TRICARE/CHAMPUS: FY99 DRG updates--DoD. Notice of DRG revised rates

This notice describes the changes made to the TRICARE/CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). It also provides the updated fixed loss cost outlier threshold, cost-to-charge ratios and the Internet address for accessing the updated adjusted standardized amounts, DRG relative weights, and beneficiary cost-share per diem rates to be used for FY 1999 under the TRICARE/CHAMPUS DRG-based payment system.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY96 DRG updates--DoD. Notice of DRG revised rates

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1996 under the CHAMPUS DRG-based payment system. It also describes the changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS).     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY97 DRG updates--DoD. Notice of DRG revised rates

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1997 under the CHAMPUS DRG-based payment system. It also describes the changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS).     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY95 DRG updates--DoD. Notice of DRG revised rates

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1995 under the CHAMPUS DRG-based payment system. It also describes the non-regulatory changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS).     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE program; reimbursement--DoD. Proposed rule

This rule proposes to revise certain requirements and procedures for reimbursement under the TRICARE program, the purpose of which is to implement a comprehensive managed health care delivery system composed of military medical treatment facilities and CHAMPUS. Issues addressed in this proposed rule include: implementation of changes made to the Medicare Prospective Payment System (PPS) upon which the CHAMPUS DRG-based payment system is modeled and required by law to follow wherever practicable, along with changes to make our DRG-based payment system operate better; extension of the balance billing limitations currently in place for individual and professional providers to non-institutional, non-professional providers; adjusting the CHAMPUS maximum allowable charge (CMAC) rate in the small number of cases where the CMAC rate is less than the Medicare rate; and implementing the government-wide debarment rule where any provider excluded or suspended from CHAMPUS shall be excluded from all other programs and activities involving Federal financial assistance, such as Medicare or Medicaid, and adding violations of our balance billing or claims filing requirements to the list of provider actions considered violations of the TRICARE/CHAMPUS program.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)--Department of Defense. Notice of revised rates

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1992 under the CHAMPUS DRG-based payment system. It also describes the non-regulatory changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS).     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)--DoD. Notice of revised rates

This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1993 under the CHAMPUS DRG-based payment system. It also describes the non-regulatory changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS).     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE Program; reimbursement--DoD. Final rule

This final rule revises certain requirements and procedures for reimbursement under the CHAMPUS program, the purpose of which is to implement a comprehensive managed health care delivery system composed of military medical treatment facilities and CHAMPUS. Issues addressed in this rule include: implementation of changes made to the Medicare Prospective Payment System (PPS) upon which the CHAMPUS DRG-based payment system is modeled and required by law to follow wherever practicable, along with changes to make our DRG-based payment system operate better; clarification of payment reduction for noncompliance with required utilization of publication of list of ambulatory surgery procedures; limitation on ambulatory surgery group payment rates; extension of the balance billing limitations currently in place for individual and professional providers to non-institutional, non-professional providers; adjustment of the CHAMPUS maximum allowable charge (CMAC) rate in the small number of cases where the CMAC rate is less than the Medicare rate; implementation of the government-wide debarment rule where any provider excluded or suspended from CHAMPUS shall be excluded from all other programs and activities involving Federal financial assistance, such as Medicare or Medicaid; elimination of the requirement for non-participating providers to file claims; and revision of the ambulatory surgery cost-share information to enable the cost-share to be assessed against the facility claim instead of the primary surgeon's claim.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); corrections to the CHAMPUS diagnosis related group (DRG) payment system rates and weights--Department of Defense. Corrections to notice of revised rates

This document corrects errors that appeared in the notice of revised rates which was published on October 30, 1991, (56 FR 55895) and which revised the rates and weights to be used in the CHAMPUS DRG-based payment system effective for admissions occurring on or after October 1, 1991.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); corrections to the CHAMPUS Diagnosis Related Group (DRG) payment system rates and weights--DoD. Corrections to notice of revised rates

This document corrects an error that appeared in the notice of revised rates which was published on January 27, 1993, (58 FR 6254) and which revised the rates and weights to be used in the CHAMPUS DRG-based payment system effective for admissions occurring on or after October 1, 1992. It also clarifies the rates and weights to be used for two DRGs for which no rates and weights were calculated.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY 96 updates--DoD. Amendment to notice

On October 3, 1995, 60 FR 51779, the Department of Defense published the "Notice of DRG Revised Rates" without Tables 1 and 2. These tables provide the rates and weights to be used under the CHAMPUS DRG-based payment system during FY 1996. This amendment is to display the updated rates and weights for Tables 1 and 2.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE program; nonavailability statement requirements--DoD. Final rule

This final rule revises certain requirements and procedures for the TRICARE Program, the purpose of which is to implement a comprehensive managed health care delivery system composed of military medical treatment facilities and CHAMPUS. Issues addressed in this rule include priority for access to care in military treatment facilities and requirements for payment of enrollment fees. This rule also includes provisions revising the requirement that certain beneficiaries obtain a non-availability statement from a military treatment facility commander prior to receiving certain health care services from civilian providers.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). Office of the Secretary, DoD. Notice of expansion of cancer treatment clinical trials demonstration project

This notice is to advise interested parties of an expansion of a demonstration project in which the DoD provides CHAMPUS reimbursement for eligible beneficiaries who receive cancer treatment under approved National Cancer Institute (NCI) clinical trials to include NCI sponsored cancer prevention clinical trials. Participation in these clinical trials will improve TRICARE/CHAMPUS eligible beneficiary access to emerging new therapies that have significant promise for the prevention and successful treatment of cancers. DoD financing of these procedures will assist in meeting clinical trial goals and arrival at conclusions regarding the safety and efficacy of emerging therapies in the prevention and treatment of cancer. At this time, there is insufficient demonstration data for a full evaluation of costs associated with enrollment in clinical trials. Expanding the current demonstration to provide reimbursement for costs associated with NCI sponsored clinical trials for cancer prevention will augment current patient accruals to clinical trials and allow for data collection in order to perform a comprehensive economic analysis. This demonstration also affects TRICARE, the managed health care program that includes CHAMPUS. This demonstration project, which is under the authority of 10 U.S.C., section 1092, will expire December 31, 1999.     

TRICARE: the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); specialized treatment services (STS) program--DoD. Notice

This notice is to advise interested parties that Naval Hospital Jacksonville (NAVHOSPJAX), Florida, has been designated a regional Specialized Treatment Services facility (STSF) for total joint replacement. The application for this STSF designation was submitted by NAVHOSPJAX and approved by the Assistant Secretary of Defense (Health Affairs). The Lead Agent for TRICARE Region 3 will oversee that the STSF maintains the quality and standards required for specialized treatment services. This designation covers the following Diagnostic Related Groups: 209--Major Joint and Limb Reattachment Procedures of Lower Extremity 491--Major Joint and Limb Reattachment Procedures of Upper Extremity DoD beneficiaries who reside in the NAVHOSPJAX STS Catchment Area must be evaluated by NAVHOSPJAX before receiving TRICARE/CHAMPUS cost sharing for procedures that fall under the above Diagnostic Related Groups, in accordance with TRICARE/CHAMPUS Nonavailability Statement policy. Travel and lodging for the patient and, if stated to be medically necessary by a referring physician, for a nonmedical attendant, will be reimbursed by NAVHOSPJAX in accordance with the provision of the Joint Federal Travel Regulation. Although evaluation in person is preferred, it is possible to conduct the evaluation telephonically if the patient is unable to travel to NAVHOSPJAX. If the procedures cannot be performed at NAVHOSPJAX, Humana Military Healthcare Services will provide a medical necessity review prior to issuance of a Nonavailability Statement or other similar authorizations. The NAVHOSPJAX STSF Catchment Area includes zip codes within TRICARE Region 3 that fall within a 200-mile radius South and West of NAVHOSPJAX.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); coverage of screening mammography and Papanicolaou (PAP) tests, certified marriage and family therapists, and requirements for coverage and reimbursement of services of physicians in teaching settings--Office of the Secretary, DoD. Final rule

This final rule revises the exclusions and limitations of the CHAMPUS regulation pertaining to preventive care and unnecessary diagnostic tests not related to a specific illness, injury, or definitive set of symptoms, to allow coverage for screening mammography and PAP tests on a preventive basis initially following the recommended guidelines of the American Cancer Society as a basis for coverage. The final rule also removes the requirement for physician supervision and referral for certified marriage and family therapists; requires all certified marriage and family therapists to accept CHAMPUS payment as payment in full; ensures that the relationship of certified marriage and family therapists is consistent with other mental health practitioners with comparable education and training; protects the CHAMPUS beneficiary from incurring added out-of-pocket costs for care rendered that is not part of the current CHAMPUS mental health benefits package; and better defines the specific requirements of existing CHAMPUS policies for coverage and reimbursement of services of teaching physicians and physicians in training. EFFECTIVE DATE: This part is effective February 22, 1994.(ABSTRACT TRUNCATED AT 250 WORDS)     

Payment method for health care services under the Supplemental Health Care Program for Active Duty Members of the Uniformed Services; adoption of CHAMPUS procedures--DoD. Final rule

This final rule partially implements 10 U.S.C. 1074(c), as amended by section 729 of the National Defense Authorization Act for Fiscal Years 1990 and 1991, Public Law 101-189. The recent amendment authorizes the Department of Defense to establish for the active duty supplemental care program payment rules similar to those used under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). The supplemental care program is the program which provides for the payment to civilian (non federal-governmental) health care providers for care provided to active duty members of the uniformed services. This final rule would adopt CHAMPUS payment amounts for the supplemental care program.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); specialized treatment services; nonavailability statements; peer review organization program; supplemental care--DoD. Final rule

This final rule: establishes a Specialized Treatment Services Program, under which CHAMPUS beneficiaries in need of certain highly specialized medical care will be referred to specially designated national or regional, military or civilian treatment facilities; revises a number of procedures applicable to the CHAMPUS Peer Review Organization program; and expands reliance on CHAMPUS payment rules and procedures for purposes of the supplemental care program, which applies to services provided by civilian providers to active duty members and certain other patients referred by military providers.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); medical documentation--Department of Defense. Final rule

This final rule amends DoD 6010.8-R (32 CFR part 199) which implements the Civilian Health and Medical Program of the Uniformed Services. The final rule clarifies and strengthens medical documentation requirements under the CHAMPUS. This will assist in the maintenance of an adequate level of quality care and help ensure that payment is made only for services rendered.     

TRICARE senior demonstration of military managed care--DOD. Notice of demonstration project

This notice is to advise interested parties of a demonstration project in which the Department of Defense (DoD) will provide health care services to Medicare-eligible military retirees in a managed care program, called TRICARE Senior, and receive reimbursement for such care from the Medicare Trust Fund. The program is authorized by section 1896 of the Social Security Act, amended by section 4015 of the Balanced Budget Act of 1997 (P.L. 105-33). The statue authorizes DoD and the Department of Health and Human Services (HHS) to conduct at six sites during January 1998 through December 2000, a three-year demonstration under which dual-eligible beneficiaries will be offered enrollment in a DoD-operated managed care plan, called TRICARE Senior Prime. The legislation also authorizes Medicare HMOs to make payments to DoD for care provided to HMO enrollees by military treatment facilities (MTFs) participating in the demonstration. This part of the demonstration, to be called Medicare Partners, will allow DoD to enter into contracts with Medicare HMOs to provide specialty and impatient care to dual-eligible beneficiaries currently provided on a space-available basis. Additional legal authority pertinent to this demonstration project is 10 U.S.C. section 1092. Under TRICARE Senior Prime, Medicare-eligible military retirees who enroll in the program will be assigned primary care manager (PCMs) at the MTF. Enrollees will be referred to specialty care providers at the MTF and to participating members of the existing TRICARE Prime network. TRICARE Senior Prime enrollees will be afforded the same priority access to MTF care as military retiree and retiree family member enrollees in TRICARE Prime. DoD will receive reimbursement from HCFA on a capitated basis at a rate which is 95 percent of the rate HCFA currently pays to Medicare-risk HMOs, less costs such as capital and graduate medical education, disproportionate share hospital payments, and some capital costs, which are already covered by DoD's annual appropriation. However, under the authorizing statute, DoD must meet its current level of effort for its Medicare-eligible beneficiaries before receiving payments from the Medicare Trust Fund. That is, DoD must continue to fund health care at a certain expenditure level for its Medicare-eligible population before it may be reimbursed by HCFA for care provided to TRICARE Senior Prime enrollees. The Balanced Budget Act of 1997 required DoD and HHS to complete a memorandum of agreement (MOA) specifying the operational requirements of the demonstration project. That MOA was completed on February 13, 1998, and is published below. Except as provided in the MOA, TRICARE Senior Prime will be implemented consistent with applicable provisions of the CHAMPUS/TRICARE regulation, particularly 32 CFR sections 199.17 and 199.18.