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 . Beginning in fiscal year 1996, the annual enrollment fees are: (i) for dependents of active duty members in pay grades of E-4 and below, $0; (ii) for active duty dependents of sponsors in pay grades E-5 and above, $0; and (iii) for retirees and their dependents, $230 individual, $460 family. (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 annually by the Assistant Secretary of Defense (Health Affairs). (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 each of the following groups: dependents of active duty members in pay grade E-1 through E-4; dependents of active duty members in pay grades of E-5 and above; and 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 ancillary services (unless provided as part of an office visit for which a copayment is collected), family health services, home health care visits, eye examinations, and immunizations. (ii) There is a copayment for outpatient mental health visits. It is a per visit fee for dependents of active duty members in pay grades E-1 through E-4; for dependents of active duty members in pay grades of E-5 and above; and for retirees and their dependents for individual visits. For group visits, there is a lower per visit fee for dependents of active duty members in pay grades E-1 through E-4; for dependents of active duty members in pay grades of E-5 and above; and for retirees and their dependents. (iii) There is a cost share of durable medical equipment, prosthetic devices, and other authorized supplies for dependents of active duty members in pay grades E-1 through E-4; for dependents of active duty members in pay grades of E-5 and above; and for retirees and their dependents. (iv) For emergency room services, there is a per visit fee for dependents of active duty members in pay grades E-1 through E-4; for dependents of active duty members in pay grades of E-5 and above; and for retirees and their dependents. (v) For ambulatory surgery services, there is a per service fee for dependents of active duty members in pay grades E-1 through E-4; for dependents of active duty members in pay grades of E-5 and above; and 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 in pay grades E-1 through E-4; for dependents of active duty members in pay grades of E-5 and above; and for retirees and their dependents. (vii) There is a copayment for ambulance services for dependents of active duty members in pay grades E-1 through E-4; for dependents of active duty members in pay grades of E-5 and above; and for retirees and their dependents. (3) Amount of outpatient cost sharing requirements. Beginning in fiscal year 1996, 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 is as follows: (A) For dependents of active duty members in pay grades E-1 through E-4, $6; (B) For dependents of active duty members in pay grades of E-5 and above, $12; and (C) For retirees and their dependents, $12. (ii) For outpatient mental health visits, the per visit fee is as follows: (A) For individual outpatient mental health visits: ( 1 ) For dependents of active duty members in pay grades E-1 through E-4, $10; ( 2 ) For dependents of active duty members in pay grades of E-5 and above, $20; and ( 3 ) For retirees and their dependents, $25. (B) For group outpatient mental health visits, there is a lower per visit fee, as follows: ( 1 ) For dependents of active duty members in pay grades E-1 through E-4, $6; ( 2 ) For dependents of active duty members in pay grades of E-5 and above, $12; and ( 3 ) For retirees and their dependents, $17. (iii) The cost share for durable medical equipment, prosthetic devices, and other authorized supplies is as follows: (A) For dependents of active duty members in pay grades E-1 through E-4, 10 percent of the negotiated fee; (B) For dependents of active duty members in pay grades of E-5 and above, 15 percent of the negotiated fee; and (C) For retirees and their dependents, 20 percent of the negotiated fee. (iv) For emergency room services, the per visit fee is as follows: (A) For dependents of active duty members in pay grades E-1 through E-4, $10; (B) For dependents of active duty members in pay grades of E-5 and above, $30; and (C) For retirees and their dependents, $30. (v) For primary surgeon services in ambulatory surgery, the per service fee is as follows: (A) For dependents of active duty members in pay grades E-1 through E-4, $25; (B) For dependents of active duty members in pay grades of E-5 and above, $25; and (C) For retirees and their dependents, $25. (vi) The copayment for each 30-day supply (or smaller quantity) of a prescription drug is as follows: (A) For dependents of active duty members in pay grades E-1 through E-4, $5; (B) For dependents of active duty members in pay grades of E-5 and above, $5; and (C) For retirees and their dependents, $9. (vii) The copayment for ambulance services is as follows: (A) For dependents of active duty members in pay grades E-1 through E-4, $10; (B) For dependents of active duty members in pay grades of E-5 and above, $15; and (C) For retirees and their dependents, $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 as a notice annually by the Assistant Secretary of Defense (Health Affairs). (2) Structure of cost sharing. For services other than mental illness or substance use treatment, there is a nominal copayment for active duty dependents and for retired members, dependents of retired members, and survivors. For inpatient mental health and substance use treatment, a separate per day charge is established. (3) Amount of inpatient cost sharing requirements. Beginning in fiscal year 1996, the inpatient cost sharing requirements are as follows: (i) For acute care admissions and other non-mental health/substance use treatment admissions, the per diem charge is as follows, with a minimum charge of $25 per admission: (A) For dependents of active duty members in pay grades E-1 through E-4, $11; (B) For dependents of active duty members in pay grades of E-5 and above, $11; and (C) For retirees and their dependents, $11. (ii) For mental health/substance use treatment admissions, and for partial hospitalization services, the per diem charge is as follows, with a minimum charge of $25 per admission: (A) For dependents of active duty members in pay grades E-1 through E-4, $20; (B) For dependents of active duty members in pay grades of E-5 and above, $20; and (C) For retirees and their dependents, $40. (f) Limit on out-of-pocket costs for retired members, dependents of retired members, and survivors under the uniform HMO benefit. 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. (g) Updates. The enrollment fees for fiscal year 1996 set under paragraph (c) of this section and the per service specific dollar amounts for fiscal year 1996 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. The Secretary shall ensure that the TRICARE program complies with statutory cost neutrality requirements.