DOD and VA Health Care: Access for Dual Eligible Beneficiaries	 
(13-JUN-03, GAO-03-904R).					 
                                                                 
The Department of Defense (DOD) reported that under its current  
policy, beneficiaries eligible for both TRICARE and the 	 
Department of Veterans Affairs' (VA) health care (dual eligible  
beneficiaries) are not allowed to utilize the services offered by
both health care systems for treatment for the same episode of	 
care. For example, if a beneficiary experiences back pain and	 
seeks treatment from VA, the beneficiary must then receive all	 
care related to that back pain from VA. Should the beneficiary	 
then decide to seek treatment for the back pain from TRICARE, any
claims related to that care would be denied. According to DOD,	 
this policy was established to ensure continuity of care for	 
beneficiaries and to ensure that there was no duplication of care
or of payments from TRICARE or VA. Under the policy, if 	 
beneficiaries are dissatisfied with the care provided by VA, they
are unable to switch to TRICARE to receive services for the same 
episode of care. On April 16, 2003, DOD reported to the Congress 
on a proposal to change its policy and promulgate regulations for
coordinating care between DOD and VA. As agreed, we focused our  
review on the reasonableness of DOD's process. To do so, we	 
reviewed the report submitted to the Congress and TRICARE	 
policies, and interviewed agency officials from DOD and VA. Our  
work was conducted in June 2003 in accordance with generally	 
accepted government auditing standards. 			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-904R					        
    ACCNO:   A07196						        
  TITLE:     DOD and VA Health Care: Access for Dual Eligible	      
Beneficiaries							 
     DATE:   06/13/2003 
  SUBJECT:   Beneficiaries					 
	     Health care planning				 
	     Health care programs				 
	     Managed health care				 
	     Policy evaluation					 
	     Strategic planning 				 
	     DOD TRICARE Program				 

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GAO-03-904R

GAO- 03- 904R DOD and VA Health Care for Dual Eligibles United States
General Accounting Office

Washington, DC 20548

June 13, 2003 The Honorable John Warner Chairman The Honorable Carl Levin
Ranking Minority Member Committee on Armed Services United States Senate

The Honorable Duncan Hunter Chairman The Honorable Ike Skelton Ranking
Minority Member Committee on Armed Services House of Representatives

Subject: DOD and VA Health Care: Access for Dual Eligible Beneficiaries
The Department of Defense (DOD) reported that under its current policy,
beneficiaries eligible for both TRICARE and the Department of Veterans
Affairs* (VA) health care (dual eligible beneficiaries) are not allowed to
utilize the services offered by both health care systems for treatment for
the same episode of care. 1 For example, if a beneficiary experiences back
pain and seeks treatment from VA, the beneficiary must then receive all
care related to that back pain from VA. Should the beneficiary then decide
to seek treatment for the back pain from TRICARE, any claims related to
that care would be denied. According to DOD, this policy was established
to ensure continuity of care for beneficiaries and to ensure that there
was no duplication of care or of payments from TRICARE or VA. Under the
policy, if beneficiaries are dissatisfied with the care provided by VA,
they are unable to switch to TRICARE to receive services for the same
episode of care.

Section 708 of the Bob Stump National Defense Authorization Act for Fiscal
Year 2003 2 directed the Secretary of Defense to establish a process for
resolving issues related to patient safety and continuity of care for
beneficiaries who are concurrently eligible for health care through DOD*s
TRICARE program and through VA. It also

1 According to DOD, an episode of care is generally accepted to be all
care related to a single injury or illness. 2 Pub. L. No. 107- 314, S:
708, 116 Stat. 2458, 2585 (2002).

GAO- 03- 904R DOD and VA Health Care for Dual Eligibles 2

required that the Comptroller General review and report on issues related
to dual eligibility.

On April 16, 2003, DOD reported 3 to the Congress on a proposal to change
its policy and promulgate regulations for coordinating care between DOD
and VA. As agreed, we focused our review on the reasonableness of DOD*s
process. To do so, we reviewed the report submitted to the Congress and
TRICARE policies, and interviewed agency officials from DOD and VA. Our
work was conducted in June 2003 in accordance with generally accepted
government auditing standards.

DOD proposes to change its basic policy to enable dual eligible
beneficiaries to access both systems for the same episode of care, thus
ensuring full freedom of choice. DOD also proposes to pay for medically
necessary care to the extent that such care would be covered by TRICARE.
DOD*s proposal appears reasonable, and it is in the process of developing
regulations to implement it.

An official with the TRICARE Management Activity reviewed a draft of this
letter and agreed the information in it is correct. We are sending copies
of this letter to the Secretary of Defense, appropriate congressional
committees, and other interested

parties. We will provide copies of it to others upon request. In addition,
it is available at no charge on the GAO Web site at http:// www. gao. gov.
If you or your staff have any questions, please contact me at (202) 512-
7101 or Michael T. Blair, Jr., at (404) 679- 1944.

Cynthia A. Bascetta Director, Health Care* Veterans*

Health and Benefits Issues (290272) 3 Report to Congress: Department of
Defense Plan for Coordinating Care Between TRICARE and the Department of
Veterans Affairs (Washington, D. C.: April 2003).

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