Tricare Prime users in the West region will now need specialty care referrals and other pre-authorizations after a waiver period ended April 15.
Beneficiaries on Tricare Prime are typically required to receive approval from both a primary care physician and Tricare's regional contract before getting specialty care. But when a Jan. 1 system overhaul and contract swap to new regional manager Health Net caused chaos and backlogs, Tricare officials put in place an approval waiver.
That now-ended waiver period allowed those users to get specialty care from an in-network provider based only on written approval from their primary care provider, paired with a downloaded waiver approval letter from Health Net.
The waiver system can be used for care through June 15, so long as it was ordered by a physician before April 15.
Tricare officials said they are confident HealthNet can now handle the required volume of pre-authorization requests. They said the contractor has been gradually ramping up to an expected 10,000 referrals per day by processing requests submitted by military treatment facilities.
Officials said they do not know how many West region beneficiaries used the waiver system.
Meanwhile, an April 13 report from the Government Accountability Office says that the Defense Health Agency, which manages Tricare, has not addressed some of the requirements for the revamped Tricare Select system, previously known as Tricare Standard.
The 2017 National Defense Authorization Act required Tricare officials to use a series of seven elements in planning and implementing Tricare Select, including making sure that at least 85 percent of the Tricare Select beneficiary population had network coverage on Jan. 1 and putting in place access standards for health care appointments.
GAO officials found that while the Pentagon's plan for Tricare Select did address all of the required elements, officials did not fully develop plans for exactly how they were going to execute them. And although they were to put in place access standards, the plan did not say how they were going to do that.
Pentagon officials told GAO that the regional contractors are developing their own access standards that must be approved by Tricare officials. They said they would provide written documentation of those standards to Congress by June 30.
Those missing pieces, GAO said, will be a roadblock for Congress when it comes time to provide oversight.
"Without the most current information, it will be difficult for Congress to determine whether the department is achieving its mission of ensuring that beneficiaries receive the right level of care, at the right time, delivered by the right provider," the report concludes.
-- Amy Bushatz can be reached at firstname.lastname@example.org.