§1097b TRICARE program: financial management

Summary

The Secretary of Defense may pay TRICARE health providers more than the usual rates if doing so is needed to keep enough qualified providers available. Any higher payment cannot be more than the lesser of (1) the local fee‑for‑service amount for the area, as the Secretary determines using methods like usual/customary/reasonable rates, the Resource Based Relative Value Scale, negotiated fee schedules, global fees, or sliding‑scale fees; or (2) 115 percent of the CHAMPUS maximum allowable charge. When setting payment rules and provider agreements, the Secretary must try to keep adequate networks of hospitals, doctors, and pharmacies. A TRICARE managed care support contract that requires building or managing a network is not treated as a contract for performing health care when deciding subcontractor status under the Federal Acquisition Regulation or other laws. Military medical treatment facilities have the same right as the United States under section 1095 to collect reasonable charges from third‑party payers for care given to covered TRICARE beneficiaries. The Secretary must write rules showing how to compute those reasonable charges for inpatient, outpatient, and other services. Those rules may use methods such as per diem rates, all‑inclusive visit rates, diagnosis‑related groups, the rates under regulations for sections 1079 and 1086, or other appropriate methods. The Secretary must consult the other administering Secretaries when carrying out these duties.