[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: 32CFR220.14]

[Page 439-441]
 
                       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. 220.14  Definitions.

    Ambulatory procedure visit. An ambulatory procedure visit is a type 
of outpatient visit in which immediate (day of procedure) pre-procedure 
and immediate post-procedure care require an unusual degree of intensity 
and are provided in an ambulatory procedure unit (APU) of the facility 
of the Uniformed Services. Care is required in the facility for less 
than 24 hours. An APU is specially designated and is accounted for 
separately from any outpatient clinic.
    Assistant Secretary of Defense (Health Affairs). This term includes 
any authorized designee of the Assistant Secretary of Defense (Health 
Affairs).
    Automobile liability insurance. Automobile liability insurance means 
insurance against legal liability for health and medical expenses 
resulting from personal injuries arising from operation of a motor 
vehicle. Automobile liability insurance includes:
    (1) Circumstances in which liability benefits are paid to an injured 
party only when the insured party's tortious acts are the cause of the 
injuries; and
    (2) Uninsured and underinsured coverage, in which there is a third 
party tortfeasor who caused the injuries (i.e., benefits are not paid on 
a no-fault basis), but the insured party is not the tortfeasor.
    CHAMPUS supplemental plan. A CHAMPUS supplemental plan is an 
insurance, medical service or health plan exclusively for the purpose of 
supplementing an eligible person's benefit under CHAMPUS. (For 
information concerning CHAMPUS, see 32 CFR part 199.) The term has the 
same meaning as set forth in the CHAMPUS regulation (32 CFR 199.2).
    Covered beneficiaries. Covered beneficiaries are all healthcare 
beneficiaries under chapter 55 of title 10, United States Code, except 
members of the Uniformed Services on active duty (as specified in 10 
U.S.C. 1074(a)). However, for purposes of Sec. 220.11 of this part, 
such members of the Uniformed Services are included as covered 
beneficiaries.
    Facility of the Uniformed Services. A facility of the Uniformed 
Services means any medical or dental treatment facility of the Uniformed 
Services (as that term is defined in 10 U.S.C. 101(43)). Contract 
facilities such as Navy NAVCARE clinics and Army and Air Force PRIMUS 
clinics that are funded by a facility of the Uniformed Services are 
considered to operate as an extension of the local military treatment 
facility and are included within the scope of this program. Facilities 
of the Uniformed Services also include several former Public Health 
Services facilities that are deemed to be facilities of the Uniformed 
Services pursuant to section 911 of Pub. L. 97-99 (often referred to as 
``Uniformed Services Treatment Facilities'' or ``USTFs'').
    Healthcare services. Healthcare services include inpatient, 
outpatient, and designated high-cost ancillary services.
    Inpatient hospital care. Treatment provided to an individual other 
than a transient patient, who is admitted (i.e., placed under treatment 
or observation) to a bed in a facility of the uniformed services that 
has authorized beds for inpatient medical or dental care.
    Insurance, medical service or health plan. Any plan (including any 
plan, policy, program, contract, or liability arrangement) that provides 
compensation, coverage, or indemnification for expenses incurred by a 
beneficiary for health or medical services, items, products, and 
supplies. It includes but is not limited to:

[[Page 440]]

    (1) Any plan offered by an insurer, re-insurer, employer, 
corporation, organization, trust, organized health care group or other 
entity.
    (2) Any plan for which the beneficiary pays a premium to an issuing 
agent as well as any plan to which the beneficiary is entitled as a 
result of employment or membership in or association with an 
organization or group.
    (3) Any Employee Retirement Income and Security Act (ERISA) plan.
    (4) Any Multiple Employer Trust (MET).
    (5) Any Multiple Employer Welfare Arrangement (MEWA).
    (6) Any Health Maintenance Organization (HMO) plan, including any 
such plan with a point-of-service provision or option.
    (7) Any individual practice association (IPA) plan.
    (8) Any exclusive provider organization (EPO) plan.
    (9) Any physician hospital organization (PHO) plan.
    (10) Any integrated delivery system (IDS) plan.
    (11) Any management service organization (MSO) plan.
    (12) Any group or individual medical services account.
    (13) Any preferred provider organization (PPO) plan or any PPO 
provision or option of any third party payer plan.
    (14) Any Medicare supplemental insurance plan.
    (15) Any automobile liability insurance plan.
    (16) Any no fault insurance plan, including any personal injury 
protection plan or medical payments benefit plan for personal injuries 
arising from the operation of a motor vehicle.
    Medicare eligible provider. Medicare participating (institutional) 
providers and physicians, suppliers and other individual providers 
eligible to participate in the Medicare program.
    Medicare supplemental insurance plan. A Medicare supplemental 
insurance plan is an insurance, medical service or health plan primarily 
for the purpose of supplementing an eligible person's benefit under 
Medicare. The term has the same meaning as ``Medicare supplemental 
policy'' in section 1882(g)(1) of the Social Security Act (42 U.S.C. 
1395ss) and 42 CFR part 403, subpart B.
    No-fault insurance. No-fault insurance means an insurance contract 
providing compensation for health and medical expenses relating to 
personal injury arising from the operation of a motor vehicle in which 
the compensation is not premised on who may have been responsible for 
causing such injury. No-fault insurance includes personal injury 
protection and medical payments benefits in cases involving personal 
injuries resulting from operation of a motor vehicle.
    Preferred provider organization. A preferred provider organization 
(PPO) is any arrangement in a third party payer plan under which 
coverage is limited to services provided by a select group of providers 
who are members of the PPO or incentives (for example, reduced 
copayments) are provided for beneficiaries under the plan to receive 
health care services from the members of the PPO rather than from other 
providers who, although authorized to be paid, are not included in the 
PPO. However, a PPO does not include any organization that is recognized 
as a health maintenance organization.
    Third party payer. A third party payer is any entity that provides 
an insurance, medical service, or health plan by contract or agreement. 
It includes but is not limited to:
    (1) State and local governments that provide such plans other than 
Medicaid.
    (2) Insurance underwriters or carriers.
    (3) Private employers or employer groups offering self-insured or 
partially self-insured medical service or health plans.
    (4) Automobile liability insurance underwriter or carrier.
    (5) No fault insurance underwriter or carrier.
    (6) Workers' compensation program or plan sponsor, underwriter, 
carrier, or self-insurer.
    (7) Any other plan or program that is designed to provide 
compensation or coverage for expenses incurred by a beneficiary for 
healthcare services or products.
    Third party payer plan. A third party payer plan is any plan or 
program provided by a third party payer, but not

[[Page 441]]

including an income or wage supplemental plan.
    Uniformed Services beneficiary. For purposes of this part, a 
Uniformed Services beneficiary is any person who is covered by 10 U.S.C. 
1074(b), 1076(a), or 1076(b). For purposes of Sec. 220.11 (but not for 
other sections), a Uniformed Services beneficiary also includes active 
duty members of the Uniformed Services.
    Workers' compensation program or plan. A workers' compensation 
program or plan is any program or plan that provides compensation for 
loss, to employees or their dependents, resulting from the injury, 
disablement, or death of an employee due to an employment related 
accident, casualty or disease. The common characteristic of such a plan 
or program is the provision of compensation regardless of fault, in 
accordance with a delineated schedule based upon loss or impairment of 
the worker's wage earning capacity, as well as indemnification or 
compensation for medical expenses relating to the employment related 
injury or disease. A workers' compensation program or plan includes any 
such program or plan:
    (1) Operated by or under the authority of any law of any State (or 
the District of Columbia, American Samoa, Guam, Puerto Rico, and the 
Virgin Islands).
    (2) Operated through an insurance arrangement or on a self-insured 
basis by an employer.
    (3) Operated under the authority of the Federal Employees 
Compensation Act or the Longshoremen's and Harbor Workers' Compensation 
Act.

[57 FR 41103, Sept. 9, 1992. Redesignated and amended at 65 FR 7729, 
7731, Feb. 16, 2000; 67 FR 57742, Sept. 12, 2002]