§1079. Contracts for medical care for spouses and children: plans
(a) To assure that medical care is available for dependents, as described in subparagraphs (A), (D), and (I) of section 1072(2) of this title, of members of the uniformed services who are on active duty for a period of more than 30 days, the Secretary of Defense, after consulting with the other administering Secretaries, shall contract, under the authority of this section, for medical care for those persons under such insurance, medical service, or health plans as he considers appropriate. The types of health care authorized under this section shall be the same as those provided under section 1076 of this title, except that-
(1) with respect to dental care, only that care required as a necessary adjunct to medical or surgical treatment may be provided;
(2) routine physical examinations and immunizations of dependents over two years of age may only be provided when required in the case of dependents who are traveling outside the United States as a result of a member's duty assignment and such travel is being performed under orders issued by a uniformed service, except that pap smears and mammograms may be provided on a diagnostic or preventive basis;
(3) not more than one eye examination may be provided to a patient in any calendar year;
(4) under joint regulations to be prescribed by the administering Secretaries, the services of Christian Science practitioners and nurses and services obtained in Christian Science sanatoriums may be provided;
(5) durable equipment, such as wheelchairs, iron lungs and hospital beds may be provided on a rental basis;
(6) inpatient mental health services may not (except as provided in subsection (i)) be provided to a patient in excess of-
(A) 30 days in any year, in the case of a patient 19 years of age or older;
(B) 45 days in any year, in the case of a patient under 19 years of age; or
(C) 150 days in any year, in the case of inpatient mental health services provided as residential treatment care;
(7) services in connection with nonemergency inpatient hospital care may not be provided if such services are available at a facility of the uniformed services located within a 40-mile radius of the residence of the patient, except that those services may be provided in any case in which another insurance plan or program provides primary coverage for those services;
(8) services of pastoral counselors, family and child counselors, or marital counselors (other than certified marriage and family therapists) may not be provided unless the patient has been referred to the counselor by a medical doctor for treatment of a specific problem with the results of that treatment to be communicated back to the medical doctor who made the referral and services of certified marriage and family therapists may be provided consistent with such rules as may be prescribed by the Secretary of Defense, including credentialing criteria and a requirement that the therapists accept payment under this section as full payment for all services provided;
(9) special education may not be provided, except when provided as secondary to the active psychiatric treatment on an institutional inpatient basis;
(10) therapy or counseling for sexual dysfunctions or sexual inadequacies may not be provided;
(11) treatment of obesity may not be provided if obesity is the sole or major condition treated;
(12) surgery which improves physical appearance but is not expected to significantly restore functions (including mammary augmentation, face lifts, and sex gender changes) may not be provided, except that-
(A) breast reconstructive surgery following a mastectomy may be provided;
(B) reconstructive surgery to correct serious deformities caused by congenital anomalies or accidental injuries may be provided; and
(C) neoplastic surgery may be provided;
(13) any service or supply which is not medically or psychologically necessary to prevent, diagnose, or treat a mental or physical illness, injury, or bodily malfunction as assessed or diagnosed by a physician, dentist, clinical psychologist, certified marriage and family therapist, optometrist, podiatrist, certified nurse-midwife, certified nurse practitioner, or certified clinical social worker, as appropriate, may not be provided, except as authorized in paragraph (4);
(14) the prohibition contained in section 1077(b)(3) of this title shall not apply in the case of a member or former member of the uniformed services;
(15) electronic cardio-respiratory home monitoring equipment (apnea monitors) for home use may be provided if a physician prescribes and supervises the use of the monitor for an infant-
(A) who has had an apparent life-threatening event,
(B) who is a subsequent sibling of a victim of sudden infant death syndrome,
(C) whose birth weight was 1,500 grams or less, or
(D) who is a pre-term infant with pathologic apnea,
in which case the coverage may include the cost of the equipment, hard copy analysis of physiological alarms, professional visits, diagnostic testing, family training on how to respond to apparent life threatening events, and assistance necessary for proper use of the equipment;
(16) hospice care may be provided only in the manner and under the conditions provided in section 1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)); and
(17) the Secretary of Defense may establish a program for the individual case management of a person covered by this section or section 1086 of this title who has extraordinary medical or psychological disorders and, under such a program, may waive benefit limitations contained in paragraphs (5) and (13) of this subsection or section 1077(b)(1) of this title and authorize the payment for comprehensive home health care services, supplies, and equipment if the Secretary determines that such a waiver is cost-effective and appropriate.
(b) Plans covered by subsection (a) shall include provisions for payment by the patient of the following amounts:
(1) $25 for each admission to a hospital, or the amount the patient would have been charged under section 1078(a) of this title had the care being paid for been obtained in a hospital of the uniformed services, whichever amount is the greater. The Secretary of Defense may exempt a patient from paying such amount if the hospital to which the patient is admitted does not impose a legal obligation on any of its patients to pay for inpatient care.
(2) Except as provided in clause (3), the first $150 each fiscal year of the charges for all types of care authorized by subsection (a) and received while in an outpatient status and 20 percent of all subsequent charges for such care during a fiscal year. Notwithstanding the preceding sentence, in the case of a dependent of an enlisted member in a pay grade below E–5, the initial deductible each fiscal year under this paragraph shall be limited to $50.
(3) A family group of two or more persons covered by this section shall not be required to pay collectively more than the first $300 (or in the case of the family group of an enlisted member in a pay grade below E–5, the first $100) each fiscal year of the charges for all types of care authorized by subsection (a) and received while in an outpatient status and 20 percent of the additional charges for such care during a fiscal year.
(4) $25 for surgical care that is authorized by subsection (a) and received while in an outpatient status and that has been designated (under joint regulations to be prescribed by the administering Secretaries) as care to be treated as inpatient care for purposes of this subsection. Any care for which payment is made under this clause shall not be considered to be care received while in an outpatient status for purposes of clauses (2) and (3).
(5) An individual or family group of two or more persons covered by this section may not be required by reason of this subsection to pay a total of more than $1,000 for health care received during any fiscal year under a plan under subsection (a).
(c) The methods for making payment under subsection (b) shall be prescribed under joint regulations issued by the administering Secretaries.
(d) Under joint regulations to be prescribed by the administering Secretaries, in the case of a dependent, as described in subparagraph (A), (D), or (I) of section 1072(2) of this title, of a member of the uniformed services on active duty for a period of more than 30 days, who is moderately or severely mentally retarded or who has a serious physical handicap, the plans covered by subsection (a) shall, with respect to the retardation or handicap of such dependent, include the following:
(1) Diagnosis.
(2) Inpatient, outpatient, and home treatment.
(3) Training, rehabilitation, and special education.
(4) Institutional care in private nonprofit, public and State institutions and facilities and, when appropriate, transportation to and from such institutions and facilities.
(e) Members shall be required to share in the cost of any benefits provided their dependents under subsection (d) as follows:
(1) Except as provided in clause (3), members in the lowest enlisted pay grade shall be required to pay the first $25 incurred each month and members in the highest commissioned pay grade shall similarly be required to pay $250 per month. The amounts to be similarly paid by members in all other pay grades shall be determined under joint regulations to be prescribed by the administering Secretaries.
(2) Except as provided in clause (4), the Government's share of the cost of any benefits provided in a particular case under subsection (d) shall not exceed $1,000 per month.
(3) Members shall also be required to pay each month that amount, if any, remaining after the Government's maximum share has been reached.
(4) A member who has more than one dependent incurring expenses in a given month under a plan covered by subsection (d) shall not be required to pay an amount greater than he would be required to pay if he had but one such dependent.
(f) To qualify for the benefits provided by subsection (d), members shall be required to use public facilities to the extent they are available and adequate as determined under joint regulations of the administering Secretaries.
(g) When a member dies while he is eligible for receipt of hostile fire pay under section 310 of title 37 or from a disease or injury incurred while eligible for such pay, his dependents who are receiving benefits under a plan covered by subsection (d) shall continue to be eligible for such benefits until they pass their twenty-first birthday. In addition, when a member dies while on active duty for a period of more than 30 days, the member's dependents who are receiving benefits under a plan covered by subsection (a) shall continue to be eligible for such benefits during the one-year period beginning on the date of the death of the member.
(h)(1) Payment for a charge for services by an individual health-care professional (or other noninstitutional health-care provider) for which a claim is submitted under a plan contracted for under subsection (a) may be denied only to the extent that the charge exceeds the amount equivalent to the 80th percentile of billed charges made for similar services in the same locality during the base period.
(2) For the purposes of paragraph (1), the 80th percentile of charges shall be determined by the Secretary of Defense, in consultation with the other administering Secretaries, and the base period shall be a period of twelve calendar months. The Secretary of Defense shall adjust the base period as frequently as he considers appropriate.
(i)(1) The limitation in subsection (a)(6) does not apply in the case of inpatient mental health services-
(A) provided under the program for the handicapped under subsection (d);
(B) provided as partial hospital care; or
(C) provided pursuant to a waiver authorized by the Secretary of Defense because of medical or psychological circumstances of the patient that are confirmed by a health professional who is not a Federal employee after a review, pursuant to rules prescribed by the Secretary, which takes into account the appropriate level of care for the patient, the intensity of services required by the patient, and the availability of that care.
(2) Notwithstanding subsection (b) or section 1086(b) of this title, the Secretary of Defense (after consulting with the other administering Secretaries) may prescribe separate payment requirements (including deductibles, copayments, and catastrophic limits) for the provision of mental health services to persons covered by this section or section 1086 of this title. The payment requirements may vary for different categories of covered beneficiaries, by type of mental health service provided, and based on the location of the covered beneficiaries.
(3) Except in the case of an emergency, the Secretary of Defense shall require preadmission authorization before inpatient mental health services may be provided to persons covered by this section or section 1086 of this title. In the case of the provision of emergency inpatient mental health services, approval for the continuation of such services shall be required within 72 hours after admission.
(j)(1) A benefit may not be paid under a plan covered by this section in the case of a person enrolled in, or covered by, any other insurance, medical service, or health plan to the extent that the benefit is also a benefit under the other plan, except in the case of a plan administered under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).
(2)(A) The amount to be paid to a provider of services for services provided under a plan covered by this section may be determined under joint regulations to be prescribed by the administering Secretaries which provide that the amount of such payments shall be determined to the extent practicable in accordance with the same reimbursement rules as apply to payments to providers of services of the same type under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
(B) In subparagraph (A), the term "provider of services" means a hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program (as defined in section 1861(dd)(2) of the Social Security Act (42 U.S.C. 1395x(dd)(2))), or other institutional facility providing services for which payment may be made under a plan covered by this section.
(k) A plan covered by this section may include provision of liver transplants (including the cost of acquisition and transportation of the donated liver) in accordance with this subsection. Such a liver transplant may be provided if-
(1) the transplant is for a dependent considered appropriate for that procedure by the Secretary of Defense in consultation with the other administering Secretaries and such other entities as the Secretary considers appropriate; and
(2) the transplant is to be carried out at a health-care facility that has been approved for that purpose by the Secretary of Defense after consultation with the other administering Secretaries and such other entities as the Secretary considers appropriate.
(l)(1) Contracts entered into under subsection (a) shall also provide for medical care for dependents of former members of the uniformed services who are authorized to receive medical and dental care under section 1076(e) of this title in facilities of the uniformed services.
(2) Except as provided in paragraph (3), medical care in the case of a dependent described in section 1076(e) shall be furnished under the same conditions and subject to the same limitations as medical care furnished under this section to spouses and children of members of the uniformed services described in the first sentence of subsection (a).
(3) Medical care may be furnished to a dependent pursuant to paragraph (1) only for an injury, illness, or other condition described in section 1076(e) of this title.
(m)(1) Subject to paragraph (2), the Secretary of Defense may, upon request, make payments under this section for a charge for services for which a claim is submitted under a plan contracted for under subsection (a) to a hospital that does not impose a legal obligation on any of its patients to pay for such services.
(2) A payment under paragraph (1) may not exceed the average amount paid for comparable services in the geographic area in which the hospital is located or, if no comparable services are available in that area, in an area similar to the area in which the hospital is located.
(3) The Secretary of Defense shall periodically review the billing practices of each hospital the Secretary approves for payment under this subsection to ensure that the hospital's practices of not billing patients for payment are not resulting in increased costs to the Government.
(4) The Secretary of Defense may require each hospital the Secretary approves for payment under this subsection to provide evidence that it has sources of revenue to cover unbilled costs.
(n) The Secretary of Defense may enter into contracts (or amend existing contracts) with fiscal intermediaries under which the intermediaries agree to organize and operate, directly or through subcontractors, managed health care networks for the provision of health care under this chapter. The managed health care networks shall include cost containment methods, such as utilization review and contracting for care on a discounted basis.
(o)(1) Health care services provided pursuant to this section or section 1086 of this title (or pursuant to any other contract or project under the Civilian Health and Medical Program of the Uniformed Services) may not include services determined under the CHAMPUS Peer Review Organization program to be not medically or psychologically necessary.
(2) The Secretary of Defense, after consulting with the other administering Secretaries, may adopt or adapt for use under the CHAMPUS Peer Review Organization program, as the Secretary considers appropriate, any of the quality and utilization review requirements and procedures that are used by the Peer Review Organization program under part B of title XI of the Social Security Act (42 U.S.C. 1320c et seq.).
(Added
| Revised section | Source (U.S. Code) | Source (Statutes at Large) |
|---|---|---|
| 1079(a)
1079(b) |
37:402(a)(2) (as applicable to 37:411(a)). 37:411(a). 37:411(b). 37:414. |
June 7, 1956, ch. 374, §§102(a)(2) (as applicable to §201(a)), 201(a), (b), 204, |
In subsection (a), the words "appointed, enlisted, inducted or called, ordered or conscripted in a uniformed service", in 37:402(a)(2) are omitted as surplusage, since it does not matter how a member became a member. The words "active duty for a period of more than 30 days" are substituted for the words "active duty or active duty for training pursuant to a call or order that does not specify a period of thirty days or less", in 37:402(a)(2), to reflect section 101(22) and (23) of this title. The words ", under the authority of this section," are substituted for the words "pursuant to the provisions of this title" to make clear that the section provides independent procurement authority. The words "all", "by the hospital", and "a period of", in 37:411(a), are omitted as surplusage.
In subsection (a)(1), the word "rooms", in 37:411(a), is substituted for the word "accommodations".
In subsection (a)(5), the word "services" is substituted for the word "procedures" and the word "performed" is substituted for the word "accomplished", in 37: 411(a). The words "or surgeon" are inserted for clarity.
In subsection (b), the word "variances" is substituted for the words "limitations, additions, exclusions". The words "or care other than that provided for in sections 1076–1078 of this title" are substituted for 37:414. The words "definitions, and related provisions", in 37:411(b), are omitted as surplusage, since the Secretary of an executive department has inherent authority to interpret laws and issue regulations.
References in Text
The Social Security Act, referred to in subsecs. (j)(1), (2)(A) and (o)(2), is act Aug. 13, 1935, ch. 531,
Prior Provisions
Provisions similar to those in subsec. (a)(7) to (14) of this section were contained in the following appropriation acts, with the exception of the provisions similar to par. (14) which first appeared in
Provisions similar to those added to subsec. (h)(2) of this section by section 1401(e)(4)(B) of
A prior section 1079, act Aug. 10, 1956, ch. 1041,
Amendments
1994-Subsec. (a).
Subsec. (d).
Subsec. (g).
1993-Subsec. (a)(7).
"(A) those services may be provided in any case in which another insurance plan or program provides primary coverage for those services; and
"(B) the Secretary of Defense may waive the 40-mile radius restriction with regard to the provision of a particular service before October 1, 1993, if the Secretary determines that the use of a different geographical area restriction will result in a more cost-effective provision of the service;".
Subsec. (a)(15).
Subsec. (o).
1992-Subsec. (a)(15).
Subsec. (a)(16).
Subsec. (a)(17).
Subsec. (j)(2)(B).
1991-Subsec. (a)(6).
Subsec. (a)(7).
Subsec. (a)(13).
Subsec. (a)(14).
Subsec. (a)(15).
Subsec. (a)(16).
Subsec. (i).
Subsec. (j)(1).
Subsec. (j)(2)(B).
Subsec. (n).
1990-Subsec. (a)(2).
Subsec. (a)(6).
Subsec. (a)(8).
Subsec. (a)(13).
Subsec. (b)(2).
Subsec. (b)(3).
Subsec. (i).
"(1) provided under the program for the handicapped under subsection (d);
"(2) provided as residential treatment care;
"(3) provided as partial hospital care; or
"(4) provided pursuant to a waiver authorized by the Secretary of Defense because of extraordinary medical or psychological circumstances that are confirmed by review by a non-Federal health professional pursuant to regulations prescribed by the Secretary of Defense."
Subsec. (j)(2)(B).
1989-Subsec. (h)(1), (2).
1988-Subsec. (b)(1).
Subsec. (m).
1987-Subsec. (a)(15).
Subsec. (b)(5).
1986-Subsec. (a)(7).
Subsec. (l).
1984-Subsec. (a).
Subsec. (a)(3).
Subsec. (a)(4).
Subsec. (a)(7) to (14).
Subsecs. (b)(4), (c), (d).
Subsec. (e).
Subsecs. (e)(1), (f).
Subsec. (h)(2).
Subsec. (j)(2)(A).
Subsec. (k)(1), (2).
1983-Subsec. (a).
Subsec. (a)(6).
Subsec. (d).
Subsec. (g).
Subsecs. (i) to (k).
1981-Subsec. (b)(4).
Subsec. (h).
1980-Subsec. (a).
Subsec. (a)(2).
Subsec. (a)(3).
Subsec. (b)(4).
Subsec. (c).
Subsec. (d).
Subsec. (e).
Subsec. (e)(2).
Subsec. (f).
Subsec. (g).
Subsec. (h).
1978-Subsec. (h).
1971-Subsec. (g).
1966-Subsec. (a).
Subsec. (b).
Subsecs. (c) to (f).
Effective Date of 1994 Amendment
Amendment by section 707(a) of
Effective Date of 1993 Amendment
Amendment by
Effective Date of 1992 Amendment
Section 1053(3) of
Effective Date of 1991 Amendment
Section 316(b) of
Effective Date of 1990 Amendment
Section 701(b) of
Section 702(b) of
Section 703(d) of
Section 712(c) of
Effective Date of 1989 Amendment
Section 730(b) of
Effective Date of 1988 Amendment
Section 646(c) of
Effective Date of 1987 Amendment
Section 721(c) of
Section 726(b) of
Effective Date of 1986 Amendment
Section 652(e)(4) of
Effective Date of 1984 Amendment
Section 632(a)(3) of
Amendment by section 1401(e)(4) of
Effective Date of 1983 Amendment
Section 931(c) of
"(1) clause (6) of section 1079(a) of title 10, United States Code, as added by subsection (a)(1), shall not apply in the case of inpatient mental health services provided to a patient admitted before January 1, 1983, for so long as that patient remains continuously in inpatient status for medically or psychologically necessary reasons; and
"(2) subsection (k) of section 1079 of such title, as added by subsection (a)(1), shall apply with respect to liver transplant operations performed on or after July 1, 1983."
Effective Date of 1981 Amendment
Section 906(b) of
Effective Date of 1980 Amendments
Amendment by section 501(13) of
Amendment by section 511 of
Section 810(c) of
Effective Date of 1978 Amendment
Section 806(b) of
Effective Date of 1971 Amendment
Section 2 of
Effective Date of 1966 Amendment
For effective date of amendment by
Programs Relating to Sale of Pharmaceuticals
Section 702 of
"(a)
"(1) establish a demonstration project that permits eligible persons described in subsection (c) to obtain prescription pharmaceuticals by mail in connection with medical care furnished to such persons under chapter 55 of title 10, United States Code; and
"(2) conduct the demonstration project in two or more regions selected by the Secretary, each of which consists of two or more States.
"(b)
"(c)
"(1) who is eligible for medical care under a contract for medical care entered into by the Secretary of Defense under section 1079 or 1086 of title 10, United States Code; or
"(2) who-
"(A) would be eligible for medical care under a contract for medical care entered into under section 1086 of such title except for operation of subsection (d)(1) of such section; and
"(B) either-
"(i) resides in an area that is adversely affected (as determined by the Secretary) by the closure of a health care facility of the uniformed services as a result of the closure or realignment of the military installation at which such facility is located; or
"(ii) can demonstrate to the satisfaction of the Secretary that the person relied upon a health care facility referred to in clause (i) before the closure of the facility to obtain the person's pharmaceuticals.
"(d)
"(A) determine the pharmaceuticals that may be obtained by eligible persons under the demonstration project established under subsection (a) or the retail pharmacy network included in a managed health care program under subsection (b); and
"(B) establish an appropriate fee, charge, or copayment to be paid by such persons for pharmaceuticals obtained under the demonstration project or managed health care program.
"(2) In the case of persons eligible to participate in the demonstration project for pharmaceuticals or the retail pharmacy network by reason of clause (ii) of subsection (c)(2)(B), the Secretary of Defense may increase the fees, charges, and copayments established under paragraph (1)(B) and otherwise applicable to such persons by an amount necessary to cover any additional costs incurred by the administering Secretaries as a result of making pharmaceuticals available to such persons under this section.
"(e)
"(1) describing the results of the demonstration project required by subsection (a);
"(2) containing such recommendations for revision of the demonstration project as the Secretary considers to be necessary; and
"(3) containing a plan (including a schedule) for implementing the demonstration project throughout the United States.
"(f)
"(1) an evaluation of the feasibility and advisability of increasing the size of those areas determined by the Secretary under subsection (c)(2) to be adversely affected by the closure of a health care facility of the uniformed services in order to increase the number of persons described in such subsection who will be eligible to participate in the demonstration project for pharmaceuticals by mail or in the retail pharmacy network under this section;
"(2) an evaluation of the feasibility and advisability of expanding the demonstration project and the retail pharmacy network under this section to include all covered beneficiaries under chapter 55 of title 10, United States Code, including those persons currently excluded from participation in the Civilian Health and Medical Program of the Uniformed Services by operation of section 1086(d)(1) of such title;
"(3) an estimation of the costs that would be incurred, and any savings that would be achieved by improving efficiencies of operation, as a result of undertaking the increase or expansion described in paragraph (1) or (2); and
"(4) such recommendations as the Secretary considers to be appropriate.
"(g)
Correction of Omission in Delay of Increase of CHAMPUS Deductibles Related to Operation Desert Storm
Section 721 of
"(a)
"(b)
"(1) was a member or former member of a uniformed service entitled to retired or retainer pay and served on active duty in the Persian Gulf theater of operations in connection with Operation Desert Storm; or
"(2) was a dependent of a member of a uniformed service who served on active duty in the Persian Gulf theater of operations in connection with Operation Desert Storm.
"(c)
"(1) for the reimbursement of the amount of any deductible paid under section 1079 or 1086 of title 10, United States Code, during the period specified in subsection (a) in excess of the amount required to be paid by operation of that subsection; or
"(2) for a credit against the annual deductible required under such sections for a fiscal year equal to the amount of the excess deductible paid.
"(d)
Temporary CHAMPUS Provisions for Dependents of Operation Desert Shield/Desert Storm Active Duty Personnel
Similar provisions were contained in
Section 312 of
"(a)
"(b)
"(2) A patient referred to in paragraph (1) is a dependent of a member of the uniformed services who serves on active duty in the Persian Gulf theater of operations in connection with Operation Desert Storm.
"(3) If a health care provider waives a payment for health care under paragraph (1), the health care provider shall certify to the Secretary of Defense that the amount charged the Federal Government for such health care was not increased above the amount that the health care provider would have charged the Federal Government for such health care had the payment not been waived. The Secretary of Defense may require a health care provider to provide information to the Secretary to show the compliance of the health care provider with this paragraph."
Transitional Health Care for Members, or Dependents of Members, Upon Release of Member From Active Duty in Connection With Operation Desert Storm
For provision authorizing transitional health care, including health benefits contracted for under subsec. (a) of this section, for members, or dependents of members, upon release of member from active duty in connection with Operation Desert Storm, see section 313 of
Section Referred to in Other Sections
This section is referred to in sections 1072, 1074b, 1080, 1081, 1082, 1083, 1086, 1086a, 1096, 1098, 1100, 1104, 1105, 1145 of this title; title 42 sections 248d, 300e–1, 1395cc.