[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: 32CFR220.10]

[Page 436-437]
 
                       TITLE 32--NATIONAL DEFENSE
 
        CHAPTER I--OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED)
 
PART 220_COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR 
 
Sec. 220.10  Special rules for Medicare supplemental plans.

    (a) Statutory obligation of Medicare supplemental plans to pay. The 
obligation of a Medicare supplemental plan to pay shall be determined as 
if the facility of the Uniformed Services were a medicare-eligible 
provider and the services provided as if they were Medicare-covered 
services. A Medicare supplemental plan is required to pay only to the 
extent that the plan would have incurred a payment obligation if the 
services had been furnished by a Medicare eligible provider.
    (b) Inpatient hospital care charges. (1) Notwithstanding the 
provisions of Sec. 220.8, charges to Medicare supplemental plans for 
inpatient hospital care services provided to beneficiaries of such plans 
shall not, for any admission, exceed the Medicare inpatient hospital 
deductible amount.
    (2) Only one deductible charge shall be made per hospital admission 
(or Medicare benefit period), regardless of whether the admission is to 
a facility of the Uniformed Services or a Medicare certified civilian 
hospital. To ensure that a Medicare supplemental insurer is not charged 
the inpatient hospital deductible twice when an individual who is 
entitled to benefits under both DoD retiree benefits and Medicare, the 
following payment rules apply:
    (i) If a dual beneficiary is first admitted to a Medicare-certified 
hospital and is later admitted to a facility of the Uniformed Services 
within the same benefit period initiated by the admission to the 
Medicare-certified hospital, the facility of the Uniformed Services 
shall not charge the Medicare supplemental insurance plan an inpatient 
hospital deductible.
    (ii) If a dual beneficiary is admitted first to a facility of the 
Uniformed Services and secondly to a Medicare-certified hospital within 
60 days of discharge from the facility of the Uniformed Services, the 
facility of the Uniformed Services shall refund to the Medicare 
supplemental insurer any inpatient hospital deductible that the insurer 
paid to the facility of the Uniformed Services so that it may pay the 
deductible to the Medicare-certified hospital.
    (c) Charges for Healthcare services other than inpatient deductible 
amount. (1) The Assistant Secretary of Defense (Health Affairs) may 
establish charge amounts for Medicare supplemental plans to collect 
reasonable charges for inpatient and outpatient copayments and other 
services covered by the Medicare supplemental plan. Any such schedule of 
charge amounts shall:
    (i) Be based on percentage amounts of the per diem, per visit and 
other rates established by Sec. 220.8 comparable to the percentage 
amounts of beneficiary financial responsibility under Medicare for the 
service involved;
    (ii) Include adjustments, as appropriate, to identify major 
components of the all inclusive per diem or per visit

[[Page 437]]

rates for which Medicare has special rules.
    (iii) Provide for offsets and/or refunds to ensure that Medicare 
supplemental insurers are not required to pay a limited benefit more 
than one time in cases in which beneficiaries receive similar services 
from both a facility of the uniformed services and a Medicare certified 
provider; and
    (iv) Otherwise conform with the requirements of this section and 
this part.
    (2) If collections are sought under paragraph (c) of this section, 
the effective date of such collections will be prospective from the date 
the Assistant Secretary of Defense (Health Affairs) provides notice of 
such collections, and will exempt policies in continuous effect without 
amendment or renewal since the date the Assistant Secretary of Defense 
(Health Affairs) provides notice of such collections.
    (d) Medicare claim not required. Notwithstanding any requirement of 
the Medicare supplemental plan policy, a Medicare supplemental plan may 
not refuse payment to a claim made pursuant to this section on the 
grounds that no claim had previously been submitted by the provider or 
beneficiary for payment under the Medicare program.
    (e) Exclusion of Medicare supplemental plans prior to November 5, 
1990. This section is not applicable to Medicare supplemental plans:
    (1) That have been in continuous effect without amendment since 
prior to November 5, 1990; and
    (2) For which the facility of the Uniformed Services (or other 
authorized representative of the United States) makes a determination, 
based on documentation provided by the Medicare supplemental plan, that 
the plan agreement clearly excludes payment for services covered by this 
section. Plans entered into, amended or renewed on or after November 5, 
1990, are subject to this section, as are prior plans that do not 
clearly exclude payment for services covered by this section.

[57 FR 41102, Sept. 9, 1992, as amended at 59 FR 49003, Sept. 26, 1994; 
67 FR 57742, Sept. 12, 2002]