Beneficiaries who live within 100 miles of a military hospital or clinic but at least 30 minutes away by car no longer need to request a waiver to stay with Tricare Prime, the Defense Department's managed-care health program.
Under the next-generation Tricare contracts that went into effect Jan. 1, patients who move to a location outside that access standard for primary care can choose to receive care at the DoD facility or, if they already receive care there, keep their primary care manager without seeking a waiver.
According to the Defense Health Agency, beneficiaries who meet the criteria will receive a letter notifying them that their homes are outside the access-standard measure, but if they don't respond, they will remain with their current primary care managers, or PCMs, at their military treatment facility.
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Those who want to change primary care managers, however, can do so by following instructions in the letter.
"This new approach will help prevent unnecessary coverage gaps and ensure families keep access to their PCMs," said Shane Pham, a DHA management and program analyst, in a news release last week.
The change was among the requirements of the new contracts, known as T-5, which were issued to TriWest Healthcare Alliance in the Tricare West Region and Humana Military in the Tricare East Region on Jan. 1.
The allowance also coincides with an effort at the Defense Department to bring family members and military retirees back into military hospitals and clinics to ensure that the facilities have enough patients to maintain provider proficiency and curb the rising costs of private-sector care.
According to a memo issued Dec. 6, 2023, by then-Deputy Secretary of Defense Kathleen Hicks, the DoD hopes to increase the number of patients seen at military treatment facilities by 7% by the end of 2026, or a total of 3.3 million patients.
In a speech to uniformed and civilian federal health officials in March, Acting Assistant Secretary of Defense for Health Affairs Dr. Stephen Ferrara said the DoD is pursuing the efforts in order to create a high-functioning medical system.
"The last thing that a family or that service member needs is to be worried about whether their family is getting adequate or high-quality care," Ferrara said.
According to Tricare officials, the decision to drop the drive time waiver was made based on patient satisfaction surveys showing that many beneficiaries are willing to drive more than 30 minutes to keep their primary care doctors and would prefer not to switch physicians.
If a Tricare Prime beneficiary moves more than 30 minutes from their PCM, their Tricare regional contract will contact all adult patients in the household by phone, text, mail and email to provide options for continuing their health coverage.
Patients will have 90 days to decide what to do. If they now live more than 30 minutes but less than 100 miles away, they won't have to do anything to keep their Tricare Prime coverage and primary care manager. Or they can switch health plans -- to Tricare Select or the U.S. Family Health Program, if it is available in their region.
If patients have moved more than 100 miles away from a Tricare Prime Service Area, they must decide within 90 days to switch to another plan. They will be dropped from Tricare Prime after 90 days and will be able to be seen at a military hospital or clinic only if space is available.
Defense Health Agency officials urge all beneficiaries to ensure that their addresses are updated in the Defense Enrollment Eligibility Reporting System, or DEERS, and they also should check the email addresses and phone numbers the DoD has on file for accuracy.
Since the contract changeover Jan. 1, Tricare providers and patients have experienced disruptions to patient care and payments, resulting in patients having to switch providers or delay care and prompting providers to take out loans to pay staff while they wait for reimbursements.
The problems have caught the eye of lawmakers on Capitol Hill as well as military leadership, including the services' top enlisted leaders.
During a hearing last week before the House Appropriations subcommittee that oversees military construction, Master Chief Petty Officer of the Navy James Honea said he personally has received complaints from providers about the reimbursement delays.
"The Defense Health Agency to their credit has worked diligently with me, with the contract, to have those bills paid as quickly as possible. But as we are continuing through this transformation, we are finding more and more places that we are challenged [to find] health care providers," Honea said.
Last month, Republican Reps. John Rutherford and Aaron Bean of Florida wrote to David Smith, the acting DHA director, asking him to explain the delays and fix them.
"It would be unacceptable for military families to lose access to critical care coverage. This crisis must be immediately rectified," they wrote.
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