TRICARE, the healthcare program of the U.S. Department of Defense (DoD) Military Health System, provides civilian healthcare benefits for military personnel, military retirees, and their dependents. Although some forms of TRICARE ensure beneficiaries receive care from providers at military treatment facilities, several forms of TRICARE allow beneficiaries to seek care from civilian providers.
However, a recent report published by the U.S. Government Accountability Office (GAO) found that nearly one in three TRICARE beneficiaries who could seek care from civilian providers have problems finding providers who take TRICARE. The report also found that only about six in ten civilian providers were accepting new TRICARE patients. Many providers cited unfamiliarity with the program and reimbursement concerns as reasons for not taking TRICARE.
As recently as 7 years ago, nearly 76 percent of civilian physicians accepted new TRICARE patients. The GAO survey results indicate that civilian providers’ awareness and acceptance of TRICARE has decreased over time.
To better understand TRICARE, it is important to differentiate between the several TRICARE options available to servicemembers. TRICARE Prime, a managed care option that requires enrollment, is mandatory for all active-duty servicemembers. These enrollees, including about 1.7 million family/dependents, receive most of their care from providers at military treatment facilities.
Servicemembers not enrolled in TRICARE Prime can choose either TRICARE Standard, a fee-for-service option, or TRICARE Extra, a preferred provider organization option. Neither program requires enrollment and all beneficiaries may obtain care at military treatment facilities, although these facilities give priority to active-duty personnel and then to beneficiaries enrolled in TRICARE Prime.
TRICARE Standard beneficiaries may obtain health care from non-network providers, providing them with maximum flexibility in selecting providers. TRICARE Extra beneficiaries who stay within the network benefit from lower copayment fees. Additionally, qualified National Guard and Reserve servicemembers may purchase a form of TRICARE called TRICARE Reserve Select.
According to retired Army Col. John J. McGraw, MD, TRICARE Reserve Select is a significant benefit for National Guardsmen and Reservists.
“Upwards of 70 percent of physicians/surgeons who were and continue on the front lines via deployment to Afghanistan and Iraq are Reservists and Guardsmen,” stated Dr. McGraw. “I know orthopaedic surgeons who were forced to change jobs or practices due to deployment. Some lost their insurance, including their family coverage. If it were not for TRICARE, that added stress on the home front would have made the deployment even more difficult.”
Network or non-network
Understanding the difference between civilian network or non-network TRICARE providers is also important. Network providers are TRICARE-authorized providers who enter contractual agreements and agree to accept TRICARE reimbursement rates. By law, TRICARE maximum allowable reimbursement rates generally must mirror Medicare rates. Network providers also agree to meet TRICARE Management Activity’s access-to-care standards.
However, non-network providers are not required to meet TRICARE’s access-to-care standards and do not have to sign a contract to provide care to TRICARE beneficiaries. Non-network civilian providers may choose to accept TRICARE reimbursement rates or may charge up to 15 percent more for their services on a case-by-case basis. Neither network nor non-network providers are obligated to accept all TRICARE beneficiaries seeking care.
Despite the different options available to civilian providers, the GAO found that only an estimated 58 percent are accepting new TRICARE patients. Further, fewer civilian providers accepted new TRICARE patients than other types of beneficiaries, according to a 2008 physician survey by the Center for Studying Health System Change (Fig. 1).
The reimbursement issue
According to the GAO, civilian primary care providers who don’t accept TRICARE patients are ‘not accepting patients’ in general. Specialty providers, cited ‘reimbursement’ as their primary reason for not accepting TRICARE patients.
“Concerns about TRICARE’s reimbursement rates—which generally mirror the Medicare program’s physician fee schedule—have increased due to the uncertainty surrounding the annual update to Medicare fees,” states the GAO. “Providers already were expressing concerns about the Medicare rate decreases and some providers said they would no longer accept TRICARE beneficiaries as patients if the rates were reduced.”
One area that should not be a concern for TRICARE patients and providers is the Affordable Care Act (ACA). TRICARE operates completely independently of the ACA and is not directly affected by the ACA. However, the ACA does open a special Medicare Part B enrollment window for certain individuals to gain coverage under the TRICARE for Life (TFL) program, which covers the cost of claims after Medicare has paid its share.
Acceptance of TRICARE will continue to be an issue as more servicemembers move to TRICARE programs with civilian providers. Beginning this month, TRICARE Prime service areas are limited to within 40 miles of current or former military bases. Servicemembers living outside these zones are advised to switch to TRICARE Standard or TRICARE Extra.
Regardless of these issues, Dr. McGraw insists it would be difficult for him to practice in a group that did not accept TRICARE. “I have been blessed in my local area with patriotic physicians and clinics that accept my TRICARE health insurance,” he said. “There are many ways to show patriotism. Accepting TRICARE health insurance is certainly one of those ways.”
Elizabeth Fassbender is the communications specialist in the AAOS office of government relations. She can be reached at email@example.com