10 U.S.C. § 1097 — Contracts for medical care for retirees,

Page 1151 TITLE 10—ARMED FORCES § 1097 ‘‘(B) urgent care; and ‘‘(C) through telehealth appointments, when ap- propriate; ‘‘(7) encourage patients to participate in making health care decisions; ‘‘(8) use evidence-based treatment protocols that improve the consistency of health care and eliminate ineffective, wasteful health care practices; and ‘‘(9) improve coordination of behavioral health services with primary health care. ‘‘(c) AGREEMENTS.— ‘‘(1) IN GENERAL.—In establishing military-civilian integrated health delivery systems through partner- ships under subsection (a), the Secretary shall seek to enter into memoranda of understanding or con- tracts between military treatment facilities and health maintenance organizations, health care cen- ters of excellence, public or private academic medical institutions, regional health organizations, inte- grated health systems, accountable care organiza- tions, and such other health systems as the Secretary considers appropriate. ‘‘(2) PRIVATE SECTOR CARE.—Memoranda of under- standing and contracts entered into under paragraph (1) shall ensure that covered beneficiaries are eligible to enroll in and receive medical services under the private sector components of military-civilian inte- grated health delivery systems established under sub- section (a). ‘‘(3) VALUE-BASED REIMBURSEMENT METHODOLO- GIES.—The Secretary shall incorporate value-based reimbursement methodologies, such as capitated pay- ments, bundled payments, or pay for performance, into memoranda of understanding and contracts en- tered into under paragraph (1) to reimburse entities for medical services provided to covered beneficiaries under such memoranda of understanding and con- tracts. ‘‘(4) QUALITY OF CARE.—Each memorandum of un- derstanding or contract entered into under paragraph (1) shall ensure that the quality of services received by covered beneficiaries through a military-civilian integrated health delivery system under such memo- randum of understanding or contract is at least com- parable to the quality of services received by covered beneficiaries from a military treatment facility. ‘‘(d) COVERED BENEFICIARY DEFINED.—In this section, the term ‘covered beneficiary’ has the meaning given that term in section 1072 of title 10, United States Code.’’ § 1097. Contracts for medical care for retirees, dependents, and survivors: alternative deliv- ery of health care (a) IN GENERAL.—The Secretary of Defense, after consulting with the other administering Secretaries, may contract for the delivery of health care to which covered beneficiaries are entitled under this chapter. The Secretary may enter into a contract under this section with any of the following: (1) Health maintenance organizations. (2) Preferred provider organizations. (3) Individual providers, individual medical facilities, or insurers. (4) Consortiums of such providers, facilities, or insurers. (b) SCOPE OF COVERAGE UNDER HEALTH CARE PLANS.—A contract entered into under this sec- tion may provide for the delivery of— (1) selected health care services; (2) total health care services for selected covered beneficiaries; or (3) total health care services for all covered beneficiaries who reside in a geographical area designated by the Secretary. (c) COORDINATION WITH FACILITIES OF THE UNI- FORMED SERVICES.—The Secretary of Defense may provide for the coordination of health care services provided pursuant to any contract or agreement under this section with those serv- ices provided in medical treatment facilities of the uniformed services. Subject to the avail- ability of space and facilities and the capabili- ties of the medical or dental staff, the Secretary may not deny access to facilities of the uni- formed services to a covered beneficiary on the basis of whether the beneficiary enrolled or de- clined enrollment in any program established under, or operating in connection with, any con- tract under this section. Notwithstanding the preferences established by sections 1074(b) and 1076 of this title, the Secretary shall, as an in- centive for enrollment, establish reasonable preferences for services in facilities of the uni- formed services for covered beneficiaries en- rolled in any program established under, or op- erating in connection with, any contract under this section. (d) COORDINATION WITH OTHER HEALTH CARE PROGRAMS.—In the case of a covered beneficiary who is enrolled in a managed health care pro- gram not operated under the authority of this chapter, the Secretary may contract under this section with such other managed health care program for the purpose of coordinating the beneficiary’s dual entitlements under such pro- gram and this chapter. A managed health care program with which arrangements may be made under this subsection includes any health main- tenance organization, competitive medical plan, health care prepayment plan, or other managed care program recognized pursuant to regulations issued by the Secretary. (e) CHARGES FOR HEALTH CARE.—(1) The Sec- retary of Defense may prescribe by regulation a premium, deductible, copayment, or other charge for health care provided under this sec- tion. In the case of contracts for health care services under this section or health care plans offered under section 1099 of this title for which the Secretary permits covered beneficiaries who are covered by section 1086 of this title and who participate in such contracts or plans to pay an enrollment fee in lieu of meeting the applicable deductible amount specified in section 1086(b) of this title, the Secretary may establish the same (or a lower) enrollment fee for covered bene- ficiaries described in section 1086(d)(1) of this title who also participate in such contracts or plans. Without imposing additional costs on cov- ered beneficiaries who participate in contracts for health care services under this section or health care plans offered under section 1099 of this title, the Secretary shall permit such cov- ered beneficiaries to pay, on a quarterly basis, any enrollment fee required for such participa- tion. Except as provided by paragraph (2), a pre- mium, deductible, copayment, or other charge prescribed by the Secretary under this sub- section may not be increased during the period beginning on April 1, 2006, and ending on Sep- tember 30, 2011. (2) Beginning October 1, 2012, the Secretary of Defense may only increase in any year the an- nual enrollment fees described in paragraph (1) by an amount equal to the percentage by which Page 1152 TITLE 10—ARMED FORCES § 1097a retired pay is increased under section 1401a of this title. (Added Pub. L. 99–661, div. A, title VII, § 701(a)(1), Nov. 14, 1986, 100 Stat. 3895; amended Pub. L. 103–337, div. A, title VII, §§ 713, 714(a), Oct. 5, 1994, 108 Stat. 2802; Pub. L. 104–106, div. A, title VII, §§ 712, 713, Feb. 10, 1996, 110 Stat. 374; Pub. L. 109–364, div. A, title VII, § 704(a), Oct. 17, 2006, 120 Stat. 2280; Pub. L. 110–181, div. A, title VII, § 701(a), Jan. 28, 2008, 122 Stat. 187; Pub. L. 110–417, [div. A], title VII, § 701(a), Oct. 14, 2008, 122 Stat. 4498; Pub. L. 111–383, div. A, title VII, § 701(a), Jan. 7, 2011, 124 Stat. 4244; Pub. L. 112–81, div. A, title VII, § 701(a), Dec. 31, 2011, 125 Stat. 1469.) Editorial Notes AMENDMENTS 2011—Subsec. (e). Pub. L. 112–81 designated existing provisions as par. (1), substituted ‘‘Except as provided by paragraph (2), a premium,’’ for ‘‘A premium,’’, and added par. (2). Subsec. (e). Pub. L. 111–383 substituted ‘‘September 30, 2011’’ for ‘‘September 30, 2009’’. 2008—Subsec. (e). Pub. L. 110–417 substituted ‘‘Sep- tember 30, 2009’’ for ‘‘September 30, 2008’’. Pub. L. 110–181 substituted ‘‘September 30, 2008’’ for ‘‘September 30, 2007’’. 2006—Subsec. (e). Pub. L. 109–364 inserted at end ‘‘A premium, deductible, copayment, or other charge pre- scribed by the Secretary under this subsection may not be increased during the period beginning on April 1, 2006, and ending on September 30, 2007.’’ 1996—Subsec. (c). Pub. L. 104–106, § 712, substituted ‘‘Notwithstanding the preferences established by sec- tions 1074(b) and 1076 of this title, the Secretary shall’’ for ‘‘However, the Secretary may’’. Subsec. (e). Pub. L. 104–106, § 713, inserted at end ‘‘Without imposing additional costs on covered bene- ficiaries who participate in contracts for health care services under this section or health care plans offered under section 1099 of this title, the Secretary shall per- mit such covered beneficiaries to pay, on a quarterly basis, any enrollment fee required for such participa- tion.’’ 1994—Subsec. (c). Pub. L. 103–337, § 714(a)(2), added subsec. (c). Former subsec. (c) redesignated (e). Pub. L. 103–337, § 713, inserted at end ‘‘In the case of contracts for health care services under this section or health care plans offered under section 1099 of this title for which the Secretary permits covered beneficiaries who are covered by section 1086 of this title and who participate in such contracts or plans to pay an enroll- ment fee in lieu of meeting the applicable deductible amount specified in section 1086(b) of this title, the Secretary may establish the same (or a lower) enroll- ment fee for covered beneficiaries described in section 1086(d)(1) of this title who also participate in such con- tracts or plans.’’ Subsecs. (d), (e). Pub. L. 103–337, § 714(a), added subsec. (d) and redesignated former subsec. (c) as (e). Statutory Notes and Related Subsidiaries CLARIFICATION OF APPLICATION FOR FISCAL YEAR 2013 Pub. L. 112–81, div. A, title VII, § 701(b), Dec. 31, 2011, 125 Stat. 1469, provided that: ‘‘The Secretary of Defense shall determine the maximum enrollment fees for TRICARE Prime under section 1097(e)(2) of title 10, United States Code, as added by subsection (a), for fis- cal year 2013 and thereafter as if the enrollment fee for each enrollee during fiscal year 2012 was the amount charged to an enrollee who enrolled for the first time during such fiscal year.’’ § 1097a. TRICARE Prime: automatic enrollments (a) AUTOMATIC ENROLLMENT OF CERTAIN DE- PENDENTS.—(1) In the case of a dependent of a member of the uniformed services who is enti- tled to medical and dental care under section 1076(a)(2)(A) of this title and resides in a catchment area in which TRICARE Prime is of- fered, the Secretary— (A) shall automatically enroll the dependent in TRICARE Prime if the member is in pay grade E–4 or below; and (B) may automatically enroll the dependent in TRICARE Prime if the member is in pay grade E–5 or higher. (2) Whenever a dependent of a member is en- rolled in TRICARE Prime under paragraph (1), the Secretary concerned shall provide written notice of the enrollment to the member. (3) The enrollment of a dependent of the mem- ber may be terminated by the member or the de- pendent at any time. (b) AUTOMATIC RENEWAL OF ENROLLMENTS OF COVERED BENEFICIARIES.—An enrollment of a covered beneficiary in TRICARE Prime shall be automatically renewed upon the expiration of the enrollment unless the renewal is declined. (c) REGULATIONS AND EXCEPTIONS.—The Sec- retary of Defense shall prescribe regulations, in- cluding procedures, to carry out this section. Regulations prescribed to carry out the auto- matic enrollment requirements under this sec- tion may include such exceptions to the auto- matic enrollment procedures as the Secretary determines appropriate for the effective oper- ation of TRICARE Prime. (d) NO COPAYMENT FOR IMMEDIATE FAMILY.—No copayment shall be charged a member for care provided under TRICARE Prime to a dependent of a member of the uniformed services described in subparagraph (A), (D), or (I) of section 1072(2) of this title. (e) AUTHORITY FOR MULTIPLE NETWORKS IN THE SAME GEOGRAPHIC AREA.—(1) The Secretary may establish a system of multiple networks of pro- viders under TRICARE Prime in the same geo- graphic area or areas. (2) Under a system established under para- graph (1), the Secretary may require a covered beneficiary enrolling in TRICARE Prime to en- roll in a specific provider network established pursuant to such system, in which case any pro- vider not in that specific provider network shall be deemed an out-of-network provider with re- spect to the covered beneficiary (regardless of whether the provider is in a different TRICARE Prime provider network) for purposes of this section or any other provision of law limiting the coverage or provision of health care services to those provided by network providers under the TRICARE program. (f) DEFINITIONS.—In this section: (1) The term ‘‘TRICARE Prime’’ means the managed care option of the TRICARE pro- gram. (2) The term ‘‘catchment area’’, with respect to a facility of a uniformed service, means the service area of the facility, as designated under regulations prescribed by the admin- istering Secretaries. (Added Pub. L. 105–261, div. A, title VII, § 712(a)(1), Oct. 17, 1998, 112 Stat. 2058; amended