(a) Admissions to Closed Psychiatric Wards. Patients will be admitted to closed psychiatric wards only when they have a psychiatric or emotional disorder which renders them dangerous to themselves or others, or when a period of careful closed psychiatric observation is necessary to determine whether such a condition exists. When a patient is admitted to a closed psychiatric ward, the reason for admission must be clearly stated in the patient's clinical record by the physician admitting the patient to the ward. These same policies apply equally in those instances when it is necessary to place a patient under constant surveillance while on an open ward.

(b) Absence From the Sick List. See § 728.4(d), (x), and (y).

(c) Charges and Collection. The charges for services rendered vary and are set yearly by the Office of Management and Budget and promulgated by a yearly NAVMEDCOMNOTE 6320, (Cost elements of medical, dental, subsistence rates, and hospitalization bills). Billing and collection actions also vary according to entitlement or eligibility and are governed by

the provisions of NAVMED P-5020, Resource Management Handbook.

(d) Convalescent Leave. Convalescent leave, a period of authorized absence granted to active duty members under medical care when such persons are not yet fit for duty, may be granted by a member's commanding officer (CO) or the hospital's CO per the following:

(1) Unless otherwise indicated, such leave shall be granted only when recommended by COMNAVMEDCOM, Washington, DC, through action taken upon the report by a medical board, or the recommended findings of a physical evaluation board or higher authority.

(2) Member's commanding officer (upon advice of attending physician); commanding officers of Navy, Army, or Air Force medical facilities; commanders of regional medical commands for persons hospitalized in designated USTFs or in civilian facilities within their respective areas of authority; and managers of Veterans Administration hospitals within the 50 United States or in Puerto Rico may grant convalescent leave to active duty naval patients, with or without reference to a medical board, physical evaluation board, or higher authority provided the:

(i) Convalescent leave is being granted subsequent to a period of hospitalization.

(ii) Member is not awaiting disciplinary action or separation from the service for medical or administrative reasons.

(iii) Medical officer in charge:

(A) Considers the convalescent leave beneficial to the patient's health.

(B) Certifies that the patient is not fit for duty, will not need hospital treatment during the contemplated convalescent leave period, and that such leave will not delay final disposition of the patient.

(3) When considered necessary by the attending physician and approved on an individual basis by the commander of the respective geographic regional medical command, convalescent leave in excess of 30 days may be granted. This authority may not be redelegated to hospital commanding officers. Member's permanent command

must be notified of such extensions (see MILPERSMAN 3020360).

(4) Care shall be exercised in granting convalescent leave to limit the duration of such leave to that which is essential in relation to diagnosis, prognosis, estimated duration of treatment, and probable final disposition of the patient.

(5) Upon return from convalescent leave:

(i) One copy of original orders of officers, bearing all endorsements, shall be forwarded to the Commander, Naval Military Personnel Command (COMNAVMILPERSCOM) (NMPC-4) or the Commandant of the Marine Corps (CMC), as appropriate.

(ii) An entry shall be made on the administrative remarks page (page 13 for Navy personnel) of the service records of enlisted personnel that convalescent leave was granted and showing the dates of departure and return.

(6) If considered beneficial to the patient's health, commanding officers of hospitals may grant convalescent leave as a delay in reporting back to the parent command.

(e) Cosmetic Surgery. (1) Defined as that surgery which is done to revise or change the texture, configuration, or relationship of contiguous structures of any feature of the human body which would be considered by the average prudent observer to be within the broad range of "normal" and acceptable variation for age or ethnic origin, and in addition, is performed for a condition which is judged by competent medical opinion to be without potential for jeopardy to physical or mental health of an individual.

(2) Commanding officers will monitor, control, and assure compliance with the following cosmetic surgery policy:

(i) Certain cosmetic procedures are a necessary part of training and retention of skills to meet the requirements of certification and recertification.

(ii) Insofar as they meet minimum requirements and serve to improve the skills and techniques needed for reconstructive surgery, the following cosmetic procedures may be performed as low priority surgery on active duty members only when time and space are available.

(A) Cosmetic facial rhytidectomies (face lifts) shall be a part of all training programs required by certifying boards.

(B) Cosmetic augmentation mammaplasties will be done only by properly credentialed surgeons and residents within surgical training programs to meet requirements of certifying boards.

(f) Cross-Utilization of Uniformed Services Facilities. To provide effective cross-utilization of medical and dental facilities of the uniformed services, eligible persons, regardless of service affiliation, will be given equal opportunity for health benefits. Catchment areas (zone boundaries), designated by zip codes, have been established by the Department of Defense for each USMTF (see § 728.2(d)). Eligible beneficiaries residing within such a catchment area are expected to utilize that inpatient facility for care. Provisions shall be made to assure that:

(1) Eligible beneficiaries residing in the catchment area served by a USMTF not of the sponsor's own service may obtain care at that facility or at a facility of the sponsor's service located in another catchment area.

(2) If the facility to which an eligible beneficiary applies cannot furnish needed care, the other facility or facilities in overlapping catchment areas will be contacted to determine whether care can be provided thereat.

(g) Disengagement. Applicable only to CHAMPUS-eligible individuals.

(1) Discontinuance of medical management by naval MTFs for only a specific episode of care. (Patient or sponsor should be advised to return to the naval MTF for any care required subsequent to receiving the care for which disengagement is made.) Considered accomplished only after alternative sources of care and attendant costs, if applicable, have been fully explained to patient or sponsor.

(2) Patients referred to civilian sources for total care (disengaged) under the CHAMPUS will be issued a Non-availability Statement (DD 1251) per § 728.33, when appropriate. CHAMPUS-eligible patients referred for total care, who do not otherwise require a DD 1251 (referred for outpa

tient care or those referred whose residence is outside the inpatient catchment area of all USMTFs), will be given a properly completed DD 2161, Referral For Civilian Medical Care, which clearly indicates that the patient is disengaged for total care under CHAMPUS. CHAMPUS-eligible beneficiaries will be disengaged for services under CHAMPUS when:

(i) Required services are beyond the capability of the naval MTF and these services cannot be appropriately provided through one of the alternative means listed in § 728.4(z), or

(ii) The naval MTF cannot effectively provide the required service or manage the overall course of care even if augmented by services procured from other Government or civilian sources utilizing naval MTF operation and maintenance funds as authorized in § 728.4(z).

(h) Domiciliary/Custodial Care. The type of care designed essentially to assist an individual in meeting the normal activities of daily living, i.e., services which constitute personal care such as help in walking and getting in or out of bed, assistance in bathing, dressing, feeding, preparation of special diets, and supervision over medications which can usually be self-administered and which does not entail or require the continuing attention of trained medical or paramedical personnel. The essential characteristics to be considered are the level of care and medical supervision that the patient requires, rather than such factors as diagnosis, type of condition, or the degree of functional limitation. Such care will not be provided in naval MTFs except when required for active duty members of the uniformed services.

(i) Emergency Care. Patients authorized only emergency care and those admitted as civilian emergencies will be treated only during the period of the emergency. Action will be initiated to effect appropriate disposition of such patients as soon as the emergency period ends.

(j) Evaluation After Admission. Each patient will be evaluated as soon as possible after admission and reevaluation will continue until disposition is made. Each patient's probable

type and date of disposition will be anticipated and necessary processing by the various medical and administrative entities will take place concurrently with the treatment of the patient. It is especially important that the medical disposition decision be made as early as possible for U.S. military patients inasmuch as immediate transfer to a VA medical center or to a VA spinal cord injury center may be in the best interest of the patient (see BUMEDINST 6320.11D). The disposition decision for military personnel of NATO nations shall be made in conformance with § 728.42(d).

(k) Extent of Care. Eligible persons shall be provided medical and dental care to the extent it is authorized, required, and available. When a person is accepted for care, all care and adjuncts thereto, such as nonstandard supplies, as determined by the commanding officer to be necessary, will be provided from resources available to the commanding officer unless specifically prohibited elsewhere in this part. Exception: Hospitalization and outpatient services may be provided outside the continental limits of the United States and in Alaska to the officers and employees of any department or agency of the Federal Government, to employees of a contractor with the United States or the contractor's subcontractor, to the accompany. ing dependents of such persons, and in emergencies to such other persons as the Secretary of the Navy may prescribe: provided, that such services shall be permitted only where facilities are not otherwise available in reasonably accessible and appropriate non-Federal facilities. When a patient has been accepted and required care is beyond the capabilities of the accepting naval MTF, the commanding officer thereof will arrange for the required care by one of the means shown below. The method of choice will be based upon professional considerations and travel economy.

(1) Transfer the patient per § 728.4(bb).

(2) Procure from civilian sources the necessary material or professional personal services required for the proper care and treatment of the patient.

(3)

The care authorized

in § 728.4(k)(2) will normally be accomplished in the naval MTF. However, when such action is not feasible, supplementation may be obtained elsewhere. Patients may be sent to other Federal or civilian facilities for specific treatment or services under § 728.4(k)(3) provided they remain under the medical management of the commanding officer of the sending facility during the entire period of care. (1) Family Planning Services. Family planning services shall be provided per the provisions of SECNAVINST 6300.2A.

(m) Grouping of Patients. Hospitalized patients will be grouped according to their requirements for housing, medical, or dental care, and will be furnished gender identified quarters, facilities, and professional supervision on that basis when appropriate. Individuals who must be retained under limited medical supervision (medical hold) solely for administrative reasons or for medical conditions which can be treated on a clinic basis will be provided quarters and messing facilities, where practicable, separately from hospitalized patients. Medical care for such patients will be furnished on a periodic clinic appointment basis (see § 728.4(p) for handling enlisted convalescent patients). Maximum use will be made of administrative versus medical personnel in the supervision of such patients.

(n) Health Benefits Advising.—(1) General. A Health Benefits Advising Program, if not established, must be implemented at all commands having one or more medical officers. The number of health benefits advisors (HBAs) of a command shall be commensurate with counseling and assistance requirements. The program is to provide health benefits information and counseling to beneficiaries of the Uniformed Services Health Benefits Program (USHBP) and to others who may or may not qualify for care in USMTFS. Office location of HBAs, their names, and telephone numbers shall be widely publicized locally. If additional assistance is required, contact MEDCOM-333 on Autovon 2941127 or commercial (202) 653-1127. In

addition to the duties described in § 728.4(n)(2), HBAs shall:

(i) Maintain a depository of up-todate officially supplied information for availability to all beneficiaries.

(ii) Provide information and guidance to beneficiaries and generally support the medical and dental staff by providing assistance to eligible beneficiaries seeking or obtaining services from USMTFs, civilian facilities, VA facilities, Medicare, MEDICAID, and other health programs.

(iii) Assure that when a referral or disengagement is required:

(A) Patients are fully informed that such action is taken to provide for their immediate medical or dental requirements and has no bearing on whether care may be available in the naval MTF for other aspects of current or other future medical conditions.

(B) CHAMPUS-eligible patients are provided the services and counseling outlined in § 728.4(n)(2) prior to their departure from the facility when such beneficiaries are referred or disengaged because care required is beyond the naval MTF's capability. In an emergency, or when the patient or sponsor cannot be seen by the HBA prior to leaving, these services and counseling assistance will be accomplished as soon thereafter as possible.

(2) Counseling and Assisting CHAMPUS-Eligible Individuals. HBAs, as a minimum, will:

(i) Explain alternatives available to the patient.

(ii) If appropriate, explain CHAMPUS as it relates to the particular circumstance, including the cost-sharing provisions applicable to the patient, allowable charges, provider participation, and claim filing procedures. The patient or sponsor must be fully informed that when a patient is disengaged for care under CHAMPUS or when cooperative care is to be considered for payment under the provisions of § 728.4(z) (5 and (6), the naval MTF is not responsible for monetary amounts above the CHAMPUS-determined allowable charge or for charges CHAMPUS does not allow.

(iii) Explain why the naval MTF is paying for the supplemental care, if appropriate (see § 728.4 (z) (3) and

(4)). Complete a DD 2161, Referral For Civilian Medical Care, marking the appropriate source of payment with the concurrence of the naval MTF commanding officer or CO's designee. Explain to the patient or sponsor how the bill will be handled.

(iv) Brief patient or sponsor on the use of the DD 2161 in USMTF payment procedures and CHAMPUS claims processing, as appropriate. Provide sufficient copies of DD 2161 and explain that CHAMPUS contractors will return claims submitted without required DD 2161. Obtain signature of patient or sponsor on the form.

(v) Advise patient or sponsor on arrangements for a completed copy of the DD 2161 to be returned to the naval MTF for payment, if appropriate, and inclusion in patient's medical record.

(vi) Arrange for counseling from appropriate sources when the patient is eligible for VA, Medicare, or MEDICAID benefits.

(vii) Serve as liaison between civilian providers and naval MTF on administrative matters related to the referral and disengagement process.

(viii) Serve as liaison between naval MTF and cooperative care coordinators on matters relating to care provided or recommended by naval MTF providers, as appropriate.

(ix) Explain why the patient is being disengaged and, per § 728.4(g)(2), provide a DD 1251, Nonavailability Statement, or DD 2161, Referral For Civilian Medical Care, as appropriate.

(0) Immunizations. Immunizations will be administered per the provisions of BUMEDINST 6230.1H, unless otherwise stipulated.

(p) Medical Holding Companies. Medical holding companies (MHC) have been established at designated activities to facilitate handling of enlisted convalescent patients whose medical conditions are such that, although they cannot be returned to full duty, they can perform light duty ashore commensurate with their condition while completing their medical care on an outpatient basis. Where feasible, such patients shall be processed for transfer.

(q) Notifications. The interests of the Navy, Marine Corps, and DOD

have been adversely affected by past procedures which emphasized making notifications only when an active duty member's condition was classed as either seriously ill or injured or classed as very seriously ill or injured. However, even temporary disabilities which preclude communication with the next of kin have generated understandable concern and criticism, especially when emergency hospitalization has resulted. Accordingly, naval MTFs shall effect procedures to make notifications required in § 728.4(q) (2) and (3) upon admission/diagnosis of members specified. The provisions of § 728.4(q) supplement articles 1810520 and 4210100 of the Naval Military Personnel Manual and chapter 1 of Marine Corps Order P3040.4B, Marine Corps Casualty Procedures Manual; they do not supersede them.

(1) Privacy Act. The right to privacy of individuals for whom hospitalization reports and other notifications are made shall be safeguarded as required by the Privacy Act, implemented in the Department of the Navy by SECNAVINST 5211.5C, U.S. Navy Regulations, the Manual of the Judge Advocate General, the Marine Corps Casualty Procedures Manual, and the Manual of the Medical Department.

(2) Active Duty Flag or General Officers and Retired Marine Corps General Officers. Upon admission of subject officers, make telephonic contact with MEDCOM-33 on Autovon 294-1179 or commercial (202) 653-1179 to provide the following information:

(i) Initial. Include in the initial report:

(A) Officer's name, grade, social security number, and designator.

(B) Duty assignment in ship or station, or other status.

(C) Date of admission.

(D) Present condition, stating if serious or very serious.

(E) Diagnosis, prognosis, and estimated period of hospitalization. To prevent possible invasion of privacy, the diagnosis shall be reported only in International Classification of Diseases-9th Edition (ICD-9-CM) code designator.

(ii) Progress Reports. Call frequency and content shall be at the discretion of the commanding officer. Changes in