Frequently Asked Questions Regarding Proposed Changes to TRICARE In the Budget Request for Fiscal Year 2015

Please click on a question below to display the answer.  Please click here to read the statement from US Family Health Plan Alliance Chief Executive Officer Henry J. “Jim” Schweiter, and David Howes, President and Chief Executive Officer of Martin’s Point Health Care and chairman of the Alliance Board of Directors, regarding the recently released fiscal year 2015 defense budget request, as it relates to military health care.

What are the changes to TRICARE being proposed to Congress by the Department of Defense (DoD)?

DoD is proposing to consolidate the various TRICARE options—TRICARE Prime, Extra, Standard, and other TRICARE Plans—into one consolidated plan, and to increase several beneficiary costs. Key changes would include:

  • Increased Cost Shares: Cost shares will depend on beneficiary category (excluding active duty) and care setting. Cost shares would be the lowest in MTFs, higher in the network, and highest out of network.
  • Increased Participation Fee (i.e., Enrollment Fee): Retirees (not medically retired), their families, and survivors of retirees (except survivors of those who died on active duty) would pay an increased annual participation fee or forfeit coverage for the plan year.
  • Open Season Enrollment: Participants proposed consolidated plan would be required to enroll for a 1-year period of coverage or lose the opportunity for TRICARE coverage.
  • Elimination of Referrals: Beneficiaries would no longer need to obtain authorizations when seeking civilian care; but costs to the beneficiary would be determined by the network status of the provider(s) they see.
  • Deductibles: The proposed combined TRICARE plan would feature deductibles that would need to be met by the beneficiary before cost-sharing takes effect. Currently, TRICARE Standard and TRICARE Extra feature deductibles, but TRICARE Prime and US Family Health Plan do not.
  • Catastrophic Cap:  The Catastrophic Cap, which is the annual, per-family limit on out-of-pocket expenses, would increase slightly from the current amount. However, the participation/enrollment fee would no longer count towards the cap.
  • Increase co-pays for pharmaceuticals: The proposed changes to beneficiaries’ pharmacy costs would be phased-in over a 10-year period, with some costs more than doubling over that period of time.

Have these proposed changes been made law?

No. Congress would first need to approve these proposed changes before they could take effect.

Is Congress likely to go along with DoD’s proposed changes?

No one has a crystal ball, but conventional wisdom suggests that it is unlikely Congress would adopt these changes during an election year. Nevertheless, you may wish to contact your elected representatives to understand their position on the proposal and to convey any concerns you may have.

Why is DoD proposing to consolidate the existing TRICARE plans into one plan?

DoD has stated that consolidating the existing plans would simplify TRICARE and save money.  However, we believe that beneficiaries should have a choice and should be able to select a plan that best meets their individual needs, rather than a one-size-fits-all plan.

How would these proposed changes affect US Family Health Plan?

At this point it is unclear how these proposed changes—if enacted—might affect US Family Health Plan, as very few specifics have been provided.  The US Family Health Plan was created in 1993 by congressional statute, and was moved under the TRICARE umbrella in 1997.

Why is DoD proposing to increase costs for TRICARE beneficiaries?

We believe the DoD is trying to reduce their cost to provide the TRICARE benefit.  However, we believe that these costs should not simply be shifted on to beneficiaries.  Furthermore, by eliminating the requirement for coordination of referrals to specialists by a primary care provider, the proposed consolidated plan would have beneficiaries navigating the health system on their own, and would likely lead to a lack of coordination of services among providers and higher health care costs in the long run.

Are these changes being proposed because of the Affordable Care Act (“Obamacare”)?

No. TRICARE is governed by a separate set of statutes, and is not directly affected by the Affordable Care Act.

What are the proposed changes to the enrollment fees?

The proposal specifies an enrollment fee increase for January 1, 2016. The enrollment fee would increase each year after that tied to that year’s cost of living increase:

Currently, TRICARE beneficiaries enrolled in Part B pay no enrollment fee. The Administration’s proposal would implement an enrollment fee for these beneficiaries beginning in fiscal year 2015. This fee would be a percentage of the sponsor’s retirement pay:

What are the proposed changes to beneficiary outpatient cost-shares in the FY2015 budget request?

These proposed outpatient cost-shares would take effect January 1, 2016:

What are the proposed changes to beneficiary inpatient cost-shares in the FY2015 budget request?

These proposed inpatient cost-shares would take effect January 1, 2016:

What are the proposed changes to pharmacy co-pays in the FY2015 budget request?

The following proposed pharmacy changes in the FY 2015 budget would take effect January 1, 2015 and be phased-in over a 10-year period:

What are the proposed deductibles?

The following proposed deductibles would take effect January 1, 2016:

General Deductible (out-of-network care)

  • E1-E4 active duty family – $150 individual/$300 family
  • E5 and others – $300 individual/$600 family

What are the proposed changes to the catastrophic cap?

The catastrophic cap is the maximum a family would pay out-of-pocket in a given year. The current catastrophic cap is $1,000 per year, per family for active duty families, and $3,000 per year, per family for retirees and their families.  Currently, all out-of-pocket costs are applied to the catastrophic cap, including the enrollment fee.  The Administration proposal would increase slightly the catastrophic cap as of January 1, 2016; however, the enrollment fee would no longer be applied to the catastrophic cap.

Catastrophic Cap (per fiscal year) – Active Duty Family

  • $1,500 network/$2,500 combined
  • $3,000 networks/$5,000 combined

FY 2015 DOD Budget Request

Statement from US Family Health Plan Alliance Chief Executive Officer Henry J. “Jim” Schweiter, and David Howes, President and Chief Executive Officer of Martin’s Point Health Care and chairman of the Alliance Board of Directors, regarding the recently released fiscal year 2015 defense budget request, as it relates to military health care.

“Yesterday the Department of Defense proposed a budget that would combine several TRICARE plans, including TRICARE Prime, into a new Consolidated Health Plan.  We look forward to learning the details of the plan in the coming weeks and to working in partnership with the Department of Defense as it moves to shape the future of the Defense Health System.  Although on the surface it would seem that efficiencies could be gained from this proposal, we have several significant concerns, including potentially higher out of pocket expenses for beneficiaries, less focus on wellness and preventive medicine, and reduced access to care.  The US Family Health Plans have provided cost effective and accessible high quality health care and continuity of care for more than 30 years to military families, and we want to continue to serve in the years ahead.”

“Although DOD’s goal of recapturing patients at its military treatment facilities is laudable, unfortunately deployments and other systemic limitations are likely to reduce the prospects for success of this effort,” said David Howes.  “We encourage the Department to work collaboratively with industry on a plan that could work for everyone in controlling costs while beneficiaries receive high quality care.”

“Service members and their families already make tremendous sacrifices for our country,” noted Schweiter.  “We owe it to them to do everything we can to ensure they continue to receive the best health care the Defense Health System can provide. I look forward to working with Congress and officials in the Pentagon to make sure the TRICARE benefit is not degraded,” Schweiter said.

About the US Family Health Plan

The US Family Health Plan (www.usfhp.com) is among the health care choices for eligible beneficiaries of the Department of Defense’s TRICARE Prime program. Health care is provided to active-duty family members, including activated National Guard and Reserve family members, and retirees and their family members. Care is provided through large, local civilian health care networks of primary care physicians, hospitals and affiliated specialists. Patients choose a primary physician who provides and coordinates care and referrals to specialists and hospitals. The US Family Health Plan Alliance is the association that represents the collective interests of the regional USFHP networks in interactions with Congress, the Department of Defense, and the private sector.

Military Beneficiaries Rate Satisfaction with US Family Health Plan in 99th Percentile

ARLINGTON, Va. (October 31, 2013) – Amid the ongoing national conversation regarding access to high-quality, affordable health care, military family members have validated that they are highly satisfied with the Department of Defense-sponsored health care option known as the US Family Health Plan (usfhp.com). The plan, for eligible military beneficiaries in six regions of the United States, has achieved a 2013 overall member satisfaction rating of 92.5 percent, far surpassing the satisfaction rates of other managed care plans for 19 consecutive years.

The national benchmark for member satisfaction with their health plan is 65.2 percent, as calculated by The Myers Group (of Duluth, Ga.) – a National Committee for Quality Assurance (NCQA) certified survey vendor – and based on 203 Commercial Audit Survey results which were submitted to the NCQA in 2013. Compared with those 203 health plans, the US Family Health Plan is in the 99th percentile for overall member satisfaction. Customer service and the ability to get needed care have been substantiated as among the key drivers of the US Family Health Plan’s consistently high member satisfaction rating.

“Our large, local health care networks of primary care physicians, hospitals and affiliated specialists are leading the way with DoD in providing patient-centered care to military family members,” said David Howes, chair of the board of the US Family Health Plan Alliance, which represents the collective interests of the plan’s regional networks in interactions with Congress, DoD and the private sector. “Our initiatives continue to align well with DoD’s Quadruple Aim Strategy to enhance family readiness, support population health, create positive care experiences, and responsibly manage health care costs.”

Henry J. “Jim” Schweiter, chief executive officer of the US Family Health Plan Alliance, said, “As a former active-duty officer and current dependent, I can assure you that we remain committed to facilitating the best health care that the Defense Health Agency can provide. Current budget pressures notwithstanding, we must ensure that military family members receive the top-notch health care that they deserve.”

The US Family Health Plan, a TRICARE Prime option, serves active-duty family members, including activated National Guard and Reserve family members, and retirees and their family members. The local health care networks through which members receive care include Brighton Marine Health Center (serving Massachusetts, Rhode Island and northern Connecticut), CHRISTUS Health (serving southeast Texas and southwest Louisiana), Johns Hopkins Medicine (serving Maryland, Washington D.C. and parts of Pennsylvania, Virginia, Delaware and West Virginia), Martin’s Point Health Care (serving Maine, New Hampshire, Vermont, upstate and western New York, and the northern tier of Pennsylvania), Pacific Medical Centers (PacMed Clinics, serving the Puget Sound area of Washington State), and St. Vincent Catholic Medical Centers (serving New York City, Long Island, southern Connecticut, New Jersey, and Philadelphia and area suburbs).

The independent assessment of 5,106 US Family Health Plan members was conducted by The Myers Group utilizing the most widely used set of metrics in the managed care industry, the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) 5.0H Survey, to measure performance on key dimensions of care and service.

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

US Family Health Plan Earns 92.6% Satisfaction Rating from Military Beneficiaries

WASHINGTON, D.C. (November 13, 2012) – The US Family Health Plan, a Department of Defense (DoD) healthcare option for military family members in six areas of the country, has achieved a 2012 overall member satisfaction rating of 92.6 percent, far exceeding the satisfaction rates of other managed care plans for 18 consecutive years. Compared to the 202 plans documented in the National Committee for Quality Assurance (NCQA) 2012 Quality Compass Report, the US Family Health Plan rating is at the 99th percentile for overall satisfaction. Ratings for customer service, access to care, claims processing, how well physicians communicate, and satisfaction with personal doctors and specialists are also at the top of industry standards.

“Our initiatives to ensure convenient, high-quality care for military family members have helped the US Family Health Plan consistently surpass national member satisfaction benchmarks,” said Dan Wasneechak, chair of the US Family Health Plan Alliance. “What’s more, our comprehensive range of care – from prevention and wellness programs to intensive disease management services for members with chronic and multiple conditions – aligns perfectly with the Military Health System’s Quadruple Aim strategy, promoting family readiness, supporting population health, creating positive care experiences, and responsibly managing healthcare costs.”

He added, “As leaders in healthcare innovation, US Family Health Plan organizations have achieved NCQA recognition for Patient Centered Medical Homes and have established transitional care programs designed to ensure continuity between levels of care and decrease hospital readmissions. The US Family Health Plan is truly leading the way with DoD in providing patient-centered care.”

Dr. Chester Schmidt, chief medical officer of Johns Hopkins HealthCare LLC, stated, “US Family Health Plan provides patient-focused, integrated care. It’s a privilege to serve the plan’s military families and retired service members, and our providers develop strong, continuous relationships with the patients. The close collaboration among the plan, medical providers and patients helps achieve optimal clinical outcomes and keep our heroes on the home front healthy.”

The independent assessment of 4,083 US Family Health Plan members was conducted by The Myers Group (of Duluth, Ga.), an NCQA-certified survey vendor. The assessment utilized the most widely used set of metrics in the managed care industry, the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) 4.0H Survey, to measure performance on key dimensions of care and service. The 2012 Public Report benchmark for member satisfaction with their health plan, derived by The Myers Group from the Quality Compass Report, was 66.1% compared to the US Family Health Plan’s 92.6% aggregate rating.

The US Family Health Plan has served military families as a TRICARE Prime option for more than 30 years, a testament to its viability throughout an ever-changing healthcare landscape. For more information, visit www.usfamilyhealthplan.org.

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Note to Editors: CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).