Medical and Public Health Law Site
DoD Directives
An image of the Department of Defense seal

Department of Defense

DIRECTIVE

NUMBER 6010.4

April 25, 1962




ASD(M)

SUBJECT:  Dependents' Medical Care

References: (a)  DoD Directive 6010.4, "Dependents' Medical Care," October 18, 1956 (hereby canceled)

(b)  DoD Instruction 1000.7, "Uniformed Services Identification and Privilege Card"

        Attached for information and guidance is the reissued Department of Defense-Department of Health, Education, and Welfare Joint Directive for implementation of Chapter 55 of title 10, United States Code, "Medical and Dental Care" (formerly the "Dependents' Medical Care Act," Public Law 560-84th Congress).
 
Reference (a) is hereby superseded and canceled.

Signed by: Robert S. McNamara, Secretary of Defense

Enclosures - 1

E1.  Joint Directive

E1.  ENCLOSURE 1

JOINT DIRECTIVE
TABLE OF CONTENTS

PAGE
SECTION 1 GENERAL INFORMATION 6
      101.
      102.
      103.
Purpose
Scope
Definition of Terms Used in This Directive
6
6
6
a. 
b. 
c. 
d. 
e. 
f. 
g. 
h. 
i. 
j.
Uniformed Services
Member of Uniformed Service
Retired Member of Uniformed Service
Dependent
Dependents Eligible for Civilian Medical Care
Secretary of a Uniformed Service
The United States
Executive Agent
Contractor
Miscellaneous Medical and Technical Terminology
6
6
6
6
7
7
7
7
7
7
(1) Diagnosis
(2) Outpatient Care
(3) Maternity and Infant Care
(4) Domiciliary Care
(5) Chronic Disease
(6) Nervous and Mental Disorders
(7) Dental Care as a Necessary Adjunct to Medical or Surgical Treatment
(8) Adjuncts to Medical Care
(9) Adjuncts to Dental Care
7
7
8
8
8
8
8
8
8
      104 Administration 8
a.
b.
The Secretary of Defense
The Secretary of Health, Education, and Welfare
8
8
Section 2 DETERMINATION OF ELIGIBILITY AND IDENTIFICATION OF DEPENDENTS 9
      201. Determination of Dependents' Eligibility 9
a. Proof of Eligibility 9
(1) Medicare Eligibility Date 9
b. Determination of Dependency 9
      202. Identification of Dependents 9

Table of Contents, Continued
a.
b.
Issuance of DD Form 1173
Administrative Provisions Governing 1173
9
9
(1) Issuance
(2) Surrender
(3) Expiration Date
(4) Dependents Listed
(5) Entitlement to Care in Civilian Facilities
9
10
10
10
10
c. Issuance and Use of DD Form 1173 10
SECTION 3 DETERMINATION OF SOURCES FROM WHICH
ELIGIBLE DEPENDENTS RECEIVE MEDICAL CARE
 
11
      301.
      302.
   
      303.
      304.
Among Uniformed Services Facilities
Between Civilian Medical Facilities and Uniformed Services Facilities
Within the United States and Puerto Rico
Exceptions: Emergency Care and Other Circumstances
Between Civilian Medical Facilities and Uniformed Services Facilities
Outside the United States and Puerto Rico
11
11
   
12
13
SECTION 4 MEDICAL CARE FOR DEPENDENTS AT MEDICAL
FACILITIES OF THE UNIFORMED SERVICES
14
      401.
      402.
      403.
      404.
      405.
      406.
      407.
      408.
Authority For Providing Medical Care To Dependents
Facilities Available
Medical Care Authorized
Medical Care Not Authorized
Dental Care
Admission of Dependents for Medical Care
Cross-Utilization of Service Medical Facilities
Charges for Dependent Medical Care
14
14
14
15
16
16
17
17
a. 
b.
Inpatient Care
Outpatient Care
17
17
      409. Transportation of Patients 17
SECTION 5 MEDICAL CARE IN CIVILIAN FACILITIES 18
      501. Eligibility for Civilian Medical Care and Full Payment Concept 18
      502. Medical and Hospital Care Authorized from Civilian Sources 18
      503. Terms of Reference and Rules for the
Provision of Authorized Medical Care From Civilian Sources
   
19

Table of Contents, Continued
a. Applicable Terms 19
(1) Hospital
(2) Semiprivate Accommodations
(3) Ward Accommodations
(4) Necessary Services and Supplies
(5) Physician or Surgeon
(6) Dentist
(7) Local Schedule of Allowances
20
20
20
20
20
20
20
b.
c.
d.
Hospital Care
Nursing Care
Professional Services
20
21
21
(1) Professional Services Related to Hospitalization
(2) Obstetrical and Maternity Services
(3) Other Professional Services
21
22
23
e. Supporting Services 23
      504. Medical Care Not Authorized 23
a. 
b. 
c.
Chronic Diseases
Nervous and Mental Disorders
Services Not Medically Indicated
23
23
23
(1) Examples of Types of Surgical Care Not Authorized
(2) Examples of Types of Inpatient Surgical Care Authorized
   For Payment Only If Certain Conditions Prevail
23
   
24
d. 
e. 
f. 
g. 
h.
Non-acute Medical Conditions
Domiciliary Care
Treatment-Procedures/Outpatient Care
Ambulance Service/Civilian Transportation
Adjuncts to Medical Care
25
25
25
25
25
      505. Admission of Dependents for Medical Care to Civilian Sources 25
a. 
b. 
c. 
d.
Identification
Nonavailibility Statement
Government's Responsibility Ceases
Exceptions
26
27
27
27
      506. Charges 28
      507. Administration 30
a. 
b.
Secy/Army, Executive Agent Executive
Agent Responsible Within United States and Puerto Rico
30
30
(1) Preparation of Terms and Placement of Contract(s)
(2) Administration of the Contract
(3) Reimbursement to Dependents or Sponsors
31
31
31
c.
d.
Care in Civilian Facilities Outside the United States and Puerto Rico
A Secretary of Uniformed Service Responsible
32
32
      508. Hospitalization Beyond Period of 365 Days 32
      509. Government Liability for Payment of Civilian Medical Care Costs 33
      510. Administration of Changes to This Directive, Effective 1 January 1960 33

Table of Contents, Continued
SECTION 6 MEDICAL CARE IN MEDICAL FACILITIES NOT OTHERWISE PROVIDED FOR 34
SECTION 7 MEDICAL CARE FOR MEMBERS OF THE UNFORMED SERVICES 35
SECTION 8 MEDICAL CARE FOR RETIRED MEMBERS OF THE UNFORMED SERVICES 36
      801. Retired Members Eligible for Care 36
      802. Ration Allowances for Retired Enlisted Members 36
      803. Charges for Officer's Subsistence 36
SECTION 9 BUDGETING AND ACCOUNTING FOR MEDICAL
AND DENTAL CARE FURNISHED IN FACILITIES OF THE UNFORMED SERVICES
   
37
SECTION 10 IMPLEMENTATION 38
SECTION 11 EFFECTIVE DATE 39
APPENDICES A.
B.
C.
DD Form 1172
DD Form 1173
DD Form 1251
40
41
42

SECTION 1

GENERAL INFORMATION

101.  Purpose

The purpose of this Directive is to prescribe policy for administering Chapter 55 of title 10, United States Code.

102.  Scope

This Directive is applicable to the Uniformed Services.

103.  Definition of Terms Used in This Directive

a.  Uniformed Services  means the Army, the Navy, the Air Force, the Marine Corps, the Coast Guard, the Commissioned Corps of the Coast and Geodetic Survey, and the Commissioned Corps of the Public Health Service.

b.  Member of a Uniformed Service  means a person appointed, enlisted, inducted or called, ordered or conscripted in a Uniformed Service who is serving on active duty or active duty for training pursuant to a call or order that does not specify a period of thirty days or less.

c.  Retired Member of a Uniformed Service  means a member or former member of a Uniformed Service who is entitled to retired, retirement, or retainer or equivalent pay as a result of service in a Uniformed Service, other than a member or former member entitled to retired or retirement pay under Title III of the Army and Air Force Vitalization and Retirement Equalization Act of 1948 who has served less than eight years on full-time duty in active Military Service other than active duty for training.

d.  Dependent  means any person who bears to a member or retired member of a Uniformed Service, or to a person who died while a member or retired member of a Uniformed Service, any of the following relationships:

(1) the lawful wife;

(2) the unremarried widow;

(3) the lawful husband, if he is in fact dependent on the member or retired member for over one-half of his support;

(4) the unremarried widower, if he was in fact dependent upon the member or retired member at the time of her death for over one-half of his support because of a mental or physical incapacity;

(5) an unmarried legitimate child (including an adopted child or stepchild), if such child has not passed his twenty-first birthday;

(6) a parent or parent-in-law, if the said parent or parent-in-law is, or was, at the time of the member's or retired member's death, in fact dependent on said member or retired member for over one-half of his support and is, or was, at the time of the member's or retired member's death, actually residing in the household of said member or retired member.  For the purposes of this Directive, the requirement of actually residing in the household shall be fulfilled when the parent or parent-in-law actually resides, or was residing at the time of death of a member or retired member, in a dwelling place provided or maintained by said member or retired member; or

(7) an unmarried legitimate child (including an adopted child or stepchild) who (a) has passed his twenty first birthday, if the child is incapable of self support because of a mental or physical incapacity that existed prior to his reaching the age of twenty one and is or was at the time of the member's or retired member's death, in fact dependent on him for over one-half of his support, or (b) has not passed his twenty-third birthday and is enrolled in a full-time course of study in an institution of higher learning as approved by the Secretary of Defense or Secretary of Health, Education, and Welfare and is, or was at the time of the member's or the retired member's death, in fact dependent on him for over one-half of his support.

e.  Dependents Eligible for Civilian Medical Care  means the lawful wife or the dependent lawful husband (spouses) and children who are dependents of members of the Uniformed Services.

f.  Secretary of a Uniformed Service  means the Secretary of the Army, the Secretary of the Navy (for the Navy and the Marine Corps), or Secretary of the Air Force, or for the other Uniformed Services (the Coast Guard, the Public Health Service, the Coast and Geodetic Survey), and the Secretary of Health, Education, and Welfare.  The latter may delegate his duties and responsibilities in relation to dependent medical care to the Surgeon General of the Public Health Service.

g.  The United States  means all of the States and the District of Columbia.

h.  Executive Agent  means the party who acts for the Uniformed Services in negotiating and administering contracts for medical (physicians) and hospital services under the policy guidance of the Department of Defense.

i.  Contractor  means the legal entity with which the Government enters into a contract for the purpose of implementing Chapter 55 of title 10, United States Code, such as a State medical society, an insurance company, Blue Shield, or Blue Cross.

j.  Miscellaneous Medical and Technical Terminology

(1) Diagnosis.  A determination of the existence and nature, or absence, of disease or injury by history with physical and mental findings, including physical examinations and the utilization of medically accepted diagnostic procedures, e.g., laboratory tests and pathology and X-ray examinations.

(2) Outpatient Care.  The medical services which are normally performed in locations such as the home, a physician's office, or the outpatient department of a hospital, clinic, or dispensary.

(3) Maternity and Infant Care.  Medical and surgical care for the mother incident to pregnancy including prenatal care, delivery, postnatal care, including care of the infant, and treatment of complications of pregnancy.

(4) Domiciliary Care.  Care which is normally given in a nursing home, convalescent home, or similar institution to a patient who requires personal care rather than active and definitive treatment in a hospital for an acute medical or surgical condition.  It includes but is not limited to nursing care required as a result of old age or chronic disease.

(5) Chronic Disease.  This term shall be construed to include nonacute conditions and disabilities in which the prognosis indicates long continued duration of the ailment.

(6) Nervous and Mental Disorders.  This term means those conditions classified as neuroses, psychoneuroses, psychopathies, or psychoses.

(7) Dental Care as a Necessary Adjunct to Medical or Surgical Treatment.  Dental care determined by the cognizant physician and dentist to be required for the proper treatment of a medical or surgical condition.

(8) Adjuncts to Medical Care.  Prosthetic devices such as artificial limbs, artificial eyes, hearing aids, orthopedic footwear, spectacles, and similar medical supports or aids.

(9) Adjuncts to Dental Care.  Removable or fixed prosthetic or fixed prosthodontic restorations and similar dental supports or aids.

104.  Administration

a.  The Secretary of Defense  has jurisdiction over the Army, the Navy, the Air Force, the Marine Corps, and the Coast Guard when operating as a Service with the Navy.

b.  The Secretary of Health, Education, and Welfare  has jurisdiction over the Public Health Service and for medical care purposes over the Coast and Geodetic Survey, and the Coast Guard when not in Service with the Navy.

SECTION 2

DETERMINATION OF ELIGIBILITY AND
IDENTIFICATION OF DEPENDENTS

201.  Determination of Dependents Eligibility

a.  The Uniformed Services will require dependents (or their sponsors) who request medical care to furnish proof of their eligibility for such care.  In order to develop uniformity in the criteria utilized by the Uniformed Services to determine dependents eligible for medical care, the Uniformed Services will utilize DD Form 1172, "Application for Uniformed Services identification and Privilege Card."  Modifications of DD Forms 1172 and 1173 may be made subject to the approval of the Secretary of Defense.

(1) Medicare Eligibility Date.  Each DD Form 1173, "Uniformed Services Identification and Privilege Card," issued will show the date on which a dependent became eligible to receive civilian medical and hospital care at Government expense.  This eligibility date will be determined in accordance with Department of Defense Instruction No. 1000.7, Subject: Uniformed Services Identification and Privilege Card."

b.  The Secretaries of the Uniformed Services and their designees are hereby authorized to make determinations of dependency for purposes of this Directive.

202.  Identification of Dependents

a.  Upon an affirmative determination by the Secretary of a Uniformed Service or his designee that a dependent is eligible for medical care, such dependent will be issued a "Uniformed Services Identification and Privilege Card," DD Form 1173.  The DD Form 1173 will serve as the primary means of identifying dependents eligible for medical care.

b.  The administrative provisions governing the application for the DD Form 1173 and its issuance to dependents of members and dependents of retired members of the Uniformed Services and dependents of a person who died while a member or a retired member of a Uniformed Service, will be as prescribed by the Secretary of the Uniformed Service concerned.  However, such regulations for active duty members with dependents will include but not be limited to provisions for the following:

(1) Issuance -- Application for, and issuance of, DD Form 1173 will be accomplished at the following times:

(a) Upon entry on active duty for a period in excess of 30 days.

(b) Upon re-enlistment.

(c) Upon change in dependency status stated on current authorization card.

(d) Upon certification of loss.

(e) Upon retirement or death.

(2) Surrender -- The DD Form 1173 shall be surrendered:

(a) Whenever a new card is issued except to replace loss.

(b) Upon expiration date.

(c) Whenever the cardholder becomes ineligible.

(d) Upon death, retirement, or release of member to inactive duty.

(3) Expiration Date -- The DD Form 1173 shall be effective for the contracted period of service of the sponsor upon whom the entitlement is based in the case of dependents of the Uniformed Services, or in the case of minors the twenty-first birthday if it occurs prior to the termination of the service of the sponsor, except that for entitlement to medical care, the provisions of Section 1, Paragraph 103.d.(7) will apply.  The Departments will insure that sponsors are directed to notify the appropriate authority immediately upon any change in status that would terminate or modify the right to any of the benefits for which the card may be used.

(4) Dependents Listed -- Each dependent, ten years or over, entitled to medical care, will be issued DD Form 1173.  Certification of minor dependents, under ten years of age, for eligibility for medical care will be the responsibility of the dependent, accompanying parent, member, or acting guardian.

(5) Entitlement to Care in Civilian Facilities -- All DD Forms 1173 will contain an appropriate notation as to those dependents who have entitlement to medical care at both medical facilities of the Uniformed Services and civilian medical facilities.  Thus, each card covering a dependent eligible for civilian medical care (see section 1-103.e.) will have a notation thereon showing that care in civilian facilities is authorized even though the situations in which such care may be obtained at Government expense are limited.  For example, such a dependent residing with the sponsor, or living in an area to which the sponsor is assigned, and whose right of election has been restricted pursuant to section 3-302. shall be entitled to receive medical care in civilian facilities at Government expense only in the case of an emergency and under other circumstances outlined in this Directive or in the Joint Regulations.

c.  The issuance and use of the DD Form 1173 will be accomplished by all the Uniformed Services.

SECTION 3

DETERMINATION OF SOURCES FROM WHICH
ELIGIBLE DEPENDENTS RECEIVE MEDICAL CARE

301.  Among Uniformed Services Facilities

Normally, a dependent requesting care at a Uniformed Services facility will be expected to use the facilities servicing the area in which the dependent resides.

302.  Between Civilian Medical Facilities and Uniformed Services Facilities Within the United States and Puerto Rico

a.  Dependents eligible for civilian medical care who are not residing with their sponsors, or in an area to which their sponsor is assigned, shall have right of election between Uniformed Services medical facilities and civilian medical facilities.

b.  Outpatient medical care at Government expense for dependents eligible for civilian medical care is not authorized from civilian sources, except that certain specified treatment for such dependents who are not hospitalized, will be authorized when in accordance with sections 5-502.f.; 503.d.(1),  (2), and (3); or 506.i.

c.  Dependents eligible for civilian medical care who reside with their sponsors, or in an area to which their sponsor is assigned, shall have right of election between Uniformed Services medical facilities and civilian medical facilities except that the Secretary of a Uniformed Service with the approval of the Secretary of Defense or the Secretary of Health, Education, and Welfare, as appropriate, may require such dependents in a prescribed area to seek medical care in a Uniformed Services medical facility if he finds that:

(1) The Uniformed Services medical facility is adequate to care for the dependents of members assigned to that area; and

(2) The use of civilian medical facilities by the dependents in that area has affected adversely the optimum economic utilization of the Uniformed Services medical facility.

d.  When necessary restrictions on right of election for a particular medical facility are imposed, the Secretary of a Uniformed Service may prescribe a local geographic area which the medical facility concerned shall serve normally.  In determining the boundaries of the geographic area, consideration shall be given to normal commuting time, distance, and usual geographic and transportation factors such as toll bridges or ferries which would increase unreasonably the time and expense of travel.  It shall be the responsibility of the Secretary of a Uniformed Service, when imposing restrictions upon the right of election of a dependent, to insure liaison and coordination among all Uniformed Services and civilian medical facilities in and adjacent to the geographical area in which restrictions have been imposed.  When any restrictions on right of election have been imposed or removed, the Executive Agent shall be so advised.

e.  In lieu of the restrictions described in sections 3-302.c. and d., above, the Secretary of Defense may specify a date as of which the restrictions described below will be effective.  On and after the specified date, a restriction on right of election shall be effective as to dependents in the United States and Puerto Rico, who are eligible for civilian medical care, who reside with their sponsors, or in an area to which their sponsor is assigned, who require care authorized under this Directive from civilian sources but have not commenced receiving such care from civilian sources on the aforesaid specified date (or, in the case of a maternity patient, whose care by her civilian physician on that date has not reached the second trimester), and who reside in an area where adequate medical facilities of a Uniformed Service are available for such dependents.  No restriction on right of election will be imposed on such dependents residing in areas where adequate medical facilities of a Uniformed Service are not available.  However, in order that the restriction may be appropriately administered, each dependent who resides with the sponsor, or in an area to which the sponsor is assigned, and who requires care authorized under this Directive from civilian sources but has not commenced receiving such care from civilian sources on the specified date (or, in the case of a maternity patient, whose care by her civilian physician on that date has not reached the second trimester), will be required to contact a Uniformed Services installation.  For those residing in areas where an adequate medical facility of a Uniformed Service is not available, DD Form 1251, "Nonavailability Statement," authorizing care from civilian sources at Government expense will be issued.  Such a statement may also be issued to a dependent residing with the sponsor, or residing in an area to which the sponsor is assigned, when the capability does not exist in the medical facility (or facilities) of the Uniformed Services in the area to provide the required care because of lack of necessary staff, facilities, or space.  The DD Form 1251, issued in the manner described above, shall be evidence of entitlement of the dependent to care authorized under this Directive from civilian sources at Government expense.  In determining whether a dependent covered under this section 3-302.e. is residing in an area where adequate medical facilities of a Uniformed Service are available, the criteria outlined in sections 3-302.c. and d. shall apply.  Detailed procedures concerning the format of the DD Form 1251 and the manner in which it is to be issued may be set forth in the Joint Regulations.  Spouses and children are considered to be residing with their sponsor if they reside in the area to which the sponsor is assigned, in the area of his permanent duty station, or the home port or home yard of a ship, even though the sponsor may be temporarily away, by reason of temporary duty with his unit or ship, from the area to which he is assigned, the permanent duty station or his home port or home yard respectively, or by reason of the sponsor's absence on individual temporary duty or temporary additional duty order.

303.  ExceptionsEmergency Care and Other Circumstances

a.  Any restrictions on right of election and the requirement for the DD Form 1251 described in section 3-302.e. shall be waived:

(1) When circumstances indicate that it was necessary for to be eligible dependent to obtain authorized medical care from civilian facilities due to a bona fide emergency, e.g., serious injury following an accident or illness of sudden onset requiring immediate treatment authorized to be obtained from civilian sources at the nearest available medical facility to preserve life, health, or to prevent undue suffering.

(2) During the period of absence on a trip of the eligible dependent from the area to which the sponsor is assigned.  This exception is not to be used to circumvent the restrictions imposed on right of election.

(3) When an eligible dependent wife, whose husband dies while on active duty, is pregnant at the time of his death.  (See section 5-505.d.)

b.  Additionally, the restrictions initially imposed by the Secretary of Defense on a specified date pursuant to section 3-302.e. and the requirement for a DD Form 1251 described therein shall be waived with regard to any eligible dependent who has commenced receiving care authorized under this Directive from civilian sources prior to that specified date (except that, for maternity patients, care in the second trimester by her civilian physician on that date must have commenced prior thereto).  The dependent involved will be entitled to complete any care which was authorized under this Directive prior to the date specified by the Secretary of Defense and which has been commenced in accordance with the preceding sentence.

304.  Between Civilian Medical Facilities and Uniformed Services Facilities Outside the United States and Puerto Rico

Dependents eligible for civilian medical care who are not residing with their sponsors, or in an area to which their sponsor is assigned, shall have right of election between Uniformed Services medical facilities and professionally acceptable local civilian sources.  Where medical facilities of the Uniformed Services are available within the area and are capable of providing the required care, spouses and children outside the United States and Puerto Rico who are residing with their sponsors, or in an area to which their sponsor is assigned, will utilize these facilities for such care.  In areas where medical facilities of the Uniformed Services are nonexistent or incapable of providing adequate medical care, spouses and children who are residing with their sponsors, or in an area to which their sponsor is assigned, may be authorized civilian medical care from professionally acceptable local sources in accordance with this Directive.

SECTION 4

MEDICAL CARE FOR DEPENDENTS AT MEDICAL FACILITIES
OF THE UNIFORMED SERVICES

401.  Authority for Providing Medical Care to Dependents

Whenever requested, medical care shall be given dependents of members and dependents of retired members of the Uniformed Services, and dependents of a person who died while a member or a retired member of a Uniformed Service, in medical facilities of the Uniformed Services subject to the availability of space and facilities, and the capabilities of the professional staff.  Determinations made by the medical officer in charge of the medical facility, or by his designee, as to availability of space, facilities, and the capabilities of the professional staff, shall be conclusive.  The furnishing of medical care to dependents shall not interfere with the primary mission of those facilities.

402.  Facilities Available

In making the determination of the availability of medical facilities at a specific location, the following criteria shall be applied:

a.  Mission of the Uniformed Services medical facility.

b.  Adequacy of professional care available for diagnosis and treatment.

c.  Maximum number of patients who can be treated without sacrificing high professional medical standards.

d.  Optimum utilization of facilities of the Uniformed Services.

403.  Medical Care Authorized

a.  Medical care of dependents in the facilities of the Uniformed Services shall be limited to the following:

(1) Diagnosis.

(2) Treatment of acute medical conditions, including acute exacerbations or acute complications of chronic diseases.

(3) Treatment of surgical conditions.

(4) Treatment of contagious diseases.

(5) Immunization.

(6) Obstetrical and infant care.

b.  Treatment may be provided for acute emergencies of any nature which are a threat to the life, health, or well being of the patient including acute emotional disorders.  Hospitalization is authorized at Government expense for such emergencies only pending completion of arrangements for care elsewhere unless the illness or condition also qualifies for care under sections 4-403.a.(1), (2), (3), (4), or (6) above.  With special exceptions as authorized by the Surgeon General of a Uniformed Service, additional care in a hospital of the Uniformed Services on a space available basis may be provided in accordance with section 4-404.b.

c.  When a hospitalized dependent patient requires care beyond the capabilities of the medical facility, the commanding officer or officer-in-charge of the facility is authorized to:

(1) Transfer the patient to the nearest medical facility of the Uniformed Services where the required treatment is available.  Government transportation may be utilized to effect such transfer; or

(2) Procure from civilian sources the necessary supplemental material and professional and personal services required for the proper care and treatment of the patient in his facility.
 
The authorization provided by this
section 4-403.c. is applicable after admission of the patient when the patient's condition so requires.

404.  Medical Care Not Authorized

Dependents shall not be provided:

a.  Hospitalization at medical facilities of the Uniformed Services for the following:

(1) Chronic diseases.  (See sections 1-103.j.(5) and 4-403.a.(2)).

(2) Nervous and mental disorders.  (See section 1-103.j.(6)).

(3) Medical or surgical care that is desired or requested by the patient which, in the opinion of cognizant medical authority, is not medically indicated; e.g., surgery solely for cosmetic purposes.

(4) Domiciliary care.  (See section 1-103.j.(4)).

b.  However, in special and unusual cases, exceptions may be made by a Surgeon General of the Uniformed Services and hospitalization may be provided for such disorders or diseases as set forth in sections 4-404.a.(1) and (2), above.  In no instance may the period of hospitalization exceed 12 months.

c.  Artificial limbs, artificial eyes, hearing aids, orthopedic footwear and spectacles, except that outside the United States and at remote stations within the United States, as designated by the Secretary of the Uniformed Service concerned and approved by the Secretary of Defense, or designated by the Surgeon General, U.S. Public Health Service, and approved by the Secretary of Health, Education, and Welfare, where adequate civilian facilities are not available, those items, if available from Government stocks, may be provided to dependents at invoice cost to the Government.

d.  Ambulance service, except in acute emergency as determined by the medical officer in charge.

e.  Home calls, except in special cases where it is determined by the cognizant medical authority to be medically necessary.

405.  Dental Care

a.  Dental care for dependents is not authorized except:

(1) Emergency dental care to relieve pain and suffering but not to include any permanent restorative dentistry or dental prosthesis.

(2) Dental care as a necessary adjunct to medical or surgical treatment.  (See section 1-103.j.(7)).

(3) Outside the United States, and in remote areas within the United States as designated by the Secretary of the Army, Navy, or Air Force and approved by the Secretary of Defense where adequate civilian dental facilities are not available to personnel at or near military installations; or as designated by the Surgeon General, U.S. Public Health Service, and approved by the Secretary of Health, Education, and Welfare for those facilities over which jurisdiction is provided in section 1-104.b.

406.  Admission of Dependents for Medical Care

a.  As indicated in sections 2-201. and 202., the DD Form 1173 will serve as the primary means of identifying dependents eligible for medical care.

b.  Procedures for admission of dependents requesting medical care at Uniformed Services medical facilities will be as follows:

(1) Identification will be by means of a DD Form 1173.  Uniformed Services medical facilities may prescribe such additional local procedures as necessary.  However, these procedures should not complicate, delay or preclude treatment of an eligible dependent nor discriminate against the dependent of members of other Services.

(2) Under emergency conditions and similar circumstances, the admitting authority may waive the requirement of producing DD Form 1173.  However, in each such instance at Uniformed Services medical facilities, certification will be required attesting to the dependent's eligibility for medical care.  This certification will be executed by either the dependent, the member, retired member, parent or guardian as appropriate.

407.  Cross-Utilization of Service Medical Facilities

To provide effective cross-utilization of medical facilities of the Uniformed Services, eligible dependents, regardless of Service affiliation, shall be given equal opportunity for medical care.  Such dependents may request and be furnished medical care at the medical facility of the Uniformed Service serving the area in which they reside or in the medical facility of the sponsor's own Uniformed Service depending upon the capability of the medical facilities concerned.  In areas where medical facilities of two or more Uniformed Services are available, the appropriate officials of each Service, with due consideration for the relative size and capabilities of the medical facilities, shall participate jointly in determining the capabilities and establishing areas of medical responsibility.  Delineation of such areas shall be published jointly and will include zones in which dependents are permitted to use either the facilities of the sponsor's own Service or the facilities which have medical responsibility for the area in which the dependent resides.  In addition, commanders of Uniformed Services hospitals will establish necessary liaison and coordination with the representatives of the local medical society and the civilian hospital facilities as appropriate, to insure, to the maximum extent possible, the smooth referral of excess dependent patient loads to civilian medical facilities when such referrals appear desirable.

408.  Charges for Dependent Medical Care

When medical care is provided dependents in facilities of the Uniformed Services, the patient shall pay the following charges:

a.  Inpatient Care.  The per diem rate of charge for inpatient care provided dependents is $1.75, which includes cost of subsistence.

b.  Outpatient Care.  As a restraint on excessive demands for medical care, uniform minimal charges may be imposed for outpatient care only after a special finding by the Secretary of Defense after consultation with the Secretary of Health, Education, and Welfare that such charges are necessary.  The Secretaries of the Uniformed Services shall have continuing responsibility for determining the nature and extent of possible abuses of outpatient care in Uniformed Services medical facilities and shall so advise the Secretary of Defense when their findings are in the affirmative.

409.  Transportation of Patients

Commercial or civilian transportation to move dependent patients to medical facilities of the Uniformed Services, between medical facilities of the Uniformed Services, or from a civilian medical facility to a medical facility of the Uniformed Services is not authorized at Government expense.

SECTION 5

MEDICAL CARE IN CIVILIAN FACILITIES

501.  Eligibility for Civilian Medical Care

Under the provisions of this section, wives, dependent husbands and children who are dependents of members of the Uniformed Services are eligible to receive at Government expense specified medical or dental care from civilian sources.  A full-payment concept is followed in operating the Dependents' Medical Care Program.  Under this concept the participating civilian physician and other sources of civilian care agree to accept the amounts allowable under the program as full payment for their services.  Eligible dependents should ascertain that the civilian sources of medical care desire to participate in the Medicare Program.  Following acceptance of the patient under the Medicare Program by the civilian source of care, the patient and his sponsor are not responsible for the payment of any amount for authorized care except as specified in section 5-506.

502.  Medical and Hospital Care Authorized from Civilian Sources

Medical and surgical care from civilian sources is authorized for spouses and children who are dependents of members of the Uniformed Services for the following:

a.  Treatment of acute medical conditions, including acute exacerbations or acute complications of chronic diseases only during hospitalization except as otherwise provided in this Directive.

b.  Treatment of surgical conditions only during hospitalization except as otherwise provided in this Directive.  (See section 5-504.c.)

c.  Treatment of contagious diseases during hospitalization.

d.  Complete obstetrical and maternity care.

e.  Three hundred sixty-five days' hospitalization in semi-private accommodations for each admission, including all necessary services and supplies furnished by the hospital during hospitalization.

f.  Services required of a physician or surgeon prior to and following hospitalization for a bodily injury or surgical operation.

g.  Treatment in a hospital for an acute emotional disorder is authorized provided that such disorder is considered to constitute an emergency, which is a threat to the life or health of a patient.  In general, care will be provided for an acute emotional disorder under this section only until the disorder subsides, until arrangements are made for care else where, or until the end of 21 days of hospitalization, whichever occurs earliest.  Under procedures to be established by the Executive Agent, or his representative, within the United States and Puerto Rico, and by the Secretaries of the Uniformed Services, or their representatives, outside the United States and Puerto Rico, extension beyond 21 days may be granted on a case-by-case basis where the member or the dependent, or the representative of either, shows that due to absence (e.g., overseas assignment when dependent is in the United States), the member was unable to make arrangements for care elsewhere within the 21-day period.  With special exceptions, as authorized by the Surgeon General of a Uniformed Service, additional care for an acute emotional disorder in a hospital of the Uniformed Services on a space available basis may be provided in accordance with section 4-404.b.  The commanding officer of a Uniformed Services hospital, or the Surgeon General of a Uniformed Service having jurisdiction over a hospital, may authorize transfer of any patient, hospitalized in a civilian hospital under any of the above subparagraphs, to that Uniformed Services medical facility on the basis of space, facility, and personnel availability.  (See sections 4-402. and 403.).  In cases covered by the two preceding sentences, Government transportation may be utilized to effect transfer to a Uniformed Services hospital.

h.  Diagnostic tests and procedures including laboratory tests and pathology and X-ray examinations, when ordered by the attending physician, only during hospitalization, except as otherwise provided in this Directive.

i.  Dental care which is a necessary adjunct to medical or surgical treatment rendered in a hospital to a dependent who is a hospital inpatient.  Such dental care shall not include removable or fixed prosthodontic restorations, orthodontia, restorative dentistry, and prolonged periodontal treatment.

j.  Notwithstanding those other provisions of this Directive with reference to dental care and to the care of chronic conditions, patients suffering from recurrently progressive debilitating diseases may be hospitalized to receive inpatient surgical care, legitimately performed by a dentist, which has been determined by the cognizant physician and dentist to be a necessary adjunct to, and required for, the proper treatment of such conditions.

503.  Terms of Reference and Rules for the Provision of Authorized Medical Care From Civilian Sources

a.  Applicable Terms.  (NOTE: These terms are primarily for use in the United States and Puerto Rico and may be modified in other areas.)

(1) Hospital.  The word "hospital" shall mean only an institution which is operated in accordance with the laws of the jurisdiction in which it is located pertaining to institutions identified as hospitals, is primarily engaged in providing diagnostic and therapeutic facilities for surgical and medical diagnosis, treatment and care of injured and sick persons by or under the supervision of staff physicians or surgeons, and continuously provides 24-hour nursing service by registered graduate nurses.  It shall specifically exclude any institution which is primarily a place of rest, a place for the aged, a place for the treatment of drug addiction or alcoholism, a nursing home, a convalescent home, or a facility operated by the Federal Government or any Agency thereof, except Freedmen's Hospital, Washington, DC.  If the experience of the Executive Agent indicates that the care provided in a hospital is substandard, or charges of a hospital are excessive, Government approval of its use in the future may be withdrawn and parent of charges by the Government denied for patients admitted subsequent to the withdrawal of approval unless the case is certified as an emergency by the attending physician or surgeon.

(2) Semiprivate Accommodations.  The term "semiprivate accommodations" signifies the presence of 2, 3, or 4 beds in a room in which a patient is hospitalized.  "Private accommodations," means one bed in a room.

(3) Ward Accommodations.  The term "ward accommodations," signifies the presence of 5 or more beds in a room in which the patient is hospitalized.  Where ward accommodations are furnished under the circumstances described herein, a portion of the cost will be borne by the Government in accordance with section 5-506.a.  Ward facilities may be used for pediatric cases whenever this is the normal medical practice.  Further, when the attending physician admits his patient to a hospital in which all semiprivate accommodations are occupied, care furnished therein shall be considered authorized care, but the patient should be transferred to a semiprivate accommodation as soon as possible.  Finally, when the patient is admitted to an otherwise eligible institution which furnishes only ward accommodations, care furnished therein shall be considered authorized care.

(4) Necessary Services and Supplies.  Those services and supplies ordered by the attending physician which are customarily provided and charged for by the hospital.

(5) Physician or Surgeons.  A person who is legally qualified to prescribe and administer all drugs and to perform all surgical procedures.

(6) Dentist.  A person who is legally qualified to prescribe and administer all drugs and perform all procedures related to the teeth, jaws, and to structure contiguous to one or the other.

(7) Local Schedule of Allowances.  The allowances for payment of physicians' services applicable to a local area negotiated with the physicians' representatives and approved by the Executive Agent for the Department of Defense and Department of Health, Education, and Welfare.

b.  Hospital Care

(1) Hospital care under this section is defined as inpatient care for 18 consecutive hours or more, except for shorter periods of hospitalization for surgical procedures, treatment of fractures or other bodily injuries, or in instances in which death occurs in a lesser period of time.

(2) Hospital care shall include board and room and necessary services and supplies up to a maximum or 365 days for each admission.

c.  Nursing Care

If, while receiving authorized hospital care, private duty nursing care is required for proper care and treatment, and if the patient's attending physician certifies to such a requirement, a portion of the cost will be borne by the Government in accordance with section 5-506.e.

d.  Professional Services

(1) Professional Services Related to Hospitalization

(a) Payment to physicians, including necessary consultants, in accordance with local Schedules of Allowances, for treatment of medical and surgical conditions during a period of hospitalization, is authorized.

(b) All diagnostic and therapeutic tests and procedures authorized by the attending physician and accomplished during a period of hospitalization are authorized for payment by the Government.  In those instances during the period of hospitalization when treatment by the use of X-ray, radium or radioisotopes is prescribed, such treatment may be continued or carried out on an outpatient status.

(c) The approved local schedules of allowances payable to a physician or surgeon for treatment in a hospital of a bodily injury or for a surgical procedure shall include prehospitalization care and normal after-care following a period of hospitalization.

(d) Those surgical procedures that are legitimately cared for by a dentist (e.g., cleft lip, cleft palate, etc.) may be treated by a dentist who is a member of the staff of a hospital and normally performs these surgical procedures in that hospital.  The removal of teeth, gingivectomies, and alveolectomies are not authorized surgical procedures under the Program unless they meet the criteria of adjunctive dental care as defined in this Directive.  When authorized surgical treatment is performed by a dentist, other procedures, diagnostic tests, services, and supplies authorized or ordered by him may be paid to the same extent as if a physician or surgeon authorized or ordered them under this Directive.

(e) Although Chapter 55 of title 10, United States Code, provides primarily for professional services during hospitalization and does not permit medical care normally considered to be outpatient care at Government expense, certain limited benefits are authorized as indicated elsewhere in this section, and below:

(i) Payment is authorized in an amount not to exceed $75.00 at Government expense for necessary diagnostic tests and procedures performed or authorized by the attending physician prior to hospitalization for the same bodily injury or surgical procedure for which hospitalized.

(ii) Payment is authorized in an amount not to exceed $50.00 at Government expense for necessary tests and procedures performed or authorized by the attending physician for proper after-care of the same bodily injury or surgical procedure for which hospitalized.

(iii) The monetary limitations in (i) and (ii) above are intended only to define the liability of the Government under the stated conditions and in no way modify, alter, or affect the fees for individual procedures contained in the local schedules of allowances; and also, they do not restrict the physician in the performance or authorization of necessary tests or procedures.

(iv) The monetary limitations in (i) and (ii) above may be exceeded only in special and extraordinary cases provided that the physician authorizing the tests and procedures, for which charges exceed the amounts specified above, submits a special report which shall be reviewed by a contractor's physician review board.  This board will make appropriate recommendations to the Executive Agent who may authorize such additional payments.

(2) Obstetrical and Maternity Services

(a) Complete obstetrical and maternity services shall include prenatal care, delivery, and postnatal care in a hospital, office, or home.  Payments for prenatal care, delivery, and postpartum care shall be made to the physician performing the respective service in accordance with the local schedules of allowances.  Allowances are authorized for laboratory tests, pathology or radiology examinations, and other procedures performed or authorized by the attending physician in the management of the pregnancy.  In instances of home or office confinements, payments are not authorized for the purchase or rental of beds, bassinets, or similar equipment, or for services of private-duty nurses. (See section 5-506.f.).

(b) Where a consultant's services are required for proper care and treatment of the patient, such care is authorized.

(c) Necessary or required infant care shall be provided during the period of hospitalization following delivery.  If the infant requires further hospitalization following delivery, such care is authorized as a continuation of the original admission.  Also, in the case of a home or office delivery, necessary or required infant care may be provided on an outpatient basis for a period not to exceed 10 days following the date of delivery.

(d) Under procedures established by the Executive Agent, or his representative, within the United States and Puerto Rico, and by the Secretaries or the Uniformed Services, or their representatives, outside the United States and Puerto Rico, required in-hospital care can be furnished to obstetrical and maternity patients who develop acute emotional disorders complicating pregnancy or constituting postpartum psychosis occurring within the six weeks postpartum period authorized for maternity care.

(3) Other Professional Services

The authorized payments for the treatment of bodily injuries when a patient is not hospitalized, including diagnostic and therapeutic tests and procedures authorized by the attending physician, are limited to treatment of fractures, dislocations, lacerations, and other wounds as prescribed in the local schedules of allowances.  Treatment of fractures, dislocations, lacerations, and other wounds that are legitimately cared for by dentists, including related diagnostic and therapeutic tests and procedures authorized by the attending dentist, may also be paid for hereunder. (See section 5-506.i.)

e.  Supporting Services

Wherever the attending physician authorizes the services of a physical therapist or of an anesthetist who is other than a physician in rendering authorized care to an eligible dependent, and certifies as to the necessity therefore, the services may be paid for hereunder.

504.  Medical Care Not Authorized

Medical care specified in this section shall not be authorized for any of the following:

a.  Chronic diseases.  (See sections 1-103.j.(5) and 5-502.a.)

b.  Nervous and mental disorders (see section 1-103.j.(6)), including acute emotional disorders except that (1) care of this type may be furnished to a dependent requiring same during the period of hospitalization of that dependent for a condition that does qualify as authorized care under sections 5-502.a. through f.; (2) care for acute emotional disorders may be furnished in connection with obstetrical and maternity services in accordance with section 5-503.d.(2)(d); and (3) care for acute emotional disorders may be furnished in accordance with section 5-502.g.

c.  Services of a surgical nature desired or requested by the patient which are not medically indicated.  The opinion of the cognizant medical authority (charge physician) will determine whether the services are medically indicated and therefore payable under this Directive, except that the types or surgery described in (1) below, are not authorized for payment under this Directive under any circumstances; and the types of surgery described in (2) below, are authorized only under the conditions stipulated therein.

(1) Examples of Types of Surgical Care Not Authorized

(a) Cosmetic surgery -- any surgery for improvement or change of appearance or for psychological reasons.

(b) Ears -- reconstruction and/or revision of the external ear; surgery based on psychological reasons.

(c) Congenital defects of skeletal and/or central nervous system which are readily identifiable as representing chronic long-term conditions and characteristically respond poorly to surgical intervention.

(d) Sterilization procedures for multiparity and/or socioeconomic reasons. (See section 5-504.c.(2)(k).)

(e) Procedures designed to correct a state of infertility or sterility.

(f) Removal of tattoos.

(2) Examples of Types or Inpatient Surgical Care Authorized For Payment Only If Certain Conditions Prevail

(a) Ears -- surgery for restoration or improvement of hearing is allowable.

(b) Eyes -- surgery for glaucoma, cataracts, strabismus (squint) or other conditions to aid or improve vision of the affected eye(s) is allowable.

(c) Harelip and/or cleft palate -- surgery for initial repairs, including surgery for subsequent repair known and established as a requirement at the time of original surgery is authorized.  Subsequent revisions are not authorized.

(d) Rhinoplasties -- authorized only for improvement of nasal respiratory physiology.

(e) Skeletal defects (e.g., club foot, congenital dislocated hip) -- surgical treatment is authorized only when treatment is required as an "in -hospital" patient to improve function.  Care normally provided on an outpatient basis and not requiring hospitalization is not authorized.

(f) Surgical treatment for removal of supernumerary digits or for correction of syndactylism is authorized only for improvement of function.

(g) Scars -- surgical treatment is authorized only when a scar is ulcerated, shows clinical evidence of malignancy, or when a contracture impairing anatomical function is present.

(h) Surgical treatment for removal of nevi, hemangiomas and/or telangiectatic lesions is authorized only if they are bleeding, ulcerated, painful, or show clinical evidence of malignancy, or if size and location produce functional impairment.

(i) Surgical treatment for removal of plantar warts, verrucae, sebaceous cysts, condylomata or moles is authorized only if they are bleeding, ulcerated, painful, or show clinical evidence of malignancy, or if size and location produce functional impairment.

(j) Mammoplasty is authorized only when severe pain or marked disability is present.

(k) Tubal ligation or other sterilization procedures -- surgical procedure is authorized only when, in the opinion of the charge physician and consulting physician(s), the procedure is a necessary requirement in the proper management of a medical or surgical condition for which treatment is authorized under this Directive.

d.  Non-acute medical conditions (see section 5-502.a.).  Examples of types of care not authorized are set forth below:

(1) Procedures designed to determine state of infertility or sterility.

(2) Pseudocyesis (false pregnancy) or pregnancy suspected but not proven.

(3) Tests to determine pregnancy, except when patient is in fact pregnant and when tests are required for proper conduct of maternity or postpartum care (hydatid mole).

(4) Diagnostic evaluation and hospital admissions in connection therewith when patients are not acutely ill or when diagnostic surveys are not followed by surgery.

(5) Rehabilitation procedures for persons with congenital defects, cerebral palsy, or poliomyelitis (except when related to "in-hospital" care of surgical procedure performed for improvement or restoration of function).

(6) Treatment for tuberculosis -- inactive (non-acute) when determined by clinical tests.  Treatment is authorized only for the active (acute) phase as determined by acceptable medical standards (positive sputa; positive gastric washings; or positive chest or other X-rays).

(7) Tests and procedures such as the following:

(a) Psychological, psychometric, or intelligence measuring tests.

(b) Speech and/or hearing therapy, remedial reading, or orthoptic training.

(c) Child guidance therapy.

e.  Domiciliary care. (See section 1-103.j.(4).)

f.  Treatment or procedures normally considered to be outpatient care.

g.  Ambulance service, or other civilian transportation used for movement of spouses or children to or between civilian medical facilities or from a civilian medical facility to a medical facility of the Uniformed Services.

h.  Adjuncts to medical care. (See section 1-103.j.(8).)

505.  Admission of Dependents for Medical Care to Civilian Sources

Dependents requesting medical care from civilian sources will be required to observe the following procedures:

a.  Identification will be established by DD Form 1173 and such other means of identification provided by the Uniformed Services.  In addition, dependents or their parent, sponsor, or guardian, as appropriate, will be required to execute a certification form to be prescribed by the Executive Agent and made available to the source of medical care.  This form will serve the purpose of assisting both in the identification of dependents and the ultimate billing made by civilian physicians, surgeons, and civilian medical facilities.  In developing this form, the Executive Agent will insure that it will include appropriate provision for:

(1) Identification of the patient.

(2) Identification of sponsoring member of Uniformed Service on active duty.

(3) Certification of the dependent, accompanying parent, member or acting guardian as to the eligibility of the dependent for care under Chapter 55 of title 10, United States Code.

(4) Diagnosis, medical services furnished and charges.

(5) Certification by the source of medical care that services were provided in accordance with Chapter 55 of title 10, United States Code.

(6) Under emergency conditions and similar circumstances, the admitting authority may waive the requirement of producing a DD Form 1173.  However, in each instance of this nature, the form prescribed by the Executive Agent and referred to in this section 5-505.a. will be executed.

b.  On and after the effective date specified by the Secretary of Defense pursuant to section 3-302. e., an eligible dependent who is residing with the sponsor, or in the area to which the sponsor is assigned, and who has not commenced receiving care from civilian sources prior to that date (or, in the case of a maternity patient, whose care from her civilian physician on that date has not reached the second trimester), in addition to complying with sections 5-505.a. and b., will be required to present a DD Form 1251, "Nonavailability Statement," to the attending physician and the hospital, when both are involved, and to the appropriate party when only one is involved, for attachment to the claim form.  Sources of civilian care other than the hospital or the attending physician may, in lieu of attaching a DD Form 1251 to the claim form, accept a statement from the person signing the certification in accordance with section 5-505.a. that a DD Form 1251 has been furnished to the attending physician (identifying him by name) or to the hospital (identifying it by name).  The DD Form 1251 shall be obtained from Uniformed Services installations and shall cover only care authorized to be obtained from civilian sources under this Directive.  A statement by the person signing the certification in accordance with section 5-505.a., above, that the patient is not residing with the sponsor, or in the area to which the sponsor is assigned, may be accepted by the source of care unless that source has actual knowledge to the contrary.  The requirement for the DD Form 1251 shall be waived in the case of an emergency, and in other circumstances outlined in section 3-303.  A statement from the attending physician on the claim form that the case is an emergency (see section 3-303.a.(1)) will be sufficient to justify an exception.  Also, a statement by the person signing the certification in accordance with section 5-505.a., above, that the patient is away on a trip from the area to which the sponsor is assigned will be sufficient to justify an exception, unless the source of care has actual knowledge to the contrary.  Where representations are made by the source of civilian medical care that it was not aware of the requirements contained in this section 5-505.b. and that it furnished care authorized under this Directive to a person claiming to be a spouse or child eligible for civilian medical care, and possessing a valid DD Form 1173, then the matter will be brought to the attention of the Uniformed Service concerned for determination whether a Nonavailability Statement can be issued.  If it is determined by the Uniformed Service concerned that the DD Form 1251 cannot be furnished, then the matter will be brought to the attention of the member concerned as an unpaid debt.  In special circumstances, and where the source of civilian care shows that collection has not been possible, then the Executive Agent or his designee may authorize payment to be made to that source, provided the claim covers care authorized under this Directive and was otherwise executed in accordance with all requirements except those set forth above concerning the Nonavailability Statement.

c.  In cases of spouses and children receiving treatment in a civilian medical facility at Government expense at the time entitlement to receive medical care from civilian sources ceases (by reason of release from active duty, or otherwise), the Government's responsibility ceases, insofar as the source of civilian care is concerned, as of the date of receipt of knowledge by the source of care that the dependent's entitlement to medical care from civilian sources has terminated or the normal expiration date on the DD Form 1173, whichever is earlier.  In any case, the Government's responsibility ceases, insofar as the dependent or member is concerned, as of the date the dependent ceases to be entitled to receive care (by reason of release of the member from active duty, or otherwise) from civilian sources at Government expense. (See section 2-202.b.(5).)  Notwithstanding the foregoing, the Government will be responsible for paying for care rendered to patients covered by section 5-505.b., only if the conditions set forth in that section are met.

d.  Exceptions to the policy in section 5-505.c. are authorized under the following circumstances:

(1) Spouses and children of members of the Uniformed Services receiving treatment in a civilian medical facility at Government expense at the time of death of the member, or such spouses and children requiring care in a civilian facility as a result of being in the same accident or the same episode which proved fatal to the member, if continued hospitalization is required, shall be transferred to a Uniformed Services medical facility as soon as the physical condition of the patient permits, subject to space, facilities, and personnel availability.  Government transportation may be utilized to effect transfer to a Uniformed Services hospital.  The cost of medical and hospital care authorized from civilian sources (see section 5-502.) which was furnished to the dependent during the period of hospitalization in the civilian facility shall be borne by the Government subject to the charges provided in section 5-506., but not after the date on which feasible arrangements for transfer have been made.

(2) Additionally, a dependent wife who is eligible for civilian medical care (see section 1-103.e.), whose husband dies while on active duty and who is pregnant at the time of his death, may be provided from civilian sources at Government expense the obstetrical and maternity care authorized under this Directive to include, where applicable, prenatal care, delivery, and postpartum care.  Neonatal care authorized elsewhere in this Directive is authorized for a child born under these circumstances.  This special provision is applicable only to those maternity cases in which delivery occurs on or after 28 July 1959.  Dependents covered in this section 5-505.d.(2) may elect to receive the authorized care described above either in Uniformed Services medical facilities or from civilian sources.

506.  Charges

a.  When the entire period of hospitalization has been in other than private accommodations, the patient shall pay to the hospital the greater of (1) or (2) below:

(1) The first twenty-five dollars ($25.00) of the expense incurred,

(2) An amount determined by multiplying the number of days of hospitalization by the per diem rate established in section 4-408.a.

b.  If hospital care in a private room is obtained by the patient because it is required for the proper care and treatment, and if the patient's attending physician so certifies, the amount of private room charge less the patient's payment set forth below will be paid by the Government.  The patient will be required to pay to the hospital the greater of (1) or (2) in addition to (3), below:

(1) The first twenty-five dollars ($25.00) of the expense incurred.

(2) An amount determined by multiplying the number of days of hospitalization by the per diem rate established in section 4-408.a.

(3) Twenty-five percent (25%) of the difference between private room charges and weighted average cost of semiprivate room charges, when private room charges are more costly.  (NOTE: For hospitals having only private rooms, the term "weighted average cost of semiprivate room charges" is defined as 90 percent of the daily hospital charges for the room furnished the dependent or $15.00 per day, whichever is lesser.)

c.  If hospital care in a private room is provided at the specific request or desire of the patient or of the sponsor, the patient will be required to pay to the hospital the greater of (1) or (2), and in addition (3), below:

(1) The first twenty-five dollars ($25.00) of the expense incurred.

(2) An amount determined by multiplying the number of days of hospitalization by the established per diem rate.

(3) The difference between private room charges and weighted average cost of semiprivate room charges, when private room charges are more costly.

d.  Except as provided in section 5-506.b.(3), above, if hospital care in a private room is provided in a hospital which has only private rooms, the Government will pay 90 percent of the daily hospital charges for the room provided the dependent, or $15.00 per day, whichever is the lesser.  The patient will be required to pay the hospital the greater of (1) or (2), and in addition (3), below:

(1) The first twenty-five dollars ($25.00) of the expense incurred.

(2) An amount determined by multiplying the number of days of hospitalization by the established per diem rate.  (See section 4-408.a.)

(3) Ten percent (10%) of the daily hospital charges for the private room provided the dependent or the total daily hospital charges for such room, less $15.00 per day, whichever is the greater.

e.  If, while receiving authorized hospital care, private duty nursing care is required for proper care and treatment, and if the patient's attending physician so certifies, 75 percent of the charges in excess of $100.00 for such private-duty nursing care will be paid by the Government.

f.  All admissions to a hospital of an obstetrical patient as an inpatient for care required in direct connection with the pregnancy, including admissions for direct complications thereof, during the period of pregnancy up to and including delivery, and those for postpartum inpatient care for complications of pregnancy where the complication arises within the authorized six weeks postpartum period and where treatment is commenced by the attending physician within that period, shall be considered as one admission for the purpose of determining charges to the dependent.  Admission for a non-obstetrical diagnosis in the course of but not connected with a pregnancy would require the patient to pay the charges for a separate admission.  Patients who are delivered in a home or office shall pay the first $15.00 of charges in connection with the delivery, if not hospitalized in direct connection with the pregnancy.

g.  Patients who previously were admitted to a hospital for authorized care, who paid at least $25.00 of the hospital charges for that admission and who are readmitted to a civilian hospital within 14 days following discharge from the previous admission for authorized treatment of the original condition for which initially hospitalized, or direct complications thereof, will not be required to pay the first twenty five dollars ($25.00) of subsequent hospitalizations, but will be required to pay an amount determined by multiplying the number of days of the current hospitalization by the established per diem rate (see section 4-408.a.), plus any additional charges that might be specified elsewhere herein.  Hospitals will be responsible for obtaining from the patient, physician, sponsor, or other hospital(s) satisfactory evidence that the patient is entitled to the lesser charge.

h.  When a patient who in an inpatient status is transferred to another hospital to obtain as an inpatient necessary treatment not available in the first hospital and no break in hospitalization occurs except for the time in transit, it shall be considered one admission for the purpose of payment of charges by the patient in accordance with this section.

i.  When a patient is treated for injury other than as an inpatient in a hospital in accordance with section 5-503.d.(3), the payments made shall be in accordance with the local schedules of allowances.  Payments not to exceed a maximum of $75.00, except as provided for under section 5-503.d.(1)(e)(iv), are also authorized for laboratory tests, pathology and radiology examinations provided they are procedures performed by or authorized by the attending physician or surgeon.  Payment of charges is also authorized for use of hospital outpatient facilities required for the treatment of the injury, e.g., a cast room.  The patient shall pay the first $15.00 of the physician's charges for each different cause or accident for which treatment and services are rendered, except that multiple injuries to the same person resulting from a single accident shall be considered as one injury for payment of the maximum required fee ($15.00) by the patient.  The Government shall pay for all costs in excess of $15.00 as authorized in the local schedules of allowances.  However, payment by the Government for laboratory tests and pathology and radiology examinations shall not exceed the $75.00 maximum except as provided for under section 5-503.d.(1)(e)(iv).

507.  Administration

a.  The Secretary of the Army, acting as Executive Agent for the Secretary of Defense, shall contract for medical care under the full-payment concept within the United States and Puerto Rico in accordance with the Armed Services Procurement Regulations with authority to redelegate such responsibilities within the Department of the Army.  The Department of the Army personnel authorization and funds will be increased by the Secretary of Defense, upon justification, to provide for the personnel required for the Dependents' Medical Care Program and to carry out the responsibilities of the Executive Agent.  The Secretary of the Army shall be responsible for the provision of personnel, space, equipment, facilities and supplies, including related budgeting, funding, administrative control of funds, facility control, training, manpower control and utilization, personnel administration, security administration, and other administrative provisions and services necessary to carry out assigned missions as Executive Agent.  The Executive Agent's authority does not extend to the conduct of the medical care program in medical facilities of the Uniformed Services.

b.  The Executive Agent shall be responsible within the United States and Puerto Rico for the following:

(1) Preparation of the terms and placement of the contract or contracts to be established to include but not limited to:

(a) Local schedules of allowances to be used in full payment of bills presented by physicians and surgeons.

(b) A provision for review and, if necessary, an adjustment of administrative payments not later than 120 days after the first year the plan or plans have been in effect and each year thereafter.

(c) Determination of administrative responsibilities of the contractors and methods of determining administrative costs.

(d) Adequate procedures for paying claims for authorized care provided to eligible dependents by physicians, treatment facilities, dentists, private-duty nurses, physical therapists and anesthetists.  (Claims may be paid under a contract or by appropriate arrangements such as direct billings between the Government and claimants.  Detailed procedures may be covered in the Joint Regulations or in contracts.)

(2) Administration of the Contract

(a) Liaison activities with the contractor.

(b) Payment of bills.

(c) The development of any budgetary information required by the Uniformed Services as prescribed by the Joint Regulations.

(d) Audit.

(e) Preparation of such statistical information as may be necessary including that for the annual report of the Secretary of Defense to Congress.

(f) The Executive Agent's responsibility shall not include as a matter of routine a detailed supervision of civilian medical procedures or a detailed inspection of civilian medical facilities.

(g) The Executive Agent shall be responsible for the processing of complaints with reference to civilian medical care and hospitalization.

(h) Contractors shall have detailed responsibility for resolving medical disputes through local grievance committees composed of civilian physicians.

(3) Reimbursement to dependents or sponsors for authorized care obtained by dependents at personal expense in accordance with the procedures set forth in the Joint Regulations subject to the proviso that such reimbursement will not exceed that portion of the charge which the Government would have paid had contract facilities or services been utilized.

c.  Care in Civilian Facilities Outside the United States and Puerto Rico

The Secretary of a Uniformed Service is authorized, with authority to redelegate such responsibilities as appropriate, to contract or provide for payment for authorized civilian medical care for spouses and children outside the United States and Puerto Rico.  (See section 3-304.)  The responsibilities of the Uniformed Services, where appropriate, shall be the same as those listed for the Executive Agent in section 5-507.b.

d.  A Secretary of a Uniformed Service shall be responsible for the following:

(1) Initial eligibility determinations and means of identification of the dependent for medical care as prescribed in this Directive in sections 2-201. and 202.

(2) Budgeting and funding for that portion of the total cost including administrative expenses which is properly attributable to his Service.

(3) Reimbursement in accordance with cross-Servicing agreements for care contracted by one Service for dependents of another Service.  Any amounts received through such reimbursement shall be deposited to the credit of the appropriation supporting such contracts for medical care.

(4) Furnishing such information as required by the Executive Agent for the performance of his duties, including such data as the Executive Agent may require on dependents' medical care from sources overseas other than Uniformed Services facilities.

508.  Hospitalization Beyond Period of 365 Days

When a spouse or child, who is a dependent, requires a period of hospitalization in excess of 365 days, the hospital shall notify the contractor who shall forward a copy of this notification to the Executive Agent or his representative.  This notification normally will be submitted not later than 300 days after admission of the patient.  Advance notice will permit arrangements to be made for proper transfer of the patient to a hospital of the Uniformed Services if this is determined to be feasible.  Government transportation may be utilized to effect transfer to a Uniformed Services hospital.  When transfer is not feasible, continuation of care in the civilian hospital at the expense of the Government may be authorized subject to the Joint Regulations.

509.  Government Liability for Payment of Civilian Medical Care Costs

As prescribed in section 2, the Uniformed Services shall provide dependents with means of identification.  When spouses and children of members of the Uniformed Services are provided civilian medical care, it is expected that the attending physician and medical facility will use reasonable care and precaution in identifying them.  When medical care has been provided in good faith by the attending physician and medical facility and it is subsequently determined that the persons concerned were not in fact entitled to medical care at Government expense under Chapter 55 of title 10, United States Code, collection and other legal action shall be taken only against the sponsor or individual who was not entitled to the medical care.  Where fraud is involved, the matter may be referred to the Attorney General of the United States with recommendation for prosecution.  Notwithstanding the foregoing, the Government will be responsible for paying for care rendered to patients covered by section 5-505.b., only if the conditions set forth in that section are met.

510.  Administration of Changes to This Directive Effective 1 January 1960

a.  The changes to this Directive made effective on 1 January 1960 (referred to in this section 5-510. as the "effective date") restored certain types of care to the Medicare Program.  On and after that date certain additional treatment specified in those changes constitutes authorized care which was not authorized on the preceding day.  That additional treatment is referred to generally in this section 5-510. as care of a type restored to the Program.  The following rules are promulgated governing administration of treatment of certain patients who commenced receiving that type of care before the effective date.

(1) Hospitalized Patients.  Where a patient is admitted to a hospital before the effective date for a type of care restored to the Program and is still in the hospital on that date receiving that care, payment may be made to the sources furnishing that care for the current uninterrupted period of hospitalization.  Where a period of hospitalization commencing prior to that day is payable, then payment for pre- and post-hospitalization diagnostic tests and procedures which were considered necessary by the attending physician or dentist and were performed by or authorized by him are payable in accordance with section 5-503.d.(1)(e).

(2) Outpatient Injury CasesSection 5-503.d.(3) covers care of this type that has been restored to the Program.  Payment is authorized for care covered by that section furnished to a patient by an authorized civilian source only in those cases where the injury occurred prior to the effective date but subsequent to 1 December 1959 and where the patient is still under the care of a physician on or after the effective date, for the same injury, from the date of commencement of care.  Payment is also authorized, in cases covered by the preceding sentence, for necessary laboratory tests, pathology and radiology examinations if the procedures are performed by or authorized by the attending physician or dentist. (See sections 5-503.d.(3) and 5-506.i.).

b.  Nothing in this section 5-510. shall waive the restrictions on right of election set forth in section 3-302.e. nor the requirement for payment by the patient of the charges specified in section 5-506.

SECTION 6

MEDICAL CARE IN MEDICAL FACILITIES NOT
OTHERWISE PROVIDED FOR

601.a.   When dependents eligible for civilian medical care receive medical care authorized by this Directive, on an emergency basis, in a medical facility which is not included in the definition of a hospital as provided for in section 5-503.a.(1) or is not a Uniformed Services medical facility, the dependent will pay the charges listed in section 5-506. and the Government will pay the difference between the amount payable by the dependent and the reimbursable cost.  Payments by the Government for such care rendered in Federal medical facilities other than those of a Uniformed Service will be on a reimbursable basis between the Executive Agent and the Department or Agency concerned.  This section does not apply to section 6-601.c., below.

b.  When dependents receive medical care authorized by this Directive in the Governmental facilities of a foreign government (not civilian), the dependent will pay the charges listed in section 5-506. and the difference between the total cost and the amount paid by the dependent will be paid by the United States Government.  In instances where a reciprocal agreement between a foreign government and the United States is in effect, which provides for no charge or a lesser charge to the dependent than those listed in section 5-506., such charges, if any, under the reciprocal agreement shall prevail.

c. This Directive does not affect dependents' medical care furnished under the provisions of section 105 of Public Law 153, 83rd Congress, as amended by section 107 of Public Law 453, 83rd Congress, which authorizes medical and dental care for eligible dependents of military personnel in Canal Zone Government medical facilities.

SECTION 7

MEDICAL CARE FOR MEMBERS OF THE UNIFORMED SERVICES

701.  Persons in the Uniformed Services on active duty or active duty for training are entitled to and shall be provided medical and dental care and adjuncts thereto.  Under ordinary circumstances, such members will receive medical care at the medical facility of the Uniformed Service which serves the organization to which the member is assigned.  A member who is away from his duty station or is on duty where there is no medical facility or his own Service available, may receive care at the nearest available medical facility of the Uniformed Services.  Commissioned officers and warrant officers on active duty or active duty for training shall pay an amount equal to the portion of the charge established under section 4-408.a. that is attributable to subsistence when hospitalized in a medical facility of the Uniformed Services.  Nothing in this Directive shall affect the existing provision for providing medical care to members of the Uniformed Services through civilian or other sources.

SECTION 8

MEDICAL CARE FOR RETIRED MEMBERS OF THE UNIFORMED SERVICES

801.  Retired Members Eligible for Care

Retired members shall be furnished required medical and dental care and adjuncts thereto to the same extent as provided for active duty members in any medical facility of a Uniformed Service, subject to mission requirements and the availability of space, facilities, and capabilities of the medical staff as determined by the cognizant medical authority in charge of the medical facility.  Nothing in this Directive is intended to change or modify the provisions of Executive Order 10122, 14 April 1950, as amended by Executive Order 10400, 27 September 1952.

802.  Ration Allowance for Retired Enlisted Members

Retired enlisted personnel, including members of the Fleet Reserve and the Fleet Marine Corps Reserve, shall not be charged for subsistence when hospitalized in a medical facility of a Uniformed Service.

803.  Charge for Officers' Subsistence

Retired commissioned officers and retired warrant officers shall pay an amount equal to the portion of the charge established under section 4-408.a. that is attributable to subsistence when hospitalized in a medical facility of the Uniformed Services.

SECTION 9

BUDGETING AND ACCOUNTING FOR MEDICAL AND DENTAL CARE FURNISHED IN FACILITIES OF THE UNIFORMED SERVICES

901.  The Secretaries of the Uniformed Services shall budget for supporting the maintenance and operation and/or subsistence of their Service medical facilities for the medical and dental care of their members, retired members and dependents furnished in the medical facilities of their respective Service.  The Secretaries of the Uniformed Services shall also budget for reimbursement for the medical and dental care of their members, retired members, and dependents receiving inpatient care in facilities of another Uniformed Service.  Reimbursement shall be made between Departments (Army, Navy, Air Force, and U.S. Public Health Service) for inpatient care furnished by one Service for members, retired members, and dependents of another Service at rates to be prescribed by the Bureau of the Budget to reflect the average cost of providing such care.  Any amounts received through reimbursement or through local collection for subsistence and/or medical care in facilities of the Uniformed Services shall be deposited to the credit of the appropriation(s) supporting the operation and maintenance of the Service medical facility furnishing care.

SECTION 10

IMPLEMENTATION

1001.  Joint implementation in accordance with this Directive, covering care of dependents, shall be accomplished as appropriate by the Uniformed Services.

SECTION 11

EFFECTIVE DATE

1101.  This Directive is effective immediately.

Signed by:Robert S. Macnamara, Secretary of Defense and Abraham Ribicoff, Secretary of Health, Education, and Welfare

APPENDIX A

DD FORM 1172

DD Form 1172

APPENDIX B

DD FORM 1173

DD Form 1173

APPENDIX C

DD FORM 1251

DD Form 1251