Editor’s Note: This article is part of MOAA’s 2021-22 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Mercer Consumer. A version of the guide appeared in the November 2021 issue of Military Officer magazine.
One of MOAA’s ongoing roles is to monitor TRICARE coverage and advocate to ensure it keeps up with new technologies, evolving treatment protocols, and changing standards set by commercial plans. Servicemembers and retirees have earned a comprehensive health care benefit, but TRICARE could quickly become a Swiss cheese of coverage gaps without the efforts of MOAA and our fellow military advocacy groups.
The case of two military children who were terminally ill is an example. A major children’s hospital approached the TRICARE for Kids Coalition (TFK) regarding a coverage gap for terminally ill military kids. The palliative care team at this hospital was concerned because two of their patients, both military kids, could not access hospice — a service they would recommend to any other family in similar circumstances — because it would mean the children would have to forego curative care per TRICARE reimbursement policy.
At that time, TRICARE’s pediatric hospice policy was outdated and based on Medicare requirements for senior adults. Medicaid and commercial plans had evolved to cover hospice in addition to curative care for pediatric patients for a variety of reasons, including the unpredictability of children’s illnesses and the fact that both parents and pediatric medical providers are reluctant to stop curative care under almost all circumstances.
The children’s hospital team noted their military kid patients needed the in-home services hospice provides even more than their civilian counterparts because their mobile military families did not have extended family nearby or long-standing relationships with others who could help.
MOAA and TFK took the issue to the Defense Health Agency (DHA). Officials there said this would require a legislative fix, so we took the issue to Capitol Hill. We met with Armed Services Committee staff and numerous member offices. Our efforts paid off with a provision in the FY 2018 National Defense Authorization Act (NDAA). As of August 2019, military families with terminally ill children have the same treatment options as their civilian counterparts.
Other Coverage Gaps
MOAA’s efforts to address TRICARE coverage gaps continue. Today, our top TRICARE policy issues include coverage for chiropractic care, updates to reflect new Medicare eligibility policy for continuous glucose monitors, and young adult coverage that is included in every other employer- sponsored plan.
The pediatric hospice issue provides a good example of how a coverage change comes about. Because TRICARE coverage is governed by statute, it is often necessary to pass a law to update TRICARE coverage policy. Even when a law isn’t necessary, MOAA plays a vital role in identifying coverage gaps and bringing them to DHA for action.
Identifying coverage gaps is a multipronged effort that includes monitoring legislative requirements for commercial plans (e.g., the Affordable Care Act) and policy updates by the Centers for Medicare & Medicaid Services (CMS). It also includes maintaining relationships with industry and coalition partners — such as TFK — that have deep knowledge in specific areas of health care, and gathering feedback directly from beneficiaries.
In recent years, MOAA has worked to achieve numerous fixes to TRICARE coverage including:
- Lab developed tests/diagnostic genetic testing (used to guide targeted cancer therapies, identify or rule out a specific genetic or chromosomal condition, or screen for genetic mutations such as cystic fibrosis carrier screening for those trying to conceive).
- Pediatric concurrent hospice
- 3D mammograms for breast cancer screening
- Expanded eligibility for continuous glucose monitors
- Breastfeeding services and supplies.
We screen coverage issues by looking at Medicare/Medicaid policies, consulting professional medical associations, and examining coverage policies of high-quality commercial plans such as Federal Employee Health Benefits plans.
Have you encountered an issue with TRICARE coverage policy? Please share your concerns with us at firstname.lastname@example.org.
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