§1097b Tricare Program: Financial Management

Summary

The Secretary of Defense can pay TRICARE health providers more than the usual rates when needed to make sure enough qualified providers are available. Any higher payment cannot be more than either the local fee‑for‑service rate (set using methods like usual/customary/reasonable amounts, the RBRVS, negotiated fee schedules, global fees, or sliding‑scale fees) or 115 percent of the CHAMPUS maximum allowable charge, whichever is less. When setting rates and rules, the Secretary must, as much as possible, keep provider networks strong (hospitals, doctors, pharmacies). A TRICARE managed care contract that requires building or running a network cannot be treated as a contract for providing health care services when deciding if network providers are subcontractors 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 TRICARE beneficiaries. The Secretary must write rules for how to compute those reasonable charges for inpatient, outpatient, and other services. The rules may use methods such as per diem rates, all‑inclusive visit fees, diagnosis‑related groups, rates under rules for sections 1079 and 1086, or other suitable methods. The Secretary must consult the other administering Secretaries when carrying out these responsibilities.