Sec. 701. Reform of health care plans available under the TRICARE program
3,206 words·~15 min read·
/bill/114/s/2943/pap/section-701·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Chapter 55 of title 10, United States Code, is amended by inserting after section 1074n the following new section: This section establishes the following health care plans under which covered beneficiaries may enroll under the TRICARE program: TRICARE Prime (the managed care option). TRICARE Choice (the self-managed option). TRICARE Supplemental. In this section, the beneficiary categories for purposes of eligibility to enroll in a health care plan under subsection
(a)and cost sharing requirements applicable to those health care plans are as follows: The category of active-duty family members consists of the following beneficiaries: Beneficiaries covered by section 1079 of this title. Beneficiaries covered by section 1086(c)(1) of this title by reason of being a retired member under chapter 61 of this title or a dependent of such a retired member. Beneficiaries covered by section 1086(c)(2) of this title. The category of retired members consists of beneficiaries covered by section 1086(c) of this title who are not— beneficiaries described in subparagraph
(B)or
(C)of paragraph (1); or beneficiaries described in section 1086(d)(2) of this title. The Secretary of Defense shall establish the TRICARE Prime health care plan in areas described in paragraph (6). TRICARE Prime is a managed care option that provides medical services to beneficiaries enrolled in such option at reduced cost-sharing amounts for beneficiaries whose care is managed by a designated primary care manager and provided by a network provider. Except as provided in subparagraph (C), a beneficiary in the active-duty family members category is eligible to enroll in TRICARE Prime under this subsection. Except as provided in subparagraph (C), a beneficiary in the retired members category is eligible to enroll in TRICARE Prime under this subsection in locations in which a facility of the uniformed services has, in the judgment of the Secretary, a significant number of health care providers, including specialty care providers, and sufficient capability to support the efficient operation of TRICARE Prime for projected enrollees in that location. A beneficiary covered by section 1076d, 1076e, 1078a, or 1086(d)(2) of this title is not eligible to enroll in TRICARE Prime under this subsection. Except as otherwise provided in this paragraph, a beneficiary enrolled in TRICARE Prime shall be required to obtain a referral for care through a designated primary care manager (or other care coordinator) prior to obtaining care under the TRICARE program. The Secretary may excuse the requirement that a beneficiary obtain a referral under subparagraph
(A)in such circumstances as the Secretary may establish for purposes of this section. Beneficiaries enrolled in TRICARE Prime shall not be required to obtain a pre-authorization for a referral for specialty care services. Notwithstanding subsections
(f)and (g), the cost-sharing requirement for a beneficiary enrolled in TRICARE Prime who does not obtain a referral for care as required under subparagraph
(A)and is not excused from obtaining such a referral under subparagraph
(B)shall be an amount equal to 50 percent of the allowed point-of-service charge for such care. The Secretary shall ensure that beneficiaries enrolled in TRICARE Prime 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 meet or exceed those of high-performing health care systems in the United States, as determined by the Secretary. In implementing subparagraph (A), the Secretary shall make special provisions for appropriate access of beneficiaries to urgent care services. Beneficiaries enrolled in TRICARE Prime shall not be subject to a pre-authorization requirement for urgent care services. Areas described in this paragraph are areas in which a facility of the uniformed services is located (other than a facility limited to members of the armed forces) that have been designated by the Secretary for purposes of this subsection. The Secretary of Defense shall establish, without limitation to certain areas, the TRICARE Choice health care plan. TRICARE Choice is a self-managed option under which beneficiaries enrolled in such option may receive care from any health care provider selected by the beneficiary, subject to such restrictions as the Secretary may establish for purposes of this subsection. A beneficiary in the active-duty family members category or the retired members category is eligible to enroll in TRICARE Choice under this subsection. The Secretary of Defense shall establish the TRICARE Supplemental health care plan. Under TRICARE Supplemental, the Secretary shall pay on behalf of a beneficiary the deductible and copayment amounts under a primary health care plan under which the beneficiary is covered, not to exceed the amount the Secretary would have paid as a primary payer to an out-of-network provider under this section. A beneficiary in the retired members category is eligible to enroll in TRICARE Supplemental under this subsection. A beneficiary who enrolls in TRICARE Supplemental shall pay an enrollment fee of ½ of the enrollment fee applicable to a beneficiary in the retired members category who enrolls in TRICARE Choice. The regulations prescribed by the Secretary under subsection
(i)may include such other limitations and provisions for TRICARE Supplemental as the Secretary determines appropriate. During calendar year 2018, beneficiaries enrolled in TRICARE Prime and TRICARE Choice under this section shall be subject to cost-sharing requirements, including an enrollment fee, a deductible amount, and copayments, in accordance with the amounts and percentages set forth in the following table: ADFM Category ADFM Category Retired Category Retired Category TRICARE Prime TRICARE Choice TRICARE Prime TRICARE Choice Enrollment Fees, Deductible, and Catastrophic Caps Annual Enrollment Fee $0 $0 $350 Individual $700 Family $150 Individual $300 Family Annual Deductible $0 E4 and below (E4?) $100 Individual $200 Family _______ E5 and above (E5?) $300 Individual $600 Family $0 $300 Individual $600 Family Annual Catas-?trophic Cap $1,500 $1,500 $4,000 $4,000 Copayments (by Service Type) Outpatient MTF Visit $0 $0 $0 $0 Outpatient Private Sector Visit $0 $15 primary network without deductible $25 specialty network without deductible _______ 20% out of network after deductible $20 primary $30 specialty $25 primary network without deductible $35 specialty network without deductible ________ 25% out of network after deductible ER Visit MTF $0 $0 $0 $0 ER Visit Private Sector $0 $50 network without deductible _______ 20% out of network after deductible $75 network $100 network without deductible ________ 25% out of network after deductible Urgent Care MTF $0 $0 $0 $0 Urgent Care Private Sector $0 $0 network without deductible _______ 20% out of network after deductible $30 network $40 network without deductible ________ 25% out of network after deductible Ambulatory Surgery MTF $0 $0 $0 $0 Ambulatory Surgery Private Sector $0 $50 network without deductible _______ 20% out of network after deductible $100 $125 network without deductible ________ 25% out of network after deductible Ambulance Service MTF $0 $0 $0 $0 Ambulance Service Private Sector $0 $15 $50 $75 Durable Medical Equipment MTF $0 $0 $0 $0 Durable Medical Equipment Private Sector $0 10% 20% 20% Hospitalization tion MTF $0 $0 $0 $0 Hospitalization Private Sector $0 $80 per admission - network without deductible _______ 20% out of network after deductible $200 per Admission $250 per admission - network without deductible ________ 25% out of network after deductible Inpatient Skilled Nursing/ Rehabili-?tation - MTF/ Network $0 $25 per day - network without deductible _______ $35 per day out of network without deductible $25 per day $25 per day - network without deductible ________ $250 per day or 20% of billed charges (whichever is less) out of network without deductible With respect to enrollment in TRICARE Choice for beneficiaries in the retired members category, for each calendar year after calendar year 2023, and with respect to all other beneficiaries, for each calendar year after calendar year 2018, each dollar amount for an annual enrollment fee in the table set forth in paragraph
(1)shall be increased by the annual percentage increase of the Consumer Price Index for Health Care Services published by the Bureau of Labor Statistics for such calendar year rounded to the next lower multiple of $1. An amount equal to the amount rounded down under subclause
(I)for an annual enrollment fee shall be accumulated with such amounts for subsequent years and added to the amount of the increase under such subclause when the aggregate accumulated amount under this subclause (and not yet so added) for such fee equals $1 or more. With respect to enrollment in TRICARE Choice for beneficiaries in the retired members category, the annual enrollment fee for calendar years 2019 through 2023 shall be— for calendar year 2019— for enrollment as an individual, $210; and for enrollment as a family, $420; for calendar year 2020— for enrollment as an individual, $270; and for enrollment as a family, $540; for calendar year 2021— for enrollment as an individual, $330; and for enrollment as a family, $660; for calendar year 2022— for enrollment as an individual, $390; and for enrollment as a family, $780; and for calendar year 2023— for enrollment as an individual, $450; and for enrollment as a family, $900. For each calendar year after calendar year 2018, each dollar amount (other than a dollar amount for an annual enrollment fee) expressed as a fixed dollar amount in the table set forth in paragraph
(1)shall be increased by an amount equal to the percentage by which retired pay is increased under section 1401a(b)(2) of this title for such calendar year rounded to the next lower multiple of $1. An amount equal to the amount rounded down under clause
(i)for a fixed dollar amount specified in the table set forth in paragraph
(1)shall be accumulated with such rounded amounts for subsequent years and added to the amount indexed under such clause when the aggregate accumulated amount under this subclause (and not yet so added) for such fixed dollar amount equals $1 or more. In the case of services and products furnished under a health care plan under this section, the Secretary may, under regulations prescribed by the Secretary, adopt special coverage and reimbursement methods, amounts, and procedures to encourage the use of high-value services and products and discourage the use of low-value services and products, as determined by the Secretary. The special coverage and reimbursement methods, amounts, and procedures adopted under subparagraph
(A)may include a reduction, waiver, or increase, as the case may be, of cost-sharing requirements set forth in paragraph
(1)(as modified under paragraph (2)). The deductible amount specified in the table set forth in paragraph
(1)(as modified under paragraph (2)) is the initial cost incurred by an individual or family enrolled in a health care plan under this section during a calendar year for services furnished by an out-of-network provider before costs may be paid under the plan. The catastrophic cap specified in the table set forth in paragraph
(1)(as modified under paragraph (2)) is the annual limit on the amount of cost-sharing that an individual or family enrolled in a health care plan under this section may be required to pay under such plan. Enrollment fees and point-of-service charges do not count against the catastrophic cap. Enrollment fees, deductible amounts, and catastrophic caps specified in the table set forth in paragraph
(1)(as modified under paragraph (2)) are on a calendar-year basis. For purposes of the table set forth in paragraph
(1)(as modified under paragraph (2)): The term ADFM Category means the active-duty family members category. The term MTF , with respect to care or services, means care or services provided at a military treatment facility. The term private sector , with respect to care or services, means care or services provided in the private sector. The term network , with respect to care or services, means care or services provided by a network provider. The term out of network , with respect to care or services, means care or services provided by an out-of-network provider. A Medicare-eligible beneficiary enrolled in a health care plan under this section is not responsible for cost sharing for care covered by section 1086(d)(3) of this title, except that the catastrophic cap specified in the table set forth in subsection (f)(1) (as modified under subsection (f)(2)) applies to such care. A remote area dependent (as described in section 1079(o) of this title) enrolled in TRICARE Choice is subject to the cost-sharing requirements for beneficiaries under TRICARE Prime. The referral requirements for a beneficiary enrolled in TRICARE Prime shall not apply to a remote area dependent described in clause (i). Cost sharing under this section does not apply to extended benefits under subsections
(d)and
(e)of section 1079 of this title. Copayments for the receipt of pharmaceutical agents under a health care plan under this section shall be the copayments set forth in section 1074g(6) of this title. The enrollment fee, deductible, and catastrophic cap under this section shall apply to pharmaceutical agents furnished under a health care plan under this section. In this subparagraph, the term pharmaceutical agent has the meaning given that term in section 1074g(2) of this title. If a beneficiary is enrolled in a program under this chapter for which an annual premium applies, including a premium under Medicare part B for care covered under section 1086(d)(3) of this title, the beneficiary is not required to pay an enrollment fee to enroll in a health care plan under this section. The Secretary of Defense shall establish— an annual open enrollment period for beneficiaries to enroll or modify enrollment in a health care plan under this section; and other appropriate circumstances under which beneficiaries may enroll or modify enrollment in such a plan outside of that period. The Secretary of Defense, in consultation with the other administering Secretaries, shall prescribe regulations to carry out this section. In this section: The term network provider means an individual or institutional health care provider that— has met the requirements established by the Secretary to become a preferred provider under this section; and improves the experience of care, meets established quality of care and effectiveness metrics, and reduces the per capita costs of health care. The term out-of-network provider means an individual or institutional health care provider, other than a network provider, that has met the requirements established by the Secretary to be an authorized provider under this section. . Such title is amended— in section 1072, by amending paragraph
(7)to read as follows: 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, including care furnished under the following health care plans: TRICARE Prime under section 1075 of this title (a managed care option). TRICARE Choice under such section 1075 (a self-managed option). TRICARE Supplemental under such section 1075. TRICARE-for-Life under section 1086(d) of this title. ; in section 1079— by amending subsection
(b)to read as follows: Plans covered by subsection
(a)shall include provisions for the payment by the patient of cost-sharing amounts as specified in section 1075 of this title. ; by striking subsection (c); and in subsection (g)— in paragraph (1), by striking
(1)When and inserting When ; and by striking paragraphs
(2)through (5); in section 1086, by amending subsection
(b)to read as follows: For persons covered by this section, plans contracted for under section 1079(a) of this title shall include provisions for the payment by the patient of cost-sharing amounts as specified in section 1075 of this title. ; in section 1097, by amending subsection
(e)to read as follows: The charges for health care provided under this section shall consist of cost-sharing amounts as specified in section 1075 of this title. ; and by striking section 1097a. The table of sections at the beginning of chapter 55 of such title is amended— by inserting after the item relating to section 1074n the following new item: 1075. TRICARE program: health care plans. ; and by striking the item relating to section 1097a. Subsection
(c)of section 1099 of title 10, United States Code, is amended to read as follows: Covered beneficiaries that seek to receive health care services under this chapter shall enroll in one of the following health care plans and pay an enrollment fee, if any, applicable to such health care plan: TRICARE Prime under section 1075 of this title. TRICARE Choice under such section 1075. TRICARE Supplemental under such section 1075. TRICARE-for-Life under section 1086(d) of this title. . Subsection (b)(1) of such section is amended by striking eligible health care plans designated by the Secretary of Defense and inserting among health care plans specified in subsection
(c). Section 1076d of title 10, United States Code, is amended— in the section heading, by striking and inserting TRICARE Standard ; and TRICARE Reserve Select by striking TRICARE Standard each place it appears and inserting TRICARE Reserve Select . Section 1076e of such title is amended— in the section heading, by striking and inserting TRICARE Standard ; TRICARE Retired Reserve by striking TRICARE Standard each place it appears, other than subsections
(b)and (c), and inserting TRICARE Retired Reserve ; in subsection (b)— in the subsection heading, by striking ; and TRICARE Standard by striking TRICARE Standard the second place it appears; and in subsection (c), by striking TRICARE Standard the fourth place it appears. Section 1079a of such title is amended— in the section heading, by striking and inserting CHAMPUS ; TRICARE program by inserting (including interagency transfers of funds or obligational authority and similar transactions) after amounts collected ; and by striking the Civilian Health and Medical Program of the Uniformed Services and inserting the TRICARE program . The table of sections at the beginning of chapter 55 of such title is amended— by striking the item relating to section 1076d and inserting the following new item: 1076d. TRICARE program: TRICARE Reserve Select coverage for members of the Selected Reserve. ; by striking the item relating to section 1076e and inserting the following new item: 1076e. TRICARE program: TRICARE Retired Reserve coverage for certain members of the Retired Reserve who are qualified for a non-regular retirement but are not yet age 60. ; and by striking the item relating to section 1079a and inserting the following new item: 1079a. TRICARE Program: treatment of refunds and other amounts collected. . With respect to cost-sharing requirements for covered beneficiaries under section 1079, 1086, or 1097 of title 10, United States Code, during the period beginning on October 1, 2017, and ending on 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 beginning on October 1, 2016, and ending on December 31, 2017. any catastrophic cap applicable during fiscal year 2017 shall apply for the 15-month period beginning on October 1, 2016, and ending on December 31, 2017. In this subsection, the term covered beneficiaries has the meaning given that term in section 1072 of such title. Except as provided in paragraph (2), this section and the amendments made by this section shall take effect on January 1, 2018. Subsection
(d)shall take effect on October 1, 2017.