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10 U.S.C. § 1097b — TRICARE program: financial management
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
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Source location: Title 10, Chapter 55, § 1097b; chapter-055-medical-and-dental-care.md
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**(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 contract for the performance of health care services or supplies on the basis of such requirement.
**(b) Third-Party Collections.—**
(1) A medical treatment facility of the uniformed services under the TRICARE program has the same right as the United States under [section 1095 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title10-section1095&num=0&edition=prelim) to collect from a third-party payer the reasonable charges for health care services described in paragraph (2) that are incurred by the facility on behalf of a covered beneficiary under that program.
(2) The Secretary of Defense shall prescribe regulations for the administration of this subsection. The regulations shall set forth the method to be used for the computation of the reasonable charges for inpatient, outpatient, and other health care services. The method of computation may be—
(A) a method that is based on—
(i) per diem rates;
(ii) all-inclusive rates for each visit;
(iii) diagnosis-related groups; or
(iv) rates prescribed under the regulations implementing sections 1079 and 1086 of this title; or
(B) any other method considered appropriate.
**(c) Consultation Requirement.—** The Secretary of Defense shall carry out the responsibilities under this section after consultation with the other administering Secretaries.
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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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Federal law — U.S. Code and appendices · legal_authorities
Page 1154
TITLE 10—ARMED FORCES
§ 1097b
‘‘(ii) the number of eligible beneficiaries who
transferred their TRICARE Prime enrollment to
a more distant available Prime service area to re-
main in TRICARE Prime, by State;
‘‘(iii) the number of eligible beneficiaries who
were eligible to transfer to a more distant avail-
able Prime service area, but chose to use
TRICARE Standard;
‘‘(iv) the number of eligible beneficiaries who
elected to return to TRICARE Prime pursuant to
subsection (c)(1); and
‘‘(v) the number of affected eligible bene-
ficiaries who, as of the date of the report, changed
residences to remain eligible for TRICARE Prime
in a new region.
‘‘(B) An estimate of the increased annual costs
per affected eligible beneficiary incurred by such
beneficiary for health care under the TRICARE pro-
gram.
‘‘(C) A description of the efforts of the Depart-
ment to assess the impact on access to health care
and beneficiary satisfaction for affected eligible
beneficiaries.
‘‘(D) A description of the estimated cost savings
realized by reducing the availability of TRICARE
Prime in regions described in subsection (d)(1)(B).
‘‘(c) ACCESS TO TRICARE PRIME.—
‘‘(1) ONE-TIME ELECTION.—Subject to paragraph (3),
the Secretary shall ensure that each affected eligible
beneficiary who is enrolled in TRICARE Prime as of
September 30, 2013, may make a one-time election to
continue such enrollment in TRICARE Prime, not-
withstanding that a contract described in subsection
(a)(2)(A) does not allow for such enrollment based on
the location in which such beneficiary resides. The
beneficiary
may
continue
such
enrollment
in
TRICARE Prime so long as the beneficiary resides in
the same ZIP code as the ZIP code in which the bene-
ficiary resided at the time of such
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