§ 199.14 Double coverage.

(a) Introduction. In enacting CHAMPUS legislation, Congress has clearly intended that CHAMPUS be secondary payer to all health benefit and insurance plans. Section 779 of Public Law 97-377 specifically provides that no CHAMPUS benefits "shall be available for the payment for any service or supply for persons enrolled in any other insurance, medical service, or health plan to the extent that the service or supply is a benefit under the other plan, except in the case of those plans administered under title XIX of the Social Security Amendments of 1965" (Medicaid). The underlying intent, in addition to preventing waste of Federal resources, is to ensure that CHAMPUS beneficiaries receive maximum benefits while ensuring that the combined payments of CHAMPUS and other health benefit and insurance plans do not exceed the total charges.

(b) Double coverage plan. A “double coverage plan" is one of the following:

(1) Insurance plan. An insurance plan is any plan or program which is designed to provide compensation or coverage for expenses incurred by a beneficiary for medical services and supplies. It includes plans or programs for which the beneficiary pays a premium to an issuing agent as well as those plans or programs to which the beneficiary is entitled by law or as a result of employment or membership in, or association with, an organization or group.

(2) Medical service or health plan. A medical service or health plan is any plan or program of an organized health care group, corporation or other entity for the provision of health care to an individual from plan providers, both professional and institutional. It includes plans or programs for which the beneficiary pays a premium to an issuing agent as well as those plans or programs to which the beneficiary is entitled by law or as a result of employment or membership in, or association with, an organization or group.

(3)

Exceptions.

plans do not include:

Double coverage

(i) Plans administered under title XIX of the Social Security Act (Medicaid);

(ii) Coverage specifically designed to supplement CHAMPUS benefits;

(iii) Entitlement to receive care from Uniformed Services Medical Care Facilities; or

(iv) Certain federal government programs, as prescribed by the Director, OCHAMPUS, which are designed to provide benefits to a distinct beneficiary population and for which entitlement does not derive from either premium payment or monetary contribution (e.g., the Indian Health Service).

(c) Application of double coverage provisions. CHAMPUS claims submitted for otherwise covered services and/or supplies, and which involve double coverage, shall be adjudicated as follows:

(1) CHAMPUS always last pay. For any claim which involves a double coverage plan as defined above, CHAMPUS shall be last pay, i.e., CHAMPUS benefits shall not be extended until all other double coverage plans have adjudicated the claim.

(2) Waiver of benefits. A CHAMPUS beneficiary may not elect to waive benefits under a double coverage plan and use CHAMPUS. Whenever double coverage exists, the provisions of this section shall be applied.

(3) Last pay limitations. CHAMPUS shall not pay more as a secondary payer than it would have in the absence of other coverage. Application of double coverage provisions does not extend or add to the CHAMPUS benefits as otherwise set forth in this and other sections of this regulation.

(d) Special considerations—(1) CHAMPUS and Medicare. In any double coverage situation involving Medicare, Medicare is always primary payer. When Part A, "Hospital Insurance", of Medicare is involved, the Medicare "lifetime reserve" benefit must be used before CHAMPUS benefits may be extended.

(2) CHAMPUS and Medicaid. Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always primary payer.

(3) CHAMPUS and worker's compensation. CHAMPUS benefits are not payable for work-related illness or injury which is covered under a worker's compensation program.

(4) Program for the Handicapped. All local resources must be considered and utilized before CHAMPUS benefits under the Program for the Handicapped may be extended. If a handicapped CHAMPUS beneficiary who is otherwise eligible for benefits under the Program for the Handicapped is eligible for other Federal, State, and/ or local assistance to the same extent as any other resident of citizen, CHAMPUS benefits are payable only on a secondary payer basis. The sponsor does not have the option of waiving available Federal, State, and/or local assistance in favor of using CHAMPUS benefits.

(e) Implementing instructions. The Director, OCHAMPUS (or a designee), shall issue such instructions, procedures, or guidelines as necessary to implement the intent of this section.

(Pub. L. 97-377)

[48 FR 28439, June 22, 1983]

§ 199.15 Federal Medical Care Recovery Act.

(a) General. The Federal Medical Care Recovery Act (FMCRA) (42 U.S.C. 2651-2653) provides that in any case in which the United States is authorized or required by law to furnish hospital, medical, surgical, or dental care and treatment to a person who is injured or suffers a disease under circumstances creating tort liability in some third person to pay damages for that care, the United States has a right to recover from the third person the reasonable value of the care and treatment furnished or to be furnished.

Example: A beneficiary is injured in an automobile accident caused by another person and the beneficiary requires medical care. The Government, under FMCRA, may recover from the negligent party the reasonable value of the medical treatment provided. This includes care that may be received by the beneficiary at a Uniformed Services facility or under CHAMPUS, or both in some instances.

(b) The relationship between the Government and the patient. The Government's right to recover the amounts expended for the patient's medical care is independent of the right the patient himself has to assert a claim against the third person for

damages. The existence of the Government's right, however, is dependent upon establishing liability of the third person under ordinary principles of law; i.e., upon providing that the third person tortiously caused the injury. The attorney for the injured beneficiary may also agree to represent the Government, and join both claims in a single action against the third person. If the attorney for the injured beneficiary does not wish to join the Government's claim with that of his or her client, and court action is required to recover the amount expended for the patient's medical care, intervention or an independent suit will be initiated by the United States for the reasonable value of the care of treatment provided.

(c) Value of care. The Office of Management and Budget has established rates for medical care provided by Uniformed Service facilities. For care in civilian facilities, the Government's CHAMPUS payment is used. The pa tient's share under CHAMPUS would remain the patient's responsibility. Guidance in this area may be obtained from the appropriate Uniformed Service legal assistance officer.

(d) Responsibility for recovery. The responsibility for recovering medical expenses incurred by the Government is that of designated appropriate legal officers of the Uniformed Services with the cooperation of the injured party.

(1) Army. All major installations have an officer designated Recovery Judge Advocate.

(2) Navy. The Naval Legal Service Office responsible for the claims Region in which the injury occurred.

(3) Air Force. Staff Judge Advocate at Air Force installations, General Court Martial jurisdictions at Major Commands and the Claims and Tort Litigation Division, Headquarters USAF/JAGC, Washington, D.C. 20314.

(4) Coast Guard, Public Health Service, National Oceanic and Atmospheric Administration. The Regional Attorney, Department of Health, Education, and Welfare.

(e) CHAMPUS obligation to notify Federal Claims Officer. In those instances where medical care is provided in civilian medical facilities and pay.

ment has been made for such care by a CHAMPUS Contractor, the CHAMPUS Contractor will promptly notify the appropriate claims officer in accordance with procedures established by the Director, OCHAMPUS.

(f) Private automobile insurance: Federal Claims Collection Act. Automobile insurance is not generally considered a medical insurance program although such policies may include payment for medical care. However, any amounts paid by CHAMPUS for medical care arising out of an automobile accident when these same amounts are also payable, in whole or in part, under a policy of automobile insurance, may be subject to recovery under the Federal Claims Collection Act (31 U.S.C. 951 SEQ.). The CHAMPUS Contractor therefore has a legal obligation to report all such cases to the appropriate legal departments of the Uniformed Services for appropriate recovery action.

§ 199.16 Appeal and hearing procedures.

(a) General. This section sets forth the policies and procedures for appealing decisions made by OCHAMPUS, OCHAMPUSEUR, and CHAMPUS fiscal intermediaries, adversely affecting the rights and liabilities of beneficiaries, participating providers, and providers denied the status of authorized provider under CHAMPUS. An appeal under CHAMPUS is an administrative review of program determinations made under the provisions of law and regulation. An appeal cannot challenge the propriety, equity or legality of any provision of law or regulation.

(1) Initial Determination-(i) Notice of Initial Determination and Right to Appeal.

(A) OCHAMPUS, OCHAMPUSEUR, and CHAMPUS fiscal intermediaries shall mail notices of initial determinations to the CHAMPUS beneficiary at the last known address. For beneficiaries who are under 18 years of age or who are incompetent, a notice issued to the parent or guardian, under established CHAMPUS procedures, constitutes notice to the beneficiary.

(B) CHAMPUS fiscal intermediaries and OCHAMPUSEUR shall notify providers of an initial determination on a claim only if the providers par

ticipated in the claim. (See § 199.13, "Claims Submission, Review and Payment.")

(C) Notice of an initial determination on a claim processed by a CHAMPUS fiscal intermediary or OCHAMPUSEUR normally shall be made on a CHAMPUS Explanation of Benefits (CEOB) form.

(D) Each notice of an initial determination on a request for benefit authorization, a request by a provider for approval as an authorized CHAMPUS provider, or a decision to disqualify or exclude a provider as an authorized provider under CHAMPUS shall state the reason for the determination and the underlying facts supporting the determination.

(E) In any case where the initial determination is adverse to the beneficiary or participating provider, or to the provider seeking approval as an authorized CHAMPUS provider, the notice shall include a statement of the beneficiary's or provider's right to appeal the determination. The procedure for filing the appeal also shall be explained.

(ii) Effect of Initial Determination. The initial determination is final unless appealed in accordance with this section, or unless the initial determination is reopened by OCHAMPUS or the CHAMPUS fiscal intermediary.

(2) Participation in an Appeal. Participation in an appeal is limited to any party to the initial determination, including CHAMPUS, and authorized representatives of the parties. Any party to the initial determination, except CHAMPUS, may appeal an adverse determination. The appealing party is the party who actually files the appeal.

(i) Parties to the Initial Determination. For purposes of the CHAMPUS appeals and hearing procedures, the following are not parties to an initial determination and are not entitled to administrative review under this sec

tion.

(A) A provider disqualified or excluded as an authorized provider under CHAMPUS based on a determination of abuse or fraudulent practices or procedures under another Federal or federally funded program is

(4) Program for the Handicapped. All local resources must be considered and utilized before CHAMPUS benefits under the Program for the Handicapped may be extended. If a handicapped CHAMPUS beneficiary who is otherwise eligible for benefits under the Program for the Handicapped is eligible for other Federal, State, and/ or local assistance to the same extent as any other resident of citizen, CHAMPUS benefits are payable only on a secondary payer basis. The sponsor does not have the option of waiving available Federal, State, and/or local assistance in favor of using CHAMPUS benefits.

(e) Implementing instructions. The Director, OCHAMPUS (or a designee), shall issue such instructions, procedures, or guidelines as necessary to implement the intent of this section.

(Pub. L. 97-377)

[48 FR 28439, June 22, 1983]

§ 199.15 Federal Medical Care Recovery Act.

(a) General. The Federal Medical Care Recovery Act (FMCRA) (42 U.S.C. 2651-2653) provides that in any case in which the United States is authorized or required by law to furnish hospital, medical, surgical, or dental care and treatment to a person who is injured or suffers a disease under circumstances creating tort liability in some third person to pay damages for that care, the United States has a right to recover from the third person the reasonable value of the care and treatment furnished or to be furnished.

Example: A beneficiary is injured in an automobile accident caused by another person and the beneficiary requires medical care. The Government, under FMCRA, may recover from the negligent party the reasonable value of the medical treatment provided. This includes care that may be received by the beneficiary at a Uniformed Services facility or under CHAMPUS, or both in some instances.

(b) The relationship between the Government and the patient. The Government's right to recover the amounts expended for the patient's medical care is independent of the right the patient himself has to assert a claim against the third person for

damages. The existence of the Government's right, however, is dependent upon establishing liability of the third person under ordinary principles of law; i.e., upon providing that the third person tortiously caused the injury. The attorney for the injured beneficiary may also agree to represent the Government, and join both claims in a single action against the third person. If the attorney for the injured beneficiary does not wish to join the Government's claim with that of his or her client, and court action is required to recover the amount expended for the patient's medical care, intervention or an independent suit will be initiated by the United States for the reasonable value of the care of treatment provided.

(c) Value of care. The Office of Management and Budget has established rates for medical care provided by Uniformed Service facilities. For care in civilian facilities, the Government's CHAMPUS payment is used. The patient's share under CHAMPUS would remain the patient's responsibility. Guidance in this area may be obtained from the appropriate Uniformed Service legal assistance officer.

(d) Responsibility for recovery. The responsibility for recovering medical expenses incurred by the Government is that of designated appropriate legal officers of the Uniformed Services with the cooperation of the injured party.

(1) Army. All major installations have an officer designated Recovery Judge Advocate.

(2) Navy. The Naval Legal Service Office responsible for the claims Region in which the injury occurred.

(3) Air Force. Staff Judge Advocate at Air Force installations, General Court Martial jurisdictions at Major Commands and the Claims and Tort Litigation Division, Headquarters USAF/JAGC, Washington, D.C. 20314.

(4) Coast Guard, Public Health Service, National Oceanic and Atmospheric Administration. The Regional Attorney, Department of Health, Education, and Welfare.

(e) CHAMPUS obligation to notify Federal Claims Officer. In those instances where medical care is provided in civilian medical facilities and pay

ment has been made for such care by a CHAMPUS Contractor, the CHAMPUS Contractor will promptly notify the appropriate claims officer in accordance with procedures established by the Director, OCHAMPUS.

(f) Private automobile insurance: Federal Claims Collection Act. Automobile insurance is not generally considered a medical insurance program although such policies may include payment for medical care. However, any amounts paid by CHAMPUS for medical care arising out of an automobile accident when these same amounts are also payable, in whole or in part, under a policy of automobile insurance, may be subject to recovery under the Federal Claims Collection Act (31 U.S.C. 951 SEQ.). The CHAMPUS Contractor therefore has a legal obligation to report all such cases to the appropriate legal departments of the Uniformed Services for appropriate recovery action.

§ 199.16 Appeal and hearing procedures.

(a) General. This section sets forth the policies and procedures for appealing decisions made by OCHAMPUS, OCHAMPUSEUR, and CHAMPUS fiscal intermediaries, adversely affecting the rights and liabilities of beneficiaries, participating providers, and providers denied the status of authorized provider under CHAMPUS. An appeal under CHAMPUS is an administrative review of program determinations made under the provisions of law and regulation. An appeal cannot challenge the propriety, equity or legality of any provision of law or regulation.

(1) Initial Determination—(i) Notice of Initial Determination and Right to Appeal.

(A) OCHAMPUS, OCHAMPUSEUR, and CHAMPUS fiscal intermediaries shall mail notices of initial determinations to the CHAMPUS beneficiary at the last known address. For beneficiaries who are under 18 years of age or who are incompetent, a notice issued to the parent or guardian, under established CHAMPUS procedures, constitutes notice to the beneficiary.

(B) CHAMPUS fiscal intermediaries and OCHAMPUSEUR shall notify providers of an initial determination on a claim only if the providers par

ticipated in the claim. (See § 199.13, "Claims Submission, Review and Payment.")

(C) Notice of an initial determination on a claim processed by a CHAMPUS fiscal intermediary or OCHAMPUSEUR normally shall be made on a CHAMPUS Explanation of Benefits (CEOB) form.

(D) Each notice of an initial determination on a request for benefit authorization, a request by a provider for approval as an authorized CHAMPUS provider, or a decision to disqualify or exclude a provider as an authorized provider under CHAMPUS shall state the reason for the determination and the underlying facts supporting the determination.

(E) In any case where the initial determination is adverse to the beneficiary or participating provider, or to the provider seeking approval as an authorized CHAMPUS provider, the notice shall include a statement of the beneficiary's or provider's right to appeal the determination. The procedure for filing the appeal also shall be explained.

(ii) Effect of Initial Determination. The initial determination is final unless appealed in accordance with this section, or unless the initial determination is reopened by OCHAMPUS or the CHAMPUS fiscal intermediary.

(2) Participation in an Appeal. Participation in an appeal is limited to any party to the initial determination, including CHAMPUS, and authorized representatives of the parties. Any party to the initial determination, except CHAMPUS, may appeal an adverse determination. The appealing party is the party who actually files the appeal.

(i) Parties to the Initial Determination. For purposes of the CHAMPUS appeals and hearing procedures, the following are not parties to an initial determination and are not entitled to administrative review under this sec

tion.

(A) A provider disqualified or excluded as an authorized provider under CHAMPUS based on a determination of abuse or fraudulent practices or procedures under another Federal or federally funded program is