Introduction to the Supplemental Health Care Program
The Supplemental Health Care Program is a crucial initiative designed to ensure that active duty members of the uniformed services receive necessary health care services. This program operates by enabling the uniformed services to purchase health care services from private sector providers, effectively supplementing the care provided within military treatment facilities (MTFs). Authorized under 10 U.S.C. 1074(c), the program adopts payment rules similar to those of CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), now known as TRICARE, with necessary adjustments to meet the specific needs of active duty personnel. While distinct from CHAMPUS, the supplemental health care program shares the fundamental principle of leveraging civilian health care resources to support the health and well-being of service members.
Purpose and Scope of the Supplemental Health Care Program
The primary purpose of the supplemental health care program is to bridge potential gaps in health care access for active duty members. It ensures that service members, who are critical to national defense and often stationed in diverse locations, have access to timely and appropriate medical care. This program is specifically applicable to health care services provided to active duty members of the uniformed services. It functions as a mechanism through which the uniformed services can procure civilian health care services, thereby expanding the network of care beyond what is immediately available in military facilities.
The administration of the supplemental health care program is supported by the Director of OCHAMPUS (Office of CHAMPUS), ensuring alignment and consistency with established health care standards and practices. Importantly, the program covers all health care services that are also covered under CHAMPUS (TRICARE). This comprehensive coverage extends to situations where a military treatment facility (MTF) provider orders services for an MTF patient who is not an active duty member, but for whom the MTF provider retains responsibility. In such cases, these services also fall under the supplemental health care program, ensuring a broad safety net of health care support.
Obligations for Health Care Providers Under the Program
Providers participating in the supplemental health care program have specific obligations to ensure seamless service delivery to active duty members. These obligations differ slightly based on the type of provider, particularly distinguishing between hospitals under the DRG-based payment system and other types of providers.
Hospitals and the DRG-Based Payment System
Hospitals that are part of the CHAMPUS DRG-based payment system must also participate in the supplemental health care program to maintain their authorized provider status under CHAMPUS (§ 199.6). As participating providers, these hospitals are required to accept the DRG-based payment amount, as determined by § 199.14, as full payment for hospital services covered under this system. This stipulation ensures that hospitals adhere to the program’s payment structure and do not seek additional payments from active duty members. Non-compliance with this obligation can lead to exclusion from being a CHAMPUS-authorized provider, impacting their ability to serve military beneficiaries.
Other Participating Providers
For institutional or individual providers not covered under the DRG-based system, participation in the supplemental health care program is also linked to their status as participating providers under CHAMPUS. These providers must accept the CHAMPUS allowable amount, as per § 199.14, as full payment for the services they render under the supplemental care program. Similar to hospitals, failure to comply with this payment obligation can result in exclusion from participating provider networks. This framework ensures a consistent and fair payment structure across different types of health care providers within the supplemental health care program.
Payment and Administration: General Guidelines
The general rule governing payment and administration of claims within the supplemental health care program is guided by the provisions of § 199.14, which also regulates claims under CHAMPUS (TRICARE). This alignment ensures a standardized approach to payment processes and administrative procedures, making it easier for both providers and the uniformed services to manage health care claims. To effectively interpret and implement § 199.14, other related provisions within Part 199 are also applicable, creating a comprehensive regulatory framework.
Special Rules and Procedures Unique to the Supplemental Program
While the general framework aligns with CHAMPUS, the supplemental health care program has specific rules and procedures that cater to the unique circumstances of active duty members. These special rules act as exceptions to the general guidelines, prioritizing the needs of service members.
No Cost Sharing for Active Duty Members
One of the most significant benefits of the supplemental health care program is that there is no cost-sharing for active duty members. This means that all amounts payable to the health care provider for covered services are fully covered by the program. Active duty members do not incur out-of-pocket expenses such as copayments or deductibles, ensuring that financial concerns do not become a barrier to accessing necessary medical care.
Preauthorization Requirements
Preauthorization is generally required for services under the supplemental health care program, except in cases of medical emergencies or when services are governed by the TRICARE Prime Remote program. It is the responsibility of active duty members to obtain preauthorization from the Uniformed Services for each health care service they seek. For emergency inpatient admissions, while initial authorization is not required, continued stay beyond the immediate emergency treatment necessitates authorization within two working days of admission. This preauthorization process helps manage and ensure the appropriateness of care, while also providing exceptions for urgent medical needs.
Claims Processing and Administrative Aspects
For administrative matters such as claims filing, the supplemental health care program leverages existing infrastructure and expertise. Responsibilities for claims processing, payment, and other administrative tasks may be assigned by the Director, OCHAMPUS to the same fiscal intermediaries or contractors who handle CHAMPUS claims. Alternatively, these responsibilities can be directed to the nearest military medical treatment facility or medical claims office. This flexible approach ensures efficient claims management and leverages existing administrative systems to support the supplemental program.
Annual Cost Pass-Throughs
Hospitals participating in the supplemental health care program can also benefit from annual cost pass-throughs for capital and direct medical education costs, similar to those available under the CHAMPUS DRG-based payment system. To claim these pass-throughs, hospitals need to include the number of active duty bed days as a separate line item in their annual request to the CHAMPUS fiscal intermediaries. This provision helps to offset some of the costs incurred by hospitals in providing care to active duty members under the program.
Payment for Non-Participating Providers
In situations involving providers who are not participating providers, the Director, OCHAMPUS has the authority to approve payments exceeding CHAMPUS allowable amounts. However, it is critical to note that regardless of the payment arrangement between the program and non-participating providers, no provider is permitted to bill an active duty member any amount exceeding the CHAMPUS allowable amount. This rule protects active duty members from unexpected or excessive medical bills, ensuring they are not financially burdened when accessing care outside of participating provider networks.
TRICARE Prime Remote for Active Duty Members
The TRICARE Prime Remote (TPR) program is a specialized component within the supplemental health care program, designed for active duty members stationed in remote locations within the United States and the District of Columbia. TPR aims to provide these service members with health care coverage and timely access standards comparable to those under TRICARE Prime (§ 199.17), despite their remote assignments. Eligible active duty members enrolled in TPR may not be required to seek routine primary medical care at a military medical treatment facility, enhancing convenience and access in remote areas.
Eligibility and Enrollment in TRICARE Prime Remote
Eligibility for TRICARE Prime Remote is based on specific criteria related to duty location and proximity to military medical facilities. To be eligible, an active duty member must:
- Be on active duty orders for more than 30 consecutive days.
- Have a permanent duty assignment located more than fifty miles or approximately one hour’s drive from a military treatment facility or clinic adequate to provide necessary primary care services.
- Reside at a location that is also more than fifty miles or approximately one hour from a suitable military medical facility or clinic.
Enrollment in TRICARE Prime Remote is mandatory for eligible active duty members. If an eligible member does not enroll, they still receive health care services under the supplemental health program but without the specific provisions and flexibilities offered by the TPR program.
Preauthorization under TRICARE Prime Remote
Preauthorization requirements under TRICARE Prime Remote are streamlined to facilitate easier access to care in remote settings. If a TRICARE Prime network exists in the remote location, enrolled active duty members will be assigned a primary care manager (PCM). However, in the absence of a local TRICARE PCM and if the member is not assigned to a military PCM for duty fitness reasons, they can directly use any local TRICARE-authorized provider for primary health care services without preauthorization. Referrals for specialty care under TRICARE Prime Remote, however, still require preauthorization, ensuring managed access to specialized medical services.
Waiver Authority and Program Flexibility
Recognizing the diverse needs and circumstances of active duty members, the supplemental health care program includes a waiver authority. The Director, OCHAMPUS, upon request from an authorized official of the relevant uniformed service, can waive restrictions or limitations within the program (excluding statutory requirements). Such waivers are granted if deemed necessary to ensure adequate availability of health care services to active duty members. This waiver authority provides essential flexibility to adapt the program’s implementation to specific situations and challenges in providing health care to service members.
Program Authorities and Responsibilities
The supplemental health care program operates under a defined structure of authorities and responsibilities to ensure effective governance and administration.
- Uniformed Services: Each uniformed service has the authority to establish additional procedures to effectively administer the supplemental care program within their respective service branches, as long as these procedures are consistent with the overarching regulations.
- Assistant Secretary of Defense for Health Affairs: This office holds responsibility for the overall policy direction of the supplemental care program and for the administration of Part 199 regulations pertaining to the program.
- Director, OCHAMPUS: The Director, OCHAMPUS is tasked with issuing procedural requirements for implementing the supplemental health care program. This includes setting requirements for claims submission, which are similar to those established by § 199.7, ensuring consistency and clarity in program operations.
Conclusion
The supplemental health care program is a vital resource for active duty members of the uniformed services, ensuring access to necessary health care services through civilian providers. By mirroring many aspects of TRICARE while incorporating specific provisions like no cost-sharing and the TRICARE Prime Remote program, it addresses the unique health care needs of military personnel. Understanding the purpose, benefits, and operational aspects of this program is crucial for both service members and health care providers to effectively utilize and support the health and readiness of the U.S. armed forces.
