Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules 7489

Tuesday, January 3, 1995 (60 FR 82).

The proposed regulations define selfdealing by private foundations.

FOR FURTHER INFORMATION CONTACT:

Terri Harris or Paul Accettura at (202)

622–6070 (not a toll-free number).

SUPPLEMENTARY INFORMATION:

Background

The proposed regulations that are the

subject of this correction are under

section 4941 of the Internal Revenue

Code.

Need for Correction

As published, the notice of proposed

rulemaking contains a typographical

error that is in need of correction.

Correction of Publication

Accordingly, the publication of the

notice of proposed rulemaking that is

the subject of FR Doc. 94–31666, is

corrected as follows:

On page 83, column 2, § 53.4941(d)-2,

paragraph (f)(3)(ii), line 11, the language

‘‘pursuant to this paragraph (f)(3)(ii).’’ is

corrected to read ‘‘pursuant to this

paragraph (f)(3).’’.

Cynthia E. Grigsby,

Chief, Regulations Unit, Assistant Chief

Counsel (Corporate).

[FR Doc. 95–3105 Filed 2–7–95; 8:45 am]

BILLING CODE 4830–01–P

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720–AA21

[DoD 6010.8–R]

Civilian Health and Medical Program of

the Uniformed Services (CHAMPUS);

TRICARE Program; Uniform HMO

Benefit; Special Health Care Delivery

Programs

AGENCY: Office of the Secretary, DoD.

ACTION: Proposed rule.

SUMMARY: This proposed rule

establishes requirements and

procedures for implementation of the

TRICARE Program, the purpose of

which is to move toward a

comprehensive managed health care

delivery system in military medical

treatment facilities and CHAMPUS.

Principal components of the proposed

rule include: establishment of a

comprehensive enrollment system;

creation of a triple option benefit,

including a Uniform HMO Benefit

required by law; a series of initiatives to

coordinate care between military and

civilian delivery systems, including

Resource Sharing Agreements, Health

Care Finders, PRIMUS and NAVCARE

Clinics, and new prescription pharmacy

services; and a consolidated schedule of

charges, incorporating steps to reduce

differences in charges between military

and civilian services. This proposed

rule also includes provisions expanding

use of nonavailability statement

authorities to require use of designated

civilian network providers for inpatient

hospital care, establishing a special

civilian provider program authority for

active duty dependents overseas, and

implementing revisions to the Managed

Care Program of the former Public

Health Service hospitals that now

function as Uniformed Services

Treatment Facilities. The TRICARE

Program is a major reform of the

Military Health Services System that

will improve services to beneficiaries

and help sustain the system during this

period of significant budgetary

limitations.

DATES: Written comments must be

received on or before April 10, 1995.

ADDRESSES: Office of the Civilian Health

and Medical Program of the Uniformed

Services (OCHAMPUS), Office of

Program Development, Aurora, CO

80045–6900.

FOR FURTHER INFORMATION CONTACT:

Steve Lillie, Office of the Assistant

Secretary of Defense (Health Affairs),

telephone (703) 695–3350.

Questions regarding payment of

specific claims under the CHAMPUS

allowable charge method should be

addressed to the appropriate CHAMPUS

contractor.

SUPPLEMENTARY INFORMATION:

I. Overview of the TRICARE Program

The medical mission of the

Department of Defense is to provide,

and maintain readiness to provide,

medical services and support to the

armed forces during military operations,

and to provide medical services and

support to members of the armed forces,

their family members, and others

entitled to DoD medical care.

Under the current Military Health

Services System (MHSS), CHAMPUSeligible beneficiaries may receive care in

the direct care system (that is, care

provided in military hospitals or clinics)

or seek care from civilian health care

providers; the government shares in the

cost of such civilian care under the

Civilian Health and Medical Program of

the Uniformed Services (CHAMPUS), or

for some beneficiaries, the Medicare

program. The substantial majority of

care for military beneficiaries is

provided within catchment areas of

inpatient military treatment facilities

(MTFs), a catchment area being roughly

defined as the area within a 40-mile

radius around an MTF.

Recently DoD has embarked on a new

program, called TRICARE, which will

improve the quality, cost, and

accessibility of services for its

beneficiaries. Because of the size and

complexity of the military health

services system, TRICARE is being

phased over a period of several years.

The principal mechanisms for the

implementation of TRICARE are the

designation of the commanders of

selected military medical centers as

Lead Agents for 12 TRICARE regions

across the country, operational

enhancements to the Military Health

Services System, and the procurement

of managed care support contracts for

the provision of civilian health care

services in those regions.

Sound management of the MHSS

requires a great degree of coordination

between the direct care system and

CHAMPUS-funded civilian care, which,

unfortunately, has not always been

present. The TRICARE Program

recognizes that ‘‘step one’’ of any

process aimed at improving

management is to identify the

beneficiaries for whom the health

program is responsible. Indeed, the

dominant feature in some private sector

health plans, enrollment of beneficiaries

in their respective health care plans, is

an essential element. This proposed rule

moves toward establishment of a basic

structure of health care enrollment for

the MHSS. Under this structure, all

health care beneficiaries become

enrolled in TRICARE and classified into

one of five enrollment categories:

1. Active duty members, all of whom

are automatically enrolled in TRICARE

Prime, an HMO-type option;

2. TRICARE Prime enrollees, who

(except for active duty members) must

be CHAMPUS eligible;

3. TRICARE Standard enrollees,

which covers all CHAMPUS-eligible

beneficiaries who do not enroll in

TRICARE Prime or another managed

care program affiliated with TRICARE;

4. Medicare-eligible beneficiaries,

who, although not eligible for TRICARE

Prime, may participate in many features

of TRICARE; and

5. Participants in other managed care

programs affiliated with TRICARE.

The second major feature of the

TRICARE Program will be the

establishment of a triple option benefit.

CHAMPUS-eligible beneficiaries will be

offered three options: They may enroll

to receive health care in an HMO-type

program called ‘‘TRICARE Prime;’’ they

may use the civilian preferred provider
7490 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

network on a case-by-case basis, under

‘‘TRICARE Extra;’’ or they may remain

in the standard CHAMPUS benefit plan,

called ‘‘TRICARE Standard.’’ Enrollees

in Prime will obtain most of their care

within the network, and pay

substantially reduced CHAMPUS cost

shares when they receive care from

civilian network providers. Enrollees in

Prime will retain freedom to utilize nonnetwork civilian providers, but they will

have to pay cost sharing considerably

higher than under Standard CHAMPUS

if they do so. Beneficiaries who choose

not to enroll in TRICARE Prime will

preserve their freedom of choice of

provider for the most part by remaining

in TRICARE Standard. These

beneficiaries will face standard

CHAMPUS cost sharing requirements,

except that their coinsurance percentage

will be lower when they opt to use the

preferred provider network under

TRICARE Extra. All beneficiaries

continue to be eligible to receive care in

military facilities. Active duty

dependents who enroll in TRICARE

Prime will have a priority over other

beneficiaries.

A third major feature of the TRICARE

program is a series of initiatives,

affecting all beneficiary enrollment

categories, designed to coordinate care

between military and civilian health

care systems. Among these is a program

of resource sharing agreements, under

which a TRICARE contractor provides

to a military treatment facility,

personnel and other resources to

increase the availability of services from

military facilities and providers.

Another initiative is establishment of

Health Care Finders, which are

administrative offices to facilitate

referrals to appropriate services in the

military facility or civilian provider

network. In addition, integrated quality

and utilization management services for

military and civilian sector providers

will be instituted. Still another initiative

is establishment of special pharmacy

programs for areas affected by base

realignment and closure actions. These

pharmacy programs will include special

eligibility for some Medicare-eligible

beneficiaries. TRICARE also makes

permanent authority for PRIMUS and

NAVCAREClinics, which are dedicated

contractor-owned and operated clinics.

These initiatives will have a major

impact on military health care delivery

systems, improving services for all

beneficiary enrollment categories.

The fourth major component of

TRICARE is the implementation of a

consolidated schedule of charges,

incorporating steps to reduce

differences in charges between military

and civilian services. In general, the

TRICARE Program reduces out-ofpocket costs for civilian sector care. For

example, the current CHAMPUS cost

sharing requirements for outpatient care

for active duty dependents include a

deductible of $150 per person or $300

per family ($50/$100 for dependents of

sponsors in pay grades E–4 and below)

and a copayment of 20 percent of the

allowable cost of the services. Under

TRICARE Prime, which incorporates the

‘‘Uniform HMO Benefit,’’ these cost

sharing requirements will be replaced

by a standard charge for most outpatient

visits of $12.00 per visit, or $6.00 per

visit for dependents of E–4 and below

sponsors.

For retirees, their dependents and

survivors, the current deductible of

$150 per person or $300 per family and

25 percent cost sharing will also be

replaced by a standard charge, which is

likewise $12.00 for most outpatient

visits.

Beneficiaries who are not under

TRICARE Prime will also have

significant opportunities to reduce

expected out-of-pocket costs under

CHAMPUS. These opportunities

include increased availability of MTF

services by virtue of resource sharing

agreements, the new special pharmacy

programs, and access to PRIMUS and

NAVCARE Clinics.

With respect to military hospitals, for

retirees, their dependents, and

survivors, consideration may be given in

the future to establishment of nominal

per-visit fees, for some or all retirees,

their family members, and survivors,

and for some or all types of services for

those beneficiaries. Fees would be

considered to help control demand for

military facility care, to free up capacity

and reduce waiting times, and lower the

costs of health care.

A user fee can be structured in many

different ways, for example, exempting

lower income segments of the covered

population. Most importantly, the

motivation for a fee is to encourage the

more efficient provision of lower cost

health care, and not to produce

budgetary savings. Accordingly,

analysis of alternatives would be based

on the assumption that revenue

produced by a user fee will be allocated

to other benefits or quality of life

programs. When this issue is considered

for possible implementation in fiscal

year 1998, if the Department decides to

establish a nominal fee for some or all

outpatient services provided to some or

all retirees, their family members, and

survivors, a proposed rule will then be

issued for public comment. Again, it

should be noted that this suggestion of

a possible outpatient fee does not

include active duty service members or

their family members.

Taken as a whole, the TRICARE

Program is a major reform of the

Military Health Services System—one

that will accomplish the transition to a

comprehensive managed health care

system that will help to achieve DoD’s

medical mission into the next century.

II. Provisions of Proposed Rule

Regarding the TRICARE Program

These regulatory changes are being

published as an amendment to the 32

CFR part 199 because the operating

details of CHAMPUS will be altered

significantly. Our regulatory approach is

to leave the existing CHAMPUS rules

largely intact and to create new

§§ 199.17 and 199.18 to describe the

TRICARE Program and the uniform

HMO benefit. The major provisions of

the proposed new § 199.17 regarding the

TRICARE Program are summarized

below.

A. Establishment of the TRICARE

Program (proposed § 199.17(a))

This paragraph introduces the

TRICARE Program, and describes its

purpose, statutory authority, and scope.

It is explained that certain usual

CHAMPUS and MHSS rules do not

apply under the TRICARE Program, and

that implementation of the Program

occurs in a specific geographic area,

such as a local catchment area or a

region. Public notice of initiation of a

Program will include a notice published

in the Federal Register.

With respect to statutory authority,

major statutory provisions are title 10,

U.S.C. sections 1099 (which calls for a

health care enrollment system), 1097

(which authorizes alternative contracts

for health care delivery and financing),

and 1096 (which allows for resource

sharing agreements). Significantly, the

National Defense Authorization Act for

Fiscal Year 1995 amended section 1097

to authorize the Secretary of Defense to

provide for the coordination of health

care services provided pursuant to any

contract of agreement with a civilian

managed care contractor with those

services provided in military medical

treatment facilities. This amendment set

the stage for many features of TRICARE,

including initiatives to improve

coordination between military and

civilian health care delivery

components and the consolidated

schedule of beneficiary charges.

B. Triple Option (proposed § 199.17(b))

This paragraph presents an overview

of the triple option feature of the

TRICARE Program. Most beneficiaries

are offered enrollment in the TRICARE
Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules 7491

Prime Plan, or ‘‘Prime.’’ They are free to

choose to enroll to obtain the benefits of

Prime, or not to enroll and remain in the

TRICARE Standard Plan, or ‘‘Standard,’’

with the option of using the preferred

provider network under the TRICARE

Extra Plan, or ‘‘Extra.’’ When the

TRICARE Program is implemented in an

area, active duty members will be

enrolled in Prime.

C. Eligibility for Enrollment in Prime

(proposed § 199.17(c))

This paragraph describes who may

enroll in the Program. All active duty

members are automatically enrolled; all

CHAMPUS-eligible beneficiaries may

enroll. Since it is likely that priorities

for enrollment will be necessary owing

to limited availability of Prime, the

order of priority for enrollment will be

as follows: First priority will be active

duty members; second priority will be

active duty family members; and third

priority will be CHAMPUS-eligible

retirees, family members of retirees, and

survivors. At this time, TRICARE Prime

will not offer enrollment to nonCHAMPUS-eligible beneficiaries.

D. Health Benefits Under Prime

(proposed § 199.17(d))

This paragraph states that the benefits

established for the Uniform HMO

Benefit option (see § 199.18, Uniform

HMO Benefit option) are applicable to

CHAMPUS eligible enrollees in

TRICARE Prime.

Under TRICARE, all enrollees in

Prime and all beneficiaries who do not

enroll remain eligible for care in MTFs.

Active duty family members who enroll

in TRICARE Prime would be given

priority for MTF access over nonenrollees; priorities for other categories

of beneficiary would be unaffected by

their enrollment. Regarding civilian

sector care, active duty member care

will continue to be arranged as needed

and paid for through the supplemental

care program.

E. Health Benefits Under Extra

(proposed § 199.17(e))

This paragraph describes the

availability of the civilian preferred

provider network under Extra. When

Extra is used, CHAMPUS cost sharing

requirements will be reduced. See Table

2 following the preamble for a

comparison of TRICARE Standard,

TRICARE Extra, and TRICARE Prime

cost sharing requirements.

F. Health Benefits Under Standard

(proposed § 199.17(f))

This paragraph describes health

benefits for beneficiaries who opt to

remain in Standard. Broadly,

participants in Standard maintain their

freedom of choice of civilian provider

under CHAMPUS (subject to

nonavailability statement requirements),

and face standard CHAMPUS cost

sharing requirements, except when they

take advantage of the preferred provider

network under Extra. The CHAMPUS

benefit package applies to Standard

participants.

G. Coordination With Other Health Care

Programs (proposed § 199.17(g))

This paragraph provides that, for

beneficiaries enrolled in managed

health care programs not operated by

DoD, DoD may establish a contract or

agreement with the other managed

health care program for the purpose of

coordinating beneficiary entitlements

under the other program and the

military health services system. This

potentially includes any private sector

health maintenance organization (HMO)

or competitive medical plan, and any

Medicare HMO. Any contract or

agreement entered into under this

paragraph may integrate health care

benefits, delivery, financing, and

administrative features of the other

managed care plan with some or all of

the features of the TRICARE Program.

This paragraph is based on 10 U.S.C.

section 1097(d), as amended by section

714 of the National Defense

Authorization Act for Fiscal Year 1995.

H. Resource Sharing Agreements

(proposed § 199.17(h))

This paragraph provides that military

treatment facilities may establish

resource sharing agreements with the

applicable managed care support

contractors for the purpose of providing

for the sharing of resources between the

two parties. Internal and external

resource sharing agreements are

authorized. Under internal resource

sharing agreements, beneficiary cost

sharing requirements are the same as in

military facilities. Under internal or

external resource sharing agreements, a

military treatment facility commander

may authorize the provision of services

pursuant to the agreement to Medicareeligible beneficiaries, if this will

promote the most cost-effective

provision of services under the

TRICARE Program.

I. Health Care Finder (proposed

§ 199.17(i))

This paragraph establishes procedures

for the Health Care Finder, an

administrative office that assists

beneficiaries in being referred to

appropriate health care providers,

especially the MTF and civilian network

providers. Health Care Finder services

are available to all beneficiaries.

J. General Quality Assurance,

Utilization Review, and

Preauthorization Requirements

(proposed § 199.17(j))

This paragraph emphasizes that all

requirements of the CHAMPUS basic

program relating to quality assurance,

utilization review, and preauthorization

of care apply to the CHAMPUS

component of Prime, Extra and

Standard. These requirements and

procedures may also be made applicable

to military facility services.

K. Pharmacy Network Services in Base

Realignment and Closure Sites

(proposed § 199.17(k))

This paragraph establishes two

special pharmacy programs, a retail

pharmacy network program and a mail

service pharmacy program. This

proposal is made with consideration of

the existing mail service pharmacy

demonstration, under which features of

the permanent, nationwide program are

being tested at a number of sites.

Proceeding to solicit public comment on

design features at this point, prior to

completion of the demonstration, will

enable us to move most expeditiously to

establish the nationwide program in the

future.

An important aspect of the mail

service and retail pharmacy programs is

that, under the authority of section 702

of the National Defense Authorization

Act for Fiscal Year 1993, Pub. L. 102–

484, there is a special rule regarding

eligibility for prescription services. The

special rule is that Medicare-eligible

beneficiaries, who are normally

ineligible for CHAMPUS, are under

certain special circumstances eligible

for the pharmacy programs. The special

circumstances are that they live in an

area adversely affected by the closure of

a military medical treatment facility. A

provision of the National Defense

Authorization Act for Fiscal Year 1995

additionally provides eligibility for

Medicare eligible beneficiaries who

demonstrate that they had been reliant

on a former military medical treatment

facility for pharmacy services.

Under the proposed rule, the area

adversely affected by the closure of a

facility is established as the catchment

area of the treatment facility that closed.

The catchment area is the existing

statutory designation of the geographical

area primarily served by a military

hospital. The catchment area is defined

in law as ‘‘the area within

approximately 40 miles of a medical

facility of the uniformed services.’’ Pub.

L. 100–180, sec. 721(f)(1), 10 U.S.C.A.
7492 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

1092 note. This is also the geographical

basis in the law for nonavailability

statements that authorize CHAMPUS

beneficiaries who live within areas

served by military hospitals to obtain

care outside the military facility. 10

U.S.C. 1079(a)(7). Because the purpose

of the special eligibility rule for

Medicare-eligible beneficiaries is to

replace the pharmacy services lost as a

consequence of the base closure, and

because the 40-mile catchment area is

the only geographical area designation

established in law to describe the

beneficiaries primarily served by a

military medical facility, we believe it

most appropriate to adopt the

established 40-mile catchment area for

purposes of the applicability of the

special eligibility rule for pharmacy

services. Thus, under the proposed rule,

Medicare-eligible beneficiaries who live

within the established 40-mile

catchment area of a treatment facility

that closed are eligible to use the

pharmacy programs if available in that

area.

There are several noteworthy special

rules regarding the area that will be

considered adversely affected by the

closure of a military treatment facility.

First, 40-mile catchment area generally

will apply in the case of the closure of

a military clinic, as it does in the case

of the closure of a hospital. Recognizing

that there may be clinic closure cases

involving very small clinics that were

not providing any significant amount of

pharmacy services to retirees and their

dependents, these cases will not be

considered to be areas adversely

affected by the closure of a medical

treatment facility. The reason for this is

simply that if the facility was not

providing a significant amount of

services, its closure will not have a

noteworthy adverse affect in the area.

Another circumstance in which a

facility closure will not be considered to

have an adverse affect on an area is if

the area is also within the catchment

area of another military medical

treatment facility that remains open and

available to the beneficiaries.

The Director, Office of CHAMPUS

may establish other procedures for the

effective operation of the pharmacy

programs, dealing with issues such as

encouragement of use of generic drugs

for prescriptions and use of appropriate

drug formularies, as well as

establishment of requirements for

demonstration of past reliance on a

military medical treatment facility for

pharmacy services.

L. PRIMUS and NAVCARE Clinics

(proposed § 199.17(l))

The proposed rule would add a new

§ 199.17(l). Under the authority of 10

U.S.C. sections 1074(c) and 1097, this

section would authorize PRIMUS and

NAVCARE Clinics, which have operated

to date under demonstration authority.

Because these contractor owned and

operated clinics have increased

beneficiariy access to care and become

very popular with beneficiaries, this

provision will make permanent the

PRIMUS and NAVCARE Clinic

authority.

As under the demonstration project,

PRIMUS and NAVCARE Clinics will

function as extensions of military

treatment facilities. As such, all

beneficiaries eligible for care in military

treatment facilities (including active

duty members, Medicare-eligible

beneficiaries, and other non-CHAMPUS

eligible beneficiaries) are eligible to use

PRIMUS and NAVCARE Clinics. For

PRIMUS and NAVCARE Clinics

established prior to October 1, 1994,

CHAMPUS deductibles and copayments

will not apply. Rather, military hospital

policy regarding beneficiary charges

will apply. For PRIMUS and NAVCARE

Clinics established after September 30,

1994, the provisions of the Uniform

HMO Beneift regarding out patient

costsharing will apply (see proposed

§ 199.18(d)(3)). Other CHAMPUS rules

and procedures, such as coordination of

benefits requirements will apply. The

Director, OCHAMPUS may waive or

modify CHAMPUS regulatory

requirements in connection with the

operation of PRIMUS and NAVCARE

Clinics.

M. Consolidated Schedule of Beneficiary

Charges (proposed § 199.17(m))

This paragraph establishes a

consolidated schedule of beneficiary

charges applicable to health care

services under TRICARE for Prime

enrollees (other than active duty

members), Standard enrollees, and

Medicare-eligible beneficiaries. The

schedule of charges is summarized at

Table 1, following the preamble. As

demonstrated by the table, TRICARE

provides for reduced beneficiary out-ofpocket costs.

Included in the consolidated schedule

of beneficiary charges is the ‘‘Uniform

HMO Benefit’’ design required by law.

This is further discussed in the next

section of the preamble.

N. Additional Health Care Management

Requirements Under Prime (proposed

§ 199.17(n))

This paragraph describes additional

health care management requirements

within Prime, and establishes the pointof-service option, under which

CHAMPUS beneficiaries retain the right

to obtain services without a referral,

albeit with higher cost sharing. Each

CHAMPUS-eligible enrollee will select

or be assigned a Primary Care Manager

who typically will be the enrollee’s

health care provider for most services,

and will serve as a referral agent to

authorize more specialized treatment if

needed. Health Care Finder offices will

also assist enrollees in obtain referrals to

appropriate providers. Referrals for care

will give first priority to the local MTF;

other referral priorities and practices

will be specified during the enrollment

process.

O. Enrollment Procedures (proposed

§ 199.17(o))

This paragraph describes procedures

for enrollment of beneficiaries other

than active duty members, who must

enroll. The Prime plan features open

season periods during which enrollment

is permitted. Prime enrollees will

maintain participation in the plan for a

12 month period, with disenrollment

only under special circumstances, such

as when a beneficiary moves from the

area. A complete explanation of the

features, rules and procedures of the

Program in the particular locality

involved will be available at the time

enrollment is offered. The features, rules

and procedures may be revised over

time, coincident with reenrollment

opportunities.

P. Civilian Preferred Provider Networks

(proposed § 199.17(p))

This paragraph sets forth the rules

governing civilian preferred provider

networks in the TRICARE Program. It

includes conformity with utilization

management and quality assurance

program procedures, provider

qualifications, and standards of access

for provider networks. In addition, the

methods which may be used to establish

networks are identified.

DoD beneficiaries who are not

CHAMPUS-eligible, such as Medicare

beneficiaries, may seek civilian care

under the rules and procedures of their

existing health insurance program.

Providers in the civilian preferred

provider network generally will be

required to participate in Medicare, so

that when Medicare beneficiaries use a

network provider they will be assured of

a participating provider.

Q. Preferred Provider Network

Establishment Under Any Qualified

Provider Method (proposed § 199.17(q))

This paragraph describes one process

that may be used to establish a preferred
Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules 7493

provider network (the ‘‘any qualified

provider method’’) and establishes the

qualifications which providers must

demonstrate in order to join the

network.

R. General Fraud, Abuse, and Conflict of

Interest Requirements Under TRICARE

Program (proposed § 199.17(r))

This paragraph establishes that all

fraud, abuse, and conflict of interest

requirements for the basic CHAMPUS

program are applicable to the TRICARE

Program.

S. Partial Implementation of TRICARE

(proposed § 199.17(s))

This paragraph explains that some

portions of TRICARE may be

implemented separately: A program

without the HMO option, or a program

covering a subset of health care services,

such as mental health services.

T. Inclusion of Veterans Hospitals in

TRICARE Networks (proposed

§ 199.17(t))

This paragraph would provide the

basis for participation by Department of

Veterans Affairs facilities in TRICARE

networks, based on agreements between

the VA and DoD.

U. Cost Sharing of Care for Family

Members of Active Duty Members in

Overseas Locations (proposed

§ 199.17(u))

This paragraph would permit

establishment of special CHAMPUS cost

sharing rules for family members of

active duty members when they

accompany the member on a tour of

duty outside the United States. A

recently initiated demonstration

program, described in the Federal

Register of September 2, 1994 (59 FR

45668), tests such a program for active

duty family members in countries

served by OCHAMPUS, Europe.

V. Administrative Procedures (proposed

§ 199.17(v))

This paragraph authorizes

establishment of administrative

procedures for the TRICARE Program.

III. Provisions of the Rule Concerning

the Uniform HMO Benefit Option

A. In General. (§ 199.18(a))

This paragraph introduces the

Uniform HMO Benefit option. The

statutory provision that establishes the

parameters for determination of the

Uniform HMO Benefit option is section

731 of the National Defense

Authorization Act for Fiscal Year 1994.

It requires the establishment of a

Uniform HMO Benefit option, which

shall ‘‘to the maximum extent

practicable’’ be included ‘‘in all future

managed health care initiatives

undertaken by’’ DoD. This option is to

provide ‘‘reduced out-of-pocket costs

and a benefit structure that is as uniform

as possible throughout the United

States.’’ The statute further requires a

determination that, in the managed care

initiative that includes the Uniform

HMO Benefit, DoD costs ‘‘are no greater

than the costs that would otherwise be

incurred to provide health care to the

covered beneficiaries who enroll in the

option.’’

In addition to this provision of the

National Defense Authorization Act for

Fiscal Year 1994, a similar requirement

is established by section 8025 of the

DoD Appropriations Act, 1994. As part

of an initiative ‘‘to implement a

nationwide managed health care

program for the military health services

system,’’ DoD shall establish ‘‘a

uniform, stabilized benefit structure

characterized by a triple option health

benefit feature.’’ Our Uniform HMO

Benefit also implements this

requirement of law.

In fiscal year 1993, DoD implemented

the expansion of the CHAMPUS Reform

Initiative to the areas of Carswell and

Bergstorm Air Force Bases in Texas and

England Air Force Base, Louisiana.

(These sites were singled out because

they were military bases identified for

closure in the Bare Realignment and

Closure, or ‘‘BRAC’’ process; thus the

benefit developed for them is called the

‘‘BRAC Benefit.’’) This expansion of the

CHAMPUS Reform Initiative offers

positive incentives for enrollment and

preserves the basic design of the original

CHAMPUS Reform Initiative program,

although it is not identical to that

program. The original CHAMPUS

Reform Initiative design featured a $5

per visit fee for most office visits, a very

much reduced schedule of other

copayments, and no deductible or

enrollment fee. Although its generosity

made it very popular with beneficiaries,

it also caused substantial concerns

regarding government budget impact.

This benefit fails to meet the statutory

requirement for cost neutrality to DoD.

The Carswell/Bergstrom/England

HMO benefit (BRAC Benefit) model

attempts partially to address these

concerns, while providing enhanced

benefits. It features enrollment fees for

some categories of beneficiaries, $5, $10,

or $15 per visit fees, depending on

beneficiary category, and inpatient per

diems of $125 for retirees, their family

members and survivors.

A new HMO benefit is being

presented in this proposed rule as the

Uniform HMO Benefit. The principal

features of the proposed benefit are

displayed in Table 3 following the

preamble. Its most significant change

from the BRAC Benefit is that inpatient

cost sharing for retirees, their

dependents and survivors is reduced to

the levels faced by active duty

dependents, with concomitant increases

in enrollment fees for these

beneficiaries. A second important

change is that there would be no

enrollment fee for dependents of active

duty members. Finally, fees are set so

that they may be held constant for a

five-year period, rather than escalating

each year with price inflation.

The development of this proposed

Uniform HMO Benefit included

painstaking analysis of utilization, cost,

and administrative effect of potential

cost sharing schedules. This analysis

included a series of assumptions

regarding most likely ramifications of

various components of the benefit and

the operation of the TRICARE Program.

Based on this exhaustive analysis, the

formulation of the Uniform HMO

Benefit in the proposed rule is the most

generous benefit DoD can offer

consistent with the statutory costneutrality mandate.

B. Benefits Covered Under the Uniform

HMO Benefit Option (§ 199.18(b))

For CHAMPUS-eligible beneficiaries,

the HMO Benefit option incorporates

the existing CHAMPUS benefit package,

with potential additions of preventive

services and a case management

program to approve coverage of usually

noncovered health care services (such as

home health services) in special

situations.

C. Deductibles, Fees, and Cost Sharing

Under the HMO Benefit Option

(proposed § 199.18(c) through (f))

Instead of usual CHAMPUS cost

sharing requirements, Uniform HMO

Benefit option participants will pay

special per-service, specific dollar

amounts or special reduced cost sharing

percentages, which would vary by

category of beneficiary.

The Uniform HMO Benefit also would

include an annual enrollment fee,

which would be in lieu of the

CHAMPUS deductible. The current

CHAMPUS deductible is $50 per person

or $100 per family for family members

of active duty members in pay grades E–

1 through E–4; and $150 per person or

$300 per family for all other

beneficiaries. The enrollment fee under

the Uniform HMO Benefit option would

vary by beneficiary category: $0 for

active duty family members, and $230

individual or $460 family for retirees,

their family members, and survivors.
7494 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

The amount of proposed enrollment

fees, outpatient charges and inpatient

copayment under the uniform HMO

benefit are presented in detail in

§ 199.18(c) through (f).

D. Applicability of the Uniform HMO

Benefit to the Uniformed Service

Treatment Facilities Managed Care

Program (proposed § 199.18(g))

The section would apply the uniform

HMO Benefit provisions to the

Uniformed Services Treatment Facility

Managed Care Program, beginning in

fiscal year 1996. This program includes

civilian contractors providing health

care services under rules quite different

from CHAMPUS, the CHAMPUS Reform

Initiative, or other CHAMPUS-related

programs.

The National Defense Authorization

Act for Fiscal Year 1991, section 718(c),

required implementation of a

‘‘managed-care delivery and

reimbursement model that will continue

to utilize the Uniformed Services

Treatment Facilities’’ in the MHSS. This

provision has been amended and

supplemented several times since that

Act. Most recently, section 718 of the

National Defense Authorization Act for

Fiscal Year 1994 authorized the

establishment of ‘‘reasonable charges for

inpatient and outpatient care provided

to all categories of beneficiaries enrolled

in the managed care program.’’ This is

a deviation from previous practice,

which had tied Uniformed Services

Treatment Facilities (USTF) rules to

those of military hospitals. This new

statutory provision also states that the

schedule and application of the

reasonable charges shall be in

accordance with terms and conditions

specified in the USTF Managed Care

Plan. The USTF Managed Care Plan

agreements call for implementation in

the USTF Managed Care Program of cost

sharing requirements based on the level

and range of cost sharing required in

DoD managed care initiatives.

Under section 731 of the FY–94

Authorization Act, the Uniform HMO

Benefit is to apply ‘‘to the maximum

extent practicable’’ to ‘‘all future

managed care initiatives undertaken by

the Secretary.’’ The Conference Report

accompanying this Act calls on DoD ‘‘to

develop and implement a plan to

introduce competitive managed care

into the areas served by the USTFs to

stimulate competition’’ among health

care provider organizations ‘‘for the

cost-effective provision of quality health

care services.’’ We have determined that

it is practicable to use the Uniform

HMO Benefit for the USTF Managed

Care Program. In addition, this action

will stimulate competition between the

USTFs and firms operating the other

DoD managed care program to which

the Uniform HMO Benefit applies.

Based on these Congressional

provisions, as well as compelling need

for a uniform HMO benefit, we propose

to include the USTF Managed Care

Program under the Uniform HMO

Benefit, effective October 1, 1995.

IV. Provisions of the Proposed Rule

Concerning Other Regulatory Changes

The proposed rule makes a number of

additional changes to support

implementation of TRICARE.

A. Nonavailability Statements

(proposed revisions to §§ 199.4(a)(9) and

199.15)

Proposed revisions to § 199.4(a)(9)

provide the basis for administrative

linkages between a determination of

medical necessity and the decision to

issue or deny a Nonavailability

Statement (NAS). NASs are issued when

an MTF lacks the capacity or capability

to provide a service, but carry no

imprimatur of medical necessity.

Proposed revisions to § 199.15 establish

ground rules for CHAMPUS PRO review

of care in military medical treatment

facilities, and would allow for

consolidated determinations of medical

necessity applicable to both the MTF

and civilian contexts when the

CHAMPUS PRO performs the review.

Additional proposed revisions to

section 199.4 relate to the issuance of

NASs by designated military clinics.

Beneficiaries residing near such

designated clinics would have to obtain

a nonavailability statement for the

selected outpatient services subject to

NAS requirements under

§ 199.4(A)(9)(i)(C).

In a notice of proposed rule making

published on May 11, 1993, we

proposed a new provision to allow

consideration of availability of care in

civilian preferred provider networks in

connection with issuance of nonavailability statements; in conjunction

with this, a considerable expansion of

the list of outpatient service for which

an NAS is required was proposed. That

proposal was not finalized. Now we

propose a more limited program,

covering only inpatient care. Recently, a

demonstration program was established

in California and Hawaii, allowing

consideration of availability of care in

civilian preferred provider networks in

connection with issuance of nonavailability statements for inpatient

services only. The results of the

demonstration will be incorporated into

a Report to Congress on the expanded

use of NASs, as required by section 735

of the National Defense Authorization

Act for FY 1995, due not later than

December 31, 1994. Early indications

are that the demonstration effort has

saved money without adverse impacts;

the report to Congress will provide a

definitive assessment. No final action to

expand the program will go into effect

until well after we comply with the

Congressional reporting requirement.

Finally, proposed revisions to

§ 199.4(a)(9) would apply NAS

requirements in cases where military

providers serving at designated military

outpatient clinics also provide inpatient

care to beneficiaries at civilian

hospitals, under External Partnership or

Resource Sharing Agreements.

B. Participating Provider Program

(proposed revisions to § 199.14)

Proposed revisions to § 199.14 change

the Participating Provider Program from

a mandatory, nationwide program to a

localized, optional program. The initial

intent of the program was to increase

the availability of participating

providers by providing a mechanism for

providers to sign up as Participating

Providers; a payment differential for

Participating Providers was to be added

as an inducement. With the advent of

the TRICARE Program and its extensive

networks of providers, the nationwide

implementation of the Participating

Provider Program would be redundant.

Accordingly, this rule would eliminate

the nationwide program. Where the

need arises, CHAMPUS contractors will

act to foster participation, including

establishment of a local Participating

Provider Program when needed, but not

including the payment differential

feature.

V. Regulatory Procedures

Executive Order 12866 requires

certain regulatory assessments for any

‘‘significant regulatory action,’’ defined

as one which would result in an annual

effect on the economy of $100 million

or more, or have other substantial

impacts.

The Regulatory Flexibility Act (RFA)

requires that each Federal agency

prepare, and make available for public

comment, a regulatory flexibility

analysis when the agency issues a

regulation which would have a

significant impact on a substantial

number of small entities.

This is not a significant regulatory

action under the provisions of Executive

Order 12866, and it would not have a

significant impact on a substantial

number of small entities.

This proposed rule will impose

additional information collection

requirements on the public under the

Paperwork Reduction Act of 1980 (44
Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules 7495

U.S.C. 3501–3511), because

beneficiaries will be required to enroll.

Information collection requirements are

under review.

This is a proposed rule. Public

comments are invited. All comments

will be considered. A discussion of the

major issues raised by public comments

will be included with issuance of the

final rule, anticipated approximately 60

days after the end of the comment

period.

TABLE 1.—CONSOLIDATED SCHEDULE OF BENEFICIARY CHARGES

TRICARE prime TRICARE standard Medicare eligible beneficiaries

Services from TRICARE Network

Providers.

Uniform HMO Benefit cost sharing

applies (see Table 4), except

unauthorized care covered by

point-of-service rules.

TRICARE Extra cost sharing applies (see Table 2).Cost sharing for Medicare participating providers generally applies.

Services from non-network providers.TRICARE Prime point-of-service

rules apply: deductible of $300

per person or $600 per family;

cost share of 50 percent.

Standard CHAMPUS cost sharing

applies.

Standard Medicare cost sharing

applies.

Internal resource sharing agreements.Same as military facility cost sharing.Same as military facility cost sharing.Where applicable, same as military facility cost sharing.

External resource sharing agreements.For professional charges, same

as military facility cost sharing;

for facility charges, same as

Uniform HMO Benefit cost sharing.

For professional charges, same

as military facility cost sharing;

for facility charges, same as

TRICARE Extra cost sharing.

Where applicable, for professional

charges, same as military facility cost sharing; for facility

charges, same as standard

Medicare cost sharing.

PRIMUS and NAVCARE Clinics

established before October 1,

1994.

Same as military facilities ............. Same as military facilities ............. Same as military facilities.

PRIMUS and NAVCARE Clinics

established after September 30,

1994.

Uniform HMO Benefit outpatient

cost sharing applies.

Uniform HMO Benefit outpatient

cost sharing applies.

Uniform HMO Benefit outpatient

cost sharing applies.

Prescription drugs from civilian

pharmacies.

As specified in Uniform HMO Benefit (see Table 4).For retail pharmacy network, 20

percent cost share; for mail

service pharmacy, $4 per prescription for active duty dependents; $8 per prescription for retirees, their dependents and

survivors.

In facility closure cases: from retail pharmacy network, 20 percent cost share; from mail service pharmacy, $8 per prescription; no deductible.

Outpatient services in military facilities.No charge ..................................... Same as TRICARE Prime ............ Same as TRICARE Prime.

Inpatient services in military facilities.Applicable daily subsistence

charges.

Same as TRICARE Prime ............ Same as TRICARE Prime.

TABLE 2.—PROPOSED TRICARE TRIPLE OPTION PROGRAM

TRICARE standard TRICARE extra TRICARE prime

ENROLLMENT FEE ..................... NONE ............................................ NONE ............................................ ACT DUTY DEPS—NONE OTHERS—$230 INDIVIDUAL, $460

FAMILY.

OUTPATIENT DEDUCTIBLE ....... $300 FAMILY ($100 E4 &

BELOW).

SAME AS STANDARD

CHAMPUS.

NONE.

OUTPATIENT SERVICES COST

SHARES, INCLUDING MENTAL HEALTH, EMERGENCY

SERVICES, ETC.

ACT DUTY DEPS—20% COPAY

AFTER DEDUCTIBLE OTHERS—25% COPAY AFTER

DEDUCTIBLE.

ACT DUTY DEPS—15% COPAY

AFTER DEDUCTIBLE OTHERS—20% COPAY AFTER

DEDUCTIBLE.

SEE TABLE 3—SCHEDULE OF

UNIFORM HMO BENEFIT

COPAYMENTS.

INPATIENT COST SHARES, INCLUDING MATERNITY AND

SKILLED NURSING FACILITIES, NOT INCLUDING MENTAL HEALTH.

ACT DUTY DEPS—$25 PER ADMISSION OR CURRENT PER

DIEM, WHICHEVER IS

GREATER OTHERS—LESSER

OF APPLICABLE PER DIEM

($323 IN FY 1995) OR 25% OF

INSTITUTIONAL CHARGES,

PLUS 25% OF PROFESSIONAL CHARGES.

ACT DUTY DEPS—SAME AS

STANDARD CHAMPUS OTHERS—LESSER OF $250 PER

DAY OR 25% OF INSTITUTIONAL CHARGES, PLUS 20%

OF PROFESSIONAL

CHARGES.

ACT DUTY DEPS—$25 PER ADMISSION OR $11 PER DIEM,

WHICHEVER IS GREATER.

OTHERS—SAME AS ACT

DUTY DEPS.

AMBULATORY SURGERY .......... ACT DUTY DEPS—$25 PER EPISODE OTHERS—25% OF ALLOWABLE CHARGES.ACT DUTY DEPS—$25 COPAY

OTHERS—20% COPAY

AFTER DEDUCTIBLE.

ACT DUTY DEPS—$25 COPAY

OTHERS—SAME AS ACT

DUTY DEPS.

PRESCRIPTION DRUG BENEFITS.ACT DUTY DEPS—20% COPAY

AFTER DEDUCTIBLE OTHERS—25% OF ALLOWABLE

CHARGES.

ACT DUTY DEPS—15% COPAY

AFTER DEDUCTIBLE; NO DEDUCTIBLE IF NETWORK

PHARMACY OTHERS—20%

COPAY AFTER DEDUCTIBLE;

NO DEDUCTIBLE IF NETWORK PHARMACY.

ACT DUTY DEPS—$5 PER PRESCRIPTION OTHERS—$9 PER

PRESCRIPTION.
7496 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

TABLE 2.—PROPOSED TRICARE TRIPLE OPTION PROGRAM—Continued

TRICARE standard TRICARE extra TRICARE prime

HOSPITALIZATION FOR MENTAL ILLNESS AND SUBSTANCE USE.ACT DUTY DEPS—$25 PER ADMISSION OR $20 PER DIEM

WHICHEVER IS GREATER

OTHERS—LESSER OF APPLICABLE PER DIEM ($132 IN FY

1995) OR 25% OF INSTITUTIONAL CHARGES, PLUS 25%

OF PROFESSIONAL

CHARGES.

ACT DUTY DEPS—SAME AS

TRICARE STANDARD OTHERS—20% OF INSTITUTIONAL AND PROFESSIONAL

CHARGES.

ACT DUTY DEPS—SAME AS

TRICARE STANDARD OTHERS—$40 PER DIEM.

Note: THIS CHART IS FOR ILLUSTRATIVE PURPOSES ONLY. IT DOES NOT INCLUDE ALL DETAILS OF BENEFITS AND COPAYMENTS.

TABLE 3.—UNIFORM HMO BENEFIT FEE AND COPAYMENT SCHEDULE

ADDs E4

and below

ADDs E5

and above

Retirees,

deps, and

survivors

Annual Enrollment Fee ............................................................................................................................ $0/$0 $0/$0 $230/$460

Outpatient Visits, Including Separate Radiology or Lab Services, Family Health, and Home Health

Visits ..................................................................................................................................................... 6 12 12

Emergency Room Visits ........................................................................................................................... 10 30 30

Mental Health Visits, Individual ................................................................................................................ 10 20 25

Mental Health Visits, Group ..................................................................................................................... 6 12 17

Ambulatory Surgery ................................................................................................................................. 25 25 25

Prescriptions ............................................................................................................................................. 5 5 9

Ambulance Services ................................................................................................................................ 10 15 20

DME, Prostheses, Supplies ..................................................................................................................... 1 10 1 15 1 20

Inpatient Per Diem, General .................................................................................................................... 2 11 2 11 2 11

Inpatient Per Diem, MH/Substance Use .................................................................................................. 2 20 2 20 40

1Percent.

2 Minimum $25 per admission.

List of Subjects in 32 CFR Part 199

Claims, Handicapped, Health

insurance, and Military personnel.

Accordingly, 32 CFR part 199 is

proposed to be amended as follows:

PART 199—[AMENDED]

1. The authority citation for part 199

continues to read as follows:

Authority: 5 U.S.C. 301, 10 U.S.C. 1079,

1086.

2. Section 199.1 is proposed to be

amended by adding a new paragraph (r),

to read as follows:

§ 199.1 General provisions.

* * * * *

(r) TRICARE Program. Many rules and

procedures established in sections of

this part are subject to revision in areas

where the TRICARE Program is

implemented. The TRICARE Program is

the means by which managed care

activities designed to improve the

delivery and financing of health care

services in the Military Health Services

System (MHSS) are carried out. Rules

and procedures for the TRICARE

Program are set forth in § 199.17.

3. Section 199.2(b) is proposed to be

amended by adding the following

definitions and placing them in

alphabetical order to read as follows:

§ 199.2 Definitions.

* * * * *

(b) * * *

External Resource Sharing

Agreement. A type of External

Partnership Agreement, established in

the context of the TRICARE program by

agreement of a military treatment

facility commander and an authorized

TRICARE contractor. External Resource

Sharing Agreements may incorporate

TRICARE features in lieu of standard

CHAMPUS features that would apply to

standard External Partnership

Agreements.

* * * * *

Internal Resource Sharing Agreement.

A type of Internal Partnership

Agreement, established in the context of

the TRICARE program by agreement of

a military treatment facility commander

and an authorized TRICARE contractor.

Internal Resource Sharing Agreements

may incorporate TRICARE features in

lieu of standard CHAMPUS features that

would apply to standard Internal

Partnership Agreements.

NAVCARE Clinics. Contractor owned,

staffed, and operated primary clinics

exclusively serving uniformed services

beneficiaries pursuant to contracts

awarded by a Military Department.

* * * * *

PRIMUS Clinics. Contractor owned,

staffed, and operated primary care

clinics exclusively serving uniformed

services beneficiaries pursuant to

contracts awarded by a Military

Department.

* * * * *

TRICARE Program. The program

established under § 199.17.

* * * * *

TRICARE Extra Plan. The health care

option, provided as part of the TRICARE

Program under § 199.17, under which

beneficiaries may choose to receive care

in facilities of the uniformed services, or

from special civilian network providers

(with reduced cost sharing), or from any

other CHAMPUS-authorized provider

(with standard cost sharing).

* * * * *

TRICARE Prime Plan. The health care

option, provided as part of the TRICARE

Program under § 199.17, under which

beneficiaries enroll to receive all health

care from facilities of the uniformed

services and civilian network providers

(with civilian care subject to

substantially reduced cost sharing).

* * * * *
Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules 7497

TRICARE Standard Plan. The health

care option, provided as part of the

TRICARE Program under § 199.17,

under which beneficiaries are eligible

for care in facilities of the uniformed

services and CHAMPUS under standard

rules and procedures.

* * * * *

Uniform HMO benefit. The health care

benefit established by § 199.18.

* * * * *

Uniformed Services Treatment

Facilities Managed Care Program. The

managed care program established

pursuant to section 718(c) of the

National Defense Authorization Act for

Fiscal Year 1991, Pub. L. 101–510, for

certain former Public Health Service

hospitals deemed to be facilities of the

uniformed services by section 911 of the

Military Construction Authorization

Act, 1982, Pub. L. 97–99, 42 U.S.C.

248C. Certain rules pertaining to this

program are established by § 199.18.

* * * * *

4. Section 199.4 is proposed to be

amended by redesignating paragraph

(a)(1) as paragraph (a)(1)(i), by adding

new paragraph (a)(1)(ii), by revising

paragraph (a)(9)(i)(C), and by adding

new paragraphs (a)(9)(vi) and (a)(9)(vii),

to read as follows:

§ 199.4 Basic program benefits.

(a) * * *

(1) * * *

(ii) Impact of TRICARE Program. The

basic program benefits set forth in this

section are applicable to the basic

CHAMPUS program. In areas in which

the TRICARE Program is implemented,

certain provisions of § 199.17 will apply

instead of the provisions of this section.

In those areas, the provisions of § 199.17

will take precedence over any

provisions of this section with which

they conflict.

* * * * *

(9) * * *

(i) * * *

(C) An NAS is also required for

selected outpatient procedures if such

services are not available at a Uniformed

Service facility (including selected

facilities which are exclusively

outpatient clinics) located within a 40-

mile radius (catchment area) of the

residence of the beneficiary. This does

not apply to emergency services or for

services for which another insurance

plan or program provides the

beneficiary primary coverage. Any

changes to the selected outpatient

procedures will be published in the

Federal Register at least 30 days before

the effective date of the change by the

ASD(HA) and will be limited to the

following categories: Outpatient surgery

and other selected outpatient

procedures which have high unit costs

and for which care may be available in

military facilities generally. The

selected outpatient procedures will be

uniform for all CHAMPUS beneficiaries.

A list of the selected outpatient clinics

to which this NAS requirement applies

will be published periodically in the

Federal Register.

* * * * *

(vi) Consideration of availability of

care in civilian preferred provider

networks in connection with issuance of

Nonavailability Statements.—(A)

General requirement. With respect to

any inpatient health care service subject

to a Nonavailability Statement

requirement under paragraph (a)(9)(B) of

this section, in determining whether to

issue a Nonavailability Statement, the

commander of the military treatment

facility may consider the availability of

services from selected civilian health

care facilities within the same

catchment area. If the commander

determines that, although the services

are not available from a military

treatment facility, the services are

available from such a selected civilian

facility, the commander may deny a

Nonavailability Statement. If a

Nonavailability Statement is denied on

this basis, CHAMPUS cost sharing is not

allowed if the services are not obtained

from the designated civilian facility.

Civilian facilities to which this

requirement applies are those facilities

that are in a preferred provider network,

established under procedures specified

by the Director, OCHAMPUS, within the

40-mile catchment are, able to provider

the services needed.

(B) Additional requirement under

External Partnership/Resource Sharing

programs. The Assistant Secretary of

Defense (Health Affairs) may designate

selected military outpatient clinics for

additional NAS requirements regarding

inpatient hospital care available under

an External Partnership or External

Resources Sharing agreement. Under

such an agreement, care will be

provided at a civilian facility, but

professional services will be provided

by on or more physicians (or other

individual health care providers) on

staff at the military outpatient clinic.

With respect to the designated military

outpatient clinics and the specified

services covered by such External

Partnership or External Resource

Sharing agreement, Nonavailability

Statements will be required to the same

extent as they are for inpatient military

hospitals located within an

approximately 40-mile radius of a

beneficiary’s residence. If services are

available under an External Partnership

Resource Sharing agreement, the

military clinic commander may deny a

Nonavailability Statement. If a

Nonavailability Statement is denied on

this basis, CHAMPUS cost sharing is not

allowed if the services are not obtained

from the designated civilian facility

under the External Partnership or

External Resource Sharing agreement. A

list of selected military outpatient

clinics and services covered by the

External Partnership or External

Resource Sharing agreement NAS

requirement will be published

periodically in the Federal Register.

(C) Exceptions. A Nonavailability

Statement may not be withheld on the

basis of paragraphs (a)(9)(vi)(A) or

(a)(9)(vi)(B) of this section in any of the

following circumstances:

(1) A case-by-case waiver is granted

based on a medical judgment made by

the commander (or other official

designated for this purpose) of the

military treatment facility (or

Specialized Treatment Service Center)

that although the care is available from

a designated civilian provider, it would

be medically inappropriate because of a

delay in the treatment or other special

reason to require that such provider be

used; or

(2) A case-by-case waiver is granted

by the commander (or other official

designated for this purpose) of the

military treatment facility (or

Specialized Treatment Service Center)

that although the care is available from

a designated civilian provider, use of

that provider would impose exceptional

hardship on the beneficiary or the

beneficiary’s family.

(D) Procedures. The waiver request

and appeal procedures established

pursuant to paragraph (a)(10)(vii) of this

section shall be applicable to the caseby-case waivers referred to in paragraph

(a)(9)(vi)(C) of this section.

(E) Preference for military facility use.

In any case in which services subject to

a Nonavailability Statement requirement

under paragraph (a)(9) of this section are

available from both a military treatment

facility and from a designated civilian

facility under paragraph (a)(9)(vi) of this

section, the military treatment facility

must be used unless use of the

designated civilian facility is

specifically authorized.

(vii) In the case of any service subject

to an NAS requirement under paragraph

(a)(9) of this section and also subject to

a preadmission (or other pre-service)

authorization requirement under § 199.4

or § 199.15, the administrative processes

for the NAS and pre-service

authorization may be combined.

* * * * *
7498 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

§ 199.14 [Amended]

5. Section 199.14 is proposed to be

amended by removing paragraph

(g)(1)(i)(C) and by redesignating

paragraph (g)(1)(i)(D) as paragraph

(g)(1)(i)(C).

6. Section 199.15 is proposed to be

amended by adding a new paragraph

(n), to read as follows:

§ 199.15 Peer Review Organization

Program.

* * * * *

(n) Authority to integrate CHAMPUS

PRO and military treatment facility

utilization review activities. (1) In the

case of a military medical treatment

facility (MTF) that has established

utilization review requirements similar

to those under the CHAMPUS PRO

program, the PRO may, at the request of

the MTF, utilize procedures comparable

to the CHAMPUS PRO program

procedures to render determinations or

recommendations with respect to MTF

utilization review requirements.

(2) In any case in which a CHAMPUS

PRO has comparable responsibility and

authority regarding utilization review in

both an MTF (or MFTs) and CHAMPUS,

determinations as to medical necessity

in connection with services from an

MTF or CHAMPUS-authorized provider

may be consolidated.

(3) In any case in which an MFT

reserves authority to separate an MTF

determination on medical necessity

from a CHAMPUS PRO program

determination on medical necessity, the

MTF determination is not binding on

CHAMPUS.

7. Sections 199.17 and 199.18 are

proposed to be added, to read as

follows:

§ 199.17 TRICARE Program.

(a) Establishment. The TRICARE

Program is established for the purpose

of implementing a comprehensive

managed health care program for the

delivery and financing of health care

services in the MHSS.

(1) Purpose. The TRICARE Program

implements management improvements

primarily through managed care support

contracts that include special

arrangements with civilian sector health

care providers and better coordination

between military treatment facilities and

these civilian providers.

Implementation of these management

improvements includes adoption of

special rules and procedures not

ordinarily followed under CHAMPUS or

military treatment facility requirements.

This section establishes those special

rules and procedures.

(2) Statutory authority. Many of the

provisions of this section are authorized

by statutory authorities other than those

which authorize the usual operation of

the CHAMPUS program, especially 10

U.S.C. 1079 and 1086. The TRICARE

Program also relies upon other available

statutory authorities, including 10

U.S.C. 1099 (health care enrollment

system), 10 U.S.C. 1097 (contracts for

medical care for retirees, dependents

and survivors: Alternative delivery of

health care), and 10 U.S.C. 1096

(resource sharing agreements).

(3) Scope of the program. The

TRICARE Program is applicable to all of

the uniformed services. Its geographical

applicability is all 50 states and the

District of Columbia. In addition, if

authorized by the Assistant Secretary of

Defense (Health Affairs), the TRICARE

Program may be implemented in areas

outside the 50 states and the District of

Columbia. In such cases, the Assistant

Secretary of Defense (Health Affairs)

may also authorize modifications to

TRICARE Program rules and procedures

as may be appropriate to the area

involved.

(4) MTF rules and procedures

affected. Much of this section relates to

rules and procedures applicable to the

delivery and financing of health care

services provided by civilian providers

outside military treatment facilities.

This section provides that certain rules,

procedures, rights and obligations set

forth elsewhere in this part (and usually

applicable to CHAMPUS) are different

under the TRICARE Program. In

addition, some rules, procedures, rights

and obligations relating to health care

services in military treatment facilities

are also different under the TRICARE

Program. In such cases, provisions of

this section take precedence and are

binding.

(5) Implementation based on local

action. The TRICARE Program is not

automatically implemented in all areas.

Therefore, provisions of this section are

not automatically implemented. Rather,

implementation of the TRICARE

Program and this section requires an

official action by an authorized

individual, such as a military treatment

facility commander, a Surgeon General,

the Assistant Secretary of Defense

(Health Affairs), or other person

authorized by the Assistant Secretary.

Public notice of the initiation of the

TRICARE Program will be achieved

through appropriate communication

and media methods and by way of an

official announcement by the Director,

OCHAMPUS, identifying the military

treatment facility catchment area or

other geographical area covered.

(6) Major features of the TRICARE

Program. The major features of the

TRICARE Program, described in this

section, include the following:

(i) Comprehensive enrollment system.

Under the TRICARE Program, all health

care beneficiaries become enrolled in

TRICARE and classified into one of five

enrollment categories:

(A) Active duty members, all of whom

are automatically enrolled in TRICARE

Prime;

(B) TRICARE Prime enrollees, who

(except for active duty members) must

be CHAMPUS eligible;

(C) TRICARE Standard enrollees,

which covers all CHAMPUS-eligible

beneficiaries who do not enroll in

TRICARE Prime or another managed

care program affiliated with TRICARE;

(D) Medicare-eligible beneficiaries,

who, although not eligible for TRICARE

Prime, may participate in many features

of TRICARE; and

(E) Participants in other managed care

program affiliated with TRICARE.

(ii) Establishment of a triple option

benefit. A second major feature of

TRICARE is the establishment for

CHAMPUS-eligible beneficiaries of

three options for receiving health care:

(A) Beneficiaries may enroll in the

‘‘TRICARE Prime Plan,’’ which features

use of military treatment facilities and

substantially reduced out-of-pocket

costs for CHAMPUS care. Beneficiaries

generally agree to use military treatment

facilities and designated civilian

provider networks.

(B) Beneficiaries may participate in

the ‘‘TRICARE Extra Plan’’ under which

the preferred provider network may be

used on a case-by-case basis, with

somewhat reduced out-of-pocket costs.

These beneficiaries also continue to be

eligible for military treatment facility

care.

(C) Beneficiaries may remain in the

‘‘TRICARE Standard Plan,’’ which

preserves broad freedom of choice of

civilian providers (subject to

nonavailability statement requirements

of § 199.4), but does not offer reduced

out-of-pocket costs. These beneficiaries

continue to be eligible to receive care in

military treatment facilities.

(iii) Coordination between military

and civilian health care delivery

systems. A third major feature of the

TRICARE Program is a series of

activities affecting all beneficiary

enrollment categories, designed to

coordinate care between military and

civilian health care systems. These

activities include:

(A) Resource sharing agreements,

under which a TRICARE contractor

provides to a military treatment facility

personnel and other resources to

increase the availability of services in

the facility. All beneficiary enrollment
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categories may benefit from this

increase.

(B) Health care finder, an

administrative office that facilitates

referrals to appropriate health care

services in the military facility and

civilian provider network. All

beneficiary enrollment categories may

use the health care finder.

(C) Integrated quality and utilization

management services, potentially

standardizing reviews for military and

civilian sector providers. All beneficiary

categories may benefit from these

services.

(D) Special pharmacy programs for

areas affected by base realignment and

closure actions. This includes special

eligibility for Medicare-eligible

beneficiaries.

(E) PRIMUS or NAVCARE Clinics, for

which all beneficiary enrollment

categories are eligible.

(iv) Consolidated schedule of charges.

A fourth major feature of TRICARE is a

consolidated schedule of charges,

incorporating revisions that reduce

differences in charges between military

and civilian services. In general, the

TRICARE Program reduces out-ofpocket costs for civilian sector care.

(b) Triple option benefit in general.

Where the TRICARE Program is

implemented, CHAMPUS-eligible

beneficiaries are given the options of

enrolling in the TRICARE Prime Plan

(also referred to as ‘‘Prime’’); being a

participant in TRICARE Extra on a caseby-case basis (also referred to as

‘‘Extra’’); or remaining in the TRICARE

Standard Plan (also referred to as

‘‘Standard’’).

(1) Choice voluntary. With the

exception of active duty members, the

choice of whether to enroll in Prime, to

participate in Extra, or to remain in

Standard is voluntary for all eligible

beneficiaries. This applies to active duty

dependents and eligible retired

members, dependents of retired

members, and survivors. For

dependents who are minors, the choice

will be exercised by a parent or

guardian.

(2) Active duty members. For active

duty members located in areas where

the TRICARE Program is implemented,

enrollment in Prime is mandatory.

(c) Eligibility for enrollment in Prime.

Where the TRICARE Program is

implemented, all CHAMPUS-eligible

beneficiaries are eligible to enroll.

However, some rules and procedures are

different for dependents of active duty

members than they are for retirees, their

dependents and survivors. In addition,

where the TRICARE Program is

implemented, a military treatment

facility commander or other authorized

individual may establish priorities,

consistent with paragraph (c) of this

section, based on availability or other

operational requirements, for when and

whether to offer the enrollment

opportunity.

(1) Active duty members. Active duty

members are required to enroll in Prime

when it is offered. Active duty members

shall have first priority for enrollment in

Prime. Because active duty members are

not CHAMPUS eligible, when active

duty members obtain care from civilian

providers outside the military treatment

facility, the supplemental care program

and its requirements (including

§ 199.16) will apply.

(2) Dependents of active duty

members. (i) Dependents of active duty

members are eligible to enroll in Prime.

After all active duty members,

dependents of active duty members will

have second priority for enrollment.

(ii) If all dependents of active duty

members within the area concerned

cannot be accepted for enrollment in

Prime at the same time, the MTF

Commander (or other authorized

individual) may establish priorities

within this beneficiary group category.

The priorities may be based on firstcome, first-served, or alternatively, be

based on rank of sponsor, beginning

with the lowest pay grade.

(3) Retired members, dependents of

retired members, and survivors. (i) All

CHAMPUS-eligible retired members,

dependents of retired members, and

survivors are eligible to enroll in Prime.

After all active duty members are

enrolled and availability of enrollment

is assured for all active duty dependents

wishing to enroll, this category of

beneficiaries will have third priority for

enrollment.

(ii) If all CHAMPUS-eligible retired

members, dependents of retired

members, and survivors within the area

concerned cannot be accepted for

enrollment in Prime at the same time,

the MTF Commander (or other

authorized individual) may allow

enrollment within this beneficiary

group category on a first come, first

served basis.

(4) Participation in Extra and

Standard. All CHAMPUS-eligible

beneficiaries who do not enroll in Prime

may particiate in Extra on a case-by-case

basis or remain in Standard.

(d) Health benefits under Prime.

Health benefits under Prime, set forth in

paragraph (d) of this section, differ from

those under Extra and Standard, set

forth in paragraphs (e) and (f) of this

section.

(1) Military Treatment Facility (MTF)

care. All participants in Prime are

eligible to receive care in military

treatment facilities. Active duty

dependents who are participants in

Prime will be given priority for such

care over other active duty dependents

who declined the opportunity to enroll

in Prime. The latter group, however,

retains priority over retirees, their

dependents and survivors. There is no

priority for MTF care among retirees,

their dependents and survivors based on

enrollment status.

(2) Non-MTF care for active duty

members. Under Prime, non-MTF care

needed by active duty members

continues to be arranged under the

supplemental care program and subject

to the rules and procedures of that

program, including those set forth in

§ 199.16.

(3) Benefits covered for CHAMPUS

eligible beneficiaries for civilian sector

care. The provisions of § 199.18

regarding the Uniform HMO Benefit

apply to TRICARE Prime enrollees.

(e) Health benefits under the

TRICARE Extra Plan. Beneficiaries not

enrolled in Prime, although not in

general required to use the Prime

civilian preferred provider network, are

eligible to use the network on a case-bycase basis under Extra. The healthy

benefits under Extra are identical to

those under Standard, set forth in

paragraph (f) of this section, except that

the CHAMPUS cost sharing percentages

are lower than usual CHAMPUS cost

sharing. The lower requirements are set

forth in the consolidated schedule of

charges in paragraph (m) of this section.

(f) Health benefits under the TRICARE

Standard Plan. Where the TRICARE

Program is implemented, health benefits

under Prime, set forth under paragraph

(d) of this section, and Extra, set forth

under paragraph (e) of this section, are

different than health benefits under

Standard, set forth in this paragraph (f).

(1) Military Treatment Facility (MTF)

care. All participants in Standard and

all nonenrollees (including beneficiaries

not eligible to enroll) continue to be

eligible to receive care in military

treatment facilities on a space available

basis.

(2) Freedom of choice of civilian

provider. Except as stated in § 199.4(a)

in connection with nonavailability

statement requirements, CHAMPUSeligible participants in Standard

maintain their freedom of choice of

civilian provider under CHAMPUS. All

nonavailability statement requirements

of § 199.4(a) apply to Standard

participants.

(3) CHAMPUS benefits apply. The

benefits, rules and procedures of the

CHAMPUS basic program as set forth in

this part, shall apply to CHAMPUSeligible participants in Standard.
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(4) Perferred provider network option

for Standard participants. Standard

participants, although not generally

required to use the TRICARE Program

preferred provider network are eligible

to use the network on a case-by-case

basis, under Extra.

(g) Coordination with other health

care programs. (1) Authority. In the case

of any beneficiary of the military health

services system, other than active duty

members, who is enrolled in a managed

health care program not operated by the

military health services system, the

Director, OCHAMPUS may establish a

contract or agreement with such other

managed health care program for the

purpose of coordinating the

beneficiary’s dual entitlements under

such program and the military health

services system.

(2) Covered programs. A managed

health care program with which

arrangements may be made under this

paragraph (g) includes any health

maintenance organization, competitive

medical plan, health care prepayment

plan, or other managed care program

recognized by the Director,

OCHAMPUS. This includes managed

care programs that operate under the

authority of the Medicare program.

(3) Coordination activities. Any

contract or agreement entered into

under this paragraph (g) may integrate

health care benefits, delivery, financing,

and administrative features of the other

managed care plan with some or all

features of the TRICARE program.

(h) Resource sharing agreements.

Under the TRICARE Program, any

military treatment facility commander

may establish resource sharing

agreements with the applicable

managed care support contractor for the

purpose of providing for the sharing of

resources between the two parties.

Internal resource sharing and external

resource sharing agreements are

authorized. The provisions of this

paragraph (h) shall apply to resource

sharing agreements under the TRICARE

Program.

(1) In connection with internal

resource sharing agreements, beneficiary

cost sharing requirements shall be the

same as those applicable to health care

services provided in facilities of the

uniformed services.

(2) Under internal resource sharing

agreements, the double coverage

requirements of § 199.8 may be replaced

by the Third Party Collection

procedures of 32 CFR part 220. In such

a case, payments made to a resource

sharing agreement provider through the

TRICARE managed care support

contractor shall be deemed to be

payments by the military treatment

facility concerned.

(3) Under internal or external resource

sharing agreements, the commander of

the military treatment facility concerned

may authorize the provision of services

pursuant to the agreement to Medicareeligible beneficiaries, if the commander

determines that this will promote the

most cost-effective provision of services

under the TRICARE program.

(i) Health Care Finder. The Health

Care Finder is an administrative office

that assists beneficiaries in being

referred to appropriate health care

providers, especially the MTF and

preferred providers. Health Care Finder

services are available to all

beneficiaries. In the case of TRICARE

Prime enrollees, the Health Care Finder

will facilitate referrals in accordance

with Prime rules and procedures. For

Standard enrollees, the Finder will

provide assistance for use of Extra. For

Medicare-eligible beneficiaries, the

Finder will facilitate referrals to

TRICARE network providers, generally

required to be Medicare participating

providers. For participants in other

managed care programs, the Finder will

assist in referrals pursuant to the

arrangements made with the other

managed care program. For all

beneficiary enrollment categories, the

finder will assist In obtaining access to

available services in the medical

treatment facility.

(j) General quality assurance,

utilization review, and preauthorization

requirements under TRICARE Program.

All quality assurance, utilization

review, and preauthorization

requirements for the basic CHAMPUS

program, as set forth in this part 199

(see especially applicable provisions of

§§ 199.4 and 199.15), are applicable to

Prime, Extra and Standard under the

TRICARE Program. Under all three

options, some methods and procedures

for implementing and enforcing these

requirements may differ from the

methods and procedures followed under

the basic CHAMPUS program in areas in

which the TRICARE Program has not

been implemented. Pursuant to an

agreement between a military treatment

facility and TRICARE managed care

support contractor, quality assurance,

utilization review, and preauthorization

requirements and procedures applicable

to health care services outside the

military treatment facility may be made

applicable, in whole or in part, to health

care services inside the military

treatment facility.

(k) Pharmacy services in base

realignment and closure sites.—(1) In

general. TRICARE includes two special

programs under which covered

beneficiaries, including Medicareeligible beneficiaries, who live in areas

adversely affected by base realignment

and closure actions are given a

pharmacy benefit for prescription drugs

provided outside military treatment

facilities. The two special programs are

the retail pharmacy network program

and the mail service pharmacy program.

(2) Retail pharmacy network program.

To the maximum extent practicable, a

retail pharmacy network program will

be included in the TRICARE Program

wherever implemented. Except for the

special rules applicable to Medicareeligible beneficiaries in areas adversely

affected by military treatment facility

closures, the retail pharmacy network

program will function in accordance

with TRICARE rules and procedures

otherwise applicable. In addition, a

retail pharmacy network program may

on a temporary, transitional basis be

established in a base realignment or

closure site independent of other

features of the TRICARE program. Such

a program may be established through

arrangements with one or more

pharmacies in the area and may

continue until a managed care program

is established to serve the affected

beneficiaries.

(3) Mail service pharmacy program. A

mail service pharmacy program will be

established to the extent required by law

as part of the TRICARE Program. The

special rules applicable to Medicareeligible beneficiaries established in this

paragraph (k) shall be applicable.

(4) Medicare-eligible beneficiaries in

areas adversely affected by military

treatment facility closures. Under the

retail pharmacy network program and

mail service pharmacy program, there is

a special eligibility rule pertaining to

Medicare-eligible beneficiaries in areas

adversely affected by military treatment

facility closures.

(i) Medicare-eligible beneficiaries. The

special eligibility rule pertains to

military system beneficiaries who are

not eligible for CHAMPUS solely

because of their eligibility for part A of

Medicare.

(ii) Area adversely affected by closure.

To be eligible for use of the retail

pharmacy network program or mail

service pharmacy program, a Medicareeligible beneficiary must maintain a

principle place of residency in the

catchment area of the military medical

treatment facility that closed. In

addition, there must be a retail

pharmacy network or mail service

pharmacy established in that area. In

identifying areas adversely affected by a

closure, the provisions of this paragraph

(k)(4)(ii) shall apply.
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(A) In the case of the closure of a

military hospital, the area adversely

affected is the established 40-mile

catchment area of the military hospital

that closed.

(B) In the case of the closure of a

military clinic (a military treatment

facility that provided no inpatient care

services), the area adversely affected is

an area approximately 40 miles in

radius from the clinic, established in a

manner comparable to the manner in

which catchment areas of military

hospitals are established. However, this

area will not be considered adversely

affected by the closure of the clinic if

the Director, OCHAMPUS determines

that the clinic was not, when it had

been in regular operation, providing a

substantial amount of pharmacy

services to retirees and their

dependents.

(C) An area that is within the 40-mile

catchment area of a military treatment

facility that closed will not be

considered adversely affected by the

closure if that area is also within a 40-

mile catchment area of another military

medical treatment facility (inpatient or

outpatient) that the Director,

OCHAMPUS determines can provide a

substantial amount of pharmacy

services to retirees and their

dependents.

(iii) Other Medicare-eligible

beneficiaries adversely affected. In

addition to beneficiaries identified in

paragraph (k)(4)(ii) of this section,

eligibility for the retail pharmacy

network program and mail service

pharmacy program is also established

for Medicare-eligible beneficiaries who

can demonstrate to the satisfaction of

the Director, OCHAMPUS that he or she

relied upon a military medical treatment

facility that closed for his or her

pharmaceuticals. The Director,

OCHAMPUS shall establish guidelines

for making such a demonstration.

(iv) Effective date of eligibility for

Medicare-eligible beneficiaries. In any

case in which, prior to the complete

closure of a military treatment facility in

the process of closure, the Director,

OCHAMPUS determines that the area

has been adversely affected by severe

reductions in access to services, the

Director, OCHAMPUS may establish an

effective date for eligibility for the retail

pharmacy network program or mail

service pharmacy program for Medicareeligible beneficiaries prior to the

complete closure of the facility.

(5) Effect of other health insurance.

The double coverage rules of § 199.8 are

applicable to services provided to all

beneficiaries under the retail pharmacy

network program or mail service

pharmacy program. For this purpose, to

the extent they provide a prescription

drug benefit, Medicare supplemental

insurance plans are double coverage

plans and will be the primary payor.

(6) Procedures. The Director,

OCHAMPUS shall establish procedures

for the effective operation of the retail

pharmacy network program and mail

service pharmacy program. Such

procedures may include the use of

appropriate drug formularies,

restrictions of the quantity of

pharmaceuticals to be dispensed,

encouragement of the use of generic

drugs, implementation of quality

assurance and utilization management

activities, and other appropriate matters.

(l) PRIMUS and NAVCARE Clinics. (1)

Authority. The Assistant Secretary of

Defense for Health Affairs may

authorize the establishment of PRIMUS

and NAVCARE Clinics. These clinics

are contractor owned, staffed, and

operated clinics that exclusively serve

uniformed services beneficiaries.

(2) Eligible beneficiaries. All

TRICARE beneficiary enrollment

categories are eligible for care in

PRIMUS and NAVCARE Clinics. This

includes active duty members, Medicare

eligible beneficiaries and other persons

not eligible for CHAMPUS.

(3) Services and charges. (i) For care

provided PRIMUS and NAVCARE

Clinics established prior to October 1,

1994, CHAMPUS rules regarding

program benefits, deductibles and cost

sharing requirements do not apply.

Services offered and charges will be

based on those applicable to care

provided in military medical treatment

facilities.

(ii) For care provided in PRIMUS and

NAVCARE Clinics established after

September 30, 1994, the provisions of

§ 199.18(d)(3) regarding outpatient cost

sharing requirements under the Uniform

HMO Benefit shall apply.

(4) Procedures. The Director,

OCHAMPUS will establish procedures

for PRIMUS and NAVCARE Clinics.

Such procedures may waive normal

requirements of this part that are not

required by law. Except to the extent

required by law, the procedures

established by the Director for PRIMUS

and NAVCARE Clinics may be based on

rules and procedures applicable to

military medical treatment facilities.

(m) Consolidated schedule of

beneficiary charges. The following

consolidated schedule of beneficiary

charges is applicable to health care

services provided under TRICARE for

Prime enrollees, Standard enrollees and

Medicare-eligible beneficiaries. (There

are no charges to active duty members.

Charges for participants in other

managed health care programs affiliated

with TRICARE will be specified in the

applicable affiliation agreements.)

(1) Cost sharing for services from

TRICARE network providers. (i) For

Prime enrollees, cost sharing is as

specified in the Uniform HMO Benefit

in § 199.18, except that for care not

authorized by the primary care manager

or Health Care Finder, rules applicable

to the TRICARE point of service option

(see paragraph (n)(3) of this section) are

applicable. The deductible is $300 per

person and $600 per family. The

beneficiary copayment per service is 50

percent.

(ii) For Standard enrollees, TRICARE

Extra cost sharing applies. The

deductible is the same as standard

CHAMPUS. Copayments are:

(A) For outpatient professional

services, cost sharing will be reduced

from 20 percent to 15 percent for

dependents of active duty members.

(B) For most services for retired

members, dependents of retired

members, and survivors, cost sharing is

reduced from 25 percent to 20 percent.

(C) In fiscal year 1995, the per diem

inpatient hospital copayment for

retirees, dependents of retirees, and

survivors when they use a preferred

provider network hospital is $250 per

day, or 25 percent of total charges,

whichever is less. There is a nominal

copayment for active duty dependents,

which is the same as under the

CHAMPUS program (see § 199.4). The

per diem amount may be updated for

subsequent years based on changes in

the standard CHAMPUS per diem.

(D) For prescription drugs obtained

from network pharmacies, the

CHAMPUS deductible will not apply.

(iii) For Medicare-eligible

beneficiaries, cost sharing will generally

be as applicable to Medicare

participating providers.

(2) Cost sharing for non-network

providers. (i) For TRICARE Prime

enrollees, rules applicable to the

TRICARE point of service option (see

paragraph (n)(3) of this section) are

applicable. The deductible is $300 per

person and $600 per family. The

beneficiary copayment per service is 50

percent.

(ii) For Standard enrollees, cost

sharing is as specified for the basic

CHAMPUS program.

(iii) For Medicare eligible

beneficiaries, cost sharing is as provided

under the Medicare program.

(3) Cost sharing under internal

resource sharing agreements. (i) For

Prime enrollees, cost sharing is as

provided in military treatment facilities.

(ii) For Standard enrollees, cost

sharing is as provided in military

treatment facilities.
7502 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

(iii) For Medicare eligible

beneficiaries, where made applicable by

the commander of the military treatment

facility concerned, cost sharing will be

as provided in military treatment

facilities.

(4) Cost sharing under external

resource sharing. (i) For Prime

enrollees, cost sharing applicable to

services provided by military facility

personnel shall be as applicable to

services in military treatment facilities;

that applicable to institutional and

related ancillary charges shall be as

applicable to services provided under

TRICARE Prime.

(ii) For Standard enrollees, cost

sharing applicable to services provided

by Military facility personnel shall be as

applicable to services in military

treatment facilities; that applicable to

institutional and related ancillary

charges shall be as applicable to services

provided under TRICARE Extra.

(iii) For Medicare-eligible

beneficiaries, where available, cost

sharing applicable to services provided

by military facility personnel shall be as

applicable to services in military

treatment facilities; that applicable to

institutional and related ancillary

charges shall be as applicable to services

provided under Medicare.

(5) Prescription drugs. (i) For Prime

enrollees, cost sharing is as specified in

the Uniform HMO Benefit.

(ii) For Standard enrollees, there is a

20 percent copayment for prescription

drugs provided by retail pharmacy

network providers. The copayment for

all beneficiaries under the mail service

pharmacy program is $4.00 for active

duty dependents and $8.00 for all other

covered beneficiaries per prescription;

for up to a 60 day supply. There is no

deductible for this program.

(iii) For Medicare-eligible

beneficiaries affected by military

treatment facility closures, there is a 20

percent copayment for prescriptions

provided under the retail pharmacy

network program, and an $8.00

copayment per prescription, for up to a

60-day supply, for prescriptions

provided by the mail service pharmacy

program. There is no deductible under

their programs.

(6) Cost share for outpatient services

in military treatment facilities. (i) For

dependents of active duty members in

all enrollment categories, there is no

charge for outpatient visits provided in

military medical treatment facilities.

(ii) For retirees, their dependents, and

survivors in all enrollment categories,

there is no charge for outpatient visits

provided in military medical treatment

facilities.

(n) Additional health care

management requirements under

TRICARE Prime. Prime has additional,

special health care management

requirements not applicable under

Extra, Standard or the CHAMPUS basic

program. Such requirements must be

approved by the Assistant Secretary of

Defense (Health Affairs). In TRICARE,

all care may be subject to review for

medical necessity and appropriateness

of level of care, regardless of whether

the care is provided in a military

treatment facility or in a civilian setting.

Adverse determinations regarding care

in military facilities will be appealable

in accordance with established military

medical department procedures, and

adverse determinations regarding

civilian care will be appealable in

accordance with § 199.15.

(1) Primary care manager. All active

duty members and Prime enrollees will

be assigned or be allowed to select a

primary care manager pursuant to a

system established by the MTF

Commander or other authorized official.

The primary care manager may be an

individual physician, a group practice,

a clinic, a treatment site, or other

designation. The primary care manager

may be part of the MTF or the Prime

civilian provider network. The enrollees

will be given the opportunity to register

a preference for primacy care manager

from a list of choices provided by the

MTF Commander. Preference requests

will be honored subject to availability

under the MTF beneficiary category

priority system and other operational

requirements established by the

commander (or other authorized

person).

(2) Restrictions on the use of

providers. The requirements of this

paragraph (n)(2) shall be applicable to

health care utilization under TRICARE

Prime, except in cases of emergency

care and under the point-of-service

option (see paragraph (n)(3) of this

section).

(i) Prime enrollees must obtain all

primary health care from the primary

care manager or from another provider

to which the enrollee is referred by the

primary care manager or Health Care

Finder.

(ii) For any necessary specialty care

and all inpatient care, the primary care

manager or Health Care Finder will

assist in making an appropriate referral.

All such nonemergency specialty care

and inpatient care must be

preauthorized by the primary care

manager or Health Care Finder.

(iii) The following procedures will

apply to health care referrals and

preauthorizations in catchment areas

under TRICARE Prime:

(A) The first priority for referral for

specialty care or inpatient care will be

to the local MTF (or to any other MTF

in which catchment area the enrollee

resides).

(B) If the local MTF(s) are unavailable

for the services needed, but there is

another MTF at which the needed

services can be provided, the enrollee

may be required to obtain the services

at that MTF. However, this requirement

will only apply to the extent that the

enrollee was informed at the time of (or

prior to) enrollment that mandatory

referrals might be made to the MTF

involved for the service involved.

(C) If the needed services are available

within civilian preferred provider

network serving the area, the enrollee

may be required to obtain the services

from a provider within the network.

Subject to availability, the enrollee will

have the freedom to choose a provider

from among those in the network.

(D) If the needed services are not

available within the civilian preferred

provider network serving the area, the

enrollee may be required to obtain the

services from a designated civilian

provider outside the area. However, this

requirement will only apply to the

extent that the enrollee was informed at

the time of (or prior to) enrollment that

mandatory referrals might be made to

the provider involved for the service

involved (with the provider and service

either identified specifically or in

connection with some appropriate

classification).

(E) In cases in which the needed

health care services cannot be provided

pursuant to the procedures identified in

paragraphs (n)(2)(iii) (A) through (D) of

this section, the enrollee will receive

authorization to obtain services from a

CHAMPUS-authorized civilian

provider(s) of the enrollee’s choice not

affiliated with the civilian preferred

provider network.

(iv) When Prime is operating in

noncatchment areas, the requirements

in paragraphs (n)(2)(iii) (B) through (E)

of this section shall apply.

(v) Any health care services obtained

by a Prime enrollee not obtained in

accordance with the utilization

management rules and procedures of the

Prime will not be paid for by Prime, but

may be covered by the point-of-service

option (see paragraph (n)(3) of this

section). However, Prime may cover

such services if the enrollee did not

know and could not reasonably have

been expected to know that the services

were not obtained in accordance with

the utilization management rules and

procedures of Prime.

(3) Point-of-service option. TRICARE

Prime enrollees retain the freedom to
Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules 7503

obtain services from civilian providers

on a point-of-service basis. In such

cases, all requirements applicable to

standard CHAMPUS shall apply, except

that there shall be higher deductible and

cost sharing requirements (as set forth in

paragraphs (m)(1)(i) and (m)(2)(i) of this

section).

(o) TRICARE Program enrollment

procedures. There are certain

requirements pertaining to procedures

for enrollment in Prime. (These

procedures do not apply to active duty

members, whose enrollment is

mandatory.)

(1) Open season enrollment.

Beneficiaries will be offered the

opportunity to enroll in Prime during

designated periods of time. Subject to

exceptions for change of residence and

other changes, enrollment will be

limited to the open season periods

announced at the time the TRICARE

Program is implemented in a particular

area.

(2) Enrollment period. The Prime

enrollment period shall be 12 months.

In general, enrollment will be effective

on the first day of the month following

expiration of the open season

enrollment period. Enrollees must

remain in Prime for a 12 month period,

at which time they may disenroll. This

requirement is subject to exceptions for

change of residence and other changes

announced at the time the TRICARE

Program is implemented in a particular

area.

(3) Periodic revision. Periodically,

certain features, rules or procedures of

Prime, Extra and/or Standard may be

revised. If such revisions will have a

significant effect on participants’ costs

or access to care, beneficiaries will be

given the opportunity to change their

enrollment status coincident with the

revisions.

(4) Effects of failure to enroll.

Beneficiaries offered the opportunity to

enroll in Prime, who do not enroll

within the time provided to enroll, will

be eligible to participate in Extra on a

case-by-case basis or remain in

Standard.

(p) Civilian preferred provider

networks. A major feature of the

TRICARE Program is the civilian

preferred provider network.

(1) Status of network providers.

Providers in the preferred provider

network are not employees or agents of

the Department of Defense or the United

States Government. Rather, they are

independent contractors of the

government (or other independent

entities having business arrangements

with the government). Although

network providers must follow

numerous rules and procedures of the

TRICARE Program, on matters of

professional judgment and professional

practice, the network provider is

independent and not operating under

the direction and control of the

Department of Defense. Each preferred

provider must have adequate

professional liability insurance, as

required by the Federal Acquisition

Regulation, and must agree to indemnify

the United States government for any

liability that may be assessed against the

United States government that is

attributable to any action or omission of

the provider.

(2) Utilization management policies.

Preferred providers are required to

follow the utilization management

policies and procedures of the TRICARE

Program. These policies and procedures

are part of discretionary judgments by

the Department of Defense regarding the

methods of delivering and financing

health care services that will best

achieve health and economic policy

objectives.

(3) Quality assurance requirements. A

number of quality assurance

requirements and procedures are

applicable to preferred network

providers. These are for the purpose of

assuring that the health care services

paid for with government funds meet

the standards called for in the contract

or provider agreement.

(4) Provider qualifications. All

preferred providers must meet the

following qualifications:

(i) They must be CHAMPUS

authorized providers and CHAMPUS

participating providers.

(ii) All physicians in the preferred

provider network must have staff

privileges in a hospital accredited by the

Joint Commission on Accreditation of

Health Care Organizations. This

requirement may be waived in any case

in which a physician’s practice does not

include the need for admitting

privileges in such a hospital. However,

in any case in which the requirement is

waived, the physician must comply

with alternative qualification standards

as are established by the MTF

Commander (or other authorized

official).

(iii) All preferred providers must

agree to follow all quality assurance and

utilization management procedures

established pursuant to this section,

make available to designated DoD

utilization management or quality

monitoring contractors medical records

and other pertinent records, and to

authorize the release of information to

MTF Commanders regarding such

quality assurance and utilization

management activities.

(iv) All preferred network providers

must be Medicare participating

providers, unless this requirement is

waived based on extraordinary

circumstances. This requirement that a

provider be a Medicare participating

provider does not apply to providers not

eligible to be participating providers

under Medicare.

(v) The provider must be available to

Extra participants.

(vi) The provider must agree to accept

the same payment rates negotiated for

Prime enrollees for any person whose

care is reimbursable by the Department

of Defense, including, for example,

Extra participants, supplemental care

cases, and beneficiaries from outside the

area.

(vii) All preferred providers must

meet all other qualification

requirements, and agree to comply with

all other rules and procedures

established for the preferred provider

network.

(5) Access standards. Preferred

provider networks will have attributes

of size, composition, mix of providers

and geographical distribution so that the

networks, coupled with the MTF

capabilities, can adequately address the

health care needs of the enrollees.

Before offering enrollment in Prime to a

beneficiary group, the MTF Commander

(or other authorized person) will assure

that the capabilities of the MTF plus

preferred provider network will meet

the following access standards with

respect to the needs of the expected

number of enrollees from the

beneficiary group being offered

enrollment:

(i) Under normal circumstances,

enrollee travel time may not exceed 30

minutes from home to primary care

delivery site unless a longer time is

necessary because of the absence of

providers (including providers not part

of the network) in the area.

(ii) The wait time for an appointment

for a well-patient visit or a specialty

care referral shall not exceed four

weeks; for a routine visit, the wait time

for an appointment for a well-patient

visit shall not exceed two weeks; and for

an urgent care visit the wait time for an

appointment shall generally not exceed

24 hours.

(iii) Emergency services shall be

available and accessible to handle

emergencies (and urgent care visits if

not available from other primary care

providers pursuant to paragraph

(p)(5)(ii) of this section), within the

service area 24 hours a day, seven days

a week.

(iv) The network shall include a

sufficient number and mix of board

certified specialists to meet reasonably
7504 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

the anticipated needs of enrollees.

Travel time for specialty care share not

exceed one hour under normal

circumstances, unless a longer time is

necessary because of the absence of

providers (including providers not part

of the network) in the area. This

requirement does not apply under the

Specialized Treatment Services

Program.

(v) Office waiting times in

nonemergency circumstances shall not

exceed 30 minutes.

(6) Special reimbursement methods

for network providers. The Director,

OCHAMPUS may establish for preferred

provider networks reimbursement rates

and methods different from those

established pursuant to § 199.14. Such

provisions may be expressed in terms of

percentage discounts off CHAMPUS

allowable amounts, or in other terms. In

circumstances in which payments are

based on hospital-specific rates (or other

rates specific to particular institutional

providers), special reimbursement

methods may permit payments based on

discounts off national or regional

prevailing payment levels, even if

higher than particular institutionspecific payment rates.

(7) Methods for establishing preferred

provider networks. There are several

methods under which the MTF

Commander (or other authorized

official) may establish a preferred

provider network. These include the

following:

(i) There may be an acquisition under

the Federal Acquisition Regulation,

either conducted locally for that

catchment area, in a larger area in

concert with other MTF Commanders,

regionally as part of a CHAMPUS

acquisition, or on some other basis.

(ii) To the extent allowed by law,

there may be a modification by the

Director, OCHAMPUS of an existing

CHAMPUS fiscal intermediary contract

to add TRICARE Program functions to

the existing responsibilities of the fiscal

intermediary contractor.

(iii) The MTF Commander (or other

authorized official) may follow the any

qualified provider method set forth in

paragraph (q) of this section.

(iv) Any other method authorized by

law may be used.

(q) Preferred provider network

establishment under any qualified

provider method. The any qualified

provider method may be used to

establish a civilian preferred provider

network. Under this method, any

CHAMPUS-authorized provider within

the geographical area involved that

meets the qualification standards

established by the MTF Commander (or

other authorized official) may become a

part of the preferred provider network.

Such standards must be publicly

announced and uniformly applied. Any

provider that meets all applicable

qualification standards may not be

excluded from the preferred provider

network. Qualifications include:

(1) The provider must meet all

applicable requirements in paragraph

(p)(4) of this section.

(2) The provider must agree to follow

all quality assurance and utilization

management procedures established

pursuant to this section.

(3) The provider must be a

Participating Provider under CHAMPUS

for all claims.

(4) The provider must meet all other

qualification requirements, and agree to

all other rules and procedures, that are

established, publicly announced, and

uniformly applied by the commander

(or other authorized official).

(5) The provider must sign a preferred

provider network agreement covering all

applicable requirements. Such

agreements will be for a duration of one

year, are renewable, and may be

canceled by the provider or the MTF

Commander (or other authorized

official) upon appropriate notice to the

other party. The Director, OCHAMPUS

shall establish an agreement model or

other guidelines to promote uniformity

in the agreements.

(r) General fraud, abuse, and conflict

of interest requirements under TRICARE

Program. All fraud, abuse, and conflict

of interest requirements for the basic

CHAMPUS program, as set forth in this

part 199 (see especially applicable

provisions of § 199.9) are applicable to

the TRICARE Program. Some methods

and procedures for implementing and

enforcing these requirements may differ

from the methods and procedures

followed under the basic CHAMPUS

program in areas in which the TRICARE

Program has not been implemented.

(s) Partial implementation. The

Assistant Secretary of Defense (Health

Affairs) may authorize the partial

implementation of the TRICARE

Program. In such cases, the TRICARE

Extra Plan and the TRICARE Standard

Plan may be offered without the

TRICARE Prime Plan. Partial

implementation may also consist of

establishment of a TRICARE Program

limited to particular services, such as

mental health services.

(t) Inclusion of Department of

Veterans Affairs Medical Centers in

TRICARE networks. TRICARE preferred

provider networks may include

Department of Veterans Affairs Medical

Centers pursuant to arrangements

between those centers and the Director,

OCHAMPUS or designated TRICARE

contractor.

(u) Care provided outside the United

States to dependents of active duty

members. The Assistant Secretary of

Defense (Health Affairs) may, in

conjunction with implementation of the

TRICARE program, authorize a special

CHAMPUS program for dependents of

active duty members who accompany

the members in their assignments in

foreign countries. Under this special

program, contracts or agreements may

be made with health care providers

under which services will be provided

to the covered dependents with the

requirements for deductibles and

copayments waived or reduced.

(v) Administrative procedures. The

Assistant Secretary of Defense (Health

Affairs), the Director, OCHAMPUS, and

MTF Commanders (or other authorized

officials) are authorized to establish

administrative requirements and

procedures, consistent with this section,

this part and other applicable DoD

Directives or Instructions, for the

implementation and operation of the

TRICARE Program.

§ 199.18 Uniform HMO Benefit.

(a) In general. There is established a

Uniform HMO Benefit. The purpose of

the Uniform HMO Benefit is to establish

a health benefit option modeled on

health maintenance organization plans.

This benefit is intended to be uniform

throughout the United States and to be

included in all managed care programs

under the MHSS. Most care purchased

from civilian health care providers

(outside a military medical treatment

facility) will be under the rules of the

Uniform HMO Benefit or the Basic

CHAMPUS Program (see § 199.4). The

Uniform HMO benefit shall apply only

as specified in this section or other

sections of this part, and shall be subject

to any special applications indicated

indicated in such other sections.

(b) Services covered under the

Uniform HMO Benefit option. (1) Except

as specifically provided or authorized

by this section, all CHAMPUS benefits

provided, and benefit limitations

established, pursuant to this part shall

apply to the Uniform HMO Benefit.

(2) Certain preventive care services

not normally provided as part of basic

program benefits under CHAMPUS are

covered benefits when provided to Plan

enrollees by providers in the civilian

provider network. Such standards shall

establish a specific schedule, including

frequency or age specifications for:

(i) Laboratory and x-ray tests,

including blood lead, rubella,

cholesterol, fecal occult blood testing,

and mammography;
Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules 7505

(ii) Pap smears;

(iii) Eye exams;

(iv) Immunizations;

(v) Periodic health promotion and

disease prevention exams;

(vi) Blood pressure screening;

(vii) Hearing exams;

(viii) Sigmoidoscopy or colonoscopy;

(ix) Serologic screening; and

(x) Appropriate education and

counseling services. The exact services

offered shall be established under

uniform standards established by the

Assistant Secretary of Defense (Health

Affairs).

(3) In addition to preventive care

services provided pursuant to paragraph

(b)(2) of this section, other benefit

enhancements may be added and other

benefit restrictions may be waived or

relaxed in connection with health care

services provided to include the

Uniform HMO Benefit. Any such other

enhancements or changes must be

approved by the Assistant Secretary of

Defense (Health Affairs) based on

uniform standards.

(c) Enrollment fee under the uniform

HMO benefit. (1) The CHAMPUS annual

deductible amount (see § 199.4(f)) is

waived under the Uniform HMO Benefit

during the period of enrollment. In lieu

of a deductible amount, an annual

enrollment fee is applicable. The

specific enrollment fee requirements

shall be published annually by the

Assistant Secretary of Defense (Health

Affairs), and shall be uniform within the

following groups: Dependents of active

duty members in pay grades E–4 and

below; active duty dependents of

sponsors in pay grades E–5 and above;

and retirees and their dependents.

(2) Amount of enrollment fees.

Beginning in fiscal year 1995, the

annual enrollment fees are:

(i) for dependents of active duty

members in pay grades of E–4 and

below, $0;

(ii) for active duty dependents of

sponsors in pay grades E–5 and above,

$0; and,

(iii) for retirees and their dependents,

$230 individual, $460 family.

(d) Outpatient cost sharing

requirements under the Uniform HMO

Benefit—(1) In general. In lieu of usual

CHAMPUS cost sharing requirements

(see § 199.4(f)), special reduced cost

sharing percentages or per service

specific dollar amounts are required.

The specific requirements shall be

uniform and shall be published

annually by the Assistant Secretary of

Defense (Health Affairs).

(2) Structure of outpatient cost

sharing. The special cost sharing

requirements for outpatient services

include the following specific structural

provisions:

(i) For most physician office visits and

other routine services, there is a per

visit fee for each of the following

groups: Dependents of active duty

members in pay grades E–1 through E–

4; dependents of active duty members in

pay grades of E–5 and above; and

retirees and their dependents. This fee

applies to primary care and specialty

care visits, except as provided

elsewhere in this paragraph (d)(2) of this

section. It also applies to ancillary

services (unless provided as part of an

office visit for which a copayment is

collected), family health services, home

health care visits, eye examinations, and

immunizations.

(ii) There is a copayment for

outpatient mental health visits. It is a

per visit fee for dependents of active

duty members in pay grades E–1

through E–4; for dependents of active

duty members in pay grades of E–5 and

above; and for retirees and their

dependents for individual visits. For

group visits, there is a lower per visit fee

for dependents of active duty members

in pay grades E–1 through E–4; for

dependents of active duty members in

pay grades of E–5 and above; and for

retirees and their dependents.

(iii) There is a cost share for durable

medical equipment, prosthetic devices,

and other authorized supplies for

dependents of active duty members in

pay grades E–1 through E–4; for

dependents of active duty members in

pay grades of E–5 and above; and for

retirees and their dependents.

(iv) For emergency room services,

there is a per visit fee for dependents of

active duty members in pay grades E–

1 through E–4; for dependents of active

duty members in pay grades of E–5 and

above; and for retirees and their

dependents.

(v) For primary surgeon services in

ambulatory surgery, there is a per

service fee for dependents of active duty

members in pay grades E–1 through E–

4; for dependents of active duty

members in pay grades of E–5 and

above; and for retirees and their

dependents.

(vi) There is a copayment for

prescription drugs per prescription,

including medical supplies necessary

for administration, for dependents of

active duty members in pay grades E–

1 through E–4; for dependents of active

duty members in pay grades of E–5 and

above; and for retirees and their

dependents.

(vii) There is a copayment for

ambulance services for dependents of

active duty members in pay grades E–

1 through E–4; for dependents of active

duty members in pay grades of E–5 and

above; and for retirees and their

dependents.

(3) Amount of outpatient cost sharing

requirements. Beginning in fiscal year

1995, the outpatient cost sharing

requirements are as follows:

(i) For most physician office visits and

other routine services, as described in

paragraph (d)(2)(i) of this section, the

per visit fee is as follows:

(A) For dependents of active duty

members in pay grades E–1 through E–

4, $6;

(B) For dependents of active duty

members in pay grades of E–5 and

above, $12; and,

(C) For retirees and their dependents,

$12.

(ii) For outpatient mental health

visits, the per visit fee is as follows:

(A) For individual outpatient mental

health visits:

(1) For dependents of active duty

members in pay grades E–1 through E–

4, $10;

(2) For dependents of active duty

members in pay grades E–5 and above,

$20; and,

(3) For retirees and their dependents,

$25.

(B) For group outpatient mental

health visits, there is a lower per visit

fee, as follows:

(1) For dependents of active duty

members in pay grades E–1 through E–

4, $6;

(2) For dependents of active duty

members in pay grades E–5 and above,

$12; and,

(3) For retirees and their dependents,

$17.

(iii) The cost share for durable

medical equipment, prosthetic devices,

and other authorized supplies is as

follows:

(A) For dependents of active duty

members in pay grades E–1 through E–

4, 10 percent of the negotiated fee;

(B) For dependents of active duty

members in pay grades E–5 and above,

15 percent of the negotiated fee; and,

(C) For retirees and their dependents,

20 percent of the negotiated fee.

(iv) For emergency room services, the

per visit fee is as follows:

(A) For dependents of active duty

members in pay grades E–1 through E–

4, $10;

(B) For dependents of active duty

members in pay grades of E–5 and

above, $30; and,

(C) For retirees and their dependents,

$30.

(v) For primary surgeon services in

ambulatory surgery, the per service fee

is as follows:

(A) For dependents of active duty

members in pay grades of E–1 through

E–4, $25;
7506 Federal Register / Vol. 60, No. 26 / Wednesday, February 8, 1995 / Proposed Rules

(B) For dependents of active duty

members in pay grades of E–5 and

above, $25; and,

(C) For retirees and their dependents,

$25.

(vi) The copayment for prescription

drugs per prescription, for a maximum

30-day supply, is as follows:

(A) For dependents of active duty

members in pay grades E–1 through E–

4, $5;

(B) For dependents of active duty

members in pay grades of E–5 and

above, $5; and,

(C) For retirees and their dependents,

$9.

(vii) The copayment for ambulance

services is as follows:

(A) For dependents of active duty

members in pay grades of E–1 through

E–4, $10;

(B) For dependents of active duty

members in pay grades of E–5 and

above, $15; and,

(C) For retirees and their dependents,

$20.

(e) Inpatient cost sharing

requirements under the Uniform HMO

Benefit.—(1) In general. In lieu of usual

CHAMPUS cost sharing requirements

(see § 199.4(f)), special cost sharing

amounts are required. The specific

requirements shall be uniform and shall

be published as a notice annually by the

Assistant Secretary of Defense (Health

Affairs).

(2) Structure of cost sharing. For

services other than mental illness or

substance use treatment, there is a

nominal copayment for active duty

dependents and for retired members,

dependents of retired members, and

survivors. For inpatient mental health

and substance use treatment, a separate

per day charge is established.

(3) Amount of inpatient cost sharing

requirements. Beginning in fiscal year

1995, the inpatient cost sharing

requirements are as follows:

(i) For acute care admissions and

other non-mental health/substance use

treatment admissions, the per diem

charge is as follows, with a minimum

charge of $25 per admission:

(A) For dependents of active duty

members in pay grades E–1 through E–

4, $11;

(B) For dependents of active duty

members in pay grades of E–5 and

above, $11; and,

(C) For retirees and their dependents,

$11.

(ii) For mental health/substance use

treatment admissions, and for partial

hospitalization services, the per diem

charge is as follows, with a minimum

charge of $25 per admission:

(A) For dependents of active duty

members in pay grades E–1 through E–

4, $20;

(B) For dependents of active duty

members in pay grades of E–5 and

above, $20; and,

(C) For retirees and their dependents,

$40.

(f) Updates. The enrollment fees for

fiscal year 1995 set under paragraph (c)

of this section and the per services

specific dollar amounts for fiscal year

1995 set under paragraphs (d) and (e) of

this section may be updated for

subsequent years to the extent necessary

to maintain compliance with statutory

requirements pertaining to government

costs. This updating does not apply to

cost sharing that is expressed as a

percentage of allowable charges; these

percentages will remain unchanged.

(g) Applicability of the Uniform HMO

Benefit to Uniformed Services

Treatment Facilities Managed Care

Program. The provisions of this section

concerning the Uniform HMO Benefit

shall apply to the Uniformed Services

Treatment Facilities Managed Care

Program, effective October 1, 1995.

Under that program, non-CHAMPUS

eligible beneficiaries have the same

payment responsibilities as CHAMPUSeligible beneficiaries.

Dated: February 2, 1995.

L.M. Bynum,

Alternate OSD Federal Register Liaison

Officer, Department of Defense.

[FR Doc. 95–3028 Filed 2–7–95; 8:45 am]

BILLING CODE 5000–04–M

ASSASSINATION RECORDS REVIEW

BOARD

36 CFR Part 1400

Guidance on Interpreting and

Implementing the President John F.

Kennedy Assassination Records

Collection Act of 1992

AGENCY: Assassination Records Review

Board (ARRB).

ACTION: Proposed interpretive

regulation.

SUMMARY: The ARRB proposes to issue

regulations providing guidance on the

interpretation of certain terms defined

in and the implementation of the

President John F. Kennedy

Assassination Records Collection Act of

1992.

DATES: To be considered, comments

must be received on or before March 10,

1995.

ADDRESSES: Comments should be

mailed to the Assassination Records

Review Board at 600 E Street, NW,

Second floor, Washington, D.C. 20530 or

delivered in person to that address

between the hours of 9:30 a.m. and 4:30

p.m., Monday through Friday (except

legal holidays). Comments may also be

faxed to the Board at (202) 724–0457.

Comments received may be inspected in

the Board’s public reading room, located

at the address shown above, between 10

a.m. and 3 p.m. Monday through Friday

(except legal holidays). Persons wishing

to inspect comments in the Board’s

public reading room should call the

Board’s office beforehand at (202) 724–

0088 for further information.

FOR FURTHER INFORMATION CONTACT:

Sheryl L. Walter (General Counsel),

(202) 724–0088.

SUPPLEMENTARY INFORMATION:

Background

The President John F. Kennedy

Assassination Records Collection Act of

1992, 44 U.S.C. 2107 note (as amended)

(ARCA), established the President John

F. Kennedy Assassination Records

Collection (the JFK Collection) at the

National Archives and Records

Administration (NARA). In establishing

the process for public disclosure of all

records relating to the assassination,

Congress created an independent agency

within the executive branch, the

Assassination Records Review Board

(the Board), which consists of five

citizens appointed by the President.

Under the statute, the Board is

empowered to decide ‘‘whether a record

constitutes an assassination record.’’ 44

U.S.C. 2107 note, Sec. 7(i)(2)(A).

Congress further made clear its intent

that the Board ‘‘issue guidance to assist

in articulating the scope or universe of

assassination records.’’ President John

F. Kennedy Assassination Records

Collection Act of 1992, S.Rep. 102–328,

102d Cong., 2d Sess. (1992) at 21.

In constructing the proposed guidance

set out here, the Board seeks to

implement congressional intent that the

JFK Collection contain ‘‘the most

comprehensive disclosure of records

related to the assassination of President

Kennedy.’’ Id. at 18. The Board is also

mindful of Congress’s instruction that

the Board apply a ‘‘broad and

encompassing’’ working definition of

‘‘assassination record’’ in order to

achieve the goal of assembling the

fullest historical record on this tragic

event in American history and on the

investigations that were undertaken in

the assassination’s aftermath. The Board

recognizes that many agencies have

already begun to organize and review

records responsive to the ARCA even

before the Board was appointed and

began its work. Nevertheless, the

Board’s aim is that this guidance will

aid in the ultimate assembly and public