DoD to cut Tricare Prime in 5 West areas

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.

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.”

This was published in the Army Times, but I can't link the Army Times here at FR. This is an alternate source. (This is circulating big on FaceBook and via email.)

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They just keep whittling at it, don't they? The biggest reason to do your 20 is becoming less so every year.

I know that we're in dire straights. I know that everyone is going to have to take a hit to deal with this massive deficit.

But WHY do they keep coming after the vets? Every friggin' time Washington decides to save a few bucks, they slap the vets around first.

Isn't it amazing that congress never touches THEIR bennies? Oh no. They can do two years in the house and lap at the public trough for the rest of their lives. Staff Sgt (ret) Snuffy puts his body, family and life on the line for this country and I guess they figure they can bleed him just a little more.

These congress wonks need to have their pay and benefits tied directly to the military. Give them an E-5 pay the first term, then they can get 'promoted' every two years with a cap at E-9. Make them eat the same medical insurance that our vets do and make it mandatory that they go to the VA hospital if one is available.

I wonder what song they would sing then?

I’m glad you are able to use Tricare standard, but if you lived in the Philippines you would be mandated into a modified Tricare Prime. I won’t go into the weeds on it except to say that the guarantee of Tricare being a choice of Standard, Extra or Prime is being removed from us and we are being forced to use a very limited number of providers, many of whom are substandard or are quacks that retirees refuse to voluntarily use. See my earlier post; http://www.freerepublic.com/focus/f-vetscor/2943197/posts

Here is a letter I wrote to a journalist that had requested our input on the Triccare Philippine Demonstration Project;

Mrs. ********;

I understand that you are getting close to putting your article on the Tricare Philippine Demonstration Project to bed.

I would like to direct your attention to a situation that will illustrate that TMA/ISOS will dramatically limit access to quality medical care in the Demonstration Project area(s).

If you will look at the areas that TMA/ISOS have identified as phase 1 you will see that Orion, Bataan is one of those areas. I have been told by a TMA representative that from his understanding of the network being set up in Orion by ISOS that ISOS will establish the boundaries of the Orion network as the political boundaries of the Municipality of Orion. In other words, the Municipality borders as designated by the Philippine government.

Assuming that the boundaries are set as described above, and using the criteria stated by TMA in the Federal Register posting of September 2011 and the outline of the Demonstration Project printed in the Tricare Operations Manual, ISOS will be required to contract with a hospital within the Orion Municipality borders. All Tricare beneficiaries living within those boundaries MUST use only the network contracted provider(s). This then presents a glaring issue of lack of access to quality medical care, as I will describe below.

Orion is a municipality in the Province of Bataan. Wikipedia says;

Orion is a 2nd class municipality in the province of Bataan, Philippines. According to the latest census, it has a population of 49,164 people in 8,735 households.

According to the 2005 MUNICIPALITY OF ORION, BATAAN
ECOLOGICAL PROFILE, Orion has 1 hospital;

“Within the municipality, there is 1 hospital (Orion St. Michael
Hospital) with a total bed capacity of 19. In addition, there
are six (6) private medical clinics, 1 rural health unit and 13
barangay health stations. At the outskirts of Orion, there is
the Bataan General Hospital located in Balanga City.”

According to the Philippine Government PhilHealth, St. Michael Hospital is a level 2 hospital. A level 2 hospital is defined as;

“Level 2 Hospital

- Non-departmentalized hospital

- general medicine, pediatrics, surgery, anesthesia, obstetrics and gynecology, first level radiology, secondary clinical laboratory, pharmacy

- nursing care for patients needing intermediate supervised care”

Because TMA has made it clear that beneficiaries residing within the network boundaries must use the network providers, Tricare beneficiaries living in Orion will be required to use a hospital that is unable to provide the medical care that elderly U.S. military retirees and their families require and have earned by their service to the United States.

In the information that I referenced above, it is stated that just outside of the Orion boundaries there is a Philippine Government Hospital, (Bataan General Hospital, a 350 bed hospital that caters to the extremely poor and the low income population). But since this is a Philippine Government Hospital, it has a few private pay rooms or private pay semi-private rooms. Most Patients are placed in wards, usually 20-30 beds each, (according to one nurse’s resume on the internet, the surgical ward is a 15 bed ward).

(The retirees in Bataan tell me that this hospital is horrible. They say that you go in on a stretcher and come out in a hearse).

The patient is required to have a “watcher”, (usually a family member that stays with the patient 24/7 and is responsible to contact the nursing station if the patient has a medical issue. The watcher also is required to go to the pharmacy to purchase the medicines prescribed. In many of the General Hospitals the watcher will have to clean the restrooms, (which will have a commode without a seat, a bucket of water to flush the toilet and for showering). Patients are frequently required to bring their own bed linens and meals.

Obviously, the Bataan General Hospital is not a hospital that meets the Tricare Manual standards for hospitals, and since it is a government hospital, there is no way that TMA/ISOS could get this hospital under contract with the Demonstration Project.

In the Provincial capital, (Balanga, population 91,059 as of December, 2010), which is a 15-20 minutes’ drive from Orion, there are 4 hospitals, Bataan Women’s Hospital, (a level 2, 30 bed hospital), Bataan St. Joseph’s Hospital, (a level 3, 18 bed tertiary hospital), Isaac Catalina Medical Center, (a level 3, 90 bed hospital), and Bataan Doctors Hospital and Medical Center, (a level 2, 25 bed tertiary hospital).

The beneficiaries in Orion will travel to Balanga, Bataan to use Isaac Catalina medical Center for moderate to critical medical care, but, under the demonstration Project, will be restricted to the 19 bed, level 2 hospital in Orion. Failure to use St. Michael Hospital in Orion will result in the beneficiary being forced to pay 100% of the medical bill with no chance of being reimbursed.

The question that needs to be asked is; why did ISOS pick Orion, instead of Balanga, to be the Demonstration Project network area? Our opinion is that ISOS was unable to get any of the hospitals in Balanga to agree to be a Demonstration Project network provider and that since TMA had identified Bataan to be one of the areas to establish the Demonstration Project in, ISOS had to find a hospital willing to contract with them. Unfortunately, Orion St. Michael Hospital was the only hospital willing to take a chance with Tricare.

The beneficiary will be denied adequate, quality medical care based on this decision and their health will be placed in jeopardy.

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