79804 Federal Register / Vol. 89, No. 190 / Tuesday, October 1, 2024 / Proposed Rules 

created electronically using word 

processing software must be filed in 

native applications or print-to-PDF 

format and not in a scanned format. 

Commenters filing electronically do not 

need to make a paper filing. 

62. Commenters that are not able to

file comments electronically may file an 

original of their comment by USPS mail 

or by courier-or other delivery services. 

For submission sent via USPS only, 

filings should be mailed to: Federal 

Energy Regulatory Commission, Office 

of the Secretary, 888 First Street NE, 

Washington, DC 20426. Submission of 

filings other than by USPS should be 

delivered to: Federal Energy Regulatory 

Commission, 12225 Wilkins Avenue, 

Rockville, MD 20852. 

VII. Document Availability

63. In addition to publishing the full

text of this document in the Federal 

Register, the Commission provides all 

interested persons an opportunity to 

view and/or print the contents of this 

document via the internet through the 

Commission’s Home Page (https://

www.ferc.gov). From the Commission’s 

Home Page on the internet, this 

information is available on eLibrary. 

The full text of this document is 

available on eLibrary in .pdf and 

Microsoft Word format for viewing, 

printing, and/or downloading. To access 

this document in eLibrary, type the 

docket number excluding the last three 

digits of this document in the docket 

number field. 

64. User assistance is available for

eLibrary and the Commission’s website 

during normal business hours from 

FERC Online Support at (202) 502–6652 

(toll free at 1–866–208–3676) or email at 

ferconlinesupport@ferc.gov, or the 

Public Reference Room at (202) 502– 

8371, TTY (202)502–8659. Email the 

Public Reference Room at 

public.referenceroom@ferc.gov. 

By direction of the Commission. 

Dated: September 19, 2024. 

Debbie-Anne A. Reese, 

Acting Secretary. 

[FR Doc. 2024–22230 Filed 9–30–24; 8:45 am] 

BILLING CODE 6717–01–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

32 CFR Part 220 

[Docket ID: DoD–2022–HA–0054] 

RIN 0720–AB87 

Medical Billing for Healthcare Services 

Provided by Department of Defense 

Military Medical Treatment Facilities to 

Civilian Non-Beneficiaries 

AGENCY: Defense Health Agency (DHA), 

Department of Defense (DoD). 

ACTION: Proposed rule. 

SUMMARY: As required by the James M. 

Inhofe National Defense Authorization 

Act for Fiscal Year 2023 (NDAA–23), 

this document proposes to reduce 

financial harm to civilians who are not 

covered beneficiaries of the Military 

Health System (MHS), and who receive 

healthcare services at DoD military 

medical treatment facilities (MTF). The 

rulemaking, once finalized, will 

implement the MHS Modified Payment 

and Waiver Program (MPWP) through 

which the DoD will apply a sliding fee 

scale and/or a catastrophic fee waiver to 

medical invoices of certain nonbeneficiaries and will accept payments 

from health insurers of nonbeneficiaries as full payment except for 

copays, coinsurance, deductibles, 

nominal fees and non-covered services. 

DATES: This rulemaking, once finalized, 

will apply to non-beneficiary patient 

medical care provided on or after June 

21, 2023. Comments to this proposed 

rule are being accepted and must be 

received by December 2, 2024. 

ADDRESSES: You may submit comments, 

identified by docket number and/or 

Regulation Identifier Number (RIN) 

number and title, by any of the 

following methods: 

• Federal eRulemaking Portal:

https://www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: Department of Defense, Office

of the Assistant to the Secretary of 

Defense for Privacy, Civil Liberties, and 

Transparency, Regulatory Directorate, 

4800 Mark Center Drive, Attn: Mailbox 

24, Suite 08D09, Alexandria, VA 22350– 

1700. 

Instructions: All submissions received 

must include the agency name and 

docket number or RIN. The general 

policy for comments is to make these 

submissions available for public 

viewing at https://www.regulations.gov 

as they are received without change, 

including any personal identifiers or 

contact information. 

FOR FURTHER INFORMATION CONTACT: Ms. 

Merlyn Jenkins, phone number: (703) 

681–7346, mailing address: Office of the 

Secretary of Defense for Health Affairs, 

Health Resources Management and 

Policy, 1200 Defense Pentagon, 

Washington, DC 20301–1200; email 

address: mailto:merlyn.jenkins.civ@

health.mil. 

SUPPLEMENTARY INFORMATION: The 

NDAA–23 also grants the Director of 

DHA discretionary authority to waive 

assessment of medical fees of nonbeneficiaries when the healthcare 

provided enhances the knowledge, 

skills, and abilities (KSAs) of healthcare 

providers, as determined by the Director 

of DHA. The DHA is proposing to 

implement the amendments to 10 U.S.C. 

1079b enacted through the NDAA–23. 

By statute (Pub. L. 117–263, div. A, title 

VII, § 716(c), Dec. 23, 2022, 136 Stat. 

2661), the sliding fee scale and/or 

catastrophic fee waivers apply to bills 

for healthcare services provided at 

MTFs on or after June 21, 2023. 

I. Background and Authority

Title 10, United States Code (U.S.C.),

section 1073d requires the Department 

of Defense (DoD) to maintain MTFs for 

the purposes of supporting the medical 

readiness of the armed forces and the 

readiness of deployable medical 

personnel. To maintain medical 

currency and bolster the KSAs of DoD 

healthcare providers, the DoD renders 

emergency, trauma, and other medical 

services to beneficiaries of the MHS 

which consist of service members and 

former service members, and their 

dependents. The MHS may provide 

healthcare services to other individuals 

who are not eligible beneficiaries, in 

certain circumstances, as authorized by 

law, and typically on a reimbursable 

basis (Pub. L. 114–328, 717(c), Dec. 23, 

2016, as amended (10 U.S.C. 1071 note); 

and § 1074(c)). 

Proposed rules implementing DoD’s 

authority under 10 U.S.C. 1095 and 

related provisions of law to compute 

reasonable charges for inpatient and 

ambulatory (outpatient) care provided 

by MTFs, including charges for 

pharmaceuticals, durable medical 

equipment, supplies, immunizations, 

injections, or other medications, are at 

32 CFR part 220, last updated on August 

20, 2020 (55 FR 21742–21750). Medical 

billing is structured under three existing 

healthcare cost recovery programs: 

Third Party Collections (10 U.S.C. 

1095); Medical Services Account (10 

U.S.C. 1079b, 1085, and 1104); and 

Medical Affirmative Claims (42 U.S.C. 

2651–2653). The rates used for billing 

are modeled after the rates published by 


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the Centers for Medicare & Medicaid 

Services. The rates are approved 

annually by the Assistant Secretary of 

Defense for Health Affairs (ASD(HA)) 

and published on the DoD Comptroller’s 

website at https://comptroller.

defense.gov/Financial-Management/ 

Reports/rates2023/. Funds collected 

through the healthcare cost recovery 

programs are used to enhance 

healthcare delivery at MTFs. 

In carrying out the DoD’s healthcare 

cost recovery programs, charges and fees 

for care provided are assessed, as 

applicable, to civilian non-beneficiary 

patients who receive treatment at MTFs. 

When medical care is provided, such 

individuals become indebted to the 

United States. The DoD has authority 

under the Debt Collection Improvement 

Act of 1996 (DCIA) (Pub. L. 104–134) to 

compromise, or terminate the collection 

of, claims involving monetary 

indebtedness to the United States. The 

Federal Claims Collection Standards 

(FCCS) promulgated at 31 CFR parts 

900through 904, which implement the 

DCIA, require that Federal agencies 

aggressively collect all debts arising out 

of activities of that agency. Collection 

activities must be undertaken promptly 

with follow-up action taken as 

necessary. Although an individual’s 

financial circumstances are considered 

in applying the FCCS, the relevance of 

such information in determinations 

concerning debt compromise or 

termination concerns the likelihood of 

repayment or successful enforced 

collection within a reasonable period of 

time, rather than the impact on or 

financial harm to an individual that is 

consequential to being indebted. 

Accordingly, DoD MTFs have generated 

medical claims and invoices for care to 

civilian non-beneficiaries rendered 

within MTFs and have administered 

delinquent accounts consistent with the 

FCCS. 

Title 10 U.S.C. 1079b, as amended by 

section 716 of NDAA–23, establishes 

financial harm to certain individual 

civilian non-beneficiaries as a statutory 

factor used in setting the amount of fees 

and charges assessed. 

II. Problem Being Addressed Through 

This Rulemaking 

Due to the high cost of healthcare in 

the United States and the mandate for 

Federal agencies to aggressively pursue 

collection of debts under FCCS, civilian 

non-beneficiaries who were provided 

emergency or trauma healthcare services 

in DoD MTFs have experienced 

financial harm after receiving 

substantial medical bills from MTFs. 

The DoD does not have authority to 

forgive indebtedness for MTF charges 

outside of the FCCS and has not had 

authority to discount charges and fees 

for medical care, in contrast to for-profit 

and non-profit hospitals that offer 

various financial assistance policies 

(FAPs). In consequence, Congress 

wholly amended 10 U.S.C. 1079b via 

section 716 of NDAA–23. Section 716 

directs DoD to apply a sliding fee and/ 

or a catastrophic fee waiver when 

assessing fees and charges to nonbeneficiaries. For non-beneficiaries with 

health insurance, Section 716 directs 

DoD to accept payments from health 

insurers as full payment and to not 

balance bill non-beneficiaries except for 

copays, coinsurance, deductibles, 

nominal fees, and non-covered services. 

It also provides the Director of DHA 

conditional, discretionary authority to 

waive the assessment of fees that 

otherwise would be charged to nonbeneficiaries when the healthcare 

provided enhances the KSAs of 

healthcare providers, as determined by 

the Director of DHA. The NDAA for FY 

2017 (NDAA–17) authorizes provision 

of such care on a reimbursable basis to 

civilians who are not covered 

beneficiaries. Public Law 114–328, 

§ 717(c), Dec. 23, 2016, as amended, 10 

U.S.C. 1071 note. 

III. Alternatives Considered 

Section 716(c) of NDAA–23 mandates 

that DoD implement the amendments to 

10 U.S.C. 1079b within 180 days of 

enactment. With this constrained 

timeline, the DoD undertook expedited 

research efforts to ascertain whether 

private sector hospitals offered 

programs similar to what the statute 

mandates and which might serve as a 

model for the DoD. Research conducted 

indicated that while there is financial 

reporting of charitable care and FAPs by 

non-Federal entities that provide 

medical care, there is no single 

accessible and authoritative source 

which outlines the content and 

structure of those programs. Programs 

vary widely across the researched 

entities. The market research also 

included a review of the rules 

pertaining to eligibility for Federal and 

State programs such as Medicaid. The 

research provided a few alternative 

models for consideration in establishing 

the MHS MPWP, including: 

• Alternative #1: Although charity 

care policies vary by state, generally, 

for-profit and non-profit hospitals 

determine a patient’s eligibility for their 

FAPs by comparing the applicant’s 

annual household income against the 

Federal Poverty Guidelines (FPGs). The 

FPGs are published annually by the 

Department of Health and Human 

Services pursuant to 42 U.S.C. 9902(2). 

There are separate FPGs for the 

contiguous 48 states and Washington 

DC, for Alaska, and for Hawaii. The 

Census Bureau annually publishes FPG 

thresholds. The threshold is a statistical 

calculation used to identify the number 

of people living in poverty. There is no 

geographic variation; the same figures 

are used for all 50 states and 

Washington DC. The Office of 

Management and Budget (OMB) 

designates the Census Bureau poverty 

thresholds as the Federal Government’s 

official statistical definition of poverty. 

The FPGs are also used by State and 

Federal agencies for determining an 

individual’s eligibility for programs 

such as Medicaid. 

• Alternative #2: Both for-profit and 

non-profit hospitals often offer 

discounted charges and fees on a sliding 

scale based upon the patient’s 

household income when compared to 

the FPGs. Predominantly, discounts are 

offered to individuals whose household 

income falls within the range of 125 

percent to 400 percent of the FPGs, with 

most hospitals offering discounts to 

patients whose income is at or below 

200 percent of the FPGs. 

• Alternative #3: Most private sector 

hospitals do not offer programs, 

additional to their needs-based FAPs for 

further waiver of charges or fees, that 

are analogous to § 1079b(c)(3)’s mandate 

for a DoD catastrophic fee waiver 

program, but a few will limit a patient’s 

bill to a maximum percentage of the 

patient’s household income (range of 10 

to 20 percent of monthly income). In 

addition, we examined the maximum 

percentage that agencies generally can 

administratively garnish from an 

individual’s monthly income (generally 

15 percent of monthly income). See 31 

U.S.C. 3720D(b)(1); 31 CFR 285.11. 

IV. Recommended Proposed Policy 

The three alternative models 

identified through market research 

represent fair and reasonable 

approaches that could readily be 

adopted for use in the administration of 

the MHS MPWP, with some 

modifications, and without incurring 

significant costs to implement. This 

regulation’s proposed way forward is a 

combination of all three alternatives that 

make up the recommended policy. 

Specifically: 

• Alternative #1: Since 10 U.S.C. 

1079b mandates the application of a 

sliding scale and catastrophic fee 

waivers, the FPGs will be used as the 

measure to determine a patient’s 

eligibility for these discounts. 

Alternative #2: The FPG range for 

eligibility for the sliding scale discount 

set by the ASD(HA) will be published 


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annually on the DoD Comptroller’s 

Reimbursement Rates website available 

at https://comptroller.defense.gov/ 

Financial-Management/Reports/ 

rates2024/. The ASD(HA) may revise 

the range, when appropriate, to mitigate 

financial harm. Alternative #3: 

Eligibility for a catastrophic fee waiver 

will be limited based on a maximum 

percentage of a patient’s monthly 

household income determined by the 

ASD(HA) and published annually on 

the DoD Comptroller’s Reimbursement 

Rates website. The ASD(HA) may revise 

the percentage applied to household 

income, when appropriate, to mitigate 

financial harm. 

In summary, the DoD proposes to 

adopt and implement fair and 

reasonable application of a sliding scale 

and catastrophic fee waivers in 

accordance with precedent and market 

best practices. The FPGs will be used as 

the definitive measure to determine a 

patient’s eligibility for discounts and 

waivers. 

The FPG range of eligibility for the 

sliding scale discount will be published 

annually on the DoD Comptroller’s 

Reimbursement Rates website, giving 

DoD maximum flexibility to mitigate 

financial harm. 

The catastrophic percentage will be 

published annually on the DoD 

Comptroller’s Reimbursement Rates 

website, giving DoD maximum 

flexibility to mitigate financial harm. 

V. Other Applicable Authority 

Section 717 of NDAA–17 

conditionally authorizes DoD to 

evaluate and treat civilian nonbeneficiaries at MTFs if the evaluation 

and treatment is necessary to maintain 

medical readiness skills and 

competencies of healthcare providers. 

Section 717(c) mandates that DoD bill 

such individuals for the costs of such 

healthcare services provided. By 

amending 10 U.S.C. 1079b, section 716 

of NDAA–23 has provided discretionary 

authority to waive an individual’s 

responsibility to pay those statutorily 

mandated charges if the provision of 

care enhances the KSAs of healthcare 

providers, as determined by the DHA. If, 

under 10 U.S.C. 1079b(b), DoD elects to 

waive charges it is otherwise statutorily 

required to collect from an individual, 

any resulting discharge of indebtedness 

may need to be reported to the Internal 

Revenue Service (IRS) in accordance 

with the reporting requirements at 26 

U.S.C. 6050P. DoD may also be required 

to issue a Form 1099–C, ‘‘Cancellation 

of Debt’’ (OMB Control Number 1545– 

1424), available at https://www.irs.gov/ 

pub/irs-pdf/f1099c.pdf, to the patient in 

accordance with the same reporting 

requirements. This discharge of 

indebtedness could result in gross 

income being attributed to the patient 

under 26 U.S.C. 61. Authority provided 

by § 1079b(c) to adjust or waive 

assessment of fees and charges for 

medical care will be exercised by 

applying criteria applicable to civilian 

non-beneficiaries, rather than by 

exercising discretion to discharge 

indebtedness with respect to nonbeneficiaries. Consequently, to reduce 

avoidable gross income to a patient 

under 26 U.S.C. 61, DoD will consider 

a waiver under 10 U.S.C. 1079b(b) of an 

individual’s responsibility to pay 

charges only after any sliding scale 

discounts and catastrophic cap on 

charges have been applied. 

VI. Summary of Current Billing and 

Collection Processes Involving NonBeneficaries 

For non-beneficiary medical 

encounters occurring prior to June 21, 

2023, an MTF processes a bill to either 

the patient, the patient’s third-party 

insurance, or to another guarantor. The 

current legal framework to process nonbeneficiary bills is established under 10 

U.S.C. 1079b (Procedures for Charging 

Fees to Civilians). Collection of medical 

debt resulting from medical bills is 

subject to the DCIA. 

Title 10 U.S.C. 1079b directs the 

Secretary of Defense to implement 

procedures by which a non-beneficiary 

will be billed. The ASD(HA) publishes 

medical rates packages that are updated 

annually. The ASD(HA) rates reflect the 

full cost to the Government of providing 

care to a non-beneficiary patient; the 

rates generally reflect the same amounts 

that DoD reimburses to civilian 

healthcare providers when care is 

rendered outside of an MTF to a 

beneficiary patient, and they are also the 

same rates that DoD uses to bill thirdparty health insurers (under 10 U.S.C. 

1095) when a beneficiary patient 

receives care in an MTF. 

A bill generated for care at an MTF 

must be paid in full, whether by the 

patient, medical insurer, or other 

guarantor. The full amount is pursued 

against the patient and/or the patient’s 

guarantor. If the debt is not paid within 

180 days of the due date (or an 

installment plan due date), the debt is 

transferred to the Cross-Servicing 

Program (‘‘Cross-Servicing’’) of the 

Department of the Treasury, Bureau of 

the Fiscal Service, for collection. 

Agencies may also refer eligible debts 

that are less than 180 days delinquent 

to the Cross-Servicing program. 

Under the current legal framework 

there is no authority to reduce the 

amount of a debt owed by a patient who 

received care at an MTF. There is an 

ability to compromise a balance that 

cannot be paid by the non-beneficiary. 

However, the FCCS governing a 

compromise requires that a debtor 

reasonably demonstrate the inability to 

pay the debt balance, which entails 

evaluation of a debtor’s current financial 

condition, and obtaining a credit report 

or other financial information in order 

to evaluate the debtor’s assets, 

liabilities, income, and expenses. 

VII. Changes With This Rulemaking 

A. MHS Modified Payment and Waiver 

Program 

Under title 10 U.S.C. 1079b, as 

amended by NDAA–23, the DoD is 

required to apply a sliding scale and/or 

catastrophic fee waivers to medical 

invoices generated by MTFs in certain 

instances. The statute also gives the 

Director of DHA discretionary authority 

to waive charges mandated by section 

717 of NDAA–17, when the care 

provided enhances the medical KSAs of 

MHS healthcare providers, as 

determined by the Director of DHA. 

Consequently, the DoD proposes to 

implement § 1079b authorities with the 

objective of mitigating financial harm to 

civilian non-beneficiaries. The MHS 

MPWP will be applied uniformly to all 

civilian non-beneficiary patients who 

apply to the program. Applicable 

discounts will be based only on 

household income and family size. All 

patients will be eligible to apply for the 

MHS MPWP in order to mitigate 

financial harm. 

The MHS MPWP will involve a 

cascading, sequential process that 

begins with collecting health insurance 

information from all patients. For 

patients with health insurance, the 

patient must agree to allow DoD to file 

medical claims on the patient’s behalf. 

Patients with health insurance who do 

not consent to allowing DoD to file 

insurance claims on their behalf will not 

be eligible for the MHS MPWP. By 

allowing DoD to file insurance claims 

on the patient’s behalf, the DoD will be 

assured that insurance remittances and 

Explanation of Benefits (EOB) 

documents are properly sent to the DoD. 

This will enable the DoD to adjust 

balances on the patient’s account 

inclusive of the amount paid by the 

insurance carrier, amounts disallowed, 

and amounts that are the patient’s 

responsibility as determined by the 

insurance carrier (i.e., copays, 

coinsurance, deductibles, nominal fees 

and non-covered services). Once the 

patient’s account is properly adjusted in 

accordance with the EOB, the DoD will 

bill insured patients only for portions of 


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the bill that are their responsibility. For 

patients without health insurance, DoD 

will bill the patient. 

Patients who are uninsured, 

underinsured and/or who have a 

remaining balance for copay, 

coinsurance, deductible, nominal fee, or 

non-covered services may apply to the 

MHS MPWP for application of the 

sliding scale discounts and catastrophic 

fee waiver discounts. 

Patients unable to pay the remaining 

balance after the application of the 

sliding scale and catastrophic fee waiver 

may also apply for a waiver of their 

medical fees under 10 U.S.C. 1079b(b), 

by submitting a completed DD Form 

3201–1, ‘‘Request for Medical Debt 

Waiver, Military Health System 

Modified Payment and Waiver 

Program’’ (https://www.esd.whs.mil/ 

Directives/forms/dd3000_3499/). 

Waivers may be approved when—at the 

discretion of the DHA Director, the care 

rendered to the patient enhanced the 

KSAs of the healthcare providers. KSAs 

are a set of clinical skill requirements a 

provider needs in order to provide 

medical care/treatment in the deployed 

environment. Additionally, waivers will 

be used sparingly and generally only in 

instances where severe financial harm 

cannot be reasonably mitigated through 

application of discounts. Waivers may 

result in financial reporting to the IRS 

and issuance of an IRS Form 1099–C to 

the patient. Generally, waivers may be 

granted if: (a) The patient has completed 

a DD Form 2569, ‘‘Third Party 

Collection Program/Medical Services 

Account/Other Health Insurance’’ (OMB 

Control Number 0720–0055), available 

at https://www.esd.whs.mil/Directives/ 

forms/dd2500_2999/; (b) the patient has 

submitted a completed application for 

the MHS MPWP via the DD Form 3201 

and any and all appropriate discounts 

have been applied; (c) DHA competent 

medical authority confirms in writing 

on the DD Form 3201–1 that the care 

provided to the patient enhanced the 

KSAs of the DoD healthcare provider; 

and (d) the DHA determines that a 

waiver is necessary to mitigate severe 

financial harm. If the above conditions 

are met, the Director of DHA may 

exercise discretionary authority to 

waive the medical invoice. 

B. Collection of Health Insurance 

Information 

All patients receiving healthcare 

services at a DoD MTF are asked to 

complete a DD Form 2569 to collect 

health insurance information along with 

the patients’ consent for the DoD to file 

a claim on their behalf. The form 

advises patients that their ‘‘records may 

be disclosed outside of DoD to 

healthcare clearinghouses, commercial 

insurance providers, and other third 

parties in order to collect amounts owed 

to the Department of Defense.’’ 

C. Billing Insurance 

For non-beneficiaries with health 

insurance who complete the DD Form 

2569, the DHA will bill the nonbeneficiary’s health insurance and 

accept remittances. When payment or 

an EOB is received from the insurance 

company, the DoD will not bill the 

patient except for copays, coinsurance, 

deductibles, nominal fees, and amounts 

for non-covered services. The DoD will 

suspend collection against the patient 

for up to 120 days to allow the patient’s 

insurance to process the claim. The DoD 

will not bill the patient until a 

determination on payment and/or an 

EOB is received from the insurance 

company, or 120 days has lapsed, 

whichever comes first. If the DoD 

receives an insurance remittance after 

120 days have elapsed, the DoD will 

deposit the check, adjust the patient’s 

account in accordance with the EOB, 

and issue the patient a refund for 

overpayments, if any have been 

received. The DoD will ensure that 

medical invoices sent to the patient 

reflect information about the MHS 

MPWP, including instructions for 

applying to the program. 

D. Delinquent Accounts 

Delinquent accounts will be 

processed in accordance with the DCIA 

as implemented by the FCCS. 

E. Applications for MHS MPWP 

Received for Delinquent Accounts 

Transferred to the Department of the 

Treasury 

Individuals may still submit an 

application for the MHS MPWP even if 

their account has been transferred to 

Cross-Servicing; however, any 

reductions to the medical invoice from 

the MPWP may be subject to interest, 

penalties, and costs. For patients who 

apply and are eligible for a reduction 

under the MHS MPWP, the DoD will 

recall the debt from Cross-Servicing. For 

patients who apply and are ineligible for 

a reduction under the MHS MPWP, the 

debt will remain at Cross-Servicing. 

Patients may request reconsideration for 

the MHS MPWP when their financial 

circumstances appear to have 

significantly changed. 

F. Income Verification and Collection of 

Income Information 

Required MHS MPWP application 

documentation. Patients who desire to 

apply for the MHS MPWP must do so 

by completing a DD Form 3201, 

‘‘Application for Military Health System 

Modified Payment and Waiver 

Program’’ (OMB Control Number 

PENDING), available at https://

www.esd.whs.mil/Directives/forms/ 

dd3000_3499/, and submitting the 

requisite documents. All DoD patient 

invoices will include a description of 

the documents that patients must 

submit together with DD Form 3201 in 

order to demonstrate their eligibility for 

the MHS MPWP. To demonstrate 

eligibility for a sliding fee/catastrophic 

fee waiver, the patient must first 

complete a DD Form 2569 (even in cases 

where the patient possesses no health 

insurance). Patients must also attach a 

copy of their most recent filed Federal 

income tax return and the patient’s (or 

guarantor’s if the patient is a minor) last 

two pay stubs. Patients who did not file 

a Federal income tax return for the 

preceding year, must certify that they 

did not file an income tax return on the 

DD Form 3201. Additionally, when the 

patient has no verifiable income, the 

patient must provide a certification to 

that effect on the DD Form 3201. The 

last two pay stubs or disability check 

stubs may be used if no Federal income 

tax return is provided in conjunction 

with the patient’s certification of annual 

income on the DD Form 3201 to 

determine the patient’s income. Finally, 

when the patient has certified to having 

no verifiable income and has neither a 

tax return nor pay stubs, other 

information may be used to validate the 

patient’s lack of income including, but 

not limited to, the last two bank 

statements (savings and checking), or a 

Social Security benefits letter. 

For patients with health insurance, 

the patient must agree to allow DoD to 

file medical claims on the patient’s 

behalf. 

G. Application for MHS MPWP 

Discounts and Waivers 

Consideration for sliding scale and 

catastrophic fee waiver requires 

evaluation of the patient’s household 

income. To receive consideration for the 

sliding fee discount or catastrophic fee 

waiver, or to be considered for a full 

waiver of fees under 10 U.S.C. 1079b(b), 

the patient must apply to the MHS 

MPWP after receiving the MTF medical 

invoice by completing and submitting 

the DD Form 3201 (OMB Control 

Number PENDING). Applications can be 

made by: (1) patients with a remaining 

balance after insurance has been billed 

by the DoD and the insurance 

remittance and/or EOB has been 

received by the DoD; (2) by patients 

without insurance who have a balance; 

and (3) by patients with a remaining 

balance after recovery from tortfeasors is 


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made. Application instructions will be 

printed on the DoD invoice. Applicants 

to the MHS MPWP will be notified of 

the status of their application via the 

following methods: (1) For approved 

applications, the DoD will issue to the 

patient a modified medical invoice 

reflecting the balance due after applying 

the sliding fee and/or catastrophic fee 

waiver; (2) for disapproved applications, 

the DoD will issue a letter reflecting the 

reason why the application was 

disapproved. The letter will inform the 

patient of the right to reapply should the 

patient’s financial circumstances 

change. 

H. Sliding Fee Discount 

Applicants to the MHS MPWP will 

first be considered for a sliding fee 

discount, and then for a catastrophic fee 

waiver. The threshold for the sliding fee 

discount will be set to a 100 percent 

medical bill discount and no nominal 

fee for applicants whose annual 

household income is at or below 100 

percent of the applicable year’s FPGs; 

and a 100 percent medical bill discount 

plus a stratified nominal fee for 

applicants whose annual household 

income is greater than 100 percent and 

up to 400 percent of the applicable 

year’s FPGs. The ASD(HA) may 

periodically adjust the threshold limits 

by issuing policy to be published on the 

DoD Reimbursement Rates website 

(https://comptroller.defense.gov/ 

Financial-Management/Reports/). 

Stratified nominal fees are generally 

established in a manner that is equitable 

with what military retirees enrolled in 

the TRICARE program would be 

required to pay in the private sector for 

comparable services. The ASD(HA) will 

annually set the stratified nominal fees 

for outpatient and inpatient care and 

may periodically adjust the nominal fee 

by issuing policy to be published on the 

DoD Reimbursement Rates website 

(available at https://comptroller.

defense.gov/Financial-Management/ 

Reports/). The initial nominal stratified 

fees are as follows: 

Household income falls within the below federal poverty guidelines 

(%) Inpatient fee Outpatient fee 

0–100 ....................................................................................................................................................................... $0 $0 

101–120 ................................................................................................................................................................... 750 50 

121–140 ................................................................................................................................................................... 1,250 50 

141–160 ................................................................................................................................................................... 2,000 50 

161–180 ................................................................................................................................................................... 3,000 50 

181–200 ................................................................................................................................................................... 4,000 50 

201–220 ................................................................................................................................................................... 5,000 50 

221–240 ................................................................................................................................................................... 6,000 50 

241–260 ................................................................................................................................................................... 7,000 50 

261–280 ................................................................................................................................................................... 8,000 50 

281–300 ................................................................................................................................................................... 9,000 50 

301–320 ................................................................................................................................................................... 10,000 50 

321–340 ................................................................................................................................................................... 11,000 50 

341–360 ................................................................................................................................................................... 12,000 50 

361–380 ................................................................................................................................................................... 13,000 50 

381–400 ................................................................................................................................................................... 14,000 50 

Applicants with annual household 

income of greater than 400 percent of 

the applicable year’s FPGs will not be 

eligible for a sliding fee discount but 

may be eligible for a catastrophic fee 

waiver. 

I. Catastrophic Fee Waiver 

The catastrophic fee waiver is based 

on a formula for adjusting the medical 

invoice over a 36-month period. The 

catastrophic fee waiver consists of 

limiting the patient’s medical bill to a 

maximum percentage of the patient’s 

monthly household income multiplied 

by 36 months and waiving fees 

associated with the balance of the 

medical bill that exceeds the 

calculation. If the calculation yields an 

amount greater than the original 

medical bill, then the catastrophic fee 

waiver will not be applicable. The 

maximum percentage will be set to 5 

percent of the patient’s monthly 

household income multiplied by 36 

months. The ASD(HA) will annually set 

the catastrophic fee waiver percentage 

and may periodically adjust the 

percentage by issuing policy to be 

published on the DoD Reimbursement 

Rates website. 

J. Collection in Installments 

As part of the implementation of the 

sliding fee and catastrophic fee waiver 

protections to prevent severe financial 

harm, patients eligible for the MHS 

MPWP may have amounts collected in 

installments for a term not to exceed 72 

months. Additionally, patients may 

request to pay their balance by lump 

sum. The minimum amount that may be 

paid by installment per month is $25. 

K. Alternative Authority for Waiver of 

Medical Fees Based on KSA 

Enhancement 

In accordance with 10 U.S.C. 

1079b(b), the Director of DHA may issue 

a full waiver of fees for care provided 

to civilian non-beneficiaries if 

determined by the Director of DHA to be 

appropriate. Accordingly, consideration 

of a waiver of medical fees will occur 

on a case-by-case basis and only after 

application for the MHS MPWP has 

occurred. A waiver under 10 U.S.C. 

1079b(b) of $600 or more will result in 

reporting to the IRS and issuance of a 

Form 1099–C to the non-beneficiary for 

the amount waived. Waivers under 10 

U.S.C. 1079b(b) shall be used sparingly 

and only when the Director of DHA 

determines that the MHS MPWP did not 

sufficiently mitigate severe financial 

harm and receives certification from 

competent medical authority that the 

care provided to the patient enhanced 

the KSAs of the treating healthcare 

provider(s). All patient invoices will 

include a statement that the patient may 

apply for a waiver based on 10 U.S.C. 

1079b(b) and 32 CFR 220.12(n) and 

include information on how to submit a 

waiver request. 

L. Applicability of the MHS MPWP to 

Tortfeasors and Third-Party Payers 

No discount or waiver of fees under 

10 U.S.C. 1079b shall be interpreted to 

be applicable to tortfeasors under the 

Federal Medical Care Recovery Act 

(FMCRA), 42 U.S.C. 2651 or to thirdparty payers under 10 U.S.C. 1095. 

Patients treated at DoD MTFs are 

responsible to identify on the DD Form 

3201 whether their injury/disease was 

caused by a third party. To be eligible 

to obtain any discounts or waivers 


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under the MHS MPWP, the patient must 

consent and agree to cooperate with the 

United States to recover the cost of care 

against any liable tortfeasor or insurance 

under the FMCRA. Patients who have a 

remaining balance after recoveries from 

third-party tortfeasors or their insurers, 

may apply for relief of any remaining 

medical debt or may be refunded 

amounts already paid toward their 

medical debt if no balance is owed. 

VIII. Expected Impact of This 

Rulemaking 

DoD anticipates that section 716 of 

the NDAA–23 will substantially 

mitigate serious financial harm to nonbeneficiaries through application of a 

sliding fee and/or a catastrophic fee 

waiver to medical invoices generated by 

MTFs. DoD anticipates that the Director 

of DHA’s discretionary authority to 

waive fees for non-beneficiaries will 

also contribute to reducing severe 

financial harm. 

The anticipated costs for the MHS 

MPWP include only the time required 

for a patient’s application to be 

completed (see Paperwork Reduction 

Act section of this preamble) and 

reviewed. This includes time required 

for civilian non-beneficiary patients to 

complete the associated DD Form 3201 

declaring their income, DoD to receive 

and assess the application, followed by 

the determination of the eligibility for a 

sliding scale discount, catastrophic fee 

waiver, or waiver under 10 U.S.C. 

1079b(b) by the Director of DHA, and 

the response time for the decision. The 

total estimated time is less than 90 days. 

In addition, costs may be incurred for 

patients who desire to apply for a 

waiver of their medical debt (via a DD 

Form 3201–1) after they have been 

approved for the MHS MPWP. 

(1) Government Burden Related to the 

DD Form 3201, ‘‘Application for 

Military Health System Modified 

Payment and Waiver Program’’: 

TABLE A—GOVERNMENT BURDEN RELATED TO THE DD FORM 3201, ‘‘APPLICATION FOR MILITARY HEALTH SYSTEM

MODIFIED PAYMENT AND WAIVER PROGRAM’’ 

Part A: Labor cost to the Federal government Part B: Operational and maintenance costs 

(1) Collection Instrument: DD Form 3201 ................................................ (1) Cost Categories. 

(a) Number of Total Annual Responses: 2,160 ....................................... (a) Equipment: $0. 

(b) Processing Time for each Response: 10 minutes ............................. (b) Printing: $0.15/printing adjusted medical bills * 2,160 = $324. 

(c) Hourly Wage of Worker(s) Processing Responses: $17.28 ............... (c) Postage: $0.66 * 2,160 = $1,425.60. 

(d) Cost to Process Each Response: $2.88 ............................................ (d) Software Purchases: $0. 

(e) Total Cost to Process Responses: $6,220.80 .................................... (e) Licensing Costs: $0. 

(2) Overall Labor Burden to the Federal Government ............................. (f) Other (Envelope): $0.24 * 2,160 = $518.40. 

(a) Total Number of Annual Responses: 2,160 ....................................... (2) Total Operational and Maintenance Cost: $2,268.00. 

(b) Total Labor Burden: $6,220.80.

Source: 2023 GS Pay Scale at GS–06, Step 1 (https://federaljobs.net/salarybase/#Base_Rate_Chart). 

Source: Printing page cost (https://www.ecfr.gov/current/title-32/subtitle-A/chapter-I/subchapter-N/part-286/subpart-E/section-286.12). Postage 

costs: United States Postal Service, https://store.usps.com/store/results/shipping-supplies/_/N-7d0v8v#content. 

Part C: Total cost to the Federal government 

(1) Total Labor Cost to the Federal Government: $6,220.80. 

(2) Total Operational and Maintenance Costs: $2,268.00. 

(3) Total Cost to the Federal Government: $8,488.80. 

(2) Government Burden Related to the 

DD Form 3201–1, ‘‘Request for a 

Medical Debt Waiver, Military Health 

System Modified Payment and Waiver 

Program’’: 

TABLE B—GOVERNMENT BURDEN RELATED TO THE DD FORM 3201–1, ‘‘REQUEST FOR A MEDICAL DEBT WAIVER, 

MILITARY HEALTH SYSTEM MODIFIED PAYMENT AND WAIVER PROGRAM’’ 

Part A: Labor cost to the Federal government Part B: Operational and maintenance costs 

(1) Collection Instrument: DD Form 3201–1 ............................................ (1) Cost Categories. 

(a) Number of Total Annual Responses: 1,080 ....................................... (a) Equipment: $0. 

(b) Processing Time per Response: 4 minutes ....................................... (b) Printing: $0.15/printing adjusted medical bills * 1,080 = $162. 

(c) Hourly Wage of Worker(s) Processing Responses: $17.28 ............... (c) Postage: $0.66 * 1,080 = $712.80. 

(d) Cost to Process Each Response: $1.15 ............................................ (d) Software Purchases: $0. 

(e) Total Cost to Process Responses: $1,244.16 .................................... (e) Licensing Costs: $0. 

(2) Overall Labor Burden to the Federal Government ............................. (f) Other (Envelope): $0.24 * 1,080 = $259.20. 

(a) Total Number of Annual Responses: 1,080 ....................................... (2) Total Operational and Maintenance Cost: $1,134.00. 

(b) Total Labor Burden: $1244.16.

Source: 2023 GS Pay Scale at GS–06, Step 1 (https://federaljobs.net/salarybase/#Base_Rate_Chart). 

Part C: Total cost to the Federal government 

(1) Total Labor Cost to the Federal Government: $1,244.16. 

(2) Total Operational and Maintenance Costs: $1,134.00. 

(3) Total Cost to the Federal Government: $2,378.16. 


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IX. Regulatory Compliance Analysis 

A. Executive Order 12866, ‘‘Regulatory 

Planning and Review,’’ as Amended by 

Executive Order 14094, ‘‘Modernizing 

Regulatory Review’’ and Executive 

Order 13563, ‘‘Improving Regulation 

and Regulatory Review’’ 

Executive Order 12866, as amended 

by 14094 (88 FR 21879, April 11, 2023), 

and Executive Order 13563 direct 

agencies to assess all costs, benefits and 

available regulatory alternatives and, if 

regulation is necessary, to select 

regulatory approaches that maximize 

net benefits (including potential 

economic, environmental, public health, 

safety effects, distributive impacts, and 

equity). These Executive Orders 

emphasize the importance of 

quantifying both costs and benefits, of 

reducing costs, of harmonizing rules, 

and of promoting flexibility. This 

proposed rule has been designated 

significant, under section 3(f) of 

Executive Order 12866, as amended by 

Executive Order 14094. 

B. Public Law 118–15, Div. B, Title III, 

‘‘Administrative Pay-As-You-Go Act of 

2023’’ 

Per the Administrative Pay-As-YouGo Act of 2023 (Fiscal Responsibility 

Act of 2023 (Pub. L. 118–5, div. B, title 

III)), agencies are required to submit 

certain information regarding the direct 

spending effects of their rules to OMB. 

Accordingly, the DoD does not 

anticipate an increase to direct 

spending, i.e., mandatory net outlays, 

stemming from the implementation of 

this proposed rule. This proposed rule 

affects only DoD’s annually 

appropriated (discretionary) salaries and 

expenses resources and does not affect 

direct spending. Healthcare services 

provided by MTFs are funded by 

discretionary appropriations. Generally, 

when MTFs render healthcare services 

to non-beneficiaries of the Department 

of Defense, such as those that will be 

covered by implementation of this 

proposed rule, the care is provided on 

a reimbursable basis. On average from 

2019–2020, MTFs generated $235.6 

million annually in medical bills for 

healthcare services rendered to nonbeneficiaries. Of that amount, an 

average of 29 percent is reimbursed by 

the third-party health insurance plans of 

insured patients, while another 30 

percent is written off in accordance with 

agreed upon terms of coverage. An 

average of 6 percent is collected from 

uninsured patients and those who are 

insured but have remaining coinsurance 

and co-pays; and an average of 35 

percent is transferred to the Department 

of the Treasury for collection actions 

due to an individual’s unresponsiveness 

to due process billing activity. Of the 35 

percent transferred to the Treasury, 

many are undocumented individuals 

without Social Security Numbers. The 

Treasury has historically recovered 

approximately 1 percent of the amount 

transferred by MTFs. All amounts 

recovered are deposited to the 

discretionary appropriation that funds 

MTF operations. 

TABLE D—HISTORICAL ACTIVITY

[FY 2019–2020] 

Percent 

Average Non-beneficiary Healthcare Billed by MTFs Annually .............................................................................. $235,618,719 

Average Paid by Third-Party Insurance .................................................................................................................. 68,473,042 29 

Insurance Write-off .................................................................................................................................................. 70,685,616 30 

Average Paid by Patients ........................................................................................................................................ 13,160,172 6 

Transferred to Treasury ........................................................................................................................................... 82,621,796 35 

Collected by Treasury .............................................................................................................................................. 2,478,654 1 

Uninsured non-beneficiary patients 

and those who are insured but have 

high coinsurance and co-pays will 

benefit most from implementation of 

this proposed rule. Of these uninsured 

and underinsured, we estimate a 

minimum of 50 percent will be eligible 

for a 100 percent discount of their MTF 

medical bill. From Calendar Years (CY) 

2018 through 2021, the average 

inpatient medical bill for this patient 

population was $47,009; and the 

average outpatient medical bill was 

$150. In Bexar County, Texas, where 

most of these costs were incurred (i.e., 

Brooke Army Medical Center in San 

Antonio, Texas), the median household 

income is $67,275 (per the 2020 U.S. 

Census Bureau) and the same source 

reports cite that the average number of 

persons living in each household in 

Bexar County is 2.71. Consequently, we 

estimate that this patient population 

will significantly benefit from this 

program. For example, using the 2020 

U.S. Census Bureau data for Bexar 

County and the average inpatient and 

outpatient medical bill amounts for CYs 

2018–2021, applying the MHS MPWP 

discounts would yield a reduction of 83 

percent to the average inpatient medical 

bill (decreasing it from $47,009 to 

$8,000) and a 67 percent reduction to 

the average outpatient medical bill 

(decreasing it from $150 to $50). 

CY 2018–2021 Average 

medical bill 

MHS MPWP 

discount % Discount New bill 

Inpatient ........................................................................................................... $47,009 $39,009 83 $8,000 

Outpatient ........................................................................................................ 150 100 67 50

Notes: Based on 2020 U.S. Census Bureau data for Bexar County, Texas, where median household income is $67,275 and the average number of persons living in each household is 2.71. 

With the implementation of the MHS 

MPWP, we anticipate the percentage of 

cases being transferred to the Treasury 

for collection activity, and the average 

amounts paid for by uninsured and 

underinsured patients, being 

substantially decreased. While this may 

cause an increase in discretionary 

spending of the Defense Health Program 

appropriation; it will not cause an 

increase in mandatory net outlays 

(direct spending). The Administrative 

Pay-As-You-Go Act of 2023 is available 

at https://www.whitehouse.gov/wpcontent/uploads/2023/09/M-23-21- 

Admin-PAYGO-Guidance.pdf. 


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C. Congressional Review Act (5 U.S.C. 

801 et seq.) 

Pursuant to Subtitle E of the Small 

Business Regulatory Enforcement 

Fairness Act of 1996 (also known as the 

Congressional Review Act), OMB’s 

Office of Information and Regulatory 

Affairs has determined that this 

proposed rule does not meet the criteria 

set forth in 5 U.S.C. 804(2). 

D. Public Law 96–354, ‘‘Regulatory 

Flexibility Act’’ (5 U.S.C. 601) 

The ASD(HA) certified that this 

proposed rule is not subject to the 

Regulatory Flexibility Act (5 U.S.C. 601) 

because it would not, if promulgated, 

have a significant economic impact on 

a substantial number of small entities. 

The Regulatory Flexibility Act aims at 

taking into account the impact of 

regulations on small businesses, small 

organizations, small governmental 

jurisdictions, and small entities. More 

specifically, the law states ‘‘. . . 

agencies shall endeavor . . . to fit 

regulatory and informational 

requirements to the scale of the 

business, organizations, and 

governmental jurisdictions subject to 

regulation.’’ (Pub. L. 96–354, September 

19, 1980; section 2 (b)) The proposed 

amendments to 32 CFR part 220 do not 

impact the small entities referenced in 

this paragraph. Therefore, the 

Regulatory Flexibility Act, as amended, 

does not require us to prepare a 

regulatory flexibility analysis. 

E. Section 202, Public Law 104–4, 

‘‘Unfunded Mandates Reform Act’’ 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (2 U.S.C. 

1532) requires agencies to assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2024, that 

threshold is approximately $183 

million. This proposed rule will not 

mandate any requirements for State, 

local, or tribal governments, and will 

not affect private sector costs. An 

unfunded mandate occurs when a State, 

local, or tribal government must perform 

certain actions or offer certain programs 

but does not receive any Federal funds 

to make it happen. The Federal 

Government passes legislation requiring 

the program, but the law does not 

include any funding. This proposed rule 

will only affect a very narrow category 

of the public and it will not impact 

State, local, or tribal governments. 

Additionally, it will not affect private 

sector costs as all proposed actions 

would be completed by Federal 

agencies. 

F. Public Law 96–511, ‘‘Paperwork 

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

It has been determined that this 

proposed rule contains information 

collection requirements. DoD has 

submitted the following proposal to 

OMB under the provisions of the 

Paperwork Reduction Act (44 U.S.C. 

chapter 35). Comments are invited on: 

(a) Whether the proposed collection of 

information is necessary for the proper 

performance of the functions of DoD, 

including whether the information will 

have practical utility; (b) the accuracy of 

the estimate of the burden of the 

proposed information collection; (c) 

ways to enhance the quality, utility, and 

clarity of the information to be 

collected; and (d) ways to minimize the 

burden of the information collection on 

respondents, including the use of 

automated collection techniques or 

other forms of information technology. 

(1) Respondent Burden Related to DD 

Form 3201, ‘‘Application for Military 

Health System Modified Payment and 

Waiver Program.’’ This is a new 

collection. Using the information 

collected on the form, DoD medical 

billing offices will determine whether 

the patient is eligible for the medical 

discount/waiver program. If the patient 

is eligible, the billing office will 

generate an adjusted medical bill and 

send it to the patient. If the patient is 

not eligible, the billing office will send 

written correspondence to the patient, 

informing them that they are not eligible 

for the discount program and of their 

right to reapply should their financial 

circumstances change. Processing of the 

application will be annotated on the last 

page of the application. The application 

will be filed in the billing office’s 

official records. 

Part A: Estimation of respondent burden Part B: Labor cost of respondent burden 

(1) Collection Instrument: DD Form 3201 ........................................... (1) Collection Instrument: DD Form 3201. 

(a) Number of Respondents: 2,160 .................................................... (a) Number of Total Annual Responses: 2,160. 

(b) Number of Responses Per Respondent: 1 ................................... (b) Response Time: 4 minutes. 

(c) Number of Total Annual Responses: 2,160 .................................. (c) Respondent Hourly Wage: $33.58.* 

(d) Response Time: 4 minutes ........................................................... (d) Labor Burden per Response: $2.24. 

(e) Respondent Burden Hours: 144 hours ......................................... (e) Total Labor Burden: $4,835.52. 

(2) Total Submission Burden .............................................................. (2) Overall Labor Burden. 

(a) Total Number of Respondents: 2,160 ........................................... (a) Total Number of Annual Reponses: 2,160. 

(b) Total Number of Annual Responses: 2,160 .................................. (b) Total Labor Burden: $4,835.52. 

(c) Total Respondent Burden Hours: 144 hours.

Approximately 8,000 civilian non-beneficiary patients are treated at DoD MTFs annually. The U.S. Census Bureau estimates that 27 percent of 

Americans are uninsured. Based on that estimate, we anticipate that 2,160 (or 27 percent of 8,000) patients will not have insurance and may 

face serious financial harm stemming from MTF medical bills. We anticipate that those uninsured individuals will apply for the MHS MPWP each 

year. 

*Source: http://www.bls.gov/web/empsit/ceseesummary.htm (Bureau of Labor Statistics national average hourly wage for all employees June 

2023) 

(2) Respondent Burden Related to DD 

Form 3201–1, ‘‘Request for Waiver of 

Medical Debt, Military Health System 

Modified Payment and Waiver 

Program’’. This is a new collection. The 

10 U.S.C. 1079b statute grants the 

Director of the Defense Health Agency 

discretionary authority to grant waivers 

to medical bills in certain instances. 

Accordingly, the DD Form 3201–1 may 

be used by non-beneficiary patients to 

apply for a waiver. For patients who are 

approved for waivers (not discounts) 

under the Director of the Defense Health 

Agency’s discretionary authority, the 

waived amount, along with the patient’s 

SSN and address, will be relayed to the 

IRS. 

Part A: Estimation of respondent burden Part B: Labor cost of respondent burden 

(1) ................. Collection Instrument: DD Form 3201–1 ............................... (1) Collection Instrument: DD Form 3201–1. 

(a) ................. Number of Respondents: 1,080 ............................................ (a) Number of Total Annual Responses: 1,080. 


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Part A: Estimation of respondent burden Part B: Labor cost of respondent burden 

(b) ................. Number of Responses Per Respondent: 1 ........................... (b) Response Time: 4 minutes. 

(c) .................. Number of Total Annual Responses: 1,080 .......................... (c) Respondent Hourly Wage: $33.58. 

(d) ................. Response Time: 4 minutes ................................................... (d) Labor Burden per Response: $2.24. 

(e) ................. Respondent Burden Hours: 72 hours ................................... (e) Total Labor Burden: $2,417.76. 

(2) ................. Total Submission Burden ...................................................... (2) Overall Labor Burden. 

(a) ................. Total Number of Respondents: 1,080 ................................... (a) Total Number of Annual Reponses: 1,080. 

(b) ................. Total Number of Annual Responses: 1,080 .......................... (b) Total Labor Burden: $2,417.76. 

(c) .................. Total Respondent Burden Hours: 72 hours.

Of the 2,160 anticipated applicants to the program, we anticipate that most will receive a substantially discounted medical bill. However, this 

estimate is prepared with a worst-case scenario in which half of the applicants desire to apply for a waiver. 

Written comments and 

recommendations on the proposed 

information collection should be sent to 

Mr. Matt Eliseo at the Office of 

Management and Budget, DoD Desk 

Officer, Room 10102, New Executive 

Office Building, Washington, DC 20503, 

with a copy to Ms. Merlyn Jenkins at the 

Office of the Secretary of Defense for 

Health Affairs, Health Resources 

Management and Policy, 1200 Defense 

Pentagon, Washington, DC 20301–1200. 

Comments can be received from 30 to 60 

days after the date of this notice, but 

comments to OMB will be most useful 

if received by OMB within 30 days after 

the date of this notice. 

You may also submit comments 

identified by docket number and title 

through the Federal eRulemaking Portal 

at http://www.regulations.gov. Follow 

the instructions for submitting 

comments. 

All submissions received must include 

the agency name, docket number and 

title 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 received without change, 

including any personal identifiers or 

contact information. 

To request more information on this 

proposed information collection or to 

obtain a copy of the proposal and 

associated collection instruments, 

please write to Ms. Merlyn Jenkins at 

the Office of the Secretary of Defense for 

Health Affairs, Health Resources 

Management and Policy, 1200 Defense 

Pentagon, Washington, DC 20301–1200, 

(703) 681–7346. 

G. Executive Order 13132, ‘‘Federalism’’ 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a rule 

that imposes substantial direct 

requirement costs on State and local 

governments, preempts state law, or 

otherwise has federalism implications. 

This proposed rule will not have a 

substantial effect on State and local 

governments. 

H. Executive Order 13175, 

‘‘Consultation and Coordination with 

Indian Tribal Governments’’ 

Executive Order 13175 establishes 

certain requirements that an agency 

must meet when it promulgates a rule 

that imposes substantial direct 

compliance costs on one or more Indian 

tribes, preempts tribal law, or effects the 

distribution of power and 

responsibilities between the Federal 

Government and Indian tribes. This 

proposed rule will not have a 

substantial effect on Indian tribal 

governments. 

List of Subjects in 32 CFR Part 220 

Accounts receivable, Civilian medical 

debt, Claims, Healthcare, Health 

insurance, Medical billing, Medical 

debt, Medical debt waiver, Military 

medical treatment facilities, Military 

personnel, and Third party collections. 

Accordingly, the DoD proposes to 

amend 32 CFR part 220 to read as 

follows: 

PART 220—MEDICAL BILLING FOR 

HEALTHCARE SERVICES PROVIDED 

BY DEPARTMENT OF DEFENSE 

MILITARY MEDICAL TREATMENT 

FACILITIES TO CIVILIAN NON– 

BENEFICIARIES 

■ 1. The authority citation for part 220 

is revised to read as follows: 

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

1097b(b), 1079b; 31 U.S.C. 3711, 3717; and 

42 U.S.C. 2651. 

■ 2. The part heading is revised to read 

as set forth above. 

■ 3. Add § 220.12 to reads as follows: 

§ 220.12 Medical billing for healthcare 

services provided by DoD Military Medical 

Treatment Facilities to civilian nonbeneficiaries. 

(a) Applicability. (1) This section 

applies to all persons who receive 

reimbursable care in a military medical 

treatment facility (MTF) who are not 

covered beneficiaries of the Department 

of Defense (DoD) as defined in § 220.14, 

other than persons who receive care in 

an MTF pursuant to an agreement 

between the United States and a foreign 

government or other entity. 

(2) This section does not apply to 

third persons (or their insurers) with a 

tort liability under the Federal Medical 

Care Recovery Act (FMCRA) (42 U.S.C. 

2651) or third-party payers under 10 

U.S.C. 1095. The discounts and waivers 

implemented by this section may not be 

used to reduce the value of the care and 

treatment that is recoverable from those 

third persons (or their insurers) under 

the FMCRA or 10 U.S.C. 1095. 

(b) Definitions. (1) Military Health 

System (MHS) Modified Payment and 

Waiver Program (MPWP). The MHS 

MPWP is a DoD program to implement 

an enacted Fiscal Year 2023 National 

Defense Authorization Act (2023– 

NDAA) amendment to section 1079b of 

title 10, United States Code (U.S.C.). 

Section 716 of the 2023–NDAA 

amended 10 U.S.C. 1079b to require, 

inter alia, the Director of the Defense 

Health Agency to reduce fees that would 

otherwise be charged to civilian nonbeneficiaries for medical care according 

to a sliding scale and to implement a 

catastrophic fee waiver to prevent 

severe financial harm. It also granted the 

Director of the Defense Health Agency 

with discretionary authority to issue 

waivers of fees for medical care if the 

provision of such care enhances the 

knowledge, skills, and abilities of 

healthcare providers. 

(2) Covered payer. A third-party payer 

or other insurance, medical service, or 

health plan. 

(3) Covered by a covered payer. A 

medical item or service is deemed to be 

covered by a covered payer when: 

(i) The patient possesses health 

insurance that is in effect on the date(s) 

that the item or service was provided; 

(ii) The health insurance plan 

provides coverage for the geographic 

area where the care was delivered; 

(iii) The care provided to the patient 

is an item or service covered by the 

terms of the insurance plan, and; 

(iv) The health insurance plan 

provides coverage for care rendered in 

a U.S. Government/DoD facility; 


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(v) The insurer agrees to pay the 

facility directly; 

(vi) The insurer agrees to provide the 

facility with an Explanation of Benefits 

(EOB) that details how the insurer 

processed the claims according to the 

insurance plan; and 

(vii) The patient authorizes the DoD to 

file insurance claims against the 

insurance policy. 

(4) Non-covered item or service. A 

medical item or service that is not 

covered by the terms of the insurance 

plan. 

(5) Third-party payer and insurance, 

medical service, or health plan have the 

meaning given those terms in 10 U.S.C. 

1095(h). 

(6) Knowledge, skills, and abilities 

(KSAs). KSAs are a set of clinical skill 

requirements that a healthcare provider 

needs in order to provide medical care 

or treatment in the deployed 

environment. 

(7) Reasonable value of medical care. 

Reasonable value of medical care is 

defined in § 220.8. The reasonable value 

of medical care is based on the amount 

billed by the MTF before application of 

any sliding scale discount, catastrophic 

fee waiver discount, or other discount or 

waiver under this section. 

(c) Notifications concerning MHS 

MPWP. The Assistant Secretary of 

Defense for Health Affairs (ASD(HA)) 

will maintain a public website 

containing information about the MHS 

MPWP, applicable forms (with links to 

the forms), and a fee discount 

calculator. The DoD will notify nonbeneficiary patients of the availability of 

the MHS MPWP. Information about the 

MHS MPWP will be posted in MTFs 

(e.g., in waiting rooms and information 

desks) and included in DoD patient 

invoices. 

(d) Requirement to complete a DD 

Form 2569. MTFs will present the DD 

Form 2569, ‘‘Third Party Collection 

Program/Medical Services Account/ 

Other Health Insurance’’ to all patients. 

It will also be available at https://

www.esd.whs.mil/Directives/forms/ 

dd2500_2999/. All patients (regardless 

of insurance status) must complete the 

DD Form 2569. 

(1) Before applying for the MHS 

MPWP, all patients (regardless of health 

insurance status) must fully complete 

(including by signing) the DD Form 

2569 and ensure that a current and 

accurate DD Form 2569 is on file with 

the applicable MTF. Successful 

completion of these steps is a condition 

of eligibility for the MHS MPWP. 

(2) For patients with health insurance, 

the DoD will file insurance claims on 

behalf of the patient. Patients with 

health insurance who do not consent to 

allowing the DoD to file health 

insurance claims on their behalf will not 

be eligible for the MHS MPWP. 

(3) Updating the DD Form 2569. The 

DoD may use a completed DD Form 

2569 for multiple episodes of care. 

Unless a DD Form 2569 completed 

within the preceding 12 months for the 

patient is available, the DoD will solicit 

an updated DD Form 2569 from patients 

who receive a subsequent episode of 

care from the MTF. However, the lack 

of an updated form will not preclude 

the DoD from filing additional claims 

against encounters for the patient. 

(e) Notifications on Medical Invoices. 

In addition to any notifications 

otherwise already required by law, 

regulation, or DoD policy, all DoD 

invoices will notify patients that– 

(1) Patients must consent to DoD 

filing insurance claims on their behalf to 

be eligible for the MHS MPWP; 

(2) The DoD will suspend fee 

assessment and patient billing actions 

against the debtor for up to 120 days 

while the DoD is pursuing an insurance 

claim or claim against a third-party 

payer; 

(3) For patients who are covered by a 

covered payer, the DoD will only bill 

the patient for the insurer-assigned 

copays, coinsurance, deductibles, 

nominal fees, and non-covered services; 

(4) The patient demonstrates potential 

eligibility for the MHS MPWP fee 

discounts and catastrophic fee waivers 

by completing and submitting DD Form 

2569 and DD Form 3201, which may 

result in a discount of their medical 

invoice after pursuit or recovery of 

claims against third party payers 

(instructions for demonstrating 

eligibility, including deadline, will also 

be included); 

(5) In addition to fee discounts and 

catastrophic fee waivers, patients may 

request a full waiver under 10 U.S.C. 

1079b(b) by submitting a DD Form 

3201–1, Request for Medical Debt 

Waiver, Military Health System 

Modified Payment and Waiver Program. 

Patients may be considered for a full 

waiver if they previously applied to the 

MHS MPWP and it did not sufficiently 

mitigate financial harm and if the 

applicable care provided is determined 

to enhance the KSAs of DoD healthcare 

providers. Waivers under 10 U.S.C. 

1079b(b) may result in information 

reporting to the Internal Revenue 

Service and issuance of a Form 1099–C, 

Cancellation of Debt, and the waived 

amount(s) may constitute gross income 

to the patient under 26 U.S.C. 61; 

(6) If fees or charges (including those 

reduced under the MHS MPWP) become 

delinquent due to non-payment, the 

DoD will establish a debt for the 

delinquent amount and commence 

efforts to collect the established debt, 

which may include transfer to the 

Department of the Treasury in 

accordance with applicable authority; 

and 

(7) That invoices issued after 

reduction or waiver of charges under the 

MHS MPWP will reflect the date by 

which an unpaid account will become 

delinquent. 

(f) DoD medical billing rates. 

Annually, the ASD(HA) publishes the 

rates that DoD uses for medical billing. 

Except for reasons listed in 32 CFR 

220.8(f) or (g), the DoD rate will be used 

for all non-beneficiary billing, including 

billing to either the insurer or patient. 

(g) For non-covered items or services. 

In any instance where an item or service 

is not covered by a covered payer, the 

DoD will bill the patient for the full 

amount of the service. 

(h) For patients who are potentially 

covered by a covered payer. In any 

instance where a patient submits a DD 

Form 2569 that indicates that the 

patient possesses valid health 

insurance, the DoD will suspend any 

collections against the patient to allow 

time for the claim remittance to be 

processed by the insurer and for a valid 

EOB to be received, or until 120 days 

have passed since filing for payment 

from the insurance company, whichever 

comes first. Upon receipt of an EOB, the 

DoD will bill the patient only for those 

amounts that are designated by the 

insurance company as a copay, 

coinsurance, deductible, nominal fee, or 

non-covered service. If insurance 

remittance and an EOB are not received 

within 120 days of filing of a claim, the 

DoD will deem the item or service to be 

a non-covered service. If insurance 

remittance and an EOB are received 

after 120 days have elapsed, the DoD 

will deposit the remittance and adjust 

the patient’s account accordingly. The 

DoD will issue to the patient a revised 

medical invoice reflecting updated 

balances. 

(i) Actions when an insurance 

payment and/or EOB is received. When 

the DoD receives an insurance payment 

and/or an EOB, the DoD will post all 

payments and adjustments for those 

items or services that are deemed as 

covered by a covered payer against the 

bill in the manner prescribed by the 

EOB. The DoD will bill the patient for 

any remaining copays, co-insurance, 

deductibles, nominal fees and noncovered services. 

(j) Application for the MHS MPWP 

(DD Form 3201). All DoD invoices 

generated for non-covered beneficiaries 

will include a statement that all patients 

applying for the MHS MPWP must 


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79814 Federal Register / Vol. 89, No. 190 / Tuesday, October 1, 2024 / Proposed Rules 

complete DD Form 3201 and must 

include instructions on how to apply 

(i.e., the deadline and where to submit 

the application). Processing of the 

application will be logged on the last 

page of the DD Form 3201. Applicants 

to the MHS MPWP will be notified of 

the status of their application via the 

following methods: 

(1) For approved applications, the 

DoD will issue to the patient a modified 

medical invoice reflecting the adjusted 

balance due after applying the sliding 

fee and/or catastrophic fee waiver. The 

invoice modified to reflect fee 

adjustments or waiver under the MHS 

MPWP will include notification of the 

requirement to transfer delinquent debts 

to the Department of the Treasury if, 

after any modification under the MHS 

MPWP, an unpaid invoice becomes 

delinquent. 

(2) For disapproved applications, the 

DoD will issue a letter reflecting the 

reason why the application was 

disapproved. The letter will inform the 

patient of their right to reapply should 

their financial circumstances change. 

(k) Requirements to apply to the MHS 

MPWP. (1) To apply to the MHS MPWP 

all patients must: 

(i) Complete a DD Form 2569 (even in 

cases where the patient possesses no 

health insurance). Insurance remittances 

must be applied before the patient can 

be considered for the MHS MPWP. 

(ii) Complete a DD Form 3201, 

‘‘Application for Military Health System 

Modified Payment and Waiver 

Program.’’ 

(iii) Attach a copy of the patient’s (or 

guarantor’s if the patient is a minor) 

most recently filed Federal Income Tax 

Return to the DD Form 3201. 

(iv) Attach a copy of the patient’s (or 

guarantor’s if the patient is a minor) last 

two pay stubs. 

(v) Indicate whether their injury/ 

disease was caused by a third party and 

provide explanatory information. 

(2) Required certifications. 

(i) If the patient did not file a Federal 

Income Tax Return for the preceding 

year, the patient must certify this on the 

DD Form 3201. 

(ii) If the patient has no verifiable 

income, the patient must certify this and 

provide a certification of their current 

annual income amount on the DD Form 

3201. 

(iii) If the patient believes that 

hospitalization/care occurred as the 

result of an action for which another 

party may be responsible, then to be 

eligible for the MHS MPWP, the patient 

must agree to cooperate and assist the 

United States to recover the cost of care 

from said party. 

(l) Basis to assign a Sliding Fee 

Discount/Catastrophic Fee Waiver—(1) 

MHS Discount Calculator. Once a year, 

the ASD(HA) will promulgate an MHS 

Discount Calculator. The initial 

calculator will assign a 100 percent 

sliding fee discount and no stratified 

nominal fee to applicants to the MHS 

MPWP whose annual household income 

is at or below 100 percent of the 

applicable year’s Federal Poverty 

Guidelines; and a 100 percent sliding 

fee discount plus a stratified nominal 

fee to applicants whose annual 

household income is greater than 100 

percent and at or below 400 percent of 

the Federal Poverty Guidelines current 

at the time of application. Applicants 

with annual household income of 

greater than 400 percent of the 

applicable year’s Federal Poverty 

Guidelines will not be eligible for a 

sliding fee discount; but may be eligible 

for a catastrophic fee waiver. 

(2) Catastrophic Fee Waiver. For 

applicants who exceed the 400 percent 

threshold, the calculator will assign an 

ASD(HA)-approved maximum 

percentage that may be charged monthly 

based on the patient’s monthly 

household income. The maximum 

percentage will be set to 5 percent. The 

monthly household income will be 

multiplied by 5 percent and the result 

will be multiplied by 36 months to 

derive the amount of downward 

adjustment to the patient’s bill. 

Amounts that exceed the recalculated 

amount will be waived. If the original 

bill is less than the recalculated bill, the 

original bill will remain as the balance 

owed. 

(3) Nominal fee. Once a year, the 

ASD(HA) will publish a stratified 

nominal inpatient and outpatient fee. 

The nominal fee will be assigned in any 

case where the sliding fee results in a 

100 percent discount of the medical 

invoice and the patient’s income is 

above 100 percent and up to 400 percent 

of the applicable year’s Federal Poverty 

Guidelines. Stratified nominal fees are 

generally established in a manner that is 

equitable with what military retirees 

enrolled in the TRICARE program 

would be required to pay in the private 

sector for comparable services. The 

initial nominal stratified fees are as 

follows: 

Household income falls within the below Federal poverty guidelines Inpatient fee Outpatient fee 

0%–100% ................................................................................................................................................................. $0 

101%–120% ............................................................................................................................................................. $750 $50 

121%–140% ............................................................................................................................................................. 1,250 50 

141%–160% ............................................................................................................................................................. 2,000 50 

161%–180% ............................................................................................................................................................. 3,000 50 

181%–200% ............................................................................................................................................................. 4,000 50 

201%–220% ............................................................................................................................................................. 5,000 50 

221% –240% ........................................................................................................................................................... 6,000 50 

241%–260% ............................................................................................................................................................. 7,000 50 

261%–280% ............................................................................................................................................................. 8,000 50 

281%–300% ............................................................................................................................................................. 9,000 50 

301%–320% ............................................................................................................................................................. 10,000 50 

321%–340% ............................................................................................................................................................. 11,000 50 

341%–360% ............................................................................................................................................................. 12,000 50 

361%–380% ............................................................................................................................................................. 13,000 50 

381%–400% ............................................................................................................................................................. 14,000 50 

(m) Notification of approved/ 

disapproved MHS MPWP applications. 

Unless additional time is needed (e.g., 

to verify a patient’s documentation), the 

DoD shall determine whether a patient 

has demonstrated eligibility for the 

MHS MPWP within 30 days of receipt 

of the complete application. If a 

decision cannot be made in 30 days, the 

DoD shall provide the patient with an 

interim written response. The DoD may 

suspend DoD collection actions against 

the patient during the review. 

(1) For approved applications, the 

DoD will issue to the patient a modified 


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Federal Register / Vol. 89, No. 190 / Tuesday, October 1, 2024 / Proposed Rules 79815 

medical invoice reflecting the adjusted 

balance due after applying the sliding 

fee and/or catastrophic fee waiver. The 

invoice modified to reflect fee 

adjustments or waiver under the MHS 

MPWP will include notification of the 

requirement to transfer delinquent debts 

to the Department of the Treasury if, 

after any modification under the MHS 

MPWP, an unpaid invoice becomes 

delinquent. 

(2) For disapproved applications, the 

DHA will issue a letter by U.S. mail to 

the patient’s last known address 

reflecting the reason why the 

application was disapproved. The letter 

will inform the patient of the right to 

reapply should the patient’s financial 

circumstances change. 

(n) Collection in installments. Patients 

approved for a sliding scale fee 

reduction or catastrophic fee waiver 

shall have amounts collected in 

installments for a term not to exceed 72 

months. Patients may choose to pay 

their balance in a lump sum payment. 

(o) Application for a 10 U.S.C. 

1079b(b) waiver. (1) Basis for a waiver. 

Waivers may be granted when— 

(i) The patient has provided the DoD 

with a completed DD Form 2569 (even 

for patients who possess no valid health 

insurance) and applicable insurance 

payments have been applied; 

(ii) The patient has previously 

submitted a completed application to 

the MHS MPWP (32 CFR 220.12(k)) and 

was provided any applicable discounts; 

(iii) The patient provided additional 

information indicating that the MHS 

MPWP did not sufficiently mitigate 

severe financial harm; and 

(iv) A DoD competent medical 

authority confirms in writing (on the DD 

Form 3201) that the care provided to the 

patient enhanced the KSAs of the DoD 

healthcare provider. 

(v) If the above conditions are met, the 

Director of DHA may exercise 

discretionary authority to waive the 

medical invoice. 

(2) Method to request a waiver. 

Patients must submit a completed DD 

Form 3201–1, ‘‘Request for Medical 

Debt Waiver Military Health System 

Modified Payment and Waiver 

Program.’’ All DoD invoices will include 

the address where a patient may submit 

a waiver request. 

(3) Response to a request for waiver. 

Unless additional time is needed (e.g., 

to verify a patient’s documentation), the 

DoD shall make a decision on the 

request within 90 days. The DoD will 

provide a response in writing to the 

patient, as well as a copy of the medical 

invoice reflecting the balance due. 

Waivers that are approved under 10 

U.S.C. 1079b(b) may require reporting to 

the IRS and issuance of a IRS Form 

1099–C. 

(p) Debts transferred to Treasury that 

are subsequently processed through 

insurance. In any instance where a debt 

is transferred to Treasury and a lower 

balance is assigned to a Treasurymanaged debt due to a claim being 

subsequently processed through 

insurance, the DoD shall recall the debt 

back to the DoD for management actions 

and notify Treasury to delete the debt 

from its systems and reverse any 

adverse reporting that occurred against 

the debt. 

(q) Delinquent Accounts. Delinquent 

accounts will be processed in 

accordance with the Debt Collection 

Improvement Act of 1996 and its 

implementing regulation 31 CFR parts 

900–904 (Federal Claims Collection 

Standards). 

(r) Applications for MHS MPWP 

Received for Delinquent Accounts 

Transferred to the Department of the 

Treasury. Individuals may still submit 

an application for the MHS MPWP after 

their account has been transferred to the 

Cross-Servicing Program (‘‘CrossServicing’’) of the Department of the 

Treasury, Bureau of the Fiscal Service; 

however, any reductions to the medical 

invoice from the MPWP may be subject 

to interest, penalties, and costs. When 

patients apply to the MHS MPWP after 

their accounts were transferred to CrossServicing, their debts will remain at 

Cross-Servicing unless and until the 

DoD determines that they are eligible for 

a reduction under the MHS MPWP. The 

DoD may recall the debt from CrossServicing after it determines that the 

debt is eligible for a reduction under the 

MHS MPWP. Patients may request 

reconsideration for the MHS MPWP 

when their financial circumstances 

appear to have significantly changed. 

(s) Reporting to IRS and Furnishing of 

IRS Forms 1099–C (Cancellation of 

Debt). The DoD will report to IRS, and 

furnish to patients, IRS Forms 1099–C 

for all 10 U.S.C. 1079b(b) waivers issued 

during the previous calendar year where 

required by 26 U.S.C. 6050P. IRS 

reporting will not be done for portions 

of a bill which have been adjusted 

downwards due to insurance 

processing, or by assignment of a sliding 

fee/catastrophic fee waiver to the debt. 

The IRS Forms 1099–C will reflect 

amounts waived under the DHA 

Director’s discretionary authority. 

(t) Refunds not permitted for amounts 

previously paid. Except for 

circumstances specified in §§ 220.12(p) 

and 220.12(u)(3), financial relief under 

the MHS MPWP may only be granted for 

amounts still due by the patient; an 

application for financial relief cannot be 

used to obtain a refund for any amounts 

previously paid. 

(u) Claims involving tortfeasors and 

third-party payers. No discount or 

waiver of fees under 10 U.S.C. 1079b 

shall be interpreted to be applicable to 

tortfeasors under the FMCRA, 42 U.S.C. 

2651, or third-party payers under 10 

U.S.C. 1095. 

(1) For patients who indicate that 

their injury/disease was caused by a 

third party, DoD MTFs will follow 

procedures established under the 

Medical Affirmative Claims program. 

(2) Patients who have a remaining 

balance after insurance remittances or 

recoveries from third-party tortfeasors 

may apply for relief of any remaining 

medical debt. 

(3) Payments toward the medical debt 

that were made by the patient prior to 

settlement of the claim with the 

tortfeasor will be offset against any 

balances owed by the patient or may be 

refunded to the patient if no balance is 

owed. 

Patricia L. Toppings, 

OSD Federal Register Liaison Officer, 

Department of Defense. 

[FR Doc. 2024–22584 Filed 9–30–24; 8:45 am] 

BILLING CODE 6001–FR–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 3 

RIN 2900–AR75 

VA Adjudication Regulations for 

Disability or Death Benefit Claims 

Based on Toxic Exposure 

AGENCY: Department of Veterans Affairs. 

ACTION: Proposed rule. 

SUMMARY: The Department of Veterans 

Affairs (VA) is proposing to amend its 

adjudication regulations to implement 

provisions of the Sergeant First Class 

Heath Robinson Honoring our Promise 

to Address Comprehensive Toxics Act 

of 2022 (PACT Act or Act). The statute 

amended procedures applicable to 

claims based on toxic exposure and 

modified or established presumptions of 

service connection related to toxic 

exposure. Pursuant to the Act, VA is 

proposing to remove the manifestation 

period requirement and the minimum 

compensable evaluation requirement 

from Persian Gulf War claims based on 

undiagnosed illness and medically 

unexplained chronic multisymptom 

illnesses. VA is also proposing to 

expand the definition of a Persian Gulf 

veteran; update the list of locations 

eligible for a presumption of exposure to 


khammond on DSKJM1Z7X2PROD with PROPOSALS