Approved and proposed changes to the military’s Tricare health-care program dramatically could affect military retirees living near Fort Stewart, according to Jeff Loomis, access assistant care manager at Winn Army Community Hospital.
Tricare Prime service areas are being reduced, effective Oct. 1, and plans to increase copays for Tricare retail and mail-order pharmacies are part of the president’s proposed budget.
“What most beneficiaries don’t understand is that Tricare is their health-care insurance plan,” said Loomis, who first noted there are a limited number of doctors at military hospitals. “Tricare contractors provide (the medical care) the military can’t provide by augmenting military-treatment-facility care with off-post referrals.”
Loomis said active-duty soldiers, retirees and family members have an option of choosing Tricare Standard or Tricare Prime to pay for off-post medical care. He said Tricare Standard is a fee-for-service, open-choice option. It includes a family deductible up to $300 a year and a catastrophic cap of $3,000 a year. It also includes copays up to 25 percent per doctor’s visit.
Tricare Prime follows the health-maintenance organization model, Loomis said. Tricare Prime enrollees are assigned a primary-care manager, either at a military-treatment facility or within the Tricare network. Enrollees must have a referral and authorization before receiving specialty care. Beginning Oct. 1, retirees and their family members who are enrolled in Tricare Prime but living more than 40 miles from an MTF will be “disenrolled” from Tricare Prime and automatically enrolled in Tricare Standard.
“I can’t make a (Tricare) Prime beneficiary drive more than 30 minutes to go to a doctor,” he said. “I can’t waive the drive-time limit.”
Loomis said that under the 2007 Tricare regional contracts, the government only requires prime service areas within 40 miles of MTFs. He said PSAs are defined by ZIP codes that fall within a 40-mile radius from a MTF. Therefore, a retiree living in Ludowici may continue to be enrolled in Tricare Prime, but a retiree living in Vidalia would not. Loomis said active-duty soldiers are not affected by the PSA limit.
Letters already are going out to those affected by the PSA limit, he said. If a retiree is notified that his family is outside the PSA, he or she can complete a new enrollment form and sign a waiver of the 30-minute drive time. The application may not be approved, however.
He said retirees can determine whether they live within the PSA by going to www.tricare.mil. They must complete the information in the box regarding their status as a military retiree, where they live and the Tricare plan they’re enrolled.
Loomis said the president’s proposed budget includes proposals to increase copays for Tricare retail and mail-order pharmacies. He explained that copays mostly are determined by whether the medication is a brand name drug or generic drug.
According to Military.com, the current copay for most generic drugs is $5, while the copay for a brand-name drug is $17. Under the proposed plan, the copay for both brand-name and generic drugs will jump then go up each year for the next five — maybe even the next 10 — years. Brand-name drugs not on the military-approved formulary would be unavailable after Oct. 1.
Loomis said it still is too early to speculate about the pharmacy copays as these are only proposed changes that would have to be approved by Congress. Congress could block the proposed changes, support them or reach a compromise, he said.
“At the end of the day, health care is a business,” Loomis said. “We have to determine how we do it responsibly with government money.”