Disability Compensation |  Services reduce claims backlogs and seek outreach to new eligible disabled retirees

CRSC Processing Turning Corner

On Aug. 26, MOAA and The Military Coalition hosted representatives from Army, Navy, and Air Force Combat-Related Special Compensation (CRSC) review boards and the Defense Finance Accounting Service (DFAS) to discuss progress and challenges on CRSC claims processing. We came away gratified by these groups’ sincere efforts to overcome start-up obstacles, reduce the claims backlogs, and increase responsiveness to the needs of disabled retirees.

Air Force and Navy officials reported that they had reduced their backlogs of unprocessed claims to less than 200 each. The Army, which with almost 30,000 CRSC applications had more than the other services combined, still had a backlog of more than 8,000 claims to be processed.

However, Army officials reported that they had achieved a breakthrough agreement with the VA that should dramatically expedite the Army’s receipt of archived information from the VA—the most time-consuming part of the process for older retirees. The Army expects this will have a substantial impact in reducing the backlog in the coming months.

The service and finance representatives engaged in a productive discussion of remaining problem areas, along with the reasons for the problems and how they might be resolved. These included individual unemployability payments for 100-percent disabled retirees, DFAS computer reprogramming challenges, and implementation alternatives for the annual “open season” choice between CRSC and concurrent receipt for retirees eligible for both.

The services also shared some important tips for a successful application:

• Documentation is key—applicants need to show, via official documentation, how a disability was incurred. Important documents include DD Form 214, complete VA ratings decisions, and pertinent medical records.
• Linkage of the disability to a discrete combat- or operations-related incident is extremely important—e.g., medical reports or citations showing a gunshot wound was sustained during combat operations or combat training or that a fighter pilot’s back injury can be traced to a specific in-flight ejection.
• Repetitive exposure claims (hearing loss, degenerative conditions, etcetera) are harder to approve. The applicant must show a clear pattern of the disability’s onset during active service, or at the very least during the exit physical or initial VA medical exam.
• Guard and Reserve retirees must be eligible to receive retired pay (i.e., be at least age 60) to be eligible for CRSC payments. Since the purpose of CRSC, in effect, is to restore lost retired pay value that has been offset by VA disability compensation, there’s no value to restore if there’s no lost retired pay.
• Don’t hesitate to reapply if your application is not approved and you later obtain additional documentation.

The service representatives stressed that they review each case on an individual basis and seek to approve applications whenever they can justify a preponderance of evidence in favor of the award. But they only can make those determinations based on specific documentation; they can’t just accept the applicant’s assertion.

Service officials expected an additional surge of CRSC applications this year, after eligibility was expanded to include Guard and Reserve members with 20 qualifying years of service (as opposed to 7,200 retirement points) and to cover combat- or operations-related disability ratings below 50 percent. They indicated surprise—and disappointment—that there has been no such surge, because that means thousands of eligible disabled retirees aren’t getting earned CRSC payments.

They asked for MOAA’s help in conducting an outreach program to locate potential eligibles and urge them to apply. This would be a great community service project for MOAA chapters and others who are making personal visits to local nursing homes, putting notices in local media, or just spreading the word to friends, neighbors, and relatives.

While some issues remain to be hammered out, all attendees were impressed by the obvious sincerity of the service and finance efforts to do the right thing by disabled retirees. They share our frustrations at initial hurdles but believe the program is now a fair and increasingly efficient one.
CRSC application forms are available online at: www.dior.whs.mil/forms/dd2860t.pdf.

Legislation  |  MOAA discusses issues with all interested legislators, parties.

Parties Seek Association Inputs

At the invitation of Rep. Melissa Hart (R-Pa.), military and veterans’ organizations attended a meeting of the Republican National Committee (RNC) Platform Coordinating Committee to address their issues of concern. MOAA and nine other military and veterans’ organizations attended the meeting.

MOAA noted that ending the Survivor Benefit Plan (SBP) age-62 benefit reduction remains our top issue and urged support for the House SBP provision in the FY 2005 Defense Authorization Bill (H.R. 4200). The House plan would eliminate the age-62 SBP annuity reduction in 31/2 years and offer a fair open-season option for new enrollees. MOAA also urged support for the Senate provision on concurrent receipt that would restore full retired pay effective January 2005 for disabled retirees with 100-percent VA ratings.

Additionally, we asked that the platform support a force structure that better meets today’s operations-tempo of increased deployments for active duty members and recalled Guard and Reserve forces. Further, benefits and compensation for reserve component members must be upgraded to reflect the dramatically increased demands being imposed upon them and their families. More specifically, Guard and Reserve forces need reliable year-round medical coverage as proposed in the Senate version of the FY 2005 Defense Authorization Act. We also pressed for increased TRICARE Standard reimbursement rates and other TRICARE improvements.

Other issues raised by one or more of the association representatives included:

• the need to restore full military pay comparability, especially for senior enlisted ranks;
• a stronger push to establish mandatory funding for VA health care;
• concerns about the use of extended deployments and stop-loss as “a back door draft” covering only those who already have completed their voluntary periods of service;
• providing a separate platform plank for veterans’ and military personnel issues, distinct from broader national security concerns; and
• sensitivity to the needs of disabled veterans, particularly the catastrophically disabled.

Earlier, MOAA, along with a group of associations covering roughly the same issues, had participated in a conference call meeting with the House Democratic leadership. That meeting was aimed at making sure the minority leadership fully understood the significant issues of concern to military and veterans’ associations.

Our reports of such meetings sometimes generate member input voicing suspicions that this means we’re siding with whatever party hosted the most recent meeting. On the contrary, MOAA conducts itself in a strictly nonpartisan manner.

We are invited to leadership meetings of each party and sometimes solicit meetings. We want to meet with both, and we provide our legislative priorities to any legislators—House or Senate, Republican or Democrat—who are willing to listen. And we support bills offered by members of either party that are consistent with MOAA’s legislative objectives.

Members who note that articles in a “Washington Scene” column seem to focus on legislators of one party or the other shouldn’t worry that that reflects a partisan bias on MOAA’s part. It’s merely a coincidence in the process of reporting the news that happened that particular month. If you go back a few issues, you’ll find articles that focus on the efforts of members of the other party.

Retired Pay  |  September court date raises visibility of former-spouse law.

USFSPA Lawsuit Hearing Set

In April 2004, an organization called USFSPA (Uniformed Services Former Spouse Protection Act) Litigation Support Group (ULSG) filed a lawsuit on behalf of 58 servicemembers and retirees against the secretary of defense, alleging that the USFSPA (which allows state courts to divide military retired pay in divorce settlements) isn’t applied fairly and denies servicemembers constitutional equal protection and due process rights.

Among other things, the ULSG suit argues that the former-spouse law violates constitutional protections, because the law was applied retroactively to members who entered the service before the enactment of the law in 1982—and these servicemembers never envisioned their retired pay being divided with their former spouses. The law sprang from a decision by the U.S. Supreme Court in 1981 (McCarty v. McCarty) that military retired pay could not be divided as marital property unless Congress passed a law expressly allowing this. The following year, Congress enacted the USFSPA.

The ULSG lawsuit also alleges that the law doesn’t provide equal protection, because state courts have applied it in different ways—in some cases, awarding excessive disbursements of retired pay, improperly including disability compensation, or requiring payments before the member actually retires.

In July, government lawyers filed a motion to dismiss the lawsuit, arguing that a legal doctrine derived from two Supreme Court cases—called the Rooker-Feldman doctrine—prevents a federal court from exercising its jurisdiction over a claim that, if successful, would nullify a final state court judgment. The government lawyers also rejected the ULSG claims of due process and equal protection violations, urging dismissal on the ground that the ULSG has no standing to present individuals’ claims because it doesn’t state who the members of ULSG are or how the ULSG has been harmed by the purported unconstitutionality of the USFSPA.

ULSG subsequently offered the court a 49-page rebuttal to the government’s motion. At press time, a hearing on the government’s motion to dismiss the case was scheduled for Sept. 10 in the federal court in Alexandria, Va.

MOAA has pushed for years to reform USFSPA, with little success so far. Legislators have been reluctant to take this issue on because emotions run high among advocates for both retirees and former spouses, and each side can cite its own examples of egregious behavior. Congress’ reluctance to take sides on further legislation has stymied progress to date, but we still think the legislative route offers the best chance of future success. We think the historic gender-oriented views of the former-spouse issue are evolving as more and more female retirees have become subject to USFSPA.

While most experts think historical court precedents give the lawsuit slim chances of success, MOAA thinks it will at least give the former-spouse issue much-needed visibility.

To read more about USFSPA, the particulars of the ULSG lawsuit, and the positions of the parties to the suit, visit MOAA’s Web Base, www.MOAA.org/legislative/USFSPA.

Guard/Reserve  |  Coalition raises utilization equity, readiness issues.

House Staff Hears TMC Concerns

MOAA’s July 30 “Legislative Update” highlighted The Military Coalition’s (TMC’s) concerns about certain proposals in the House- and Senate-passed versions of the FY 2005 Defense Authorization Act governing utilization of Guard and Reserve members. (See
www.themilitarycoalition.org/library/04letters/26jul04hunter.pdf.)

MOAA is grateful that the House Armed Services Committee staff set up a late-August meeting to give members of TMC’s Guard and Reserve Committee an opportunity to discuss those concerns in more detail.

TMC representatives reiterated their understanding of the need for additional flexibility in some areas. But they stressed that the proposed changes appear to go far beyond the current need and urged the committee to at least hold hearings on longer-term utilization, retention, and readiness impacts before writing such sweeping changes into law.

Specifically, TMC is concerned that some of the proposed changes would:

• make Guard and Reserve units divert essential training time and resources to operational and other requirements;
• change the rules to make guardmembers perform federal missions under provisions of law that normally govern state duties, which would deny them veteran status and cut their compensation; and
• continue to ignore worrisome, fundamental questions about how much of the active duty mission can be shifted to reserve component forces without significant retention and readiness consequences.

TMC recognizes the importance of increased reliance on the Guard and Reserve in the current operational environment but does not think this immediate requirement justifies continued failure to address fundamental utilization and readiness implications for the longer term.

Coalition representatives made the case that the final Defense Authorization Bill should:

• establish clear “fencing” of resources for essential training (drill) time, separate from those for operational or other requirements;
• provide consistent compensation and veteran status rules for all federal missions performed by guardmembers;
• prescribe reasonable boundaries on DoD’s increased substitution of Guard and Reserve forces for active duty forces pending a broader review of the issue; and
• establish an independent commission to examine the broader issues concerning roles, missions, and utilization of the Guard and Reserve forces, including the extent to which changes need to be made in personnel, compensation, and other programs to recognize the increased demands being placed on the reserve components.

Health Care  |  Other insurance pharmacy copayments can be claimed.

TRICARE Reimburses OHI

On June 1, Express Scripts Inc. (ESI) took over the TRICARE Retail Pharmacy program. Since that time, some of our members have experienced problems with reimbursement of copayments for other health insurance (OHI). If you are a TRICARE beneficiary who has OHI, you are eligible to have TRICARE reimburse those pharmacy copayments.
 
You can do this by filing a paper TRICARE claim (DD Form 2642). Along with the form, you must enclose further documentation—providing a copy of the pharmacy receipt on the pharmacy’s letterhead or a billing form showing the:

• name of the drug;
• strength (100 mg, 500 mg, etcetera);
• quantity (number of pills or doses);
• cost paid by your OHI;
• amount you paid;
• prescription number and date of fill;
• prescriber’s name or DEA number;
• pharmacy’s name;
• pharmacist’s signature only if the claim is not printed on an “acceptable format” (pharmacy stamp, letterhead, etcetera). If it looks like it was printed on a home computer (plain paper), then a signature is required; and
• beneficiary’s name imprinted on the receipt.

(The days supply (e.g., 30, 90 days) is not explicitly required. However, if days supplied can’t be determined based on the information provided, calling the pharmacy, etcetera, the claim will be rejected.)

If you use a TRICARE network pharmacy, you will be reimbursed the full copayment in most situations. If you use a non-TRICARE network pharmacy, you must first meet the annual TRICARE deductibles. After that, in most circumstances, DoD will refund the copayment amount.

Forms should be sent to:
ESI
P.O. Box 66518
St. Louis, MO 63166-6518

For more information contact:
TRICARE Retail Pharmacy (TRRx): (866) 363-8779 or
http://member.express-scripts.com/dodcustom/home.do.

TRICARE Mail-Order Pharmacy (TMOP): (866) DoD-tmop (363-8667) or
www.tricare.osd.mil/pharmacy/tmop.cfm.

Health Care  |  Contract changeover has ups and downs.

TRICARE Transition Moves Forward

The TRICARE transition to new TRICARE Next Generation (TNEX) contracts will be completed Nov. 1, when Humana Military Healthcare Services takes over Region 6 (Arkansas, Louisiana, Oklahoma, and Texas). That change is the last step in consolidating the TRICARE administration into three regions: North (Health Net Federal Services), South (Humana Military Healthcare Services), and West (TriWest Healthcare Alliance Corporation). While the transition has been on schedule, implementation has had its ups and downs for beneficiaries.

The contracts are intended to improve the administration of TRICARE by:

• streamlining TRICARE claims processing to conform to Medicare requirements;
• facilitating electronic claims processing for under-65 Medicare users;
• allowing retired TRICARE Prime users to pay enrollment fees by allotment; and
• instituting a monthly payment option for Prime enrollment fees.

However, the initial transition periods have not run smoothly in all areas. Beneficiaries have encountered customer service and care delivery obstacles—some of which the contractors still are working on.

Customer Service: With each changeover, beneficiaries have called on the new customer service centers for help on a range of issues such as enrollment questions, picking a new primary care manager (PCM), finding a specialist, and understanding the referral and authorization process. At first, the call volume overwhelmed the centers. TriWest received more than 17,000 calls a day in some centers, and hold times averaged well over two minutes. Health Net and Humana had up to 25,000 calls a day with similar hold-time experiences.

Calls to customer service centers at TriWest and Health Net have since dropped to less than 7,000 a day, with hold times within the 30-second TRICARE standard. Humana’s calls remain above 20,000 on Mondays but taper off to 15,000 later in the week. Beneficiaries should try to avoid calling during periods of peak volume (Mondays or right after holidays).

Provider Networks: Most beneficiaries have seen little or no change in where and how they get their care. However, the transition has been problematic at some locations where provider networks had to be rebuilt or expanded.

In the West, Yuma, Ariz.; San Diego and Monterey, Calif.; and Portland, Ore., experienced significant provider network disruption. TriWest also had to reassign more than 35,000 Prime beneficiaries to a new PCM. This has been understandably upsetting for beneficiaries who had long relationships with their previous primary doctors. TriWest has worked hard to bring more providers into the networks in Arizona, California, and Idaho, and now TriWest has more network providers in Monterey and Yuma than under the previous contract.

In the North region, fewer than 400 beneficiaries had to find a new PCM. Health Net was able to “buy” the networks of civilian providers that had been built by previous TRICARE contractors, so virtually all doctors previously contracted to provide TRICARE services in the North region will continue to do so.
In the South, Humana already has begun servicing Region 3 (Southeast) and Region 4 (Gulf South) and has retained most of their provider networks, so most Prime enrollees can remain with their previous PCMs.

Referrals and Authorizations: Because of delays in the rollout of TRICARE’s new automated Enterprise Wide Referral and Authorization System, the contractors unexpectedly have had to manually process all referrals and authorizations. Predictably, referrals backed up quickly and caused headaches for providers, patients, and contractors.

TriWest, Health Net, and Humana have hired 250 additional people to handle this increased workload. All regions cleared their backlogs within a few weeks, but not without considerable consternation for providers and beneficiaries. At press time, the manual process seemed to be working fairly well. Urgent referrals were being handled within one day and most routine referrals within three days.

The government also has established a “tiger team” to address the automation issues needed to streamline benefit delivery to TRICARE beneficiaries. MOAA will track the progress of this effort and report developments as they occur.

Hopefully, the two remaining contract transitions, Regions 7 and 8 (Central Region) and Region 6 (Southwest), will go more smoothly as the contractors apply their recent experiences to these new challenges. TriWest already serves the Central Region—meaning that current provider networks will continue in place.

Humana, which will take over Region 6 from Health Net Nov. 1, will use its preexisting commercial provider networks as the primary source of civilian providers. The contractor reports that its provider networks will provide access to a TRICARE provider for 99 percent of beneficiaries.

MOAA will continue to monitor the transitions and make recommendations as needed to meet beneficiaries’ needs.