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10 U.S.C. § 1095 — Health care services incurred on behalf of covered beneficiaries: collection from third-party payers
Federal law — U.S. Code and appendices · legal_authorities
**(a)**
(1) In the case of a person who is a covered beneficiary, the United States shall have the right to collect from a third-party payer reasonable charges for health care services incurred by the United States on behalf of such person through a facility of the uniformed services to the extent that the person would be eligible to receive reimbursement or indemnification from the third-party payer if the person were to incur such charges on the person’s own behalf. If the insurance, medical service, or health plan of that payer includes a requirement for a deductible or copayment by the beneficiary of the plan, then the amount that the United States may collect from the third-party payer is a reasonable charge for the care provided less the appropriate deductible or copayment amount.
(2) A covered beneficiary may not be required to pay an additional amount to the United States for health care services by reason of this section.
**(b)** No provision of any insurance, medical service, or health plan contract or agreement having the effect of excluding from coverage or limiting payment of charges for certain care shall operate to prevent collection by the United States under subsection (a) if that care is provided—
(1) through a facility of the uniformed services;
(2) directly or indirectly by a governmental entity;
(3) to an individual who has no obligation to pay for that care or for whom no other person has a legal obligation to pay; or
(4) by a provider with which the third party payer has no participation agreement.
**(c)** Under regulations prescribed under subsection (f), records of the facility of the uniformed services that provided health care services to a beneficiary of an insurance, medical service, or health plan of a third-party payer shall be mad
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Stable record: federal_law:legal_authorities:record_usc_420048ca889c2d814a13e0e9
Source file: Laws/federal/codes/united-states-code/title-10/section-1095-health-care-services-incurred-on-behalf-of-covered-beneficiaries-collect--4759444ad9.md
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Source location: Title 10, Chapter 55, § 1095; chapter-055-medical-and-dental-care.md
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**(a)**
(1) In the case of a person who is a covered beneficiary, the United States shall have the right to collect from a third-party payer reasonable charges for health care services incurred by the United States on behalf of such person through a facility of the uniformed services to the extent that the person would be eligible to receive reimbursement or indemnification from the third-party payer if the person were to incur such charges on the person’s own behalf. If the insurance, medical service, or health plan of that payer includes a requirement for a deductible or copayment by the beneficiary of the plan, then the amount that the United States may collect from the third-party payer is a reasonable charge for the care provided less the appropriate deductible or copayment amount.
(2) A covered beneficiary may not be required to pay an additional amount to the United States for health care services by reason of this section.
**(b)** No provision of any insurance, medical service, or health plan contract or agreement having the effect of excluding from coverage or limiting payment of charges for certain care shall operate to prevent collection by the United States under subsection (a) if that care is provided—
(1) through a facility of the uniformed services;
(2) directly or indirectly by a governmental entity;
(3) to an individual who has no obligation to pay for that care or for whom no other person has a legal obligation to pay; or
(4) by a provider with which the third party payer has no participation agreement.
**(c)** Under regulations prescribed under subsection (f), records of the facility of the uniformed services that provided health care services to a beneficiary of an insurance, medical service, or health plan of a third-party payer shall be made available for inspection and review by representatives of the payer from which collection by the United States is sought.
**(d)** Notwithstanding subsections (a) and (b), and except as provided in subsection (j), collection may not be made under this section in the case of a plan administered under title XVIII or XIX of the Social Security Act ([42 U.S.C. 1395](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395&num=0&edition=prelim) et seq.).
**(e)**
(1) The United States may institute and prosecute legal proceedings against a third-party payer to enforce a right of the United States under this section.
(2) The administering Secretary may compromise, settle, or waive a claim of the United States under this section.
**(f)** The Secretary of Defense, in consultation with the other administering Secretaries, shall prescribe regulations for the administration of this section. Such regulations shall provide for computation of the reasonable cost of health care services. Computation of such reasonable cost may be based on—
(1) per diem rates;
(2) all-inclusive per visit rates;
(3) diagnosis-related groups; or
(4) such other method as may be appropriate.
**(g)** Amounts collected under this section from a third-party payer or under any other provision of law from any other payer for health care services provided at or through a facility of the uniformed services shall be credited to the appropriation supporting the maintenance and operation of the facility and shall not be taken into consideration in establishing the operating budget of the facility.
**(h)** In this section:
(1) The term “third-party payer” means an entity that provides an insurance, medical service, or health plan by contract or agreement, including an automobile liability insurance or no fault insurance carrier, and any other plan or program that is designed to provide compensation or coverage for expenses incurred by a beneficiary for health care services or products. Such term also includes entities described in subsection (j) under the terms and to the extent provided in such subsection.
(2) The term “insurance, medical service, or health plan” includes a preferred provider organization, an insurance plan described as Medicare supplemental insurance, and a personal injury protection plan or medical payments benefit plan for personal injuries resulting from the operation of a motor vehicle.
(3) The term “health care services” includes products provided or purchased through a facility of the uniformed services.
**(i)**
(1) In the case of a third-party payer that is an automobile liability insurance or no fault insurance carrier, the right of the United States to collect under this section shall extend to health care services provided to a person entitled to health care under [section 1074(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title10-section1074/a&num=0&edition=prelim).
(2) In cases in which a tort liability is created upon some third person, collection from a third-party payer that is an automobile liability insurance carrier shall be governed by the provisions of Public Law 87–693 ([42 U.S.C. 2651](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2651&num=0&edition=prelim) et seq.).
**(j)** The Secretary of Defense may enter into an agreement with any health maintenance organization, competitive medical plan, health care prepayment plan, or other similar plan (pursuant to regulations issued by the Secretary) providing for collection under this section from such organization or plan for services provided to a covered beneficiary who is an enrollee in such organization or plan.
**(k)**
(1) To improve the administration of this section and sections 1079(j)(1) 11 See References in Text note below. and 1086(d) of this title, the Secretary of Defense, in consultation with the other administering Secretaries, may prescribe regulations providing for the collection of information regarding insurance, medical service, or health plans of third-party payers held by covered beneficiaries.
(2) The collection of information under regulations prescribed under paragraph (1) shall be conducted in the same manner as is provided in section 1862(b)(5) of the Social Security Act ([42 U.S.C. 1395y(b)(5)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/b/5&num=0&edition=prelim)). The Secretary may provide for obtaining from the Commissioner of Social Security employment information comparable to the information provided to the Administrator of the Centers for Medicare & Medicaid Services pursuant to such section. Such regulations may require the mandatory disclosure of Social Security account numbers for all covered beneficiaries.
(3) The Secretary may disclose relevant employment information collected under this subsection to fiscal intermediaries or other designated contractors.
(4) The Secretary may provide for contacting employers of covered beneficiaries to obtain group health plan information comparable to the information authorized to be obtained under section 1862(b)(5)(C) of the Social Security Act ([42 U.S.C. 1395y(b)(5)(C)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/b/5/C&num=0&edition=prelim)). Notwithstanding clause (iii) of such section, clause (ii) of such section regarding the imposition of civil money penalties shall apply to the collection of information under this paragraph.
(5) Information obtained under this subsection may not be disclosed for any purpose other than to carry out the purpose of this section and sections 1079(j)(1) 1 and 1086(d) of this title.
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Conditions; exceptions; persons liable; amount of recovery; subrogation; assignment** In any case in which the United States is authorized or required by law to furnish or pay for hospital, medical, surgical, or dental care and treatment (including prostheses and medical appliances) to a person who is injured or suffers a disease, after the effective date of this Act, under circumstances creating a tort liability upon some third person (other than or in addition to the United States and except employers of seamen treated under the provisions of [section 249 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section249&num=0&edition=prelim)) to pay damages therefor, the United States shall have a right to recover (independent of the rights of the injured or diseased person) from said third person, or that person’s insurer, the reasonable value of the care and treatment so furnished, to be furnished, paid for, or to be paid for and shall, as to this right be subrogated to any right or claim that the injured or diseased person, his guardian, personal representative, estate, dependents, or survivors has against such third person to the extent of the reasonable value of the care and treatment so furnished, to be furnished, paid for, or to be paid for. The head of the department or agency of the United States furnishing such care or treatment may also require the injured or diseased person, his guardian, personal representative, estate, dependents, or survivors, as appropriate, to assign his claim or cause of action against the third person to the extent of that right or claim.
**(b) Recovery of cost of pay for member of uniformed services unable to perform duties** If a member of the uniformed services is injured, or contracts a diseas
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 2651
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Federal law — U.S. Code and appendices · legal_authorities
**(a)** Under regulations prescribed by the President, the Secretary concerned shall pay (by advancement or reimbursement) any person who is a former captive, and any dependent of that person or of a person who is in a captive status, for health care and other expenses related to such care, to the extent that such care—
(1) is incident to the captive status; and
(2) is not covered—
(A) by any other Government medical or health program; or
(B) by insurance.
**(b)** In the case of any person who is eligible for medical care under section 1074 or 1076 of this title, such regulations shall require that, whenever practicable, such care be provided in a facility of the uniformed services.
**(c)** In this section:
(1) The terms “captive status” and “former captive” have the meanings given those terms in [section 559 of title 37](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title37-section559&num=0&edition=prelim).
(2) The term “dependent” has the meaning given that term in section 551 of that title.
Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1095a
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Federal law — U.S. Code and appendices · legal_authorities
This chapter may be cited as the “Social Security Act”.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1305
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Conditions of participation; protection of individual rights; notification of State entities; use of home health aides; medical equipment; individual’s plan of care; compliance with Federal, State, and local laws and regulations** The conditions of participation that a home health agency is required to meet under this subsection are as follows:
(1) The agency protects and promotes the rights of each individual under its care, including each of the following rights:
(A) The right to be fully informed in advance about the care and treatment to be provided by the agency, to be fully informed in advance of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being, and (except with respect to an individual adjudged incompetent) to participate in planning care and treatment or changes in care or treatment.
(B) The right to voice grievances with respect to treatment or care that is (or fails to be) furnished without discrimination or reprisal for voicing grievances.
(C) The right to confidentiality of the clinical records described in section 1395x(o)(3) of this title.
(D) The right to have one’s property treated with respect.
(E) The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of—
(i) all items and services furnished by (or under arrangements with) the agency for which payment may be made under this subchapter,
(ii) the coverage available for such items and services under this subchapter, subchapter XIX, and any other Federal program of which the agency is reasonably aware,
(iii) any charges for items and services not covered under this subchapter and any charges the individual may have to pay with respect to items and services furn
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395
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Federal law — U.S. Code and appendices · legal_authorities
The purpose of this chapter is to create and maintain high morale in the uniformed services by providing an improved and uniform program of medical and dental care for members and certain former members of those services, and for their dependents.
Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1071
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Eligibility.—**
(1) Except as provided in paragraph (2), a member of the Selected Reserve of the Ready Reserve of a reserve component of the armed forces is eligible for health benefits under TRICARE Reserve Select as provided in this section.
(2) During the period preceding January 1, 2030, paragraph (1) does not apply to a member who is enrolled, or is eligible to enroll, in a health benefits plan under chapter 89 of title 5.
**(b) Termination of Eligibility Upon Termination of Service.—**
(1) Except as provided in paragraph (2), eligibility for TRICARE Reserve Select coverage of a member under this section shall terminate upon the termination of the member’s service in the Selected Reserve.
(2) During the period beginning on the date of the enactment of this paragraph and ending December 31, 2018, eligibility for a member under this section who is involuntarily separated from the Selected Reserve under other than adverse conditions, as characterized by the Secretary concerned, shall terminate 180 days after the date on which the member is separated.
**(c) Family Members.—** While a member of a reserve component is covered by TRICARE Reserve Select under the section, the members of the immediate family of such member are eligible for TRICARE Reserve Select coverage as dependents of the member. If a member of a reserve component dies while in a period of coverage under this section, the eligibility of the members of the immediate family of such member for TRICARE Reserve Select coverage shall continue for three years beyond the date of death of the member.
**(d) Premiums.—**
(1) A member of a reserve component covered by TRICARE Reserve Select under this section shall pay a premium for that coverage. Such premium shall apply instead of any enrollment fees
Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1076d
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Payment of Claims.—**
(1) The Secretary of Defense may authorize a contractor under the TRICARE program to pay a claim described in paragraph (2) before seeking to recover from a third-party payer the costs incurred by the contractor to provide health care services that are the basis of the claim to a beneficiary under such program.
(2) A claim under this paragraph is a claim—
(A) that is submitted to the contractor by a provider under the TRICARE program for payment for services for health care provided to a covered beneficiary; and
(B) that is identified by the contractor as a claim for which a third-party payer may be liable.
**(b) Recovery From Third-Party Payers.—** The United States shall have the same right to collect charges related to claims described in subsection (a) as charges for claims under [section 1095 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title10-section1095&num=0&edition=prelim).
**(c) Definition of Third-Party Payer.—** In this section, the term “third-party payer” has the meaning given that term in [section 1095(h) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title10-section1095/h&num=0&edition=prelim), except that such term excludes primary medical insurers.
Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1095b
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Reduction of Processing Time.—**
(1) With respect to claims for payment for medical care provided under the TRICARE program, the Secretary of Defense shall implement a system for processing of claims under which—
(A) 95 percent of all clean claims must be processed not later than 30 days after the date that such claims are submitted to the claims processor; and
(B) 100 percent of all clean claims must be processed not later than 100 days after the date that such claims are submitted to the claims processor.
(2) The Secretary may, under the system required by paragraph (1) and consistent with the provisions in chapter 39 of title 31 (commonly referred to as the “Prompt Payment Act”), require that interest be paid on clean claims that are not processed within 30 days.
(3) For purposes of this subsection, the term “clean claim” means a claim that has no defect, impropriety (including a lack of any required substantiating documentation), or particular circumstance requiring special treatment that prevents timely payment on the claim under this section.
**(b) Requirement to Provide Start-Up Time For Certain Contractors.—**
(1) Except as provided in paragraph (3), the Secretary of Defense shall not require that a contractor described in paragraph (2) begin to provide managed care support pursuant to a contract to provide such support under the TRICARE program until at least nine months after the date of the award of the contract, but in no case later than one year after the date of such award.
(2) A contractor under this paragraph is a contractor who is awarded a contract to provide managed care support under the TRICARE program—
(A) who has not previously been awarded such a contract by the Department of Defense; or
(B) who has previously been awarded
Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1095c
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Reimbursement of Providers.—**
(1) Subject to paragraph (2), the Secretary of Defense may reimburse health care providers under the TRICARE program at rates higher than the reimbursement rates otherwise authorized for the providers under that program if the Secretary determines that application of the higher rates is necessary in order to ensure the availability of an adequate number of qualified health care providers under that program.
(2) The amount of reimbursement provided under paragraph (1) with respect to a health care service may not exceed the lesser of the following:
(A) The amount equal to the local fee for service charge for the service in the service area in which the service is provided as determined by the Secretary based on one or more of the following payment rates:
(i) Usual, customary, and reasonable.
(ii) The Health Care Finance Administration’s Resource Based Relative Value Scale.
(iii) Negotiated fee schedules.
(iv) Global fees.
(v) Sliding scale individual fee allowances.
(B) The amount equal to 115 percent of the CHAMPUS maximum allowable charge for the service.
(3) In establishing rates and procedures for reimbursement of providers and other administrative requirements, including those contained in provider network agreements, the Secretary shall, to the extent practicable, maintain adequate networks of providers, including institutional, professional, and pharmacy. For the purpose of determining whether network providers under such provider network agreements are subcontractors for purposes of the Federal Acquisition Regulation or any other law, a TRICARE managed care support contract that includes the requirement to establish, manage, or maintain a network of providers may not be considered to be a cont
Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1097b
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Federal law — U.S. Code and appendices · legal_authorities
**(a)** For the purpose of this section—
(1) “captive” means any individual in a captive status commencing while such individual is—
(A) in the Civil Service, or
(B) a citizen, national, or resident alien of the United States rendering personal service to the United States similar to the service of an individual in the Civil Service (other than as a member of the uniformed services);
(2) “captive status” means a missing status which, as determined by the President, arises because of a hostile action and is a result of the individual’s relationship with the Government;
(3) “missing status”—
(A) in the case of an employee, has the meaning provided under [section 5561(5) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section5561/5&num=0&edition=prelim); and
(B) in the case of an individual other than an employee, has a similar meaning; and
(4) “family member”, as used with respect to a person, means—
(A) any dependent of such person; and
(B) any individual (other than a dependent under subparagraph (A)) who is a member of such person’s family or household.
**(b)**
(1) The Secretary of the Treasury shall establish a savings fund to which the head of an agency may allot all or any portion of the pay and allowances of any captive to the extent that such pay and allowances are not subject to an allotment under [section 5563 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section5563&num=0&edition=prelim) or any other provision of law.
(2) Amounts so allotted to the savings fund shall bear interest at a rate which, for any calendar quarter, shall be equal to the average rate paid on United States Treasury bills with 3-month maturities issued during the preceding calendar quarter. Suc
Source: Supplied U.S. Code snapshot — release unconfirmed · 5 U.S.C. § 5569
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