may use a 

different grouper than DoD or not 

involve a grouper at all. Moreover, third 

party payers are increasingly replacing 

fee-for-service with value-based 

performance payment portfolios (e.g., 

pay for performance, bundled payments, 

shared savings/accountable care 


amozie on DSK3GDR082PROD with PROPOSALS1
64770 Federal Register / Vol. 83, No. 242 / Tuesday, December 18, 2018 / Proposed Rules 

organizations) for providers, including 

DoD MTFs. Itemized billing using IRU 

based rates provides payers with the 

detailed data needed for whatever 

reimbursement process they use 

yielding fewer requests for additional 

information and re-processing of claims 

and increased potential reimbursement. 

Additional benefits from allowing for 

IRU based charges include: 

(1) Providing greater transparency of 

DoD MTFs’ financial efficiency and 

performance through more detailed 

purchasing, dispensing, and financial 

billing functions. IRU based charges 

provide information necessary to 

complete detailed analyses into what 

and how a MTF is purchasing, 

dispensing, and billing, which will lead 

to more informed decisions on how to 

save money, time, and effort at each of 

those three stages. 

(2) Enabling different MTF 

departments and decision makers to 

come together to discuss common 

practices, terminology, and reporting, 

allowing for the development and 

analysis of benchmarks evaluating 

clinical performance, and identifying 

and implementing the most costeffective delivery modes available. 

(3) Providing the ability to track and 

monitor resources used to treat patients, 

thereby allowing MTF staff, 

management, and leadership to better 

control and manage costs, and optimize 

the efficiency of operations to deliver 

efficient care or prevent unnecessary 

care. 

This IRU based charges approach is 

consistent with 10 U.S.C. 1095(f) and 

1097b(b) that authorize the ASD(HA) to 

calculate all third party payment 

collections and rates charged to 

civilians and interagency payers based 

on any appropriate method. It is the 

Assistant Secretary’s determination that 

itemized IRU based rates for inpatient 

and ambulatory resources and also for 

pharmaceuticals, DME, supplies, 

immunizations, injections or medication 

administered or provided better 

represents the reasonable charges and 

costs of providing care to all patients in 

MTFs. 

The rule also replaces ‘‘hospital’’ with 

‘‘institutional’’ throughout most of the 

regulation to align it with civilian 

healthcare insurance industry 

terminology. The current regulation 

uses ‘‘hospital’’ interchangeably to mean 

both: (1) A facility that provides 

emergency, inpatient, and in some cases 

outpatient medical care for sick or 

injured people; and (2) the institutional 

component of a hospital stay (i.e., 

overhead and ancillary, diagnostic and 

treatment services, other than 

professional services provided by the 

facility during the inpatient stay such as 

room and board, laboratory tests and the 

technical component of radiology 

services). It is the general rule under 

CHAMPUS, 32 CFR 220.8(b) and also 

industry best practice to identify and 

charge separately for institutional and 

inpatient professional services. This 

nomenclature change helps DoD MTFs 

reinforce the distinction and better 

promotes identification and separate 

billing of institutional and professional 

services as required by 32 CFR 220.8(b) 

and in accordance with health 

insurance industry best practice. 

D. Regulatory Procedures 

Executive Order 12866, ‘‘Regulatory 

Planning and Review,’’ and Executive 

Order 13563, ‘‘Improving Regulation 

and Regulatory Review’’ 

Executive Orders 13563 and 12866 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distribute impacts, and equity). 

Executive Order 13563 emphasizes the 

importance of quantifying both costs 

and benefits, of reducing costs, of 

harmonizing rules, and of promoting 

flexibility. It has been determined that 

this rule is not a significant regulatory 

action. The rule does not: (1) Have an 

annual effect on the economy of $100 

million or more or adversely affect in a 

material way the economy; a section of 

the economy; productivity; competition; 

jobs; the environment; public health or 

safety; or State, local, or tribal 

governments or communities; (2) Create 

a serious inconsistency or otherwise 

interfere with an action taken or 

planned by another Agency; (3) 

Materially alter the budgetary impact of 

entitlements, grants, user fees, or loan 

programs, or the rights and obligations 

of recipients thereof; or (4) Raise novel 

legal or policy issues arising out of legal 

mandates, the President’s priorities, or 

the principles set forth in these 

Executive Orders. 

Executive Order 13771, ‘‘Reducing 

Regulation and Controlling Regulatory 

Costs’’ 

There are no cost savings to the public 

anticipated by amending the current 32 

CFR part 220. Consistent with the 

analysis of transfer payments under 

OMB Circular A–4, this proposed rule 

does not involve regulatory costs subject 

to Executive Order 13771, ‘‘Reducing 

Regulation and Controlling Regulatory 

Costs.’’ 

Unfunded Mandates Reform Act (Sec. 

202, Pub. L. 104–4) 

Section 202 of Public Law 104–4, 

‘‘Unfunded Mandates Reform Act,’’ (2 

U.S.C. 1532) requires that an analysis be 

performed to determine whether any 

federal mandate may result in the 

expenditure by State, local and tribal 

governments, in the aggregate, or by the 

private sector of $100 million in any one 

year. It has been certified that this 

proposed rule does not contain a 

Federal mandate that may result in the 

expenditure by State, local and tribal 

governments, in aggregate, or by the 

private sector, of $100 million or more 

in any one year, and thus this proposed 

rule is not subject to this requirement. 

Public Law 96–354, ‘‘Regulatory 

Flexibility Act’’ (5 U.S.C. 601 et seq.) 

Public Law 96–354, ‘‘Regulatory 

Flexibility Act’’ (RFA) (5 U.S.C. 601), 

requires that each Federal agency 

prepare a regulatory flexibility analysis 

when the agency issues a regulation 

which would have a significant impact 

on a substantial number of small 

entities. This proposed rule is not an 

economically significant regulatory 

action, and it has been certified that it 

will not have a significant impact on a 

substantial number of small entities. 

Therefore, this proposed rule is not 

subject to the requirements of the RFA. 

Public Law 96–511, ‘‘Paperwork 

Reduction Act’’ (44 U.S.C. Chapter 35) 

This rule does not contain a 

‘‘collection of information’’ requirement 

and will not impose additional 

information collection requirements on 

the public under Public Law 96–511, 

‘‘Paperwork Reduction Act’’ (44 U.S.C. 

Chapter 35). 

Executive Order 13132, ‘‘Federalism’’ 

E.O. 13132, ‘‘Federalism,’’ requires 

that an impact analysis be performed to 

determine whether the rule has 

federalism implications that would have 

substantial direct effects on the States, 

on the relationship between the national 

government and the States, or on the 

distribution of power and 

responsibilities among the various 

levels of government. It has been 

certified that this proposed rule does 

not have federalism implications, as set 

forth in E.O. 13132. 

List of Subjects in 32 CFR Part 220 

Claims, Health care, Health insurance, 

and Military personnel. 

Accordingly, 32 CFR part 220 is 

proposed to be amended as follows: 


amozie on DSK3GDR082PROD with PROPOSALS1
Federal Register / Vol. 83, No. 242 / Tuesday, December 18, 2018 / Proposed Rules 64771 

PART 220—[AMENDED] 

■ 1. The authority citation for part 220 

is revised to read as follows: 

Authority: 5 U.S.C. 301; 10 U.S.C. 1095(f), 

1097b(b) and 1079b. 

■ 2. Amend § 220.8 by: 

■ a. Revising paragraphs (b), (c)(1), (5), 

(f)(2), (5) and (6), 

■ b. Adding new paragraph (f)(8); and 

■ c. Removing in paragraph (d) the 

wording ‘‘inpatient hospital care’’ and 

adding in its place ‘‘care.’’ 

The revisions and additions read as 

follows: 

§ 220.8 Reasonable charges. 

* * * * * 

(b) Inpatient institutional and 

professional services on or after October 

1, 2017. Reasonable charges for 

inpatient institutional services provided 

on or after October 1, 2017, are based on 

either of two methods as determined by 

the ASD(HA). The first uses the 

CHAMPUS Diagnosis Related Group 

(DRG) payment system rates under 32 

CFR 199.14(a)(1). Certain adjustments 

are made to reflect differences between 

the CHAMPUS payment system and 

MHS billing solutions. Among these are 

to include in the inpatient hospital 

service charges adjustments related to 

direct medical education and capital 

costs (which in the CHAMPUS system 

are handled as annual pass through 

payments). Additional adjustments are 

made for long stay outlier cases. The 

second method uses Itemized Resource 

Utilization (IRU) rates based on the cost 

to provide inpatient institutional 

resources. Like the CHAMPUS system, 

inpatient professional services are not 

included in the inpatient institutional 

services charges calculated under either 

methodology, but are billed separately 

in accordance with paragraph (e) of this 

section. In lieu of either method 

described in this paragraph (b), the 

method in effect prior to April 1, 2003 

(described in paragraph (c) of this 

section), may continue to be used for a 

period of time after April 1, 2003, if the 

ASD(HA) determines that effective 

implementation requires a temporary 

deferral. 

(c) Inpatient institutional and 

inpatient professional services before 

April 1, 2003. (1) In general. Prior to 

April 1, 2003, the computation of 

reasonable charges for inpatient 

institutional and professional services is 

reasonable costs based on diagnosis 

related groups (DRGs). Costs shall be 

based on the inpatient full 

reimbursement rate per hospital 

discharge, weighted to reflect the 

intensity of the principal diagnosis 

involved. The average charge per case 

shall be published annually as an 

inpatient standardized amount. A 

relative weight for each DRG shall be 

the same as the DRG weights published 

annually for hospital reimbursement 

rates under CHAMPUS pursuant to 32 

CFR 199.14(a)(1). The method in effect 

prior to April 1, 2003 (as described in 

this paragraph (c)), may continue to be 

used for a period of time after April 1, 

2003, if the ASD(HA) determines that 

effective implementation requires a 

temporary deferral of the method 

described in paragraph (b) of this 

section. 

* * * * * 

(5) Identification of professional and 

institutional charges. For purposes of 

billing third party payers other than 

automobile liability and no-fault 

insurance carriers, inpatient billings are 

subdivided into two categories: 

(i) Institutional charges (which refer 

to routine service charges associated 

with the facility encounter or hospital 

stay and ancillary charges). 

* * * * * 

(f) * * * 

* * * * * 

(2) With respect to inpatient 

institutional charges in the Burn Center 

at Brooke Army Medical Center, the 

ASD(HA) may establish an adjustment 

to the rate otherwise applicable under 

the payment methodologies under this 

section to reflect unique attributes of the 

Burn Center. 

* * * * * 

(5) The charge for immunizations, 

allergin extracts, allergic condition tests, 

and the administration of certain 

medications when these services are 

provided by or through a facility of the 

Uniformed Services or a separate 

immunizations or shot clinic, are based 

either on CHAMPUS prevailing rates or 

on IRU rates based on the cost to 

provide these items, exclusive of any 

costs considered for purposes of any 

outpatient visit. A separate charge shall 

be made for each immunization, 

injection or medication administered. 

(6) The charges for pharmacy, durable 

medical equipment and supply 

resources are based either on 

CHAMPUS prevailing rates or on IRU 

rates based on the cost to provide these 

items, exclusive of any costs considered 

for purposes of any outpatient visit. A 

separate charge shall be made for each 

item provided. 

* * * * * 

(8) Ambulatory (outpatient) 

institutional services on or after October 

1, 2017. Reasonable charges for 

institutional facility charges for 

ambulatory services provided on or after 

October 1, 2017, are based on any of 

three methods as determined by the 

ASD(HA). The first uses the CHAMPUS 

Ambulatory Payment Classification 

(APC) and Ambulatory Surgery Center 

(ASC) payment system rates under 32 

CFR 199.14(a)(1)(ii) and (iii) and 32 CFR 

199.14(d) respectively. The second uses 

a bundled MHS Ambulatory Procedure 

Visit (APV) payment system rate charge 

reflected by the average cost of 

providing an APV exclusive of 

professional services. The third method 

uses IRU rates based on the cost to 

provide ambulatory institutional 

resources. Like the CHAMPUS system, 

ambulatory professional services are not 

included in the ambulatory institutional 

facility charges calculated under any of 

the three methodologies, but are billed 

separately in accordance with paragraph 

(e) of this section. 

* * * * * 

Dated: December 11, 2018. 

Aaron T. Siegel, 

Alternate OSD Federal Register Liaison 

Officer, Department of Defense. 

[FR Doc. 2018–27186 Filed 12–17–18; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF HOMELAND 

SECURITY 

Coast Guard 

33 CFR Part 165 

[Docket Number USCG–2018–1065] 

RIN 1625–AA00 

Safety Zone; Oregon Inlet, Dare 

County, NC 

AGENCY: Coast Guard, DHS. 

ACTION: Notice of proposed rulemaking. 

SUMMARY: The Coast Guard is proposing 

to establish a temporary safety zone on 

the navigable waters of Oregon Inlet in 

Dare County, North Carolina in support 

of demolition of the old Herbert C. 

Bonner Bridge. This temporary safety 

zone is intended to protect mariners, 

vessels, and demolition crews from the 

hazards associated with demolishing the 

old bridge, and will restrict vessel traffic 

on portions of Oregon Inlet near active 

demolition work and demolition 

equipment. This proposed rulemaking 

would prohibit vessels or persons from 

being in the safety zone. We invite your 

comments on this proposed rulemaking. 

DATES: Comments and related material 

must be received by the Coast Guard on 

or before January 17, 2019. 

ADDRESSES: You may submit comments 

identified by docket number USCG– 


amozie on DSK3GDR082PROD with PROPOSALS1