As a Hospital Corpsman, you could be assigned to or responsible for the administrative affairs concerning inpatients or outpatients. This chapter will provide information on the function of healthcare programs you may be involved with or responsible for. We will also discuss the legal implications in medical care, including the various aspects of consent, incident reports, and release or nonrelease of medical information under the Privacy and/or Freedom of Information Acts. Further, guidance concerning your relationship and interaction with law enforcement personnel and the legal community will also be outlined.

PATIENT ELIGIBILITY FOR HOSPITALIZATION AND NONFEDERAL CARE

LEARNING OBJECTIVE: Recognize the policies and procedures for DEERS, CHAMPUS, and TRICARE.

The fact that a person seeking treatment is or was connected with the federal government does not automatically entitle him to treatment at a naval medical treatment facility. A number of factors determine eligibility for certain types of medical attention and the source and amount of remuneration for that treatment. The following section deals with eligibility verification by presentation of a valid ID card and utilization of the Defense Enrollment Eligibility System (DEERS). Further guidance can be obtained by familiarizing yourself with the following sources:

NAVMEDCOMINST 6320.3, Medical and Dental Care for Eligible Persons at Navy Medical Department Facilities

NAVMEDCOMINST 6320.18, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Regulation
NAVMED P-5020, Resources Management Handbook

DEFENSE ENROLLMENT ELIGIBILITY REPORTING SYSTEM (DEERS)

The Defense Enrollment Eligibility Reporting System (DEERS) was developed to improve distribution and control of military healthcare services. Additionally, DEERS was implemented to assist in the projection and allocation of costs for healthcare programs and to minimize fraudulent healthcare claims. Navy medicine's eligibility for care instruction, NAVMEDCOMINST 6320.3, provides guidance as to who and under what circumstances members can receive medical and dental care at Navy Medical Department facilities; the extent and conditions under which such care may be provided; and the collection process to pay for that care.

Enrollment for all seven uniformed services (i.e., Army, Air Force, Marine Corps, Navy, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration) is accomplished through completion and submission of an Application for Uniformed Services Identification and Privilege Card, DD 1172, for a member's dependent. When a new ID card is obtained for the dependent, the member's DEERS data is updated online. If problems exist within a patient's database, active duty personnel and their dependents must be referred to the sponsor's personnel office. Refer all other beneficiaries (e.g., retired personnel and their dependents) to the nearest personnel office.

Direct Care System Procedures
In addition to providing authorization to standard medical care through inclusion in its membership database, DEERS now includes a dental policy based upon beneficiary information (versus the previous policy based on sponsor information). This change in policy occurred in part because of the increased accuracy of the database as well as the percentage of personnel enrolled.

Although DEERS and the ID card system are related, there are instances when the beneficiary is in possession of a valid ID card and the DEERS system shows the patient as ineligible or not in the database. In these instances, eligibility verification using the ID card shall not override DEERS without some other type of collateral documentation. (See sections on DEERS overrides and exceptions later in this chapter.) It must be stressed that military treatment facilities (MTFs) are to verify eligibility. Establishment of eligibility is under the cognizance of the respective service personnel offices.

Eligibility
Patients who present for non-emergency treatment without a valid ID card but who are in the DEERS database will not be provided medical care without first signing a statement that they are eligible and giving the reason why a valid ID card is not in their possession. If a valid ID card is not provided within 30 calendar days, the patient is referred for billing as a Civilian Humanitarian Non-indigent, in accordance with the Resources Management Handbook, NAVMED P-5020. Such billing may be delayed if the commanding officer of the facility is convinced proof is delayed for reasons beyond the control of the patient or sponsor. In all cases where a patient presents without an ID card and does not appear in the DEERS database, non-emergency care will be denied.

REASONS FOR INELIGIBILITY.-When a DEERS check is performed and the patient is found ineligible for any of the following reasons, routine non-emergency healthcare will be denied (except as noted later in this section).

Sponsor not enrolled in DEERS

Dependent not enrolled in DEERS
Ineligible due to passed terminal (end) eligibility date

Sponsor has separated from active duty
Spouse is divorced from sponsor and is not entitled to benefits as a former spouse

Dependent child is married
UNDER NO CIRCUMSTANCES WILL THE CLERK PERFORMING THE ELIGIBILITY CHECK DENY THE REQUESTED CARE. Only command-designated supervisory personnel can perform this function.

DEERS ELIGIBILITY OVERRIDES.-The nine "DEERS eligibility overrides" are listed below. Unless otherwise stated, all overrides must be supported by a valid ID card.

1. DD 1172-The patient presents an original or copy of the DD 1172 used for DEERS enrollment. There are specific items required for verification, and current service directives must be checked.

2. All Other Dependents Recently Becoming Eligible for Benefits-Patients who become eligible for benefits in the previous 120 days may be treated upon presentation of a valid ID card. For children under 10 years of age, a valid ID card of a parent or guardian is acceptable. Upon application for care beyond 120 days, follow the procedure in item 1, above.

3. New Identification Card-Patients presenting with a new valid ID card, issued within the previous 120 days, will not be denied care.

4. Ineligible Due to ID Card Expiration-When the database shows a patient as ineligible because of ID card expiration, care may be rendered as long as the patient has a new ID card issued within the previous 120 days. After 120 days, follow the procedure in item 1, above.

5. Sponsors Entering Active Duty Status for a Period of Greater than 30 Days-A copy of orders ordering a reservist or guardsman to an active duty period of greater than 30 days may be accepted for the first 120 days of the active duty period. After that, follow the procedure in step 1.

6. Newborns-Newborns will not be denied care for a period of 1 year following birth. The patient's birth certificate suffices when presented with a parent's valid ID card.

7. Emergency Care-This is a medical decision and shall be determined by criteria established within the command.

8. Sponsor's Duty Station is Outside the 50 United States or has an APO/FPO Address-Dependents whose sponsors are assigned outside the 50 United States or to a duty station with an APO/FPO address will not be denied care as long as the sponsor is enrolled and eligible in DEERS.

9. Survivors-When an eligibility check indicates that a deceased sponsor is not enrolled in DEERS or the survivor is listed as the sponsor, the survivor will be treated on the first visit and referred to the appropriate personnel office for correction of the DEERS database. For second and subsequent visits, the survivor will be required to follow the procedure in item 1, above.