Tricare operations manual 6010.56 m

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CHAPTER 26 The Military Managed Care Health System M. NICHOLAS COPPOLA, RONALD P. HUDAK, FOREST S. KIM, LAWRENCE FULTON, JEFFREY P. HARRISON, AND BERNIE J. KERR, JR.

STUDY OBJECTIVES

• Understand the difference between direct care and purchased care • Understand the importance of readiness in the military health system • Understand the governance process in military managed care • Understand TRICARE performance metrics • Understand the in�luence of outside stakeholders on military health care policy • Understand the current and future challenges faced by the military health system • Understand the relationships and competing priorities of actors within the Managed Care Quaternion

DISCUSSION TOPICS

1. Discuss the following statement made by a former Assistant Secretary of Defense for Health Affairs, “The military health system operates the only health maintenance organization that goes to war.” Why is this statement important in understanding the military health system?

2. Discuss key legislative events in military health care that resulted in the implementation of the current TRICARE program. 3. Discuss key differences and advantages of TRICARE Prime, Extra, and Standard. What other TRICARE programs are available for speci�ic

bene�iciaries? 4. Discuss the historical events that resulted in “TRICARE for Life” becoming a right for eligible bene�iciaries. 5. Discuss opinions on how best to ensure the survival of the military health system. 6. Discuss and describe the Parity of Healthcare.

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INTRODUCTION

This chapter discusses the Military Health System (MHS). The MHS operates a specialized form of managed care called TRICARE and responds to the challenge of maintaining medical combat readiness while providing health services for all eligible bene�iciaries. TRICARE brings together the worldwide health resources of the Army, Navy, Air Force, Coast Guard, and Commissioned Corps of the Public Health Service (often referred to as direct care) and supplements this capability with network and non-network civilian health professionals, hospitals, pharmacies, and suppliers (referred to as purchased care) to provide better access and quality service while maintaining the capability to support military operations. In essence, TRICARE can be considered a group of health plans within the MHS.

On the direct care side, the MHS, worldwide, oversees over 50 military hospitals and medical centers, 364 medical clinics, and 282 dental clinics at the time of publication. The MHS also operates a fully accredited medical school, graduate programs, and 36 medical research laboratories. It also offers scholarships at a number of major universities as well as broad programs in medical research and development. Each service’s medical department is headed by a Surgeon General who is the senior of�icer, meaning general of�icers in the Army and Air Force and an admiral in the Navy.* (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26fn1) Each military Surgeon General is responsible for the care provided in his or her respective service’s military treatment facilities (MTFs). MTFs are analogous to civilian medical centers, hospitals, and health clinics.

In the purchased care side, there are over 380,000 network providers and over 60,000 retail pharmacies. In a typical week, the MHS does more than 23,000 inpatient admissions; 1.8 million professional encounters (outpatient); 2,400 births; 230,000 behavioral health outpatient services; and �ills 2.6 million prescriptions. In addition, over 3.5 million claims are processed and 12.6 million electronic health record messages are completed.1 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en1)

TRICARE offers a range of primary, secondary, and tertiary care health services to almost 10 million eligible bene�iciaries with an annual cost of over $49 billion. Approximately 3.7 million are enrolled in the direct care system, 1.6 million are enrolled in TRICARE’s purchased care contractor networks, and the remainder are in other TRICARE programs. A unique aspect of military managed care is the MHS’s readiness mission. Readiness is de�ined as the ability of forces, units, technical systems, and equipment to deliver the output for which they were designed.2 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en2) Readiness is also associated with maintaining the health status of active duty personnel well above the health standing associated with nonmilitary personnel. Furthermore, readiness is synonymous with ensuring ef�icient supplies are available for national disasters and war, and ensuring that appropriate processes are in place to support mobilizations. This means that readiness is associated with the ability of certain elements of brick-and-mortar health care facilities to become mobile and deploy worldwide when necessary. Finally, readiness is concerned with operations management processes and the ef�icient and effective use associated with the transformation of inputs into outputs. No other managed care plan in the United States—or the world—has a similar focus and responsibility. Former Assistant Secretary of Defense for Health Affairs Dr. Sue Bailey once said that the military health system operates the only health maintenance organization (HMO) that goes to war.3 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en3)

To understand the current structure and process of military managed care, it is �irst necessary to review the seminal events in military managed care evolution. Factors affecting military managed care evolution stem from issues in war, directives from Congress, bene�iciary demands, and adoption of civilian best practices over 200 years. In contrast, some civilian managed care practices may have antecedent roots in earlier military health programs. The end result is a civilian managed care system with undeniable ties to military initiatives and a military managed care system that is similar to civilian managed care in many ways while still maintaining distinctiveness in mission and purpose. In essence, the MHS can be considered:

• A provider of health care; • An employer of health care professionals; • An insurer of bene�iciaries; • An educator of clinical and nonclinical personnel, unique within the U.S. health care industry; • A military component prepared to go anywhere, anytime in defense of our nation.

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26.1 BRIEF HISTORY OF THE MILITARY HEALTH SYSTEM

Military health care began when the country did, and has undergone considerable and continual change. The history of the military health system is brie�ly described next.

The Revolutionary War through Post World War II

The history of military health care traces its origins to the establishment of the Army Medical Department on July 27, 1775. During the American Revolution, military health care was delivered in the �ield, often in churches and barns. After 1777, several �ixed facility hospitals were established in various northern states. On March 2, 1799, Congress established An Act to Regulate the Medical Establishment. This legislation gave the Physician General (renamed from the Director General and Chief Physician) the authority and responsibility of overseeing the development of (primarily) Army hospitals. That same year, General George Washington approved the construction of one of the �irst military hospitals in the Colonies, in Morristown, New Jersey. Although the act did not provide for dependants of one service to be treated in the hospital of another branch of service, both the Army and the Navy routinely took care of members from their sister service.4 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en4) , 5 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en5)

One of the other unique features of the 1779 Act was a directive to collect prospective payments for health care services. The 1779 Act also directed the Secretary of the Navy to deduct 20 cents a month from the pay of sailors and marines for their care in civilian treatment facilities. Proceedings suggest that the practice of collecting money for health care services not received—but promised at some future time and place—may represent the �irst time in U.S. managed care history that prospective health services were established in the United States health system.6 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en6)

From the Revolutionary War through the Civil War, the military attempted to differentiate between care for dependants and active duty access. However, the westward growth of the nation required Army posts to be located in remote areas with no alternative access to health care. As military posts expanded west, families accompanied soldiers. Although departmental regulations prohibited military surgeons from treating civilians, some exceptions were granted. Finally, in 1834, the Adjutant General ruled that military surgeons had permission to treat civilians when it did not interfere with their required military duties.7 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en7) This policy established the bene�it—and later entitlement—to free health care for authorized dependants of the military that currently exists. More important, this may also be the �irst instance in U.S. health care that nonmonetary bene�its, speci�ically health care bene�its, were granted by an organization to family members of the employed person. The preponderance of the civilian sector did not adopt a similar provision for providing free health care to an employed person’s family on a regular basis until the next century, as described in Chapter 1 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i9#ch01) .

CHAMPUS and the Modern Military Health Care Era

In 1956, in an effort to keep up with a growing civilian trend to offer health care bene�its and entitlements to retired persons, Congress enacted the Dependants Medical Care Act. This act provided that “medical and dental care in any medical facility of the uniformed services may, under regulations prescribed jointly by the Secretaries of Defense and Health, Education and Welfare, be furnished upon request and subject to the availability of space, facilities, and capabilities of the medical staff, to retired members of uniformed services.” The act additionally applied to dependants of uniformed retirees. The signi�icance of the Act was that it legitimized standing policies already in widespread application throughout the military health system.8 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en8) In 1965, Congress created Medicare and Medicaid. One of the original goals of Medicare was to provide health care for retired workers who were no longer covered by a health plan after retirement. However, a problem existed for many military personnel who often retired from a military career in their mid- to late 40s. As a result of the space availability clause of the Dependants Medical Care Act, a problem arose where some military retired members could not gain access to MTF—and were too young to participate in Medicare. As a result, some service members found themselves paying for medical care in civilian institutions out of pocket.

In an effort to address the inability to gain access to health care for some categories of bene�iciaries, Congress amended the Dependants Medical Care Act and created the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). CHAMPUS was created under Public Law 89-614, the Military Medical Bene�its Amendments Act of 1966. Modeled after the Blue Cross and Blue Shield options of the time, CHAMPUS was a fee-for-service bene�it that provided for comprehensive medical care when there was no space available in the MTF.9 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en9) For the �irst time in the history of the military, two different systems existed to provide care to bene�iciaries. The resulting composite organization was composed of a direct military care system for active duty personnel that used all available military hospitals and clinics, and a second system monitored through CHAMPUS that acted as a gatekeeper to the civilian care system.10 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en10) Although CHAMPUS did not require a monthly premium like Medicare did (for Part B only; see Chapter 24 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i283#ch24) ), CHAMPUS had an annual deductible and a cost share for care received outside of the MTF.

Through the late 1980s, CHAMPUS bene�its remained relatively stable and unchanged. However, spiraling health care costs in the 1980s affecting civilian health care organizations also began affecting CHAMPUS. As a result, the Department of Defense (DOD) began to explore options and alternatives to control costs, monitor access, and maintain health care quality. One option centered on closing inef�icient military hospitals. The second option focused on reengineering military health care.

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The �irst option implemented by Congress to control military health care costs was the Base Realignment and Closure (BRAC) initiative. From 1987 through 1997, Congress mandated a 35% reduction of military health care assets.11 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en11) The second option focused on quality and access and resulted in a series of �ive notable demonstration projects initiated from 1986 through 1993. These demonstration projects were conducted to validate the ability to use de�ined civilian networks effectively to treat military bene�iciaries as well as to conduct a cost-bene�it analysis between purchased civilian health care services and CHAMPUS expenditures. These demonstrations included the CHAMPUS Reform Initiative (CRI), the New Orleans managed care demonstration, Catchment Area Management (CAM) projects, the Southeast Region Preferred Provider Organization (PPO) demonstration, and the Contracted Provider Arrangement (CPA) in Norfolk, Virginia.12 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en12) –14 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en14) For a more detailed review and historical presentation of these projects, readers are referred to the third edition of The Managed Health Care Handbook.15 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en15)

CHAMPUS Demonstration Project Outcomes and the Creation of TRICARE

In 1993, the CHAMPUS demonstration projects suggested a reorganization of military health care by providing some evidence that civilian managed care techniques could help the military contain costs, improve quality, increase access, and advance patient satisfaction. In 1994, Congress enacted the National Defense Authorization Act (NDAA). The NDAA directed the DOD to prescribe and implement a health bene�it option for bene�iciaries eligible for health care under Chapter 55 of Title 10, United States Code (USC). The NDAA also directed the military health system to implement health programs modeled on managed care plans in the private sector.

In response to the DOD and Congress, the military health system developed the military managed care plan called TRICARE. TRICARE’s name was coined to represent the three primary military services involved in providing health care to DOD bene�iciaries (Army, Navy, and Air Force). The name also represents the three managed care options originally developed to administer care, called TRICARE Prime, TRICARE Extra, and TRICARE Standard (Table 26-1 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i311#ch26tab1) ). Although several others have been added since TRICARE’s inception, most MHS bene�iciaries are enrolled in these three options. Overall, TRICARE adopted several successful managed care features, such as primary care managers, gatekeeper access, enrolled bene�iciaries, and empanelled providers. The program also includes case, disease, risk, and utilization management principles.

Enhanced TRICARE Bene�its

TRICARE continually seeks to enhance the bene�it offered to uniformed service members, their families, and retirees and their families. As a result, in addition to the managed care options of Prime, Standard, and Extra, several niche-speci�ic programs and adaptations have evolved to provide bene�its to a larger population of bene�iciaries. The preponderance of these programs resulted from initiatives in Congress to improve health care access and quality of care. One of the most signi�icant changes to TRICARE came about with the signing of Public Law 106-398 as part of the 2001 NDAA. Dr. J. Jarrett Clinton, the acting Assistant Secretary of Defense for Health Affairs in 2001, said, “Collectively, this act represents the most signi�icant change to military healthcare bene�its since the implementation of the CHAMPUS in 1966.”16 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en16) The 2001 NDAA authorized several key TRICARE improvements, including the following:

1. Established TRICARE as the secondary payer for Medicare-eligible military retirees (MEMR); 2. Established a pharmacy bene�it for MEMR called TRICARE Senior Pharmacy Program (TSPP); 3. Established a MEMR Healthcare Trust Fund (HCTF); 4. Eliminated copayments for TRICARE Prime active duty family members; 5. Expanded TRICARE Prime Remote; 6. Introduced chiropractic care for active duty soldiers; 7. Established the Individual Case Management Program (ICMP) for persons with extraordinary conditions; and 8. Reduced the catastrophic cap from $7,500 to $1,000 for active duty families and $3,000 for all others.17

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Other mentionable bene�its included in this Act were permanent health bene�its for Medal of Honor recipients and their families, extension of medical and dental bene�its for survivors of deceased active duty soldiers, and authorization of payment for school physicals. The 2001 NDAA also authorized the DOD to expand TRICARE health bene�its to niche-speci�ic programs. The signi�icant programs that were eventually enacted as a result of the original 2001 NDAA—and subsequent amendments—included TRICARE for Life, TRICARE Reserve Select, and the TRICARE Dental Program.

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26.2 THE TRICARE PROGRAM

The components of the TRICARE program are discussed next.

TRICARE and the Patient Protection and Affordable Care Act

TRICARE is an entitlement program, meaning anyone who quali�ies as eligible can enroll in TRICARE (eligibility is discussed next). Because it is an entitlement program, it is not affected by the Patient Protection and Affordable Care Act (ACA). The two other major entitlement programs, Medicare (Chapter 24 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i283#ch24) ) and Medicaid (Chapter 25 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i298#ch25) ), are addressed speci�ically in the ACA, but as separate Titles within the Act, not by inclusion with the new nonentitlement health bene�its coverage requirements; TRICARE, however, is not addressed in the ACA at all.

Long before passage of the ACA, TRICARE already met all but one of the major coverage requirements, bene�its, and prohibition on various limitations that the ACA now requires for commercial coverage by 2014. The only one it didn’t meet, extending coverage to children of covered individuals up to age 26 if those children do not have access to coverage through their own work, was resolved when the NDAA of �iscal 2011 authorized the premium-based Young Adult Program that provides for this type of coverage extension. The ACA is not addressed further in the chapter.

TABLE 26-1 TRICARE Bene�iciary Costs, 2010

Source: TRICARE: Summary of Bene�iciary Costs, www.tricare.mil/mybene�it/Download/Forms/Bene_Cost_Br_L_011510.pdf (http://www.tricare.mil/mybene�it/Download/Forms/Bene_Cost_Br_L_011510.pdf) . Accessed November 2, 2010.

TRICARE Eligibility

TRICARE is the health care program serving active duty uniformed service members, National Guard and Reserve members, retirees, their families, survivors, and certain former spouses worldwide of the U.S. Army, U.S. Navy, U.S. Air Force, U.S. Marine Corps, U.S. Coast Guard, as well as the Commissioned Corps of the U.S. Public Health Service and the National Oceanic and Atmospheric Administration. Family members include spouses, unmarried children under age 26, and stepchildren adopted by the sponsor. National Guard and Reservists become eligible for TRICARE when called to active duty for more than 30 days. All who are eligible for TRICARE must be listed in the Defense Department’s worldwide, computerized database, the Defense Enrollment Eligibility Reporting System (DEERS). The following are not

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eligible for TRICARE bene�its: parents and parents-in-law of active duty service members, or retirees and people who are eligible for health bene�its under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). Out-of-pocket costs for each TRICARE option are provided in Table 26-1 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i311#ch26tab1) .

TRICARE Governance

To implement and administer TRICARE, in 1994, the DOD originally reorganized the military health system into 12 joint-service regions. All 12 regions were subordinate to the TRICARE Management Agency (TMA). The decision to separate contracts for different TRICARE regions was made in an effort to prevent any one contractor from having too much control over the care delivered to DOD bene�iciaries.

In 2004, the Assistant Secretary of Defense (Health Affairs) and the services’ Surgeons General established a governance structure consisting of three TRICARE regions. The new governance structure is designed to monitor performance and resolve problems at the lowest possible level for managing the military health bene�it with force readiness as the �irst priority, followed closely by bene�iciary satisfaction. Each of the three TRICARE regions in the United States has a regional contractor to coordinate medical services available at the MTF and the civilian network. The regional contractors work with the TRICARE regional of�ices (TROs) to manage TRICARE at a regional level. Both the regional contractors and the TROs receive overall guidance from the TMA. The three TRICARE regions are organized geographically into a North, South, and West region, as depicted in Figure 26-1 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i311#ch26�ig1) .

Governance of the three TRICARE service regions remains complex. The TRICARE regional of�ices are responsible for planning, coordinating, and monitoring all health care delivered throughout their region. Additionally, each region establishes contracts with civilian health care organizations to provide medical care to bene�iciaries. However, both military commanders and civilian contractors struggle with dual missions to maintain wartime readiness requirements and peace time bene�iciary health care with limited budgets in a not-for-pro�it environment.

TRICARE Program Options

The TRICARE program has three main options: TRICARE Prime, TRICARE Standard, and TRICARE Extra. There are also three additional options available under certain circumstances: TRICARE for Life, TRICARE Reserve Select, and TRICARE Retired Reserve.

TRICARE Prime

TRICARE Prime is the HMO-like plan in which bene�iciaries enroll in this bene�it option where it is offered. Each enrollee chooses, or is assigned, a primary care manager (PCM), a health care professional who is responsible for helping the patient manage his or her health, promoting preventive health services (e.g., routine exams, immunizations), and arranging for specialty provider services as appropriate. Prime offers enrollees additional bene�its such as access standards in terms of maximum allowable waiting times to obtain an appointment, emergency services (24 hours per day, 7 days per week), and waiting times in doctors’ of�ices, as well as preventive and wellness services (routine eye exams, immunizations, hearing tests, mammograms, Pap tests, prostate examinations). A point-of-service (POS) option permits enrollees to seek care from non-network providers, but with signi�icantly higher cost-sharing.

Active duty service members must enroll in TRICARE Prime and must receive all health care bene�its at an MTF unless otherwise authorized. All health care bene�its are free, and there are no out-of-pocket costs to service members. TRICARE Prime is also available to other eligible bene�iciaries, such as family members of active duty service members and retirees under age 65. If enrolled in TRICARE Prime, active duty family members must also receive health care at an MTF unless otherwise directed. Retirees not eligible for Medicare can enroll in TRICARE Prime; however, they must pay an annual enrollment fee as well as copayments for care received in civilian facilities. TRICARE Prime enrollees must follow well-de�ined rules and procedures. Failure to follow strict TRICARE Prime guidelines may result in refusal of care, refusal of payment, and costly POS option charges.

FIGURE 26-1 TRICARE Regions Source: TRICARE Choices: Your Guide to Selecting the TRICARE Program Option That’s Best for You. Available at: www.tricare.mil/mybene�it/Download/Forms/Choices_Handbook.pdf (http://www.tricare.mil/mybene�it/Download/Forms/Choices_Handbook.pdf) . Accessed

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November 2, 2010.

In addition to low to no out-of-pocket costs, an advantage of being enrolled in TRICARE Prime is the policy-directed access to care standards for appointments. Access to care standards differ by the level of care sought. For emergency care, MHS bene�iciaries have the right to access emergency health care services when and where the need arises. For urgent (acute) care, the standard is an appointment within 24 hours and within 30 minutes travel time; routine care within 7 calendar days and within 30 minutes drive time; for wellness and specialty care, the appointment must be within 28 days and within 1 hour drive time from the bene�iciary’s residence. If these access standards cannot be met, TRICARE offers the bene�iciary a referral and authorization to seek care in the civilian network. Moreover, TRICARE access standards state that of�ice waiting times in nonemergency circumstances shall not exceed 30 minutes for Prime enrollees.

For service members and their families who do not live near an MTF, TRICARE offers TRICARE Prime Remote (TPR). TPR is speci�ic to certain geographic locations, and eligibility is based on residence and/or work address. To be eligible for TPR, active duty members and their families must live and work more than 50 miles—or approximately 1 hour drive time—from the nearest MTF. TPR offers the same access standards and low out-of-pocket costs as TRICARE Prime. Like TRICARE Prime, enrollment in TPR is required.

Another TRICARE Prime option is the Uniformed Services Family Health Plan (USFHP) and is available to active duty family members, retirees, and their eligible family members (including those age 65 and older regardless if they are enrolled in Medicare Part B). The USFHP is available through networks of community-based, not-for-pro�it health care systems in six areas of the United States. Enrollment in USFHP is required and enrollment fees apply for retirees and their eligible family members. If enrolled in USFHP, access to care at an MTF or use of MTF pharmacies is excluded. This managed care option has the same coverage and costs as Prime, but also offers additional services at the local level.

TRICARE Standard

TRICARE Standard is the traditional indemnity bene�it, also known as fee-for-service (FFS), and formerly known as CHAMPUS. It is open to all eligible Department of Defense bene�iciaries, except active duty service members and, until recently, Medicare eligibles. No enrollment is required to obtain care from civilian providers. TRICARE Standard gives bene�iciaries the option to see any provider. Advantages include a wider selection of providers and health care facilities and the option to participate in TRICARE Extra. There is no required annual enrollment, and the option offers comprehensive health care coverage for bene�iciaries not enrolled in TRICARE Prime.

While Standard offers the greatest �lexibility in choosing a provider, the plan also has the most out-of-pocket cost-sharing by the bene�iciary; for example, TRICARE Standard requires that the bene�iciary satisfy a yearly deductible before TRICARE cost-sharing begins. Furthermore, the plan requires bene�iciaries to pay copayments or cost shares for outpatient care, medications, and inpatient care. Another disadvantage is that the patient may also be required to �ile his or her own claims. Finally, the option also does not provide a PCM bene�it.

TRICARE Extra

TRICARE Extra is based on a civilian PPO model in which bene�iciaries eligible for TRICARE Standard may decide to use preferred civilian network providers on a case-by-case basis (they may switch between the Standard and Extra bene�its). TRICARE Extra is open to any TRICARE-eligible bene�iciary who is not active duty, not otherwise enrolled in Prime, and not eligible for TRICARE for Life (discussed next). TRICARE Extra requires no enrollment and there is no enrollment fee. Under this option, bene�iciaries can see civilian providers and go to civilian health care organizations that are on an approved list of TRICARE providers called the TRICARE Provider Directory.

TRICARE Extra is essentially an option for TRICARE Standard bene�iciaries who want to save on out-of-pocket expenses by making an appointment with a TRICARE Prime network provider. TRICARE Extra requires the same deductible as TRICARE Standard; however, by using network providers, bene�iciaries reduce their cost-sharing by 5%. An advantage of TRICARE Extra is that the Extra option user can expect that the network provider will �ile all claims forms—similar to TRICARE Prime. An additional advantage is that the access to the authorized provider may be more geographically convenient to the Extra user. However, disadvantages include extra fees associated with deductibles and copayments, the loss of a PCM, some restrictions on specialty care access, and limited provider choice.

TRICARE for Life

Over the years, military recruiters marketed “free health care for life” to potential recruits, promising this bene�it for the recruit and certain family members if they served a certain amount of time in uniform.18 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en18) However, in 1956, Public Law 569 changed the century-old, quasi–health care for life entitlement to a bene�it. PL 569, Section 301, changed from: “Hospital space SHALL be made available” to “Hospital space MAY be made available [sic].”19 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en19) Despite the change in law, retirees and family members continued to receive bene�its well into the early 1990s. However, in the mid-1990s, under congressional and presidential guidance, these bene�iciaries were required to use a civilian health care provider, use a civilian organization, and rely on Medicare or other health insurance (OHI) as payers.20 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en20)

The Pentagon estimated that approximately 1.5 million personnel, approximately 20% of the bene�iciary base, were locked out of the military health system in the late 1990s.21 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en21) Based partially on the grassroots response to restricted access to health care options, TRICARE for Life (TFL) was signed into public law (PL 106-398) as part of the 2001 NDAA.

TFL effectively ful�ills the promise of lifetime health care made to older retirees for a career in uniform. TFL restores TRICARE coverage for all Medicare-eligible retired bene�iciaries regardless of age or place of residence who are enrolled in Medicare Parts A and B.22 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en22) Congress established TFL as a “fully funded entitlement program” by means of a new

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Medicare-Eligible Retiree Health Care Trust Fund.23 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en23) To qualify for TFL, a retiree must have served at least 20 years in the uniformed services (including retired members of the National Guard and the Reserves). There are no enrollment fees, premiums, or deductibles for TFL. Bene�iciaries receive most of their care from civilian providers and Medicare is the �irst payer, whereas TRICARE (or other health insurance) serves as the secondary payer. TFL makes TRICARE a secondary payer to Medicare at no cost to a retiree.

Another option available to eligible TFL bene�iciaries is TRICARE Plus. TRICARE Plus affords bene�iciaries the opportunity to receive primary care and specialty care at their local MTF, provided that facility has space available. There are no charges or fees for TRICARE Plus, if offered by the MTF. Another bene�it of TRICARE Plus is that bene�iciaries are entitled to the same primary care access standards as bene�iciaries in TRICARE Prime. For example, the bene�iciary would be assured of a primary care appointment within one week. However, TRICARE Plus is not available at all MTFs due to the availability of care. Also, the MTF commander may limit the program to only certain bene�iciary categories, again based on local staf�ing and other considerations.

Another limitation is that bene�iciaries already enrolled in TRICARE Prime, a purchased care HMO, or a Medicare HMO are not eligible. Basically, TRICARE for Life (bene�its received from civilian providers) and TRICARE Plus (care received at MTFs) give bene�iciaries more coverage while simultaneously allowing the military health system the ability to control costs and access due to local, medically related considerations. The enactment of TFL represents one of the many military managed care outcomes that can be traced to antecedent activist actions by constituents.

TRICARE Reserve Select

The NDAA of 2005 authorized a program called TRICARE Reserve Select (TRS). TRS is a premium-based health plan for eligible Reserve component members. TRS offers comprehensive health care coverage similar to TRICARE Standard and TRICARE Extra. TRS members and covered family members can access care by making an appointment with any TRICARE authorized provider, hospital, or pharmacy or TRICARE network or non-network. TRS members may access care at an MTF on a space-available basis only; however, pharmacy services are available from an MTF pharmacy, the TRICARE Mail Order Pharmacy, or TRICARE network and non-network retail pharmacies. Medical coverage (direct care at the MTF) is available when the member is activated. When ordered to active duty for more than 30 consecutive days, Reserve component members and their families have comprehensive health care coverage under TRICARE.24 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en24)

TRICARE Retired Reserve

TRICARE Retired Reserve (TRR) provides comprehensive coverage for a speci�ied group of bene�iciaries. Eligibility for this program is limited to retired Reserve individuals who are quali�ied for nonregular retirement and their families. Also, they must be under the age of 60 and not eligible for, or enrolled in, the Federal Employees Health Bene�its Program (FEHBP).25 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en25)

In addition, survivors of retired Reserve members may be quali�ied if they meet certain requirements: the Reserve member was covered by TRR at time of death; the survivors must be immediate family members and the spouse must not have remarried; and the coverage would begin before the Reserve member would have turned 60. However, eligibility for FEHBP is not necessary for the survivors.

TRR is a premium-based plan that offers TRICARE bene�its worldwide by TRICARE-authorized providers. Similar to other TRICARE programs, there are annual deductibles and copays. However, unlike some of the other TRICARE plans, the law does not provide any government subsidy, therefore, enrollees pay the full cost of the program. Nevertheless, the cost is less if the providers are in the TRICARE network.

Other advantages of the program include bene�iciaries being authorized to receive care in military hospitals on a space-available basis. Also, the bene�iciary may visit any TRICARE-authorized provider whether or not that provider is in the network. However, if the provider is in the network, the bene�iciary will pay less and the provider will �ile the claim on behalf of the bene�iciary. There is no referral, although some medical services may require preauthorization by TRICARE. Finally, continuity of care may be enhanced because there is no requirement for eligible Reserve personnel to change providers if they already have one. A description of all of the TRICARE program options is provided in Table 26-2 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i311#ch26tab2) .

TABLE 26-2 TRICARE Program Descriptions

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Source: TRICARE Choices: At a Glance. Available at: www.tricare.mil/tricaresmart�iles/Prod_539/TRICARE_Choices_At_a_Glance_Br_10_LoRes.pdf (http://www.tricare.mil/tricaresmart�iles/Prod_539/TRICARE_Choices_At_a_Glance_Br_10_LoRes.pdf) . Accessed November 2, 2010.

TRICARE Pharmacy Program

The MHS provides comprehensive prescription drug coverage to all its bene�iciaries including active duty service members and their families, retirees and their families, and bene�iciaries who are over age 65. Also, this coverage is the same regardless of the TRICARE program in which the bene�iciary is enrolled. Pharmaceuticals may be obtained at MTFs or through the TRICARE Pharmacy program (TPharm), which includes home delivery, retail network pharmacies, and non-network pharmacies.

TPharm is a contractor-provided bene�it, which provides convenience and low cost to bene�iciaries. TPharm has the combined features of a home delivery (by mail order) service and a retail pharmacy. In addition to not requiring enrollment, there are several other advantages to bene�iciaries:

• A single call center and a help desk are available for convenience; • Prescriptions are easily transferred between pharmacies regardless of whether they are retail, military, or mail order; and • Although the prescription drug coverage is the same regardless of health plan, there are �inancial incentives for bene�iciaries to utilize

home delivery (mail order) rather than retail pharmacies.26 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en26)

TRICARE Dental Programs

The TRICARE Dental Program (TDP) is a voluntary dental insurance program that is available to eligible active duty family members, select reserve component personnel, Individual Ready Reserve (IRR) members, select retirees, and other eligible bene�iciaries. This premium- based program has annual costs and deductibles for both family members of active duty personnel as well as other classes of bene�iciaries.27 (http://content.thuzelearning.com/books/Kongstvedt.2332.17.1/sections/i314#ch26en27) The plan covers ordinary dental procedures such as annual screenings, preventive care, and standard dental treatments.

Another dental program exists solely for active duty and activated Reserve and National Guard service members. This program, the Active Duty Dental Program (ADDP), is administered by a civilian contractor who provides care for service members who live and work more than 50 miles from a military dental clinic as well as service members in the U.S. Virgin Islands, Puerto Rico, as well as the Paci�ic islands of Guam,

http://www.tricare.mil/tricaresmartfiles/Prod_539/TRICARE_Choices_At_a_Glance_Br_10_LoRes.pdf
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American Samoa, and the Northern Mariana Islands. Although there is no enrollment feature, treatment must be provided by the contractor’s network provider.

Other TRICARE Programs