PART 220—MEDICAL BILLING FOR HEALTHCARE SERVICES PROVIDED BY DEPARTMENT OF DEFENSE MILITARY MEDICAL TREATMENT FACILITIES TO CIVILIAN NON-BENEFICIARIES Authority: 5 U.S.C. 301; 10 U.S.C. 1095, 1097b(b), 1079b; 31 U.S.C. 3711, 3717; and 42 U.S.C. 2651. Source: 55 FR 21748, May 29, 1990, unless otherwise noted. § 220.1 Purpose and applicability. (a) This part implements the provisions of 10 U.S.C. 1095, 1097b(b), and 1079b. In general, 10 U.S.C. 1095 establishes the statutory obligation of third party payers to reimburse the United States the reasonable charges of healthcare services provided by facilities of the Uniformed Services to covered beneficiaries who are also covered by a third party payer's plan. Section 1097b(b) elaborates on the methods for computation of reasonable charges. Section 1079b addresses charges for civilian patients who are not normally beneficiaries of the Military Health System. This part establishes the Department of Defense interpretations and requirements applicable to all healthcare services subject to 10 U.S.C. 1095, 1097b(b), and 1079b. (b) This part applies to all facilities of the Uniformed Services; the Department of Transportation administers this part with respect to facilities to the Coast Guard, not the Department of Defense. (c) This part applies to pathology services provided by the Armed Forces Institute of Pathology. However, in lieu of the rules and procedures otherwise applicable under this part, the Assistant Secretary of Defense (Health Affairs) may establish special rules and procedures under the authority of 10 U.S.C. 176 and 177 in relation to cooperative enterprises between the Armed Forces Institute of Pathology and the American Registry of Pathology. [67 FR 57740, Sept. 12, 2002] § 220.2 Statutory obligation of third party payer to pay. (a) Basic rule. (b) Application of cost shares. (c) Claim from United States exclusive. (d) Assignment of benefits or other submission by beneficiary not necessary. (e) Preemption of conflicting State laws. [55 FR 21748, May 29, 1990, as amended at 57 FR 41101, Sept. 9, 1992; 65 FR 7727, Feb. 16, 2000; 67 FR 57740, Sept. 12, 2002] § 220.3 Exclusions impermissible. (a) Statutory requirement. (b) General rules. (1) Express exclusions or limitations in third party payer plans that are inconsistent with 10 U.S.C. 1095(b) are inoperative. (2) No objection, precondition or limitation may be asserted that defeats the statutory purpose of collecting from third party payers. (3) Third party payers may not treat claims arising from services provided in facilities of the uniformed services less favorably than they treat claims arising from services provided in other hospitals. (4) No objection, precondition or limitation may be asserted that is contrary to the basic nature of facilities of the uniformed services. (c) Specific examples of impermissible exclusion. (1) Care provided by a government entity. (2) No obligation to pay. (3) Exclusion of military beneficiaries. (4) No participation agreement. (5) Medicare carve-out and Medicare secondary payer provisions. (i) Expressly disallows payment as the primary payer to all providers to whom payment would not be made under Medicare (including payment under Part A, Part B, a Medicare HMO, or a Medicare+Choice plan); and (ii) Is otherwise in accordance with applicable law. [55 FR 21748, May 29, 1990, as amended at 57 FR 41101, Sept. 9, 1992; 65 FR 7728, Feb. 16, 2000] § 220.4 Reasonable terms and conditions of health plan permissible. (a) Statutory requirement. (b) General rules. (2) Except as provided by 10 U.S.C. 1095, this part, or other applicable law, third party payers are not required to treat claims arising from services provided in or through facilities of the Uniformed Services more favorably than they treat claims arising from services provided in other facilities or by other health care providers. (c) Specific examples of permissible terms and conditions. (1) Generally applicable coverage provisions. (2) Generally applicable utilization review provisions. (ii) Such provisions are not permissible if they are applied in a manner that would result in claims arising from services provided by or through facilities of the Uniformed Services being treated less favorably than claims arising from services provided by other hospitals or providers. (iii) Such provisions are not permissible if they would not affect a third party payer's obligation under this part. For example, concurrent review of an inpatient hospitalization would generally not affect the third party payer's obligation because of the DRG-based, per-admission basis for calculating reasonable charges under § 220.8(a) (except in long stay outlier cases, noted in § 220.8(a)(4)). (3) Restrictions in HMO plans. (d) Procedures for establishing reasonable terms and conditions. [55 FR 21748, May 29, 1990, as amended at 65 FR 7728, Feb. 16, 2000; 67 FR 57740, Sept. 12, 2002] § 220.5 Records available. Pursuant to 10 U.S.C. 1095(c), facilities of the uniformed services, when requested, shall make available to representatives of any third party payer from which the United States seeks payment under 10 U.S.C. 1095 for inspection and review appropriate health care records (or copies of such records) of individuals for whose care payment is sought. Appropriate records which will be made available are records which document that the services which are the subject of the claims for payment under 10 U.S.C. 1095 were provided as claimed and were provided in a manner consistent with permissible terms and conditions of the third party payer's plan. This is the sole purpose for which patient care records will be made available. Records not needed for this purpose will not be made available. § 220.6 Certain payers excluded. (a) Medicare and Medicaid. (b) Supplemental plans. (c) Third party payer plans prior to April 7, 1986. (d) Third party payer plans prior to November 5, 1990, in connection with outpatient care. (1) That have been in continuous effect without amendment or renewal since prior to November 5, 1990; and (2) For which the facility of the Uniformed Services or other authorized representative for the United States makes a determination, based on documentation provided by the third party payer, that the policy or plan clearly excludes payment for such services. Plans entered into, amended or renewed on or after November 5, 1990, are subject to this section, as are prior plans that do not clearly exclude payment for services covered by this section. [55 FR 21748, May 29, 1990, as amended at 57 FR 41101, Sept. 9, 1992] § 220.7 Remedies and procedures. (a) Pursuant to 10 U.S.C. 1095(e)(1), the United States may institute and prosecute legal proceedings against a third party payer to enforce a right of the United States under 10 U.S.C. 1095 and this part. (b) Pursuant to 10 U.S.C. 1095(e)(2), an authorized representative of the United States may compromise, settle or waive a claim of the United States under 10 U.S.C. 1095 and this part. (c) The authorities provided by 31 U.S.C. 3701, et seq., (d) A third party payer may not, without the consent of a U.S. Government official authorized to take action under 10 U.S.C. 1095 and this part, offset or reduce any payment due under 10 U.S.C. 1095 or this part on the grounds that the payer considers itself due a refund from a facility of the Uniformed Services. A request for refund must be submitted and adjudicated separately from any other claims submitted to the third party payer under 10 U.S.C. 1095 or this part. [55 FR 21748, May 29, 1990, as amended at 65 FR 7728, Feb. 16, 2000] § 220.8 Reasonable charges. (a) In general. (2) The general rule is that reasonable charges under this part are based on the rates used by CHAMPUS under 32 CFR 199.14 to reimburse authorized providers. There are some exceptions to this general rule, as outlined in this section. (b) Inpatient institutional and professional services on or after October 1, 2017. (c) Inpatient hospital and inpatient professional services before April 1, 2003 In general. (2) Standard amount. (3) DRG relative weights. (4) Adjustments for outliers, area wages, and indirect medical education. (5) Identification of professional and institutional charges. (i) Institutional charges (which refer to routine service charges associated with the facility encounter or hospital stay and ancillary charges). (ii) Professional charges (which refers to professional services provided by physicians and certain other providers). (d) Medical services and subsistence charges included. (e) Reasonable charges for professional services. (f) Miscellaneous Healthcare services. (1) The charge for ambulance services is based on the full costs of operating the ambulance service. (2) With respect to inpatient institutional charges in the Burn Center at Brooke Army Medical Center, the ASD(HA) may establish an adjustment to the rate otherwise applicable under the payment methodologies under this section to reflect unique attributes of the Burn Center. (3) Charges for dental services (including oral diagnosis and prevention, periodontics, prosthodontics (fixed and removable), implantology, oral surgery, orthodontics, pediatric dentistry and endodontics) will be based on a full cost of the dental services. (4) With respect to service provided prior to January 1, 2003, reasonable charges for anesthesia services will be based on an average DoD cost of service in all Military Treatment Facilities. With respect to services provided on or after January 1, 2003, reasonable charges for anesthesia services will be based on an average cost per minute of service in all Military Treatment Facilities. (5) The charge for immunizations, allergen extracts, allergic condition tests, and the administration of certain medications when these services are provided by or through a facility of the Uniformed Services or a separate immunizations or shot clinic, are based either on CHAMPUS prevailing rates or on IRU rates based on the cost to provide these items, exclusive of any costs considered for purposes of any outpatient visit. A separate charge shall be made for each immunization, injection or medication administered. (6) The charges for pharmacy, durable medical equipment and supply resources are based either on CHAMPUS prevailing rates or on IRU rates based on the cost to provide these items, exclusive of any costs considered for purposes of any outpatient visit. A separate charge shall be made for each item provided. (7) Charges for aero-medical evacuation will be based on the full cost of the aero-medical evacuation services. (8) Ambulatory (outpatient) institutional services on or after October 1, 2017. Reasonable charges for institutional facility charges for ambulatory services provided on or after October 1, 2017, are based on any of three methods as determined by the ASD(HA). The first uses the CHAMPUS Ambulatory Payment Classification (APC) and Ambulatory Surgery Center (ASC) payment system rates under 32 CFR 199.14(a)(1)(ii) and (iii) and 32 CFR 199.14(d) respectively. The second uses a bundled MHS Ambulatory Procedure Visit (APV) payment system rate charge reflected by the average cost of providing an APV exclusive of professional services. The third method uses IRU rates based on the cost to provide ambulatory institutional resources. Like the CHAMPUS system, ambulatory professional services are not included in the ambulatory institutional facility charges calculated under any of the three methodologies, but are billed separately in accordance with paragraph (e) of this section. (g) Special rule for services ordered and paid for by a facility of the Uniformed Services but provided by another provider. (h) Special rule for TRICARE Resource Sharing Agreements. (i) Alternative determination of reasonable charges. (j) Exception authority for extraordinary circumstances. [57 FR 41101, Sept. 9, 1992, as amended at 59 FR 49002, Sept. 26, 1994; 61 FR 6542, Feb. 21, 1996; 62 FR 941, Jan. 7, 1997; 65 FR 7728, Feb. 16, 2000; 67 FR 57740, Sept. 12, 2002; 85 FR 51351, Aug. 20, 2020] § 220.9 Rights and obligations of beneficiaries. (a) No additional cost share. (b) Availability of healthcare services unaffected. (c) Obligation to disclose information and cooperate with collection efforts. (2) Uniformed Services beneficiaries are required to take other reasonable steps to cooperate with the efforts of the facility of the Uniformed Services to make collections under 10 U.S.C. 1095 and this part, such as submitting to the third party payer (or other entity involved in adjudicating a claim) any requests or documentation that might be required by the third party payer (or other entity), if consistent with this part, to facilitate payment under this part. (3) Intentionally providing false information or willfully failing to satisfy a beneficiary's obligations are grounds for disqualification for health care services from facilities of the Uniformed Services. (d) Mandatory disclosure of Social Security account numbers. [55 FR 21748, May 29, 1990, as amended at 57 FR 41102, Sept. 9, 1992; 63 FR 11600, Mar. 10, 1998; 65 FR 7729, Feb. 16, 2000] § 220.10 Special rules for Medicare supplemental plans. (a) Statutory obligation of Medicare supplemental plans to pay. (b) Inpatient hospital care charges. (2) Only one deductible charge shall be made per hospital admission (or Medicare benefit period), regardless of whether the admission is to a facility of the Uniformed Services or a Medicare certified civilian hospital. To ensure that a Medicare supplemental insurer is not charged the inpatient hospital deductible twice when an individual who is entitled to benefits under both DoD retiree benefits and Medicare, the following payment rules apply: (i) If a dual beneficiary is first admitted to a Medicare-certified hospital and is later admitted to a facility of the Uniformed Services within the same benefit period initiated by the admission to the Medicare-certified hospital, the facility of the Uniformed Services shall not charge the Medicare supplemental insurance plan an inpatient hospital deductible. (ii) If a dual beneficiary is admitted first to a facility of the Uniformed Services and secondly to a Medicare-certified hospital within 60 days of discharge from the facility of the Uniformed Services, the facility of the Uniformed Services shall refund to the Medicare supplemental insurer any inpatient hospital deductible that the insurer paid to the facility of the Uniformed Services so that it may pay the deductible to the Medicare-certified hospital. (c) Charges for Healthcare services other than inpatient deductible amount. (i) Be based on percentage amounts of the per diem, per visit and other rates established by § 220.8 comparable to the percentage amounts of beneficiary financial responsibility under Medicare for the service involved; (ii) Include adjustments, as appropriate, to identify major components of the all inclusive per diem or per visit rates for which Medicare has special rules. (iii) Provide for offsets and/or refunds to ensure that Medicare supplemental insurers are not required to pay a limited benefit more than one time in cases in which beneficiaries receive similar services from both a facility of the uniformed services and a Medicare certified provider; and (iv) Otherwise conform with the requirements of this section and this part. (2) If collections are sought under paragraph (c) of this section, the effective date of such collections will be prospective from the date the Assistant Secretary of Defense (Health Affairs) provides notice of such collections, and will exempt policies in continuous effect without amendment or renewal since the date the Assistant Secretary of Defense (Health Affairs) provides notice of such collections. (d) Medicare claim not required. (e) Exclusion of Medicare supplemental plans prior to November 5, 1990. (1) That have been in continuous effect without amendment since prior to November 5, 1990; and (2) For which the facility of the Uniformed Services (or other authorized representative of the United States) makes a determination, based on documentation provided by the Medicare supplemental plan, that the plan agreement clearly excludes payment for services covered by this section. Plans entered into, amended or renewed on or after November 5, 1990, are subject to this section, as are prior plans that do not clearly exclude payment for services covered by this section. [57 FR 41102, Sept. 9, 1992, as amended at 59 FR 49003, Sept. 26, 1994; 67 FR 57742, Sept. 12, 2002] § 220.11 Special rules for automobile liability insurance and no-fault automobile insurance. (a) Active duty members covered. (b) Effect of concurrent applicability of the Federal Medical Care Recovery Act In general. et seq. (2) Cases involving tort liability. (c) Exclusion of automobile liability insurance and no-fault automobile insurance plans prior to November 5, 1990. (1) That have been in continuous effect without amendment since prior to November 5, 1990; and (2) For which the facility of the Uniformed Services (or other authorized representative of the United States) makes a determination, based on documentation provided by the third party payer, that the policy or plan clearly excludes payment for services covered by this section. Plans entered into, amended or renewed on or after November 5, 1990, are subject to this section, as are prior plans that do not clearly exclude payment for services covered by this section. [57 FR 41103, Sept. 9, 1992] § 220.12 Medical billing for healthcare services provided by DoD Military Medical Treatment Facilities to civilian non-beneficiaries. (a) Applicability. (2) This section does not apply to third persons (or their insurers) with a tort liability under the Federal Medical Care Recovery Act (FMCRA) (42 U.S.C. 2651) or third-party payers under 10 U.S.C. 1095. The discounts and waivers implemented by this section may not be used to reduce the value of the care and treatment that is recoverable from those third persons (or their insurers) under the FMCRA or 10 U.S.C. 1095. (b) Definitions. Military Health System (MHS) Modified Payment and Waiver Program (MPWP). (2) Covered payer. (3) Covered by a covered payer. (i) The patient possesses health insurance that is in effect on the date(s) that the item or service was provided; (ii) The health insurance plan provides coverage for the geographic area where the care was delivered; (iii) The care provided to the patient is an item or service covered by the terms of the insurance plan, and; (iv) The health insurance plan provides coverage for care rendered in a U.S. Government/DoD facility; (v) The insurer agrees to pay the facility directly; (vi) The insurer agrees to provide the facility with an Explanation of Benefits (EOB) that details how the insurer processed the claims according to the insurance plan; and (vii) The patient authorizes the DoD to file insurance claims against the insurance policy. (4) Non-covered item or service. (5) Third-party payer insurance, medical service, or health plan (6) Knowledges, Skills, and Abilities (KSAs). (7) Reasonable value of medical care. (c) Notifications concerning MHS MPWP. e.g., (d) Requirement to complete a DD Form 2569. https://www.esd.whs.mil/Directives/forms/dd2500_2999/. (1) Before applying for the MHS MPWP, all patients (regardless of health insurance status) must fully complete (including by signing) the DD Form 2569 and ensure that a current and accurate DD Form 2569 is on file with the applicable MTF. Successful completion of these steps is a condition of eligibility for the MHS MPWP. (2) For patients with health insurance, the DoD will file insurance claims on behalf of the patient. Patients with health insurance who do not consent to allowing the DoD to file health insurance claims on their behalf will not be eligible for the MHS MPWP (inclusive of the discount and waiver portions). (3) The DoD may use a completed DD Form 2569 for multiple episodes of care. Unless a DD Form 2569 completed within the preceding 12 months for the patient is available, the DoD will solicit an updated DD Form 2569 from patients who receive a subsequent episode of care from the MTF. However, the lack of an updated form will not preclude the DoD from filing additional claims against encounters for the patient. (e) Notifications on medical invoices. (1) Patients must consent to DoD filing insurance claims on their behalf to be eligible for the MHS MPWP; (2) The DoD will suspend fee assessment and patient billing actions against the debtor for up to 120 days while the DoD is pursuing an insurance claim or claim against a third-party payer; (3) For patients who are covered by a covered payer, the DoD will only bill the patient for the insurer-assigned copays, coinsurance, deductibles, nominal fees, and non-covered services; (4) The patient demonstrates potential eligibility for the MHS MPWP fee discounts and catastrophic fee waivers by completing and submitting DD Form 2569 and DD Form 3201, which may result in a discount of their medical invoice after pursuit or recovery of claims against third party payers (instructions for demonstrating eligibility, including deadline, will also be included); (5) In addition to sliding fee discounts and catastrophic fee waivers, patients may request a waiver under 10 U.S.C. 1079b(b) by submitting a DD Form 3201-1, “Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program.” Patients may be considered for a partial or full waiver if they previously applied to and were approved for the MHS MPWP discount program, and it did not sufficiently mitigate financial harm and if the applicable care provided is determined to enhance the KSAs of DoD healthcare providers, as confirmed by competent medical authority competent medical authority at the MTF that provided the care. Confirmation will be done by the competent medical authority on the DD Form 3201-1A. Waivers under 10 U.S.C. 1079b(b) may result in information reporting to the Internal Revenue Service and issuance of a Form 1099-C, Cancellation of Debt. The waived amount(s) may constitute gross income to the patient under 26 U.S.C. 61; (6) If fees or charges (including those reduced under the MHS MPWP) become delinquent due to non-payment, the DoD will establish a debt for the delinquent amount and commence efforts to collect the established debt, which may include transfer to the Department of the Treasury in accordance with applicable authority; and (7) That invoices issued after reduction or waiver of charges under the MHS MPWP will reflect the date by which an unpaid account will become delinquent. (f) DoD medical billing rates. (g) For non-covered items or services. (h) For patients who are potentially covered by a covered payer. (i) Actions when an insurance payment and/or EOB is received. (j) Application for the MHS MPWP (DD Form 3201). i.e., (1) For approved applications, the DoD will issue to the patient a modified medical invoice reflecting the adjusted balance due after applying the sliding fee and/or catastrophic fee waiver and including a revised (reset) payment due date. The invoice modified to reflect fee adjustments or waiver under the MHS MPWP will include notification of the requirement to transfer delinquent debts to the Department of the Treasury if, after any modification under the MHS MPWP, an unpaid invoice becomes delinquent. (2) For disapproved applications, the DoD will issue a letter reflecting the reason why the application was disapproved. The letter will inform the patient of their right to reapply should their financial circumstances change. (k) Requirements to apply to the MHS MPWP. (i) Complete a DD Form 2569 (even in cases where the patient possesses no health insurance). Insurance remittances must be applied before the patient can be considered for the MHS MPWP. (ii) Complete a DD Form 3201, “Application for Military Health System Modified Payment and Waiver Program.” (iii) Attach a copy of the patient's (or guarantor's if the patient is a minor) most recently filed Federal Income Tax Return to the DD Form 3201. (iv) Attach a copy of the patient's (or guarantor's if the patient is a minor) last two pay stubs. (v) Indicate whether their injury/disease was caused by a third party and provide explanatory information. (2) Patients applying for the MHS MPWP are required to certify whether or not they filed a Federal Income Tax Return for the preceding year. (i) If the patient did not file a Federal Income Tax Return for the preceding year, the patient must certify this in the space provided on the DD Form 3201. (ii) If the patient has no verifiable income, the patient must certify this and provide a certification of their current annual income amount in the space provided on the DD Form 3201. (iii) When the patient has certified to having no verifiable income and has neither a tax return nor pay stubs, other information may be used to validate the patient's lack of income including, but not limited to, the last two bank statements (savings and checking), or a Social Security benefits letter verifying that no benefits are being received. (iv) If the patient believes that hospitalization/care occurred as the result of an action for which another party may be responsible, then to be eligible for the MHS MPWP, the patient must agree to cooperate and assist the United States to recover the cost of care from said party in the space provided on the DD Form 3201. (l) Basis to assign a Sliding Fee Discount/Catastrophic Fee Waiver MHS Discount Calculator. (2) Catastrophic Fee Waiver. (3) Nominal fee. Table 1 to Paragraph ( l Household income falls within the below Federal poverty guidelines Inpatient fee Outpatient fee 0%-100% $0 101%-120% 750 50 121%-140% 1,250 50 141%-160% 2,000 50 161%-180% 3,000 50 181%-200% 4,000 50 201%-220% 5,000 50 221%-240% 6,000 50 241%-260% 7,000 50 261%-280% 8,000 50 281%-300% 9,000 50 301%-320% 10,000 50 321%-340% 11,000 50 341%-360% 12,000 50 361%-380% 13,000 50 381%-400% 14,000 50 (m) Notification of approved/disapproved MHS MPWP applications. e.g., (1) For approved applications, the DoD will issue to the patient a modified medical invoice reflecting the adjusted balance due after applying the sliding fee and/or catastrophic fee waiver. The invoice modified to reflect fee adjustments under the MHS MPWP will include notification of the requirement to transfer delinquent debts to the Department of the Treasury if, after any modification under the MHS MPWP, an unpaid invoice becomes delinquent. (2) For disapproved applications, the DHA will issue a letter by U.S. mail to the patient's last known address reflecting the reason why the application was disapproved. The letter will inform the patient of the right to reapply should the patient's financial circumstances change. (n) Collection in installments. (o) Application for a 10 U.S.C. 1079b(b) waiver Basis for a waiver. (i) The patient has provided the DoD with a completed DD Form 2569 (even for patients who possess no valid health insurance) and applicable insurance payments have been applied; (ii) The patient has previously submitted a completed application to the MHS MPWP (32 CFR 220.12(k)) and was approved for any applicable discounts; (iii) The patient submitted a DD Form 3201-1, “Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program,” requesting waiver of already discounted fees; and (iv) A DoD competent medical authority at the treating MTF confirms in writing (on the DD Form 3201-1A, “MHS Modified Payment and Waiver Program (MPWP) Medical Skills Sustainment Scoring Worksheet”) that the care provided to the patient enhanced the KSAs of the DoD healthcare provider. The completed DD Form 3201-1A yields whether a partial or full waiver of already discounted fees may be applied. (v) If the conditions in paragraphs (o)(1)(i) through (iv) are met, the Director of DHA may exercise discretionary authority to waive the medical invoice. (2) Method to request a waiver. (3) Response to a request for waiver. e.g., (p) Debts transferred to Treasury that are subsequently processed through insurance. (q) Delinquent Accounts. (r) Applications for MHS MPWP Received for Delinquent Accounts Transferred to the Department of the Treasury. (s) Reporting to IRS and Furnishing of IRS Forms 1099-C (Cancellation of Debt). (t) Refunds not permitted for amounts previously paid. (u) Claims involving tortfeasors and third-party payers. (1) For patients who indicate that their injury/disease was caused by a third party, DoD MTFs will follow procedures established under the Medical Affirmative Claims program. (2) Patients who have a remaining balance after insurance remittances or recoveries from third-party tortfeasors may apply for relief of any remaining medical debt. (3) Payments toward the medical debt that were made by the patient prior to settlement of the claim with the tortfeasor will be offset against any balances owed by the patient or may be refunded to the patient if no balance is owed. [91 FR 5313, Feb. 6, 2026] § 220.13 Special rules for workers' compensation programs. (a) Basic rule. (b) Special rules for lump-sum settlements. (1) Lump-sum commutation of future benefits. (2) Lump-sum compromise settlement. (ii) If a settlement appears to represent an attempt to shift to the facility of the Uniformed Services the responsibility of providing uncompensated services or items for the treatment of the work-related condition, the settlement will not be recognized and reimbursement to the uniformed health care facility will be required. For example, if the parties to a settlement attempt to maximize the amount of disability benefits paid under workers' compensation by releasing the employer or workers' compensation carrier from liability for medical expenses for a particular condition even though the facts show that the condition is work-related, the facility of the Uniformed Services must be reimbursed. (iii) Except as specified in paragraph (b)(2)(iv) of this section, if a lump-sum compromise settlement forecloses the possibility of future payment or workers' compensation benefits, medical expenses incurred by a facility of the Uniformed Services after the date of the settlement are not reimbursable under this section. (iv) As an exception to the rule of paragraph (b)(2)(iii) of this section, if the settlement agreement allocates certain amounts for specific future medical services, the facility of the Uniformed Services is entitled to reimbursement for those specific services and items provided resulting from the work-related injury, illness, or disease up to the amount of the lump-sum settlement allocated to future expenses. (3) Apportionment of a lump-sum compromise settlement of a workers' compensation claim. [65 FR 7730, Feb. 16, 2000, as amended at 67 FR 57742, Sept. 12, 2002] § 220.14 Definitions. Ambulatory procedure visit. Assistant Secretary of Defense (Health Affairs). Automobile liability insurance. (1) Circumstances in which liability benefits are paid to an injured party only when the insured party's tortious acts are the cause of the injuries; and (2) Uninsured and underinsured coverage, in which there is a third party tortfeasor who caused the injuries (i.e., benefits are not paid on a no-fault basis), but the insured party is not the tortfeasor. CHAMPUS supplemental plan. Covered beneficiaries. Facility of the Uniformed Services. Healthcare services. Inpatient hospital care. Insurance, medical service or health plan. (1) Any plan offered by an insurer, re-insurer, employer, corporation, organization, trust, organized health care group or other entity. (2) Any plan for which the beneficiary pays a premium to an issuing agent as well as any plan to which the beneficiary is entitled as a result of employment or membership in or association with an organization or group. (3) Any Employee Retirement Income and Security Act (ERISA) plan. (4) Any Multiple Employer Trust (MET). (5) Any Multiple Employer Welfare Arrangement (MEWA). (6) Any Health Maintenance Organization (HMO) plan, including any such plan with a point-of-service provision or option. (7) Any individual practice association (IPA) plan. (8) Any exclusive provider organization (EPO) plan. (9) Any physician hospital organization (PHO) plan. (10) Any integrated delivery system (IDS) plan. (11) Any management service organization (MSO) plan. (12) Any group or individual medical services account. (13) Any preferred provider organization (PPO) plan or any PPO provision or option of any third party payer plan. (14) Any Medicare supplemental insurance plan. (15) Any automobile liability insurance plan. (16) Any no fault insurance plan, including any personal injury protection plan or medical payments benefit plan for personal injuries arising from the operation of a motor vehicle. Medicare eligible provider. Medicare supplemental insurance plan. No-fault insurance. Preferred provider organization. Third party payer. (1) State and local governments that provide such plans other than Medicaid. (2) Insurance underwriters or carriers. (3) Private employers or employer groups offering self-insured or partially self-insured medical service or health plans. (4) Automobile liability insurance underwriter or carrier. (5) No fault insurance underwriter or carrier. (6) Workers' compensation program or plan sponsor, underwriter, carrier, or self-insurer. (7) Any other plan or program that is designed to provide compensation or coverage for expenses incurred by a beneficiary for healthcare services or products. Third party payer plan. Uniformed Services beneficiary. Workers' compensation program or plan. (1) Operated by or under the authority of any law of any State (or the District of Columbia, American Samoa, Guam, Puerto Rico, and the Virgin Islands). (2) Operated through an insurance arrangement or on a self-insured basis by an employer. (3) Operated under the authority of the Federal Employees Compensation Act or the Longshoremen's and Harbor Workers' Compensation Act. [57 FR 41103, Sept. 9, 1992. Redesignated and amended at 65 FR 7729, 7731, Feb. 16, 2000; 67 FR 57742, Sept. 12, 2002]