TRICARE: Enrollment of the Department of Defense's TRICARE	 
Beneficiaries in Medicare Part B (30-JUN-06, GAO-06-489R).	 
                                                                 
TRICARE is the Department of Defense's (DOD) health care system  
for active duty and retired uniformed service members and their  
families. TRICARE consists of four separate programs. Three of	 
these programs--TRICARE Prime, a managed care option; TRICARE	 
Extra, a preferred provider option; and TRICARE Standard, a fee  
for service option--cover active duty personnel, their		 
dependents, and retirees under age 65. Prior to 2001, TRICARE	 
beneficiaries would lose their TRICARE coverage when they reached
age 65, and Medicare--the federal health insurance program that  
provides medical benefits to over 42 million elderly and disabled
Americans--would become their primary health insurer. However, in
2001, the Congress expanded TRICARE by establishing a fourth	 
program, known as TRICARE for Life (TFL). TFL provides		 
supplementary health care coverage for TRICARE beneficiaries who 
are entitled to Medicare Part A, and enrolled in Part B. It pays 
for many services that Medicare only partially covers. While	 
TRICARE beneficiaries do not have to pay for their TFL coverage, 
they are required to pay premiums for Medicare Part B. Section	 
625 of the Medicare Prescription Drug, Improvement, and 	 
Modernization Act of 2003 (MMA) provided enrollment incentives to
TRICARE beneficiaries who were entitled to Medicare Part A, but  
were not enrolled in Medicare Part B during their initial	 
eligibility period. Four federal organizations had a role in	 
implementing Section 625 of MMA. DOD's TRICARE Management	 
Activity (TMA), which oversees the TFL program, and DOD's Defense
Manpower Data Center (DMDC), which maintains the military's	 
personnel database in its Defense Enrollment Eligibility	 
Reporting System (DEERS), both had key roles in implementing the 
new law. In addition, the Centers for Medicare & Medicaid	 
Services (CMS)--the Department of Health and Human Services	 
agency that oversees the Medicare program--and SSA, which enrolls
Medicare beneficiaries and assists with the collection of	 
Medicare premiums on CMS's behalf, had significant		 
responsibilities. Interested in determining the extent to which  
TRICARE beneficiaries benefited from the provisions of Section	 
625 of MMA, Congress asked GAO to report on the implementation of
this law. This report describes (1) the steps that TMA, DMDC,	 
CMS, and SSA took in response to Section 625 of MMA, including	 
their efforts to correct problems encountered during the law's	 
implementation, and (2) the extent to which TRICARE beneficiaries
were served.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-489R					        
    ACCNO:   A57020						        
  TITLE:     TRICARE: Enrollment of the Department of Defense's       
TRICARE Beneficiaries in Medicare Part B			 
     DATE:   06/30/2006 
  SUBJECT:   Beneficiaries					 
	     Computer matching					 
	     Data collection					 
	     Data integrity					 
	     Eligibility determinations 			 
	     Government information dissemination		 
	     Health insurance					 
	     Interagency relations				 
	     Managed health care				 
	     Medicare						 
	     Military dependents				 
	     Military personnel 				 
	     Retired military personnel 			 
	     Data sharing					 
	     Enrollment periods 				 
	     DOD TRICARE For Life Program			 
	     DOD TRICARE Program				 

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GAO-06-489R

     

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June 30, 2006

The Honorable Pete Stark

Ranking Minority Member

Subcommittee on Health

Committee on Ways and Means

House of Representatives

The Honorable Benjamin L. Cardin

House of Representatives

Subject: TRICARE: Enrollment of the Department of Defense's TRICARE
Beneficiaries in Medicare Part B

TRICARE is the Department of Defense's (DOD) health care system for active
duty and retired uniformed service members and their families. TRICARE
consists of four separate programs. Three of these programs-TRICARE Prime,
a managed care option; TRICARE Extra, a preferred provider option; and
TRICARE Standard, a fee for service option-cover active duty personnel,
their dependents, and retirees under age 65. Prior to 2001, TRICARE
beneficiaries would lose their TRICARE coverage when they reached age 65,
and Medicare-the federal health insurance program that provides medical
benefits to over 42 million elderly and disabled Americans-would become
their primary health insurer. However, in 2001, the Congress expanded
TRICARE by establishing a fourth program, known as TRICARE for Life (TFL).
TFL provides supplementary health care coverage for TRICARE beneficiaries1
who are entitled to Medicare Part A,2 and enrolled in Part B. It pays for
many services that Medicare only partially covers. While TRICARE
beneficiaries do not have to pay for their TFL coverage, they are required
to pay premiums for Medicare Part B.

DOD generally encourages TRICARE beneficiaries to enroll in Medicare Part
B when they reach age 65 or when the Social Security Administration (SSA)
determines that they are disabled and they have been receiving disability
benefits for 24 months. Those who do not enroll in Part B when first
eligible must wait, like other beneficiaries, for Medicare's general
enrollment period, which is held annually, from January 1 to March 31,
with coverage beginning on July 1 of that same year. In addition, those
who enroll during the general enrollment period are assessed a surcharge
for each 12-month period that enrollment was delayed after their initial
eligibility. Not all TRICARE beneficiaries enrolled in Medicare Part B
when they first became eligible to do so and, as a result, were assessed
premium surcharges when they eventually signed up for it.

1Hereafter, we use the term TRICARE beneficiaries to include military
retirees and their dependents and survivors who are entitled to Medicare
Part A.

2Medicare Part A covers inpatient hospital, skilled nursing facility,
hospice, and certain home health services. Part B covers certain
physician, outpatient hospital, laboratory, and other services. Another
component of the Medicare program is Part D, which provides prescription
drug coverage for Medicare beneficiaries.

Section 625 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) provided enrollment incentives to TRICARE
beneficiaries who were entitled to Medicare Part A, but were not enrolled
in Medicare Part B during their initial eligibility period.3 In
particular, Section 625 waived premium surcharges for TRICARE
beneficiaries who enrolled in Medicare Part B from 2001 through 2004. The
law also required that the Secretary of Health and Human Services
establish a method for providing rebates for Part B premium surcharges
that this group had paid since 2004. Further, the law directed the
Secretary to provide a Part B special enrollment period for TRICARE
beneficiaries who had not enrolled in Part B as of the date of MMA's
enactment-December 8, 2003. The law mandated that this special enrollment
period begin as soon as possible after MMA's enactment and end on December
31, 2004.

Four federal organizations had a role in implementing Section 625 of MMA.
DOD's TRICARE Management Activity (TMA), which oversees the TFL program,
and DOD's Defense Manpower Data Center (DMDC), which maintains the
military's personnel database in its Defense Enrollment Eligibility
Reporting System (DEERS), both had key roles in implementing the new law.4
In addition, the Centers for Medicare & Medicaid Services (CMS)-the
Department of Health and Human Services agency that oversees the Medicare
program-and SSA, which enrolls Medicare beneficiaries and assists with the
collection of Medicare premiums on CMS's behalf, had significant
responsibilities. TMA, DMDC, and CMS had to identify which TRICARE
beneficiaries were targeted for the Section 625 enrollment incentives. SSA
had to enroll the TRICARE beneficiaries in Medicare Part B, waive the late
enrollment premium surcharges, and repay the surcharges paid for their
premiums since 2004.

Although the four organizations worked together to implement the new law,
there were problems with the data that were used to initially identify
which TRICARE beneficiaries were targeted by Section 625. As a result,
some of the TRICARE beneficiaries who should have been identified were
inadvertently excluded. Interested in determining the extent to which
TRICARE beneficiaries benefited from the provisions of Section 625 of MMA,
you asked us to report on the implementation of this law. This report
describes (1) the steps that TMA, DMDC, CMS, and SSA took in response to
Section 625 of MMA, including their efforts to correct problems
encountered during the law's implementation, and (2) the extent to which
TRICARE beneficiaries were served.

3Pub. L. No. 108-173, S: 625, 117 Stat. 2066, 2317-18 (2003).

4The DEERS database contains the service-related and demographic data that
are used to determine eligibility for military benefits, including health
care, for all active duty servicemembers, military retirees, and the
dependents and survivors of activity duty servicemembers and military
retirees. As individuals join the military, the various services enter
information on them into DEERS and update the information as their
military status changes. The individual servicemember is responsible for
providing information to DEERS on dependents and for reporting changes
concerning dependents.

To describe the steps that TMA, DMDC, CMS, and SSA took in response to
Section 625 of MMA, including their efforts to correct problems
encountered, we reviewed the TMA, DMDC, and CMS agreements to share
enrollment and eligibility data. We also interviewed CMS and SSA
officials, as well as DOD representatives from TMA and DMDC. We focused
our work on those organizations' efforts to identify, enroll, waive, and
repay premium surcharges to eligible TRICARE beneficiaries.

To describe the extent to which TRICARE beneficiaries were served, we
obtained data from the involved agencies on the number of TRICARE
beneficiaries who were enrolled in Part B or whose premium surcharges were
repaid. We assessed the reliability of the DOD, CMS, and SSA data by
corroborating them with available documentation from TMA, DMDC, CMS, and
SSA. While we previously reported on weaknesses in DEERS, we determined
that those weaknesses were not germane for the purposes of this report.5
We reviewed the Part B enrollment and premium surcharge data for
consistency and discussed the discrepancies with CMS and SSA officials and
determined that these data were reliable for purposes of this report. In
addition, we examined the notices and other correspondence that the
organizations sent to TRICARE beneficiaries to determine when and how they
were given the opportunity to enroll in Medicare Part B. We also
determined whether the notices included information on their right to
appeal the amount of the premium surcharges that were repaid, if they
disagreed with SSA's calculation. Our scope was limited to the actions
taken by TMA, DMDC, CMS, and SSA to implement Section 625 of MMA.6 We
performed our work from July 2005 through May 2006 in accordance with
generally accepted government auditing standards.

RESULTS IN BRIEF

All four organizations-TMA, DMDC, CMS, and SSA-collaborated to implement
Section 625 of MMA. The organizations took a series of steps, including
reaching agreement to share necessary data. To identify the targeted
TRICARE beneficiaries, the organizations worked together, from May through
July of 2004, to perform a data match-a process during which they compared
and matched Social Security numbers and dates of birth of TRICARE
beneficiaries in their respective databases. DMDC mailed information to
TRICARE beneficiaries in September 2004, alerting them that they would
receive important information from SSA concerning their Medicare Part B
enrollment. Also in September 2004, after the data match was finalized,
SSA sent notices to about 49,000 TRICARE beneficiaries advising them that
they had been automatically enrolled in Part B or that they were eligible
for a repayment of their premium surcharges. However, the data used for
this match were incomplete. As a result, TRICARE beneficiaries who should
have been identified were inadvertently excluded. Some of those who did
not receive a notice from SSA alerted federal officials to the error,
within days of the SSA mailing. Over the next several months, DOD and CMS
worked unsuccessfully to resolve the error. They decided, in December
2004, that it would be more expeditious to conduct a second data match
than to pinpoint and correct the problems associated with the first data
match. The organizations completed the second data match by mid-February
2005. CMS extended the Part B special enrollment period mandated by
Section 625 of MMA from December 2004 through June 2005. Beneficiaries
identified by the second data match had the option of enrolling in any
month of 2004 or in one of the first 6 months of 2005. In addition, SSA
developed processes to enroll individuals who presented themselves, but
had not received letters.

5See GAO, Defense Health Care: TRICARE Claims Processing Has Improved but
Inefficiencies Remain, GAO-04-69 (Washington, D.C.: Oct. 15, 2003), and
Defense Health Care: Most Reservists Have Civilian Health Coverage but
More Assistance Is Needed When TRICARE Is Used, GAO-02-829 (Washington,
D.C.: Sept. 6, 2002).

6The Railroad Retirement Board (RRB) also enrolls Medicare beneficiaries
and collects Part B premiums on behalf of CMS. Less than 0.2 percent of
the TRICARE beneficiaries targeted by Section 625 of MMA were RRB
annuitants; as a result, we did not include this agency in the scope of
our review.

Information on the total number of TRICARE beneficiaries served under
Section 625 of MMA is not known. Available SSA and CMS data show that over
44,000 TRICARE beneficiaries were either enrolled in Medicare Part B or
repaid for their 2004 premium surcharges, under the provisions of Section
625 of MMA. About 26,000 TRICARE beneficiaries enrolled during the special
enrollment period, and about 18,700 additional TRICARE beneficiaries were
either credited or repaid for premium surcharges. Although SSA determined
that it had received nearly 15,000 TFL-related inquiries since January
2004, it did not separately track how many of these inquiries resulted in
enrollments in Part B, premium adjustments, or repayments. Further, SSA
did not separately track how many TFL-related appeals it received or the
disposition of such appeals, so such information is unavailable.

We provided a draft of this report to CMS, DOD, and SSA. We received
written comments from CMS and DOD. SSA also provided us with comments by
e-mail. All three agencies generally concurred with our findings.

BACKGROUND

The Floyd D. Spence National Defense Authorization Act for Fiscal Year
2001 authorized the creation of the DOD Medicare-Eligible Retiree Health
Care Fund, which covers the full cost of TFL coverage for military
retirees, certain dependents, and survivors who are entitled to Medicare
Part A, and enrolled in Part B.7 TFL alleviates the need to purchase
supplemental health insurance because it covers Medicare's co-payment and
deductible medical expenses. TFL also alleviates the need for TRICARE
beneficiaries to enroll in Medicare Part D because, under TFL, they can
obtain prescription drugs at no cost from military treatment facilities,
at low cost through DOD's National Mail Order Pharmacy, or, at higher
costs from retail network or non-network pharmacies. In addition, TFL pays
for certain skilled nursing and inpatient hospitalization services that
Medicare does not cover.

7Pub. L. No. 106-398, S: 713, 114 Stat. 1654, 1654A-179.

Individuals who are entitled to Social Security retirement or disability
benefits are automatically enrolled in Medicare Parts A and B. CMS sends
these individuals an initial enrollment period package that includes
information about the Medicare program, a Medicare card, and a form that
can be used to decline Part B enrollment. The package does not include a
similar form to decline Part A coverage because beneficiaries cannot
decline Part A. All other individuals who file an application for either
Social Security benefits or Medicare are automatically enrolled in
Medicare Part A. If these individuals choose to elect Part B coverage,
they must do so at the time the application is filed. Most people do not
pay a premium for Part A;8 however, all beneficiaries who elect Part B
coverage must pay the Part B premium. People who do not receive Social
Security benefits are billed for 3 months of Part B coverage at a time,
with the first payment due 1 month before their 65th birthday. If
individuals who accept Part B enrollment also receive Social Security
benefits, SSA will deduct the Part B monthly premium from their Social
Security benefit payments, beginning with the month before they are
entitled to Part B. However, those who do not enroll in Part B when first
eligible must wait for Medicare's annual general enrollment period, from
January 1 to March 31, to sign up for coverage.

The surcharges that people pay for delayed Part B enrollment can be
substantial because they are assessed 10 percent of the cost of the
premium, for each full 12-month period that they delay enrolling.
Moreover, these surcharges are added to the cost of the premium for the
life of the coverage.9 For example, figure 1 shows four hypothetical
Medicare beneficiaries who enrolled in Part B at different ages and the
impact of their enrollment dates on the premium surcharges they incurred.
As shown, by the end of 2004, the Medicare beneficiary who delayed
enrollment until age 68 would have paid nearly $500 in premium surcharges,
or twice the amount of the Medicare beneficiary who enrolled at age 67,
while those enrolling at ages 66 or 65 would pay no surcharge at all.

8Most people are entitled to Part A without paying a premium because they
or their spouses already paid for this coverage through employer payroll
deductions, including deductions paid while in military service. However,
some people may not qualify for premium-free Part A because they or their
spouses did not work or did not pay enough in Medicare taxes while
employed. Most persons age 65 or older must have worked 10 years, or 40
quarters, to receive coverage for premium-free Part A. The Part A premium
for people who are not eligible for premium-free Part A with less than 30
quarters of coverage was $343 per month in 2004 and $375 per month in
2005. The Part A premium for people not entitled to premium-free Part A
but with 30 or more quarters of coverage was $189 per month in 2004 and
$206 per month in 2005.

9The Medicare Part B premium is adjusted annually, based on the program's
projected costs for the coming year. The premium for 2005 was $78.20 per
person, per month. The premiums for 2001 through 2004 were $50.00, $54.00,
$58.70, and $66.60, respectively.

Figure 1: Example of Medicare Part B Premium Surcharges Paid for Late
Enrollment by the End of 2004

Note: According to CMS policy, premiums that are not multiples of 10 cents
are rounded to the nearest dime.

ORGANIZATIONS COLLABORATED TO IMPLEMENT

LAW AND TO CORRECT INITIAL ENROLLMENT ERRORS

All four organizations-TMA, DMDC, CMS, and SSA-worked together to
implement Section 625 of MMA. DOD and CMS signed a memorandum of
understanding (MOU) in May 2004, which established the role of each
organization and also recognized that the successful implementation of the
law depended on their sharing accurate and complete sets of data. The
organizations agreed to perform an analysis, known as a data match, to
identify the TRICARE beneficiaries who were eligible under Section 625 to
enroll in Part B during the special enrollment period or entitled to have
their premium surcharges waived and the 2004 surcharges repaid. Despite
their efforts, the data that were used in this data match were incomplete
and some TRICARE beneficiaries were inadvertently excluded. The agencies
conducted a second data match to develop a comprehensive list of TRICARE
beneficiaries and also extended the special enrollment period.

Initial Steps to

Implement Section 625

By March 2004, officials from all four organizations decided that rather
than waiting for TRICARE beneficiaries to individually apply for Part B
enrollment, it would be more efficient for SSA to automatically enroll
them in Part B. To do this, the organizations opted to conduct a data
match, which would require them to obtain and extract information from
their respective databases to identify who was (1) eligible to enroll
during the Section 625 special enrollment period, (2) entitled to have
Part B premium surcharges waived, and (3) due a repayment for 2004 premium
surcharges. TMA, CMS, and SSA officials told us that they posted
information on their organizations' Web sites prior to this data match.
This information was intended to alert TRICARE beneficiaries that they
would be contacted by SSA as soon as implementation procedures were
finalized. SSA officials also trained their field office staff on how to
handle inquiries, should they be contacted before the procedures were
finalized.

Each organization had different sets of information and had to take
particular steps to identify the TRICARE beneficiaries. TMA had
information on TRICARE beneficiaries receiving TFL coverage. DMDC, which
maintains the DEERS database, had information on all active duty members
of the uniformed services, military retirees, and the dependents and
survivors of active duty servicemembers and military retirees. CMS, in its
enrollment database, had enrollment and entitlement information on all of
the people who were or have been enrolled in Medicare. CMS's data also
included information on the person's age, gender, state and county of
residence, and date of enrollment. SSA's Master Beneficiary Record, which
is its principal beneficiary file, had information on SSA's current and
previous retirement and disability beneficiaries and applicants. The
Master Beneficiary Record also contained information on Medicare
enrollment, premiums, and premium surcharges. TMA and DMDC provided the
DOD information on TRICARE beneficiaries to CMS. CMS extracted data on
those meeting the selection criteria and shared its results with SSA. SSA,
in turn, eliminated duplicate entries and the names of deceased TRICARE
beneficiaries, which finalized the results of the data match. Figure 2
illustrates the Section 625 data match and the information that TMA, DMDC,
CMS, and SSA used to identify TRICARE beneficiaries.

Figure 2: Initial Steps Federal Organizations Took to Identify Those
Eligible for Medicare Part B

Organizations Completed Data Match

and Discovered Errors

TMA, DMDC, and CMS had difficulty identifying the TRICARE beneficiaries
targeted by Section 625 of MMA. The MOU they signed specified the
information that they would share. TMA and DMDC agreed to provide CMS with
the Social Security numbers and dates of birth of TRICARE beneficiaries
from the DEERS database. CMS agreed to match that information with data in
its enrollment database and identify which TRICARE beneficiaries were
entitled to premium-free Part A and were not enrolled in Medicare Part B.
CMS also agreed to identify TRICARE beneficiaries who were eligible to
have their Part B premiums surcharges waived and their 2004 premium
surcharges repaid. CMS would then share the results of the data match with
SSA, which would take steps to enroll the TRICARE beneficiaries in Part B
and arrange for the 2004 premium surcharges to be repaid.

However, DMDC and CMS officials did not agree on how many TRICARE
beneficiaries were included in the files used for this initial data match.
DMDC officials told us that they sent two files to CMS, from May 10
through 13, 2004, containing data on a combined total of 7.2 million
TRICARE beneficiaries. However, CMS officials told us they received one
file containing information on about 6.9 million TRICARE beneficiaries-a
difference of about 300,000 TRICARE beneficiaries.

From mid-May to mid-June, CMS matched the data it received from DMDC with
data in its enrollment database to identify the TRICARE beneficiaries
targeted for Section 625 enrollment incentives. CMS identified three
distinct groups of TRICARE beneficiaries who were entitled to premium-free
Part A: (1) those who were not enrolled in Part B, (2) those who had
enrolled in Part B and were paying premium surcharges and were potentially
eligible for premium surcharge waivers and for surcharge repayments, and
(3) those who enrolled during Medicare's 2004 general enrollment period
and to whom CMS offered the choice of making their coverage retroactive to
an earlier month during 2004, in addition to waiving any premium
surcharge.10 CMS electronically transmitted these three files to SSA in
mid-June 2004.

According to SSA officials, in July 2004, they eliminated duplicate
entries and the names of deceased TRICARE beneficiaries from the
information provided by CMS. From September 4, 2004, through September 10,
2004, SSA sent notices to the over 49,000 remaining TRICARE beneficiaries
concerning their eligibility under Section 625 of MMA. SSA notified the
first group of TRICARE beneficiaries-those that had not enrolled in Part
B-that the agency had automatically enrolled them in Part B, with a
September 1, 2004, effective date. SSA also informed them that it had
deducted 2 months worth of premiums from their Social Security benefit
checks and that those who did not receive benefit checks would be billed
separately by CMS. The notice also explained that because MMA mandated
that a special enrollment period be offered to them, they could choose to
make their Part B coverage effective in any month in 2004. SSA's notice to
this first group of TRICARE beneficiaries also explained how to decline
Part B enrollment.

SSA informed the second group of TRICARE beneficiaries-who were paying
premium surcharges-that their premium surcharges would be waived and that
the surcharges they paid for Part B in 2004 would either be included in
their Social Security benefit checks or credited toward future premiums,
if they were billed for Part B coverage. SSA notified the TRICARE
beneficiaries in the third group-who had enrolled during Medicare's 2004
general enrollment period-that they could make their coverage retroactive
to as early as January 2004, instead of the customary July 1 effective
date. TRICARE beneficiaries in this third group were also informed that
their premium surcharges would be waived and that any surcharges they
might have paid would be repaid or credited toward future premiums.
Additionally, SSA's notices advised them how to appeal, if they disagreed
with the agency's Part B enrollment determination or the repayment
calculation.

10MMA called for the special enrollment period to begin as soon as
possible following the law's enactment. Because it took 5 months to
finalize implementation procedures, CMS identified the third group of
TRICARE beneficiaries-those who had enrolled during the 2004 general
enrollment period-and offered them the option of beginning Part B coverage
sooner than the customary July 1 effective date.

In September 2004, DMDC alerted TRICARE beneficiaries by mail that they
would receive important information from SSA concerning their Medicare
Part B enrollment. DMDC also categorized TRICARE beneficiaries into three
groups; these groups were different from the three categories used by CMS
and SSA.11 Beginning in September 2004, within days of the SSA mailing,
TMA, CMS, and SSA received inquiries from concerned TRICARE beneficiaries
who had received letters from DMDC but had not received enrollment
information from SSA. According to officials from TMA, CMS, and SSA, these
calls were their first indication that some of the targeted TRICARE
beneficiaries had not been identified through their data match efforts.
TMA's and DMDC's internal quality review estimated that DMDC had mailed
notices to about 42,000 more TRICARE beneficiaries than SSA had notified.
According to CMS, it determined that, in early December 2004, most of the
beneficiaries who said they had not received a letter from SSA were not
included on the initial file received from DMDC. As a result, CMS had not
transmitted data on these beneficiaries to SSA in June 2004.

Organizations Obtained Corrected Data and

Extended the Enrollment Period

On December 29, 2004, TMA, DMDC, CMS, and SSA officials agreed that it
would be more expeditious to perform a second data match than to continue
investigating why some TRICARE beneficiaries had not been identified by
their initial efforts. The next day, December 30, 2004, CMS received the
Social Security numbers and dates of birth of approximately 7.4 million
TRICARE beneficiaries from DMDC, which included data on over 500,000 more
TRICARE beneficiaries than used for the initial data match. This time,
DMDC transmitted data on all the TRICARE beneficiaries potentially
eligible for TFL benefits in its database in a single file, not in two
separate files as organization officials said had been done for the
initial data match. Matching these data with its enrollment database, from
January 10 through January 12, 2005, CMS identified two groups of TRICARE
beneficiaries who were entitled to premium-free Part A: (1) those who were
not enrolled in Part B and (2) those who were enrolled in Part B and
potentially eligible for their premium surcharges to be waived and for the
2004 surcharges to be repaid.12 CMS transmitted information on these
TRICARE beneficiaries to SSA on January 12, 2005.

11The DMDC categories were for TRICARE beneficiaries who were entitled to
premium-free Medicare Part A and were (1) under age 65 and not enrolled in
Part B, (2) age 65 and over and not enrolled in Part B, or (3) enrolled in
the Uniformed Services Family Health Plan-a TRICARE managed care option
that is only available in six areas of the country. The letters to the
first and second groups contained information on their upcoming automatic
enrollment in Part B, the monthly or quarterly Part B premiums they would
need to pay, and the consequences of declining Part B coverage. The letter
to the third group explained that once they disenrolled from the Uniformed
Services Family Health Plan, they would need to immediately enroll in
Medicare Part B for continued TRICARE coverage under TFL.

12Because the 2005 general enrollment period had just begun, CMS did not
separately identify TRICARE beneficiaries who enrolled during general
enrollment, as it had done for the first data match.

By mid-February, SSA reviewed the data it received from CMS-eliminating
duplicate entries and the names of deceased persons. In March 2005, SSA
sent the identified 41,345 TRICARE beneficiaries instructions on how to
enroll in Part B and an enrollment form, and offered those who chose to
enroll the option of selecting any month in calendar year 2004 or the
first 7 months of 2005 for their Part B coverage to begin.13 However, CMS,
SSA, and TMA officials agreed that it would be preferable to offer
information on Part B enrollment, rather than automatically enrolling
TRICARE beneficiaries as had been done following the first data match.
These officials expressed several concerns with automatic enrollment.
First, CMS and SSA officials told us that an automatic enrollment would
not save time. Instead, they told us that they were concerned that it
would take as long to automatically enroll those identified by the second
data match as it had taken them to enroll TRICARE beneficiaries after the
initial data match. Second, SSA pointed out that some of the individuals
identified by the second data match were already in the process of being
enrolled. Third, TMA officials told us they were also concerned that some
TRICARE beneficiaries might have declined coverage and would be irritated
if SSA enrolled them a second time and deducted 2 months' premiums from
their Social Security benefit checks.

In addition, on April 27, 2005, SSA provided written instructions to its
field offices on how to enroll and process repayments for TRICARE
beneficiaries who might not have received either its September 2004 or
March 2005 notice, but who may subsequently have learned about their
eligibility under Section 625 of MMA. These instructions also extended the
special enrollment period through June 2005 because, according to CMS and
SSA officials, not all of the eligible TRICARE beneficiaries had an ample
opportunity to enroll during the special enrollment period specified in
the law. The instructions also included provisions for enrolling eligible
TRICARE beneficiaries after June 2005, on a case-by-case basis. The
instructions also reminded SSA field staff that there is no time limit for
waiving or repaying the Part B premium surcharges. Figure 3 illustrates
the agencies' efforts to implement Section 625 of MMA, including their
efforts to correct the problems encountered after the initial data match.

13An SSA official told us that the agency generally gives people 3 months
to respond to an agency notice, so that an enrollment notice sent in March
2005 would typically give an individual until June 2005 to respond and
elect Part B coverage.

Figure 3: Timeline of Federal Actions to Implement Section 625 of MMA

Note: CMS extended the Section 625 special enrollment period through June
2005. In addition, SSA's April 27, 2005, instruction to its field offices
included provisions for enrolling TRICARE beneficiaries and repaying
premium surcharges after June 2005, on a case-by-case basis.

DATA ON TRICARE BENEFICIARIES SERVED UNDER

SECTION 625 OF MMA ARE INCOMPLETE

Although the total number of TRICARE beneficiaries served by the
implementation of Section 625 is not fully known, we found that over
44,000 TRICARE beneficiaries benefited from this law, most as a result of
the first data match. Data from SSA's automated processing system showed
that it enrolled or provided Part B premium surcharge repayments to 43,948
TRICARE beneficiaries, as a result of Section 625 of MMA. SSA also told us
other TRICARE beneficiaries were served by Section 625 of MMA, but were
not tracked by its automated systems. In addition, CMS officials reported
that implementation of Section 625 of MMA resulted in premium surcharge
repayments or credits toward future premiums for 462 TRICARE
beneficiaries, who were billed for Part B coverage.

Over 44,000 TRICARE Beneficiaries Enrolled in Part B

or Were Repaid for Premium Surcharges

By December 2005, SSA's automated processing system showed that 43,948
TRICARE beneficiaries benefited from Section 625. SSA enrolled 25,697
TRICARE beneficiaries in Part B and repaid premium surcharges to an
additional 18,251 TRICARE beneficiaries. However, according to SSA
officials, this does not include data on an unspecified number of TRICARE
beneficiaries associated with about 2,000 Social Security numbers, who
were not enrolled, repaid, nor had their premium surcharges waived by the
agency's automated processing system.14 Most of the TRICARE beneficiaries
who enrolled or received repayments for their premium surcharges were as a
result of the first data match.

In June 2004, CMS identified a total of 59,918 TRICARE beneficiaries who
were entitled to premium-free Part A and potentially eligible for the
Section 625 enrollment incentives, as a result of the first data match.
CMS determined that these 59,918 TRICARE beneficiaries could be
categorized into three groups. The first group comprised 32,044 TRICARE
beneficiaries who were not enrolled in Part B and the second group
comprised 18,700 TRICARE beneficiaries who were enrolled in Part B and
were paying premium surcharges for their late enrollment. The third group
comprised 9,174 TRICARE beneficiaries who had enrolled in Part B during
the 2004 January-March general enrollment period. CMS offered this third
group the option of making their Part B coverage retroactive to as early
as January 2004, instead of the customary July 1 effective date for
general enrollment.15 After SSA reviewed the CMS data, in July 2004, SSA
determined that a total of 49,117 TRICARE beneficiaries were not enrolled
in Part B or were enrolled and eligible for premium surcharge waivers and
surcharge repayments. Although SSA processed most-47,803-of these cases16
through its automated processing system, 1,314 were rejected by this
system and had to be processed manually.17 SSA officials explained that
the data that they provided to us were from its automated systems and, as
a result, did not include information on the Part B enrollments and
repayments for the 1,314 TRICARE beneficiaries whose cases were manually
processed.

From the second data match, CMS identified a total of 57,480 TRICARE
beneficiaries as potentially eligible for the Section 625 enrollment
incentives, including an unknown number of TRICARE beneficiaries who were
identified by both data matches. CMS officials explained that TRICARE
beneficiaries who had either declined Part B or had allowed their coverage
to lapse by the time the second match was conducted would have been
identified by both data matches. According to information in CMS's
enrollment database, of those TRICARE beneficiaries who were entitled to
premium-free Part A, (1) 55,102 TRICARE beneficiaries were not enrolled in
Part B and (2) 2,378 TRICARE beneficiaries were enrolled in Part B and
potentially due premium surcharge waivers and surcharge repayments.

14An SSA official told us that in addition to the TRICARE beneficiary, a
spouse and dependents may also be receiving benefits based on the TRICARE
beneficiary's Social Security number. Therefore, one Social Security
number may have multiple TRICARE beneficiaries associated with it.

15This group of TRICARE beneficiaries was also entitled to a repayment of
the premium surcharges they might have paid for 2004 Part B coverage.

16SSA defines a case as a matter affecting a record associated with a
specific Social Security number and possibly involving multiple Social
Security beneficiaries.

17An SSA official explained that the agency's automated claims processing
system can reject a case from being processed automatically for numerous
reasons, including missing or conflicting information.

SSA reviewed the CMS data and determined that a total of 41,345 TRICARE
beneficiaries were either not enrolled in Part B or eligible for premium
surcharges to be waived and repayments of their 2004 surcharges. However,
of these 41,345 TRICARE beneficiaries, SSA was able to issue notices about
enrolling in Part B and process premium surcharge waivers, and repayments
for 40,703 through its automated systems. This number excludes 642 cases
that were not processed by SSA's automated processing system. According to
SSA officials, some of the TRICARE beneficiaries associated with these
cases could have enrolled or pursued repayment of their premium surcharges
through their local SSA field offices. Because these cases were manually
processed, they were also not included in the data that SSA provided to
us.

A total of 43,948 TRICARE beneficiaries had been served under Section 625
by December 2005, according to data from SSA's automated processing
system. As shown in table 1, SSA enrolled 25,697 TRICARE beneficiaries in
Part B and repaid premium surcharges to an additional 18,251 TRICARE
beneficiaries. Initially, only TRICARE beneficiaries who received Social
Security benefit checks received repayments for their premium surcharges.
Those whom CMS billed for Part B coverage had their premium surcharges
credited toward future premiums.

Table 1: Section 625 of MMA Part B Enrollments and Premium Surcharges
Repaid by SSA, as of December 2, 2005

                                              First match Second match  Total 
Number of TRICARE beneficiaries SSA                                        
enrolled in Part Ba                             21,956        3,741 25,697
Number of TRICARE beneficiaries who                                        
received repaymentsb                            16,525        1,726 18,251
Average amount repaidb                         $309.96      $524.00 

Source: GAO analysis of SSA data.

aAccording to SSA, 9,322 of the 31,278 eligible TRICARE beneficiaries
identified by the first match declined Part B coverage; many were already
enrolled in a group health plan.

bThe TRICARE beneficiaries who received repayments as a result of the
first data match are not included among those who received repayments as a
result of the second data match.

CMS subsequently determined that it would repay, rather than credit,
premium surcharges for qualifying TRICARE beneficiaries. In May 2005, CMS
identified 462 TRICARE beneficiaries who were billed for Part B and
qualified for repayments under Section 625 of MMA. According to CMS, by
the time the agency identified these 462 TRICARE beneficiaries, 195 of
them had already had the money credited for their Part B premiums. By the
end of June 2005, SSA had notified TRICARE beneficiaries of their premium
surcharge refunds and Medicare repaid $112,300 to 267 of these
beneficiaries whose credit balances had not been depleted. In addition,
CMS determined that it would repay the premium surcharges for any
additional TRICARE beneficiaries who qualified under Section 625 of MMA,
but had not yet been identified as eligible. In total, SSA and CMS repaid
or credited 18,713 TRICARE beneficiaries for the premium surcharges they
had paid for 2004 Part B coverage.

Not All Aspects of Section 625

Implementation Are Known

Despite the availability of much data, some details concerning the law's
implementation are unknown. SSA officials noted that the agency's
automated processing system did not track the number of TRICARE
beneficiaries who changed the effective date of their Part B coverage, as
a result of Section 625 of MMA. SSA also could not identify the number of
appeals filed by TRICARE beneficiaries that were affected by Section 625.
Although SSA tracked the number of TFL-related inquiries that its field
offices had received since January 2004, the agency had not determined
whether those nearly 15,000 inquiries resulted in additional enrollments,
waivers of premium surcharges, or repayments for premium surcharges.
According to SSA, it determined that because of the relatively small size
of the TRICARE workload, it would not be cost effective to change its
reporting systems to capture this information. Finally, none of the
involved organizations-DMDC, TMA, CMS, or SSA-tracked data on the
disposition of cases involving undelivered mail. Consequently, the number
of TRICARE beneficiaries who never received notices is unknown.

AGENCY COMMENTS

We provided a draft of this report to CMS, DOD, and SSA. We received
written comments from CMS and DOD. We have reprinted CMS's and DOD's
letters in enclosures I and II, respectively. SSA also provided us with
comments by e-mail. All three agencies generally concurred with our
findings and provided additional information clarifying their respective
roles in the implementation of Section 625. We revised our report to
reflect this information. All three agencies also offered technical
comments, which we incorporated as appropriate.

                                   - - - - -

As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its date. At that time, we will send copies to the Secretary of
Defense, the Secretary of Health and Human Services, the Administrator of
CMS, the Commissioner of SSA, and other interested parties. We will also
make copies available to others upon request. In addition, this report
will be available at no charge on GAO's Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact
me at (312) 220-7600 or [email protected]. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. Geraldine Redican-Bigott, Assistant Director;
Enchelle Bolden; Chir-Jen Huang; Kevin Milne; and Jessica Cobert Smith
made key contributions to this report.

Leslie G. Aronovitz

Director, Health Care

Enclosures -- 2

           Comments from the Centers for Medicare & Medicaid Services

                    Comments from the Department of Defense

(290475)

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