Civilian health and medical program of uniformed services (CHAMPUS): TRICARE program— network providers; financial protection,

[Federal Register: October 21, 1998 (Volume 63, Number 203)]

[Rules and Regulations]

[Page 56081-56082]

From the Federal Register Online via GPO Access [wais.access.gpo.gov]

[DOCID:fr21oc98-2]

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720-AA46

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE Prime Balance Billing

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

SUMMARY: This final rule establishes financial protections for TRICARE Prime enrollees in limited circumstances when they receive covered services from a non-network provider.

DATES: This rule is effective March 16, 1998.

ADDRESSES: TRICARE Management Activity, Program Development Branch, Aurora, CO 80045-6900.

FOR FURTHER INFORMATION CONTACT: Kathleen Larkin, Office of the Assistant Secretary of Defense (Health Affairs)/TRICARE Management Activity, telephone (703) 681-1745.

Questions regarding payment of specific claims under the CHAMPUS allowable charge method should be addressed to the appropriate TRICARE/ CHAMPUS contractor.

SUPPLEMENTARY INFORMATION:

1. Overview of the Rule

   This final rule implements section 731 of the FY 1996 National Defense Authorization Act and section 711 of the FY 1997 National Defense Authorization Act which modified 10 U.S.C. 1079(h) to provide protections for TRICARE Prime enrollees from balance billing situations in limited circumstances. Balance billing can otherwise occur when a provider bills a TRICARE Prime enrollee an actual charge in excess of the allowable amount. Each regional TRICARE managed care support contractor is required to establish a network of civilian providers in areas where TRICARE Prime (the enrollment option) is offered. As is standard for Health Maintenance Organizations, enrollees in TRICARE Prime receive care from network providers. But on occasion, such as when a network provider is not available and they are referred to a non-network provider, or in emergencies, they may receive covered services from non-network providers. This rule provides protection in these situations; TRICARE Prime enrollees will be responsible for their copayments, but not for balance billing by non-participating providers.

   Public Comments. The interim final rule was published in the Federal Register on February 13, 1998. We received one comment letter. We thank the commenter who approved of the Department's steps taken to further protect TRICARE Prime beneficiaries from the uncertainties of balance billing by non-network providers. The commenter also suggested that we more clearly define balance billing protections for ``out-of- network referrals'' and more specifically state our definition of ``providers'' with respect to references to non-participating providers.

   Response. The rule is designed to limit TRICARE Prime beneficiary liability when properly referred by the primary care manager or Health Care Finder for authorized care outside of the TRICARE network in limited instances where there is a lack of network providers, or there is a mistaken referral to an out-of-network provider. Emergency care requires no prior authorization; however, balance billing protections also apply to TRICARE Prime beneficiaries who receive care in an emergency setting from non-network providers. With respect to the request to further define the term ``providers,'' the definition is contained in 199.2 of this part and is generally considered to be a hospital, or other institutional provider, a physician, or other individual professional provider, or other provider of services or supplies.

   Provisions of Final Rule. The final rule is consistent with the interim final rule.

2. Rulemaking 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

   [[Page 56082]]

   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.

   The final rule will not impose additional information collection requirements on the public under the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35).

   PART 199--[AMENDED]

   1. The authority citation for Part 199 continues to read as follows:

      Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.

   2. Section 199.14 is amended by adding paragraph (h)(1)(i)(D) to read as follows:

      Sec. 199.14 Provider reimbursement methods.

      * * * * *

      (h) Reimbursement of Individual Health Care Professionals and Other Non-Institutional Health Care Providers. * * *

      (1) Allowable charge method. * * *

      (i) Introduction. * * *

      (D) Special rule for TRICARE Prime Enrollees. In the case of a TRICARE Prime enrollee (see section 199.17) who receives authorized care from a non-participating provider, the CHAMPUS determined reasonable charge will be the CMAC level as established in paragraph (h)(1)(i)(B) of this section plus any balance billing amount up to the balance billing limit as referred to in paragraph (h)(1)(i)(C) of this section. The authorization for such care shall be pursuant to the procedures established by the Director, OCHAMPUS (also referred to as the TRICARE Support Office). * * * * *

      Dated: October 15, 1998. L.M. Bynum, Alternate Federal Register Liaison Officer, Department of Defense.

      [FR Doc. 98-28140Filed10-20-98; 8:45 am]

      BILLING CODE 5000-04-M