TRICARE Contracting Changes Creating Turbulence for Military Beneficiaries

By Capt. Kathryn M. Beasley, USN (Ret), director of health affairs, MOAA Government Relations

Recent reforms of the Military Health System included plans to reduce TRICARE regions from three to two. The objective was to reduce federal spending while decreasing administrative hassles for military beneficiaries, who tend to move between regions frequently. This part has worked out well.

What has not worked so well for beneficiaries have been numerous issues caused by the change in TRICARE contractors Jan. 1. Contractor changes between regions happen every five to seven years, and although most beneficiaries expect a few glitches, they typically are well planned and anticipated. This transition has been anything but smooth sailing.

MOAA has received an earful from members describing billing and claims problems, referral and authorization issues, dropped enrollments, poor customer experience, lack of provider networks resulting in higher cost shares, and many other concerns. We met with TRICARE officials this week to discuss these problems, find out if the Defense Health Agency was aware of them and, if so, learn what they are doing to solve them.

We were happy to find the DHA is very aware of these issues and is taking action to hold the new contractors accountable. Both managed care support contractors, Humana Government Business and Health Net Federal Services, have experienced early challenges with customer call centers, websites, etc.

Humana is compliant with all major requirements except provider directory accuracy. Unfortunately, Health Net - which has TRICARE's West region - remains noncompliant with several major requirements and has been placed on a corrective action plan to fix key issues, including:

  • Customer Service - failure to meet multiple contract standards, call center standards, etc.
  • Referral and Utilization Management - more than 70,000 backlogged referrals
  • Provider network adequacy - failure to meet targets (85% coverage is required) in multiple Prime Service Areas and Select networks; this includes both primary care and specialty providers shortages, with some areas having no network providers
  • Provider directory accuracy - multiple issues
  • Medical management - multiple issues with web-based systems

Needless to say, these are serious issues affecting beneficiaries right now. To address them, the DHA has put out guidance, effective immediately through March 18, allowing Health Net to waive its usual authorization process for TRICARE Prime referrals in the West Region as well as addressing specialty care referrals, enrollment applications, and call center wait times.

MOAA is monitoring these mitigation strategies and contract performance deficiencies closely; we will continue to report beneficiary experiences to officials at the DHA. We appreciate the oversight efforts by the DHA and would like to see the needle move in the right direction on these issues as quickly as possible. These issues have resulted in more out-of-pocket costs for many beneficiaries, which is totally unacceptable.