[Federal Register: February 13, 1998 (Volume 63, Number 30)] [Rules and Regulations] [Page 7287-7288] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr13fe98-8] ======================================================================= ----------------------------------------------------------------------- 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: Interim final rule. ----------------------------------------------------------------------- SUMMARY: This interim final rule establishes financial protections for TRICARE Prime enrollees in limited circumstances when they receive covered services from a non-network provider. This rule is being published to provide protection for TRICARE Prime enrollees. DATES: This rule is effective March 16, 1998. Public comments must be received by April 14, 1998. ADDRESSES: TRICARE Support Office (TSO), Program Development Branch, Aurora, CO 80045-6900. FOR FURTHER INFORMATION CONTACT: Kathleen Larkin, 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 TRICARE/ CHAMPUS contractor. SUPPLEMENTARY INFORMATION: I. Overview of the Rule This interim 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. 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, 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. 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. It has determined that this is not a significant regulatory action. The interim final rule will not impose additional information collection requirements on the public under the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 55). This rule is being issued as an interim final rule, with comment period, as an exception to our standard practice of soliciting pubic comments prior to issuance. The Assistant Secretary of Defense (Health Affairs) has determined that following the standard practice in this case would be impracticable, unnecessary, and contrary to the pubic interest. This determination is based on several factors. First, this change directly implements a statutory amendment enacted by Congress expressly for this purpose. (See House Conference Report 104-724, p. 762, and House Report 104-563, p. 318) Second, this rule implements the statutory policy without embellishment. The rule simply implements the unambiguous Congressional policy of adjusting TRICARE/CHAMPUS payment rates to protect Prime enrollees when receiving authorized care for nonparticipating providers. Third, implementation of the statutory amendment, enacted September 23, 1996, has already been substantially delayed because of a separate statutory provision (section 8008 of the Department of Defense Appropriations Act), which expired September 30, 1997, and a further delay is unwarranted. Fourth, TRICARE Prime is a major ``quality of life'' program of the Department of Defense. Its success is of great importance to maintaining adequate retention rates of military personnel and, thus, the conduct of the military affairs function of the United States. Fifth, the unexpected imposition of balance billing requirements on TRICARE prime enrollees receiving authorized care has been voiced as a major complaint, undermining beneficiary trust in commitments made to Prime enrollees and ultimately the success of the TRICARE initiative. Public comments are invited. All comments will be carefully considered. A discussion of the major issues received by public comments will be included with the issuance of the permanent 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, Reporting and recordkeeping requirements. 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 199.14 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. * * * [[Page 7288]] (1) Introduction. * * * (D) Special rule for TRICARE Prime Enrollees. In the case of a TRICARE Prime enrollee (see Sec. 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: February 6, 1998. L.M. Bynum, Alternate Federal Register Liaison Officer, Department of Defense. [FR Doc. 98-3502 Filed 2-12-98; 8:45 am] BILLING CODE 5000-04-M