Civilian Health and Medical Program of the Department of Veterans Affairs
Proposed rule.
CFR Part: "38 CFR Part 17"
RIN Number: "RIN 2900-AP02"
Citation: "83 FR 2396"
Page Number: "2396"
"Proposed Rules"
SUMMARY: The
EFFECTIVE DATE: Written comments must be received on or before
ADDRESSES: Written comments may be submitted through http://www.Regulations.gov; by mail or hand-delivery to the Director, Regulation and Policy Management (00REG),
FOR FURTHER INFORMATION CONTACT:
SUPPLEMENTARY INFORMATION:
Under section 1781,
VA interprets the mandate in 38 U.S.C. 1781(b) to administer CHAMPVA in the "same or similar manner . . . as medical care is furnished . . . under title 10 chapter 55 (CHAMPUS)" to mean that we must generally administer CHAMPVA in a "same or similar manner" as the TRICARE Standard plan. The phrase "same or similar manner" does not require the programs to be administered in an identical manner. Rather, we broadly interpret this language as affording us needed flexibility to administer the program for CHAMPVA beneficiaries. For this reason, not every aspect of CHAMPVA will find a corollary in the TRICARE Standard Plan.
TRICARE has undergone changes in legal authority and policy that have prompted these proposed revisions to our CHAMPVA regulations. This rulemaking is intended to ensure that our regulations continue to be, again broadly speaking, the same or similar to the regulations and policies governing TRICARE. As noted throughout this proposed rule, there are necessary variations from TRICARE, particularly due to TRICARE's current benefit structure with varying degrees of medical benefits under multiple plan options, but we believe these variations satisfy the same or similar requirement in 38 U.S.C. 1781(b).
This rulemaking also proposes clarifications and revisions that will improve our ability to effectively administer CHAMPVA, as well as technical revisions to make our regulations more understandable.
17.270 General Provisions and Definitions
Current SEC 17.270(a) broadly discusses general administrative provisions of CHAMPVA, and current
Proposed SEC 17.270(a) would continue to provide an overview of CHAMPVA, including a general summary of the manner in which CHAMPVA is administered. We would refer to CHAMPUS, as we do in the current regulation, but would also reference TRICARE because the reference to CHAMPUS is outdated, as explained above, and may be misunderstood by CHAMPVA beneficiaries. Current
Proposed SEC 17.270(a)(1) would state that an authorized non-
With regards to CHAMPVA beneficiaries receiving care in
Proposed SEC 17.270(a)(3) would newly indicate in regulation that outpatient prescription medications may be provided to certain CHAMPVA beneficiaries through Medications by Mail (MbM), administered by
Proposed paragraph (a)(3)(ii) would provide that smoking cessation pharmaceutical supplies are available only through MbM. Section 713 of the Duncan Hunter National Defense Authorization Act for Fiscal Year 2009, Public Law 110-417 (
For clarity, we would establish abbreviations for the
Proposed SEC 17.270(b) would establish definitions for the CHAMPVA regulations. We would define "accepted assignment" as the action of an authorized non-
We would define "calendar year" as the period of time between and including
The term "CHAMPVA beneficiary" would be defined as a person enrolled for CHAMPVA under
We would define "CHAMPVA-covered services and supplies" to mean those medical services and supplies that are medically necessary and appropriate for the treatment of a condition and that are not specifically excluded from coverage under proposed
We would define "CHAMPVA determined allowable amount" by referencing the proposed paragraph that would relate to this term, proposed
We would define "CHAMPVA In-house Treatment Initiative (CITI)" to mean the initiative under section 1781(b) under which participating
We would define the term "child" consistent with 38 U.S.C. 101, as we do in the current regulation at
We would define the term "claim" consistent with the current use and understanding of the term in the context of CHAMPVA, as a request by an authorized non-
We would define "fiscal year" as the period of time starting on
We would define "Medications by Mail (MbM)" to mean the initiative under which
We would define "other health insurance" (OHI) as a health insurance plan or program (to include Medicare) or third-party coverage that provides coverage to a CHAMPVA beneficiary for expenses incurred for medical services and supplies. The inclusion of Medicare is consistent with the TRICARE regulation related to double coverage. See 32 CFR 199.8(d)(1).
We would define the term "payer" to mean OHI, as defined in this rulemaking, that is obligated to pay for CHAMPVA-covered medical services and supplies. In a situation in which more than one insurer is responsible to pay for such services and supplies (e.g., a "double coverage" situation), there would be a primary payer (i.e., the payer obligated to pay first), a secondary payer (i.e., the payer obligated to pay after the primary payer), etc. In double coverage situations, CHAMPVA would be the last payer, after payment by the primary payer and all other secondary payers.
Defining a "payer" and designating different payer types would not affect the administration of CHAMPVA because these concepts of relative payment responsibility are all accepted and understood by the insurance industry and current CHAMPVA beneficiaries and are an essential part of current CHAMPVA billing practices. For instance, Medicare would be the primary payer in situations governed by current
The definition of "service-connected" in current
Consistent with the waiver provisions of TRICARE, see 32 CFR 199.1(n), new proposed paragraph (c) would establish the discretionary authority of
17.271 Eligibility
Current SEC 17.271 identifies persons who may be eligible for CHAMPVA benefits. We would revise
17.272 Benefits Limitations/Exclusions
Current SEC 17.272 provides general information about what medical services and supplies are covered by CHAMPVA and lists coverage limitations along with the exclusions. The general information concerning coverage in current
Current SEC 17.272(a)(2) excludes the provision of services and supplies required as a result of an occupational disease or injury for which benefits are payable under workers' compensation or a similar protection plan. We propose to update the verbiage to clarify the exclusion for the reader.
Current SEC 17.272(a)(3) excludes the provision of services and supplies that are paid directly or indirectly by local, State, or Federal government agencies, with certain exceptions listed in
Current SEC 17.272(a)(21) excludes dental care generally, with exceptions to such exclusion listed in paragraphs (a)(21)(i) through (xii). We would amend paragraph (a)(21)(ix) to clarify that the provision of initial imaging services for the treatment of temporomandibular joint disorder (TMD) could specifically include Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) services. We believe the sole reference to "initial radiographs" in current
A majority of the remaining proposed changes to CHAMPVA coverage exclusions in proposed
List of Comparable CHAMPVA and TRICARE Exclusions CHAMPVA provision (identified paragraphs TRICARE provision (identified are from 38 CFR 17.272(a)) paragraphs are from 32 CFR 199.4(g), or as otherwise noted) (1) (11). (2) (23). (3) (13). (4) (1). (5) (2). (6) (3). (7) (4). (8) (5). (9) (6). (10) (7). (11) (8). (12) (9). (13) (14). (14), (81) (15). (15) (16). (16) (17). (17) (19). (18) (21). (19), (82) (24). (20) (26). (21) (27). (22) (28). (23) (29). (24) (30). (25) (31). (27) (33). (28) (34). (29) (35). (30) (36). (31) (37). (32) (38). (33) (39). (34) (40). (35) (41). (36) (20), (42). (37) (43). (38) (44). (40) (46). (41) (47). (42) (50). (43) (51). (44) (48). (45) (49). (46) (52). (47) (53). (48) (54). (49) (55). (50) (56). (51) (57). (52) (58). (53) (60). (54) (61). (55), (57) (62). (56) (64). (57) (65). (58) (66). (59) (67). (60) (72). (62) 32 CFR 199.4(a)(12) and (b)(10)(iv). (63) through (65) 32 CFR 199.4(e)(4) and (h). (66) (73). (67), (68) 32 CFR 199.2(b) and 199.4(e)(2). (69) 32 CFR 199.4(c)(3)(ix) and 199.4(e)(4). (70), (71) 32 CFR 199.4(e)(17). (73) 32 CFR 199.4(g)(15)(iv). (74) (69). (75) 32 CFR 199.4(a)(1). (76) 32 CFR 199.4(g)(74). (77) (39), (42). (78) (25). (79) 32 CFR 199.4(g)(15). (80) 32 CFR 199.2(b) and 199.4(b)(2)(v), (b)(3)(iii), (b)(5)(v), (d)(3)(vi), (e)(11)(i). (83) 32 CFR 199.4(c)(2), (c)(3), (e)(8)(i)(E). (84) 32 CFR 199.4(e)(8). (85), (86) 32 CFR 199.2(b), 199.4(e)(8), (g)(24).
We note that even where our current provisions are not identical to a TRICARE provision, our intent has consistently been to apply CHAMPVA comparable exclusions or limitations in the same or similar manner to their TRICARE counterpart in accordance with 38 U.S.C. 1781(b). The same is true for our proposed revisions below, which are consistent with changes in
The first change we would make to our limitations and exclusions based on TRICARE regulatory and policy changes concerns current
Under section 711 of the 2009 NDAA, TRICARE must waive all beneficiary costs associated with certain preventive services, unless the beneficiary is also Medicare-eligible. TRICARE regulations were revised to delete from 32 CFR 199.4(g)(37) the list of preventive services not excluded from coverage, and these services were moved to new
We note that the TRICARE final rule that implemented the amendments made by section 711 of the 2009 NDAA does not include an annual physical exam benefit for all TRICARE beneficiaries; instead, such benefit is limited to certain dependents of Active Duty military personnel who are traveling outside
We also note that we would except "[v]accinations/immunizations" from the general exclusion of preventive services. Although subsection (d)(1)(F) of section 711 of the 2009 NDAA exempts "vaccination" only, TRICARE's guidance on this issue additionally exempts immunizations. See TRICARE Reimbursement Manual 6010.61-
Current SEC 17.272(a)(39) excludes coverage for audiological services or speech therapy, except when prescribed by a physician and rendered as part of a treatment addressing a physical defect, which correlates with a provision not addressed in the chart above because it has been removed from TRICARE regulations. See 75 FR 50880 (
As stated earlier in this rulemaking, pursuant to section 713 of the 2009 NDAA, TRICARE must make available smoking cessation benefits, as specified in the law, to beneficiaries who are not also eligible for Medicare. The four categories of smoking cessation benefits available to these beneficiaries are set forth in TRICARE's regulations under 32 CFR 199.4(e)(30)(ii)(A)-(D). Hence, we would revise our regulations by removing our correlate restriction on smoking cessation services and supplies in current
Redesignated paragraphs (a)(57) through (59) would be revised to reference coverage of mental health benefits in a "calendar year" versus the current reference to "fiscal year." We propose to change the yearly basis of this coverage because our beneficiaries and providers are more familiar with calendar year events, and the impact of the change from fiscal to calendar on the functioning of CHAMPVA would be minimal.
With the proposed removal of
Current SEC 17.272(a)(72) excludes from coverage drug maintenance programs where one addictive drug is substituted for another such as methadone substituted for heroin. A TRICARE final rule published on
Current SEC 17.272(a)(80), as proposed to be redesignated as paragraph (a)(76), excludes from CHAMPVA benefits medications not requiring a prescription, except for insulin and related diabetic testing supplies and syringes. We would revise redesignated paragraph (a)(76) to instead exclude "over-the-counter products" and would additionally expand the exception to this exclusion to cover over-the-counter smoking cessation pharmaceutical supplies that are approved by the
Section 702 of the 2013 NDAA grants the Secretary of Defense the authority to add certain over-the-counter medications to the TRICARE formulary so that such medications may be administered as if they were prescription medications. CHAMPVA does not have a same or similar uniform formulary as
Lastly, we would add two new exclusions to
Due to the multiple proposed deletions and additions in
Current SEC 17.272(b) establishes the "CHAMPVA determined allowable amount," and paragraph (b)(1) states that the term "allowable amount" is the maximum amount that CHAMPVA will pay an authorized provider for a covered benefit, which is determined prior to cost sharing and the application of deductibles or OHI. (This means, for instance, that the cost-share would be a percentage of the entire CHAMPVA determined allowable amount.) However, this is merely a definition and not a statement of coverage limitation or exclusions. We would revise paragraph (b) to clearly indicate that amounts above the CHAMPVA determined allowable amount are excluded from CHAMPVA coverage. The actual payment methodology--the amount to which cost sharing and deductibles will be applied--is addressed in proposed
Proposed SEC 17.272(b)(1) would explain that the CHAMPVA determined allowable amount is the maximum level of payment to an authorized non-
Current SEC 17.272(b)(2) states that a Medicare-participating hospital must accept the CHAMPVA determined allowable amount for inpatient services as payment in full and references 42 CFR parts 489 and 1003. While this is a true statement of law under 42 CFR 489.25, the references to 42 CFR parts 489 and 1003 are vague, and part 1003 is not relevant to the issue of what amounts Medicare-participating hospitals must accept as payment in full from CHAMPVA. See 42 CFR part 1003 (describing civil money penalties, assessments, and exclusions generally for individuals who violate provisions of or agreements with Federal health care programs). Proposed
Section 503 of The Caregivers and Veterans Omnibus Health Services Act of 2010, Public Law 111-163, revised 38 U.S.C. 1781 by adding new subsection (e), which states: "Payment by the Secretary under this section on behalf of a covered beneficiary for medical care shall constitute payment in full and extinguish any liability on the part of the beneficiary for that care." Current
Current SEC 17.272(b)(4) provides that a provider who has collected and not made an appropriate refund, or attempts to collect from the beneficiary any amount in excess of the CHAMPVA determined allowable amount may be subject to exclusion from Federal benefit programs. The underlying authority for this rule is 42 CFR 1003.105, which establishes the terms for a health care provider's permissive or mandatory exclusion from participation in the Medicare program and other Federal health care programs. Exclusion may result, for instance, if a provider files false claims under these programs. We would move this information to proposed
17.273 Preauthorization
CHAMPVA preauthorization requirements for certain medical care and services are based on CHAMPVA needs and are substantially the same or similar as those required by TRICARE. See 32 CFR 199.4 passim. We propose to revise the preauthorization requirements by adding language to indicate when a beneficiary has "other health insurance" that provides primary coverage for the benefit, preauthorization requirements will not apply. TRICARE waives preauthorization requirements in all instances when OHI, to include Medicare, is the primary payer. See TRICARE Policy Manual 6010.60-M, Chapter 1 ("Administration"), section 6.1 ("Special Authorization Requirements") (
Finally, we would add new proposed
17.274 Cost Sharing
Current SEC 17.274(a) provides in general that CHAMPVA is a cost sharing program in which the cost of CHAMPVA-covered services and supplies is shared with the beneficiary, with the exception of services obtained through
Subsections (d)(1)(A) through (d)(1)(F) of section 711 of the 2009 NDAA, as discussed earlier, set forth certain preventive services for which TRICARE waives all out-of-pocket costs, even if the beneficiary has not paid the amount necessary to cover the beneficiary's deductible requirement for the year. We propose to revise
For TRICARE, the waiver of beneficiary costs associated with preventive services in proposed
The general provisions in current
Current SEC 17.274(c) establishes a calendar year limit on the "cost-share amount" incurred by a CHAMPVA beneficiary through the payment of both cost-shares and deductible amounts (See current 38 CFR 17.274(c), indicating that the cap is "limited to the applied annual deductible(s) and the beneficiary cost-share amount."). Proposed
We do not propose any substantive changes to current
We propose to add a new paragraph (e) to
In accordance with current practice, and as proposed in
Proposed SEC 17.274(e)(2) would establish the CHAMPVA beneficiary cost share for covered inpatient facility services and supplies that are subject to the CHAMPVA mental health low volume per diem reimbursement methodology. This methodology covers mental health inpatient services for lower volume hospitals and units (less than 25 mental health discharges per federal fiscal year). For these services, the CHAMPVA beneficiary cost share would be the lesser of a fixed per diem amount multiplied by the number of inpatient days or 25 percent of the hospital's billed charges. This calculation is similar to that used in TRICARE regulations. See 32 CFR 199.4(f)(3)(ii)(B) and (f)(8)(ii).
Although, as noted above, a majority of the CHAMPVA cost-share methodologies are the same or similar as TRICARE's, we would not adopt a recent TRICARE exception to its general 25 percent cost-share rule for prescription medications. Section 712 of the 2013 NDAA requires the Secretary of
17.275 CHAMPVA Determined Allowable Amount Calculation
We propose to add a new
Proposed SEC 17.275(a) would establish in regulation the CHAMPVA determined allowable amount for reimbursement of inpatient hospital services based on the CHAMPVA DRG-based payment system. Proposed paragraph (a) would explain that, unless exempt or subject to a methodology in proposed paragraph (b) or (c), hospital services provided in the 50 States, the
Proposed SEC 17.275(b) would establish in regulation the current CHAMPVA inpatient mental health per diem payment system used to calculate reimbursement for inpatient mental health hospital care in specialty psychiatric hospitals and psychiatric units of general acute hospitals that are exempt from the CHAMPVA DRG-based payment system. The per diem rate would be calculated based on the daily rate times the number of days (length of stay). CHAMPVA's mental health per diem rates are updated each fiscal year for both high volume hospitals (25 or more discharges per fiscal year) and low volume hospitals (less than 25 discharges per fiscal year). The per diem rates used by CHAMPVA are determined by TRICARE per diem rates. See 32 CFR 199.14(a).
Proposed SEC 17.275(c) would establish in regulation the CHAMPVA CTC payment system that is used to calculate the CHAMPVA determined allowable amount for inpatient services furnished by hospitals or facilities that are exempt from the CHAMPVA DRG-based payment system or the CHAMPVA inpatient mental health per diem payment system. TRICARE establishes an alternate methodology to calculate payments for inpatient services that are exempt from its DRG and inpatient mental health per diem payment systems. See 32 CFR 199.14(a)(4). Proposed
Proposed SEC 17.275(d) would establish in regulation the CHAMPVA outpatient prospective payment system (OPPS) used to calculate the allowable amount for outpatient services provided in a hospital subject to Medicare OPPS. This will include the utilization of TRICARE's reimbursement methodology to include specific coding requirements, ambulatory payment classifications (APCs), nationally established APC amounts, and associated adjustments (e.g., discounting for multiple surgery procedures, wage adjustments for variations in labor-related costs across geographical regions, and outlier calculations). The CHAMPVA OPPS is the same as that utilized by TRICARE under 32 CFR 199.14, which is similar to Medicare's basic OPPS methodology. There are differences between TRICARE's OPPS methodology and Medicare's basic OPPS methodology due to variations in benefit structure and beneficiary population. CHAMPVA is adopting TRICARE's OPPS because the CHAMPVA beneficiary population is more similar to the TRICARE beneficiary population than to the Medicare beneficiary population. See 32 CFR 199.14(a)(6)(ii).
Proposed SEC 17.275(e) would establish in regulation the reimbursement methodology for services and supplies provided by authorized non-
Proposed SEC 17.275(f) would establish in regulation the current payment methodology for outpatient CHAMPVA pharmacy points of service. CHAMPVA negotiates rates with retail pharmacies through its contract with the pharmacy benefit manager. For services and supplies obtained from a retail "in-network" pharmacy, proposed
Proposed SEC 17.275(g) would set forth in regulation the current CHAMPVA reimbursement methodology for the provision of services in a Skilled Nursing Facility (SNF). This methodology is based on the CMS prospective payment system for SNFs under 42 CFR part 413, subpart J (
Proposed SEC 17.275(h) would set forth in regulation the current reimbursement methodology for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Reimbursement of DMEPOS would be based on the same amounts established under the CMS DMEPOS fee schedule under 42 CFR part 414, subpart D, which is the same methodology used in TRICARE regulations to calculate DMEPOS payments. See 32 CFR 199.14(k). The allowed amount would be that which is in effect in the specific geographic location at the time CHAMPVA-covered services and supplies are provided to a CHAMPVA beneficiary.
Proposed SEC 17.275(i) would establish in regulation the current payment methodology for all ambulance services. CHAMPVA adopts Medicare's Ambulance Fee Schedule (AFS) for ambulance services, which is based on the same methodology used by TRICARE. See TRICARE Reimbursement Manual 6010.61-M, Chapter 1 ("General"), section 14 ("Ambulance Services") (
Proposed SEC 17.275(j) would establish in regulation the current reimbursement methodology for hospice care. This methodology uses rates in the CMS hospice per diem rate payment system, which is the same methodology used in TRICARE regulations to calculate hospice payments. See 32 CFR 199.14(g)(9).
Proposed SEC 17.275(k) would establish in regulation a reimbursement methodology for intermittent or part-time home health services similar to the methodology used in TRICARE, which is based on Medicare's payment methods and rates. See 32 CFR 199.14(h). Under this methodology, a fixed case-mix and wage-adjusted national 60-day episode payment amount will act as payment in full for costs associated with furnishing home health services with exceptions allowing for additional payment to be established. This would be a new limitation in payments for services but is in line with the 60-day episode amount specified in the TRICARE regulation. See 32 CFR 199.14(h).
Proposed SEC 17.275(l) would establish in regulation the current reimbursement methodology for facility charges associated with procedures performed in a freestanding surgery center, which is the basis of a prospectively determined amount, similar to that used by TRICARE. See 32 CFR 199.14(d). These facility charges would not include physician fees, anesthesiologist fees, or fees of other authorized non-
Proposed SEC 17.275(m) states that
Proposed SEC 17.275(n) would establish in regulation the reimbursement methodology for inpatient services provided in a
17.276 Claim-Filing Deadlines
Proposed SEC 17.276 is a revision and renumbering of current
Proposed SEC 17.276(c) would clarify that claims for services and supplies provided to an individual before the date of the event that qualifies the individual as eligible under
We further propose to add new paragraph (d) to proposed
17.277 Appeals
Proposed SEC 17.277 is a revision and renumbering of current
We propose to renumber current SUBSEC 17.277-17.278 to SUBSEC 17.278-17.279. Additionally, as with proposed
Effect of Rulemaking
The Code of Federal Regulations, as proposed to be revised by this proposed rulemaking, would represent the exclusive legal authority on this subject. No contrary rules or procedures would be authorized. All
Paperwork Reduction Act
This proposed rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521).
Regulatory Flexibility Act
The Secretary hereby certifies that this proposed rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. The new proposed payment methods in this rulemaking will include new reimbursement rates for the Outpatient Prospective Payment System (OPPS), Home Health Prospective Payment System (HH PPS), and Sole Community Hospitals (SCHs) reimbursement methodologies. These revised methodologies would not significantly affect small businesses due to the following reasons: (1) The health care industry, to include Medicare and TRICARE, is currently using these payment methods and most providers are used to these reimbursement rates, if not expecting to receive them; (2) CHAMPVA's beneficiary population is relatively small compared to these other health care payers. Further support and data can also be found in
Executive Orders 12866, 13563 and 13771
Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages; distributive impacts; and equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 (Regulatory Planning and Review) defines a "significant regulatory action," which requires review by the
The economic, interagency, budgetary, legal, and policy implications of this regulatory action have been examined and OMB has determined the regulatory action to be economically significant, because it will have an annual effect on the economy of
This proposed rule is not expected to be subject to the requirements of EO13771 because this proposed rule is expected to result in no more than de minimis costs.
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, or tribal governments, in the aggregate, or by the private sector, of
Catalog of Federal Domestic Assistance
The Catalog of Federal Domestic Assistance numbers and titles for the programs affected by this document are 64.009, Veterans Medical Care Benefits; 64.010, Veterans
Signing Authority
The Secretary of
List of Subjects in 38 CFR Part 17
Administrative practice and procedure, Archives and records, Claims, Dental health, Drug abuse, Health care, Health facilities, Health professions, Health records, Medical devices, Mental health programs, Nursing homes, Veterans.
Dated:
Director,
For the reasons stated in the preamble, The
PART 17--MEDICAL
1. The authority citation for part 17 continues to read in part as follows:
Authority: 38 U.S.C. 501, and as noted in specific sections.
* * * * *
2. Revise
(a) Overview of CHAMPVA. CHAMPVA is the
(1) By an authorized non-
(2) By a
(3) Through VA Medications by Mail (MbM).
(i) Only CHAMPVA beneficiaries who do not have any other type of health insurance that pays for prescriptions, including Medicare Part D, may use MbM.
(ii) Smoking cessation pharmaceutical supplies will only be provided through MbM and only to CHAMPVA beneficiaries that are not also eligible for Medicare.
(b) Definitions. The following definitions apply to CHAMPVA (SUBSEC 17.270 through 17.278):
Accepted assignment refers to the action of an authorized non-
Authorized non-
(i) Is licensed or certified by a State to provide the medical services and supplies; or
(ii) Where a State does not offer licensure or certification, is otherwise certified by an appropriate national or professional association that sets standards for the specific medical provider.
Calendar year means
CHAMPVA beneficiary means a person enrolled under
CHAMPVA-covered services and supplies mean those medical services and supplies that are medically necessary and appropriate for the treatment of a condition and that are not specifically excluded under
CHAMPVA determined allowable amount has the meaning set forth in
CHAMPVA In-house Treatment Initiative (CITI) means the initiative under 38 U.S.C. 1781(b) under which participating
Child has the definition established in 38 U.S.C. 101.
Claim means a request by an authorized non-
Fiscal year means
Medications by Mail (MbM) means the initiative under which
Other health insurance (OHI) means health insurance plans or programs (including Medicare) or third-party coverage that provide coverage to a CHAMPVA beneficiary for expenses incurred for medical services and supplies.
Payer refers to OHI, as defined in this section, that is obligated to pay for CHAMPVA-covered medical services and supplies. In a situation in which, in addition to CHAMPVA, one or more payers is/are responsible to pay for such services and supplies (i.e., a "double coverage" situation), there would be a primary payer (i.e., the payer obligated to pay first), secondary payer (i.e., the payer obligated to pay after the primary payer), etc. In double coverage situations, CHAMPVA would be the last payer.
Service-connected has the definition established in 38 U.S.C. 101.
Spouse refers to a person who is married to a veteran and whose marriage is valid as determined under 38 U.S.C. 103(c).
Surviving spouse refers to a person who was married to and is the widow(er) of a veteran as determined under 38 U.S.C. 103(c).
(c) Discretionary authority. When it is determined to be in the best interest of
(Authority: 38 U.S.C. 501, 1781)
3. Amend
a. Removing the word "and" at the end of paragraph (a)(3).
b. Redesignating paragraph (a)(4) as paragraph (a)(5).
c. Adding a new paragraph (a)(4).
d. Revising the authority citation following paragraph (a).
The addition and revision read as follows:
(a) * * *
(4) An individual designated as a Primary Family Caregiver, under 38 CFR 71.25(f), who is not entitled to care or services under a health-plan contract (as defined in 38 U.S.C. 1725(f)(2)); and
* * * * *
(Authority: 38 U.S.C. 501, 1720G(a)(7)(A), 1781)
* * * * *
4. Amend
a. Revising paragraph (a)(2).
b. In paragraph (a)(3) introductory text, removing the phrase "(Medicaid excluded)".
c. Adding paragraphs (a)(3)(iii) and (iv).
d. Revising paragraph (a)(21)(ix).
e. Removing paragraph (a)(26).
f. Redesignating paragraphs (a)(27) through (38) as paragraphs (a)(26) through (37), respectively.
g. In newly redesignated paragraph (a)(30), revising the introductory text and paragraphs (a)(30)(v) and (vi) and adding paragraphs (a)(30)(xi) through (xiv).
h. Removing paragraph (a)(39).
i. Redesignating paragraphs (a)(40) through (56) as paragraphs (a)(38) through (54), respectively.
j. In newly redesiganted paragraph (a)(40)(iv), removing "(a)(42)(iii)(A)" and adding in its place "(a)(40)(iii)(A)."
k. Removing paragraph (a)(57).
l. Redesignating paragraphs (a)(58) through (71) as paragraphs (a)(55) through (68), respectively.
m. Revising newly redesignated paragraphs (a)(57) through (59).
n. Removing paragraph (a)(72).
o. Redesignating paragraphs (a)(73) through (86) as paragraphs (a)(69) through (82), respectively.
p. Revising newly redesignated paragraph (a)(76).
q. Adding paragraphs (a)(83) and (84).
r. Revising paragraph (b).
The revisions and additions read as follows:
(a) * * *
(2) Services and supplies required as a result of an occupational disease or injury for which benefits are payable under workers' compensation or similar protection plan (whether or not such benefits have been applied for or paid) except when such benefits are exhausted and the services and supplies are otherwise not excluded from CHAMPVA coverage.
(3) * * *
(iii)
(iv) CHAMPVA supplemental policies.
* * * * *
(21) * * *
(ix) Treatment for stabilization of myofascial pain dysfunction syndrome, also referred to as temporomandibular joint disorder (TMD). Authorization is limited to initial imaging such as radiographs, Computed Tomography, or Magnetic Resonance Imaging; up to four office visits; and the construction of an occlusal splint.
* * * * *
(30) Preventive care (such as employment-requested physical examinations and routine screening procedures). The following exceptions apply, including but not limited to:
* * * * *
(v) Cervical cancer screening.
(vi) Breast cancer screening.
* * * * *
(xi) Colorectal cancer screening.
(xii) Prostate cancer screening.
(xiii) Annual physical examination.
(xiv) Vaccinations/immunizations.
* * * * *
(57) Unless a waiver for extended coverage is granted in advance: Inpatient mental health services in excess of 30 days in any calendar year (or in an admission), in the case of a patient 19 years of age or older; 45 days in any calendar year (or in an admission), in the case of a patient under 19 years of age; or 150 days of residential treatment care in any calendar year (or in an admission).
(58) Outpatient mental health services in excess of 23 visits in a calendar year unless a waiver for extended coverage is granted in advance.
(59) Institutional services for partial hospitalization in excess of 60 treatment days in any calendar year (or in an admission) unless a waiver for extended coverage is granted in advance.
* * * * *
(76) Over-the-counter products except for pharmaceutical smoking cessation supplies that are approved by the
* * * * *
(83) Medications not approved by the
(84) Services and supplies related to the treatment of dyslexia.
(b) Costs of services and supplies to the extent such amounts are billed over the CHAMPVA determined allowable amount are specifically excluded from coverage.
(1) The CHAMPVA determined allowable amount is the maximum level of payment by CHAMPVA to an authorized non-
(2) A Medicare-participating hospital must accept the CHAMPVA determined allowable amount for inpatient services provided to a CHAMPVA beneficiary as payment in full. See 42 CFR 489.25.
(3) An authorized non-
* * * * *
5. Amend
a. Revising the introductory text and paragraph (d).
b. Removing paragraph (e).
c. Redesignating paragraph (f) as paragraph (e).
d. Adding new paragraph (f).
The revisions and addition read as follows:
Preauthorization or advance approval is required for any of the following, except when the benefit is covered by the CHAMPVA beneficiary's other health insurance (OHI):
* * * * *
(d) Dental care. For limitations on dental care, see
* * * * *
(f) CHAMPVA will perform a retrospective medical necessity review during the coordination of benefits process if:
(1) It is determined that CHAMPVA is the responsible payer for services and supplies but CHAMPVA preauthorization was not obtained prior to delivery of the services or supplies; and,
(2) The claim for payment is filed within the appropriate one-year period.
* * * * *
6. Amend
a. Revising paragraphs (a), (b), and (c).
b. Adding a heading for paragraph (d).
c. Adding paragraph (e).
The revisions and additions read as follows:
(a) Cost sharing generally. CHAMPVA is a cost sharing program in which the cost of covered services is shared with the CHAMPVA beneficiary. CHAMPVA pays the CHAMPVA determined allowable amount less the CHAMPVA deductible, if applicable, and less the CHAMPVA beneficiary cost share.
(1) CHAMPVA beneficiary cost-share requirements do not apply to the following:
(i) Supplies provided through VA MbM.
(ii) Any medical services and supplies provided to a CHAMPVA beneficiary through CITI.
(iii) The following services, even if not provided through CITI:
(A) Colorectal cancer screening.
(B) Breast cancer screening.
(C) Cervical cancer screening.
(D) Prostate cancer screening.
(E) Annual physical exams.
(F) Vaccinations/immunizations.
(G) Well child care from birth to age six, as described in
(iv) Hospice services.
(v) Or other services as determined by the Secretary of
(2) [Reserved]
(b) Deductibles. In addition to the CHAMPVA beneficiary cost share, an annual (calendar year) outpatient deductible requirement (
(1) CHAMPVA-covered services and supplies provided through VA MbM or through CITI.
(2) Inpatient services.
(3) Preventive services listed in paragraph (a)(1)(iii) of this section.
(4) Hospice services.
(5) Or other services as determined by the Secretary of
(c) Cost sharing limitations. To provide financial protection against the impact of a long-term illness or injury, there is a
(d) Non-payment. * * *
(e) Cost share calculation. The CHAMPVA beneficiary's cost-share amount, if not waived under paragraph (a)(1) of this section, is 25 percent of the CHAMPVA determined allowable amount in excess of the annual calendar year deductible (see
(1) For inpatient services subject to the
(i) The per diem rate multiplied by the number of inpatient days;
(ii) 25 percent of the hospital's billed amount; or
(iii) The base CHAMPVA DRG rate.
(2) For inpatient mental health low volume hospitals and units (less than 25 mental health discharges per federal fiscal year), the cost share is the lesser of:
(i) The fixed per diem rate multiplied by the number of inpatient days; or
(ii) 25 percent of the hospital's billed charges.
* * * * *
SUBSEC 17.275 through 17.278 [Redesignated as SUBSEC 17.276 through 17.279]
7. Redesignate SUBSEC 17.275 through 17.278 as SUBSEC 17.276 through 17.279.
8. Add new
CHAMPVA calculates the allowable amount in the following ways, for the following covered services and supplies:
(a) Inpatient hospital services (non-mental health). Unless exempt or subject to a methodology under paragraph (b) or (c) of this section, inpatient hospital services provided in the 50 States, the
(b) Inpatient hospital services (mental health). The CHAMPVA inpatient mental health per diem reimbursement methodology is used to calculate reimbursement for inpatient mental health hospital care in specialty psychiatric hospitals and psychiatric units of general acute hospitals that are exempt from the CHAMPVA DRG-based payment system. The per diem rate is calculated by multiplying the daily rate by the number of days (length of stay). The daily rate is updated each fiscal year for both high volume hospitals (25 or more discharges per fiscal year) and low volume hospitals (fewer than 25 discharges per fiscal year).
(c) Other inpatient hospital services. (1) The CHAMPVA CTC reimbursement methodology is used to calculate reimbursement for inpatient care furnished by hospitals or facilities that are exempt from either of the methodologies in paragraph (a) or (b) of this section. Such hospitals or facilities will be paid at the CHAMPVA CTC ratio times the billed charges that are customary and not in excess of rates or fees the hospital or facility charges the general public for similar services in a community.
(2) The following hospitals and services are subject to the CHAMPVA CTC payment methodology:
(i) Any hospital that qualifies as a cancer hospital under Medicare standards and has elected to be exempt from the
(ii) Christian Science sanatoriums.
(iii) Critical Access Hospitals.
(iv) Any hospital outside the 50 States, the
(v) Hospitals within hospitals.
(vi) Long-term care hospitals.
(vii) Non-Medicare participating hospitals.
(viii) Non-VA Federal Health Care Facilities (e.g., military treatment facilities,
(ix) Rehabilitation hospitals.
(x) Hospital or hospital-based services subject to State waiver in any State that has implemented a separate DRG-based payment system or similar payment system in order to control costs.
(xi) Hospitals and services as determined by the Secretary of
(d) Outpatient hospital services. The CHAMPVA outpatient prospective payment system (OPPS) is used to calculate the allowable amount for outpatient services provided in hospitals subject to Medicare OPPS. This will include the utilization of TRICARE's reimbursement methodology to include specific coding requirements, ambulatory payment classifications (APCs), nationally established APC amounts, and associated adjustments.
(e) Outpatient and inpatient non-hospital services. Payments to individual authorized non-
(1) The CHAMPVA Maximum Allowable Charge;
(2) The prevailing amount, which is the amount equal to the maximum reasonable amount allowed providers for a specific procedure in a specific locality; or,
(3) The billed amount.
(f) Pharmacy services and supplies. The CHAMPVA pharmacy services and supplies payment methodology is based on specific CHAMPVA pharmacy points of service, which dictate the amounts paid by
(1) For services and supplies obtained from a retail in-network pharmacy, the lesser of the billed amount or the contracted rate; or
(2) For supplies obtained from a retail out-of-network pharmacy, the lesser of the billed amount plus a dispensing fee or the average wholesale price plus a dispensing fee.
(g) Skilled Nursing Facility (SNF) care. The CHAMPVA SNF reimbursement methodology is based on the CMS prospective payment system for SNFs under 42 CFR part 413, subpart J (
(h) Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). The CHAMPVA DMEPOS reimbursement methodology is based on the same amounts established under the CMS DMEPOS fee schedule under 42 CFR part 414, subpart D. The CHAMPVA determined allowable amount for DMEPOS is the amount in effect in the specific geographic location at the time CHAMPVA-covered medical services and supplies are provided to a CHAMPVA beneficiary.
(i) Ambulance services. CHAMPVA adopts Medicare's Ambulance Fee Schedule (AFS) for ambulance services, with the exception of services furnished by a
(j) Hospice care. CHAMPVA hospice reimbursement methodology uses Medicare per diem hospice rates.
(k) Home health care (intermittent or part-time). CHAMPVA home health care reimbursement methodology, based on Medicare's home health prospective payment system, uses a fixed case-mix and wage-adjusted national 60-day episode payment amount to act as payment in full for costs associated with furnishing home health services with exceptions allowing for additional payment to be established.
(l) Ambulatory surgery. The CHAMPVA reimbursement methodology for facility charges associated with procedures performed in a freestanding ambulatory surgery center is based on a prospectively determined amount, similar to that used by TRICARE. These facility charges do not include physician fees, anesthesiologist fees, or fees of other authorized non-
(m) CHAMPVA-covered medical services and supplies provided outside
(n) Sole Community Hospitals. The CHAMPVA reimbursement methodology for inpatient services provided in a
(Authority: 38 U.S.C. 501, 1781)
9. Amend newly redesignated
b. Revising paragraphs (a) introductory text and (b).
c. Adding paragraphs (c) and (d).
The revisions and additions read as follows:
(a) Unless an exception is granted under paragraph (b) of this section, claims for medical services and supplies must be filed no later than:
* * * * *
(b) Requests for an exception to the claim filing deadline must be submitted in writing and include a complete explanation of the circumstances resulting in late filing along with all available supporting documentation. Each request for an exception to the claim filing deadline will be reviewed individually and considered on its own merit.
(c) Claims for CHAMPVA-covered services and supplies provided before the date of the event that qualifies an individual under
(d) CHAMPVA is the last payer to OHI, as that term is defined in
* * * * *
10. Revise newly redesignated
Notice of the initial determination regarding payment of CHAMPVA benefits will be provided to the CHAMPVA beneficiary on a CHAMPVA Explanation of Benefits (EOB) form. The EOB form is generated by the CHAMPVA automated payment processing system. If a CHAMPVA beneficiary or provider disagrees with the determination concerning CHAMPVA-covered services and supplies or calculation of benefits, he or she may request reconsideration. Such requests must be submitted to
(Authority: 38 U.S.C. 501, 1781)
11. Revise newly redesignated
VA will actively pursue medical care cost recovery in accordance with applicable law.
(Authority: 42 U.S.C. 2651; 38 U.S.C. 501, 1781)
[FR Doc. 2018-00332 Filed 1-16-18;
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