Download presentation
Presentation is loading. Please wait.
Published byJasper Caldwell Modified over 6 years ago
1
Understanding TRICARE: Present and Future Challenges/Changes
Brief to US Army Recruiting Command Annual Leaders’ Training Conference Mr. Michael Griffin, Health Plan Management, G-3/5/7 26 October 2017 Unclassified
2
Purpose and Outline Outline: Recent History
Purpose: Provide an overview on past, present, and future events that have shaped the current TRICARE Health Plan and provide an overview of upcoming changes. Outline: Recent History TRICARE/Military Health System Overview Comparison of TRICARE to US HC System Overview of upcoming changes Unclassified//FOUO
3
Recent History NDAA 17 approved DEC 16 with Major TRICARE and Direct Care Changes Report critical of MTF access to care as well as cumbersome referral and authorization process for specialty care NDAA 16 – No major change other than UCC Pilot AD in Direct Care But A Proposed FEHBP Like Option with a Basic Allowance for Health Care for Others APR 2015 – National Military Family Association Report on Acute Care Campaign Findings & Recommendations released. Jan Military Compensation and Retirement Modernization Commission (MCRMC) final report released. May 2014 – SECDEF ordered MHS Review of Access, Quality, and Safety following concerns at VA Unclassified//FOUO
4
National Defense Authorization Act
NDAA 2017 Section 701: TRICARE Select replaces Standard; beneficiary must be in Prime or Select to have coverage; fee changes, etc. Section 702: Reform Admin of DHA and MTFs Section 704: Access to Urgent/Primary Care under TRICARE; mandates expansion of hours at MTFs where needed Section 705: Push for Value Based Purchasing Section 709: Standardized system for scheduling appointments at all MTFs Section 718: Enhancement on the use of telehealth in MTFs Numerous other provisions in NDAA 17: For more information see Unclassified//FOUO
5
What is TRICARE? DoD’s integrated health care delivery system (MTF + civilian sector care). Administered by the ASD(HA). Congress and Legislation drives this train….
7
7
10
MTF and PSA Enrollment Areas
TRO Enrollment Waiver & Prime Travel Benefit MTF and PSA Enrollment Areas MTF Enrollment Waiver TRICARE Prime Remote Prime Service Area “Catchment Area” MTF Enrollment Area MTF 30 min drive time 40 miles 50 miles/1hr drive time < 100 miles HA Policy 100 miles
11
Military Health System
Direct Care System Purchased Care System MTF Business Plan MTF Optimization Leakage (good or bad?) MTF Business Plan Military Treatment Facilities (MTFs) TRICARE Contractors TRICARE Prime Enrollees Some Space Available Care Patients Enroll - TRICARE Prime or Choose Standard or Extra
12
How Has the Landscape Changed?
Since 2004: National HC costs have gone from 16% to nearly 18% of GDP DoD HC has gone from 7% to almost 8.3% 23.6% beneficiaries are over 65; by 2020 could be 25% Large drop in those with other health insurance Addition of numerous health plans covering more lives Little to no change in fee structure since 1995! Minimal Congressional changes until past two years. Unclassified//FOUO
13
TRICARE Triple Option Across the spectrum...Current Options
(Freedom of Choice relational to Cost) ALL ADSM To include RC on Orders >30 days ADFM / Retirees Personal Cost $$ FFS – TRICARE Standard PPO – TRICARE Extra As an EMPLOEE you need to understand this simple aspect of health plans. The more freedom of choice, the more expensive to the consumer. CQ HEALTHBEAT NEWS Aug. 17, 2007 – 3:39 p.m. Health Care Costs Rise for Employers, Workers By CQ Staff The average yearly premium for employer-sponsored coverage rose from $6,772 in 2000 to $10,728 in 2005, according to new data from the Agency for Healthcare Research and Quality (AHRQ). During the same period, the average annual premium cost of single-person coverage increased from $2,655 to $3,991. For family coverage, workers contributed $971 more in 2005 than they did in 2000, with premiums increasing 60 percent, from $1,614 to $2,585 per year. Workers with single-person coverage paid an average of $273 more per year for their premium in 2005 compared with 2000, a 61 percent increase. The employer’s share of benefit costs also rose during that period, paying 58 percent more — from $5,158 to $8,143 per year — for each family plan taken by employees. Employers also paid $1,063 more for each single plan in 2005 compared with 2000, a 48 percent increase. Among the nation’s 10 largest cities, New York City had the highest average overall cost for a family plan premium at $11,819. Workers paid $2,564 of that total. Los Angeles had the lowest average overall cost for a family plan at $10,122, with workers paying $2,386. HMO – TRICARE Prime Freedom of Choice
14
Other TRICARE Plans TRICARE:
Young Adult – children up to age 26; standard or prime; $216 or $319/month (CY 17 Rates) Reserve Select : RC member/family - $47.82 or $217.51/month (CY17) Retired Reserve: Retired RC member/family - $ or $ /month (CY 17) For Life – MEDICARE wraparound coverage; member must pay part MEDICARE part B premium: If drawing Social Security $109/month Plus – MTF Commanders Program; Allows TFL beneficiary to have “prime” access to MTF for primary care. US Family Health Plan – Prime option is six areas of country via community based not-for-profit health system; enrollee not eligible for MTF care TRICARE Prime Retiree $ or $ (annual enrollment fee). Unclassified//FOUO
15
Initial Discussion Questions
Do we have a healthcare system or a disease management system in the US? Incentives - what do we have vs. what should we have? How much personal responsibility do we take? What does the future hold? Who are the winners and losers? Unclassified//FOUO
16
A System Out of Balance Unclassified//FOUO
17
Distribution of Health Plan Enrollment for
Covered Workers, by Plan Type, NOTE: Information was not obtained for POS plans in A portion of the change in plan type enrollment for 2005 is likely attributable to incorporating more recent Census Bureau estimates of the number of state and local government workers and removing federal workers from the weights. See the Survey Design and Methods section from the 2005 Kaiser/HRET Survey of Employer-Sponsored Health Benefits for additional information. SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, ; KPMG Survey of Employer-Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988.
21
The Future of TRICARE Thank you for having me with you today.
This brief provides an overview of upcoming TRICARE changes that affect your medical benefits.
22
Today’s Agenda TRICARE is our health care program for uniformed service members and their families around the world. The vision is for TRICARE to be a world-class health care system that supports the military mission by fostering, protecting, sustaining and restoring health. The Defense Health Agency, or DHA, is modernizing the Military Health System to better serve our 9.4 million beneficiaries worldwide and respond to changes in law and policy. On Jan. 1, 2018, there will be several changes to your TRICARE benefit. As a TRICARE beneficiary, you can expect a modernized and easier to understand plan with: More benefit choices Improved access to care Simplified cost shares, and more This brief outlines a few of the changes you will notice in 2018 and some recent updates to your TRICARE benefit that have already occurred. Today we will talk through the seven listed on this slide: Increasing access to care Benefit updates Consolidating TRICARE regions Moving to TRICARE Select Enrollment changes Health plan costs TRICARE changes checklist Take command of your health care: TRICARE is changing: Changes are coming to TRICARE beginning Jan. 1, 2018. This is your benefit: We want to you to be aware of the changes to your TRICARE benefit and connect you to resources to navigate your benefit. Are you ready?: We will help you know when and how to take action to prepare for the upcoming changes.
23
Increasing Access to Care
The Defense Health Agency, or DHA, initiated many improvements to improve the focus on patients, starting with better access to care: Nurse Advice Line: You can talk to a registered nurse 24/7 who can help you determine the right level of care you need for yourself or your child, schedule military hospital or clinic appointments and much more. Mobile Health/eHealth: Access to care was expanded through online and mobile apps. There are now many ways to engage with a doctor. Urgent Care: There will be more access to urgent care services without a preauthorization. One Call Resolution: This is a policy in place since 2015 to resolve appointment requests on the first call from the patient. This policy requires first call resolution for all patients requesting appointments at military hospitals and clinics. Under this policy, beneficiaries will not be asked to call back for an appointment. Expanded Hours: We understand the challenges of working families and expanded hours for primary care services to serve beneficiaries, now mandated by Congress. Check with your local military hospital or clinic for options in your area. Put all of these together, and we have one of the most accessible primary health systems in the country. But, there are more opportunities ahead that DHA is working quickly to modernize health care benefits. In 2018, you will have even greater access to care. At military hospitals and clinics, this will include: More appointments available, especially after work or school. More urgent care clinics opening at facilities with high demand and volume. Faster specialty care appointing once you get a referral for care. A streamlined process for getting network referred appointment results. Also, we will partner with designated network urgent care clinics to provide integrated, seamless access to care. , Option 1
24
Expanding Mental Health Benefits
TRICARE expanded mental health and substance use disorder, or SUD, medical benefits by adding intensive outpatient programs and expanding options for opioid treatment. Improvements in coverage now include: Increased access to mental health and substance use disorder programs, including opioid treatment programs and office-based opioid treatment Inpatient, residential and outpatient care for mental health and SUD Reduced restrictions on the number of treatments for SUD treatment, smoking cessation counseling and outpatient treatment Lower out-of-pocket costs In addition to other improvements, this expansion improves access to care and increases opportunities for mental health and substance use disorder treatment. It also makes it easier for beneficiaries to access the right level of care for their health and wellness needs. Families will pay the same out-of-pocket costs for mental health and substance use disorder services that they pay for medical and surgical care. The mental health and substance use disorder benefit covers dependent beneficiaries and retirees, but does not apply to active duty service members. To find a provider, beneficiaries can contact their respective regional contractor or visit Learn more about mental health and substance use disorder care that TRICARE now covers at When you have a mental health emergency, call 911 or go to the nearest emergency room. For emergencies overseas, call your TRICARE Overseas Program Regional Call Center and choose option 1 for medical assistance.
25
Express Scripts Automatic Refill Program
With Express Scripts Automatic Refill program, your prescriptions are automatically refilled for you and delivered right to your home. Beginning Sept. 1, 2017, Express Scripts will require annual consent from patients who want to receive automatic refills of their medications enrolled in TRICARE Pharmacy Home Delivery. When the last refill of a medication enrolled in the Auto Refill program ships, Express Scripts will contact you by telephone and/or to know: If you would like your doctor to be contacted to renew the prescription and If you would like to continue in the Auto Refill program Express Scripts will not re-enroll your medication unless they hear from you. You have several ways to respond: Online at Via the automated phone call from Express Scripts By calling an Express Scripts Patient Advocate at Learn more about this change and what action is required at
26
TRICARE 2017: Two Regions Health Net Humana
There are also additional changes in store that will impact how TRICARE is managed and delivered to beneficiaries. In 2016, DHA awarded new regional contracts. These are known as the T2017 contracts that consolidate the current three regions into two. Starting Jan. 1, 2018, TRICARE North and South will combine to form TRICARE East, while TRICARE West will remain mostly unchanged. Humana Military, of Louisville, Kentucky, will manage the East Region contract. Health Net Federal Services, LLC, of Rancho Cordova, California, will manage the West Region contract. There will be added improvements in the delivery, quality and cost of your health care from previous contracts. An example of an improvement is a hip or knee replacement. TRICARE will cover a global fee for up to 30 days post surgery, so hospitals and doctors are incentivized to get you to the right physical therapy, and the right home support services, so you recover more quickly…and don’t need to be readmitted. Such changes will address Congress’ requirement to introduce “value based payments” that means beneficiaries will pay for the outcomes they receive. The DHA is looking for opportunities to do more around the concept of “value based care” with the patient’s needs in mind first. We want to look at simplifying the rules, and make it easier for patients to connect with their doctors without an appointment. If you have ideas, please share them. Changes will be minimal for overseas beneficiaries. To make sure you are prepared for the transition, please visit the “Changes” page on the TRICARE website at
27
Moving to TRICARE Select
As a result of the 2017 NDAA discussed earlier, there also will be changes to TRICARE programs. Starting Jan. 1, 2018, TRICARE Select will replace the TRICARE Standard and TRICARE Extra health plans, and act as a preferred provider organization (PPO) style plan. Most provisions will go into effect on Jan. 1, 2018, with full implementation occurring on Jan. 1, 2019. Those currently eligible for TRICARE Standard or Extra will be automatically enrolled in the new plan, TRICARE Select. New active duty family members will be automatically enrolled in TRICARE Prime if their zip code is in a Prime Service Area. If active duty family members live outside a Prime Service Area or overseas, they will be enrolled in TRICARE Select. Otherwise, beneficiaries eligible for TRICARE Standard or Extra will need to select either TRICARE Prime or Select to maintain purchased care coverage. Beneficiaries who change to TRICARE Select will not get a decrease in coverage. TRICARE Reserve Select, TRICARE Retired Reserve and TRICARE Young Adult plans will continue as is with comparable co-pays to TRICARE Select.
28
Enrollment Changes During open enrollment season, all eligible enrollees will be able to change their TRICARE enrollment to another TRICARE plan or do nothing and stay in the same plan. Administration of the TRICARE benefit transitions from a Fiscal Year (October – September) to a Calendar Year (January – December). There will be a transition period for beneficiaries from Oct. 1, 2017 to Dec. 31, During this time: Enrollment fees will be prorated for the three-month period (Oct. 1, 2017 – Dec. 31, 2017) and billed accordingly for beneficiaries who pay on a monthly or quarterly basis. Beneficiaries who pay fees on an annual basis will have their payments credited toward the transition period and any future enrollment fees. TRICARE Prime beneficiaries will need to pay one quarter’s premium to cover Oct. 1, 2017 – Dec. 31, Then actual renewal will begin on Jan. 1, 2018. Beneficiaries may enroll and disenroll in TRICARE health plans at will during the grace period between Jan. 1, 2018 and Dec. 1, 2018. Beginning Jan. 1, 2019, if beneficiaries choose to switch between Prime and Select, they must do so during an open enrollment period or within 90 days of a qualifying life event like marriage, divorce, child birth, moving and others.
29
Enrollment Freeze Due to the 20th of the month rule and the enrollment freeze beginning Dec. 1, 2017, beneficiaries should complete all enrollment actions on or before Nov. 20, 2017. TRICARE Prime coverage effective date for the initial enrollment of active duty family members and non-active duty is determined by the 20th of the month rule. If your regional contractor receives your enrollment application on or before the 20th of the month, your coverage will begin on the first day of the next month. If the application is received after the 20th of the month, the coverage begins on the first day of the second month following receipt of your application. Starting Dec. 1, 2017, there will be an enrollment freeze for TRICARE Prime enrollments, and primary care manager changes will be delayed during the transfer of files to new regional contractors. You will still be able to receive care during the enrollment freeze. If you have a problem accessing care, contact your regional contractor. Eligible beneficiaries must be registered in the Defense Enrollment Eligibility Reporting System, or DEERS, to enroll in TRICARE Prime or a Prime option online, by phone or by mail. You can enroll by: Using the Beneficiary Web Enrollment, or BWE, website at Calling your regional contractor Submitting a TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form (DD Form 2876) to your regional contractor. Visit to download DD Form 2876.
30
Health Plan Costs for 2018 Starting on Jan. 1, 2018, costs for TRICARE benefits will be charged by Calendar Year (January - December) instead of Fiscal Year (October – September). You will fall into one of two groups based on when you or your sponsor entered active duty. Each group will have different enrollment fees and out-of-pocket costs: Group A: If you or your sponsor’s initial enlistment or appointment occurred before Jan. 1, 2018, you are in Group A. Group B: If you or your sponsor’s initial enlistment or appointment occurs on or after Jan. 1, 2018, you are in Group B. You may need to pay an enrollment fee, depending on your plan and when you became eligible for TRICARE. Some costs will change annually starting on Jan. 1, 2018.
31
Costs for Active Duty Family Members
If you’re an active duty family member using a TRICARE Prime plan or TRICARE Select plan: You won’t pay an annual enrollment fee, but you may have to pay cost-shares when you get care outside of the military hospital or clinic. Regardless of health plan, your family catastrophic cap will be $1,000 each year. If you use TRICARE Select, you will also have individual and family deductibles. If you’re in TRICARE Prime and choose to get specialty care without referral or authorization, that is our point-of-service, or POS, option. With POS, you will have to pay the deductible and 50 percent of the cost for your TRICARE covered treatment. Any deductibles or cost-shares for POS don’t count toward your catastrophic cap. TRICARE costs are subject to change. Special conditions for differing costs may exist. Go to for the most up-to-date cost information.
32
Costs for Retirees, Retiree Family and Other Plan Users
If you’re a retired service member, retiree family member or using any of the premium-based plans: You may pay an enrollment fee depending on your group and your plan. You may also have deductibles, and cost-shares. Regardless of health plan, you will be protected by a catastrophic cap. If you’re in TRICARE Prime and choose to get specialty care without referral or authorization, that is our point-of-service, or POS option. With POS, you will have to pay the deductible and 50 percent of the cost for your TRICARE covered treatment. Any deductibles or cost-shares for POS don’t count toward your catastrophic cap. Premium-based plans include: TRICARE Young Adult (TYA) TRICARE Retired Reserve (TRR) TRICARE Reserve Select (TRS) Continued Health Care Benefit Program (CHCBP) If you have a premium-based plan, you will continue to see your yearly premiums adjusted each year on Jan. 1 the way they have been in the past. These yearly adjustments are required by law, and will be calculated the same way they are today. Costs won’t change for TRICARE For Life, or TFL. Also, there are no changes in TFL eligibility, benefits, or the requirement to have Medicare Part A and B. TRICARE costs are subject to change. Special conditions for differing costs may exist. Go to for the most up-to-date cost information.
33
TRICARE Changes Checklist: What You Need to Do
In the coming months, you’ll here more about changes to TRICARE in 2018. Use this checklist, which highlights some things you can do to prepare now for changes in 2018 and when to expect some of these changes. To learn more, visit
34
TRICARE Changes Checklist: What You Need to Know
Take command and prepare now for changes in 2018.
35
Are you Ready? To have more control over your healthcare, prepare for the upcoming changes to TRICARE by taking the following actions: Update your contact information in the Defense Enrollment Eligibility Reporting System, or DEERS, for you and your family. Go to Call (TTY/TDD: ). Fax updates to Sign up for eCorrespondence in milConnect to get notifications. Log in to and update your profile. Visit the TRICARE website. Go to Sign up for alerts about the changes at the link available at You will get an anytime this page is updated.
36
Looking for More Information?
This slide shows current contact information for stateside and overseas regional contractors, as well as other important information sources. Remember, your regional contractor is based on where you live. Starting Jan. 1, 2018, TRICARE North and South will combine to form TRICARE East, while TRICARE West will remain the same. Humana Military, of Louisville, Kentucky, will manage the East Region contract. Health Net Federal Services, LLC, of Rancho Cordova, California, will manage the West Region contract. Your new regional contractor will contact you in the fall. Your regional contractor is your main resource for customer service, claims processing and prior authorization for certain health care services.
37
TRICARE Option’s Effective 1 JAN 2018
Across the spectrum... (Freedom of Choice relational to Cost) ALL ADSM To include RC on Orders >30 days ADFM / Retirees Personal Cost $$ FFS – TRICARE Select (Out of Network Provider) PPO – TRICARE Select (In Network Provider) HMO – TRICARE Prime Freedom of Choice Enrollment required for both Prime and Select or access to Direct Care System only
38
Questions
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.