PRIA, Government Policy, Made Personal

Summary

The Secretary of Defense may make contracts to provide health care for people entitled to care under this chapter, after talking with the other military service secretaries. Contracts can be made with health maintenance organizations, preferred provider organizations, individual doctors or medical facilities or insurers, or groups of those providers. A contract can cover some services only, all services for certain eligible people, or all services for everyone who lives in a geographic area the Secretary picks. The Secretary may make these contracted services work together with care at military hospitals and clinics. If space, facilities, and staff allow, the Secretary cannot bar someone from using a military facility just because they joined or did not join a contracted program. The Secretary may give reasonable priority for care at military facilities to people who enroll in such programs as an incentive. The Secretary may also arrange with other managed care programs (for example HMOs or similar plans) to coordinate benefits when someone is covered by both programs. The Secretary can set premiums, deductibles, copayments, enrollment fees, or other charges. For certain beneficiaries covered by section 1086, an enrollment fee may be allowed instead of the deductible, and the fee for those in section 1086(d)(1) may be the same or lower. Enrollment fees may be paid quarterly without extra cost. Charges may not be raised from April 1, 2006, through September 30, 2011. Starting October 1, 2012, yearly increases in enrollment fees may only match the percentage increase in retired pay under section 1401a.

Title 10, §1097

Armed Forces, Source: USLM XML via OLRC

(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 section may provide for the delivery of— (1)

(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 Uniformed 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 services provided in medical treatment facilities of the uniformed services. Subject to the availability of space and facilities and the capabilities of the medical or dental staff, the Secretary may not deny access to facilities of the uniformed services to a covered beneficiary on the basis of whether the beneficiary enrolled or declined enrollment in any program established under, or operating in connection with, any contract under this section. Notwithstanding the preferences established by section 1074(b) and 1076 of this title, the Secretary shall, as an incentive for enrollment, establish reasonable preferences for services in facilities of the uniformed services for covered beneficiaries enrolled in any program established under, or operating 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 program 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 program and this chapter. A managed health care program with which arrangements may be made under this subsection includes any health maintenance 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 Secretary of Defense may prescribe by regulation a premium, deductible, copayment, or other charge for health care provided under this section. 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 beneficiaries described in section 1086(d)(1) of this title who also participate in such contracts or plans. Without imposing additional costs on covered 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 covered beneficiaries to pay, on a quarterly basis, any enrollment fee required for such participation. Except as provided by paragraph (2), a premium, deductible, copayment, or other charge prescribed by the Secretary under this subsection may not be increased during the period beginning on April 1, 2006, and ending on September 30, 2011.

(2)Beginning October 1, 2012, the Secretary of Defense may only increase in any year the annual enrollment fees described in paragraph (1) by an amount equal to the percentage by which retired pay is increased under section 1401a of this title.

Notes & Related Subsidiaries

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 “

September 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 prescribed 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 section 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 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 covered beneficiaries to pay, on a quarterly basis, any enrollment fee required for such participation.” 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 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 beneficiaries described in section 1086(d)(1) of this title who also participate in such contracts 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 fiscal 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.”

§1097 Contracts for Medical Care for Retirees, Dependents, and Survivors: Alternative Delivery of Health Care