A short sentence buried in a series of major Tricare reforms passed by Congress in 2016, set to roll out late this year, is causing alarm among military family advocates. They worry that the measure will block Tricare beneficiaries from accessing the healthcare they need.
Currently, active duty military families can at any time switch members of their household from Tricare Prime (the system's default, military clinic-based plan) to the plan currently known as Tricare Standard. That plan allows civilian-based care and self-referrals. Once users make the swap, they often are locked into the new plan for a year.
But new rules passed by Congress in 2016 include a requirement that families who want to use Tricare Standard, soon to be known as Tricare Select, go through an "open enrollment" period each year or automatically move into Tricare Prime. Missing the open enrollment period will lock users into the Prime plan unless they experience a "qualifying life event" (QLE) that allows them to move, according to the legislation.
The change does not impact Tricare for Life.
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Many active duty military families currently report using the ability to swap from Tricare Prime, which is free, to cost share-based Tricare Standard as an "escape hatch" -- to flee from what they see as inadequate care or being plagued by hassles and long wait times, officials with the National Military Family Association (NMFA) said.
For example, military spouses often switch to Standard so they can avoid giving birth at a military treatment facility and instead use a civilian hospital, NMFA said. Others make the switch for the ability to more easily access specialty care without first going through their primary care manager, a requirement under the Prime plan.
But the new law does not dictate what counts as a "qualifying event," leaving it up to the Defense Health Agency, which oversees Tricare, to set the policy. And that has military family advocates worried. Although Tricare officials have not yet publicized the qualifications, the civilian health care industry has a set of reasons seen as "industry standard" -- and pregnancy and care complaints are not among them.
"Commercial plans typically define QLEs as changes in household (e.g., getting married or divorced, birth of a baby or adopting a child), relocation or loss of health insurance. Without a QLE, you're stuck with your Tricare plan choice until the next open enrollment -- even if the health care you're receiving doesn't pass the smell test," officials with the National Military Family Association noted in a recent post on their site. "We're concerned that an annual open enrollment period may effectively trap military families in the MTF, regardless of the problems they experience with access or quality of care."
Tricare users may have more than just grievances behind their reasons for wanting to switch plans, officials with NMFA said. Picking Tricare Prime over Standard means accessing the military treatment facility and being willing to jockey for appointments, both of which can involve major time commitments when compared to civilian, community-based care.
"There are several different reasons I can think of as to why a family might want to switch to Standard -- and they might not want to wait six months to do so," Karen Ruedisueli, a government relations deputy director at NMFA told Military.com. "It can even be as simple as a spouse gets a job and no longer has the time to devote to getting care at the MTF and navigating [Tricare] Prime."
Ruedisueli said Tricare officials are working with NMFA and others for feedback on the changes, and she is hopeful that policy makers will take into account the reasons military families choose Standard over the free Prime plan as they write the new rules.
"This presents the perfect opportunity for DoD to understand why is it that some people want to pay out of pocket for medical care when you have this no-cost option," she said.
This story was updated July 24 to clarify which Tricare users are impacted by the change.