[Federal Register: June 17, 1999 (Volume 64, Number 116)]
[Proposed Rules]               
[Page 32451]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr17jn99-41]                         


[[Page 32451]]

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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]
BILLING CODE 1001-10-M