Sec. 701. Improved TRICARE health plan choices
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Section 1099(c) of title 10, United States Code, is amended to read as follows: Health care services for covered beneficiaries under this chapter require enrollment by the covered beneficiary, including payment of the applicable enrollment fee, in one of the following health care plans: TRICARE Select under section 1075 of this title. TRICARE Choice under section 1075 of this title. TRICARE-for-Life plan under section 1086(d) of this title. TRICARE Second Payer plan under section 1075 of this title. .
Chapter 55 of title 10, United States Code, is amended by inserting after section 1074n the following new section: This section establishes three principal health plan enrollment options for covered beneficiaries under the TRICARE program: TRICARE Select (the managed care option); TRICARE Choice (the self-managed option); and the Second Payer Option. An additional option, the TRICARE-for-Life option, is established under section 1086(d) of this chapter. The beneficiary categories for purposes of eligibility to enroll in a health plan option under this section and cost-sharing requirements applicable to those options are as follows:
This category consists of beneficiaries who are covered by section 1074(a) of this title. This category consists of beneficiaries who are— covered by section 1079 of this title (as dependents of active duty members); disability retirees and their family members 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 survivors covered by section 1086(c)(2) of this title. This category consists of beneficiaries covered by section 1086(c) of this title other than those beneficiaries referred to in paragraph
(ii)or (iii). The Secretary of Defense shall establish in areas in which a facility of the uniformed services (other than a facility limited to members of the armed forces) is located the TRICARE Select Option, to provide reduced cost-sharing amounts for enrolled beneficiaries whose care is provided by or managed by a designated primary care manager and network providers. TRICARE Select is the managed care option. A beneficiary in the active duty family member beneficiary category (as described in paragraph (b)(1)(B) of this section) is eligible to enroll in the TRICARE Select Option. A beneficiary in the retired beneficiary category (as described in paragraph (b)(1)(C)) is eligible to enroll in the Managed Care Option in selected locations to the extent a facility of the uniformed services in the location has, in the judgment of the Secretary, a significant number of uniformed health care providers, including specialty providers, and sufficient capability to support efficient operation of the TRICARE Select Option in the area for the projected enrollees. Notwithstanding subparagraphs
(A)and (B), a beneficiary under sections 1076d, 1076e, 1078a, or 1086(d)(2) is not eligible to enroll in TRICARE Select. A TRICARE Select Option enrollee shall, subject to such regulations as the Secretary of Defense may establish, be required to obtain care or a referral for care from a designated primary care manager (or other care coordinator) prior to obtaining care under the TRICARE program. In the case of an unexcused failure to obtain such referral, the cost-sharing requirement for such care (referred to as point-of-service charges) shall be equal to the amount that is 50 percent of the allowed charge for such care. The Secretary of Defense shall establish in all areas a TRICARE Choice Option under which eligible beneficiaries will generally not have restrictions on their freedom of choice of health care providers. TRICARE Choice is a self-managed option. A beneficiary in the active duty family member beneficiary category or the retired beneficiary category is eligible to enroll in the TRICARE Choice Option. This subsection establishes cost-sharing requirements under the TRICARE Select Option and the TRICARE Choice Option. Both options have an annual enrollment fee as a pre-condition for benefits under that option. Neither option has a deductible for health care services received from network providers. Both options have a deductible amount for health care services received from non-network providers. The deductible amount refers to the initial cost incurred by an individual or family unit during a calendar year for services provided by a non-network provider before costs may be paid under the plan option. Under both options, copayments are generally required for services provided outside of facilities of the uniformed services and generally not required for services inside such facilities. Under both options, there is an annual limitation on the amount of cost sharing that a family may be required to pay. Upon reaching the applicable limit, certain further cost-sharing requirements are waived. Enrollment fees and point-of-service charges do not count against the catastrophic cap. Beneficiaries (other than active duty members) enrolled in the TRICARE Select Option and the TRICARE Choice Option shall be subject to cost-sharing requirements in accordance with the amounts and percentages under the following table during calendar year 2018 and as such amounts are adjusted under paragraph
(2)for subsequent years: ADFM Category Retired Category TRICARE Select Option TRICARE Choice Option TRICARE Select Option TRICARE Choice Option * If a beneficiary in the TRICARE Select option chooses to receive care without authorization, the beneficiary will be subject to the deductible and a 50% cost share that will not count toward the catastrophic cap. Fees, Deductible and Catastrophic Caps Annual Enrollment Fee $0 $0 $350 Individual $450 Individual $700 Family $900 Family Annual Deductible $0 E4 and below (E4<) $0 $300 Individual $100 Individual $600 Family $200 Family E5 and above (E5>) $300 Individual $600 Family Annual Catastrophic Cap $1,500 $1,500 $4,000 $4,000 Co-Pays (by Service Type) Outpatient MTF Visit $0 $0 $0 $0 Outpatient Civilian Visit $0 with authorization* $15 primary network without deductible $20 primary $25 primary network without deductible $25 specialty network without deductible $30 specialty with authorization* $35 specialty network without deductible 20% out of network after deductible 25% out of network after deductible ER Visit MTF $0 $0 $0 $0 ER Visit Civilian $0 $50 network without deductible $75 network $90 network without deductible 20% out of network after deductible 25% out of network after deductible Urgent Care MTF $0 $0 $0 $0 Urgent Care Civilian $0 with authorization* $25 network without deductible $30 network with authorization* $40 network without deductible 20% out of network after deductible 25% out of network after deductible Ambulatory Surgery MTF $0 $0 $0 $0 Ambulatory Surgery Civilian $0 with authorization* $50 network without deductible $100 with authorization* $125 network without deductible 20% out of network after deductible 25% out of network after deductible Ambulance Service MTF $0 $0 $0 $0 Ambulance Service Civilian $0 $15 $20 $25 Durable Medical Equipment MTF $0 $0 $0 $0 Durable Medical Equipment Civilian $0 10% 20% 20% Hospitalization MTF $0 $0 $0 $0 Hospitalization Civilian $0 with authorization* $80 per admission–network without deductible $200 per admission with authorization* $250 per admission–network without deductible 20% out of network after deductible 25% out of network after deductible Inpatient Skilled Nursing/Rehabilitation MTF/Network $0 with authorization* $25 per day–network without deductible $25 per day with authorization* $25 per day without deductible $35 per day–non-network without deductible $250 per day or 20% of billed charges Each dollar amount expressed as a fixed dollar amount in the table set forth in paragraph 1 shall be annually indexed by the National Health Expenditures per capita rate, as established by the Secretary of Health and Human Services, rounded to the next lower multiple of $1. The remaining amount above such multiple of $1 shall be carried over to, and accumulated with, the amount of the increase for the subsequent year or years and made when the aggregate amount of increases carried over under this clause for a year is $1 or more. There are no cost-sharing requirements under this section for active duty members. Cost sharing under this section does not apply to a Medicare-eligible beneficiary for care covered by section 1086(d)(3) of this title, except that the catastrophic cap does apply to such care. Cost sharing under this section does not apply to extended health care services under subsections
(d)and
(e)of section 1079 of this title. This section does not apply to premiums established under other sections of this chapter. For a program under this chapter for which such a premium applies, the enrollment fee under this section 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. Cost-sharing requirements for a remote area dependent (as described in subsection 1079(o) of this title) are those established under the TRICARE Select Option but without a referral requirement. A beneficiary in the Retired beneficiary category (as described in subsection (b)(1)(C)) who enrolls in the TRICARE Second Payer Option shall pay an enrollment fee of one-half of the enrollment fee applicable to such a beneficiary who enrolls in the TRICARE Choice Option. Under the Second Payer Option, TRICARE shall pay the standard deductible and copayment amounts under the beneficiary’s primary plan, not to exceed the amount TRICARE would have paid as primary payer to a non-network provider under this section. The regulations required by subsection
(h)may include such other limitations and provisions for this option as the Secretary determines appropriate. Enrollment fees, deductible amounts, and catastrophic caps under this section are on a calendar-year basis. The Secretary of Defense, after consultation with the other administering Secretaries, shall prescribe regulations to carry out this section. Such regulations shall include the following provisions. A covered beneficiary enrolled in the TRICARE Select Option shall have access to primary care and specialty care services from facilities of the uniformed services or network providers in the applicable area within specific timeliness standards that are at least comparable to those of leading health care systems in the United States. In implementing the requirements of paragraph (1), the Secretary shall make special provisions for appropriate access to urgent care services. As part of the administration of the TRICARE Select Option and the TRICARE Choice Option under this section, the Secretary shall publish on a publically available Internet website of the Department of Defense data on all measures the Secretary considers appropriate that are used by the Department to assess patient safety, quality of care, patient satisfaction, and health outcomes. Such measures shall include appropriate measures for each military medical treatment facility. The published measures shall be updated no less frequently than quarterly. As part of the administration of the enrollment options under this section, the Secretary shall ensure that the enrollment status of covered beneficiaries is portable between or among TRICARE program regions of the United States and that effective procedures are in place for automatic electronic transfer of information between or among contractors responsible for administration in such regions and prompt communication with such beneficiaries. Each covered beneficiary enrolled in the TRICARE Select Option who has relocated the beneficiary’s primary residence to a new area in which enrollment in the TRICARE Select Option is available shall be able to obtain a new primary health care manager or provider within ten days of the relocation and associated request for such manager or provider. As part of the administration of the TRICARE Select Option and the TRICARE Choice Option under this section, the Secretary shall develop and implement value-based incentives to promote improvement in the quality of care, the experience of care, the health of beneficiaries, and the cost-effectiveness of the TRICARE program. The Secretary shall ensure an ongoing process of evidence-based assessment and improvement of such incentives. In the administration of this section, the Secretary shall provide covered beneficiaries an annual open season enrollment period and opportunities during other periods for enrollment modifications under appropriate circumstances. The Secretary may establish such other provisions as the Secretary determines appropriate for the effective and efficient administration of the TRICARE program, including provisions on any matter not specifically addressed in this chapter or any other law. In this section: The term network provider means a health care provider who has met the requirements established by the Secretary to become a preferred provider. The term out-of-network provider means a health care provider, other than a provider referred to in paragraph (1), who has met the requirements established by the Secretary to be an authorized provider. . 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, 2017, through December 31, 2017: Any enrollment fee shall be one-fourth of the amount in effect during fiscal year 2017. Any deductible amount applicable during fiscal year 2017 shall apply for the 15-month period of October 1, 2016, through December 31, 2017. Any catastrophic cap applicable during fiscal year 2017 shall apply for the 15-month period of October 1, 2016, through December 31, 2017. 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. It includes the following health plan options: TRICARE Select (a managed care option). TRICARE Choice (a self-managed option). TRICARE-for-Life. TRICARE Second Payer. . Section 1074(c)(2) is amended by striking TRICARE Prime and inserting TRICARE Select . Section 1076d is amended by striking TRICARE Standard each place it appears (including in the heading of such section) and inserting TRICARE Reserve Select . 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— by amending subsection
(b)to read: Section 1075 of this title shall apply to health care services under this section. ; by striking subsection (c); by striking the designation of paragraph
(1)and striking paragraphs
(2)through (5); and by amending subsection (p)(1) by striking known as TRICARE Prime . Section 1079a is amended— by striking in the heading and inserting CHAMPUS ; TRICARE program by inserting after amounts collected the following: (including interagency transfers of funds or obligational authority and similar transactions) ; and by striking the Civilian Health and Medical Program of the Uniformed Services and inserting the TRICARE program . Section 1086(b) is amended to read as follows: Section 1075 of this title shall apply to health care services under this section. . Section 1097(e) is amended to read as follows: Section 1075 of this title applies to health care services under this section. . Section 1097a is repealed. 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 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 item relating to section 1097a. Except as provided in paragraph (2), this section and the amendments made by this section shall take effect on January 1, 2018. Subsection
(c)shall take effect on October 1, 2017.