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Supplemental Health Care Insurance
The purpose of Supplemental Health Care Insurance is to implement, with respect to health care services provided under the supplemental health care program for active duty members of the uniformed services, the provision of 10 U.S.C. 1074(c). This section of law authorizes DoD to establish for the supplemental care program the same payment rules, subject to appropriate modifications, as apply under CHAMPUS (Civilian Health And Medical Program Of The Uniformed Services). |
| Supplemental Medical Insurance offers voluntary employee health insurance benefits including
dental, accident, life, cancer, long-term care, and short-term
disability. |
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This section applies to the program, known as the supplemental care program, which provides for the payment by the uniformed services to private sector health care providers for health care services provided to active duty members of the uniformed services. |
Although not part of CHAMPUS, the Supplemental Health Care Insurance program is similar to CHAMPUS in that it is a program for the uniformed services to purchase civilian health care services for active duty members. For this reason, the Director, OCHAMPUS assists the uniformed services in the administration of the Supplemental Health Care Insurance program.
This section applies to all health care services covered by the CHAMPUS. For purposes of this section, health care services ordered by a military treatment facility (MTF) provider for an MTF patient who is not an active duty member for whom the MTF provider maintains responsibility are also covered by the Supplemental Health Care Insurance program and subject to the requirements of this section. (b) Obligation of providers concerning payment for supplemental health care for active duty members-(1) Hospitals covered by DRG-based payment system. For a hospital covered by the CHAMPUS DRG-based payment system to maintain its status as an authorized provider for CHAMPUS pursuant to Sec. 199.6, that hospital must also be a participating provider for purposes of the Supplemental Health Care Insurance program. As a participating provider, each hospital must accept the DRG-based payment system amount determined pursuant to Sec. 199.14 as payment in full for the hospital services covered by the system. The failure of any hospital to comply with this obligation subjects that hospital to exclusion as a CHAMPUS-authorized provider.
For any institutional or individual provider, other than those described in paragraph (b)(1) of this section that is a participating provider, the provider must also be a participating provider for purposes of the Supplemental Health Care Insurance program. The provider must accept the CHAMPUS allowable amount determined pursuant to Sec. 199.14 as payment in full for the hospital services covered by the system. The failure of any provider to comply with this obligation subjects the provider to exclusion as a participating provider. (c) General rule for payment and administration. Subject to the special rules and procedures in paragraph (d) of this section and the waiver authority in paragraph (e) of this section, as a general rule the provisions of Sec. 199.14 shall govern payment and administration of claims under the Supplemental Health Care Insurance program as they do claims under CHAMPUS. To the extent necessary to interpret or implement the provisions of Sec. 199.14, related provisions of this part shall also be applicable.
Preauthorization by the Uniformed Services of each service is required for the Supplemental Health Care Insurance program except for services in cases of medical emergency (for which the definition in Sec. 199.2 shall apply) or in cases governed by the TRICARE Prime Remote program for active duty services members set forth in paragraph (e) of this section. It is the responsibility of the active duty members to obtain preauthorization for each service. With respect to each emergency inpatient admission, after such time as the emergency condition is addressed, authorization for any proposed continued stay must be obtained within two working days of admission. (3) With respect to the filing of claims and similar administrative matters for which this part refers to activities of the CHAMPUS fiscal intermediaries, for purposes of the Supplemental Health Care Insurance program, responsibilities for claims processing, payment and some other administrative matters may be assigned by the Director, OCHAMPUS to the same fiscal intermediaries, other contractor, or to the nearest military medical treatment facility or medical claims office.
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| Supplemental Medical Insurance does not cover eye and hearing exams, foot care, immunizations, or physical exams. |
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