Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Individual Case Management

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]

RIN 0720-AA30

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); Individual Case Management

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

-----------------------------------------------------------------------

SUMMARY: This final rule implements provisions of the 1993 National

Defense Authorization Act which allows the Secretary of Defense to

establish a case management program for CHAMPUS beneficiaries with

extraordinary medical or psychological disorders and to allow such

beneficiaries medical or psychological services, supplies, or durable

medical equipment excluded by law or regulation as a TRICARE/CHAMPUS

benefit. Under this program, waiver of benefit limits or exclusions to

the basic TRICARE/CHAMPUS program may be authorized for beneficiaries

when the provision of such services or supplies is cost effective and

clinically appropriate, as compared to historical or projected TRICARE/

CHAMPUS utilization of health care services. Such waivers will also

provide families in crisis time for transition to other sources of

support when TRICARE/CHAMPUS benefits have been exhausted. This case

management program is designed to provide a cost-effective plan of care

by targeting appropriate resources to meet the individual needs of the

beneficiary.

DATED: March 15, 1999.

FOR FURTHER INFORMATION CONTACT: CDR Tracy Malone, TRICARE Management

Activity, (703) 681-1745.

SUPPLEMENTARY INFORMATION: The Civilian Health and Medical Program of

the Uniformed Services (CHAMPUS) supplements the availability of health

care in military hospitals and clinics.

Statutory Authority

The case management program is based on the authority of 10 U.S.C.

1079(a)(17), which provides:

The Secretary of Defense may establish a program for the

individual case management of a person covered by this section or

section 1086 of this title who has extraordinary medical or

psychological disorders and, under such a program, may waive benefit

limitations contained in paragraph (5) and (13) of this subsection

or section 1077(b)(1) of this title and authorize the payment for

comprehensive home health care services, supplies, and equipment if

the Secretary determines that such a waiver is cost effective and

appropriate.

Statutory and Legislative History

This provision was enacted in 1992 by Congress as section 704 of

the National Defense Authorization Act for Fiscal Year 1993, Pub. L.

102-484, Oct. 23, 1992. It is substantively identical to a provision

recommended by the Department of Defense in a report to Congress

submitted a few months earlier by the Assistant Secretary of Defense

(Health Affairs) and entitled, ``Report to Congress: Comprehensive Home

Health Care as a CHAMPUS Benefit.'' The 1992 Report to Congress and

statutory

[[Page 7085]]

enactment were the outgrowth of a series of legislative provisions

dating back to 1985, when Congress directed the Department of Defense

to ``conduct a pilot test project of providing home health care'' to

certain CHAMPUS beneficiaries. Department of Defense Appropriations

Act, 1986, PUb. L. 99-190, Section 8084. A similar provision was

enacted a year later. Department of Defense Appropriations Act, 1987,

Pub. L. 99-591, Section 9074.

In 1987, Congress directed the Department of Defense to establish a

second, expanded demonstration project. The statute required DoD to

``conduct an expanded pilot project of providing home Health care as

part of an individualized case-managed range of benefits that may

reasonably deviate from otherwise payable types, amounts and levels of

care'' for patients ``with exceptionally serious, long-range, costly

and incapacitating physical or mental conditions.'' Department of

Defense Appropriations Act, 1988, Pub. L. 100-202, Section 8071. A

similar provision was enacted the following year. Department of Defense

Appropriations act, 1989, Pub. L. 100-463, Section 8058. Based on these

two demonstration projects, in 1991, the House and Senate

Appropriations Committees directed the Department of Defense to

investigate the possibility of including comprehensive home health care

as a CHAMPUS benefit and report to Congress on its findings. H. Rept.

No. 102-95, p. 89; S. Rept. No. 102-154, p. 37. The resulting report to

Congress led to enactment of section 1079(a)(17), which is being

implemented by this final rule.

In enacting this provision, Congress took another major step to

direct and allow DoD to, in the words of the previous statute,

``reasonably deviate from'' the normal, restrictive statutory coverage

for health services for patients with ``exceptionally serious, long-

range, costly and incapacitating'' conditions. Pub. L. 100-202, Section

8071. A dominant statutory restriction affecting health care for such

patients is the statutory exclusion of ``domiciliary or custodial

care.'' 10 U.S.C. Section 1077(b)(1). This exclusion is made applicable

to CHAMPUS by the introductory text of 10 U.S.C. Section 1079(a) and is

implemented in its most important respect for CHAMPUS by regulations at

32 CFR sections 199.2 and 199.4(e)(12).

These regulations are well known and have been the subject of

litigation from time to time in recent years, including a widely

circulated, adverse District of Columbia Court of Appeals decision in

1987. Barnett v. Weinberger, 818 F.2d 953 (D.C. Cir. 1987); see also

Fiduk v. Montgomery, No. 3:96-CV-409 RM (N.D. Ind., Mar. 27, 1998). The

regulations are also well known to Congress, which has moved to create

reasonable exceptions to the statutory and regulatory exclusion of

custodial care.

This was, in fact, a primary reason Congress established the case

management program by enacting section 1079(a)(17), and why the statute

expressly authorizes a waiver of the custodial care exclusion section

of 1077(b)(1) under the case management program when ``the Secretary

determines that such a waiver is cost-effective and appropriate.'' This

congressional purpose was explicitly stated in the explanation of the

members of the Conference Committee that agreed to the final version of

the section 1079(a)(17). The Conference Report explains:

The conferees believe the case management program is the best

approach to address the need of beneficiaries for whom regular

CHAMPUS benefits are limited by the custodial care exclusion and

other restrictions contained in the Law and CHAMPUS regulations.

H. Conf. Rept. 102-966, 102d Cong., 2d Sess., 719. The Department of

Defense agrees with Congress that the case management program is the

best approach to address the custodial care issue. Culminating a series

of statutory enactments dating back to 1985, the case management

program will allow CHAMPUS to assist beneficiaries who need long-term

custodial care to transition to programs, which, unlike CHAMPUS,

provide long-term custodial care. This was a principal objective of

Congress in enacting the case management program and is a principal

focus of the regulatory implementation of the program.

Case Management

Case management is used in many TRICARE/CHAMPUS settings to

organize acute and outpatient health care services. This final rule

focuses specifically on the use of case management to address complex

health care needs of catastrophically ill or injured beneficiaries, It

offers a system for organizing multidisciplinary services often

required for management of extraordinary medical or psychological

disorders and provides a bridge between acute and long term care

services generally excluded under TRICARE/CHAMPUS. It is designed to

improve quality of care, control costs, and support patients and

families through catastrophic medical events.

The TRICARE/CHAMPUS individual case management program seeks to

achieve cost effective quality health care by considering alternatives

to current TRICARE/CHAMPUS benefit limitations or exclusions that, when

provided, are cost effective and clinically appropriate. Section 199.4

provides, as a case management related benefit, authority for services

or supplies that would otherwise be excluded as non-medical or

duplicate durable equipment, custodial care, or domiciliary care.

Waivers of benefit limits will be approved and coordinated by case

managers and may include, but are not limited to, services or supplies

such as home healthcare, medical supplies, back-up durable medical

equipment, extended skilled nursing care and home health aides.

Services or supplies provided in the home by other than already

recognized providers of care must fall under the auspices of a home

health care agency which has been either authorized by Medicare or

licensed by the State in which it operates. Providers of other services

as a result of such waivers must be licensed or certified by the

prevailing authority for that service. Section 199.2 revises the

definition of ``treatment plan'' to include inpatient and outpatient

care and adds definitions for waiver of benefit limits, case

management, case manager, case management multidisciplinary team,

extraordinary condition, and primary caregiver.

Eligibility

Although participation in the TRICARE/CHAMPUS case management

program is voluntary, certain conditions must exist for a beneficiary

to be eligible for participation. These conditions are: (1) The

presence of an extraordinary medical condition which has resulted in

high utilization of TRICARE/CHAMPUS resources, (2) the cost

effectiveness of providing the alternative services or supplies, (3)

the willingness of the beneficiary to participate, and (4) a competent

patient or the presence of a primary caregiver in the home when the

services provided include home health care.

Custodial Care

We expect patients and their families will require varying levels

of support and time to stabilize following a catastrophic illness. Case

managers will determine on a case-by-case basis the need and

appropriate amount of time for temporary waivers to custodial care

exclusions. Waivers to custodial care exclusions will be subject to a

lifetime maximum of 365 days and must be cost effective when compared

to available covered services. Such waivers are

[[Page 7086]]

designed to allow families sufficient opportunity for transition to

alternative funding sources and services.

Prior Authorization

Prior authorization from case managers will be required before the

delivery of any case managed benefits. Because eligibility for a waiver

of benefit limits/exclusions is based on an in depth assessment of

medical needs, as well as the cost effectiveness and clinical

appropriateness of alternate services, any services provided absent

prior authorization will not be covered by TRICARE/CHAMPUS.

Retrospective requests for coverage under this program will not be

authorized.

Military Health System Resource Management

To ensure cost efficient as well as cost-effective use of

resources, the Department of Defense requires establishment of case

management programs, as described in this rule, in all TRICARE/CHAMPUS

managed care support contracts. Managed care support contractors will

be authorized to make available case management services to Military

Medical Treatment Facilities (MTFs). MTFs will be provided the

opportunity to refer potential candidates to the appropriate TRICARE/

CHAMPUS case manager. Where possible, MTFs will provide care and

services or supplies in support of regional case management programs.

Beneficiary Acknowledgment

Case management is a collaborative process involving the case

manager, beneficiary, primary caregiver, and professional health care

providers. For case management to be successful, the beneficiary and

primary caregiver must participate in the process and be aware of and

agree with the requirements of the program. To document the

understanding of their roles, rights and responsibilities, a standard

acknowledgment, signed by the beneficiary (or representative) and the

primary caregiver, will be required prior to the start of case

management services.

Denial/Appeals Process

Beneficiaries and/or providers who dispute a determination

regarding medical appropriateness or necessity of proposed services or

treatment under the case management program might appeal those

decisions. The existing Appeal and Hearing Procedures outlined in 32

CFR section 199.10 will be used for these cases.

CHAMPUS HHC/HHC-CM Demonstration

The 1986 Home Health Care and 1988 Home Health Care-Case Management

Demonstration projects were developed to test whether case management,

coupled with home healthcare benefits, could reduce medical costs and

improve services to CHAMPUS beneficiaries. Under the 1986

demonstration, case management services were limited to beneficiaries

who, in the absence of case managed home health care, would have

remained hospitalized. The 1988 program was less restrictive and no

longer required case management services only as a substitute for

continued hospitalization. The General Accounting Office (GAO)

addressed the effectiveness of methods for identifying potentially

eligible beneficiaries and establishing the clinical appropriateness

and cost-effectiveness of services provided. In its report, ``DEFENSE

HEALTH CARE: Further Testing and Evaluation of Case Managed Home Care

Is Needed,'' the GAO identified a need for stronger cost controls and

improved targeting of potential candidates before implementation of a

permanent case management program under CHAMPUS. With the GAO's

recommendations and observations in mind, the Department is

establishing this TRICARE/CHAMPUS case management program which

provides clinically appropriate, cost effective alternatives to covered

services, organizes complex or multidisciplinary services, and allows

families a transition period to arrange for long term care not provided

under TRICARE/CHAMPUS. The organized delivery of services for these

patients is designed to improve continuity and quality of care, lower

overall costs to the Department, and result in better quality of life.

Public Comments

The proposed rule was published in the Federal Register Thursday,

January 4, 1996, (61 FR 339). Significant effort has been undetaken in

the ensuing months to resolve several difficult issues, primarily

relating to long term care. Providing a reasonable safety net for

beneficiaries who require custodial or long-term services continues to

be a difficult challenge for the health care industry. With this

management program, the Department is attempting to strike a delicate

balance between its primary mission of medical readiness and

appropriate support for medical system beneficiaries when they are most

vulnerable.

We received seven comment letters, all of which were from providers

and provider associations. Several commentors were quite detailed,

providing helpful insights and the benefit of many years' experience.

We thank those who took the time to provide suggestions, many of which

have been incorporated into this final rule. Significant items raised

by commentors and our analysis of the comments are summarized below.

1. Access to Case Management Benefits

Several commentors expressed concern that the proposed rule limited

case management services to catastrophically ill or injured patients

and placed undue emphasis on the use of inpatient acute services as a

prerequisite for this program. They point out that case management is

widely used in private sector health plans to enhance the cost

effective delivery of quality care for a wide range of patients, not

just those facing catastrophic events. We are aware that case

management has many applications, some of which are already required

and used by the Department in both military medical treatment

facilities and by TRICARE Managed Care Support contractors. The broad

application of case management in these settings requires no new

regulatory authority. This final rule specifically addresses the unique

circumstances of catastrophic illness and provides new authority to

waive benefit limitations/exclusions when there are more cost

effective, clinically appropriate alternatives to higher intensity

covered services. We agree that use of impatient services as a

prerequisite for participation in this case management program

inappropriately excludes opportunities for better management of certain

complex of catastrophic illnesses. We have clarified eligibility

requirements to extend case management benefits to individuals who have

demonstrated extraordinarily high TRICARE/CHAMPUS resource utilization,

regardless of whether or not treatment has included an acute inpatient

stay.

2. Quality and Outcomes

One provider expressed concern that there was insufficient emphasis

on quality of care, quality of life, and outcomes in the proposed rule.

While cost effectiveness is an important requirement for application of

the new waiver authority described in this rule, it does not take

precedence over quality of care. Proposed treatment provided as part of

this program must be clinically appropriate, high quality and cost

effective. In addition to outcome measures already used by DoD,

specific

[[Page 7087]]

performance measures for this program will be developed and included in

more detailed operational guidance.

3. Primary Cargiver

We received many comments on our requirement for the presence of a

primary caregiver as a condition for participation in this program.

This requirement was based on the idea that individuals who required a

monitored or controlled environment could not safely move outside

institutional care without the presence of a primary caregiver, most

likely a family member. We reasoned that primary caregivers would be

essential components in this transfer, not only to assure the patient's

safety, but also to participate in the effective implementation of a

case management treatment plan. Commentors presented several scenarios

in which individuals who would benefit from this program may not have a

primary caregiver as described in the proposed rule. We agree with

these comments and have modified the eligibility requirement to state

there must be a patient capable of self-support or be assisted by a

primary caregiver. We have retained the requirement for presence of a

primary caregiver when the program includes a waiver for provision of

custodial care services in the home.

4. Program Operation

We received numerous detailed comments and suggestions about

specific operation of the proposed case management program, including

requirements and contents for treatment plans, reporting requirements

and methods for transition from case management services, These are

detailed program elements, which will be included in operational

policies following publication of this rule.

5. Case Management for Extraordinary Psychological Illnesses

Several commentors expressed concern that the proposed rule did not

seem to allow exceptions to benefit exclusions for treatment of

catastrophic physiological illness. This is not the case. The rule

proposes case management services and associated appropriate relief

from otherwise excluded services for both medical and psychological

disorders. Exceptions to benefit limitations must be medically and/or

psychologically appropriate and must be cost effective when compared to

available covered services.

6. Qualifications of Case Managers

We received comments from a provider association regarding our

requirement that case managers be either registered nurses or licensed

social workers with at least two-year case management experience. The

commentor believed this requirement should be broadened to allow other

professional specialties, such as physicians or psychologists, to act

as case managers. Although it is not typical practice for health plans

to employ physicians, psychologists, or other similarly trained

professionals as case managers; we have no objection to their acting in

this capacity. Accordingly, we have modified the case manager

definition to allow physicians and psychologists with at least two

years experience in case management to act as case managers for TRICARE

programs. This rule focuses on care of catastrophic illness or injury

that requires both basic knowledge of medical and psychological

disorders and experience in coordinating services for seriously ill

beneficiaries. Because of this, we do not believe it appropriate to

reduce professional qualifications from those proposed.

Regulatory Procedures

Executive Order (EO) 12866 requires that a comprehensive regulatory

impact analysis be performed on any economically significant regulatory

action, defined as one which would result in an annual effect of $100

million or more on the national economy or which would 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 rule is has been reviewed and approved by OMB and under EO

12866. In addition, we certify that this rule will not significantly

affect a substantial number of small entities.

Paperwork Reduction Act

This rule, as written, imposes no burden as defined by the

Paperwork Reduction Act of 1995. If however, any program implemented

under this rule causes such a burden to be imposed, approval therefore

will be sought of the Office of Management and Budget in accordance

with the Act, prior to implementation.

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 199.2(b) is amended by adding new definitions in

alphabetical order:

Sec. 199.2 Definitions.

* * * * *

Case management. Case management is a collaborative process which

assesses, plans, implements, coordinates, monitors, and evaluates the

options and services required to meet an individual's health needs,

using communication and available resources to promote quality, cost

effective outcomes.

Case managers. A licensed registered nurse, licensed clinical

social worker, licensed psychologist or licensed physician who has a

minimum of two (2) years case management experience.

Extraordinary condition. A complex clinical condition, which

resulted, or is expected to result, in extraordinary TRICARE/CHAMPUS

costs or utilization, based on thresholds established by the Director,

OCHAMPUS, or designee.

Primary caregiver. An individual who renders to a beneficiary

services to support the essentials of daily living (as defined in

Sec. 199.2) and specific services essential to the safe management of

the beneficiary's condition.

Waiver of benefit limits. Extension of current benefit limitations

under the Case Management Program, of medical care, services, and/or

equipment, not otherwise a benefit under the TRICARE/CHAMPUS program.

3. Section 199.4 is amended by adding new paragraphs (e)(20) and

(i) as follows:

Sec. 199.4 Basic program benefits.

* * * * *

(e) Special benefit information.

* * *

(20) Case management services. As part of case management for

beneficiaries with complex medical or psychological conditions, payment

for services or supplies not otherwise covered by the basic CHAMPUS/

TRICARE program may be authorized when they are provided in accordance

with Sec. 199.4(i). Waiver of benefit limits/exclusions to the basic

CHAMPUS/TRICARE program may be cost shared where it is demonstrated

that the absence of such services would result in the exacerbation of

an existing extraordinary condition, as defined in Sec. 199.2, to the

extent that frequent or

[[Page 7088]]

extensive services are required; and such services are a cost effective

alternative to the Basic CHAMPUS program.

* * * * *

(i) Case management program. (1) In general. Case management, as it

applies to this program, provides a collaborative process among the

case manager, beneficiary, primary caregiver, professional health care

providers and funding sources to meet the medical needs of an

individual with an extraordinary condition. It is designed to promote

quality and cost-effective outcomes through assessment, planning,

implementing, monitoring and evaluating the options and services

required. Payment for services or supplies limited or not otherwise

covered by the basic TRICARE/CHAMPUS program may be authorized when

they are provided in accordance with paragraph (i) of this section.

Waiver of benefit limits/exclusions may be cost-shared where it is

demonstrated that the absence of such services would result in the

exacerbation of an existing extraordinary condition, as defined in

Sec. 199.2, to the extent that such services are a cost-effective

alternative to the basic TRICARE/CHAMPUS program.

(2) Applicability of case management program. A CHAMPUS eligible

beneficiary may participate in the case management program if he/she

has an extraordinary condition, which is disabling and requires

extensive utilization of TRICARE resources. The medical or

psychological condition must also:

(i) Be contained in the latest revision of the International

Classification of Diseases Clinical Modification, or the Diagnostic and

Statistical Manual of Mental Disorders;

(ii) Meet at least one of the following:

(A) Demonstrate a prior history of high CHAMPUS costs in the year

immediately preceding eligibility for the case management program; or

(B) Require clinically appropriate services or supplies from

multiple providers to address an extraordinary condition; and

(iii) Can be treated more appropriately and cost effectively at a

less intensive level of care.

(3) Prior authorization required. Services or supplies allowable as

a benefit exception under this Section shall be cost-shared only when a

beneficiary's entire treatment has received prior authorization through

an individual case management program.

(4) Cost effective requirement. Treatment must be determined to be

cost effective by comparison to alternative treatment that would

otherwise be required or when compared to existing reimbursement

methodology. Treatment must meet the requirements of appropriate

medical care as defined in Sec. 199.2.

(5) Limited waiver of exclusions and limitations. Limited waivers

of exclusions and limitations normally applicable to the basic program

may be granted for specific services or supplies only when a

beneficiary's entire treatment has received prior authorization through

the individual case management program described in paragraph (i) of

this section. The Director, OCHAMPUS may grant a patient-specific

waiver of benefit limits for services or supplies in the following

categories, subject to the waiver requirements of this section.

(i) Durable equipment. The cost of a device or apparatus which does

not qualify as Durable Medical Equipment (as defined in Sec. 199.2) or

back-up durable medical equipment may be shared when determined by the

Director, OCHAMPUS to be cost-effective and clinically appropriate.

(ii) Custodial care. The cost of services or supplies rendered to a

beneficiary that would otherwise be excluded as custodial care (as

defined in Sec. 199.2) may be cost-shared for a maximum lifetime period

of 365 days when determined by the Director, OCHAMPUS, to be cost

effective and clinically appropriate. To qualify for a waiver of

benefit limits of custodial care, the patient must meet all eligibility

requirements of paragraph (i) of this section, including that the

absence of the waived services would result in the exacerbation of an

existing extraordinary condition. In addition:

(A) The proposed treatment must be cost effective and clinically

appropriate as determined by the individual case manager. For example,

the treatment would be determined to be cost effective by comparison to

alternative care that would otherwise be required or when compared to

existing reimbursement methodology.

(B) For patients receiving care at home, there must be a primary

caregiver or the patient is capable of self-support.

(iii) Domiciliary care. The cost of services or supplies rendered

to be a beneficiary what would otherwise be excluded as domiciliary

care (as defined in Sec. 199.2) may be shared when determined by the

Director, OCHAMPUS to be cost effective and clinically appropriate.

Waivers for domiciliary care are subject to the same requirements as

paragraphs (i)(5)(ii) of this section.

(iv) In home services. The cost of the following in-home services

may be shared when determined by the Director, OCHAMPUS to be cost

effective and clinically appropriate: nursing care, physical,

occupational, speech therapy, medical social services, intermittent or

part-time services of a home health aide, beneficiary transportation

required for treatment plan implementation, and training for the

beneficiary and primary caregiver sufficient to allow them to assume

all feasible responsibility for the care of the beneficiary that will

facilitate movement of the beneficiary to the least resource-intensive,

clinically appropriate setting. (Qualifications for home health aides

shall be based on the standards at 42 CFR 848.36.)

(6) Case management acknowledgment. The beneficiary, or

representative, and the primary caregiver shall sign a case management

acknowledgment as a prerequisite to prior authorization of case

management services. The acknowledgment shall include, in part, all of

the following provisions:

(i) The right to participate fully in the development and ongoing

assessment of the treatment;

(ii) That all health care services for which TRICARE/CHAMPUS cost

sharing is sought shall be authorized by the case manager prior to

their delivery;

(iii) That there are limitations in scope and duration of the

planned case management treatment, including provisions to transition

to other arrangements; and

(iv) The conditions under which case management services are

provided, including the requirement that the services must be cost

effective and clinically appropriate;

(v) That a beneficiary's participation in the case management

program shall be discontinued for any of the following reasons:

(A) The loss of TRICARE/CHAMPUS eligibility;

(B) A determination that the services or supplies provided are not

cost effective or clinically appropriate;

(C) The beneficiary, or representative, and/or primary caregiver,

terminates participation in writing;

(D) The beneficiary and/or primary caregiver's failure to comply

with requirements in this paragraph (i); or

(E) A determination that the beneficiary's condition no longer

meets the requirements of participation as described in paragraph (i)

of this section.

(7) Other administrative requirements. (i) Qualified providers of

services or items not covered under the basic

[[Page 7089]]

program, or who are not otherwise eligible for TRICARE/CHAMPUS

authorized status, may be authorized for a time-limited period when

such authorization is essential to implement the planned treatment

under case management. Such providers must not be excluded or suspended

as a CHAMPUS provider, must hold Medicare or state certification or

licensure appropriate to the service, and must agree to participate on

all claims related to the case management treatment.

(ii) Retrospective requests for authorization of waiver of benefit

limits/exclusions will not be considered. Authorization of waiver of

benefit limits/exclusions is allowed only after all other options for

services or supplies have been considered and either appropriately

utilized or determined to be clinically inappropriate and/or not cost-

effective.

(iii) Experimental or investigational treatment or procedures shall

not be cost-shared as an exception to standard benefits under this

part.

(iv) TRICARE/CHAMPUS case management services may be provided by

contractors designated by the Director, OCHAMPUS.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 99-3441 Filed 2-11-99; 8:45 am]

BILLING CODE 5000-04-M