DoD to cut Tricare Prime in 5 West areas

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DoD to cut Tricare Prime in 5 West areas




By Patricia Kime - Staff writer
Posted : Thursday Oct 18, 2012 22:05:45 EDT

The Pentagon is moving ahead with plans to slash its network of Tricare Prime providers, starting by eliminating the Prime option in three states and two cities in the Tricare West region.

As of April 1, as many as 30,000 Prime beneficiaries — retirees, Active Guard and Reserve troops, and family members — in Iowa; Minnesota; Oregon; Reno, Nev.; and Springfield, Mo., will have to switch to Tricare Standard, a traditional fee-for-service health plan, according to a source with knowledge of the reorganization.

Pentagon officials would not confirm that the five areas will lose Prime in April.

The areas lie outside Prime service areas covered under new Tricare regional contracts awarded by the Pentagon.

Under those contracts, Tricare will offer Prime networks only within “catchment areas,” defined as a 40-mile radius around military treatment facilities and in areas affected by the 2005 base closure and realignment process.

However, there are provisions to allow Prime beneficiaries who see a physician outside the 40-mile service area to stay in Prime if they live within 100 miles of an available primary care manager and sign an access waiver.

New enrollments also would be allowed for those outside Prime service areas if there is network capacity and the primary care manager is less than 100 miles from the beneficiary’s residence.

Spokeswoman Cynthia Smith said the intent is to bolster health care support for the core active-duty populations near military treatment facilities that have been left short-handed “due to the deployment requirements of military medical providers.”

But the move would save big money for the Pentagon because it cuts contract administration overhead in these Prime areas and shifts more of the costs of care to beneficiaries.


What it means for beneficiaries


Active-duty family members in Prime pay no enrollment fees or co-pays. Military retirees pay annual enrollment fees of $269.26 for an individual and $538.56 for families, and their co-pays for outpatient care are just $12. Prime requires no deductibles.

Under the changes that will start April 1, as many as 170,000 Prime enrollees across all three regions eventually may have to drive longer distances to see a Prime provider or switch to Tricare Standard, which has no enrollment fees but carries greater out-of-pocket costs:

• Cost shares are 20 percent for active-duty family members and 25 percent for retirees and other eligible beneficiaries.

• Annual deductibles for outpatient care are $50 for an individual and $100 for a family for active-duty members in paygrades E-4 and below, and $150 for an individual and $300 for a family for all others.

• The annual catastrophic cap — the maximum health care costs a beneficiary must pay in any one fiscal year — is $1,000 for active-duty families and $3,000 for retirees.

The move to eliminate Prime service areas away from military installations has been in the works since 2007, when the Defense Department released a draft of its new Tricare contract proposal. But a series of contract disputes delayed the launch of the new initiative.

“The can got kicked down the road” because of the contract protests, said retired Air Force Col. Steve Strobridge, director of government relations for the Military Officers Association of America. “Beneficiaries are going to have to change what they are used to. With something as basic as health care, this always raises a certain level of angst.”

With the contract disputes now resolved, the changes in the initial five areas could be just the beginning.

Under the old contracts, the entire Tricare South region was designated a Prime service area. In the West and North regions, the companies that managed the contracts also expanded Prime into areas not located near military bases, populated mainly by retirees, Active Guard and Reserve troops and their families.

“We’re worried mostly about the South” because Humana Military Health Services, the contractor for that region, “now provides Prime everywhere,” said Barbara Cohoon, deputy government relations director for the National Military Family Association.

Beneficiaries in the South “already are hearing from their providers” that they will not remain in Prime, Cohoon said.

Health Net Federal Services manages the North region contract. Beginning April 1, UnitedHealth Federal Services takes over the West region from TriWest Healthcare Alliance.

Officials with all three regional contractors declined to comment and referred all questions to the Defense Department.

Dismantling Prime networks outside the immediate vicinity of military treatment facilities also will eliminate Tricare Extra in these places; that option allowed non-Prime users to lower their costs by seeing Prime network providers.

“All beneficiaries can choose to use Tricare Standard, which gives the beneficiary the most flexibility and greatest choice of any of the Tricare products,” Smith said.

According to the Pentagon, those in Tricare Prime Remote — a program for active-duty troops and their families living in rural areas — as well as those on or near an installation with a hospital or clinic will see no change to their health benefits.

“This will not affect active-duty military and their families,” Smith said.

“This change also will not impact areas where there is a military treatment facility.”

http://www.armytimes.com/news/2012/1...medium=twitter

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SEC. 704. REPORT ON THE FUTURE AVAILABILITY OF TRICARE PRIME THROUGHOUT THE UNITED STATES.

(a) Report Required- Not later than 120 days after the date of the enactment of this Act, the Secretary of Defense shall submit to the Committees on Armed Services of the Senate and the House of Representatives a report setting forth the policy of the Department of Defense on the future availability of TRICARE Prime under the TRICARE program for eligible beneficiaries in all TRICARE regions throughout the United States.

(b) Elements- The report required by subsection (a) shall include the following:

(1) A description, by region, of the difference in availability of TRICARE Prime for eligible beneficiaries (other than eligible beneficiaries on active duty in the Armed Forces) under newly-awarded TRICARE managed care contracts, including, in particular, an identification of the regions or areas in which TRICARE Prime will no longer be available for such beneficiaries under such contracts.

(2) A description of the transition and outreach plans for eligible beneficiaries described in paragraph (1) who will no longer have access to TRICARE Prime under the contracts described in that paragraph.

(3) An estimate of the increased costs to be incurred for healthcare under the TRICARE program for eligible beneficiaries described in paragraph (2).

(4) An estimate of the saving to be achieved by the Department as a result of the contracts described in paragraph (1).

(5) A description of the plans of the Department to continue to assess the impact on access to healthcare for eligible beneficiaries described in paragraph (2).

http://www.govtrack.us/congress/bills/112/s3254/text

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Some beneficiaries who see local Prime coverage end will be able to enroll in a remaining Prime network near base. To do so they would have to reside less than 100 miles from that exiting network and would have to waive the driving-distance standard that TRICARE imposes for patient safety.