Tricare Prime, the military's managed care option for 5.5 million beneficiaries who enroll for a modest fee to be guaranteed timely access to primary care, would cease to exist within a few years under the "Consolidated Tricare" plan proposed in the 2015 defense budget.
Networks of care providers, built for Prime, would not go away and neither would their military patients, say architects of the plan. Instead, patients and providers would see the Tricare program transformed into a preferred provider network with higher fees and more choice.
Patients could stay with their providers or exercise the freedom of a preferred provider system to choose their own physicians.
Those who opt to find new physicians would receive discounts on fees if they select doctors who remain in the Tricare network.
Families whose care is managed by military providers under a "medical home" concept could stay there, but would not be "enrolled," as under Prime, where every referral to a specialist needs pre-authorization.
The end of Prime, consolidation of Tricare as a preferred provider plan, plus charts of higher fees and co-pays, are highlights of the plan to transform the military health benefit, as delivered to Congress last week.
Fee increases would be more broad than deep, with some surprising exceptions.
For example, current Tricare for Life beneficiaries would be exempt from the first enrollment for that plan.
Only retirees and family members who age into the plan after the fee takes effect would be impacted, protecting the generation most often promised free health care for life.
By fiscal 2016, new Tricare for Life users would be charged 1 percent of gross retired pay but no more than $300 a year ($400 for flag and general officers). The fee would rise to 2 percent of retired pay by 2018, capped at $600 ($800 for generals and admirals). Caps thereafter would be raised yearly to match inflation.
Also exempt from most fee increases would be medically retired service members and survivors of members who die while on active duty.
One controversial change would be an annual "participation fee" for most retirees under 65 to stay eligible for military health care. As of Jan. 1, 2016, when consolidated Tricare is to take effect, the participation fee would be set at $286 per individual, $572 for a family.
The participation fee and size inspired one critic to describe consolidated Tricare as "Tricare Standard with an enrollment fee."
That description is off mark, said Army Maj. Gen. Richard W. Thomas, director of health care operations for the Defense Health Agency, because it ignores the "robust, high quality Tricare network of providers" that the Defense Health Agency vows to sustain.
"Beneficiaries will have access to tools we have brought online over the last decade or so, to include Tricare Online which allows them to make appointments, email military providers over a secure system, and obtain prescription drugs. And importantly, beneficiaries who use military treatment facilities or network care will have no deductible and substantially lower costs than those who select the non-network, civilian-only care of Tricare Standard today," Thomas said.
With Consolidated Tricare, beneficiaries could keep their providers and see "slightly increased copayments for care, but these remain below Standard and below most private health insurance cost-sharing levels."
Over the past eight years, every Pentagon plan to corral health care costs focused exclusively on raising fees, co-pays and deductibles, with the biggest pops aimed at working-age military retirees. This year Defense leaders adopted for a new playbook for Tricare reform, desperate to find immediate health care savings because of budget sequestration and to support the Military Compensation and Retirement Modernization Commission. The Joint Chiefs have joined in backing fee increases that are less severe than The Pentagon sought earlier, but are accompanied by profound changes to the Tricare benefit.
Total projected savings are $9.3 billion over the first five years, with almost $4 billion of that from benefit consolidation rather than fee hikes.
Active duty members would continue to receive priority access to care at no cost. Other beneficiaries still would see their lowest costs on base, followed by preferred provider care, and then care from outside the network.
Most retirees under age 65 and their dependents would face co-pays for the first time at base clinics or hospitals: $10 for a primary care visit; $20 for specialty care, $30 for urgent care and $50 for an emergency room visit, a move intended to curb abuse of ERs to receive routine care.
The same working-age retirees and family members would face co-pays $10 to $25 higher using preferred providers. To use out-of-network providers, active duty family members would pay 20 percent of allowable costs and working-age retirees and families 25 percent, as under Standard.
Working-age retirees would pay the annual TRICARE participation fee even if they use employer health insurance as first payer.
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