Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Five Separate Changes

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]

RIN-0720-AA26

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); Five Separate Changes

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

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SUMMARY: This final rule addresses five separate changes to comply with

provisions affecting CHAMPUS. These changes will update this part to

include as a benefit, a screen to check for the level of lead in the

blood of an infant; to eliminate the implied statement that ambulance

services are covered only to, from, and between hospitals; to include

other forms of prescribed contraceptives by eliminating the reference

that limits prescribed contraceptives only to those taken orally; to

identify three additional Gulf Conflict groups eligible for the delay

in the increased deductible; and to establish lower limits on the

fiscal year catastrophic cap from $10,000 to $7,500 for all eligibles

except dependents of active duty personnel, whose limit remains at

$1,000.

EFFECTIVE DATE: This final rule is effective February 20, 1997 except

for the changes in section 199.4 which are listed below:

1. Paragraph (c)(3)(xi)(A)(7) is effective December 5, 1991;

2. Paragraph (e)(3)(i)(A)(3) is effective October 29, 1992;

3. Paragraph (f)(2)(i)(G) is effective on October 1, 1991; and

4. Paragraph (f)(10) is effective on October 1, 1992.

ADDRESSES: Office of the Civilian Health and Medical Program of the

Uniformed Services (OCHAMPUS), Program Development Branch, Aurora, CO

80045-6900.

FOR FURTHER INFORMATION CONTACT:

Margaret Brown, Program Development Branch, OCHAMPUS, telephone (303)

361-1181.

SUPPLEMENTARY INFORMATION: A proposed rule regarding these changes was

published in the Federal Register on March 21, 1995 (60 FR 14920). Our

responses to those comments received regarding the proposed rule may be

found in the review of comments section of this final rule.

32 CFR 199.4 lists Basic Program benefits including exclusions and

limitations. Paragraph (c) defines, in general terms, the scope of

reimbursable services provided by physicians and other authorized

individual professional providers; paragraph (e) extends benefits under

certain circumstances, to conditions and limitations that are subject

to applicable definitions, conditions, or exclusions that are set forth

in this or other sections of this part; and paragraph (f) identifies

the liabilities, in the form of cost-shares and deductibles, to be paid

by beneficiaries or sponsors.

Well-baby care: Paragraph (c)(3)(xi), provides for certain well-

baby care services for infants up to the age of two years. A paragraph

(c)(3)(xi)(A)(7) is added to list blood lead test as a benefit for

infants. This change is effective for services provided on or after

December 5, 1991.

Ambulance service: Ambulance services are covered between points

deemed to be medically necessary for the covered medical condition,

therefore, the restrictive language, ``to, from, and between

hospitals'' is removed from paragraph (d)(3)(v).

Family planning: Paragraph (e)(3) provides for a family planning

benefit. Paragraph (e)(3)(i)(A)(3) of this section allows benefits for

prescribed oral contraceptives. With the development of new methods of

contraception, prescribed contraceptives are no longer limited to those

taken orally. We have, therefore, amended that paragraph by removing

the word ``oral'' to expand the coverage accordingly.

Financial liability-deductibles: Under paragraph (f) of this

section, CHAMPUS beneficiaries and sponsors have some financial

responsibility when medical care is received from civilian sources.

Financial liability is imposed in order to encourage use of the

Uniformed Services direct medical care system whenever facilities and

services are available. Beneficiaries are responsible for payment of

certain deductibles and cost-sharing amounts in connection with

otherwise covered services and supplies. The cost-share and deductible

[[Page 59338]]

amounts are controlled by statute and subject to change by

congressional action. Previous legislation had deferred a statutory

increase in the deductible amount from April 1, 1991 to October 1,

1991, for dependents of active duty members who served in the Gulf

Conflict. The National Defense Authorization Act for Fiscal Year 1993

contains language which prompts a revision of paragraph (f)(2)(i)(G) of

this section to identify three new groups of Gulf Conflict

beneficiaries, besides the dependents of active duty members, eligible

for the delay in the increased deductibles, and to allow credit or

reimbursement of excess amounts inadvertently paid by those groups

subject to availability of appropriated funds.

Catastrophic loss: The National Defense Authorization Act for

Fiscal Years 1988 and 1989 (Pub. L. 100-180) amended Title 10, United

States Code and established catastrophic loss protection for CHAMPUS

beneficiaries on a government fiscal year basis. The law placed fiscal

year limits or catastrophic caps on beneficiary liability for cost-

shares and deductibles under the CHAMPUS Basic Program. After the

fiscal year cap is met by the beneficiary, the CHAMPUS-determined

allowable amounts for all covered services or supplies received under

the Basic Program are to be paid in full by CHAMPUS.

For dependents of active duty members, the maximum family liability

is $1,000 for deductibles and cost-shares based on allowed charges for

the Basic Program services and supplies received in a fiscal year. For

all other categories of beneficiary families, the previous fiscal year

cap of $10,000 under Public Law 100-180 has been reduced under the 1993

Defense Authorization Act (Pub. L. 102-484) to $7,500. This final rule

implements the law which reduces the fiscal year catastrophic loss

protection cap for all categories of beneficiaries other than those of

active duty dependents, effective for Basic Program services and

supplies received on or after October 1, 1992.

Review of Comments

As a result of the proposed rule, the following comments were

received from interested associations and agencies.

Comment: The Air Force Consultant for Pediatrics recommended that

the blood lead level screening should be extended to siblings above the

age of two years in cases where an infant tested positive on the

initial lead level screen.

Response: The inclusion of a lead level screening in the absence of

symptoms was promulgated by statute in 10 U.S.C. chapter 55, section

1077(a)(8), and covers only infants. Other necessary laboratory

services for all CHAMPUS eligibles are available through Chapter 4 of

DoD 6010.8-R, to confirm or establish suspected symptoms.

Comment: One comment suggested that we reconsider removing the

long-standing exclusion of aversion therapy for the treatment of

alcoholism as CHAMPUS currently reimburses less intrusive therapies.

Response: We based our intent to remove the long-standing exclusion

of aversion therapy on an assessment performed by the Agency for Health

Care Policy and Research. The assessment concluded that chemical

aversion conditioning is no less effective than other therapies for

alcoholism when it is provided following the failure of less intrusive

therapies. To be certain that the removal of the exclusionary language

was in the best interest of our beneficiaries, we performed a

literature search looking for well-controlled studies of clinically

meaningful endpoints, published in the referred medical literature that

would support that chemical aversion therapy was safe, effective and

comparable to current therapies. Failing to find such well-controlled

studies, we agree that the exclusion of chemical aversion therapy

should remain.

Summary of Regulatory Modifications

The following modifications were made as a result of suggestions

received during the public comment period:

(1) Paragraph (e)(3)(i)(A)(3) was amended to read, ``Prescription

contraceptives.''

(2) Several editorial comments were received. All of these comments

were adopted and incorporated into the final rule.

Regulatory Procedures: Executive Order 12866 requires that a

regulatory impact analysis be performed on any major rule. A ``major

rule'' is defined as one which would result in an annual effect on the

national 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 final rule is not a major rule under Executive Order 12866,

and it would not have a significant impact on a substantial number of

small entities. The changes set forth in this final rule are minor

revisions to the existing part. This rule does not impose information

collection requirements. Therefore, it does not need to be reviewed by

the Executive Office of Management and Budget under authority of the

Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520).

List of Subjects in 32 CFR Part 199

Claims, Handicapped, Health insurance, and Military personnel.

Accordingly, 32 CFR part 199 is amended as follows:

PART 199--[AMENDED]

1. The authority citation for part 199 continues to read as

follows:

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

2. Section 199.4 is amended by adding paragraph (c)(3)(xi)(A)(7);

by revising paragraph (e)(3)(i)(A)(3) and the first sentence of both

paragraphs (d)(3)(v) and (f)(2)(i)(G); and by adding paragraph (f)(10)

to read as follows:

Sec. 199.4 Basic program benefits.

* * * * *

(c) * * *

(3) * * *

(xi) * * *

(A) * * *

(7) Blood lead test. (Effective date December 5, 1991.)

* * * * *

(d) * * *

(3) * * *

(v) Ambulance. Civilian ambulance service is covered when medically

necessary in connection with otherwise covered services and supplies

and a covered medical condition.

* * * * *

(e) * * *

(3) * * *

(i) * * *

(A) * * *

(3) Prescription contraceptives.

* * * * *

(f) * * *

(2) * * *

(i) * * *

(G) Notwithstanding the dates specified in paragraphs (f)(2)(i)(A)

and (f)(B)(2)(i) of this section in the case of dependents of active

duty members of rank E-5 or above with Persian Gulf Conflict service,

dependents of service members who were killed in the Gulf, or who died

subsequent to Gulf service, and of members who retired prior to October

1, 1991, after having served in the Gulf War, the deductible shall be

the amount specified in paragraph (f)(2)(i)(A) of this section for care

[[Page 59339]]

rendered prior to October 1, 1991, and the amount specified in

paragraph (f)(2)(i)(B) of this section for care rendered on or after

October 1, 1991.

* * * * *

(10) Catastrophic loss protection for basic program benefits.

Fiscal year limits, or catastrophic caps, on the amounts beneficiaries

are required to pay are established as follows:

(i) Dependents of active duty members. The maximum family liability

is $1,000 for deductibles and cost-shares based on allowable charges

for Basic Program services and supplies received in a fiscal year.

(ii) All other beneficiaries. For all other categories of

beneficiary families (including those eligible under CHAMPVA) the

fiscal year cap is $10,000.

(iii) Payment after cap is met. After a family has paid the maximum

cost-share and deductible amounts (dependents of active duty members

$1,000 and all others $10,000), for a fiscal year, CHAMPUS will pay

allowable amounts for remaining covered services through the end of

that fiscal year.

Note to paragraph (f)(10): Under the Defense Authorization Act

for Fiscal Year 1993, the cap for beneficiaries other than

dependents of active duty members was reduced from $10,000 to $7,500

on October 1, 1992. The cap remains at $1,000 for dependents of

active duty members.

* * * * *

Dated: November 14, 1996.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 96-29571 Filed 11-21-96; 8:45 am]

BILLING CODE 5000-04-M