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Tricare Prime still out of reach for thousands of beneficiaries

May. 21, 2014 - 06:00AM   |  
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Retired Air Force Master Sgt. John Rytkonen was not happy last October when he was dropped from his Tricare Prime military health program.

In October, the Pentagon downsized areas served by Prime, and Rytkonen, in Sulfur, Louisiana, lives far from a military base where Prime is still offered.

He and his wife were forced to drop out of the health maintenance-style program and shift to Tricare Standard, the military’s fee-for-service program, which is more expensive for the couple.

So Rytkonen was excited to hear that Congress included a provision in the fiscal 2014 defense bill that would let him opt back into Prime.

What he didn’t know was that the original version of the bill, which would have given most of the 171,000 retirees and family members who lost Prime on Oct. 1, 2013, the chance to re-enroll in the program, had been watered down.

The final version guaranteed Prime access only to those who live within 100 miles of a military treatment facility and who agree to choose a network doctor within 40 miles of a military hospital or clinic — which means some beneficiaries might have to travel up to 60 miles for routine care.

The deal is essentially the same one Rytkonen had been offered when he first lost Prime, only with guaranteed access instead of being at the mercy of Prime availability at the base.

Either way, he and his wife would have to change doctors. And the closest physician who fit the program is 40 miles away down a treacherous two-lane road.

“Under Prime, we could manage our health care costs. We knew how much we paid for hospitalizations, appointments and co-payments,” Rytkonen said. “Now we’re afraid to see a doctor because if they order something that isn’t approved by Tricare, it could ruin us.”

About 76,000 Tricare beneficiaries received letters last month informing them they can re-enroll in Prime. But like Rytkonen, many are likely to have to change doctors and drive farther to see the new physician.

Managed health care programs like Tricare Prime were introduced in the 1990s to control rising costs of medical care and promote overall health, with an assumption that preventive medicine and healthy lifestyle choices would reduce future medical costs.

Prime service areas were expanded under previous Tricare contracts because “at the time, Tricare Prime was projected to [cost] less than Tricare Standard,” according to a Pentagon memo.

But this has not turned out to be the case and in 2007, when the Defense Department drafted the next generation of Tricare contracts, it moved to rein in Prime availability where it was offered by the Tricare regional contract managers.

The result: Roughly 171,000 Tricare Prime beneficiaries — retirees and family members — were disenrolled in October, with about 76,000 now being allowed back in under the significant new caveats.

Pentagon officials say Tricare Standard maintains the highest customer satisfaction of all Tricare programs and offers the most choice for treatments and care.

Unlike Prime, Standard requires no enrollment fees. But depending on how much health care a beneficiary needs, out-of-pocket costs can be higher under Standard, which requires cost-shares of 25 percent for most visits and an annual catastrophic cap of $1,000 for active duty families and Tricare Reserve Select beneficiaries and $3,000 for all others per family.

Many former Tricare Prime beneficiaries in the South region can save money by going to the physicians they were seeing before they were disenrolled, since the regional contract manager, Humana Military, maintains the same network of providers who offer a discount of a 20 percent cost-share.

Retired Air Force Col. Brady Cheek said he has been happy with Prime and watched the legislative moves last year carefully.

He lives about 100 miles from Fort Bragg, North Carolina, but was on Prime during the time when the entire South region was a Prime service area.

He is among many beneficiaries disappointed in the final version of the law.

“Bottom line, I can’t see the same doctors as I had under my original Prime,” Cheek said.

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