New TRICARE Change Could Force You to Stay with PRIME
“My Primary Care Manager (PCM) fought with me for two years, insisting I didn’t need the thyroid medication I had previously been prescribed” Army spouse Kristen, explained. Later, after being injured in a riding accident, Kristen faced more challenges with her PCM. “The ER brushed me off, my PCM insisted it was nothing and refused to refer me for an MRI.”
But after six weeks with no progress, Kristen decided to switch to TRICARE Standard (soon to be rebranded as TRICARE Select.)
“I called TRICARE at 9:00 a.m. on a Tuesday morning to switch to Standard, and 30 minutes later, I had an appointment with a specialist for my thyroid issues, as well as a same-day appointment for my knee and hand from the riding injury,” she said.
Only a few hours after switching from TRICARE Prime, Kristen’s new doctor evaluated her, did an x-ray, scheduled an MRI, and referred her to an orthopedist. Because she was able to switch to Standard, she got the right care, at the right time, and the right place.
But switching from Prime to Standard at the drop of a hat may not be that easy for long.
Currently, military families who have TRICARE Prime can switch to TRICARE Standard at any time, for any reason. This provides a critical escape hatch for military dependents, like Kristen, who feel they aren’t receiving adequate access and medical care at their Military Treatment Facilities (MTF).
But the National Defense Authorization Act (NDAA) mandates a TRICARE annual open enrollment period that could close the escape hatch and limit military family options for switching from Prime to Standard/Select.
With an annual open enrollment period, military families will have one specified period each year to select a TRICARE plan. Once you’ve made your selection, you are locked in for an entire year until the next open enrollment period.
The only way to get out of your selection would be a “qualifying life event” or QLE. The NDAA does not list specific QLEs and gives DoD some discretion in defining them. However, commercial plans typically define QLEs as changes in household (e.g., getting married or divorced, birth of a baby or adopting a child), relocation, or loss of health insurance. Without a QLE, you’re stuck with your TRICARE plan choice until the next open enrollment—even if the health care you’re receiving doesn’t pass the smell test.
Military families who decide to make the switch from TRICARE Prime to TRICARE Standard cite different reasons for doing so. For example, many military spouses choose to switch from Prime to Standard for prenatal care. However, depending on how the policy is written, pregnancy may not be considered a qualifying life event.
Navy spouse, Jenna, who has a history of ectopic pregnancies, didn’t want to risk it. Her previous doctors strongly urged her to be evaluated immediately with all future pregnancies. Jenna found out she was pregnant a week after her husband deployed.
“I called to get an appointment and was told I couldn’t be seen until I was 14 weeks, even with the risk of another ectopic pregnancy. The scheduler refused to give me an appointment,” she shared.
Jenna was told to go to the ER if she felt she was experiencing a miscarriage. After sharing this medical advice with her husband, both felt it was safest to switch to TRICARE Standard. She did, and was evaluated right away.
The reasons when and why military families switch from Prime to Standard vary based on the unique needs of each family member.
We’re concerned that an annual open enrollment period may effectively trap military families in the MTF, regardless of the problems they experience with access or quality of care.
“While there are many wonderful military health care providers, the system has conditioned us to accept substandard treatment when it happens to us,” said Kristen. “I'm done with it.” Kristen’s frustration comes from 18 months of after-effects from not receiving adequate or prompt care in her MTF.
We appreciate the opportunity given us by the Defense Health Agency (DHA) to provide military family feedback as they translate the NDAA legislation into TRICARE policy. Our Association is not opposed to an open enrollment period as long as families can keep the option of switching to Standard/Select if they are dissatisfied with their health care or patient experience at the MTF. We believe one potential solution is to include “dissatisfaction with MTF access or quality of care” as a qualifying life event. Not only would this allow families like yours to switch to civilian care if necessary, but it would also provide accountability within the MTFs.
We look forward to meeting with DHA to share military family feedback about how an annual open enrollment period could impact families like yours..
Your military family’s story will help shape TRICARE reform, so tell us: How do you feel about this policy change that would limit your options for switching from Prime to Standard? If you’ve already made the switch to Standard, how would this have affected your family?
Posted July 18, 2017