Some Tricare users will soon be allowed to use in-network urgent care providers without receiving any authorization under a new Tricare pilot program set to start May 23, according to policy documents released Tuesday.
The three-year pilot, ordered by Congress as part of the 2016 National Defense Authorization Act, will allow most Tricare users two urgent care visits per beneficiary, per fiscal year without official authorization from a provider or official. After those two visits have been used, beneficiaries can continue to use urgent care as long as they receive a referral.
"The purpose of the pilot is to ... determine if the elimination of the requirement to obtain a referral or preauthorization for urgent care visits improves access to urgent care, helps enrollees to choose the most appropriate source for the health care they need … potentially lowers health care costs for the Department of Defense (DoD) and/or improves patient satisfaction," the policy document states.
Currently Tricare Prime users must receive prior authorization to visit an urgent care. Emergency room visits, however, are free. Because of that military families often default to emergency room use when they cannot get an appointment with their primary care provider, military family watchdogs say. The urgent care pilot program, they say, is aimed at fixing that.
Most Tricare users will be a part of the pilot, the document states. Active-duty service members and activated Guard and Reserve members enrolled in Tricare Prime Remote and all other beneficiaries enrolled in Tricare Prime, Tricare Prime Remote or Tricare Young Adult, including retirees, will be allowed two non-authorized visits per year. Tricare Overseas Program users seeking care in the U.S. will be permitted unlimited urgent care visits without authorization, the policy state.
Not included in the pilot, however, are enrollees in Tricare Standard, Tricare Reserve Select or Tricare Retired Reserve. Those users currently do not need urgent care authorization and receive care there at no cost provided their yearly $300 deductible and up to $3,000 catastrophic cap has been met. Tricare Overseas Program users who are not in the U.S. also do not qualify for the program. Tricare for Life users are also not included in the pilot program.
To avoid using one of their no-authorization urgent care visits, Tricare officials say included users should get a referral from their primary care provider or the Tricare nurse advice line at 1-800-874-2273.
Tricare is required by law to update Congress annually on the pilot program’s results, including on whether or not it is helping the system save money on emergency room visits by allowing beneficiaries easy access to urgent care.
Officials with the National Military Family Association said they are pleased with the pilot roll-out but wish it included more allowed non-referral visits.
"We don’t oppose a cap, but we believe a cap should’ve been higher," said Karen Ruedisueli, deputy director of government relations for NMFA. There are many legitimate reasons why people might have to have more than two urgent care visits. If they had had a higher cap, let’s say six or eight a year, it would’ve really allowed them to see how much suppressed demand is out there."