32 CFR 199.18 - Uniform HMO Benefit.

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§ 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 § 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.
(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 § 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 § 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 § 199.21) and under the point of service option of TRICARE Prime (see § 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 § 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 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 § 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 § 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 § 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 § 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-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 § 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]

Title 32 published on 2013-07-01

The following are only the Rules published in the Federal Register after the published date of Title 32.

For a complete list of all Rules, Proposed Rules, and Notices view the Rulemaking tab.

  • 2014-07-17; vol. 79 # 137 - Thursday, July 17, 2014
    1. 79 FR 41636 - TRICARE Certified Mental Health Counselors
      GPO FDSys XML | Text
      DEPARTMENT OF DEFENSE, Office of the Secretary
      Final rule.
      Effective Date: This rule is effective August 18, 2014.
      32 CFR Part 199

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].

It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.


United States Code
U.S. Code: Title 10 - ARMED FORCES

§ 1071 - Purpose of this chapter

§ 1072 - Definitions

§ 1073 - Administration of this chapter

§ 1073a - Contracts for health care: best value contracting

§ 1073b - Recurring reports

§ 1074 - Medical and dental care for members and certain former members

§ 1074a - Medical and dental care: members on duty other than active duty for a period of more than 30 days

§ 1074b - Medical and dental care: Academy cadets and midshipmen; members of, and designated applicants for membership in, Senior ROTC

§ 1074c - Medical care: authority to provide a wig

§ 1074d - Certain primary and preventive health care services

§ 1074e - Medical care: certain Reserves who served in Southwest Asia during the Persian Gulf Conflict

§ 1074f - Medical tracking system for members deployed overseas

§ 1074g - Pharmacy benefits program

§ 1074h - Medical and dental care: medal of honor recipients; dependents

§ 1074i - Reimbursement for certain travel expenses

§ 1074j - Sub-acute care program

§ 1074k - Long-term care insurance

10 U.S. Code § -

§ 1074m - Mental health assessments for members of the armed forces deployed in support of a contingency operation

§ 1075 - Repealed.

§ 1076 - Medical and dental care for dependents: general rule

§ 1076a - TRICARE dental program

§ 1076b - Repealed.

§ 1076c - Dental insurance plan: certain retirees and their surviving spouses and other dependents

§ 1076d - TRICARE program: TRICARE Standard coverage for members of the Selected Reserve

§ 1076e - TRICARE program: TRICARE Standard coverage for certain members of the Retired Reserve who are qualified for a non-regular retirement but are not yet age 60

§ 1077 - Medical care for dependents: authorized care in facilities of uniformed services

§ 1078 - Medical and dental care for dependents: charges

§ 1078a - Continued health benefits coverage

§ 1078b - Provision of food to certain members and dependents not receiving inpatient care in military medical treatment facilities

§ 1079 - Contracts for medical care for spouses and children: plans

§ 1079a - CHAMPUS: treatment of refunds and other amounts collected

§ 1079b - Procedures for charging fees for care provided to civilians; retention and use of fees collected

§ 1080 - Contracts for medical care for spouses and children: election of facilities

§ 1081 - Contracts for medical care for spouses and children: review and adjustment of payments

§ 1082 - Contracts for health care: advisory committees

§ 1083 - Contracts for medical care for spouses and children: additional hospitalization

§ 1084 - Determinations of dependency

§ 1085 - Medical and dental care from another executive department: reimbursement

§ 1086 - Contracts for health benefits for certain members, former members, and their dependents

§ 1086a - Certain former spouses: extension of period of eligibility for health benefits

§ 1086b - Prohibition against requiring retired members to receive health care solely through the Department of Defense

§ 1087 - Programing facilities for certain members, former members, and their dependents in construction projects of the uniformed services

§ 1088 - Air evacuation patients: furnished subsistence

§ 1089 - Defense of certain suits arising out of medical malpractice

§ 1090 - Identifying and treating drug and alcohol dependence

§ 1090a - Commanding officer and supervisor referrals of members for mental health evaluations

§ 1091 - Personal services contracts

§ 1092 - Studies and demonstration projects relating to delivery of health and medical care

§ 1092a - Persons entering the armed forces: baseline health data

§ 1093 - Performance of abortions: restrictions

§ 1094 - Licensure requirement for health-care professionals

§ 1094a - Continuing medical education requirements: system for monitoring physician compliance

§ 1095 - Health care services incurred on behalf of covered beneficiaries: collection from third-party payers

§ 1095a - Medical care: members held as captives and their dependents

§ 1095b - TRICARE program: contractor payment of certain claims

§ 1095c - TRICARE program: facilitation of processing of claims

§ 1095d - TRICARE program: waiver of certain deductibles

§ 1095e - TRICARE program: beneficiary counseling and assistance coordinators

§ 1095f - TRICARE program: referrals for specialty health care

§ 1096 - Military-civilian health services partnership program

§ 1097 - Contracts for medical care for retirees, dependents, and survivors: alternative delivery of health care

§ 1097a - TRICARE Prime: automatic enrollments; payment options

§ 1097b - TRICARE program: financial management

§ 1097c - TRICARE program: relationship with employer-sponsored group health plans

§ 1098 - Incentives for participation in cost-effective health care plans

§ 1099 - Health care enrollment system

§ 1100 - Defense Health Program Account

§ 1101 - Resource allocation methods: capitation or diagnosis-related groups

§ 1102 - Confidentiality of medical quality assurance records: qualified immunity for participants

§ 1103 - Contracts for medical and dental care: State and local preemption

§ 1104 - Sharing of health-care resources with the Department of Veterans Affairs

§ 1105 - Specialized treatment facility program

§ 1106 - Submittal of claims: standard form; time limits

§ 1107 - Notice of use of an investigational new drug or a drug unapproved for its applied use

§ 1107a - Emergency use products

§ 1108 - Health care coverage through Federal Employees Health Benefits program: demonstration project

§ 1109 - Organ and tissue donor program

§ 1110 - Anthrax vaccine immunization program; procedures for exemptions and monitoring reactions

§ 1110a - Notification of certain individuals regarding options for enrollment under Medicare part B

§ 1110b - TRICARE program: extension of dependent coverage

Title 32 published on 2013-07-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 32 CFR 199 after this date.

  • 2014-07-17; vol. 79 # 137 - Thursday, July 17, 2014
    1. 79 FR 41636 - TRICARE Certified Mental Health Counselors
      GPO FDSys XML | Text
      DEPARTMENT OF DEFENSE, Office of the Secretary
      Final rule.
      Effective Date: This rule is effective August 18, 2014.
      32 CFR Part 199