[Code of Federal Regulations]
[Title 32, Volume 2]
[Revised as of July 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 32CFR199.16]

[Page 316-318]
 
                       TITLE 32--NATIONAL DEFENSE
 
        CHAPTER I--OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED)
 
PART 199_CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES 
 
Sec. 199.16  Supplemental Health Care Program for active duty members.

    (a) Purpose and applicability. (1) The purpose of this section is to 
implement, with respect to health care services provided under the 
supplemental health care program for active duty members of the 
uniformed services, the provision of 10 U.S.C. 1074(c). This section of 
law authorizes DoD to establish for the supplemental care program the 
same payment rules, subject to appropriate modifications, as apply under 
CHAMPUS.
    (2) This section applies to the program, known as the supplemental 
care program, which provides for the payment by the uniformed services 
to private sector health care providers for health care services 
provided to active duty members of the uniformed services. Although not 
part of CHAMPUS, the supplemental care program is similar to CHAMPUS in 
that it is a program for the uniformed services to purchase civilian 
health care services for active duty members. For this reason, the 
Director, OCHAMPUS assists the uniformed services in the administration 
of the supplemental care program.
    (3) This section applies to all health care services covered by the 
CHAMPUS. For purposes of this section, health care services ordered by a 
military treatment facility (MTF) provider for an MTF patient (who is 
not an active duty member) for whom the MTF provider maintains 
responsibility are also covered by the supplemental care program and 
subject to the requirements of this section.
    (b) Obligation of providers concerning payment for supplemental 
health care for active duty members--(1) Hospitals covered by DRG-based 
payment system. For a hospital covered by the CHAMPUS DRG-based payment 
system to maintain its status as an authorized provider for CHAMPUS 
pursuant to Sec. 199.6, that hospital must also be a participating 
provider for purposes of the supplemental care program. As a 
participating provider, each hospital must accept the DRG-based payment 
system amount determined pursuant to Sec. 199.14 as payment in full for 
the hospital services covered by the system. The failure of any hospital 
to comply with this obligation subjects that hospital to exclusion as a 
CHAMPUS-authorized provider.
    (2) Other participating providers. For any institutional or 
individual provider, other than those described in paragraph (b)(1) of 
this section that is a participating provider, the provider must also be 
a participating provider for purposes of the supplemental care program. 
The provider must accept the

[[Page 317]]

CHAMPUS allowable amount determined pursuant to Sec. 199.14 as payment 
in full for the hospital services covered by the system. The failure of 
any provider to comply with this obligation subjects the provider to 
exclusion as a participating provider.
    (c) General rule for payment and administration. Subject to the 
special rules and procedures in paragraph (d) of this section and the 
waiver authority in paragraph (e) of this section, as a general rule the 
provisions of Sec. 199.14 shall govern payment and administration of 
claims under the supplemental care program as they do claims under 
CHAMPUS. To the extent necessary to interpret or implement the 
provisions of Sec. 199.14, related provisions of this part shall also 
be applicable.
    (d) Special rules and procedure. As exceptions to the general rule 
in paragraph (c) of this section, the special rules and procedures in 
this section shall govern payment and administration of claims under the 
supplemental care program. These special rules and procedures are 
subject to the TRICARE Prime Remote program for active duty service 
members set forth in paragraph (e) of this section and the waiver 
authority of paragraph (f) of this section.
    (1) There is no patient cost sharing under the supplemental care 
program. All amounts due to be paid to the provider shall be paid by the 
program.
    (2) Preauthorization by the Uniformed Services of each service is 
required for the supplemental care program except for services in cases 
of medical emergency (for which the definition in Sec. 199.2 shall 
apply) or in cases governed by the TRICARE Prime Remote program for 
active duty service members set forth in paragraph (e) of this section. 
It is the responsibility of the active duty members to obtain 
preauthorization for each service. With respect to each emergency 
inpatient admission, after such time as the emergency condition is 
addressed, authorization for any proposed continued stay must be 
obtained within two working days of admission.
    (3) With respect to the filing of claims and similar administrative 
matters for which this part refers to activities of the CHAMPUS fiscal 
intermediaries, for purposes of the supplemental care program, 
responsibilities for claims processing, payment and some other 
administrative matters may be assigned by the Director, OCHAMPUS to the 
same fiscal intermediaries, other contractor, or to the nearest military 
medical treatment facility or medical claims office.
    (4) The annual cost pass-throughs for capital and direct medical 
education costs that are available under the CHAMPUS DRG-based payment 
system are also available, upon request, under the supplemental care 
program. To obtain payment include the number of active duty bed days as 
a separate line item on the annual request to the CHAMPUS fiscal 
intermediaries.
    (5) For providers other than participating providers, the Director, 
OCHAMPUS may authorize payment in excess of CHAMPUS allowable amounts. 
No provider may bill an active duty member any amount in excess of the 
CHAMPUS allowable amount.
    (e) TRICARE Prime Remote for Active Duty Members--(1) General. The 
TRICARE Prime Remote (TPR) program is available for certain active duty 
members of the Uniformed Services assigned to remote locations in the 
United States and the District of Columbia who are entitled to coverage 
of medical care, and the standards for timely access to such care, 
outside a military treatment facility that are comparable to coverage 
for medical care and standards for timely access to such care as exist 
under TRICARE Prime under Sec. 199.17. Those active duty members who 
are eligible under the provisions of 10 U.S.C. 1074(c)(3) and who enroll 
in the TRICARE Prime Remote program, may not be required to receive 
routine primary medical care at a military medical treatment facility.
    (2) Eligibility. To receive health care services under the TRICARE 
Prime Remote program, an individual must be an active duty member of the 
Uniformed Services on orders for more than thirty consecutive days who 
meet the following requirements:
    (i) Has a permanent duty assignment that is greater than fifty miles 
or approximately one hour drive from a military treatment facility or 
military

[[Page 318]]

clinic designated as adequate to provide the needed primary care 
services to the active duty service member; and
    (ii) Pursuant to the assignment of such duty, resides at a location 
that is greater than fifty miles or approximately one hour from a 
military medical treatment facility or military clinic designated as 
adequate to provide the needed primary care services to the active duty 
service member.
    (3) Enrollment. An active duty service member eligible for the 
TRICARE Prime Remote program must enroll in the program. If an eligible 
active duty member does not enroll in the TRICARE Prime Remote program, 
the member shall receive health care services provide under the 
supplemental health program subject to all requirements of this section 
without application of the provisions of paragraph (e) of this section.
    (4) Preauthorization. If a TRICARE Prime network under Sec. 199.17 
exists in the remote location, the TRICARE Prime Remote enrolled active 
duty member will select or be assigned a primary care manager. In the 
absence of a TRICARE primary care manager in the remote location and if 
the active duty member is not assigned to a military primary care 
manager based on fitness for duty requirements, the TRICARE Prime Remote 
enrolled active duty member may use a local TRICARE authorized provider 
for primary health care services without preauthorization. Any referral 
for specialty care will require the TRICARE Prime Remote enrolled active 
duty member to obtain preauthorization for such services.
    (f) Waiver authority. With the exception of statutory requirements, 
any restrictions or limitations pursuant to the general rule in 
paragraph (c) of this section, and special rules and procedures in 
paragraph (d) of this section, may be waived by the Director, OCHAMPUS, 
at the request of an authorized official of the uniformed service 
concerned, based on a determination that such waiver is necessary to 
assure adequate availability of health care services to active duty 
members.
    (g) Authorities. (1) The Uniformed Services may establish additional 
procedures, consistent with this part, for the effective administration 
of the supplemental care program in their respective services.
    (2) The Assistant Secretary of Defense for Health Affairs is 
responsible for the overall policy direction of the supplemental care 
program and the administration of this part.
    (3) The Director, OCHAMPUS shall issue procedural requirements for 
the implementation of this section, including requirement for claims 
submission similar to those established by Sec. 199.7.

[56 FR 23801, May 24, 1991, as amended at 58 FR 58963, Nov. 5, 1993; 67 
FR 5479, Feb. 6, 2002; 71 FR 50348, Aug. 25, 2006]