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Code · BILL · 114th Congress · S. 1118 (Introduced in Senate) — To authorize appropriations for fiscal year 2016 for military activities of the Department of Defense and for militar... · Sec. 701

Sec. 701. Consolidated TRICARE health plan

3,486 words·~16 min read·/bill/114/s/1118/is/section-701

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Chapter 55 of title 10, United States Code, is amended by inserting after section 1073b the following new section: A covered beneficiary may choose to receive medical and dental care and health benefits care from any of the points of service specified in subsection (b), subject to availability. The points of service specified in this subsection are as follows: Facilities of the uniformed services. Providers under the TRICARE program designated as network providers for the purposes of this chapter by the Secretary of Defense. Providers under the TRICARE program other than those described in paragraphs
(1)and (2), to be known as out-of-network providers. . Such chapter is further amended by inserting after section 1074n the following new section: This section establishes cost-sharing requirements for beneficiaries under the TRICARE program. The beneficiary categories for purposes of cost-sharing requirements under the TRICARE program are as follows: Category 1 consists of beneficiaries who are covered by section 1074(a) of this title. Category 2 consists of beneficiaries who are covered by section 1079 of this title. Category 3 consists of beneficiaries (other than Category 5 beneficiaries) who are— covered by section 1086(c)(1) of this title by reason of being retired under chapter 61 of this title or being a dependent of such a member; or covered by section 1086(c)(2) of this title. Category 4 consists of beneficiaries covered by section 1086(c) of this title other than Category 3 beneficiaries and Category 5 beneficiaries. Category 5 consists of beneficiaries who are described in section 1086(d)(2) of this title. Category 6 consists of beneficiaries covered by section 1076d of this title. The cost-sharing groups for purposes of cost-sharing requirements under the TRICARE program are as follows: A beneficiary is a Group A beneficiary if the beneficiary is— a Category 2 beneficiary who is a dependent of a member in pay grade E–1 through E–4; a Category 6 beneficiary who is a member of the Selected Reserve of the Ready Reserve in pay grade E–1 through E–4 or dependent of such a member; a Category 3 beneficiary who retired under chapter 61 of this title in pay grade E–1 through E–4 or who is a dependent of such a member; or a Category 3 beneficiary who is covered by section 1086(c)(2) of this title by reason of being a dependent of a member who was in pay grade E–1 through E–4 at the time of death. A beneficiary is a Group B beneficiary if the beneficiary is— a Category 2 beneficiary who is a dependent of a member in pay grade E–5 through O–3; a Category 6 beneficiary who is a member of the Selected Reserve of the Ready Reserve in pay grade E–5 through O–3 or dependent of such a member; a Category 3 beneficiary who retired under chapter 61 of this title in pay grade E–5 through O–3 or who is a dependent of such a member; or a Category 3 beneficiary who is covered by section 1086(c)(2) of this title by reason of being a dependent of a member who was in pay grade E–5 through O–3 at the time of death. A beneficiary is a Group C beneficiary if the beneficiary is— a Category 2 beneficiary who is a dependent of a member in pay grade O–4 or above; a Category 6 beneficiary who is a member of the Selected Reserve of the Ready Reserve in pay grade O–4 or above or dependent of such a member; a Category 3 beneficiary who retired under chapter 61 of this title in pay grade O–4 or above or who is a dependent of such a member; or a Category 3 beneficiary who is covered by section 1086(c)(2) of this title by reason of being a dependent of a member who was in pay grade O–4 or above at the time of death. A beneficiary is a Group D beneficiary if the beneficiary is— a Category 4 beneficiary; or a Category 5 beneficiary with respect to care not covered by section 1086(d)(3). The Primary Care Manager Program enrollment status for purposes of cost-sharing requirements under the TRICARE program are as follows: A beneficiary is a PCM-Managed beneficiary if the beneficiary is enrolled in the Primary Care Manager Program established in accordance with subsection (c). A beneficiary is a Self-Managed beneficiary if the beneficiary is not enrolled in the Primary Care Manager Program and is not a remote area dependent. A beneficiary is a remote area dependent if the beneficiary 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; 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; 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; or a dependent other than one described in subparagraphs
(A)through
(C)if the Secretary of Defense determines that exceptional circumstances warrant designation for this purpose. The Secretary of Defense may establish a program, to be known as the Primary Care Manager Program, to provide reduced cost-sharing amounts for enrolled beneficiaries whose care is provided by or managed by a designated primary care manager. A Category 2 beneficiary who is not a remote area dependent is eligible to enroll in the Primary Care Manager Program. A PCM-Managed beneficiary shall, subject to such rules and regulations as the Secretary of Defense shall establish, be required to obtain care or a referral for care from a designated primary care manager prior to obtaining care under the TRICARE program. If a PCM-Managed beneficiary obtains care without a referral as required under paragraph (3), the cost-sharing requirement for such care shall be equal to the amount that is 50 percent of the allowed charge for such care. There are no cost-sharing requirements under this section for Category 1 beneficiaries. Cost sharing under this section does not apply to a Category 5 beneficiary for care covered by section 1086(d)(3) of this title, except that the catastrophic cap under subsection (h)(3) does apply to such care. Except as provided in subparagraph
(B)and subsection (c)(4), there are no out-patient cost-sharing requirements under subsection
(i)or in-patient cost-sharing requirements under subsection
(j)for PCM-Managed beneficiaries and remote area dependents. For non-emergency care provided by an emergency department to PCM-Managed beneficiaries and remote area dependents, the cost-sharing requirements applicable to Self-Managed beneficiaries under subsection
(i)apply. Cost sharing under this section does not apply to extended health care services under section 1079(d) and
(e)of this title. This section does not apply to premiums established under this chapter under sections other than 1079 and 1086. For a program under this chapter for which such a premium applies, the enrollment fee under subsection
(f)does not apply. Required copayments for services under the Pharmacy Benefits Program are set forth in section 1074g of this title. The enrollment fee, deductible, and catastrophic cap under this section apply to the Pharmacy Benefits Program under that section. Enrollment fees, deductible amounts, and catastrophic caps under this section are on a calendar-year basis. Amounts received under this section for care provided by a facility of the uniformed services shall be deposited to the credit of the appropriation supporting the maintenance and operation of that facility. As a condition of eligibility for the TRICARE program in any year (including care in facilities of the uniformed services and pharmacy benefits under section 1074g of this title), a Category 4 beneficiary shall pay an enrollment fee for that year. The amount of such fee for any year is the baseline amount as adjusted under subsection (k). The baseline amount is the amount that would have been charged for enrollment in TRICARE Prime during fiscal year 2016 under section 1097 of this title on the day before the effective date of this section. For Group A, B, C, and D beneficiaries, the cost-sharing requirements applicable under this section include an annual deductible of the charges for outpatient care received under the TRICARE program during a year. The annual deductible described in paragraph
(1)is the following: For a Group A beneficiary, the first $150 (or $300 for a family group of two or more persons) each year of the charges for outpatient care provided by out-of-network providers. For a Group B beneficiary, the first $300 (or $600 for a family group of two or more persons) each year for outpatient care provided by out-of-network providers. For a Group C beneficiary, the first $300 (or $600 for a family group of two or more persons) each year for outpatient care provided by out-of-network providers. For a Group D beneficiary, the first $300 (or $600 for a family group of two or more persons) each year for outpatient care provided by out-of-network providers. The total amount of cost sharing required to be paid by a beneficiary under the TRICARE program for a year is limited to a maximum amount, referred to as a catastrophic cap. The following shall not be counted toward the catastrophic cap: An enrollment fee paid under subsection (f). A point-of-service charge under subsection (c)(2). The catastrophic cap has been reached for a beneficiary during a year if the total amount of cost sharing requirements (other than amounts excluded under paragraph (2)) incurred under the TRICARE program by all beneficiaries in the beneficiary's family group during that year is the following: For a Category 2, 3 or 6 beneficiary, $1,500 for health care provided by network providers or $2,500 for all health care. For Category 4 or 5 beneficiary, $3,000 for health care provided by military treatment facilities and network providers or $5,000 for all health care. A Group A, B, C, or D beneficiary shall be subject to cost-sharing for outpatient care in accordance with the amounts and percentages under the following table, as such amounts are adjusted under subsection (k): Services TRICARE Network and Facilities of the Uniformed Services
(FUS)Out-of-Network Group A/Group B/ Group C Group D Groups A, B, and C Group D PCM Managed c / Remote Area Dependent Self- Managed a No cost for clinical preventive services as determined by the Secretary consistent with criteria applicable under the Patient Protection and Affordable Care Act (Public Law 111–148), as amended. b Percentage of TRICARE maximum allowable charge after deductible is met. c If a PCM managed beneficiary obtains care without a referral, Point of Service charges will apply: 50% of the allowed charge after deductible is met. Note: PT—physical therapy; OT—occupational therapy; BH—behavioral health; DME—durable medical equipment. Clinical preventive services a $0 $0 $0 $0 $0 Primary care visit $0/0/0 FUS; $0/0/0 network referral $0/0/0 FUS; $10/15/20 network $10 FUS; $20 network 20% b 25% b Specialty care visit (including PT, OT, speech) $0/0/0 FUS or network BH group visit; $0/0/0 network visit $0/0/0 FUS; $20/25/30 network $20 FUS or network BH group visit; $30 network 20% b 25% b Urgent care center $0/0/0 FUS visit; $0/0/0 network referral $0/0/0 FUS; $25/40/50 network $30 FUS; $50 network 20% b 25% b Emergency department—emergency care $0/0/0 FUS visit; $0/0/0 network $0/0/0 FUS; $30/50/70 network $50 FUS; $75 network 20% b 25% b Emergency department—nonemergency care $30/50/70 FUS for misuse; $30/50/70 network fee for misuse $30/50/70 FUS for misuse; $30/50/70 network $50 FUS; $75 network 20% b 25% b Ambulance regardless of destination (FUS or network $0/0/0 trip $10/15/20 trip $20 trip 20% b 25% b DME, prosthetics, orthotics, and supplies $0/0/0 FUS; $0/0/0 network referral 10% of ne­goti­ated net­work fee 20% of FUS cost or network negotiated fee 20% b 25% b Ambulatory surgery $0/0/0 FUS; $0/0/0 network referral $0/0/0 FUS; $25/50/75 network $50 FUS; $100 network 20% b 25% b The cost sharing amounts specified in the table under paragraph
(1)shall apply only after any applicable deductible under subsection
(g)has been met. For purposes of the table under paragraph (1), the Secretary of Defense shall develop guidance for determining emergency room care is clearly inappropriate under the TRICARE program. The Secretary will establish procedures to provide information to beneficiaries about the appropriate sites for such health conditions and services. The Secretary will ensure the availability of, and wide dissemination of information concerning, means (such as a nurse advice line and other methods) for beneficiaries with uncertainty about the appropriate site for care in specific cases to obtain guidance. In any case in which a beneficiary has a reasonable belief, taking into account the beneficiary’s (or in the case of a minor, the parent or guardians) level of maturity and understanding, that the circumstances presented a medical emergency, the care provided will not be considered emergency room misuse. A Group A, B, C, or D beneficiary shall be subject to cost sharing for inpatient care in accordance with the amounts and percentages under the following table, as such amounts are adjusted under subsection (k): Services TRICARE Network and Facility of the Uniformed Services
(FUS)Out-of-Network Group A/Group B/Group C Group D Group A/Group B/Group C Group D PCM Managed/Remote Area Dependents Self- Managed a Percentage of TRICARE maximum allowable charge after deductible is met. b Inpatient skilled nursing/rehabilitation is generally not offered in MTFs for anyone other than servicemembers. Hospitalization $0 FUS; $0 network referred $0 FUS per day; $50/80/110 per day network $17.35 FUS per day; $200 network per admission 20% a 25% a Inpatient skilled nursing/rehabilitation b $0 network referred $17/25/35 network per day $25 per day $25/35/45 per day $250 per day or 20% a of billed charges for in­sti­tu­tion­al services, whichever is less, plus 20% for separately billed services For any year after 2017, the dollar amounts specified in paragraph
(2)shall be equal to such dollar amounts increased by the percentage by which retired pay has been increased under section 1401a(b)(2) of this title since 2017, rounded to the next lower multiple of $1. Paragraph
(1)applies to the following: The amount of the enrollment fee in effect under subsection (f). Each deductible amount in effect under subsection (g). Each catastrophic cap amount in effect under subsection (h). Each amount in effect under subsection
(i)for outpatient care. Each amount in effect under subsection
(j)for inpatient care. The Secretary of Defense, after consultation with the other administering Secretaries, shall prescribe regulations to carry out this section. The regulations prescribed under paragraph
(1)shall include the following: Provisions to ensure, to the extent practicable, the availability of network providers to at least 85 percent of beneficiaries for whom the TRICARE program provides primary health benefits. Provisions for an annual open season enrollment period and for enrollment modifications under appropriate circumstances. Priorities for access to care in facilities of the uniformed services and other standards to ensure timely access to care. Those regulations may provide for TRICARE eligibility and alternate cost sharing for beneficiaries other than Category 1 beneficiaries who have other health insurance that provides primary health benefits. Those regulations may include such other provisions as the Secretary determines appropriate for the effective and efficient administration of the TRICARE program, including any matter not specifically addressed in this chapter or any other law. In this section: The term network provider means a health care provider referred to in section 1073c(b)(2) of this title. The term out-of-network provider means a health care provider referred to in section 1073c(b)(3) of this title. . With respect to cost sharing requirements applicable under sections 1079, 1086, or 1097 of title 10, United States Code, to a covered beneficiary under such sections during the period October 1, 2016, through December 31, 2016: Any enrollment fee shall be one-fourth of the amount in effect during fiscal year 2016. Any deductible amount applicable during fiscal year 2016 shall apply for the 15-month period of October 1, 2015, through December 31, 2016. Any catastrophic cap applicable during fiscal year 2016 shall apply for the 15-month period of October 1, 2015, through December 31, 2016. The following provisions of law are repealed: Section 1078 of title 10, United States Code. Section 1097a of title 10, United States Code. Section 1099 of title 10, United States Code. Section 731 of the National Defense Authorization Act for Fiscal Year 1994 ( Public Law 103–160 ; 10 U.S.C. 1073 note). Title 10, United States Code is amended as follows: Section 1072 is amended by striking paragraph
(7)and inserting the following: The term TRICARE program means the various programs carried out by the Secretary of Defense under this chapter and any other provision of law providing for the furnishing of medical and dental care and health benefits to members and former members of the uniformed services and their dependents. . Section 1074(c)(2) is amended by striking the managed care option of the TRICARE program known as TRICARE Prime and inserting the TRICARE program . Section 1076d is amended— by striking TRICARE Standard each place it appears (including in the heading of such section) and inserting TRICARE Reserve Select , and in clause (f)(2)(B), by striking subject to the same rates and conditions as apply to persons covered under that section and substituting subject to the same scope of benefits as apply to persons covered under that section and cost sharing requirements as provided in section 1075 of this title . Section 1076e is amended by striking TRICARE Standard each place it appears (including in the heading of such section) and inserting TRICARE Retired Reserve . Section 1076e is further amended by striking TRICARE Retired Reserve Coverage at age 60 (as inserted by paragraph (4)) and inserting TRICARE coverage at age 60 . Section 1079 is amended— in subsection (b), by striking of the following amounts: and all that follows and inserting of amounts as provided under section 1075 of this title. ; and by striking subsections (c), (g), and (p). Section 1079a is amended— by striking in the heading and inserting CHAMPUS ; and TRICARE program by striking the Civilian Health and Medical Program of the Uniformed Services and inserting the TRICARE program . Section 1086(b) is amended by striking contain the following and all that follows and inserting include provisions for payment by the patient as provided under section 1075 of this title. . Section 1097(e) is amended to read as follows: Section 1075 of this title applies to health care services under this section. . Section 721 of the National Defense Authorization Act for Fiscal Year 1997 ( Public Law 104–201 ; 10 U.S.C. 1073 note) is amended— in paragraph (7), by striking the health plan known as the ; and TRICARE PRIME option under in paragraph (9), by striking all that follows The term and inserting TRICARE program has the meaning given that term in section 1072(7) of title 10, United States Code. . Section 723(a) of such Act ( Public Law 104–201 ; 10 U.S.C. 1073 note) is amended by striking section 731 of the National Defense Authorization Act for Fiscal Year 1994 ( and inserting Public Law 103–160 ; 10 U.S.C. 1073 note) section 1075 of title 10, United States Code . Section 706 of the National Defense Authorization Act for Fiscal Year 2000 ( Public Law 106–65 ; 113 Stat. 684) is amended— in subsection (c), by striking Prime Remote ; and in subsection (d), by striking the TRICARE Standard plan and inserting the TRICARE program . The table of sections at the beginning of chapter 55 of title 10, United States Code, is amended— by inserting after the item relating to section 1073b the following new item: 1073c. TRICARE program: freedom of choice for points of service. ; by inserting after the item relating to section 1074n the following new item: 1075. TRICARE program: cost-sharing requirements. ; in the item relating to section 1076d, by striking TRICARE Standard and inserting TRICARE Reserve Select ; in the item relating to section 1076e, by striking TRICARE Standard and inserting TRICARE Retired Reserve ; in the item relating to section 1079a, by striking CHAMPUS and inserting TRICARE program ; and by striking the items relating to sections 1078, 1097a, and 1099. Except as provided in paragraph (2), this section and the amendments made by the section shall take effect on January 1, 2017. Subsection
(c)shall take effect on October 1, 2016.
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  • Pub. L. 111-148
  • Pub. L. 103-160
  • Pub. L. 104-201
  • Pub. L. 106-65
  • 113 Stat. 684
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cites case law
Sec. 701
Consolidated TRICARE health plan
U.S.C.§ 1073
Pub. L.Pub. L. 111-148
Pub. L.Pub. L. 103-160
Pub. L.Pub. L. 104-201
Pub. L.Pub. L. 106-65
Stat.113 Stat. 684
Cites 6Cited by 0 across 0 sources
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