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Six million military healthcare beneficiaries, those who live in TRICARE's North and South regions, will have new managed care support contractors and claim processors to deal with by April of next year.
In a surprise development, two of three current TRICARE contractors -- Health Net Federal Services and Humana Military Healthcare Services -- lost to rival firms in their bids to handle next-generation support contracts. The three contracts are worth a total of $55.5 billion over five years.
Support contractors are critical to how beneficiaries perceive benefits. They run TRICARE's triple option of managed care (TRICARE Prime), preferred provider network (TRICARE Extra) and fee-for-service insurance (TRICARE Standard). Contractors build and manage provider networks, and control care referrals, enrollment, claims processing and customer service.
Aetna Government Health Plans of Hartford, Conn., will take over from Health Net in the North Region for three million beneficiaries in Connecticut, Delaware, District of Columbia, Illinois, Indiana, Iowa (Rock Island Arsenal area only); Kentucky (except Fort Campbell area); Maine, Maryland, Massachusetts, Michigan, Missouri (St. Louis area only); New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, and Wisconsin.
UnitedHealth Military & Veterans Services of Minnetonka, Minn., will take over the South Region from Humana. Its 2.9 million beneficiaries live in Alabama, Arkansas, Florida, Georgia, Kentucky (Fort Campbell area only), Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee, and Texas (excluding areas of Western Texas). UnitedHealth also will administer the Continued Health Care Benefit Program which provides premium-based transition health coverage to beneficiaries who lose military benefits.
TriWest Healthcare Alliance of Phoenix, Ariz., will remain TRICARE's support contractor for 2.7 million beneficiaries in the West Region. Here's a link to more information on the new contracts: http://www.tricare.mil/t3contracts/
It won't be known for another week or two whether losing bidders will file official protests. Barring any legal delays, health care delivery under the new contracts will begin April 1 after a ten-month transition.
Joyce Wessel Raezer, director of government relations for the National Military Family Association (NMFA), said this dramatic shift in contractors, affecting two-thirds of beneficiaries, was unexpected and creates uncertainties in a military community already under enormous stress.
"We were thinking maybe one incumbent would go, because you don't want to have such big contracts in a small group [of firms] forever. But the idea that two would go? Looking at how this might affect military families, I'm a little nervous," Raezer said.
Under current contracts, the TRICARE system "matured and became a source of stability in a very unstable time," Raezer said. Any big complaints today involve base clinics and hospitals, "not the contractor side," she added.
TRICARE officials say the new contracts will ensure a smooth transition with no decline in quality of care or services. Military treatment facilities will still be the center of the system, the first choice for patient care. But incentives are designed to improve contractor performance, the quality of clinical care and disease management, and encourage cost efficiencies.
TRICARE Prime and Extra still will be available in the areas surrounding existing military treatment facilities and at designated base-closure areas. However, managed care networks now run more than 40 miles from a military treatment facility are expected to disappear.
By one estimate this could force up to 175,000 Prime users - all of them retirees, retiree spouses or survivors - to shift to use TRICARE Standard. Standard users typically have higher out-of-pocket costs but also more freedom to choose their own health care providers.
TRICARE officials say they don't know yet how many remote Prime Service Areas will end with the new contracts. But the new contracts alone can't be blamed for tighter controls on managed care. TRICARE policy already requires beneficiaries who live more than a 30-minute drive from a military treatment facility, but less than 100 miles away, to get a waiver from the MTF commander and TRICARE region to remain in managed care.
"We knew there weren't going to be as many Prime Service Areas," said Raezer. This shouldn't impact active duty families who still will have access to TRICARE Prime Remote benefits. A greater concern with turnover in contractors, she said, will be ensuring that change orders to current contracts that help the "most vulnerable" -- wounded warriors, special needs children and chronically ill patients -- don't fall away in the transition.
She referred to a pilot program to allow autistic children to receive Applied Behavioral Analysis therapy from more care providers and an effort to hire more behavioral health experts to treat families under stress.
"And every contractor has developed some sort of system to support wounded service members in their region," said Raezer. "A lot of these initiatives weren't in the RFP" -- Request for Proposal -- that Aetna and UnitedHealth answered to win their contracts. So will these changes survive?
"I'm not saying they can't do it but it needs a lot of attention at a very high level in the Department of Defense and a lot of coordination," she said.
Raezer also worries about claim processing. Humana and Health Net both have partnered with PGBA of South Carolina to process claims. The results have been "impressive," she said. "They are getting providers to file electronically. There is a short turnaround." Complaints about inaccurate payments, once a "huge issue," aren't heard much anymore, she said.
Aetna and UnitedHealth are promising TRICARE beneficiaries no drop in quality of service.
Symptoms of combat stress and post-traumatic stress disorder (PTSD) include: continual nightmares, avoidance behaviors, denial, grief, anger and fear. The solution for combating PTSD came in the creation of a new intensive eight-week therapeutic post-traumatic stress disorder day treatment program called "evolution" that began in March 2009 at Landstuhl Regional Medical Center (LRMC). Patients enrolled in the program participate in multiple disciplines and interests, including art therapy, yoga and meditation classes, substance abuse groups, anger and grief management, tobacco cessation, pain management and multiple PTSD evidence-based practice protocols. The goal at the beginning of this holistic program is to provide patients with a number of tools they can use to help calm down when feeling overwhelmed and also enable the patient to learn how to combat the symptoms of this disorder. To read the article in full, click here.
Eleven military hospitals and clinics are gearing up this summer to ensure more active duty service members (ADSMs) have access to chiropractic services. The 2009 National Defense Authorization Act called for the Department of Defense to expand the number of military facilities offering chiropractic services to ADSMs. To read this article in full,go here.For a complete list of military facilities offering ADSMs chiropractic care, see the TRICARE website.
The Naval Medical Center Portsmouth, Va., and Naval Medical Center San Diego are pilot sites for a new e-mail-based communication service for military families that have a member with autism spectrum disorder (ASD).TRICARE encourages beneficiaries in the pilot program areas who have children with autism spectrum disorders to subscribe to this e-mail service at http://www.tprmedia.com/origin/nmcp-asd.do for Naval Medical Center Portsmouth, and http://www.tprmedia.com/origin/nmcsd-asd.do for Naval Medical Center San Diego. The service begins when a patient is diagnosed with ASD. For the first eight weeks after the diagnosis, the patient's family receives customized weekly e-mails, followed by bi-weekly e-mails sent throughout the first year after diagnosis. The e-mails focus on coping, family life, research, resources, and others' experiences with ASD-all to support the family and let them know they are not alone. Hospital-specific and Department of Defense "need-to-know" information is included in the e-mails along with local and national resources. The program allows the military treatment facilities to provide authoritative information for patients' families all by e-mail. "Knowing what a difficult and overwhelming time this is for parents, enrolling patients into this service is truly an act of caring for these families," said Navy Capt. Gretchen A. Meyer, a neuro-developmental pediatrician at Naval Medical Center Portsmouth. "It contains the key information providers want their patients' families to know, as well as hospital-specific, local and national resources." For information about TRICARE programs for beneficiaries with autism spectrum disorders, go to http://www.tricare.mil/echoand select the link for TRICARE's Autism Services Demonstration.
Starting September 1, DoD will waive copayments for some preventive services for TRICARE beneficiaries under age 65. More specifically, copays will be dropped for screenings for colorectal, breast, cervical, and prostate cancer. Immunizations and well-child visits for children under age six also will be free of any copays. This change comes as a result of MOAA-supported legislative guidance in the FY2009 Defense Authorization Act. The intent of the law-change was to ensure that fee structures don't discourage beneficiaries from obtaining needed preventive care. The hope is that encouraging greater use of preventive services will lead to earlier detection and treatment of certain conditions. This should result in reduced reliance on high-cost treatments and help beneficiaries live healthier and longer lives. Although the implementation date is September 1, 2009, the law makes the free coverage retroactive for qualifying services received on or after October 14, 2008. Beneficiaries who were charged a copayment or deductible for any of those services since Oct. 14, 2008 can file a claim for reimbursement through their TRICARE contractor- but any such retroactive claim can't be filed before September 1st.
A new DoD policy aimed at "cleaning up" TRICARE Prime enrollment at military treatment facilities (MTF) could mean some significant changes for many Prime enrollees.
TRICARE has long had established travel access standards to help beneficiaries receive timely health care. The standards require that enrollees shouldn't be assigned a primary care manager (PCM) at a military hospital or clinic that's more than a 30-minute drive from the beneficiary's home address.
As a practical matter, DoD never really enforced that policy. But it will be enforced now.
If they want to continue to be seen in the MTF, current Prime enrollees in the U.S. who live farther away than a 30-minute drive from the MTF will have to request a waiver of the drive-time standard from the MTF commander or the TRICARE Regional Office. Drive times will be determined by a computer program similar to MapQuest. Approved waivers will have to be renewed annually from now on.
Unless they apply for and are granted a waiver before October 1, enrollees who live more than 30 minutes (but less than 40 miles) from the MTF will be assigned a civilian primary care manager closer to their residence. Absent a waiver, those who live more than 40 miles from the MTF will be disenrolled from Prime and revert to TRICARE Standard as of October 1.
TRICARE contractors are mailing letters to all affected beneficiaries, providing detailed instructions on the waiver process.