Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Double Coverage

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720-AA50

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); Double Coverage

AGENCY: Office of the Secretary, DOD.

ACTION: Proposed rule.

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SUMMARY: This proposed rule clarifies our double coverage policy for

non-institutional claims for beneficiaries with primary health

insurance. TRICARE network, non-network but participating, and non-

participating providers are all reimbursed differently under current

procedures. This has had the unintended effect of discouraging TRICARE

network participation since non-network but participating providers

receive the most favorable treatment with respect to double coverage

calculations. The Department proposes to revise double coverage

reimbursement calculations by reimbursing all providers up to 100

percent of the CHAMPUS Maximum Allowable Charge after the primary

health insurance has paid or 115 percent for nonparticipating

providers.

DATES: Public comments must be received by August 16, 1999.

ADDRESSES: TRICARE Management Activity (TMA), Program Development

Branch, Aurora, CO 80045-6900.

FOR FURTHER INFORMATION CONTACT: Lt. Col. 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:

I. Overview of the Rule

This proposed rule clarifies our double coverage policy for non-

institutional claims for beneficiaries with primary health insurance.

TRICARE network, non-network but participating, and non-participating

providers are all reimbursed differently under current procedures and

this has had the unintended effect of discouraging TRICARE network

participation since non-network but participating providers receive the

most favorable treatment with respect to double coverage calculations.

The Department proposes to revise double coverage reimbursement

calculations by reimbursing all providers up to 100 percent of the

CHAMPUS Maximum Allowable Charge after the primary health insurance has

paid or up to 115 percent for nonparticipating providers.

II. 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 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 proposed rule will not impose additional information collection

requirements on the public under the Paperwork Reduction Act of 1995

(44 U.S.C. Chapter 55).

A discussion of the major issues received by public comments will

be included with the issuance of the final rule, anticipated

approximately 60 days after the end of the comment period.

List of Subjects in 32 CFR Part 199

Claims, Health insurance, Individuals with disabilities, 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 199.8 is amended by adding a new paragraph (c)(4) to

read as follows:

Sec. 199.8 Double coverage.

* * * * *

(c) Application of double coverage provisions. * * *

(4) Effect of Network Participation. For non-institutional claims,

providers receive TRICARE/CHAMPUS payment up to 100 percent of the CMAC

(established under Sec. 199.14(h)(1)(i)(B)) after the primary health

insurance has paid. For nonparticipating providers, CHAMPUS will pay

the difference between the amount paid by the other health insurance

and the 115 percent balance billing limit established in

Sec. 199.14(h)(1)(i)(C).

* * * * *

Dated: June 10, 1999.

L.M. Bynum,

Alternate Federal Register Liaison Officer, Department of Defense.

[FR Doc. 99-15185 Filed 6-16-99; 8:45 am]

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