10 U.S.C. § 1079 — Contracts for medical care for spouses and children: plans

submitted 68 years ago by Pub. L. 85-861 to r/title-10-ARMED-FORCES · 5,225 words · no verdicts yet

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The Secretary of Defense must contract for health care for specified dependents of active-duty uniformed-service members. This section sets covered services, exclusions, patient cost sharing, extended benefits, survivor coverage, reimbursement, other-insurance rules, and special programs.

(a) The Secretary of Defense, after consulting the other administering Secretaries, must contract for medical care for dependents described in section 1072(2)(A), (D), and (I) of members on active duty for more than 30 days. The care generally matches section 1076, with these rules: (1) dental care is limited to care necessary to support medical or surgical treatment, except that for patients with developmental, mental, or physical disabilities or children age 5 or younger, only institutional and anesthesia services may be provided; (2) under the Secretary’s screening and immunization regulations, children under 6 may receive health-promotion and disease-prevention visits and immunizations, while dependents 6 or older may receive those visits with immunizations or specified cervical, breast, colon, and prostate screening; (3) no more than one eye examination may be provided in a calendar year; (4) Christian Science practitioners, nurses, and sanatorium services may be provided under joint regulations; (5) durable equipment may be rented; (6) nonemergency inpatient services are unavailable when an adequate uniformed-services facility is within 40 miles of the patient’s home, unless another insurance plan is primary; (7) pastoral, family, child, and marital counselors other than certified marriage and family therapists require a medical-doctor referral for a specific problem and must report results to that doctor, while certified marriage and family therapists are subject to Defense regulations and must accept this payment as full payment; (8) special education is excluded except as secondary to active inpatient psychiatric treatment; (9) sexual-dysfunction or sexual-inadequacy therapy and counseling are excluded; (10) obesity treatment is excluded when obesity is the only or main condition; (11) appearance-improving surgery not expected to significantly restore function is excluded, except breast reconstruction after mastectomy, reconstruction of serious congenital or accidental deformities, and neoplastic surgery; (12) services or supplies not medically or psychologically necessary to prevent, diagnose, or treat illness, injury, or bodily malfunction are excluded, as judged by listed qualified providers or another designated class, except for Christian Science services. The Secretary may waive this rule for NIH-sponsored or approved clinical trials under an agreement with Health and Human Services when the waiver promotes access to promising treatments and their development; (13) section 1077(b)(3)’s prohibition does not apply to a member or former member; (14) physician-prescribed and supervised home apnea monitors may be provided for an infant with an apparent life-threatening event, a later sibling of a sudden-infant-death victim, birth weight of 1,500 grams or less, or pathological apnea from prematurity, including equipment, alarm analysis, visits, testing, family training, and necessary use assistance; (15) hospice care follows Social Security Act section 1861(dd), except a person under 21 may receive it along with care or hospitalization for the same condition; (16) forensic examinations after sexual assault or domestic violence may be provided; (17) breastfeeding support, supplies, pumps, related equipment, and counseling must be provided as appropriate during pregnancy and postpartum; (18) eating-disorder treatment may be provided under (r); (19) one lifetime preconception or prenatal carrier test per condition must be provided for cystic fibrosis, spinal muscular atrophy, fragile X syndrome, Tay-Sachs disease, hemoglobinopathies, and conditions linked to Ashkenazi Jewish descent; and (20) medical interventions for gender dysphoria that could sterilize may not be provided to a child under 18. (b) Plans must require: (1) $25 for each hospital admission, or the larger amount the patient would have paid under section 1078(a) for a uniformed-services hospital. The Secretary may exempt a patient if the hospital creates no legal obligation for any patient to pay inpatient charges; (2) for outpatient care, the first $150 each calendar year plus 20 percent of later charges, with a $50 initial deductible for a dependent of an enlisted member below pay grade E–5; (3) a family of two or more pays no more than the first $300, or $100 for such an enlisted member’s family, plus 20 percent of later charges; (4) $25 for designated outpatient surgery treated as inpatient care, which is not counted under (2) or (3); and (5) no person or family pays more than $1,000 in a calendar year under a plan. (c) Joint regulations set the payment methods. (d) (1) The Secretary must establish a registration-required extended-benefits program, potentially including comprehensive care and case management, to reduce a qualifying condition’s disabling effects. (2) The Secretary must issue regulations. (3) “Eligible dependent” means a qualifying dependent of a member on active duty more than 30 days. “Qualifying condition” means moderate or severe mental retardation, serious physical disability, or an extraordinary physical or psychological condition. (e) (1) Extended benefits may include comprehensive and case-management services and, when not supplied elsewhere in this chapter, diagnosis and screening; inpatient, outpatient, and comprehensive home-health supplies and services, including appropriate cost-effective services beyond part-time or intermittent care; rehabilitation services and devices; respite care; service and modification of durable equipment and assistive technology; special education; vocational training at home or a facility; and other services or supplies the Secretary finds appropriate despite (a)(12). (2) Respite care is limited by regulation to 32 hours per month per primary caregiver; unused hours cannot carry over; and it may be provided whether or not another benefit is received. (3) Equipment service or modification requires a finding that it is necessary for the dependent’s use, cannot be provided for misuse, loss, or theft, and cannot be for a deluxe, luxury, or immaterial feature. Training the dependent and immediate family may be included. (f) (1) Members share costs: the lowest enlisted grade pays the first $25 each month and the highest commissioned grade the first $250; other grades are set by regulation. A member with several dependents cannot owe more than if only one incurred expenses. (2) For rehabilitation, equipment, special education, or vocational training, the Government share in a year is no more than $36,000, prorated by the Secretary, except exempt costs; the member pays the remainder in addition to (1). (3) For several dependents, the member’s monthly amount under (2) cannot exceed the amount for one. (4) The dependent must use available and adequate public facilities for those benefits. (5) The Secretary must issue regulations. (g) (1) If a member dies while eligible for hostile-fire pay, or from an injury or disease incurred while eligible, dependents receiving (d) benefits remain eligible until age 21. (2) If a member dies on active duty over 30 days, dependents receiving (a) benefits remain eligible for TRICARE Prime for 3 years. For a dependent described in section 1072(2)(D) or (I), eligibility lasts for the longest of 3 years, until age 21, or, for a dependent age 21 who is in full-time secondary or approved higher education and was more than half supported by the member, until the earlier end of study or age 23. (3) A reasonable transition between secondary and higher education counts as enrollment. (4) The health-benefit terms are those that would apply if the member were alive and on active duty. (5) “TRICARE Prime” means TRICARE’s managed-care option. (h) (1) Individual professional providers are paid, as practicable, under Medicare-like reimbursement rules. (2) Regulations may make exceptions needed for adequate access, including higher payments for nonparticipating providers; during the transition from pre-February 10, 1996 methods, an amount may not fall by more than 15 percent from the immediately prior 12-month amount or another period set by the Secretary. (3) The Secretary may let facility commanders, lead agents, and contractors modify limits for providers when needed for availability and lower cost, and with provider consent may reduce payment below the normal limit. (4) Regulations must limit beneficiary liability and bar billing above the specified Medicare limiting-charge excess plus unpaid deductibles or copayments. For a reserve-component member’s dependent, the Secretary may also pay that excess. (5) The Secretary may set locality rates when otherwise access would be severely impaired, considering provider numbers, participating providers, beneficiaries, military providers, and other relevant factors. (i) (1) No benefit is paid when another insurance, medical-service, or health plan, including a third-party payer, also covers it, except a title XIX plan. (2) Provider payments follow Medicare-like rules as far as practicable. (3) Contracts must bar balance billing beyond the regulated payment, except unpaid deductibles or copayments owed directly by the person. (4) “Provider of services” means a hospital, skilled-nursing facility, comprehensive outpatient rehabilitation facility, home-health agency, hospice program, or other institution that provides covered services. (j) A plan may cover a liver transplant, including acquiring and transporting the liver, if the Secretary approves the dependent after consultation and the transplant facility is approved after consultation. (k) (1) Contracts must also cover dependents of former members authorized by section 1076(e) to receive care in uniformed-services facilities. (2) Except under (3), the same conditions and limits apply as for the dependents in (a). (3) Care is limited to the injury, illness, or condition described in section 1076(e). (l) (1) On request, the Secretary may pay a hospital that does not legally require patients to pay for its services. (2) Payment cannot exceed the geographic area’s average for comparable services, or a similar area’s average if none is available locally. (3) The Secretary must review each approved hospital’s billing practices to ensure they do not raise Government costs. (4) The Secretary may require evidence of revenue sources covering unbilled costs. (m) The Secretary may contract with fiscal intermediaries to organize and operate managed-care networks directly or through subcontractors. Networks must contain cost controls such as utilization review and discounted-care contracts. (n) (1) Care under this section, section 1086, or another CHAMPUS contract may not include services found by the CHAMPUS Peer Review Organization program not medically or psychologically necessary. (2) The Secretary may adopt or adapt the quality and utilization-review rules used under title XI, part B of the Social Security Act. (o) (1) Subject to exceptions, coverage and timely-access standards for specified dependents must be comparable to TRICARE Prime. (2) The Secretary must arrange efficient claims processing. (3) This applies to a dependent living with a member described in section 1074(c)(3), a dependent left at a remote location after the member permanently relocates without the dependent when orders do not pay to move dependents, or a reserve-component member’s dependent living with the member more than 50 miles or about one hour from an adequate military treatment facility. (4) Exceptional circumstances may justify coverage for another dependent. (5) The Secretary must consult the other administering Secretaries. (p) Subject to (a), a physician or practitioner eligible for Medicare reimbursement is approved to provide care unless the administering Secretaries have information about Medicare, TRICARE, or other federal-program integrity violations. (q) For a “pharmaceutical agent” under section 1074g(i), the Secretary may use special reimbursement methods, amounts, and procedures to encourage high-value and discourage low-value products. (r) (1) Eating-disorder care may include outpatient in-person or telehealth care, partial hospitalization, intensive outpatient services, and inpatient services. Residential services are included only when medically indicated for a primary eating-disorder diagnosis. (2) Care is provided regardless of the dependent’s age, except residential care is only for a dependent not eligible for Medicare hospital insurance, and regardless of whether the disorder is primary or secondary except as stated for residential care. (3) “Eating disorder” has the meaning of “feeding and eating disorders” in the fifth or successor edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

the actual law source: uscode.house.gov ↗public domain

(a)

To assure that medical care is available for dependents, as described in subparagraphs (A), (D), and (I) of section 1072(2) of this title, of members of the uniformed services who are on active duty for a period of more than 30 days, the Secretary of Defense, after consulting with the other administering Secretaries, shall contract, under the authority of this section, for medical care for those persons under such insurance, medical service, or health plans as he considers appropriate. The types of health care authorized under this section shall be the same as those provided under section 1076 of this title, except as follows:

(1)

With respect to dental care—

(A)

except as provided in subparagraph (B), only that care required as a necessary adjunct to medical or surgical treatment may be provided; and

(B)

in connection with dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or under, only institutional and anesthesia services may be provided.

(2)

Consistent with such regulations as the Secretary of Defense may prescribe regarding the content of health promotion and disease prevention visits, the schedule and method of cervical cancer screenings and breast cancer screenings, the schedule and method of colon and prostate cancer screenings, and the types and schedule of immunizations—

(A)

for dependents under six years of age, both health promotion and disease prevention visits and immunizations may be provided; and

(B)

for dependents six years of age or older, health promotion and disease prevention visits may be provided in connection with immunizations or with diagnostic or preventive cervical and breast cancer screenings or colon and prostate cancer screenings.

(3)

Not more than one eye examination may be provided to a patient in any calendar year.

(4)

Under joint regulations to be prescribed by the administering Secretaries, the services of Christian Science practitioners and nurses and services obtained in Christian Science sanatoriums may be provided.

(5)

Durable equipment provided under this section may be provided on a rental basis.

(6)

Services in connection with nonemergency inpatient hospital care may not be provided if such services are available at a facility of the uniformed services located within a 40-mile radius of the residence of the patient, except that those services may be provided in any case in which another insurance plan or program provides primary coverage for those services.

(7)

Services of pastoral counselors, family and child counselors, or marital counselors (other than certified marriage and family therapists) may not be provided unless the patient has been referred to the counselor by a medical doctor for treatment of a specific problem with the results of that treatment to be communicated back to the medical doctor who made the referral and services of certified marriage and family therapists may be provided consistent with such rules as may be prescribed by the Secretary of Defense, including credentialing criteria and a requirement that the therapists accept payment under this section as full payment for all services provided.

(8)

Special education may not be provided, except when provided as secondary to the active psychiatric treatment on an institutional inpatient basis.

(9)

Therapy or counseling for sexual dysfunctions or sexual inadequacies may not be provided.

(10)

Treatment of obesity may not be provided if obesity is the sole or major condition treated.

(11)

Surgery which improves physical appearance but is not expected to significantly restore functions (including mammary augmentation, face lifts, and sex gender changes) may not be provided, except that—

(A)

breast reconstructive surgery following a mastectomy may be provided;

(B)

reconstructive surgery to correct serious deformities caused by congenital anomalies or accidental injuries may be provided; and

(C)

neoplastic surgery may be provided.

(12)

Any service or supply which is not medically or psychologically necessary to prevent, diagnose, or treat a mental or physical illness, injury, or bodily malfunction as assessed or diagnosed by a physician, dentist, clinical psychologist, certified marriage and family therapist, optometrist, podiatrist, certified nurse-midwife, certified nurse practitioner, certified clinical social worker, or other class of provider as designated by the Secretary of Defense, as appropriate, may not be provided, except as authorized in paragraph (4). Pursuant to an agreement with the Secretary of Health and Human Services and under such regulations as the Secretary of Defense may prescribe, the Secretary of Defense may waive the operation of this paragraph in connection with clinical trials sponsored or approved by the National Institutes of Health if the Secretary of Defense determines that such a waiver will promote access by covered beneficiaries to promising new treatments and contribute to the development of such treatments.

(13)

The prohibition contained in section 1077(b)(3) of this title shall not apply in the case of a member or former member of the uniformed services.

(14)

Electronic cardio-respiratory home monitoring equipment (apnea monitors) for home use may be provided if a physician prescribes and supervises the use of the monitor for an infant—

(A)

who has had an apparent life-threatening event,

(B)

who is a subsequent sibling of a victim of sudden infant death syndrome,

(C)

whose birth weight was 1,500 grams or less, or

(D)

who is a pre-term infant with pathologic apnea,

in which case the coverage may include the cost of the equipment, hard copy analysis of physiological alarms, professional visits, diagnostic testing, family training on how to respond to apparent life threatening events, and assistance necessary for proper use of the equipment.

(15)

Hospice care may be provided only in the manner and under the conditions provided in section 1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)), except that hospice care may be provided to an individual under the age of 21 concurrently with health care services or hospitalization for the same condition.

(16)

Forensic examinations following a sexual assault or domestic violence may be provided.

(17)

Breastfeeding support, supplies (including breast pumps and associated equipment), and counseling shall be provided as appropriate during pregnancy and the postpartum period.

(18)

Treatment for eating disorders may be provided in accordance with subsection (r).

(19)

Preconception and prenatal carrier screening tests shall be provided to eligible covered beneficiaries, with a limit per beneficiary of one test per condition per lifetime, for the following conditions:

(A)

Cystic Fibrosis.

(B)

Spinal Muscular Atrophy.

(C)

Fragile X Syndrome.

(D)

Tay-Sachs Disease.

(E)

Hemoglobinopathies.

(F)

Conditions linked with Ashkenazi Jewish descent.

(20)

Medical interventions for the treatment of gender dysphoria that could result in sterilization may not be provided to a child under the age of 18.

(b)

Plans covered by subsection (a) shall include provisions for payment by the patient of the following amounts:

(1)

$25 for each admission to a hospital, or the amount the patient would have been charged under section 1078(a) of this title had the care being paid for been obtained in a hospital of the uniformed services, whichever amount is the greater. The Secretary of Defense may exempt a patient from paying such amount if the hospital to which the patient is admitted does not impose a legal obligation on any of its patients to pay for inpatient care.

(2)

Except as provided in clause (3), the first $150 each calendar year of the charges for all types of care authorized by subsection (a) and received while in an outpatient status and 20 percent of all subsequent charges for such care during a calendar year. Notwithstanding the preceding sentence, in the case of a dependent of an enlisted member in a pay grade below E–5, the initial deductible each calendar year under this paragraph shall be limited to $50.

(3)

A family group of two or more persons covered by this section shall not be required to pay collectively more than the first $300 (or in the case of the family group of an enlisted member in a pay grade below E–5, the first $100) each calendar year of the charges for all types of care authorized by subsection (a) and received while in an outpatient status and 20 percent of the additional charges for such care during a calendar year.

(4)

$25 for surgical care that is authorized by subsection (a) and received while in an outpatient status and that has been designated (under joint regulations to be prescribed by the administering Secretaries) as care to be treated as inpatient care for purposes of this subsection. Any care for which payment is made under this clause shall not be considered to be care received while in an outpatient status for purposes of clauses (2) and (3).

(5)

An individual or family group of two or more persons covered by this section may not be required by reason of this subsection to pay a total of more than $1,000 for health care received during any calendar year under a plan under subsection (a).

(c)

The methods for making payment under subsection (b) shall be prescribed under joint regulations issued by the administering Secretaries.

(d)

(1)

The Secretary of Defense shall establish a program to provide extended benefits for eligible dependents, which may include the provision of comprehensive health care services, including case management services, to assist in the reduction of the disabling effects of a qualifying condition of an eligible dependent. Registration shall be required to receive the extended benefits.

(2)

The Secretary of Defense, after consultation with the other administering Secretaries, shall promulgate regulations to carry out this subsection.

(3)

In this subsection:

(A)

The term “eligible dependent” means a dependent of a member of the uniformed services on active duty for a period of more than 30 days, as described in subparagraph (A), (D), or (I) of section 1072(2) of this title, who has a qualifying condition.

(B)

The term “qualifying condition” means the condition of a dependent who is moderately or severely mentally retarded, has a serious physical disability, or has an extraordinary physical or psychological condition.

(e)

(1)

Extended benefits for eligible dependents under subsection (d) may include comprehensive health care services (including services necessary to maintain, or minimize or prevent deterioration of, function of the patient) and case management services with respect to the qualifying condition of such a dependent, and include, to the extent such benefits are not provided under provisions of this chapter other than under this section, the following:

(A)

Diagnosis and screening.

(B)

Inpatient, outpatient, and comprehensive home health care supplies and services which may include cost-effective and medically appropriate services other than part-time or intermittent services (within the meaning of such terms as used in the second sentence of section 1861(m) of the Social Security Act (42 U.S.C. 1395x)).

(C)

Rehabilitation services and devices.

(D)

In accordance with paragraph (2), respite care for the primary caregiver of the eligible dependent.

(E)

In accordance with paragraph (3), service and modification of durable equipment and assistive technology devices.

(F)

Special education.

(G)

Vocational training, which may be furnished to an eligible dependent in the residence of the eligible dependent or at a facility in which such training is provided.

(H)

Such other services and supplies as determined appropriate by the Secretary, notwithstanding the limitations in subsection (a)(12).

(2)

Respite care under paragraph (1)(D) shall be provided subject to the following conditions:

(A)

Pursuant to regulations prescribed by the Secretary for purposes of this paragraph, such respite care shall be limited to 32 hours per month for a primary caregiver.

(B)

Unused hours of such respite care may not be carried over to another month.

(C)

Such respite care may be provided to an eligible beneficiary regardless of whether the eligible beneficiary is receiving another benefit under this subsection.

(3)

(A)

Service and modification of durable equipment and assistive technology devices under paragraph (1)(E) may be provided only upon determination by the Secretary that the service or modification is necessary for the use of such equipment or device by the eligible dependent.

(B)

Service and modification of durable equipment and assistive technology devices under such paragraph may not be provided—

(i)

in the case of misuse, loss, or theft of the equipment or device; or

(ii)

for a deluxe, luxury, or immaterial feature of the equipment or device, as determined by the Secretary.

(C)

Service and modification of durable equipment and assistive technology devices under such paragraph may include training of the eligible dependent and immediate family members of the eligible dependent on the use of the equipment or device.

(f)

(1)

Members shall be required to share in the cost of any benefits provided to their dependents under subsection (d) as follows:

(A)

Members in the lowest enlisted pay grade shall be required to pay the first $25 incurred each month, and members in the highest commissioned pay grade shall be required to pay the first $250 incurred each month. The amounts to be paid by members in all other pay grades shall be determined under regulations to be prescribed by the Secretary of Defense in consultation with the administering Secretaries.

(B)

A member who has more than one dependent incurring expenses in a given month under a plan covered by subsection (d) shall not be required to pay an amount greater than would be required if the member had only one such dependent.

(2)

In the case of extended benefits provided under subparagraph (C), (E), (F), or (G) of subsection (e)(1) to a dependent of a member of the uniformed services—

(A)

the Government’s share of the total cost of providing such benefits in any year shall not exceed $36,000, prorated as determined by the Secretary of Defense, except for costs that a member is exempt from paying under paragraph (3); and

(B)

the member shall pay (in addition to any amount payable under paragraph (1)) the amount, if any, by which the amount of such total cost for the year exceeds the Government’s maximum share under subparagraph (A).

(3)

A member of the uniformed services who incurs expenses under paragraph (2) for a month for more than one dependent shall not be required to pay for the month under subparagraph (B) of that paragraph an amount greater than the amount the member would otherwise be required to pay under that subparagraph for the month if the member were incurring expenses under that subparagraph for only one dependent.

(4)

To qualify for extended benefits under subparagraph (C), (E), (F), or (G) of subsection (e)(1), a dependent of a member of the uniformed services shall be required to use public facilities to the extent such facilities are available and adequate, as determined under joint regulations of the administering Secretaries.

(5)

The Secretary of Defense, in consultation with the other administering Secretaries, shall prescribe regulations to carry out this subsection.

(g)

(1)

When a member dies while he is eligible for receipt of hostile fire pay under section 310 or 351 of title 37 or from a disease or injury incurred while eligible for such pay, his dependents who are receiving benefits under a plan covered by subsection (d) shall continue to be eligible for such benefits until they pass their twenty-first birthday.

(2)

In addition to any continuation of eligibility for benefits under paragraph (1), when a member dies while on active duty for a period of more than 30 days, the member’s dependents who are receiving benefits under a plan covered by subsection (a) shall continue to be eligible for benefits under TRICARE Prime during the three-year period beginning on the date of the member’s death, except that, in the case of such a dependent of the deceased who is described by subparagraph (D) or (I) of section 1072(2) of this title, the period of continued eligibility shall be the longer of the following periods beginning on such date:

(A)

Three years.

(B)

The period ending on the date on which such dependent attains 21 years of age.

(C)

In the case of such a dependent who, at 21 years of age, is enrolled in a full-time course of study in a secondary school or in a full-time course of study in an institution of higher education approved by the administering Secretary and was, at the time of the member’s death, in fact dependent on the member for over one-half of such dependent’s support, the period ending on the earlier of the following dates:

(i)

The date on which such dependent ceases to pursue such a course of study, as determined by the administering Secretary.

(ii)

The date on which such dependent attains 23 years of age.

(3)

For the purposes of paragraph (2)(C), a dependent shall be treated as being enrolled in a full-time course of study in an institution of higher education during any reasonable period of transition between the dependent’s completion of a full-time course of study in a secondary school and the commencement of an enrollment in a full-time course of study in an institution of higher education, as determined by the administering Secretary.

(4)

The terms and conditions under which health benefits are provided under this chapter to a dependent of a deceased member under paragraph (2) shall be the same as those that would apply to the dependent under this chapter if the member were living and serving on active duty for a period of more than 30 days.

(5)

In this subsection, the term “TRICARE Prime” means the managed care option of the TRICARE program.

(h)

(1)

Except as provided in paragraphs (2) and (3), payment for a charge for services by an individual health care professional (or other noninstitutional health care provider) for which a claim is submitted under a plan contracted for under subsection (a) shall be equal to an amount determined to be appropriate, to the extent practicable, in accordance with the same reimbursement rules as apply to payments for similar services under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). The Secretary of Defense shall determine the appropriate payment amount under this paragraph in consultation with the other administering Secretaries.

(2)

The Secretary of Defense, in consultation with the other administering Secretaries, shall prescribe regulations to provide for such exceptions to the payment limitations under paragraph (1) as the Secretary determines to be necessary to assure that covered beneficiaries retain adequate access to health care services. Such exceptions may include the payment of amounts higher than the amount allowed under paragraph (1) when enrollees in managed care programs obtain covered services from nonparticipating providers. To provide a suitable transition from the payment methodologies in effect before February 10, 1996, to the methodology required by paragraph (1), the amount allowable for any service may not be reduced by more than 15 percent below the amount allowed for the same service during the immediately preceding 12-month period (or other period as established by the Secretary of Defense).

(3)

In addition to the authority provided under paragraph (2), the Secretary of Defense may authorize the commander of a facility of the uniformed services, the lead agent (if other than the commander), and the health care contractor to modify the payment limitations under paragraph (1) for certain health care providers when necessary to ensure both the availability of certain services for covered beneficiaries and lower costs than would otherwise be incurred to provide the services. With the consent of the health care provider, the Secretary is also authorized to reduce the authorized payment for certain health care services below the amount otherwise required by the payment limitations under paragraph (1).

(4)

(A)

The Secretary of Defense, in consultation with the other administering Secretaries, shall prescribe regulations to establish limitations (similar to the limitations established under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.)) on beneficiary liability for charges of an individual health care professional (or other noninstitutional health care provider).

(B)

The regulations shall include a restriction that prohibits an individual health care professional (or other noninstitutional health care provider) from billing a beneficiary for services for more than the amount that is equal to—

(i)

the excess of the limiting charge (as defined in section 1848(g)(2) of the Social Security Act (42 U.S.C. 1395w–4(g)(2))) that would be applicable if the services had been provided by the professional (or other provider) as an individual health care professional (or other noninstitutional health care provider) on a nonassignment-related basis under part B of title XVIII of such Act over the amount that is payable by the United States for those services under this subsection, plus

(ii)

any unpaid amounts of deductibles or copayments that are payable directly to the professional (or other provider) by the beneficiary.

(C)

(i)

In the case of a dependent described in clause (ii), the regulations shall provide that, in addition to amounts otherwise payable by the United States, the Secretary may pay the amount referred to in subparagraph (B)(i).

(ii)

This subparagraph applies to a dependent referred to in subsection (a) of a member of a reserve component serving on active duty pursuant to a call or order to active duty for a period of more than 30 days.

(5)

To assure access to care for all covered beneficiaries, the Secretary of Defense, in consultation with the other administering Secretaries, shall designate specific rates for reimbursement for services in certain localities if the Secretary determines that without payment of such rates access to health care services would be severely impaired. Such a determination shall be based on consideration of the number of providers in a locality who provide the services, the number of such providers who are CHAMPUS participating providers, the number of covered beneficiaries under CHAMPUS in the locality, the availability of military providers in the location or a nearby location, and any other factors determined to be relevant by the Secretary.

(i)

(1)

A benefit may not be paid under a plan covered by this section in the case of a person enrolled in, or covered by, any other insurance, medical service, or health plan, including any plan offered by a third-party payer (as defined in section 1095(h)(1) of this title), to the extent that the benefit is also a benefit under the other plan, except in the case of a plan administered under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).

(2)

The amount to be paid to a provider of services for services provided under a plan covered by this section shall be determined under joint regulations to be prescribed by the administering Secretaries which provide that the amount of such payments shall be determined to the extent practicable in accordance with the same reimbursement rules as apply to payments to providers of services of the same type under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

(3)

A contract for a plan covered by this section shall include a clause that prohibits each provider of services under the plan from billing any person covered by the plan for any balance of charges for services in excess of the amount paid for those services under the joint regulations referred to in paragraph (2), except for any unpaid amounts of deductibles or copayments that are payable directly to the provider by the person.

(4)

In this subsection, the term “provider of services” means a hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program (as defined in section 1861(dd)(2) of the Social Security Act (42 U.S.C. 1395x(dd)(2))), or other institutional facility providing services for which payment may be made under a plan covered by this section.

(j)

A plan covered by this section may include provision of liver transplants (including the cost of acquisition and transportation of the donated liver) in accordance with this subsection. Such a liver transplant may be provided if—

(1)

the transplant is for a dependent considered appropriate for that procedure by the Secretary of Defense in consultation with the other administering Secretaries and such other entities as the Secretary considers appropriate; and

(2)

the transplant is to be carried out at a health-care facility that has been approved for that purpose by the Secretary of Defense after consultation with the other administering Secretaries and such other entities as the Secretary considers appropriate.

(k)

(1)

Contracts entered into under subsection (a) shall also provide for medical care for dependents of former members of the uniformed services who are authorized to receive medical and dental care under section 1076(e) of this title in facilities of the uniformed services.

(2)

Except as provided in paragraph (3), medical care in the case of a dependent described in section 1076(e) shall be furnished under the same conditions and subject to the same limitations as medical care furnished under this section to spouses and children of members of the uniformed services described in the first sentence of subsection (a).

(3)

Medical care may be furnished to a dependent pursuant to paragraph (1) only for an injury, illness, or other condition described in section 1076(e) of this title.

(l)

(1)

Subject to paragraph (2), the Secretary of Defense may, upon request, make payments under this section for a charge for services for which a claim is submitted under a plan contracted for under subsection (a) to a hospital that does not impose a legal obligation on any of its patients to pay for such services.

(2)

A payment under paragraph (1) may not exceed the average amount paid for comparable services in the geographic area in which the hospital is located or, if no comparable services are available in that area, in an area similar to the area in which the hospital is located.

(3)

The Secretary of Defense shall periodically review the billing practices of each hospital the Secretary approves for payment under this subsection to ensure that the hospital’s practices of not billing patients for payment are not resulting in increased costs to the Government.

(4)

The Secretary of Defense may require each hospital the Secretary approves for payment under this subsection to provide evidence that it has sources of revenue to cover unbilled costs.

(m)

The Secretary of Defense may enter into contracts (or amend existing contracts) with fiscal intermediaries under which the intermediaries agree to organize and operate, directly or through subcontractors, managed health care networks for the provision of health care under this chapter. The managed health care networks shall include cost containment methods, such as utilization review and contracting for care on a discounted basis.

(n)

(1)

Health care services provided pursuant to this section or section 1086 of this title (or pursuant to any other contract or project under the Civilian Health and Medical Program of the Uniformed Services) may not include services determined under the CHAMPUS Peer Review Organization program to be not medically or psychologically necessary.

(2)

The Secretary of Defense, after consulting with the other administering Secretaries, may adopt or adapt for use under the CHAMPUS Peer Review Organization program, as the Secretary considers appropriate, any of the quality and utilization review requirements and procedures that are used by the Peer Review Organization program under part B of title XI of the Social Security Act (42 U.S.C. 1320c et seq.).

(o)

(1)

Subject to such exceptions as the Secretary of Defense considers necessary, coverage for medical care under this section for the dependents described in paragraph (3), and standards with respect to timely access to such care, shall be comparable to coverage for medical care and standards for timely access to such care under the managed care option of the TRICARE program known as TRICARE Prime.

(2)

The Secretary of Defense shall enter into arrangements with contractors under the TRICARE program or with other appropriate contractors for the timely and efficient processing of claims under this subsection.

(3)

This subsection applies with respect to a dependent referred to in subsection (a) who—

(A)

is a dependent of a member of the uniformed services referred to in section 1074(c)(3) of this title and is residing with the member;

(B)

is a dependent of a member who, after having served in a duty assignment described in section 1074(c)(3) of this title, has relocated without the dependent pursuant to orders for a permanent change of duty station from a remote location described in subparagraph (B)(ii) of such section where the member and the dependent resided together while the member served in such assignment, if the orders do not authorize dependents to accompany the member to the new duty station at the expense of the United States and the dependent continues to reside at the same remote location, or

(C)

is a dependent of a reserve component member ordered to active duty for a period of more than 30 days and is residing with the member, and the residence is located more than 50 miles, or approximately one hour of driving time, from the nearest military medical treatment facility adequate to provide the needed care.

(4)

The Secretary of Defense may provide for coverage of a dependent referred to in subsection (a) who is not described in paragraph (3) if the Secretary determines that exceptional circumstances warrant such coverage.

(5)

The Secretary of Defense shall consult with the other administering Secretaries in the administration of this subsection.

(p)

Subject to subsection (a), a physician or other health care practitioner who is eligible to receive reimbursement for services provided under medicare (as defined in section 1086(d)(3)(C) of this title) shall be considered approved to provide medical care authorized under this section and section 1086 of this title unless the administering Secretaries have information indicating medicare, TRICARE, or other Federal health care program integrity violations by the physician or other health care practitioner.

(q)

In the case of any pharmaceutical agent (as defined in section 1074g(i) of this title) provided under a contract entered into under this section by a physician, in an outpatient department of a hospital, or otherwise as part of any medical services provided under such a contract, the Secretary of Defense may, under regulations prescribed by the Secretary, adopt special reimbursement methods, amounts, and procedures to encourage the use of high-value products and discourage the use of low-value products, as determined by the Secretary.

(r)

(1)

The provision of health care services for an eating disorder under subsection (a)(18) may include the following services:

(A)

Outpatient services for in-person or telehealth care, including partial hospitalization services and intensive outpatient services.

(B)

Inpatient services, which shall include residential services only if medically indicated for treatment of a primary diagnosis of an eating disorder.

(2)

A dependent provided health care services for an eating disorder under subsection (a)(18) shall be provided such services without regard to—

(A)

the age of the dependent, except with respect to residential services under paragraph (1)(B), which may be provided only to a dependent who is not eligible for hospital insurance benefits under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.); and

(B)

except as otherwise specified in paragraph (1)(B), whether the eating disorder is the primary or secondary diagnosis of the dependent.

(3)

In this section, the term “eating disorder” has the meaning given the term “feeding and eating disorders” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (or successor edition), published by the American Psychiatric Association.

Source credit: (Added Pub. L. 85–861, § 1(25)(B), Sept. 2, 1958, 72 Stat. 1448; amended Pub. L. 89–614, § 2(6), Sept. 30, 1966, 80 Stat. 863; Pub. L. 92–58, § 1, July 29, 1971, 85 Stat. 157; Pub. L. 95–485, title VIII, § 806(a)(1), Oct. 20, 1978, 92 Stat. 1622; Pub. L. 96–342, title VIII, § 810(a), (b), Sept. 8, 1980, 94 Stat. 1097; Pub. L. 96–513, title V, §§ 501(13), 511(36), (38), Dec. 12, 1980, 94 Stat. 2908, 2923; Pub. L. 96–552, Dec. 19, 1980, 94 Stat. 3254; Pub. L. 97–22, § 11(a)(2), July 10, 1981, 95 Stat. 137; Pub. L. 97–86, title IX, § 906(a)(1), Dec. 1, 1981, 95 Stat. 1117; Pub. L. 98–94, title IX, § 931(a), title XII, § 1268(4), Sept. 24, 1983, 97 Stat. 648, 705; Pub. L. 98–525, title VI, § 632(a)(1), title XIV, §§ 1401(e)(4), 1405(23), Oct. 19, 1984, 98 Stat. 2543, 2617, 2623; Pub. L. 98–557, § 19(7), Oct. 30, 1984, 98 Stat. 2869; Pub. L. 99–661, div. A, title VI, § 652(d), title VII, § 703, Nov. 14, 1986, 100 Stat. 3889, 3900; Pub. L. 100–180, div. A, title VII, §§ 721(a), 726(a), Dec. 4, 1987, 101 Stat. 1115, 1117; Pub. L. 100–456, div. A, title VI, § 646(a), Sept. 29, 1988, 102 Stat. 1989; Pub. L. 101–189, div. A, title VII, § 730(a), Nov. 29, 1989, 103 Stat. 1481; Pub. L. 101–510, div. A, title VII, §§ 701(a), 702(a), 703(a), (b), 712(a), title XIV, § 1484(g)(1), Nov. 5, 1990, 104 Stat. 1580, 1581, 1583, 1717; Pub. L. 102–25, title III, § 316(b), Apr. 6, 1991, 105 Stat. 87; Pub. L. 102–190, div. A, title VII, §§ 702(b), 711, 712(a), 713, Dec. 5, 1991, 105 Stat. 1400, 1402, 1403; Pub. L. 102–484, div. A, title VII, § 704, title X, §§ 1052(13), 1053(3), Oct. 23, 1992, 106 Stat. 2432, 2499, 2501; Pub. L. 103–35, title II, § 202(a)(5), May 31, 1993, 107 Stat. 101; Pub. L. 103–160, div. A, title VII, §§ 711, 716(c), Nov. 30, 1993, 107 Stat. 1688, 1693; Pub. L. 103–337, div. A, title VII, §§ 702(a), 707(a), Oct. 5, 1994, 108 Stat. 2797, 2800; Pub. L. 104–106, div. A, title VII, §§ 701, 731(a)–(d), Feb. 10, 1996, 110 Stat. 370, 380, 381; Pub. L. 104–201, div. A, title VII, §§ 701(b)(2), 711, 731, 732, 735(c), Sept. 23, 1996, 110 Stat. 2587, 2590, 2597, 2599; Pub. L. 105–85, div. A, title VII, § 735, Nov. 18, 1997, 111 Stat. 1813; Pub. L. 106–398, § 1 [[div. A], title VII, §§ 701(c)(1), 704(b), 722(b)(1), 757(a)], Oct. 30, 2000, 114 Stat. 1654, 1654A–172, 1654A–175, 1654A–185, 1654A–198; Pub. L. 107–107, div. A, title VII, §§ 701(b), (g)(2), 703(b), 707(a), (b), title X, § 1048(c)(5), Dec. 28, 2001, 115 Stat. 1158, 1161–1163, 1226; Pub. L. 107–314, div. A, title VII, §§ 701(a), § 702, § 705(a), Dec. 2, 2002, 116 Stat. 2583, 2584; Pub. L. 108–375, div. A, title VII, § 705, Oct. 28, 2004, 118 Stat. 1983; Pub. L. 109–163, div. A, title VII, §§ 714, 715(a), Jan. 6, 2006, 119 Stat. 3344; Pub. L. 109–364, div. A, title VII, §§ 701, 702, 703(b), Oct. 17, 2006, 120 Stat. 2279; Pub. L. 110–417, [div. A], title VII, § 732, Oct. 14, 2008, 122 Stat. 4511; Pub. L. 111–84, div. A, title X, § 1073(a)(12), Oct. 28, 2009, 123 Stat. 2473; Pub. L. 113–291, div. A, title VII, §§ 703(a), (c)(1), 706, Dec. 19, 2014, 128 Stat. 3411–3413; Pub. L. 114–328, div. A, title VI, § 618(b), title VII, § 748(b), Dec. 23, 2016, 130 Stat. 2160, 2242; Pub. L. 115–91, div. A, title VII, §§ 702(b)(2), 704, 739(d)(1), Dec. 12, 2017, 131 Stat. 1434, 1435, 1447; Pub. L. 115–232, div. A, title VII, § 715(b), Aug. 13, 2018, 132 Stat. 1814; Pub. L. 116–283, div. A, title VII, §§ 703–704(b), title X, § 1081(a)(25), Jan. 1, 2021, 134 Stat. 3687, 3688, 3872; Pub. L. 117–81, div. A, title VII, §§ 701(a), 702, Dec. 27, 2021, 135 Stat. 1777, 1779; Pub. L. 118–159, div. A, title VII, § 708, Dec. 23, 2024, 138 Stat. 1945.)

history & why it existsrecord from the source credit

1958Enacted · Pub. L. 85-861 · 72 Stat. 1448
1966Amended · Pub. L. 89-614 · 80 Stat. 863
1971Amended · Pub. L. 92-58 · 85 Stat. 157
1978Amended · Pub. L. 95-485 · 92 Stat. 1622
1980Amended · Pub. L. 96-342 · 94 Stat. 1097
1980Amended · Pub. L. 96-513 · 94 Stat. 2908, 2923
1980Amended · Pub. L. 96-552 · 94 Stat. 3254
1981Amended · Pub. L. 97-22 · 95 Stat. 137
1981Amended · Pub. L. 97-86 · 95 Stat. 1117
1983Amended · Pub. L. 98-94 · 97 Stat. 648, 705
1984Amended · Pub. L. 98-525 · 98 Stat. 2543, 2617, 2623
1984Amended · Pub. L. 98-557 · 98 Stat. 2869
1986Amended · Pub. L. 99-661 · 100 Stat. 3889, 3900
1987Amended · Pub. L. 100-180 · 101 Stat. 1115, 1117
1988Amended · Pub. L. 100-456 · 102 Stat. 1989
1989Amended · Pub. L. 101-189 · 103 Stat. 1481
1990Amended · Pub. L. 101-510 · 104 Stat. 1580, 1581, 1583, 1717
1991Amended · Pub. L. 102-25 · 105 Stat. 87
1991Amended · Pub. L. 102-190 · 105 Stat. 1400, 1402, 1403
1992Amended · Pub. L. 102-484 · 106 Stat. 2432, 2499, 2501
1993Amended · Pub. L. 103-35 · 107 Stat. 101
1993Amended · Pub. L. 103-160 · 107 Stat. 1688, 1693
1994Amended · Pub. L. 103-337 · 108 Stat. 2797, 2800
1996Amended · Pub. L. 104-106 · 110 Stat. 370, 380, 381
1996Amended · Pub. L. 104-201 · 110 Stat. 2587, 2590, 2597, 2599
1997Amended · Pub. L. 105-85 · 111 Stat. 1813
2000Amended · Pub. L. 106-398 · 114 Stat. 1654, 1654
2001Amended · Pub. L. 107-107 · 115 Stat. 1158, 1161
2002Amended · Pub. L. 107-314 · 116 Stat. 2583, 2584
2004Amended · Pub. L. 108-375 · 118 Stat. 1983
2006Amended · Pub. L. 109-163 · 119 Stat. 3344
2006Amended · Pub. L. 109-364 · 120 Stat. 2279
2008Amended · Pub. L. 110-417 · 122 Stat. 4511
2009Amended · Pub. L. 111-84 · 123 Stat. 2473
2014Amended · Pub. L. 113-291 · 128 Stat. 3411
2016Amended · Pub. L. 114-328 · 130 Stat. 2160, 2242
2017Amended · Pub. L. 115-91 · 131 Stat. 1434, 1435, 1447
2018Amended · Pub. L. 115-232 · 132 Stat. 1814
2021Amended · Pub. L. 116-283 · 134 Stat. 3687, 3688, 3872
2021Amended · Pub. L. 117-81 · 135 Stat. 1777, 1779
2024Amended · Pub. L. 118-159 · 138 Stat. 1945

A history note hasn’t been published yet. The record shows enactment by Pub. L. 85-861 on 1958-09-02.

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