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Potential Tricare

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From alamostation email (ALLVETS)

Military Update: Task force to recommend Tricare reform

By Tom Philpott, Special to Stars and Stripes

Pacific edition, Saturday, May 26, 2007

The Pentagon-appointed Task Force on the Future of Military Health will endorse higher Tricare fees, deductibles and co-payments for under-65 retirees and their families in an interim report to be sent to Congress on May 31.

It also will back other key features of the Tricare “reform” package first proposed last year by the Department of Defense. These include:

Raising beneficiary co-payments on prescriptions filled in the Tricare retail pharmacy network.

Indexing Tricare fees and deductibles so that automatic annual adjustments keep them in step with rising health-care costs.

Establishing tiers for the new Tricare fee structure, probably based on rank at retirement, so retirees with bigger annuities pay more for their health-care coverage and retirees with smaller annuities pay less.

The task force won’t endorse every aspect of the “Sustain the Benefit” plan floated last year to raise beneficiary cost shares. For example, the task force wants higher fees and deductibles phased in over three to five years rather than over two years, as DOD initially proposed, or the single-year spike in fees unveiled, with a whiff of desperation, in DOD’s 2008 budget.

Also, the task force will propose that higher Tricare fees and deductibles be set so that, when fully phased in, they are no more burdensome for retirees and their families than fee levels set in 1996 when Tricare was launched.

The task force goes further than the DOD’s proposal in one area. It favors periodic adjustments to Tricare’s catastrophic cap, the maximum amount of out-of-pocket expenses beneficiaries face in any given year. The current cap is $1,000 for active-duty families and $3,000 for other Tricare-eligible families. The original DOD plan would have left the caps unchanged.

Co-chaired by economist Gail R. Wilensky and Air Force Vice Chief of Staff Gen. John D.W. Corley, the 14-member task force outlined its interim recommendations May 23 at a public meeting of the Defense Health Board.

The health board is a standing panel of experts who advise the secretary of defense. The task force functions as a subcommittee of the health board. But it was Congress that ordered it established last year to review Tricare costs and fees after lawmakers rejected the DOD proposals.

The task force’s interim recommendations fall into four areas, two of which would directly impact beneficiary cost shares: higher retail drug co-pays and higher Tricare fees. Specific levels of fees, deductibles and co-pays recommended won’t be detailed until a “final report,” Wilensky said. That report is due in December.

The task force, she said, wants pharmacy co-payments raised on prescriptions filled outside of military treatment facilities to encourage use of more cost-effective alternatives, particularly the Tricare mail order option.

The task force wants Tricare fees realigned for under-65 retirees so they are more “fair” to taxpayers yet still recognize retirees’ “years of demanding service” to the nation, she said. Again, the task force won’t unveil specific proposed fee levels until their final report.

Wilensky said Tricare benefits will remain generous compared to all other public or private plans. The higher fees, however, will take into account “very large expansions in benefits” since the mid-1990s while Tricare fees, deductibles and co-pays were left unchanged.

“The portion of the cost borne by beneficiaries should be increased to levels that are below” the Federal Employees Health Benefit Plan (FEHBP) or the most generous private sector plans, Wilensky said. They also should be set at or below inflation-adjusted fee levels beneficiaries paid back 1996.

To soften the blow of higher fees and of indexing them to inflation, Wilensky said Congress could consider a one-time increase in military retirement pay, if deemed appropriate. But Wilensky suggested it is past time to begin to reverse the ever-widening cost differential for health care paid by working-age military retirees versus other American workers.

Besides adjusting pharmacy co-pays and Tricare fees, the task force will endorse: “best practice” acquisition strategies for pharmacy drugs; spot audits of the Defense Enrollment Eligibility Reporting System (DEERS) to ensure enrollees truly are eligible for Tricare; closer screening of retirees and dependents for alternative health insurance which, by law, must reimburse Tricare for care provided to any dual-eligible beneficiaries.

Steve Strobridge, co-chair of The Military Coalition, an umbrella group of service and veterans association, urged the task force during the meeting’s public comment period, not to ignore factors that might have skewed the cost of military health care since 1996. For example, in measuring DOD cost growth compared to fee levels, he said, the task force should consider the downsizing and closing of many base hospitals and the cost today of sending military doctors to war and, therefore, many more beneficiaries to get care more costly care from Tricare civilian providers.

Wilensky said fees won’t be reset based on some percentage of overall military health care costs. But the task force will recognize that fees have been flat for 11 years, she said, and during that time the beneficiary’s cost share has slipped from about 11 percent down to four percent.

Over the same period, added another task force member, retired Army Maj. Gen. Nancy Adams, the value of the health benefit has improved greatly. For retirees, the promise of “space available care” first made in the 1950s has been replaced with “universal access” to care on base or, more often, through a network of civilian physicians. Adams called it a “highest-quality” benefit having few limitations.

Dr. Gregory A. Poland, Defense Health Board president, advised the task force that the board is “very supportive” of its interim recommendations.

To comment, e-mail milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111 or visit: www.militaryupdate.com

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GRADUATE ! Nov 2nd 2007 American Military University !

When thousands of Americans faced annihilation in the 1800s Chief

Osceola's response to his people, the Seminoles, was

simply "They(the US Army)have guns, but so do we."

Sameo to us -They (VA) have 38 CFR ,38 USC, and M21-1- but so do we.

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Seems that an additional clause needs to be added to Tricare.

Under any conditions, Tricare shall pay providers at least the amount paid for the same services as Medicare & Medicaid combined.

Or even better, Tricare shall pay providers the same amounts paid by insurance plans that are offered/available to govt employees and members of the US Senate and House.

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I was amazed at how little Tri-Care paid on some of the charges my husband had --The doctor told us that Tri-Care paid less for the chemo than it cost the doctor - but they made up the difference on office fees etc.

When we were ordering home medical equipment - the provider told us that Tri-Care pays the same rate that Medicare does for equipment. That might be true for most of their payments - they run pretty close to Medicare.

We have Tri-Care Prime, which might make a difference. With that you have to go to a Military Provider if one is available -and have to get authorizations for things. But we never had a problem with those.

In fact -- my husband needed something that Tri_care and medicare usually don't cover - but I called Tri-Care and they said they could pre-authorize it if he had a letter of medical neccessity.

Both the doctor's office and medical equipment supplier kept telling me they woudn't cover it -- but they did.

Just because they won't AUTOMATICALLY cover something - no questions asked -- does not mean they will not cover it. You just have to jump through more hoops to show you need it.

When I told the nurse we needed a letter of medical neccessity - She said that was what the precription was. NOT! No wonder they never get those things approved --if they don't understand that a precription is not a letter explaining WHY something is medically neccessary.

In fact the first time they told me that Tri_care had DENIED the claim. She showed me the letter. It didn't say the claim was denied. It said it wasn't approved yet - as they needed more information.

So I think sometimes the providers themselves cause the problems that they balme on Tri-Care.

I did have some problems with some physicians trying to charge above the copay amount after my husband's death. Tri-care has a daily rate for being in the hospital. And everything is covered. But several doctor's, technicians, etc sent me bills - showing my husband still owed money. Rather than fighting each one of the about it - I just called Tri-care and told them the providers were trying to charge us fees that were not allowable. Tri_care handled it. They sent the providers a letter and sent me a copy - telling them they could not do that.

Had I not known my husband's coverage - I would have just paid the bills. I imagine a lot of people do.

I was reading an article where some retiree's tried to sue because they were promised FREE medical care for themselves and their dependents. The lawsuit was about TriCare requiring 65+ retirees to purchase medicare. They did not win the suit. The Supreme Court said the promises for free medical care were backed by statute - not contract.

http://www.ll.georgetown.edu/federal/judic...ns/99-1402.html

I think that is also one of the reasons vets are denied things with the VA. Like equitable tolling in many cases. Anything that is considered an "entitlement" isn't as protected by law as you would think.

For instance, if you file a claim within one year of complete disability -- they can go back one year. But if you wait over a year -- it only goes by te filing date.

My husband did not file within a year of his cancer diagnosis because he was misinformed about the type of cancer. He was treated at the Air Force Base - but had his surgery at a civilian hospital. For a whole year the Air Force Docs kept telling him it was small cell lung cancer..which grows pretty quickly. It is in all his medical records at the Base (post service records).

After a year - they read the biopsy reports and told him that it was NONsmall cell lung cancer - and due to the slow growth rate of pulmonary adenocarcinoma - that it had most likely started 12 - 15 years before he retired from the service.

The doctor even noted in the records that the records had been wrong and the patient had been misinformed as to the type of cancer. (But he still just noted "Important differences explained to the patient") and gave him a handwritten note of the growth rates and doubling times).

Anyway -- in a civil court - this would be a case for equitable tolling. Or as my husband explained in his inital letter of claim - he did not file sooner because he had been misinformed. So a civil court would equitably toll the 1 year filing deadline.

But from the cases I have read at the VA -- that wouldn't fly at the VA. 1 year is 1 year. It was not the VA that misinformed him (thought it WAS military doctors) - and VA benefits are an "entitlement" -- not a "right." etc. etc. etc.

Free

Free

Seems that an additional clause needs to be added to Tricare.

Under any conditions, Tricare shall pay providers at least the amount paid for the same services as Medicare & Medicaid combined.

Or even better, Tricare shall pay providers the same amounts paid by insurance plans that are offered/available to govt employees and members of the US Senate and House.

Think Outside the Box!
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Again, I can only speak about my own experience. I have not had trouble with TriCare, the claims that have been submitted have been settled in a timely manner, I have had no doctor indicate that they do not like TriCare (other than the codes), nor have I had trouble finding a provider. I will have to disagree that TriCare is run by TriCare, it is in fact contracted out in each region.

I've been in Tricare east, Tricare south and, now, Tricare west....these are the three Tricare areas in this country and all were equally horrible.

The problem with many folks, in this regard, is that a lot of veterans have been in the military health care system for their entire lives and have NO clue how health care *should* work. They only seem to consider that the health care is cheap and, therefore, good. Try a good civilian health provider that covers dental, medical and eye......see how much less red tape there is and just how many more doctors actually accept said insurance (as compared to tricare).

We are the richest nation on earth and we shouldn't have to beg for services from some pencil pusher sitting behind a desk.....be it civilians or military.

Yes, tricare will eventually cover most things if you go to their crappy doctors and jump through a ridiculous amount of hoops, but it's simply not worth it to me and it's designed, just like the VA system, to discourage folks from seeking benefits. Could I go to some idiot nurse practitioner for my wife's psych meds? Sure, if I was willing to travel for 1.5 hrs, get on a 5 month waiting list and fill out 25 forms that need to go to 10 different departments ONLY after getting authorization from her PCM. Personally, I'd rather pay out of pocket and get a REAL psychiatrist that is GOOD at his job and can actually HELP her.

Part of the reason that she has been so bad over the last 5 years is because we were stuck using tricare's list of providers....the instant we decided to pay out of pocket we found a psych that specializes in anxiety disorders and has been very open with her in the med process. Because of this, she is more stable than she's ever been on the best set of meds she's had thus far.

So, if you like bad doctors that are willing to accept pennies on the dollar then go for it....I would rather have a qualified doctor that actually has a medical degree and not a glorified nurse and/or some idiot with a general bachelor’s degree with 2 years of wanna-be med school (IE - a PA).

P.S. - Despite the nonsense the media tries to feed the average American, military health care (for active duty) is among the worst health care in the world. They have the least qualified doctors with the least experience and the least educated and trained staff of any health care system on the planet.....3rd world nations get better health care. But it's free, so I guess that means it's good /sigh.

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We see a military doctor on base. Referrals are quick and we have never had a problem finding a doc. If our primary puts in a referral we usually get a letter from the local tricare office providing that the referral is approved and we have an appoint with doctor x on x date which is usually within two weeks. If it is a hurry up kind of thing our doc usually calls a civilian doc and gets us in within 48 hours and then he takes care of tricare.

So for me and my family tricare is wonderful. We can call in at 8 am and get a same day appointment for minor things such as colds etc...... So I am one happy camper and I hate to see the rates increase. I will write as many letters as I can to my congress and senate idiots asking that they step on DoD an stomp hard when they do. If DoD is having a hard time maybe they should cut a few cost items themselves.

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On base care is typically quick and tricare is quick to pay because it's VERY cheap for them. The reason it's cheap is that most military doctors aren't even licensed to practice medicine and/or they are undereducated PAs and NPs. Quick + cheap doesn't always mean good.....

The military needs to do away with stateside military hospitals as does the VA....they are costly and useless.

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