Military Health: Increased TRICARE Eligibility for Reservists
Presents Educational Challenges (12-FEB-07, GAO-07-195).
Since 2001, the number of reservists mobilized for active duty
has increased dramatically. Congress has expanded reservists' and
their dependents' eligibility for TRICARE, the Department of
Defense's (DOD) health insurance program. The National Defense
Authorization Act (NDAA) for Fiscal Year 2004 directed GAO to
examine the health insurance coverage of reservists and their
dependents. This report (1) identifies the extent to which
reservists have civilian health insurance, (2) examines DOD's
efforts to educate reservists and their dependents about TRICARE,
and (3) describes reservists' level of satisfaction with TRICARE
and the types of problems reservists and their dependents
experienced when using it. To do this, GAO relied on interviews
with DOD and DOD's survey data. GAO also administered a survey of
TRICARE benefit assistance coordinators.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-07-195
ACCNO: A65805
TITLE: Military Health: Increased TRICARE Eligibility for
Reservists Presents Educational Challenges
DATE: 02/12/2007
SUBJECT: Armed forces reserves
Eligibility criteria
Eligibility determinations
Government information dissemination
Health insurance
Health surveys
Managed health care
Military dependents
Military reserve personnel
Mobilization
Education program evaluation
Comparative analysis
Policies and procedures
Defense Enrollment Eligibility Reporting
System
DOD TRICARE Program
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GAO-07-195
* [1]Results in Brief
* [2]Background
* [3]Health Insurance Protections for Reservists
* [4]Expanded TRICARE Eligibility for Reservists and Their Depend
* [5]Defense Enrollment Eligibility Reporting System
* [6]TRICARE Options for Mobilized Reservists and Their Dependent
* [7]Most Reservists Have Civilian Health Insurance, and Many Res
* [8]Reservists Covered by Health Insurance at Rates Similar to T
* [9]Many Mobilized Reservists Choose to Maintain Civilian Covera
* [10]Relatively Few Reservists Have Enrolled in TRS
* [11]DOD Is Challenged by the Task of Educating Reservists and Th
* [12]DOD Is Educating an Increased Number of Reservists and Depen
* [13]Most Reservists and Their Dependents Are Not Well-Informed a
* [14]DOD Uses a Variety of Tools to Educate Reservists and Their
* [15]DOD Officials Recognize the Need for Improved TRICARE Educat
* [16]Most Reservists Are Satisfied with Their TRICARE Benefits, b
* [17]Most Reservists Are Satisfied with TRICARE
* [18]Some Reservists and Their Dependents Experienced Difficultie
* [19]Understanding Benefits
* [20]Establishing Eligibility
* [21]Finding Assistance
* [22]Finding Medical Providers
* [23]Conclusions
* [24]Recommendation
* [25]Agency Comments and Our Evaluation
* [26]Appendix I: Objectives, Scope, and Methodology
* [27]Appendix II: Selected Legislation Pertaining to TRICARE Elig
* [28]Appendix III: Comments from the Department of Defense
* [29]Appendix IV: GAO Contact and Staff Acknowledgments
* [30]GAO Contact
* [31]Acknowledgments
* [32]Order by Mail or Phone
Report to Congressional Committees
United States Government Accountability Office
GAO
February 2007
MILITARY HEALTH
Increased TRICARE Eligibility for Reservists Presents Educational
Challenges
GAO-07-195
Contents
Letter 1
Results in Brief 3
Background 5
Most Reservists Have Civilian Health Insurance, and Many Reservists Choose
to Maintain Their Civilian Insurance When Mobilized 12
DOD Is Challenged by the Task of Educating Reservists and Their Dependents
about TRICARE 16
Most Reservists Are Satisfied with Their TRICARE Benefits, but Some
Reservists Experience Difficulties Using TRICARE 22
Conclusions 26
Recommendation 26
Agency Comments and Our Evaluation 26
Appendix I Objectives, Scope, and Methodology 28
Appendix II Selected Legislation Pertaining to TRICARE Eligibility for
Reservists 30
Appendix III Comments from the Department of Defense 31
Appendix IV GAO Contact and Staff Acknowledgments 33
Tables
Table 1: Selected TRS Eligibility Criteria and Premiums for Selected
Reservists as of October 1, 2006 10
Table 2: TRICARE Options Available to Reservists and Their Dependents 12
Figures
Figure 1: Periods of TRICARE Eligibility for Mobilized Reservists and
their Dependents, as of July 2006 9
Figure 2: Sources of Reservists' and Their Dependents' Health Insurance,
Prior to Mobilization, 2003 14
Figure 3: Reservists' Knowledge about Various Aspects of TRICARE 18
Figure 4: Comparison of Specific Aspects of Reservists' TRICARE Health
Insurance to Civilian Health Insurance 23
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separately.
United States Government Accountability Office
Washington, DC 20548
February 12, 2007
The Honorable Carl Levin
Chairman
The Honorable John McCain
Ranking Minority Member
Committee on Armed Services
United States Senate
The Honorable Ike Skelton
Chairman
The Honorable Duncan L. Hunter
Ranking Minority Member
Committee on Armed Services
House of Representatives
Since the September 11, 2001, terrorist attacks, the Department of Defense
(DOD) has increased its reliance on reservists to support the global war
on terrorism, and particularly Operations Enduring Freedom and Iraqi
Freedom.^1,2 This has increased the number of reservists supporting DOD's
current operations and the duration of reservists' active-duty service. In
recent years, Congress has increased the health care benefits available to
mobilized reservists and their dependents, which generally include family
members such as spouses and dependent children. Although all active-duty
military personnel must enroll in TRICARE, the military health insurance
program, reservists and their dependents have historically been eligible
for TRICARE only while the reservist was serving on active duty for an
extended period of time following mobilization.^3 The National Defense
Authorization Acts (NDAA) for Fiscal Years 2004, 2005, 2006, and 2007
expanded the number of reservists and their dependents who are eligible
for TRICARE, and the duration of their eligibility. These expansions in
eligibility increased the number of reservists that DOD, working through
the reserve components, is required to educate about TRICARE. Reservists
who are mobilized for a period of more than 30 days become eligible for
TRICARE, as do their dependents. Those who have private health insurance
that covers their dependents may choose to cancel that coverage and switch
to TRICARE or continue that coverage.
^1For the purposes of this report, the term reservist includes all members
of the seven reserve components. These reserve components are the Army
National Guard and the Air National Guard, as well as the Army Reserve,
the Naval Reserve, the Marine Corps Reserve, the Air Force Reserve, and
the Coast Guard Reserve.
^2Operation Enduring Freedom, which began in October 2001, supports combat
operations in Afghanistan and other locations, and Operation Iraqi
Freedom, which began in March 2003, supports combat operations in Iraq and
other locations.
^3Mobilization is the process by which the armed forces are brought into a
state of readiness for war or national emergency or to support some other
operational mission. In this report, we use the term mobilization to refer
to the process of calling up reserve components for active-duty service.
We use the term mobilized reservist to refer to a reservist that has
received his or her order to active duty.
The increased dependence on reservists in recent years has raised
questions by some members of Congress as to whether reservists and their
dependents have adequate health insurance when they are not on active duty
and whether they have difficulty using TRICARE when they are eligible for
it. The NDAA for Fiscal Year 2004 directed that we study the health
insurance coverage of reservists and their dependents, DOD's efforts to
provide assistance specifically to reservists and their dependents to
facilitate their access to and use of TRICARE benefits, and reservists'
and their dependents' experiences using TRICARE.^4 Specifically, as
discussed with the committees of jurisdiction, we (1) identified the
extent to which reservists have civilian health insurance, (2) examined
DOD's efforts to educate reservists and their dependents about TRICARE,
and (3) described reservists' level of satisfaction with TRICARE and the
types of problems reservists and their dependents experienced when using
TRICARE.
To determine the extent to which reservists have civilian health insurance
coverage, we relied on the results of DOD's 2003 and 2004 Status of Forces
Surveys of Reserve Component Members, the most recent surveys that include
questions about reservists' insurance coverage.^5 Through our review of
the relevant documentation and our discussion with DOD officials, we
determined that the data presented in the surveys were sufficiently
reliable for our purposes. We interviewed representatives from DOD's
Office of Reserve Affairs, the TRICARE Management Activity (TMA), Defense
Manpower Data Center, and each of the seven reserve components. We also
reviewed reports from the Congressional Research Service and Congressional
Budget Office as well as GAO's prior work on reservists and defense health
care.
^4Pub. L. No. 108-136, S 705, 117 Stat. 1392, 1528-29 (2003).
^5The Status of Forces Surveys are a series of surveys of reserve and
active-duty personnel that provide DOD with information for evaluating and
monitoring existing programs and policies. Each year, the Status of Forces
Survey includes different questions covering different issues. The 2003
and 2004 surveys each asked reservists a different set of health-related
questions. We did not use the 2005 Status of Forces Survey because it did
not contain any health-related questions. The 2006 Survey was not
available when we performed this work.
To examine DOD's efforts to educate reservists and their dependents about
TRICARE and to describe reservists' level of satisfaction with TRICARE and
the types of problems reservists and their dependents experienced when
using TRICARE, we interviewed over 100 reservists from the Army National
Guard and Navy Reserve. We selected these two groups because they had
large numbers of reservists demobilizing that we were able to interview
during the course of our work. We used these interviews to validate and
update information that we gathered from DOD's 2003 and 2004 Status of
Forces Surveys of Reserve Component Members, the 2002 Survey of Spouses of
Activated National Guard and Reserve Component Members, and the 2000
Survey of Reserve Component Members. We also developed and conducted our
own survey of TRICARE benefit counseling and assistance coordinators
(BCAC). With the assistance of DOD officials, we identified BCACs who had
direct experience providing TRICARE counseling and assistance to
reservists and their dependents. DOD officials said that because BCACs
assist reservists and their dependents with problems using TRICARE, they
could provide us with perspective on the types of problems that reservists
experience.
For a complete discussion of our scope and methodology, see appendix I. We
conducted our work from October 2005 through December 2006 in accordance
with generally accepted government auditing standards.
Results in Brief
Most reservists have civilian health insurance and many of them choose to
maintain this insurance for their dependents during mobilizations. Prior
to being mobilized, 80 percent of reservists had civilian health
insurance--a rate similar to that of comparable groups within the U.S.
population between 18 and 64 years old. Reservists higher in age and rank
are more likely to have health insurance than their junior counterparts.
Reservists with dependents are also more likely to have insurance than
those that do not have dependents. Reservists obtained coverage through a
variety of sources, and some reservists had more than one source of
coverage. The most common sources of health insurance were the reservists'
employer-based health plans and their spouses' employer-based health
plans. Over half of all reservists kept their civilian health insurance
for their dependents during their most recent mobilizations, even though
they were eligible to receive coverage under TRICARE with no associated
premiums.
DOD is challenged by the task of educating reservists and their dependents
about TRICARE, and many reservists and dependents consider themselves to
be ill-informed about it. Increased mobilizations of reservists and
successive legislative changes that have increased reservists' eligibility
for TRICARE have complicated DOD's efforts to educate reservists about
TRICARE. According to the 2003 Status of Forces Survey, fewer than 20
percent of all reservists said that they and their dependents are well
informed about TRICARE. In the 2004 Survey, approximately 41 percent of
reservists reported that their dependents did not use TRICARE because of
its complexity. Fifty-eight percent of TRICARE BCACs that responded to our
survey said that reservists' ability to understand TRICARE is the biggest
problem they face. DOD's primary educational tools are TRICARE briefings
provided to reservists at mobilization sites just prior to being deployed
to the location of their active-duty service, and at demobilization sites
when they return. These briefings are supplemented by family support
programs, Web sites, toll-free customer assistance numbers, and print
materials. TRICARE officials have noted that education could be improved
for reservists by providing additional TRICARE briefings at times when
reservists are not being mobilized or demobilized because reservists are
distracted by other concerns during these times. They have also suggested
targeting additional TRICARE education to dependents. DOD officials
recognize the need to improve TRICARE education, but do not plan to
provide additional TRICARE briefings for reservists and their dependents.
A majority of reservists report that they are satisfied with their TRICARE
benefits; however, some reservists have experienced difficulties when
using TRICARE. When we interviewed reservists, over half reported
satisfaction with TRICARE, which was consistent with data from DOD's 2003
Status of Forces Survey in which over 60 percent of the reservists who
used TRICARE reported being satisfied with it. Additionally, the 2004
Status of Forces Survey showed that 70 percent of reservists thought
TRICARE was either equal to or better than their civilian health
insurance. However, the survey also showed that when reservists and their
dependents experienced problems related to TRICARE, among the most
commonly reported difficulties was a general lack of understanding about
TRICARE. Other difficulties included establishing TRICARE eligibility,
obtaining TRICARE assistance, and finding a health care provider that
accepts TRICARE. DOD officials we interviewed said they believed that some
of these difficulties stemmed from problems with the recording of
reservists' eligibility for TRICARE, which is done by reserve component
administrative personnel rather than TMA personnel. Therefore, a reservist
who was not properly registered in DOD's system for recording eligibility
might seek assistance from a TRICARE BCAC, who would be unable to assist
the reservist with his or her problem, rather than the administrative
personnel who could assist with such problems.
In light of the increasing number of reservists that are eligible for
TRICARE, and reservists' continued concerns that they are ill-informed
about TRICARE, we recommend that the Secretary of Defense improve TRICARE
education for reservists and their dependents by providing additional
TRICARE briefings at times other than at mobilization and demobilization,
or at the time that reservists are first informed of their impending
mobilization. In commenting on this recommendation, DOD agreed that
TRICARE information should be provided to reservists and their dependents
when they are first informed of a pending mobilization of the member;
however, it disagreed that TRICARE briefings should be provided at other
times. DOD stated that training time is limited during training periods
not associated with mobilization and must be prioritized to maximize its
value. We understand the importance for DOD to effectively use limited
training time. However, we continue to believe that providing TRICARE
briefings whenever time becomes available during reservist training
periods--a time when reservists are not distracted by other concerns
associated with mobilization--would be an effective way to help ensure
that reservists are aware of the most current information about TRICARE.
Background
Since the end of the cold war, there has been a change in the way reserve
forces have been used in military operations. During the cold war era, the
reserve components were a manpower tool that was rarely tapped. For
example, from 1945 to 1989, reservists were mobilized by the federal
government only four times, an average of less than once per decade. Since
1990, reservists have been mobilized by the federal government six times,
an average of nearly once every 3 years, and have been used extensively to
support operations in the global war on terrorism. Since September 11,
2001, about 500,000 reservists have been mobilized, primarily to support
operations in Afghanistan and Iraq.^6 This increased use of the reserves
has led to greater congressional interest in the types of benefits
provided to reservists, including the health insurance provided to
reservists and their dependents under TRICARE. Specifically, advocates for
expanding TRICARE have suggested that increasing reservists' access to
TRICARE could improve the medical readiness of reservists by facilitating
early detection and treatment of medical conditions which otherwise might
disqualify a reservist from deploying. Additionally, increased access to
TRICARE could smooth the transition to and from active duty for reservists
and their dependents, an important factor given the increased
mobilizations of reservists.
Health Insurance Protections for Reservists
Reservists' private health insurance coverage is protected by the
Servicemembers Civil Relief Act (SCRA)^7 and the Uniformed Services
Employment and Reemployment Rights Act of 1994 (USERRA).^8 Included in
these acts are protections for reinstating and maintaining reservists'
health insurance. Specifically, when a reservist whose individual coverage
was terminated while the reservist was on active duty returns from that
duty, SCRA requires private insurance companies to reinstate coverage at
the premium rate the reservist would have been paying had coverage not
been terminated.^9 It also requires insurance companies to cover most
preexisting conditions after a reservist's insurance is reinstated.^10
USERRA allows reservists to elect to keep employer-provided health
benefits while the reservists are absent from employment due to active
duty, up to a maximum period of 24 months. For absences of 30 days or
less, the employer must continue to pay its share of the premium. For
absences of 31 days or more, the reservist may elect to continue the
civilian coverage, but the employer may charge the reservist the full
premium, including the employer contributions.^11 In addition, under
USERRA, employers must generally reinstate reservists' health coverage
upon their reemployment and no waiting period or exclusions may be imposed
in connection with that reinstatement.^12 The protections found in SCRA
and USERRA also apply to the health benefits of a reservist's dependents,
if those dependents were covered under the reservist's policy prior to his
or her active-duty service.
^6In 2005, 88 percent of reservists were a part of the Selected Reserve,
which is one category of reservists. The Selected Reserve contains those
units and individuals considered essential to wartime missions. The other
reserve categories are the Individual Ready Reserve, the Inactive National
Guard, Standby Reserve, and Retired Reserve.
^7Pub. L. No. 108-189, 117 Stat. 2835 (2003) (codified at 50 U.S.C. App.
SS 501-596). National Guard members are eligible for SCRA protection only
when they have been called to active duty for more than 30 days to respond
to a national emergency declared by the President and that active duty is
supported by federal funds.
^8Pub. L. No. 103-353, 108 Stat. 3149 (codified as amended at 38 U.S.C. SS
4301-4334).
^9The reservist's individual insurance premium may be increased during the
period between termination and reinstatement, but only to the extent it
would have been increased for other persons covered by that insurance
during that period.
^10Preexisting conditions that are service connected are excluded from
coverage. For example, individual policies would not have to cover
injuries incurred in the line of duty that could be covered first by DOD
and then by the Department of Veterans Affairs. In addition, preexisting
conditions excluded during the original period of coverage may also be
excluded after reinstatement.
Expanded TRICARE Eligibility for Reservists and Their Dependents
Prior to fiscal year 2004, reservists that were not on active duty had
limited eligibility for TRICARE. Specifically, they were entitled to
receive treatment through TRICARE at a military medical facility for
illnesses or injuries incurred during training or periods of active duty.
Family members of reservists had generally not been entitled to use
TRICARE, but became eligible if the reservist was serving on active duty
for more than 30 days.
Beginning in fiscal year 2004, Congress made successive changes to TRICARE
that included several provisions which significantly expanded access to
TRICARE for reservists that are not on active duty, and their dependents.
(For a detailed description of the legislative changes that expanded the
TRICARE eligibility of reservists, see app. II.) The NDAA for Fiscal Year
2004^13 included a temporary provision in which Congress authorized
members of the Selected Reserve and the Individual Ready Reserve to enroll
in TRICARE if the reservists were eligible for unemployment compensation
or ineligible for health care coverage from their civilian employer.^14
Another temporary provision allowed reservists who had received their
active-duty orders to use TRICARE for up to 90 days before their
active-duty service began. A third temporary provision extended the length
of time that service members could use TRICARE under the Transitional
Assistance Management Program (TAMP) to 180 days after they were released
from active duty.^15
^11For deployments of 31 days or more, USERRA permits the employer to
assess an additional 2 percent administrative fee if reservists elect to
continue with civilian insurance and pay the full premium, including the
employer share. The employer is not required to charge the full premium or
the 2 percent administrative fee and some employers continue to pay some
or all of the premium during the reservist's absence.
^12Waiting periods or exclusions are permitted in cases where they would
have been in effect had coverage not been interrupted by the reservist's
absence and in cases where the illness or injury has been incurred during
or aggravated by the reservist's service.
^13Pub. L. No. 108-136, 117 Stat. 1392 (2003).
The NDAA for Fiscal Year 2005^16 indefinitely extended the provisions that
provided up to 90 days of TRICARE coverage to reservists prior to the
beginning of active-duty service and 180 days after.^17 It also authorized
the program that DOD has named TRICARE Reserve Select (TRS), which makes
TRICARE coverage available for purchase by certain reservists after their
TAMP coverage ends. As originally authorized, TRS provided the option of
purchasing TRICARE coverage to members of the Selected Reserve who were
mobilized since September 11, 2001, and who continuously served on active
duty for 90 days or more in support of a contingency operation.^18 To
qualify for TRS, reservists had to enter into an agreement with their
respective reserve components to serve in the Selected Reserve for the
number of years that they wished to participate in TRS. They could receive
1 year of coverage for each 90-day period of this qualifying service.^19
Electing to enroll in this TRS program was a one-time opportunity, and as
originally authorized, the program required reservists to sign the new
service agreement and register for TRS before leaving active duty.^20
Figure 1 describes the various periods of TRICARE eligibility for
mobilized reservists and their dependents.
^14We use the term temporary provision to refer to statutory requirements
that are effective for a limited amount of time or have a set expiration
date.
^15These three temporary provisions expired on December 31, 2004.
^16Pub. L. No. 108-375, 118 Stat. 1811 (2004).
^17Both the preactive-duty benefit and TAMP coverage are also available
for dependents of the reservists. See 32 C.F.R. SS 199.3(b)(5) and
199.3(e).
^18A contingency operation is generally defined as an operation designated
by DOD as one in which members of the armed forces are or may become
involved in military actions against an enemy of the United States or
against an opposing military force, or an operation that results in the
call to active duty of members of the uniformed services under any
applicable provision of law during a war or national emergency declared by
the President or Congress. See 10 U.S.C. S 101(a)(13). Examples of
contingency operations include Operations Enduring Freedom and Iraqi
Freedom.
^19Reservists who were ordered to active duty for a period of more than 30
days, but served less than 90 continuous days due to an injury, illness,
or disease incurred or aggravated while deployed, were eligible for 1 year
of TRICARE coverage under TRS as originally authorized.
Figure 1: Periods of TRICARE Eligibility for Mobilized Reservists and
their Dependents, as of July 2006
aFor a reservist to qualify for TRICARE, the active-duty order must be for
a period of over 30 days.
bThe reserve component will validate eligibility.
The NDAA for Fiscal Year 2006^21 further expanded the number of reservists
and dependents eligible to participate in the TRS program. Under the
expanded program, which became effective on October 1, 2006, almost all
reservists and dependents--regardless of the reservist's prior active-duty
service--have the option of purchasing TRICARE coverage. Similar to the
original TRS program, members of the Selected Reserve and dependents
choosing to enroll in the expanded TRS program must pay a monthly premium
to receive TRICARE coverage. The premium paid by reservists and their
dependents for coverage varies based on certain qualifying conditions that
must be met, such as whether the reservist has access to an
employer-sponsored health plan. Those who would have been eligible under
the original TRS program because they have qualifying service in support
of a contingency operation pay the lowest premium. In addition, those
reservists with qualifying service in support of a contingency operation
would now have up to 90 days after leaving active duty to sign the new
service agreement required to be eligible for this lowest premium tier.
Table 1 describes the Selected Reservists who are eligible to purchase TRS
and the associated premiums.
^20Reservists who qualified could also obtain coverage for their
dependents by paying the appropriate premium.
^21Pub. L. No. 109-163, 119 Stat. 3136 (2006).
Table 1: Selected TRS Eligibility Criteria and Premiums for Selected
Reservists as of October 1, 2006
Monthly
TRICARE
premium cost
for calendar
year 2006^b
Percentage
of TRICARE TRS
premium paid member Duration
by the TRS member and of
Eligibility criteria reservist^a only family coverage
Tier 1: Reservist 28 $81.00 $253.00 1 year of
must have qualifying coverage
active-duty service for each
in support of a continuous
contingency 90 days of
operation on or qualifying
after September 11, service.
2001, for at least
90 days, and must
maintain Selected
Reserve^c status for
each year of TRS
coverage purchased.
Tier 2: Reservist 50 $145.29 $451.42 Up to 1
must not be eligible year of
for coverage
employer-sponsored with an
health insurance; or annual
must be eligible for option to
unemployment renew.
compensation, or
self-employed; must
renew service
agreement and
maintain Selected
Reserve status for
each year of TRS
coverage purchased.
Tier 3: Reservist 85 $247.00 $767.41 Up to 1
not eligible for year of
Tier 1 or 2; may be coverage
eligible for with an
employer-sponsored annual
insurance, but must option to
renew service renew.
agreement and
maintain Selected
Reserve status for
each year of TRS
coverage purchased.
Source: GAO.
aThe total amount of the premium is the amount determined by the Secretary
of Defense for Health Affairs, based on an appropriate actuarial basis.
bDOD plans to recalculate the monthly premiums annually.
cThe Selected Reserve component contains those units and individuals
considered essential to wartime missions. In 2005, 88 percent of
reservists were a part of the Selected Reserve.
The NDAA for Fiscal Year 2007 significantly restructured the TRS program
by eliminating the three-tiered premium structure.^22 This law provides
that members of the Selected Reserve will be eligible to purchase TRICARE
coverage for themselves and their dependents at the 28 percent premium
rate regardless of whether they have served on active duty in support of a
contingency operation.^23 In addition, eligibility at the 28 percent
premium rate will not depend on the length of a service agreement entered
into following a period of active-duty service. Instead, reservists will
be eligible for TRS for the duration of their service in the Selected
Reserve. The law requires DOD to implement these changes no later than
October 1, 2007.
Defense Enrollment Eligibility Reporting System
In order to use TRICARE, reservists must establish their own and their
dependents' eligibility in the Defense Enrollment Eligibility Reporting
System (DEERS)--the computerized database which DOD uses to store the
identity of active-duty members and reservists, and their dependents.
Proper registration in DEERS is necessary to use TRICARE. Reservists are
automatically registered in DEERS by reserve component administrative
personnel, but reservists must register their dependents and ensure that
those dependents are correctly entered into the database. Although TRICARE
is administered by TMA, reserve components' administrative personnel
record reservists' enrollment in DEERS and resolve any DEERS-related
problems.
TRICARE Options for Mobilized Reservists and Their Dependents
Once determined to be eligible for TRICARE, mobilized reservists and their
dependents are able to choose among several TRICARE options. These
beneficiaries may obtain health care through DOD's direct care system of
military hospitals and clinics, commonly referred to as military treatment
facilities (MTF), or through DOD's system of civilian providers. DOD uses
managed care support contractors to develop networks of civilian providers
to complement the care available in MTFs. Upon arriving at their final
duty station, mobilized reservists must enroll in TRICARE Prime, TRICARE's
managed care option. Their dependents may enroll in TRICARE Prime. If they
do not enroll in TRICARE Prime, they may receive care through TRICARE
Standard, TRICARE's fee-for-service option, or TRICARE Extra, TRICARE's
preferred provider option. While all beneficiaries may receive care on a
space-available basis at MTFs, TRICARE Prime enrollees have priority for
care at these facilities. Under TRICARE, the dependents of mobilized
reservists do not pay premiums for their health care coverage; however,
depending on the option chosen, they may be responsible for co-payments
and deductibles. Table 2 provides an overview of these options.
^22See Pub. L. No. 109-364, S 706, 120 Stat. 2083, (to be codified at 10
U.S.C. S 1076(d)).
^23The law lists one exception. Members of the Selected Reserve who are
eligible for coverage under the Federal Employees Health Benefit Plan will
not be eligible to purchase TRICARE for themselves or for their
dependents.
Table 2: TRICARE Options Available to Reservists and Their Dependents
Yearly
TRICARE plan option Providers^a Copayments deductible
Prime (managed care) Network providers None None
Extra (preferred Network providers 15 percent of Annual
provider) negotiated deductibles may
rate^b apply
Standard Non-network providers 20 percent of Annual
(fee-for-service) who will accept TRICARE allowable deductibles may
rates charge^c apply
Source: GAO analysis of TRICARE Web data.
aAll beneficiaries may receive care at MTFs as space and capabilities are
available, but TRICARE Prime enrollees have priority for care in MTFs.
bA negotiated rate is the rate that TRICARE has agreed to pay the
preferred provider.
cAn allowable charge is the maximum amount TRICARE is allowed to authorize
for each procedure or service and is tied by law to Medicare's allowable
charges. See 10 U.S.C. S 1079(h). Non-network providers are prohibited
from billing beneficiaries more than 115 percent of the TRICARE allowable
charge for a given procedure or service.
Most Reservists Have Civilian Health Insurance, and Many Reservists Choose to
Maintain Their Civilian Insurance When Mobilized
Most reservists have civilian health insurance, and over half of all
reservists choose to maintain their civilian health insurance during
mobilization. Prior to being mobilized, 80 percent of reservists had
civilian health insurance--a rate which is similar to that of the U.S.
population between 18 and 64 years old. Insurance coverage varies by rank
and age, with officers and senior personnel more likely to have coverage
than junior personnel. Reservists with dependents are also more likely to
have coverage than those that do not have dependents. Reservists obtained
coverage through a variety of sources, and some reservists had more than
one source of coverage. Even when reservists were mobilized and eligible
for TRICARE, over half opted to keep their civilian health insurance for
their dependents during their most recent mobilization. As of December
2006, less than 3 percent of eligible reservists had opted to enroll in
TRS.
Reservists Covered by Health Insurance at Rates Similar to Those Found in the
General Population
The percentage of reservists with health insurance--80 percent--is similar
to that of the U.S. population between 18 and 64 years old. Insurance
coverage for reservists varies by rank and age. According to the 2003
Status of Forces Survey, officers and senior-enlisted reservists were more
likely to have health insurance than junior-enlisted personnel. Ninety-one
percent of officers and 87 percent of senior-enlisted personnel, both of
whom have an average age of over 37 years, reported having health
insurance; 67 percent of junior-enlisted reservists, with an average age
of 25 years, reported having health insurance.^24
Insurance coverage for reservists also varies between those with
dependents and those without dependents. For example, 87 percent of
reservists with dependents reported having civilian health insurance prior
to their most recent activation, while only 65 percent of reservists
without dependents reported having civilian health insurance. Similarly,
91 percent of senior-enlisted reservists with dependents had such
insurance prior to their most recent mobilization, compared with 70
percent of senior-enlisted personnel without dependents.
The percentage of reservists with health insurance has remained relatively
consistent over time. In prior work we reported that in 2000, nearly 80
percent of all reservists had health insurance, and 60 percent of junior
enlisted reservists had health insurance. Eighty-six percent of reservists
with dependents had health insurance and 63 percent of reservists without
dependents reported having insurance.^25 Within the general population,
there has been a slight decrease in the number of individuals with health
insurance over the past 6 years: In 2000, 82 percent of the 18 to 64 year
old population had health insurance, as compared with 80 percent in 2005.
Reservists and their dependents obtained health insurance through a
variety of sources, and some had more than one source of insurance
coverage. Figure 2 shows the sources of reservists' and their dependents'
health insurance prior to mobilization. The primary source of health
insurance was civilian employers. About three-quarters of reservists and
their dependents were covered by their civilian employers' health plan,
and over one-quarter were also covered by their spouses' civilian
employer's health plan.
^24Age data provided by DOD as of October 2006. DOD categorizes enlisted
personnel as either junior enlisted (classified as E-1 to E-4) or senior
enlisted (classified as E-5 to E-9). The average age of junior-enlisted
Selected Reservists is 25 years old; the average age of senior-enlisted
Selected Reservists is 37 years old. The average age for officers in
Selected Reserve status is 39 years old.
^25GAO, Defense Health Care: Most Reservists Have Civilian Health Coverage
but More Assistance Is Needed When TRICARE Is Used, [33]GAO-02-829
(Washington, D.C.: Sept. 6, 2002).
Figure 2: Sources of Reservists' and Their Dependents' Health Insurance,
Prior to Mobilization, 2003
Note: Margin of error within +- 2 percent.
Percentages total more than 100 because some survey respondents reported
more than one source of health insurance for themselves or their
dependents.
Many Mobilized Reservists Choose to Maintain Civilian Coverage
Although reservists are required to enroll in TRICARE and their dependents
become eligible for TRICARE when the reservists are mobilized, most opt to
maintain their civilian insurance for their dependents during their
active-duty service. According to the 2003 Status of Forces Survey, 52
percent of reservists maintained their civilian employer's health
insurance during their most recent mobilization. The 2004 Status of Forces
Survey found that 85 percent of reservists reported that their civilian
employer continued to pay at least a portion of their insurance premium.
According to the survey and our interviews with DOD officials, many
reservists maintained their civilian health insurance to avoid disruptions
associated with changing to TRICARE and to ensure that their dependents
could continue seeing their current providers who may not accept TRICARE.
Relatively Few Reservists Have Enrolled in TRS
On April 27, 2005, TRS became available to certain reservists returning
from active duty on contingency operations. In October 2006, TRS became
available to an expanded number of reservists based upon their health
insurance status. As of December 2006, less than 3 percent of eligible
reservists had enrolled in TRS. DOD officials reported that more than
485,000 reservists were eligible to enroll in TRS, and as of December
2006, over 11,000 reservists had enrolled themselves or their dependents
in TRS.^26 DOD officials said that one reason for the low enrollment rate
may be the result of an enrollment process which, until passage of the
NDAA for Fiscal Year 2006, required reservists to take the first step
toward enrollment while they were still on active duty. To become eligible
to purchase coverage in TRS, a reservist had to execute a service
agreement to remain in Selected Reserve status while still serving on
active duty. This usually occurred at a demobilization site. Officials
told us that they believe that a primary reason that reservists did not
take this first step in the enrollment process was that reservists were
generally more focused on returning to their families during this period
than they were on making decisions about their health insurance. The NDAA
for Fiscal Year 2006 changed this requirement so that reservists have up
to 90 days from the end of their active-duty service to execute the
service agreement and the length of the agreement determines the time
period of their eligibility for TRS at the 28 percent premium. The NDAA
for Fiscal Year 2007 eliminated the service agreement requirement and,
under this law, eligibility for TRS will end only upon the termination of
the reservist's service in the Selected Reserve. Finally, some DOD
officials said that a lack of education about the program may also have
resulted in low participation rates.
^26As of the end of April 2006, over 485,000 reservists had been mobilized
for a contingency operation. About 19 percent have served more than once.
DOD Is Challenged by the Task of Educating Reservists and Their Dependents about
TRICARE
The increased number of reservists being mobilized and changing TRICARE
eligibility requirements for reservists have challenged DOD in its efforts
to educate reservists and their dependents about TRICARE. Reservists have
reported that they and their dependents are not well informed about
TRICARE, with less than 20 percent saying they were well informed. The
primary educational resources DOD relies on are the TRICARE briefings
provided by each reserve component to mobilized reservists just prior to
deployment, and those given at demobilization sites when reservists return
from deployment. These briefings are supplemented by family support
programs, Web sites, toll-free customer assistance numbers, and print
materials. DOD officials said that education could be improved for
reservists and their dependents by providing TRICARE briefings to
reservists at times not associated with mobilization or demobilization,
targeting TRICARE education for dependents, and improving other existing
educational resources. DOD has worked to improve several of its tools for
educating reservists about TRICARE, but it currently has no plans to
require that the reserve components provide additional TRICARE briefings.
DOD Is Educating an Increased Number of Reservists and Dependents about TRICARE
Increased mobilizations of reservists and continuing changes to TRICARE
eligibility have increased the number of reservists and dependents that
DOD must educate about TRICARE. The terrorist attacks of September 11,
2001, marked the beginning of a substantial increase in the number of
reservists being mobilized and therefore eligible for TRICARE. From 1996
to 2001, DOD provided TRICARE education to approximately 10,000 mobilized
reservists annually. Since the beginning of fiscal year 2002, DOD has
provided TRICARE education to about 125,000 mobilized reservists annually,
according to DOD officials.
Steadily expanding TRICARE eligibility for reservists has also placed new
challenges on DOD to continually update its educational programs. These
expansions (described in app. II) have required DOD to revise its training
materials, update its Web site, and retrain benefits counseling and
assistance coordinators to provide more current information to reservists
and their dependents. For example, the pre-active duty benefits discussed
earlier were expanded, from 30 days to up to 90 days prior to the date
active-duty service begins. TAMP, which provides continued TRICARE
coverage to reservists separating from active duty, was extended from 60
days to 180 days. In fiscal year 2005, with the initial implementation of
TRS, DOD developed new educational materials to inform reservists and
their dependents of their new benefits. The NDAA for Fiscal Years 2006 and
2007 each revised the provisions of TRS. In response to these
requirements, DOD updated its educational tools because the tools
describing who is eligible, what premiums they pay, and when they must
register changed with each revision.
Most Reservists and Their Dependents Are Not Well-Informed about TRICARE
Reservists reported that they and their dependents are not well informed
about TRICARE. TRICARE BCACs that responded to our survey in 2006 reported
that the most commonly experienced problem that reservists and their
dependents face when using TRICARE is a poor understanding of the program.
According to DOD's 2003 Status of Forces Survey, the last time DOD
surveyed reservists about their knowledge of TRICARE, less than 20 percent
of all reservists believed that they were well-informed about their
TRICARE benefits.
These findings are consistent with our past work on civilian health
coverage of reservists and their dependents, and they indicate that DOD
has been challenged by the task of educating reservists about TRICARE
since at least 2000. In past work, we found that reservists and their
dependents that had dropped their private health insurance for TRICARE
reported problems understanding TRICARE. We concluded that they could
benefit from improved TRICARE education.^27 Figure 3 illustrates data from
DOD's 2003 Status of Forces Survey showing reservists' opinions of how
well-informed they felt about various aspects of TRICARE. Reservists' two
most frequently cited areas of confusion included knowing which doctors
participated in the TRICARE provider network, and which services are
covered by TRICARE.^28
27 [34]GAO-02-829 , p. 19.
^28In 2005, DOD consolidated its TRICARE regions from 12 to 3, with a
similar reduction in the number of contractors responsible for maintaining
the network of physicians in each region. We did not specifically assess
the impact, if any, this has had on reservists but it represents one more
change that TRICARE has faced in educating reservists about TRICARE.
Figure 3: Reservists' Knowledge about Various Aspects of TRICARE
Note: Margin of error within +- 2 percent.
Surveys indicate a lack of awareness about DOD programs designed to assist
family members in learning about and using TRICARE. DOD officials said
that they were interested in reaching out to reservists' dependents
because they recognize that reservists' dependents, specifically spouses,
often play a major role in the family's understanding and use of TRICARE.
However, DOD's 2000 Survey of Reserve Component Members indicated that
fewer than 50 percent of the spouses of mobilized reservists were aware of
the family support programs designed to assist them in understanding and
using TRICARE. The 2002 survey showed that fewer than 10 percent of
spouses used these programs.
DOD Uses a Variety of Tools to Educate Reservists and Their Dependents about
TRICARE
DOD relies on a several methods to educate reservists and their dependents
about TRICARE. TRICARE briefings by each reservist's reserve component are
the primary tool DOD uses to educate reservists about TRICARE. The
briefings generally occur when a reservist is mobilized and when the
reservist returns from a mobilization. However, many DOD officials and
TRICARE BCACs have said that this is not an ideal time for reservists to
initially learn about TRICARE. According to DOD officials, these days of
training are often so full of critical information that it is difficult
for the reservist to absorb all of the details of TRICARE. These briefings
also occur at a time when a reservist may have already been eligible for
TRICARE for up to 90 days without realizing it.^29 Similarly at
demobilization sites, where reservists are debriefed upon returning from
theater, officials tell us that many reservists are focused on returning
home to their families rather than learning the details of their TRICARE
benefits. In addition, briefings at mobilization and demobilization sites
typically do not include reservists' dependents.
Family support programs designed to educate reservists' dependents about
TRICARE are used by most of the reserve components, including the National
Guard, Air Force, Army, Navy, and the Marines. DOD officials said that
these programs are important because reservists' dependents often play a
major role in understanding and using reservists' TRICARE benefits. Family
support programs are intended to increase knowledge about a variety of
military benefits, including TRICARE. For example, the Air Force Reserve
Command provides TRICARE information and assistance at family support
offices. In order to provide the most current information to reservists
and their dependents, personnel at these locations are educated regularly
about new programs that affect reservists. Similarly, the National Guard
Bureau has established family assistance centers that provide support for
dependents of deployed soldiers in the National Guard and other reserve
components, as well as assistance for demobilizing soldiers. However,
reservists have reported a lack of awareness about these programs and
fewer than 10 percent of reservists' spouses said they took advantage of
these programs.
DOD relies on other educational resources such as the TRICARE Web site,
toll-free customer assistance phone numbers, the use of BCACs, and print
materials sent directly to reservists and their dependents. However, most
of these resources are helpful only to reservists and their dependents
that actively seek TRICARE information; they do not reach out to
reservists that are not already pursuing the information.
^29DOD officials said that while pre-active-duty benefits give reservists
up to 90 days of TRICARE coverage prior to the date their active duty
begins, reservists are rarely given 90 days notice of upcoming active
duty.
In a survey administered by DOD in 2005, a third of reservists cited the
TRICARE Web site as their primary source of information when they seek
assistance. However, DOD officials acknowledged that the site was
cumbersome, with a satisfaction rate of less than 60 percent. DOD reported
in January 2006 that its TRICARE Web site contained over 538,000 pages of
content and over 300 subsites.^30
In DOD's 2005 survey, close to 13 percent of reservists cited a preference
for obtaining assistance from toll-free customer assistance numbers.
However, as of December 2006, the TRICARE Web Site listed at least 25
different toll-free customer assistance numbers. This doesn't include any
toll-free numbers that each reserve component might have available. This
large number of TRICARE customer service numbers confuses beneficiaries.
TRICARE users ranked phone and electronic sources of information as the
most difficult to use. DOD's Communications and Customer Service Group
acknowledged that such a multitude of customer assistance numbers is
sometimes not helpful.
Finally, less than 3 percent of reservists said that they rely on print
materials such as newspapers and newsletters. Although DOD has updated
some of its print materials with information about TRS, these materials
are not reaching all reservists. DOD said that the reserve components'
administrative personnel update the file of reservists' addresses in DEERS
when notified by the member, but incorrect addresses remain for
approximately 10 percent of reservists. According to DOD officials, this
results in approximately 10 percent of TRICARE mailings being returned to
sender as misdirected mail.
Individual reserve units also provide TRICARE education to their members.
This is sometimes a reservist's primary source of information about his or
her TRICARE benefits. However, DOD officials said the quality of this
information can vary greatly across units and depends largely on the
individuals charged with providing the information.
^30TRICARE Conference, "Military Medicine: Transforming the Future"
(Washington, D.C.: Jan. 30-Feb. 2, 2006).
DOD Officials Recognize the Need for Improved TRICARE Education
DOD officials recognize that TRICARE education could be improved, but they
currently do not plan to require that the reserve components provide
additional TRICARE briefings. DOD officials have suggested that TRICARE
education could be made more effective by supplementing the TRICARE
briefings provided at mobilization and demobilization sites with annual
briefings during training periods when reservists are not being mobilized
and are therefore better able to focus on the material covered in the
briefing. DOD officials said that briefings at mobilization sites are a
logical time to remind reservists of their available TRICARE benefits, but
this is not the best time to expose reservists to TRICARE information for
the first time. However, as of July 2006, DOD had no plans to require
reserve components to increase the number of TRICARE briefings they
provide to reservists or change the time that they provide them.
Half of the TRICARE BCACs that responded to our survey said that education
should be improved. Some suggested targeting additional education to
dependents of mobilized reservists. Other DOD officials agreed and said
that the spouses of reservists are generally responsible for the family's
health care decisions when the member is mobilized, so dependents should
therefore be a focus of DOD's educational efforts. However, DOD officials
we interviewed noted that when dependents are invited to briefings they
often do not attend. They said that publicizing information to families
could be a challenge, but suggested that reservists and their families
also bear some responsibility for being aware of these programs.
In November 2006, DOD launched a redesigned TRICARE Web site and TMA has
plans to reduce the number and redundancy of pages on the Web site. DOD
officials acknowledge that they have inaccurate addresses on file for some
reservists. They continue to send reminders to reservists to keep the
information in DEERS current, but they expect there will always be a
number of incorrect addresses on file.
Most Reservists Are Satisfied with Their TRICARE Benefits, but Some Reservists
Experience Difficulties Using TRICARE
A majority of reservists report that they are satisfied with their TRICARE
benefits; however, some reservists have experienced difficulties when
using TRICARE. According to our interviews with reservists and DOD's most
recently available data, over half of the reservists who used TRICARE were
satisfied with it. Additionally, 70 percent of reservists thought that
TRICARE was either equal to or better than their civilian health
insurance. However, when reservists did experience problems with TRICARE,
the most commonly reported difficulties were (1) a general lack of
understanding about the TRICARE program, (2) establishing TRICARE
eligibility, (3) obtaining TRICARE assistance, and (4) finding a health
care provider. DOD officials said they believed that some of these
problems stemmed from difficulties reservists encounter in establishing
their eligibility in DEERS, which is done through reserve component
administrative personnel. Registration in DEERS is necessary for
reservists and their dependents to use TRICARE. The officials we
interviewed observed that helping reservists understand their benefits,
establishing reservists' eligibility for TRICARE, and addressing specific
concerns is complicated because responsibility for resolving problems is
divided across organizational units. TRICARE is administered by TMA, but
recording reservists' eligibility in DEERS is managed by each reserve
component's administrative personnel.
Most Reservists Are Satisfied with TRICARE
In our interviews with over 100 reservists, we found that over half
reported that they were satisfied with their TRICARE benefit. This was
also supported by DOD's 2004 Status of Forces Survey, which showed that 70
percent of reservists thought TRICARE was either equal to or better than
their civilian health insurance plans. DOD's 2003 Status of Forces Survey
showed that over 60 percent of the reservists who used TRICARE reported
being satisfied with their own TRICARE benefits and with their dependents'
TRICARE benefits. Only 20 percent of reservists reported dissatisfaction
with the benefits in the 2003 Status of Forces Survey. Figure 4
illustrates how specific aspects of TRICARE compared with reservists'
civilian health insurance.
Figure 4: Comparison of Specific Aspects of Reservists' TRICARE Health
Insurance to Civilian Health Insurance
Note: Margin of error within +- 2 percent.
Percentages may not total 100 due to rounding.
Some Reservists and Their Dependents Experienced Difficulties When Using TRICARE
Some reservists and their dependents experienced difficulties when they
used TRICARE. Our surveys of BCACs and interviews with reservists and DOD
officials indicated that when reservists experienced difficulties using
TRICARE, the most common difficulties included a lack of knowledge about
TRICARE benefits, problems establishing TRICARE eligibility, obtaining
TRICARE assistance, and finding medical providers. These findings were
consistent with data from DOD's 2003 Status of Forces Survey.
Understanding Benefits
Fifty-eight percent of the TRICARE BCACs that responded to our survey
reported that the biggest problem reservists and their dependents faced
when using TRICARE is their ability to understand TRICARE. Many reservists
and their dependents lack a basic understanding of TRICARE. According to
the 2004 Status of Forces Survey, about 41 percent of reservists reported
that their dependents did not use TRICARE insurance because of the
complexity of TRICARE. Some BCACs said that reservists and their
dependents continue to experience difficulties understanding the
complexity of the various options, knowing which benefits are covered,
understanding the referral process and authorizations required, and the
changing enrollment requirements. For example, enrollment requirements
change throughout the periods before, during, and after a reservist's
active-duty service. Dependents of reservists who have been ordered to
active duty for a period of more than 30 consecutive days may enroll in
TRICARE Prime if they wish to be covered by that option. Dependents
enrolled in TRICARE Prime must then re-enroll to continue TRICARE Prime
coverage during their TAMP period when the reservist returns from active
duty. However, dependents using TRICARE Extra and TRICARE Standard are not
required to re-enroll to receive TAMP benefits. Access to TRICARE could be
impaired if reservists and their dependents fail to adhere to the changing
enrollment requirements.
Establishing Eligibility
Establishing eligibility for TRICARE in the DEERS database--DOD's
computerized database used to record TRICARE eligibility--has been
problematic for many reservists and their dependents. Almost half of the
BCACs that responded to our survey said that the process for establishing
TRICARE eligibility in DEERS needed to be improved. DEERS stores the
identity of reservists, dependents, and others who are entitled to TRICARE
benefits as well as their dates of eligibility. BCACs that we surveyed and
other DOD officials said that many reservists and their dependents are
incorrectly entered into DEERS when the reservists are mobilized. When
reservists return from a mobilization, they are required to update their
status in DEERS and to keep their dependents' information updated as well
in order to receive the benefits for which they are eligible. Reservists
sometimes do not do this. When DEERS is not properly updated, reservists
or their dependents might be denied medical care, or be charged
incorrectly for medical services. According to DOD officials we
interviewed, dependents of active-duty members also have problems with
DEERS, but these problems are accentuated for dependents of reservists
because their eligibility status can change more frequently.
DOD does not collect data on how many reservists and their dependents
experience problems with the information entered into the DEERS system.
However, DOD officials said that they believe that some of the problems
reservists face in using TRICARE, including the other problems described
in this report, stem from problems in their DEERS enrollment. This problem
is exacerbated by the fact that BCACs and other TMA staff are not able to
resolve reservists' problems with DEERS because each reserve component's
administrative personnel, rather than TMA, record reservists' eligibility
information in DEERS. Reservists often do not realize that they need to
seek assistance with DEERS from a different office than that from which
they would seek benefits assistance. For example, a reservist who was not
properly registered in DEERS might seek assistance from a TRICARE BCAC,
who would be unable to assist the reservist with his or her problem,
rather than the administrative personnel who could assist with these
problems.
Finding Assistance
Almost a third of the BCACs that responded to our survey said that many
reservists and their dependents experience difficulties in obtaining
TRICARE assistance when problems or questions about TRICARE arise. Many
reservists do not have a designated TRICARE expert within their unit and
are not aware of the many resources available to assist them with their
TRICARE benefits. BCACs we surveyed also reported that when reservists
call for information, sometimes even unit-designated TRICARE
representatives are confused by reservists' benefits and cannot answer
beneficiary questions. Some BCACs responsible for assisting reservists in
using TRICARE do not have access to DEERS and are therefore unable to
provide accurate information about TRICARE eligibility to reservists and
their dependents.
Finding Medical Providers
Over a quarter of the BCACs that responded to our survey reported that
finding a medical provider is one of the problems most commonly
experienced by reservists and their dependents when using TRICARE
benefits. Some DOD officials we spoke with also said that reservists and
their dependents experience difficulties finding medical providers that
accept TRICARE. However, other work we have done reviewing access to care
for TRICARE beneficiaries indicates that there are a large number of
TRICARE providers accepting new patients except where there are few
practicing providers in general, such as in geographically remote
areas.^31 We could not determine whether reservists that experienced
difficulty finding TRICARE providers lived in geographically remote areas.
^31GAO, Defense Health Care: Access to Care for Beneficiaries Who Have Not
Enrolled in TRICARE's Managed Care Option, [35]GAO-07-48 (Washington,
D.C.: Dec. 22, 2006).
Conclusions
Changes to reservists' TRICARE eligibility have resulted in DOD having to
educate a growing number of reservists and their dependents about their
eligibility requirements and benefits under TRICARE. Despite DOD's use of
a variety of tools to educate reservists about TRICARE, reservists, BCACs,
and DOD officials continue to suggest that TRICARE education could be
improved by providing TRICARE briefings at times other than when
reservists are being mobilized or returning from mobilizations. For
example, reservists have other required training periods during the year
where a discussion of TRICARE benefits could be a part of the program. In
addition, while reservists and their dependents become eligible for
TRICARE up to 90 days before the reservists' active-duty service begins,
they might not learn of this eligibility until the TRICARE briefing they
receive at the mobilization site. Despite this shortcoming, DOD has no
plans to add additional TRICARE briefings during times other than
mobilization and demobilization.
Recommendation
We recommend that the Assistant Secretary of Defense for Health Affairs
improve TRICARE education for reservists and their dependents by providing
additional TRICARE briefings to reservists and their dependents. These
briefings could be provided to reservists during training periods not
associated with mobilizations or at the time that reservists are first
informed of their impending mobilization.
Agency Comments and Our Evaluation
DOD provided written comments on a draft of this report. DOD partially
concurred with our recommendation, agreeing that information about TRICARE
should be provided to reservists and their family members when they are
first informed of a pending mobilization of the member or any time a
member is ordered to active duty or full-time National Guard duty for more
than 30 days. However, DOD did not agree that providing additional
briefings during periods not associated with mobilizations would be
beneficial. DOD's comments are reprinted in appendix III.
DOD noted that reservists' training time is limited and must be
prioritized to maximize its value. DOD further noted the difficulty in
holding the interest of an audience to describe a benefit for which they
are not yet eligible. DOD stated that it has provided an abundance of
information about TRICARE to reservists and their family members.
As we noted earlier, DOD has revised its training materials and updated
its Web site to provide more current information to reservists and their
dependents. However, our surveys and interviews with BCACs and reservists
indicate that these materials are not reaching all reservists, but instead
reach only those that actively seek TRICARE information. Furthermore, we
understand the importance for DOD to effectively use limited training
time. However, we continue to believe that providing TRICARE briefings
whenever time becomes available during reservist training periods--a time
when reservists are not distracted by other concerns associated with
mobilization--would be an effective way to help ensure that reservists are
aware of the most current information about TRICARE.
DOD also provided technical comments, which we have incorporated where
appropriate.
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties. We
will also make copies available to others upon request. In addition, the
report is available at no charge on the GAO Web site at
http://www.gao.gov .
If you or your staff have questions about this report, please contact me
at (202) 512-7119. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this report.
Another contact and staff acknowledgments are listed in appendix III.
Marcia Crosse
Director, Health Care
Appendix I: Objectives, Scope, and Methodology
The National Defense Authorization Act (NDAA) for Fiscal Year 2004
directed that we study the health insurance coverage of reservists and
their dependents, DOD's efforts to provide assistance specifically to
reservists and their dependents to facilitate their access to and use of
TRICARE benefits, and reservists' and their dependents' experiences using
TRICARE.^1 To do this, we (1) identified the extent to which reservists
have civilian health insurance, (2) examined DOD's efforts to educate
reservists and their dependents about TRICARE, and (3) described
reservists' level of satisfaction with TRICARE and the types of problems
reservists and their dependents experienced when using TRICARE.
To determine the extent to which reservists had civilian health insurance,
we obtained data from the Department of Defense's (DOD) 2003 and 2004
Status of Forces Surveys of Reserve Component Members and DOD's 2000
Survey of Reserve Component Members. We discussed the limitations of the
surveys with DOD officials and determined that the survey data were
reliable for our purposes. We did not independently assess the reliability
of DOD's data. To learn about the extent of TRICARE benefits available to
reservists and their dependents, we reviewed pertinent legislation,
regulations, documents, reports, and information related to the TRICARE
health benefits available to activated reservists and their dependents. In
addition, we interviewed officials in the offices of the Assistant
Secretary of Defense for Reserve Affairs, the TRICARE Management Activity
(TMA), the Defense Manpower Data Center, and representatives of the seven
reserve components.^2 We also interviewed members of selected reserve
military service organizations: the Enlisted Association of the National
Guard of the United States; the Reserve Officers Association of the United
States; and the Military Officers Association of America. Finally, we
reviewed and evaluated reports from the Congressional Research Service and
Congressional Budget Office as well as prior GAO reports.
To examine DOD's efforts to educate reservists and their dependents about
TRICARE, we interviewed representatives from DOD's TMA, the Office of
Reserve Affairs, and each of the seven reserve components about their
efforts to educate reservists about TRICARE. We also interviewed officials
from outside stakeholder groups. We interviewed over 100 reservists from
the Army National Guard and the Navy Reserves. We selected these two
groups because they had large numbers of reservists demobilizing that we
were able to interview during the course of our work. We used these
interviews to validate and update information that we had gathered from
the various surveys that we used as the basis of our work. We also
reviewed DOD TRICARE Web sites and other materials designed to inform
servicemembers and their dependents about TRICARE. We developed and
administered a Web-based survey of benefit counseling and assistance
coordinators (BCAC) who respond to problems encountered by reservists and
their dependents when they use TRICARE. With the assistance of DOD
officials, we identified BCACs who had direct experience providing TRICARE
counseling and assistance to reservists and their dependents. We received
survey responses from 226 BCACs who were currently engaged in providing
TRICARE counseling and assistance. Because these 226 respondents were not
selected at random from a larger population of known BCACs, the
information they provided cannot be projected to any other BCACs. In
addition, we reviewed our prior work on reservists and military health
care. We also used DOD's 2003 and 2004 Status of Forces Surveys of Reserve
Component Members, DOD's 2002 Survey of Spouses of Activated National
Guard and Reserve Component Members, and DOD's 2000 Survey of Reserve
Component Members to provide us with information about reservists'
opinions about TRICARE.
^1See Pub. L. No. 108-136, S 705, 117 Stat. 1392, 1528-29 (2003).
^2The seven reserve components include the Army National Guard and the Air
National Guard, as well as the Army Reserve, the Naval Reserve, the Marine
Corps Reserve, the Air Force Reserve, and the Coast Guard Reserve.
To describe reservists' level of satisfaction with TRICARE and the types
of problems reservists and their dependents experienced when using
TRICARE, we interviewed DOD officials as mentioned above, and we relied on
our own survey of BCACs. We used information from the interviews of
reservists as described above. We also obtained and analyzed the results
of the DOD's 2003 and 2004 Status of Forces Surveys of Reserve Component
Members.
Finally, the NDAA for Fiscal Year 2004 mandated that we describe DOD's
options for continuing civilian health care coverage while reservists are
mobilized. We did not address this part of the mandate in this report
because it was addressed in our October 19, 2005 report, Defense Health
Care: Health Insurance Stipend Program Expected to Cost More Than TRICARE
But Could Improve Continuity of Care for Dependents of Activated Reserve
Component Members ( [37]GAO-06-128R ).
We performed our work from October 2005 through December 2006 in
accordance with generally accepted government auditing standards.
Appendix II: Selected Legislation Pertaining to TRICARE Eligibility for
Reservists
Laws Description
National Defense Contained a provision which allowed nonactivated
Authorization Act for members of the Selected Reserve and the
Fiscal Year 2004, Pub. L. Individual Ready Reserve and their family
No. 108-136, SS 702-704, members to enroll in TRICARE if the member was
117 Stat. 1392, 1525-28 eligible for unemployment compensation or was
(2003). ineligible for health care coverage from his or
her civilian employer.^a Another provision
allowed reservists who had pending active-duty
orders to use TRICARE for up to 90 days before
their active-duty service began. A third
provision extended the length of time which
service members, including demobilized
reservists, could use TRICARE after they had
been released from active duty to 180 days.
These provisions were set to expire on December
31, 2004.
Ronald W. Reagan National Indefinitely extended the temporary provision
Defense Authorization Act passed in 2003 which allowed reservists with
for Fiscal Year 2005, pending active-duty orders to use the military
Pub. L. No. 108-375, SS health care system up to 90 days before their
701, 703, 706, 118 Stat. active-duty service began. It also indefinitely
1811, 1980-84 (2004). extended the temporary provision which extended
the length of time which service members could
use TRICARE after they had been released from
active-duty service to 180 days. This
legislation did not extend the provision which
authorized TRICARE access for reservists who
were eligible for unemployment compensation or
were ineligible for health care coverage from
their civilian employer.
Another provision provided TRICARE Standard
coverage through a new program that DOD named
TRICARE Reserve Select (TRS). This was made
available to reservists who had been activated
for a period of more than 30 days in support of
a contingency operation on or after September
11, 2001, and who agreed to continue serving in
the Selected Reserves after release from active
duty. Under this provision, reservists are
eligible to purchase TRICARE coverage for
themselves and their family members for up to 1
year for each 90 days of active duty served, or
the number of full years for which they agreed
to continue service, whichever is less.^b
Reservists pay a monthly premium of 28 percent
of the total amount determined by the Secretary
of Defense on an appropriate actuarial basis as
being reasonable for coverage.
National Defense Extended eligibility for TRICARE Standard to all
Authorization Act for Selected Reserve component personnel. Those
Fiscal Year 2006, Pub. L. reservists who meet TRS requirements established
No. 109-163, SS 701-702, in the NDAA for Fiscal Year 2005 will continue
119 Stat. 3136, 3339-42 to pay the 28 percent premium. Those who are
(2006). eligible for unemployment compensation, are
self-employed, or who are not eligible for
insurance through an employer-sponsored plan
will pay 50 percent. Those who do not qualify
for the two lower premium levels, such as those
who are eligible for employer-based insurance
but prefer to enroll in TRICARE, will pay 85
percent.
John Warner National Restructures the TRS program by eliminating the
Defense Authorization Act three-tiered premium structure. Establishes that
for Fiscal Year 2007, reservists who are eligible for the Federal
Pub. L. No. 109-364, SS Employees Health Benefit Plan are not eligible
701-702, 120 Stat. 2083 to purchase TRICARE coverage. Under this
(2006). provision, members of the Selected Reserve will
be eligible to purchase TRICARE coverage for
themselves and their dependents at the 28
percent premium rate regardless of whether they
have served on active duty in support of a
contingency operation. In addition, eligibility
will not depend on the length of a service
agreement entered into following a period of
active duty; instead, reservists will be
eligible for TRS for the duration of their
service in the Selected Reserve. DOD is required
to implement these changes by October 1, 2007.
Source: GAO.
aUnder this temporary provision, eligible reservists would have been
required to pay a premium equivalent to 28 percent of the total amount
determined by the Secretary of Defense on an appropriate actuarial basis
as being reasonable for coverage. DOD did not implement this provision
before it expired on December 31, 2004, citing a lack of authorized funds.
bReservists who were ordered to active duty for a period of more than 30
days, but served less than 90 continuous days due to an injury, illness,
or disease incurred or aggravated while deployed are eligible for 1 year
of TRICARE coverage under this provision.
Appendix III: Comments from the Department of Defense Appendix III:
Comments from the Department of Defense
Appendix IV: GAO Contact and Staff Acknowledgments
GAO Contact
Marcia Crosse, (202) 512-7119 or crossem@gao.gov
Acknowledgments
In addition to the contact named above, Thomas Conahan, Assistant
Director; Cathleen Hamann; Adrienne Griffin; Carolina Morgan; and Suzanne
Worth made key contributions to this report.
(290492)
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Highlights of [46]GAO-07-195 , a report to congressional committees
February 2007
MILITARY HEALTH
Increased TRICARE Eligibility for Reservists Presents Educational
Challenges
Since 2001, the number of reservists mobilized for active duty has
increased dramatically. Congress has expanded reservists' and their
dependents' eligibility for TRICARE, the Department of Defense's (DOD)
health insurance program. The National Defense Authorization Act (NDAA)
for Fiscal Year 2004 directed GAO to examine the health insurance coverage
of reservists and their dependents. This report (1) identifies the extent
to which reservists have civilian health insurance, (2) examines DOD's
efforts to educate reservists and their dependents about TRICARE, and (3)
describes reservists' level of satisfaction with TRICARE and the types of
problems reservists and their dependents experienced when using it. To do
this, GAO relied on interviews with DOD and DOD's survey data. GAO also
administered a survey of TRICARE benefit assistance coordinators.
[47]What GAO Recommends
GAO recommends that DOD provide additional TRICARE briefings to reservists
and their dependents during regular training or when they are first
notified of mobilization. DOD partially concurred, agreeing that briefings
should occur when members are first informed of mobilization, but
disagreeing that briefings are needed during other periods. GAO continues
to believe that such briefings would be effective.
Eighty percent of mobilized reservists have civilian health insurance--a
rate similar to that of the U.S. population between 18 and 64 years old.
The number of reservists with civilian health insurance varies among
reservists, with older reservists and reservists of higher rank having a
greater rate of insurance than younger reservists and reservists of more
junior rank, and reservists with dependents being more likely to have
insurance than reservists without dependents. Reservists and their
dependents obtained coverage through a variety of sources and over half of
all reservists kept their civilian health insurance during mobilizations,
even though they were eligible to enroll in TRICARE. Many reservists
reported that they maintained their civilian coverage to avoid disruptions
associated with a change to TRICARE and to ensure that their dependents
could continue seeing their current providers who might not accept
TRICARE.
Increased mobilizations of reservists and successive legislative changes
that have increased reservists' and their dependents' eligibility for
TRICARE have complicated DOD's efforts to educate reservists about
TRICARE. DOD's primary educational tools are the TRICARE briefings
provided at mobilization sites and demobilization sites. According to DOD
officials, these days of training are often so full of critical
information that it is difficult for reservists to absorb all of the
details of TRICARE. These briefings also occur at a time when a reservist
may have already been eligible for TRICARE for up to 90 days without
realizing it. These briefings are supplemented by family support programs,
Web sites, toll-free customer assistance numbers, and print materials. DOD
officials recognize the need to improve TRICARE education, but do not plan
to provide additional TRICARE briefings for reservists and their
dependents.
When reservists used TRICARE, most reported that they were satisfied with
TRICARE, although some reported experiencing difficulties. Over 60 percent
of reservists who used TRICARE reported being satisfied. In addition, 70
percent of reservists thought TRICARE was either equal to or better than
their civilian health insurance. However, according to DOD's and GAO's
surveys, when reservists and their dependents did experience problems with
TRICARE, a few of the most frequently reported problems include
difficulties understanding TRICARE, establishing TRICARE eligibility,
obtaining TRICARE assistance, and finding a health care provider that
accepts TRICARE.
References
Visible links
33. http://www.gao.gov/cgi-bin/getrpt?GAO-02-829
34. http://www.gao.gov/cgi-bin/getrpt?GAO-02-829
35. http://www.gao.gov/cgi-bin/getrpt?GAO-07-48
37. http://www.gao.gov/cgi-bin/getrpt?GAO-06-128R
46. http://www.gao.gov/cgi-bin/getrpt?GAO-07-195
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