[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: 32CFR199.18]

[Page 333-336]
 
                       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. 199.18  Uniform HMO Benefit.

    (a) In general. There is established a Uniform HMO Benefit. The 
purpose of the Uniform HMO benefit is to establish a health benefit 
option modeled on health maintenance organization plans. This benefit is 
intended to be uniform wherever offered throughout the United States and 
to be included in all managed care programs under the MHSS. Most care 
purchased from civilian health care providers (outside an MTF) will be 
under the rules of the Uniform HMO Benefit or the Basic CHAMPUS Program 
(see Sec. 199.4). The Uniform HMO Benefit shall apply only as specified 
in this section or other sections of this part, and shall be subject to 
any special applications indicated in such other sections.

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    (b) Services covered under the uniform HMO benefit option. (1) 
Except as specifically provided or authorized by this section, all 
CHAMPUS benefits provided, and benefit limitations established, pursuant 
to this part, shall apply to the Uniform HMO Benefit.
    (2) Certain preventive care services not normally provided as part 
of basic program benefits under CHAMPUS are covered benefits when 
provided to Prime enrollees by providers in the civilian provider 
network. Standards for preventive care services shall be developed based 
on guidelines from the U.S. Department of Health and Human Services. 
Such standards shall establish a specific schedule, including frequency 
or age specifications for:
    (i) Laboratory and x-ray tests, including blood lead, rubella, 
cholesterol, fecal occult blood testing, and mammography;
    (ii) Pap smears;
    (iii) Eye exams;
    (iv) Immunizations;
    (v) Periodic health promotion and disease prevention exams;
    (vi) Blood pressure screening;
    (vii) Hearing exams;
    (viii) Sigmoidoscopy or colonoscopy;
    (ix) Serologic screening; and
    (x) Appropriate education and counseling services. The exact 
services offered shall be established under uniform standards 
established by the Assistant Secretary of Defense (Health Affairs).
    (3) In addition to preventive care services provided pursuant to 
paragraph (b)(2) of this section, other benefit enhancements may be 
added and other benefit restrictions may be waived or relaxed in 
connection with health care services provided to include the Uniform HMO 
Benefit. Any such other enhancements or changes must be approved by the 
Assistant Secretary of Defense (Health Affairs) based on uniform 
standards.
    (c) Enrollment fee under the uniform HMO benefit. (1) The CHAMPUS 
annual deductible amount (see Sec. 199.4(f)) is waived under the 
Uniform HMO Benefit during the period of enrollment. In lieu of a 
deductible amount, an annual enrollment fee is applicable. The specific 
enrollment fee requirements shall be published annually by the Assistant 
Secretary of Defense (Health Affairs), and shall be uniform within the 
following groups: dependents of active duty members in pay grades of E-4 
and below; active duty dependents of sponsors in pay grades E-5 and 
above; and retirees and their dependents.
    (2) Amount of enrollment fees. In fiscal year 2001, the annual 
enrollment fee for retirees and their dependents is $230 individual, 
$460 family.
    (3) Waiver of enrollment fee for certain beneficiaries. The 
Assistant Secretary of Defense (Health Affairs) may waive the enrollment 
fee requirements of this section for Medicare-eligible beneficiaries.
    (d) Outpatient cost sharing requirements under the uniform HMO 
benefit--(1) In general. In lieu of usual CHAMPUS cost sharing 
requirements (see Sec. 199.4(f)), special reduced cost sharing 
percentages or per service specific dollar amounts are required. The 
specific requirements shall be uniform and shall be published 
periodically by the Assistant Secretary of Defense (Health Affairs). For 
care provided on or after April 1, 2001, no copayment shall be charged 
for care provided under TRICARE Prime to a dependent of an active duty 
member, except for the copayments charged under the Pharmacy Benefits 
Program (see Sec. 199.21) and under the point of service option of 
TRICARE Prime (see Sec. 199.17(n)(4)).
    (2) Structure of outpatient cost sharing. The special cost sharing 
requirements for outpatient services include the following specific 
structural provisions:
    (i) For most physician office visits and other routine services, 
there is a per visit fee for retirees and their dependents. This fee 
applies to primary care and specialty care visits, except as provided 
elsewhere in this paragraph (d)(2) of this section. It also applies to 
family health services, home health care visits, eye examinations, and 
immunizations. It does not apply to ancillary health services or to 
preventive health services described in paragraph (b)(2) of this 
section, or to maternity services under Sec. 199.4(e)(16).
    (ii) There is a copayment for outpatient mental health visits. It is 
a per visit fee for retirees and their dependents for individual visits. 
For group

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visits, there is a lower per visit fee for retirees and their 
dependents.
    (iii) There is a cost share of durable medical equipment, prosthetic 
devices, and other authorized supplies for retirees and their 
dependents.
    (iv) For emergency room services, there is a per visit fee for 
retirees and their dependents.
    (v) For ambulatory surgery services, there is a per service fee for 
retirees and their dependents.
    (vi) There is a copayment for prescription drugs per prescription, 
including medical supplies necessary for administration, for dependents 
of active duty members and for retirees and their dependents under the 
Pharmacy Benefits Program (see Sec. 199.17(m)(5)).
    (vii) There is a copayment for ambulance services for retirees and 
their dependents.
    (3) Amount of outpatient cost sharing requirements. In fiscal year 
2001, the outpatient cost sharing requirements are as follows:
    (i) For most physician office visits and other routine services, as 
described in paragraph (d)(2)(i) of this section, the per visit fee for 
retirees and their dependents is $12.
    (ii) For outpatient mental health visits, the per visit fee for 
retirees and their dependents is $25. For group outpatient mental health 
visits, there is a lower per visit fee for retirees and their dependents 
of $17.
    (iii) The cost share for durable medical equipment, prosthetic 
devices, and other authorized supplies for retirees and their dependents 
is 20 percent of the negotiated fee.
    (iv) For emergency room services, the per visit fee for retirees and 
their dependents is $30.
    (v) For primary surgeon services in ambulatory surgery, the per 
service fee for retirees and their dependents is $25.
    (vi) The copayments for prescription drugs are established under the 
Pharmacy Benefits Program (see Sec. 199.21).
    (vii) The copayment for ambulance services for retirees and their 
dependents is $20.
    (e) Inpatient cost sharing requirements under the uniform HMO 
benefit--(1) In general. In lieu of usual CHAMPUS cost sharing 
requirements (see Sec. 199.4(f)), special cost sharing amounts are 
required. The specific requirements shall be uniform and shall be 
published periodically by the Assistant Secretary of Defense (Health 
Affairs). For services provided on or after April 1, 2001, no co-payment 
shall be charged for inpatient care provided under TRICARE Prime to a 
dependent of an active duty member except under the point of service 
option of TRICARE Prime (see Sec. 199.17(n)(4)). In addition, for 
services provided on or after April 1, 2001, no copayment shall be 
charged for inpatient care provided under TRICARE Prime to a dependent 
of an active duty member in military medical treatment facilities.
    (2) Structure of cost sharing. For services other than mental 
illness or substance use treatment, there is a nominal copayment for 
retired members, dependents of retired members, and survivors. For 
inpatient mental health and substance use treatment, a separate per day 
charge is established. For services provided on or after April 1, 2001, 
no inpatient copayment shall be charged an active duty dependent 
enrolled in TRICARE Prime. This elimination of inpatient copayments 
applies to active duty dependents enrolled in TRICARE Prime who are 
admitted to a civilian or military inpatient facility.
    (3) Amount of inpatient cost sharing requirements. In fiscal year 
2001, the inpatient cost sharing requirements for retirees and their 
dependents for acute care admissions and other non-mental health/
substance use treatment admissions is a per diem charge of $11, with a 
minimum charge of $25 per admission. For mental health/substance use 
treatment admissions, and for partial hospitalization services, the per 
diem charge for retirees and their dependents is $40.
    (f) Limit on out-of-pocket costs under the uniform HMO benefit. (1) 
Total out-of-pocket costs per family of dependents of active duty 
members under the Uniform HMO Benefit may not exceed $1,000 during the 
one-year enrollment period. Total out-of-pocket costs per family of 
retired members, dependents of retired members and survivors under the 
Uniform HMO Benefit may not exceed $3,000 during the one-year enrollment 
period. For this purpose, out-of-

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pocket costs means all payments required of beneficiaries under 
paragraphs (c), (d), and (e) of this section. In any case in which a 
family reaches this limit, all remaining payments that would have been 
required of the beneficiary under paragraphs (c), (d), and (e) of this 
section will be made by the program in which the Uniform HMO Benefit is 
in effect.
    (2) The limits established by paragraph (f)(1) of this section do 
not apply to out-of-pocket costs incurred pursuant to paragraph 
(m)(1)(i) or (m)(2)(i) of Sec. 199.17 under the point-of-service option 
of TRICARE Prime.
    (g) Updates. The enrollment fees for fiscal year 2001 set under 
paragraph (c) of this section and the per service specific dollar 
amounts for fiscal year 2001 set under paragraphs (d) and (e) of this 
section may be updated for subsequent years to the extent necessary to 
maintain compliance with statutory requirements pertaining to government 
costs. This updating does not apply to cost sharing that is expressed as 
a percentage of allowable charges; these percentages will remain 
unchanged.

[60 FR 52101, Oct. 5, 1995, as amended at 63 FR 9143, Feb. 24, 1998; 63 
FR 48448, Sept. 10, 1998; 66 FR 9656, Feb. 9, 2001; 66 FR 16400, Mar. 
26, 2001]