§1097b Tricare Program: Financial Management

Summary

The Secretary of Defense may pay TRICARE health care providers more than the usual rates when needed to keep enough qualified providers available. Any higher payment cannot be more than the smaller of two amounts: the local fee for the service as set by the Secretary using one or more payment methods (usual, customary, and reasonable; the Health Care Finance Administration’s Resource Based Relative Value Scale; negotiated fee schedules; global fees; or sliding-scale fees), or 115 percent of the CHAMPUS maximum allowable charge. The Secretary must try to keep adequate networks of hospitals, doctors, and pharmacies. A TRICARE managed care support contract that only requires creating or running a network cannot be treated as a contract to provide health care services for purposes of procurement rules. Military medical facilities may collect from other payers the reasonable charges for care they give to TRICARE patients, with the same rights the United States has under law. The Secretary must write rules that explain how to compute those reasonable charges for inpatient, outpatient, and other services. The calculation may use per diem rates, all‑inclusive visit rates, diagnosis‑related groups, rates under rules for sections 1079 and 1086, or other appropriate methods. The Secretary must consult with the other administering Secretaries when doing this.