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Military Medical Care: Frequently Asked Questions

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Military Medical Care: Frequently Asked Questions

Updated December 20, 2018 (R45399)
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Contents

Summary

Military Military Medical Care: Frequently Asked October 25, 2021 Questions Bryce H. P. Mendez Military medical care is a congressionally authorized entitlement that has expanded in Analyst in Defense Health size and scope since the late 19th century. Chapter 55 Chapters 55 and 56 of Title 10, U.S. Code, entitles Care Policy entitle certain health benefits to military personnel, retirees, and their families. These health benefits are administered by a Military Health System (MHS). The primary objectives of the MHS, which includes the Defense Department's hospitals, clinics, and medical personnel, are (1) to maintain the health of military personnel so they can carry out their military missions missions, and (2) to be prepared to deliver health care during wartime. Health care services are delivered through either Department of Defense (DOD) medical facilities, known as military treatment facilities (MTFs), as space is available, or through networks of participating civilian health care providers. As of 20172020, the MHS operates 681 721 MTFs, employs nearly 6361,000 civilians and 8478,000 military personnel, and serves 9.4 million6 mil ion beneficiaries across the United States and in overseas locations.

Since 1966, civilian care for millions of mil ions of military retirees, as well wel as dependents of active duty military personnel and retirees, has been provided through a program still stil known in law as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), more commonly known as TRICARE. TRICARE has three main benefit plans: a health maintenance organization option (TRICARE Prime), a preferred provider option (TRICARE Select), and a Medicare supplement option (TRICARE for Life) for Medicare-eligible retirees. Other TRICARE plans include TRICARE Young Adult, TRICARE Reserve Select, and TRICARE Retired Reserve. TRICARE also includes a pharmacy program and optional dental and vision plans. Options available to beneficiaries vary by the sponsor's duty status and geographic location.

This report answers selected frequently asked questions about military health care, including

  • the following:  How is the Military Health System structured?
  •  How is the MHS Funded?  What is TRICARE?
  • What are the different TRICARE plans and who is eligible?
  • What are the costs of military health care to beneficiaries?
  • What is the relationship of TRICARE to Medicare?
  • How does the Affordable Care Act affect TRICARE?
  • When can beneficiaries change their TRICARE plan?
  • What is the Medicare Eligible Retiree Health Care fundFund, which funds TRICARE for Life?

This report does not address issues specific to battlefield medicine, veterans,veterans or the Veterans Health Administration. Veterans' health issues are addressed in CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by Sidath Viranga Panangala and Jared S. Sussman. Congressional Research Service link to page 5 link to page 6 link to page 6 link to page 6 link to page 8 link to page 9 link to page 10 link to page 12 link to page 13 link to page 14 link to page 14 link to page 15 link to page 16 link to page 16 link to page 18 link to page 21 link to page 22 link to page 22 link to page 22 link to page 23 link to page 23 link to page 24 link to page 25 link to page 25 link to page 26 link to page 26 link to page 26 link to page 27 link to page 27 link to page 28 link to page 28 link to page 28 link to page 29 link to page 29 link to page 30 link to page 30 link to page 30 link to page 31 link to page 32 link to page 33 link to page 8 link to page 10 link to page 12 Military Medical Care: Frequently Asked Questions Contents Background.................................................................................................................... 1 Questions and Answers .................................................................................................... 2 1. How is the Military Health System Structured?........................................................... 2 MHS Governance Entities ..................................................................................... 2 Defense Health Agency ......................................................................................... 4 Military Service Medical Departments..................................................................... 5 2. How is the Military Health System Funded?............................................................... 6 3. What is the Medicare-Eligible Retiree Health Care Fund (MERHCF)? ........................... 8 4. What are Military Treatment Facilities? ..................................................................... 9 5. What is TRICARE? .............................................................................................. 10 TRICARE Regional Managed Health Care Support Contracts ................................... 10 6. Who Is Eligible for TRICARE? .............................................................................. 11 7. What are the Different TRICARE Plans? ................................................................. 12 TRICARE Prime ................................................................................................ 12 TRICARE Select................................................................................................ 14 TRICARE Reserve Select.................................................................................... 17 TRICARE Retired Reserve .................................................................................. 18 TRICARE Young Adult....................................................................................... 18 TRICARE for Life ............................................................................................. 18 8. When can beneficiaries enroll in or change their TRICARE plan?................................ 19 9. What is the DOD Pharmacy Benefits Program? ........................................................ 19 Prescriptions Fil ed Through Military Treatment Facilities ........................................ 20 Prescriptions Fil ed Through Retail Pharmacies ...................................................... 21 Prescriptions Fil ed by Mail Order ........................................................................ 21 Co-payment Adjustments..................................................................................... 22 10. Who Pays First When a Beneficiary is Enrolled in TRICARE and Other Health Insurance (OHI)? .................................................................................................. 22 11. How Are Priorities for Care in Military Treatment Facilities Assigned? ....................... 23 12. What are DOD’s Access to Care Standards? ........................................................... 23 13. How Does the Patient Protection and Affordable Care Act Affect TRICARE? .............. 24 14. How does DOD Determine What Health Care Services are Covered by TRICARE? .......................................................................................................... 24 15. How does DOD Determine the TRICARE Reimbursement Rates? ............................. 25 Reimbursement for Inpatient Care......................................................................... 25 Reimbursement for Hospital-based Outpatient Care ................................................. 26 Reimbursement for Outpatient Care and Health Care-Related Services ....................... 26 16. What DOD Health Benefits are Available to Reservists? ........................................... 26 17. Have Military Personnel Been Promised Free Medical Care for Life?......................... 27 18. Does TRICARE Cover Abortion? ......................................................................... 28 19. What is DOD’s policy on Use Animals in Medical Research or Training? ................... 29 Figures Figure 1. Military Health System Governance ..................................................................... 4 Figure 2. Military Health System Organizational Structure .................................................... 6 Figure 3. FY2022 Unified Medical Budget Request.............................................................. 8 Congressional Research Service link to page 15 link to page 16 link to page 11 link to page 17 link to page 19 link to page 23 link to page 26 link to page 31 link to page 34 link to page 35 Military Medical Care: Frequently Asked Questions Figure 4. TRICARE Regions in the United States .............................................................. 11 Figure 5. Eligible Beneficiaries, FY2020 .......................................................................... 12 Tables Table 1. MHS Funding by Appropriations Bill, Title, and Account .......................................... 7 Table 2. Cost Sharing Features for TRICARE Prime........................................................... 13 Table 3. Cost Sharing Features for TRICARE Select........................................................... 15 Table 4. Qualifying Life Events ....................................................................................... 19 Table 5. TRICARE Pharmacy Copayments, 2018-2027....................................................... 22 Table 6. DOD Health Benefits Available to Members of the Reserve Component .................... 27 Appendixes Appendix. Glossary of Acronyms .................................................................................... 30 Contacts Author Information ....................................................................................................... 31 Congressional Research Service Military Medical Care: Frequently Asked Questions Background Military by [author name scrubbed].

Military medical care is a congressionally authorized entitlement that has expanded in size and scope since the late 19th century. Chapter 55 of Title 10 U.S. Code, entitles certain health benefits to military personnel, retirees, and their families. These health benefits are administered by a Military Health System (MHS). The primary objectives of the MHS, which includes the Defense Department's hospitals, clinics, and medical personnel, are (1) to maintain the health of military personnel so they can carry out their military missions and (2) to be prepared to deliver health care during wartime. Health care services are delivered through either Department of Defense (DOD) medical facilities, known as military treatment facilities (MTFs) as space is available, or through civilian health care providers. As of 2017, the MHS operates 681 MTFs, employs nearly 63,000 civilians and 84,000 military personnel, and serves 9.4 million beneficiaries across the United States and in overseas locations.

Since 1966, civilian care for millions of retirees, as well as dependents of active duty military personnel and retirees, has been provided through a program still known in law as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), more commonly known as TRICARE. TRICARE has three main benefit plans: a health maintenance organization option (TRICARE Prime), a preferred provider option (TRICARE Select), and a Medicare supplement option (TRICARE for Life) for Medicare-eligible retirees. Other TRICARE plans include TRICARE Young Adult, TRICARE Reserve Select, and TRICARE Retired Reserve. TRICARE also includes a pharmacy program and optional dental and vision plans. Options available to beneficiaries vary by the sponsor's duty status and geographic location.

This report answers selected frequently asked questions about military health care, including

  • How is the Military Health System structured?
  • What is TRICARE?
  • What are the different TRICARE plans and who is eligible?
  • What are the costs of military health care to beneficiaries?
  • What is the relationship of TRICARE to Medicare?
  • How does the Affordable Care Act affect TRICARE?
  • When can beneficiaries change their TRICARE plan?
  • What is the Medicare Eligible Retiree Health Care fund, which funds TRICARE for Life?

This report does not address issues specific to battlefield medicine, veterans, or the Veterans Health Administration. Veterans' health issues are addressed in CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed].

Military medical care is a congressionally authorized entitlement that has expanded in size and scope since the late 19th century. Chapter 55 of Title 10 U.S. Code, entitles certain health benefits to military personnel, retirees, and their families. These health benefits are administered by a Military Health System (MHS). The primary objectives of the MHS, which includes the Defense Department's hospitals, clinics, and medical personnel, are (1) to maintain the health of military personnel so they can carry out their military missions and (2) to be prepared to deliver health care during wartime. Health care services are delivered through either Department of Defense (DOD) medical facilities, known as military treatment facilities (MTFs) as space is available, or through civilian health care providers. As of 2017, the MHS operates 681 MTFs, employs nearly 63,000 civilians and 84,000 military personnel, and serves 9.4 million beneficiaries across the United States and in overseas locations.

Since 1966, civilian care for millions of retirees, as well as dependents of active duty military personnel and retirees, has been provided through a program still known in law as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), more commonly known as TRICARE. TRICARE has three main benefit plans: a health maintenance organization option (TRICARE Prime), a preferred provider option (TRICARE Select), and a Medicare supplement option (TRICARE for Life) for Medicare-eligible retirees. Other TRICARE plans include TRICARE Young Adult, TRICARE Reserve Select, and TRICARE Retired Reserve. TRICARE also includes a pharmacy program and optional dental and vision plans. Options available to beneficiaries vary by the sponsor's duty status and geographic location.

This report answers selected frequently asked questions about military health care, including

  • How is the Military Health System structured?
  • What is TRICARE?
  • What are the different TRICARE plans and who is eligible?
  • What are the costs of military health care to beneficiaries?
  • What is the relationship of TRICARE to Medicare?
  • How does the Affordable Care Act affect TRICARE?
  • When can beneficiaries change their TRICARE plan?
  • What is the Medicare Eligible Retiree Health Care fund, which funds TRICARE for Life?

This report does not address issues specific to battlefield medicine, veterans, or the Veterans Health Administration. Veterans' health issues are addressed in CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by [author name scrubbed].


Background

Military medical care is a congressionally authorized entitlement that has expanded in size and scope since the late 19th19th century. Chapter 55 Chapters 55 and 56 of Title 10, U.S. Code, entitles entitle certain health benefits to military personnel, retirees, and their families. These health benefits are administered by a Military Health System (MHS). The primary objectives of the MHS, which includes the Defense Department's hospitals, clinics, and medical personnel, are (1) to maintain the health of military personnel so they can carry out their military missions, and (2) to be prepared to deliver health care during wartime. The MHS is one of the largest health systems in the United States and serves over 9.6 mil ion beneficiaries.1 Theserves over 9.4 million beneficiaries.1 The primary mission of the MHS is to maintain the health and wellnesswel ness of military personnel so they can carry out their military missions, and to be prepared to deliver health care during wartime.22 This mission is further defined in law

  • "… as follows:  “... to create and maintain high morale in the uniformed services by providing an improved and uniform program of medical and dental care for members and certain former members of those services, and their dependents."3
  • "”3  “To support the medical readiness of the armed forces and the readiness of medical personnel…"4
  • ....”4  Perform medical research that is "of potential medical interest to the Department of Defense."5
  • ”5  Conduct "humanitarian and civic assistance activities in conjunction with authorized military operations…"6

....”6 Health care within the MHS is delivered through either Department of Defense (DOD) medical facilities, known as military treatment facilities (MTFs), as space is available, or through networks of participating civilian health care providers. The MHS operates 681721 MTFs and employs nearly 6361,000 civilians and 8478,000 military personnel across the United States and in overseas locations.7

7 The MHS also covers dependents of active duty personnel, military retirees, and their dependents, including some members of the reserve components. Since 1966, civilian health care to millions mil ions of retirees, as well wel as dependents of active duty military personnel and retirees, has been provided through a program still stil known in law as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), but more commonly known as TRICARE.88 A Medicare wrap- 1 David J. Smith, Raquel C. Bono, and Bryce J. Slinger, "T ransforming the Military Health System," Journal of the Am erican Medical Association, vol. 318, no. 24 (2017), pp. 2427 -2428; Department of Defense (DOD) , Evaluation of the TRICARE Program : Fiscal Year 2021 Report to Congress, February 26, 2021, p. 31, https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/Annual-Evaluation-of-the-TRICARE-Program. 2 For more informat ion about the Military Health System’s mission and strategic initiatives, see https://health.mil/About -MHS. 3 10 U.S.C. §1071. 4 10 U.S.C. §1073d. 5 10 U.S.C. §2358. 6 10 U.S.C. §401. Humanitarian and civic assistance activities includes medical, surgical, dental, and veterinary care, among others. 7 DOD, Evaluation of the TRICARE Program: Fiscal Year 2021 Report to Congress, February 26, 2021, p. 31. 8 T he “T RI” in “ TRICARE” originally referred to its init ial three main benefit plan options: a health maintenance organization option (TRICARE Prime), a preferred provider option ( formerly known as “ T RICARE Extra”), and a fee-for-service option (formerly known as “ T RICARE Standard”). Congressional Research Service 1 link to page 8 Military Medical Care: Frequently Asked Questions A Medicare wrap-around option (TRICARE for Life) for Medicare-eligible retirees was added in 2002. Other TRICARE plans include TRICARE Young Adult, TRICARE Reserve Select, and TRICARE Retired Reserve. TRICARE also includes a pharmacy program, optional dental plans, and a vision plan that are to be made available for certain beneficiaries in 2019 and optional dental and vision plans. Options available to beneficiaries vary by the sponsor's duty status and geographic location.

location. Questions and Answers

1. How is the Military Health System Structured?

The MHS is administered by five primary DOD organizations Five primary DOD organizations participate in administering the MHS: Office of the Assistant Secretary of Defense for Health Affairs (ASD(HA)[HA]), Defense Health Agency (DHA), Army Medical Command (MEDCOM), Navy Bureau of Medicine and Surgery (BUMED), and Air Force Medical Service (AFMSReadiness Agency (AFMRA). Each maintains separate and distinct responsibilities in executing the primary mission of the MHS. In general,:  Office of the ASD(HA). Responsible for the development of MHS-wide policies, budget administration, and oversight activities are assigned to the Office of the ASD(HA), while policy execution functions.9  DHA. Responsible for policy execution, administration and management of MTFs, coordination of Defense Health Program research funding, and the delivery of health care through the TRICARE program.10  Service Medical Departments (MEDCOM, BUMED, AFMRA). Responsible for recruiting, organizing, training, and equipping military medical forces to DHA or combatant commanders for the provision of medical care or health services support.11 DOD has established a governance structure to facilitate the decision delivery of health care is assigned to the DHA and the Service medical departments. Despite being administered by various DOD entities, a governance structure has been established to facilitate the decision-making process, maintain oversight of DOD health care, and coordinate health programs, services, and benefits.

MHS Governance Entities

Military Health System Executive Review (MHSER)

The MHSER serves as a senior-level forum for DOD leadership input on strategic, transitional, and emerging issues. The MHSER advises the Office ofresources, and benefits within the MHS (see Figure 1). MHS Governance Entities Defense Health Board (DHB) The DHB is chartered under the Federal Advisory Committee Act to advise the Secretary of Defense (SECDEF).12 The Board provides “independent advice and recommendations to maximize the safety and quality of, as wel as access to, health care” for DOD beneficiaries.13 The 9 DOD Directive 5136.01, Assistant Secretary of Defense for Health Affairs (ASD(HA)), updated August 10, 2017, https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodd/513601p.pdf . 10 10 U.S.C. §1073c, §1073c note, and DOD Directive 5136.13, Defense Health Agency (DHA), September 30, 2013, https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/do dd/513613p.pdf. 11 10 U.S.C. §1073c note, §7036, §8077, and §9036. 12 For more on federal advisory committees, see CRS Report R44253, Federal Advisory Committees: An Introduction and Overview, by Meghan M. Stuessy. 13 DOD, Defense Health Board Charter, December 6, 2020, p. 1, https://www.health.mil/About -MHS/OASDHA/Defense-Health-Agency/Defense-Health-Board. Congressional Research Service 2 Military Medical Care: Frequently Asked Questions Board does not have a formal role in governing the MHS, rather, provides advice specifical y on DOD:  health care policy and program management;  health research programs;  requirements for the treatment and prevention of disease and injury;  health promotion and wel ness, including the effective and efficient delivery of high-quality health care services; and  other health-related matters of special interest.14 The DHB is composed of no more than 19 members who are not full-time or permanent part-time federal officers or employees and are considered “eminent authorities” in public health, health system management, health care delivery, medical research, or other related disciplines.15 Military Health System Executive Review (MHSER) The MHSER serves as a senior-level forum for DOD leadership input on strategic, transitional, and emerging issues. The MHSER advises the SECDEF and the Office of the Deputy Secretary of Defense (DEPSECDEF) about performance chal enges and direction. The MHSER is composed of the following senior DOD leaders:  Under Secretary of Defense (Personnel and Readiness) (USD[P&R]) (Chair);  Principal Deputy Under Secretary of Defense (Personnel and Readiness);  ASD(HA);  Military Service Vice Chiefs;  Military Department Assistant Secretaries for Manpower and Reserve Affairs;  Director of Cost Assessment and Program Evaluation;  Principal Deputy Under Secretary of Defense (Comptroller);  Director of the Joint Staff; and  Military Service Surgeons General (ex-officio members).16 Senior Military Medical Action Council (SMMAC) The SMMAC is the highest governing body in the MHS, which presents enterprise-level guidance and operational issues for decision making by the ASD(HA). The SMMAC is comprised of the following senior military health leaders:  ASD(HA) (Chair);  Principal Deputy Assistant Secretary of Defense (Health Affairs) (PDASD[HA]);  Military Service Surgeons General;  DHA Director; 14 Ibid. 15 Ibid, p. 2. 16 DOD, Plan for Reform of the Administration of the Military Health System , October 25, 2013, p. 3, https://health.mil/Reference-Center/Reports/2013/11/25/Plan-for-Reform-of-the-Administration-of-the-Military-Health-System; and Email communication with DOD officials, August 25, 2021. Congressional Research Service 3 Military Medical Care: Frequently Asked Questions  Joint Staff Surgeon (JSS); and  other attendees as required.17 Joint Medical Oversight Council (JMOC) Reporting to the SMMAC is the JMOC, which ensures that actions are coordinated and aligned with MHS strategy, policies, directives, and initiatives. The JMOC is comprised of the following military health leaders:  PDASD(HA) (Chair);  Military Service Deputy Surgeons General;  DHA Deputy Director; and  JSS Representative.18 Figure 1. Military Health System Governance Source: CRS graphic based on email communication with DOD officials, August 25, 2021. Defense (SECDEF) and the Office of the Deputy Secretary of Defense (DEPSECDEF) about performance challenges and direction. The MHSER is comprised of the following senior DOD leaders

  • Under Secretary of Defense (Personnel and Readiness) (USD(P&R)) (Chair);
  • Principal Deputy Under Secretary of Defense (Personnel and Readiness);
  • ASD(HA);
  • Military Service Vice Chiefs (including the Assistant Commandant of the Marine Corps);
  • Military Department Assistant Secretaries for Manpower and Reserve Affairs;
  • Director of Cost Assessment and Program Evaluation;
  • Principal Deputy Under Secretary of Defense (Comptroller);
  • Director of the Joint Staff; and
  • Military Service Surgeons General (ex-officio members).9
Senior Military Medical Action Council (SMMAC)

The SMMAC is the highest governing body in the MHS, which presents enterprise-level guidance and operational issues for decision-making by the ASD(HA). The following senior military health leaders are members of the SMMAC:

  • ASD(HA) (Chair);
  • Principal Deputy Assistant Secretary of Defense (Health Affairs) (PDASD(HA));
  • Military Service Surgeons General;
  • DHA Director;
  • Joint Staff Surgeon; and
  • other attendees as required.10
Medical Deputies Action Group (MDAG)

Reporting to the SMMAC is the MDAG, which ensures that actions are coordinated and aligned with MHS strategy, policies, directives, and initiatives. The MDAG is comprised of:

  • PDASD(HA) (Chair);
  • Military Service Deputy Surgeons General;
  • DHA Deputy Director; and
  • Joint Staff Surgeon Representative.11

Reporting to the MDAG are four supporting governing bodies:

  • The Medical Operations Group (MOG) consists of the senior health care operations directors of the Service medical departments, the DHA Director of Healthcare Operations, and a Joint Staff Surgeon representative, with the chairmanship rotating among these members. The MOG carries out MDAG assigned tasks and provides a collaborative and transparent forum supporting enterprise-wide oversight of direct and purchased care systems focused on sustaining and improving the MHS.12
  • The Medical Business Operations Group (MBOG) consists of the senior resource managers of the Service medical departments and the DHA Director of Business Operations, with the chairmanship rotating among these members. The MBOG provides a forum for providing resource management input to the MDAG on direct and purchased care issues and initiatives focused on sustaining and improving the MHS.13
  • The Manpower and Personnel Operations Group (MPOG) consists of the senior human resources and manpower representatives from the Service medical departments and the DHA, with the chairmanship rotating among these members. The MPOG supports centralized, coordinated policy execution, and guidance for development of coordinated human resources and manpower policies and procedures for the MHS.14
  • The Enhanced Multi-Service Markets (eMSM) Leadership Group. eMSMs are geographic MHS markets served by more than one military department under the direction of a designated Market Manager (typically a general or flag officer) with limited authorities.15 The six eMSMs are:
  • 1. Tidewater, Virginia
  • 2. Puget Sound, Washington
  • 3. Colorado Springs, Colorado
  • 4. San Antonio, Texas
  • 5. Oahu, Hawaii
  • 6. National Capital Region
  • The eMSM Leadership Group is composed of the six Market Managers with the chairmanship rotating among these members. The eMSM Leadership Group provides a forum for eMSM Managers to discuss clinical and business issues, policies, performance standards, and opportunities.16

Finally, the ASD(HA) is supported and advised by the Policy Advisory Council (PAC), composed of the Deputy Assistant Secretaries of Defense (Health Affairs), DHA Deputy Director, Deputy Surgeons General, and a representative of the Joint Staff. The PAC provides a forum for supporting MHS-wide policy development and oversight in a unified manner.17

Figure 1. Military Health System Governance

Source: Department of Defense, 2018.

Notes: Adapted by CRS.

Defense Health Agency

Defense Health Agency The DHA is a designated Combat Support Agency that focuses on enabling medical readiness of the Armed Forces and delivering a ready medical force to Combatant Commanders during peacetime and wartime.1819 Established in September 2013, the role of DHA is to:

  • 17 Ibid. 18 Email communication with DOD officials, August 25, 2021. 19 A Combat Support Agency (CSA) is defined in DOD Directive 3000.06 as an organization, designated by 10 U.S.C. Congressional Research Service 4 Military Medical Care: Frequently Asked Questions  manage the TRICARE program;  manage the TRICARE program;
  • manage and execute the Defense Health Program appropriation and the Medicare Eligible Eligible Retiree Health Care Fund (MERHCF);
  • support coordinated management of the eMSMsmilitary health care markets to create and sustain a cost-effective, coordinated, and high-quality health care system;
  • exercise management responsibility for shared services, functions, and activities of the MHS;
  • exercise authority, direction, and control over MTFs within the National Capital Region;19 and
  • Region;20 and  support the effective execution of the DOD medical mission.20

21 Pursuant to 10 U.S.C. §1073c, as amended, DHA is also responsible for administering al MTFs and coordinating Defense Health Program funding for Research, Development, Test, and Evaluation (RDT&E) programs.22 The DHA Director leads the organization and is appointed by and reports to the ASD(HA). The Director is typicallytypical y a general or flag officer in the grade of Lieutenant General/Vice Admiral. Military Service Medical Departments The military service medical departments (i.e., MEDCOM, BUMED, AFMRA) are established under each respective military department to recruit, organize, train, and equip military medical personnel, maintain medical readiness of the Armed Forces, and advise their military service chief on medical matters. The medical departments are led by a Surgeon General,23 who also functions as the principal advisor to their respective military service secretary and service chief for al health and medical matters.24 §193 or the Secretary of Defense, to “ provide and plan for the optimum support capabilities attainable within existing and programmed resources to the operational commanders within the parameters of the CSA’s statutory responsibility and its chartering DOD Directive.” 20 MT Fs in the National Capital Region include Walter Reed National Military Medical Center, Fort Belvoir Community Hospital, DiLorenzo T RICARE Health Clinic, T ri-Service Dental Clinic, Family Health Center Fairfax, and Family Health Center Dumfries. 21 DOD, DOD Directive 5136.13, Defense Health Agency, September 30, 2013; DOD, “Plan 3: Implementation Plan for the Complete T ransition of Military Medical T reatment Facilities to the Defense Health Agency,” June 24, 2019. 22 Prior to October 1, 2021, certain MTFs were administered by the respective military service medical departments or the DHA. Section 702 of the FY2017 NDAA (P.L. 114-328) and Section 711 of the FY2019 NDAA (P.L. 115-232) directed the transfer of administration and management of MT Fs from the military service medical departments to the DHA no later than September 30, 2021. For m ore, see CRS In Focus IF11273, Military Health System Reform , by Bryce H. P. Mendez. 23 Service Surgeons General are typically general or flag officers in the grade of Lieutenant General or Rear Admiral (Upper Half). 24 Statutory duties assigned to the Service Surgeons General are described in 10 U.S.C. §7036, §8077, and §9036. Congressional Research Service 5 link to page 11 link to page 12 Military Medical Care: Frequently Asked Questions Figure 2. Military Health System Organizational Structure Source: CRS graphic based on 10 U.S.C. §7036, §8077, §9036; and DOD, “Plan 3: Implementation Plan for the Complete Transition of Military Medical Treatment Facilities to the Defense Health Agency,” June 24, 2019. Lieutenant General/Vice Admiral.

On October 1, 2018, the military service medical departments began transferring the responsibilities to administer and manage each MTF to the DHA, as directed by Section 702 of the National Defense Authorization Act (NDAA) for Fiscal Year 2017 (P.L. 114-328). The first wave of MTFs transferred to the DHA include:

  • Womack Army Medical Center and all associated clinics;
  • Naval Hospital Jacksonville and all associated clinics;
  • 81st Medical Group;
  • 4th Medical Group; and
  • 43rd Medical Squadron.21

The transfer of these responsibilities is required to be completed no later than September 30, 2021.22

Military Service Medical Departments

The military service medical departments (i.e., MEDCOM, BUMED, AFMS) are established under each respective military department to organize, train, and equip military medical personnel, maintain medical readiness of the Armed Forces, and administer, manage, and provide health care in MTFs. The medical departments are led by a Surgeon General,23 who also functions as the principal advisor to their respective military service secretary and service chief for all health and medical matters.24

Figure 2. Military Health System Organizational Structure through September 2021

Source: Department of Defense, 2018.

Notes: Adapted by CRS.

After September 30, 2021, the military departments are no longer to administer and manage MTFs; instead, they are to focus on other statutory responsibilities (e.g., medical readiness, providing DHA with medical personnel to staff MTFs, providing medical personnel to support combatant commander requirements).25

Figure 3. Military Health System Organizational Structure after September 2021

Source: Department of Defense, 2018.

Notes: Adapted by CRS.

2. How is the Military Health System Funded?

2. How is the Military Health System Funded? The ASD(HA) prepares and submits a unified medical budget that includes resources for the al DOD medical activities under his or her control within DOD.responsibility.25 The unified medical budget is primarily discretionary funding for all al fixed MTFs and military medical activities, including costs for real property maintenance, environmental compliance, minor construction, base operations support, health care delivery, and medical personnel. Accrual and accrual payments to the Medicare Eligible Retiree Health Care Fund (MERHCF) are also included as mandatory spending.26.26 The unified medical budget does not include funding associated with combat support medical units/activities; in these instances the funding responsibility is typical y assigned to combatant or military service commands. While DOD submits its funding request for the MHS in a unified medical budget, Congress historical y appropriates these funds in several accounts within the annual Defense appropriations bil and the Military Construction, Veterans Affairs, and Related Agencies appropriations bil (see Table 1). 25 For more on the unified medical budget and MHS funding requests, see CRS In Focus IF11856, FY2022 Budget Request for the Military Health System , by Bryce H. P. Mendez. 26 “Fixed” MT Fs refer to the medical facilities defined in 10 U.S.C. §1073d and does not include deployable MT Fs or other medical platforms. See question “ 3. What is the Medicare-Eligible Retiree Health Care Fund (MERHCF)?” for a discussion of the MERHCF. Congressional Research Service 6 link to page 12 Military Medical Care: Frequently Asked Questions Table 1. MHS Funding by Appropriations Bill, Title, and Account Appropriations Bill Title Account Description Defense appropriations Operation & Maintenance Defense Health Program Funds MTF care; private bil (O&M) (DHP) sector care; procurement activities; and medical research, development, test, and evaluation activities Defense appropriations Military Personnel MILPERS accounts by Funds active and reserve bil (MILPERS) various military services component medical personnel (doctors, nurses, medics, technicians, and other health care providers) and accrual payments to the MERHCF Military Construction, Department of Defense Military Construction, Funds major MHS Veterans Affairs, and Defense-Wide (MILCON) construction products Related Agencies appropriations bil Source: CRS analysis of historical congressional appropriations and congressional justification documents accompanying DOD’s annual budget request. In the past, Congress appropriated funds for war-related military health care inassigned to combatant or military service commands.

Unified medical budget funding has traditionally been appropriated through the following means:

  • The defense appropriations bill provides Operation and Maintenance (O&M), Procurement, and Research, Development, Test and Evaluation (RDT&E) funding under the heading Defense Health Program.
  • Funding for military medical personnel (doctors, nurses, medics, technicians, and other health care providers) and TRICARE for Life accrual payments are generally provided in the defense appropriations bill under the Military Personnel (MILPERS) title.
  • Funding for medical military construction (MILCON) is generally provided under the Department of Defense title of the Military Construction and Veterans Affairs bill.
  • A standing authorization for transfers from the MERHCF to reimburse TRICARE for the cost of services provided to Medicare eligible retirees is provided by 10 U.S.C. §1113 as mandatory spending.
  • Costs of war-related military health care are generally funded through supplemental appropriations bil s or designated certain funds for Overseas Contingency Operations/Global War on Terrorism in the annual Defense appropriations bil . For FY2022, DOD requests war-related military health care funding in the DHP account only. As il ustrated in Figure 3, the President’s FY2022 unified medical budget request totals $53.9 bil ion and includes the following:27  $35.6 bil ion for the DHP;  $8.5 bil ion for MILPERS;  $0.5 bil ion for medical MILCON; and  $9.3 bil ion for accrual payments to the MERHCF. 27 DOD, FY 2022 Budget Request Overview, May 2021, p. 5-5, Figure 5.2, https://comptroller.defense.gov/Portals/45/Documents/defbudget/FY2022/FY2022_Budget_Request_Overview_Book.pdf. Congressional Research Service 7 link to page 26 link to page 26 Military Medical Care: Frequently Asked Questions Figure 3. FY2022appropriations bills.

Other resources are made available to the MHS from third-party collections27 authorized by 10 U.S.C. §1097b(b) and a number of other reimbursable program and transfer authorities.

As illustrated in Figure 4 the Trump Administration's FY2019 unified medical budget request totals $50.6 billion and includes the following:28

  • $33.7 billion for the DHP;
  • $8.9 billion for MILPERS;
  • $0.4 billion for medical MILCON; and
  • $7.5 billion for accrual payments to the MERHCF.

Figure 4. FY2019 Unified Medical Budget Request

(billions)

Unified Medical Budget Request (bil ions) Source: Department of Defense, FY 2019 FY 2022 Budget Request Overview, February 2018 May 2021, p. 5-4.

5. Notes: Graphic adapted by CRS.

Other resources are made available to the MHS from third-party collections28 authorized by 10 U.S.C. §1097b(b) and a number of other reimbursable program and transfer authorities.29 3. What is the Medicare-Eligible Retiree Health Care Fund (MERHCF)?

The Floyd D. Spence NDAA for FY2001 directed the establishment of the Medicare-Eligible Retiree Health Care Fund to pay for Medicare-eligible retiree health care beginning on October 1, 2002, via a new program calledcal ed TRICARE for Life.2930 Prior to this date, Medicare-eligible beneficiaries could only receive space-available care in an MTF. The MERHCF covers Medicare-eligible beneficiaries, regardless of age.

The FY2001 NDAA also established an independent three-member DOD Medicare-Eligible Retiree Health Care Board of Actuaries appointed by the Secretary of Defense. Accrual deposits into the MERHCF are made by the agencies that employ future beneficiaries of the uniformed servicesHistorical y, Congress appropriates annual discretionary funds to the military departments within DOD and 28 Third-party collections are funds collected from additional health insurance payers for beneficiary care delivered by an MT F. For more on third-party collections, see 32 C.F.R. §199.12. 29 Third-party collections are funds collected from additional health insurance payers for beneficiary care delivered by an MT F. For more on third-party collections, see 32 C.F.R. §199.12 and question “ 10. Who Pays First When a Beneficiary is Enrolled in T RICARE and Other Health Insurance (OHI)?”. 30 P.L. 106-398 §712. Congressional Research Service 8 Military Medical Care: Frequently Asked Questions other federal agencies that administer a uniformed service and serve as the accrual deposits into the MERHCF based upon estimates of future TRICARE for Life expenses.31 Mandatory transfers based upon estimates of future TRICARE for Life expenses.30 Transfers out are made to the Defense Health Program based on estimates of the cost of care actuallyto be provided each year.32 As of September 30, 20162019, the Fundfund had assets of over $239.3 billion to cover future expenses.31

The Board277.8 bil ion to cover future expenses.33 The board is required to review the actuarial status of the fund, report annuallyannual y to the Secretary of Defense, and report to the President and Congress on the status of the fund at least every four years. The DOD Office of the Actuary provides all al technical and administrative support to the Board board. The Secretary of Defense delegates operational oversight responsibilities and management of the MERHCF to the ASD(HA). The Defense Finance and Accounting Service provides accounting and investment services for the Fund.

4. What is TRICARE?

TRICARE is a health insurance-like program that pays for care delivered by civilian fund. 4. What are Military Treatment Facilities? By law, DOD is required to maintain MTFs to “support the medical readiness of the armed forces and the readiness of medical personnel.”34 MTFs are typical y located on or near military instal ations in the United States or overseas.35 The DHA Director, after reviewing nominations from the military services, appoints a civilian director or military commander to lead an MTF.36 There are three types of MTFs that vary in clinical scope and size.  Medical Centers. Facilities that provide multi-specialty inpatient and outpatient care in “areas with a large population” of beneficiaries, serves as a tertiary referral center, administers graduate medical education programs, and has comprehensive trauma care capabilities.37  Hospitals. Facilities that provide limited-specialty inpatient and outpatient care in “areas where civilian health care facilities are unable to support the health care needs” of beneficiaries.38 31 10 U.S.C §1116. Federal agencies that contribute to the MERHCF are DOD (Air Force, Army, Marine Corps, Navy, and Space Force), Department of Health and Human Services (Public Health Service), Department of Homeland Security (Coast Guard), and Department of Commerce (National Oceanic and Atmospheric Administration). According to the Congressional Budget Office (CBO), congressional appropriations for accrual payments into the MERHCF are “classified as discretionary spending.” T ransfers out of the MERHCF are “classified in the budget as mandatory spending because they can be made without further appropriations. For more on the spending categories associated with the MERHCF, see CBO, A Review of CBO’s Estim ate of Spending From the Departm ent of Defense’s Medicare -Eligible Retiree Health Care Fund, October 2020, p. 3, https://www.cbo.gov/system/files/2020-10/56653-MERHCF.pdf. 3210 U.S.C. §1113. 33 DOD, Valuation of the Medicare-Eligible Retiree Health Care Fund, February 2021, p. 4, https://media.defense.gov/2021/Feb/23/2002587387/-1/-1/0/MERHCF%20VAL%20RPT %202019.PDF. 34 10 U.S.C. §1073d. 35 For more on MT F locations, see https://tricare.mil/MTF. 36 10 U.S.C. §1073c(a)(2). 37 10 U.S.C. §1073d(b). DOD defines medical center trauma capabilities as those with at least the following five critical wartime specialties: anesthesiology, critical care/trauma medicine, emergency medicine, general surgery, and orthopedic surgery. For more see, DOD, Restructuring and Realignm ent of Military Medical Treatm ent Facilities, February 19, 2020, p. 19, https://www.health.mil/About -MHS/OASDHA/Defense-Health-Agency/Congressional-Relations/Restructuring-and-Realignment -of-Military-Medical-Treatment-Facilities. 38 10 U.S.C. §1073d(c). Congressional Research Service 9 Military Medical Care: Frequently Asked Questions Ambulatory Care Centers. Facilities that provide outpatient primary care required to “maintain medical readiness.”39 5. What is TRICARE? Section 1072(7) of Title 10, U.S. Code defines TRICARE as the: various programs carried out by the Secretary of Defense under this chapter and any other provision of law providing for the furnishing of medical and dental care and health benefits to members and former members of the uniformed services and their dependents.... More general y, TRICARE is a health insurance-like program that pays for care delivered by civilian providers. TRICARE has three main benefit plans: a health maintenance organization option (TRICARE Prime), a preferred provider option (TRICARE Select), and a Medicare wrap-around option (TRICARE for Life) for Medicare-eligible retirees. Other TRICARE plans include TRICARE Young Adult, TRICARE Reserve Select, and TRICARE Retired Reserve. TRICARE also includes a pharmacy program and optional dental or vision plans. Options available to beneficiaries vary by the beneficiary's relationship to a sponsor, sponsor's duty status, and geographic location.

The foundations of TRICARE began with the Dependents Medical Care Act of 1956 (P.L. 84-569), which provided a statutory basis for dependents of active duty members, retirees, and dependents of retirees to seek care at MTFs. The 1956 act allowedal owed DOD to contract for a health insurance plan for coverage of civilian hospital services for active duty dependents. Due to growing use of MTFs by eligible civilians and resource constraints, Congress adopted the Military Military Medical Benefits Amendments in 1966 (P.L. 89-614), which allowedal owed DOD to contract with civilian health providers to provide non-hospital-based care to eligible dependents and retirees. Since 1966, civilian care to millionsmil ions of retirees and dependents of active duty military personnel and retirees has been provided through a program still stil known in law as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), but since 1994 more commonly known as TRICARE.32

40 TRICARE Regional Managed Health Care Support Contracts

TRICARE within the United States (not including certain U.S. commonwealths or territories) is overseen by two TRICAREDHA regional offices and administered through two managed care support contracts. Each contractor is required to perform the following functions: tasks organized under a variety of categories, including: claims processing, management of enrollment processes, health care finder and referral services, establishment and maintenance of adequate provider networks, customer services for beneficiaries and network providers, and medical management of certain beneficiary populations.33

  • TRICARE populations.41  DHA Regional OfficeEast oversees the East Region, which includes Alabama, Arkansas, Connecticut, Delaware, the District of Columbia, Florida, Georgia, IllinoisIl inois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, New Hampshire, New Jersey, New York, 39 10 U.S.C. §1073d(d). 40 P.L. 103-337 §738. For more on the history of T RICARE, see Michelle Dolfini-Reed and Jennifer Jebo, The Evolution of the Military Health Care System : Changes in Public Law an d DOD Regulations, Center for Naval Analyses, Alexandria, VA, July 2000, https://www.cna.org/CNA_files/PDF/D0000437.A3.pdf . 41 DOD, Request for Proposals – Section C: Description/Specifications/Work Statement (HT 9402-15-R-0002), April 24, 2015, https://sam.gov/opp/10c30f5ad057f790a2c5811139ddd4b6/view. Congressional Research Service 10 Military Medical Care: Frequently Asked Questions Massachusetts, Michigan, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia, Wisconsin, and portions of Iowa, Missouri, Tennessee, and most of Texas. The TRICARE East regionalEast region contractor is Humana Military.
  • TRICARE  DHA Regional OfficeWest oversees the West Region, which includes Alaska, Arizona, California, Colorado, HawaiiHawai , Idaho, most of Iowa, Kansas, Minnesota, most of Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, western portions of Texas, Utah, Washington, and Wyoming. The TRICARE West regionalWest region contractor is HealthNet Federal Services.

Figure 54. TRICARE Regions in the United States

Source: Department of Defense, Source: DOD, Defense Health Agency, TRICARE Regions, accessed August 9, 201812, 2021, https://www.tricare.mil/About/Regions.

Notes: Graphic adapted from the Defense Health Agency.

. These two contracts were re-competedrecompeted in 2015, and after resolving bid protests, the new contracts known as T-2017 became operational in 2017.34 Health care delivery under the T-2017 contracts began on January 1, 2018.

Both contracts are scheduled to end in 2023.42 The total value of the T-2017 contracts is $58 bil ion.43 TRICARE outside of the United States (including certain U.S. commonwealths and territories) is overseen by the TRICARE Overseas Program Office and administered by the health services support contractor, International SOS.

5 6. Who Is Eligible for TRICARE?

Eligibility for TRICARE is determined by the uniformed services and recorded in the Defense Enrollment Eligibility Reporting System (DEERS). All eligible 44 Al eligible beneficiaries must have their eligibility eligibility status recorded in DEERS.

42 U.S. Government Accountability Office (GAO), GAO Decision in the Matter of UnitedHealth Military & Veteran Services LLC; WellPoint Military Care Corporation; Health Net Federal Services, LLC, B-411837.2, November 9, 2016, https://www.gao.gov/assets/690/681207.pdf. 43 DOD, “Contracts for July 21, 2016,” accessed August 6, 2021, https://www.defense.gov/Newsroom/Contracts/Contract/Article/852455/. 44 For more on the Defense Enrollment Eligibility Reporting System, see https://milconnect.dmdc.osd.mil/milconnect/public/faq/DEERS-About_DEERS. Congressional Research Service 11 link to page 16 Military Medical Care: Frequently Asked Questions TRICARE beneficiaries can be divided into two main categories: sponsors and dependents. Sponsor refers to the person who is serving or who has served on active duty or in the National Guard or Reserves. Dependent is defined in 10 U.S.C. §1072 and includes a variety of familial relationships, (e.g., spouses ([including same-sex spouses)], children, certain unremarried former spouses, and dependent parents).

Figure 6 illustrates Figure 5 il ustrates the major categories of eligible beneficiaries. Figure 5beneficiaries.

Figure 6. Eligible Beneficiaries, FY2017

Source: Defense Health Agency, FY2020 Source: DOD, Evaluation of the TRICARE Program: Fiscal Year 2018 2021 Report to Congress, Washington, DC, 2018, p. 18.

6February 26, 2021, p. 33. 7. What are the Different TRICARE Plans?

TRICARE Prime

TRICARE Prime is a managed health care option similar to a health maintenance organization (HMO) program. This plan features a military or civilian primary care provider who manages a beneficiary's overall beneficiary’s overal health care and facilitates referrals to specialists. Referrals generallygeneral y are required for specialty care visits. Enrollees receive first priority for appointments at MTFs and pay less out of -of-pocket than beneficiaries who use theenrolled in other TRICARE plans. TRICARE Prime does not have an annual deductible.

Active duty servicemembers are required to use TRICARE Prime. Active duty servicemembers, their dependents, and transitional survivors35survivors45 are exempt from the annual enrollment fee. Retired 45 Dependents of active duty servicemembers who have died are deemed transitional survivors. T his status is granted for the first three years after the sponsor dies. After the third year, dependents are then deemed as survivors of active duty servicem em bers and are subject to the cost sharing requirements for retirees. Congressional Research Service 12 link to page 17 link to page 18 link to page 18 Military Medical Care: Frequently Asked Questions are exempt from the annual enrollment fee. Retired servicemembers, their families, survivors of active duty servicemembers, eligible former spouses, and others are required to pay an annual enrollment fee, which is applied to the annual catastrophic cap.36

46 TRICARE Prime is offered only in geographic areas designated as a Prime Service Area (PSA). PSAs are typicallytypical y near an MTF and former military locations subjected to Base Realignment and Closure (BRAC).37

Table 1 47 Table 2 shows the costs and fees associated with TRICARE Prime.

Table 12. Cost Sharing Features for TRICARE Prime Group Aa Group Bb Annual ADSMs, ADFMs, Transitional Survivors: ADSMs, ADFMs, Transitional Survivors: Enrollment Fee $0 $0 Retirees, their families, others: Retirees, their families, others: $303/single $366/single $606/family $732/family Annual $0 $0 Deductible Preventive Care ADSMs, ADFMs, Transitional Survivors: ADSMs, ADFMs, Transitional Survivors: Visit $0 $0 Retirees, their families, others: Retirees, their families, others: $0 $0 Primary Care ADSMs, ADFMs, Transitional Survivors: ADSMs, ADFMs, Transitional Survivors: Outpatient Visit $0 $0 Retirees, their families, others: Retirees, their families, others: $21 $21 Specialty Care ADSMs, ADFMs, Transitional Survivors: ADSMs, ADFMs, Transitional Survivors: Outpatient Visit $0 $0 Retirees, their families, others: Retirees, their families, others: $31 $31 46 T he catastrophic cap is an annual maximum limit that a beneficiary pays out -of-pocket for TRICARE cost sharing. In general, point of service charges, T RS, T RR, and T YA premiums, non -T RICARE covered benefits, and balance billing charges do not apply to the catastrophic cap. 47 32 C.F.R. §199.17(b)(1) authorizes the DHA Director to designate geographic locations in which T RICARE Prime may be offered. Health Affairs Policy 11-008 requires PSAs to be established within a 40-mile radius from an MT F or BRAC installation. 32 C.F.R. §199.17(b)(1) also authorizes active duty servicemembers and their dependents assigned to remote locations outside of a PSA to participate in T RICARE Prime Remote (T PR), a similar option to TRICARE Prime. For more information about T PR, see https://tricare.mil/primeremote. Congressional Research Service 13 link to page 18 link to page 18 Military Medical Care: Frequently Asked Questions Group Aa Group Bb Urgent Care ADSMs, ADFMs, Transitional Survivors: ADSMs, ADFMs, Transitional Survivors: Center Visit $0 $0 Retirees, their families, others: Retirees, their families, others: $31 $31 Emergency ADSMs, ADFMs, Transitional Survivors: ADSMs, ADFMs, Transitional Survivors: Room Visit $0 $0 Retirees, their families, others: Retirees, their families, others: $63 $63 Inpatient ADSMs, ADFMs, Transitional Survivors: ADSMs, ADFMs, Transitional Survivors: Admission $0 $0 (Hospitalization) Retirees, their families, others: Retirees, their families, others: $158/admission $158/admission Maximum ADSMs ADSMs Annual Out-of- $0 $0 Pocket Charge (Catastrophic Cap) ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: . Cost Sharing Features for TRICARE Prime

 

Group Aa

Group Bb

Annual Enrollment Fee

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$297/single

$594/family

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$360/single

$720/family

Annual Deductible

$0

$0

Preventive Care Visit

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$0

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$0

Primary Care Outpatient Visit

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$20

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$20

Specialty Care Outpatient Visit

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$30

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$30

Urgent Care Center Visit

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$30

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$30

Emergency Room Visit

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$61

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$61

Inpatient Admission (Hospitalization)

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$154/admission

ADSMs, ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$154/admission

Maximum Annual Out-of-Pocket Charge (Catastrophic Cap)

ADSMs

$0

ADFMs, Transitional Survivors:

$1,000 per family

Retirees, their families, others:

$3,000 per family

ADSMs

$0

ADFMs, Transitional Survivors:

$1,028 per family

Retirees$1,000 per family $1,058 per family Retirees, their families, others: Retirees, their families, others:

$3,598 $3,000 per family $3,703 per family Source: DOD, TRICARE Costs and Fees 2021, October 2021, per family

Source: Department of Defense, TRICARE Costs and Fees 2019, November 2018, https://tricare.mil/-/media/Files/TRICARE/Publications/Misc/Costs_Sheet_2019.pdf?la=en&hash=10163205984EF86728CAE4BF3B335E02C1E4D88494A1134B03986A00403A2D02.

Costs_Sheet_2021.pdf. Notes: ADSM = active duty service member; servicemember; ADFM = active duty family member.

a. Group A includes beneficiaries whose uniformed services sponsor entered initial military service prior to service prior to January 1, 2018.

b. b. Group B includes beneficiaries whose uniformed services sponsor entered initial military service service on or after January 1, 2018.

TRICARE Select

TRICARE Select is a self-managed, preferred provider option (PPO) available worldwide for eligible eligible beneficiaries. Active duty servicemembers and TRICARE for Life beneficiaries are not eligible eligible for this plan. TRICARE Select allowsal ows beneficiaries greater flexibility in managing their own health care and dodoes not require a referral for specialty care. This plan allowsal ows enrollees to use authorized, non-network civilian providers, but at a higher out of -of-pocket cost than using a network civilian provider. Some services may require prior authorization (e.g., hospice care, home health services, applied behavioral analysis).

Congressional Research Service 14 link to page 19 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 Military Medical Care: Frequently Asked Questions TRICARE Select features an annual enrollment fee, deductibles, and fixed co-pays when receiving care from a network provider or paying a percentage of the allowableal owable charge when receiving care from a TRICARE-authorized, non-network provider. Eligible beneficiaries residing outside of the United States may still stil enroll in TRICARE Select, however the availability of network providers may be limited based on geographic location.

Table 2 3 outlines the costs and fees associated with TRICARE Select.

Table 23. Cost Sharing Features for TRICARE Select

 

Group Aa

Group Bb

Annual Group Aa Group Bb Annual Enrollment Fee ADFMs, Transitional Survivors: Enrollment Fee

ADFMs, Transitional Survivors: $0 $0 Retirees, their families, others: Retirees, their families, others: $150/single $474/single $300/family $948/family Annual Deductible Sponsor Survivors:

$0

Retirees, their families, others:

$0

ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$462/single

$924/family

Annual Deductible

Sponsor is E-4 and below

$50 (Individual)

$100 (Family)

Sponsor is E-5 and above

$150 (Individual)

$300 (Family)

Retirees, their families, others:

$150 (Individual)

$300 (Family)

Sponsor is E-4 and below

$51 (Individual)

$102 (Family)

Sponsor is E-4 and below Sponsor is E-4 and below $50 (Individual) $52 (Individual) $100 (Family) $105 (Family) Sponsor is E-5 and above Sponsor is E-5 and above $150 (Individual) $158 (Individual) $300 (Family) $317 (Family) Retirees, their families, others: Retirees, their families, others: $150 (Individual) $158 Network/$317is E-5 and above

$154 (Individual)

$308 (Family)

Retirees, their families, others:

$154 Network/$308 Non-Network Non-Network $300 (Family) (Individual) $317 Network/$634(Individual)

$308 Network/$616 Non-Network (Family) Preventive (Family)

Preventive Care Visit

Care Visit ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: $0 $0 Retirees, their families, others: Retirees, their families, others: $0 $0 Primary Care Outpatient Visit ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: $22 Network $15 Network 20%c Non-Network 20%c Non-Network Retirees, their families, others: Retirees, their families, others: $30 Network $26 Network 25%c Non-Network 25%c Non-Network Congressional Research Service 15 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 link to page 21 Military Medical Care: Frequently Asked Questions Group Aa Group Bb Specialty Care Outpatient Visit ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: $34 Network $26 Network 20%c Non-Network 20%c Non-Network Retirees, their families, others: Retirees, their families, others: $46 Network $42 Network 25%c Non-Network 25%c Non-Network Urgent Care Center Visit ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: $22 Network $21 Network 20%c Non-Network 20%c Non-Network Retirees, their families, others: Retirees, their families, others: $30 Network $42 Network 25%c Non-Network 25%c Non-Network Emergency Room Visit ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: $93 Network $42 Network 20%c Non-Network 20%c Non-Network Retirees, their families, others: Retirees, their families, others: $125 Network $84 Network 25%c Non-Network 25%c Non-Network Inpatient Admission ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: (Hospitalization) $20.15/day or $25/admission $63/admission Network (whichever is greater) $20%c Non-Network Retirees, their families, others: Retirees, their families, others: Survivors:

$0

Retirees, their families, others:

$0

ADFMs, Transitional Survivors:

$0

Retirees, their families, others:

$0

Primary Care Outpatient Visit

ADFMs, Transitional Survivors:

$21 Network

20%c Non-Network

Retirees, their families, others:

$29 Network

25%c Non-Network

ADFMs, Transitional Survivors:

$15 Network

20%c Non-Network

Retirees, their families, others:

$25 Network

25%c Non-Network

Specialty Care Outpatient Visit

ADFMs, Transitional Survivors:

$31 Network

20%c Non-Network

Retirees, their families, others:

$41 Network

25%c Non-Network

ADFMs, Transitional Survivors:

$25 Network

20%c Non-Network

Retirees, their families, others:

$41 Network

25%c Non-Network

Urgent Care Center Visit

ADFMs, Transitional Survivors:

$21 Network

20%c Non-Network

Retirees, their families, others:

$29 Network

25%c Non-Network

ADFMs, Transitional Survivors:

$20 Network

20%c Non-Network

Retirees, their families, others:

$41 Network

25%c Non-Network

Emergency Room Visit

ADFMs, Transitional Survivors:

$83 Network

20%c Non-Network

Retirees, their families, others:

$111 Network

25%c Non-Network

ADFMs, Transitional Survivors:

$41 Network

20%c Non-Network

Retirees, their families, others:

$82 Network

25%c Non-Network

Inpatient Admission (Hospitalization)

ADFMs, Transitional Survivors:

$19.05/day or $25/admission

(whichever is greater)

Retirees, their families, others:

$250/day or up to 25% hospital $250/day or up to 25% hospital $185/admission Network charge (whichever is less); plus 20% separately billed services; Network

$953 25%c Non-Network separately bil ed services; Network $1,034/day or up to 25% hospital charge (whichever is less); plus 25% separately billedbil ed services; Non-Network

ADFMs, Transitional Survivors:

$61/admission Network

$20%c Non-Network

Retirees, their families, others:

$179/admission Network

25%c Non-Network

Inpatient Admission (MTF Hospitalization)

$19.05/day (subsistence charge)

Maximum Annual Out-of-Pocket Charge (Catastrophic Cap)

ADSMs

$0

ADFMs, Transitional Survivors:

$1,000 per family

Retirees, their families, others:

$3,000 per family

ADSMs

$0

ADFMs, Transitional Survivors:

$1,028 per family

Retirees, their families, others:

$3,598 Non-Network Inpatient Admission (MTF Hospitalization) $20.15/day (subsistence charge) Congressional Research Service 16 link to page 21 link to page 21 Military Medical Care: Frequently Asked Questions Group Aa Group Bb Maximum Annual Out-of- ADSMs ADSMs Pocket Charge (Catastrophic $0 $0 Cap) ADFMs, Transitional Survivors: ADFMs, Transitional Survivors: $1,000 per family $1,058 per family Retirees, their families, others: Retirees, their families, others: $3,500 per family $3,703 per family Source: DOD, TRICARE Costs and Fees 2021, October 2021, per family

Source: Department of Defense, TRICARE Costs and Fees 2019, November 2018, https://tricare.mil/-/media/Files/TRICARE/Publications/Misc/Costs_Sheet_2019.pdf?la=en&hash=10163205984EF86728CAE4BF3B335E02C1E4D88494A1134B03986A00403A2D02.

Notes: NetworkCosts_Sheet_2021.pdf. Notes: “Network” means a provider in the TRICARE network. Non-Network means a TRICARE-authorized provider not in the TRICARE network. ADSM = active duty service member; servicemember; ADFM = active duty family member.

a. Group A includes beneficiaries whose uniformed services sponsor entered initial military service prior to January 1, 2018.

b. service prior to January 1, 2018. b. Group B includes beneficiaries whose uniformed services sponsor entered initial military service service on or after January 1, 2018.

c. c. Percentage of TRICARE maximum-allowable al owable charge after deductible is met.

TRICARE Reserve Select

The TRICARE Reserve Select (TRS) program was authorized by Section 701 of the Ronald W. Reagan NDAA for FY2005 (P.L. 108-375).38 ).48 TRS is a premium-based health plan available worldwide for qualified Selected Reserve members of the Ready Reserve and their families.39 49 Servicemembers are not eligible for TRS if they are on active duty orders, covered under the Transitional Assistance Management Program,4050 eligible for or enrolled in the Federal Employees Health Benefits Program (FEHBP), or currently covered under the FEHBP through a family member.41

member.51 In general, TRS mirrors the benefits, costs, and fees established for TRICARE Select. The government subsidizes the cost of the program with members paying 28% of the cost of the program in the form of premiums. For CY2019CY2021, the monthly premiums are $42.8347.20 for member- only and $218.01238.99 for member and family coverage.42

52 48 10 U.S.C. §1076d. 49 For more on the Ready Reserve and Selected Reserve see Question 2 of CRS Report RL30802, Reserve Component Personnel Issues: Questions and Answers, by Lawrence Kapp and Barbara Salazar T orreon . 50 T he Transitional Assistance Management Program (TAMP) provides an additional 180 days of premium-free coverage for T RICARE Prime or T RICARE Select. Beneficiaries are eligible for T AMP if their sponsor is subject to certain transitional events, such as involuntary separation under honorable conditions, demobilizing member of the Reserve Component, sole survivorship discharge, or transition from the Active Component to the Reserve Component. For more information about T AMP, see https://tricare.mil/tamp. 51 10 U.S.C. §1076d specifies that members of the Selected Reserves who are “eligible to enroll in a health benefits plan under chapter 89 of title 5” are not eligible to enroll in T RICARE Reserve Select. For more on the limits on T RICARE eligibility for reservists, see CRS Report R45968, Lim its on TRICARE for Reservists: Frequently Asked Questions, by Bryce H. P. Mendez and Barbara Salazar T orreon . 52 DOD, TRICARE Costs and Fees 2021, October 2021, p. 2, https://tricare.mil/- Congressional Research Service 17 Military Medical Care: Frequently Asked Questions TRICARE Retired Reserve TRICARE Retired Reserve

Section 705 of the NDAA for FY2010 (P.L. 111-84) authorized a TRICARE coverage option for so-cal edso-called gray area reservists, defined as those who have retired but are too young to draw retirement pay.43,4453 The program established under this authority is known as TRICARE Retired Reserve (TRR). Previously, such individuals were not eligible for any TRICARE coverage.

TRR is a premium-based health plan that qualified retired members of the National Guard and Reserve under the age of 60 may purchase for themselves and eligible family members. TRR differs from TRS in that there is no government subsidy. As such, retired Reserve Component members who elect to purchase TRICARE Retired ReserveTRR must pay the full cost of the calculated premium plus an additional administrative fee. For CY2019CY2021, the monthly premiums are $451.51484.83 for member-only and $1,083.40165.01 for member and family coverage.4554 Upon reaching the age of 60, retired Reserve Component members and their eligible family members become eligible to purchase TRICARE Prime or TRICARE Select.

TRICARE Young Adult

Section 702 of the Ike Skelton NDAA for Fiscal Year 2011 (P.L. 111-383) extended TRICARE eligibility eligibility for dependents, allowingal owing unmarried children up to age 26, who are not otherwise eligible eligible to enroll in an employer-sponsored plan, to purchase TRICARE coverage.4655 The option established under this authority is known as TRICARE Young Adult (TYA). Unlike insurance coverage mandated by the Patient Protection and Affordable Care Act (P.L. 111-148), TYA provides individual coverage, rather than coverage under a family plan. A separate premium is charged. The law requires payment of a premium equal to the cost of the coverage as determined by the Secretary of Defense on an appropriate actuarial basis.4756 For CY2019CY2021, the monthly premiums are $358459 for TYA Prime and $214257 TYA Select.48

57 TRICARE for Life

TRICARE for Life (TFL) was created as supplemental coverage for Medicare-eligible military retirees by Section 712 of the Floyd D. Spence NDAA for FY2001 (P.L. 106-398). TFL functions as a secondary payer, or wrap-around, to Medicare. As a wrap-around, TFL will wil pay the out of -of-pocket costs for Medicare-covered services as well wel as those only covered by TRICARE. Prior to the creation of TFL, coverage for Medicare-eligible individuals was limited to space-available care in MTFs. TFL cost sharing for beneficiaries is limited and there is no enrollment charge or premium.

premium. To participate in TFL, TRICARE-eligible beneficiaries must enroll in and pay monthly premiums for Medicare Part B.4958 TRICARE-eligible beneficiaries who are entitled to Medicare Part A based /media/Files/T RICARE/Publications/Misc/Costs_Sheet_2021.pdf . 53 10 U.S.C. §1076e. For more on military retirement, see CRS Report RL34751, Military Retirement: Background and Recent Developm ents, by Kristy N. Kamarck. 54 DOD, TRICARE Costs and Fees 2021, October 2021, p. 2, https://tricare.mil/-/media/Files/T RICARE/Publications/Misc/Costs_Sheet_2021.pdf . 55 10 U.S.C. §1110b. 56 P.L. 111-383 §702. 57 DOD, TRICARE Costs and Fees 2021, October 2021, p. 2, https://tricare.mil/-/media/Files/T RICARE/Publications/Misc/Costs_Sheet_2021.pdf . 58 Medicare Part B is covers medically necessary outpatient services and equipment (e.g., physicians’ and nonphysician Congressional Research Service 18 link to page 28 link to page 23 Military Medical Care: Frequently Asked Questions beneficiaries who are entitled to Medicare Part A based on age, disability, or diagnosis of End Stage Renal Disease (ESRD), but decline Part B, lose eligibility eligibility for TRICARE benefits.5059 Individuals who choose not to enroll in Medicare Part B upon becoming eligible may elect to do so later during the special enrollment period or an annual enrollment period; however, the Medicare Part B late enrollment penalty may apply (see question "12 “13. How Does the Patient Protection and Affordable Care Act Affect TRICARE?").51

7”).60 8. When can beneficiaries enroll in or change their TRICARE plan?

In general, eligible beneficiaries may enroll in a TRICARE health plan during the annual open enrollment season (November 12-December 12), or, which DHA typical y designates during a four-week period between November and December.61 Eligible beneficiaries may also enroll, change, or terminate their enrollment within 90 days after a Qualifying Life Event (QLE).5262 Table 3 4 identifies military or family-related life changes that are deemed a QLE:

Table 34. Qualifying Life Events Military Changes Family Changes  Permanent change of station/moving  Marriage  Initial military commissioning or enlistment  Divorce  Reserve Component member  Having a baby or adopting activation/deactivation  Children going to col ege  Injured on active duty  Children becoming adults  Separating from active duty  Change in Medicare or Medicaid eligibility  Retiring  Moving  Military-directed change of primary . Qualifying Life Events

Military Changes

Family Changes

  • Permanent change of station/moving
  • Initial military commissioning or enlistment
  • Reserve Component member activation/deactivation
  • Injured on active duty
  • Separating from active duty
  • Retiring
  • Military-directed change of primary care manager
  • Marriage
  • Divorce
  • Having a baby or adopting
  • Children going to college
  • Children becoming adults
  • Becoming Medicare-eligible
  • Moving
  • Death in Family
  • Loss care manager  Death in Family  Change in overseas command-sponsorship  Loss or gain of other health insurance

Source: 32 C.F.R. §199.17(o).

and DOD, TRICARE Policy Manual 6010.60-M, Eligibility and Enrol ment, “TRICARE Prime and TRICARE Select Enrol ment,” updated September 11, 2019, https://manuals.health.mil/pages/DisplayManualHtmlFile/2021-08-10/AsOf/TP15/C10S2_1.html. Notes: Adapted by CRS. 9Notes: Adapted by CRS.

8. What is the DOD Pharmacy Benefits Program?

Section 701 of the NDAA for FY2000 (P.L. 106-65) directed the creation of an "effective, efficient, integrated pharmacy benefits program," also known as the DOD pharmacy benefits program.53 program.63 Features of the program include:

  • Availability of pharmaceutical agents for all therapeutic classes;
  • Establishing services, outpatient hospital services, durable medical equipment, clinical laboratory tests, ambulance services, and limited prescription drugs and biologics). Participation in Medicare Part B is voluntary, howe ver enrollment and monthly premiums are required for those who opt -in. For more information on Medicare Part B, see CRS Report R40425, Medicare Prim er, coordinated by Patricia A. Davis. 59 10 U.S.C. §1086(d). 60 CRS Report R40082, Medicare Part B: Enrollment and Premiums, by Patricia A. Davis. 61 DOD, T RICARE Policy Manual 6010.60-M, Eligibility and Enrollment, “TRICARE Prime and T RICARE Select Enrollment,” updated September 11, 2019, https://manuals.health.mil/pages/DisplayManualHtmlFile/2021-08-10/AsOf/T P15/C10S2_1.html. 62 Ibid. 63 10 U.S.C. §1074g. Congressional Research Service 19 Military Medical Care: Frequently Asked Questions  availability of pharmaceutical agents for al therapeutic classes;  establishing a uniform formulary based on clinical effectiveness and cost- a uniform formulary based on clinical effectiveness and cost-effectiveness; and
  • Assuring the availability of clinicallyeffectiveness; and  assuring the availability of clinical y appropriate pharmaceutical agents to uniformed services members uniformed servicemembers, retirees, and family members.

The program dispenses pharmaceuticals to eligible beneficiaries through three venues: MTF pharmacies, TRICARE retail pharmacies, and the TRICARE Mail Order Program. Currently, MTF pharmacies are administered and managed by each military service medical department (i.e., MEDCOM, BUMED, and AFMS and AFMRA), while the TRICARE retail and mail order pharmacy programs are managed by the DHA. Since 2003, DOD has contracted a pharmacy benefits manager, Express Scripts, Inc.. (ESI), to administer the TRICARE pharmacy programs.5464 ESI maintains a national network of retail pharmacies and a home-delivery program, and it processes pharmacy claims on behalf of beneficiaries. There are no additional costs to participate in the DOD pharmacy benefits program.

The program is required to maintain a formulary of pharmaceutical agents (hereinafter also referred to as drugs or medications) in the complete range of therapeutic classes. This is known as the Uniform Formulary. Selection of drugs for inclusion on the formulary is based on the relative clinical and cost effectiveness of the agents in each class.5565 The law further specifies that the formulary is to be maintained and updated by a Pharmacy and Therapeutics Committee whose membership is composed of representatives of both MTF pharmacies and health care providers.56

66 A Beneficiary Advisory Panel (BAP) is required to review and comment on formulary recommendations presented by the Pharmacy and Therapeutics Committee prior to those recommendations going to the DHA Director for approval.5767 The BAP is composed of representatives of non-governmentalnongovernmental organizations and associations that represent the views and interests of a large number of eligible covered beneficiaries, contractors responsible for the TRICARE retail retail pharmacy program, contractors responsible for the national mail-order pharmacy program, and TRICARE network providers.

Prescriptions Filled throughThrough Military Treatment Facilities

At an MTF, TRICARE beneficiaries may fill fil prescriptions from a civilian or military provider without a copaymentco-payment. Enrollment in a specific TRICARE plan is not required to fill a fil a prescription at an MTF. As of June 2018, 167May 2021, 159 MTF pharmacies accept electronic prescriptions from civilian health care providers.58

68 64 Express Scripts, Inc., "Express Scripts Awarded T RICARE Pharmacy Program Contract," press release, June 27, 2008, https://globenewswire.com/news-release/2008/06/27/380555/145445/en/Express-Scripts-Awarded-T RICARE-Pharmacy-Program-Contract.html. 65 10 U.S.C. §1074g(a)(2)(A). 66 10 U.S.C. §1074g(b). T he Pharmacy and Therapeutics Committee meets at least quarterly and its minutes are publicly available at the Defense Health Agency Pharmacy Operations Division website: https://health.mil/About -MHS/OASDHA/Defense-Health-Agency/Operations/Pharmacy-Division/DoD-Pharmacy-and-Therapeutics-Committee. 67 T he Beneficiary Advisory Panel (BAP) is a federal advisory committee established by 10 U.S.C. §1074g(c). For more information on the BAP, see https://health.mil/bap. 68 DHA provides a publicly-available list of MT F pharmacies that accept electronic prescriptions from civilian providers. See https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Access-to-Healthcare/Pharmacy-Program/Electronic-Prescribing. Congressional Research Service 20 Military Medical Care: Frequently Asked Questions MTFs are required to stock a subset of the Uniform Formulary known as the Basic Core Formulary. Additional drugs on the Uniform Formulary may also be carried by individual MTFs in order to meet local requirements. Non-formularyNonformulary drugs are generallygeneral y not available through MTFs. Certain Uniform Formulary-covered pharmaceuticals, however, may not be carried due to national contracts with pharmaceutical manufacturers.5969 The DHA's Pharmacy Operations Division collaborates with the Defense Supply Center Philadelphia (DSCP) in coordination with the Department of Veterans Affairs (VA) Pharmacy Benefits Management Strategic Health Group and the VA National Acquisition Center in Hines, IllinoisIl inois, in developing contracting strategies and technical evaluation factors for national pharmaceutical contracting initiatives.60

70 Prescriptions Filled throughThrough Retail Pharmacies

TRICARE beneficiaries may also fill fil prescriptions through retail pharmacies. DOD contracts for a TRICARE pharmacy benefit manager to administer both the retail and mail order options. The current contractor is ESI, to which DOD awarded a sevenpotential eight-year contract in 2014.61 2021.71 Among other matters, ESI maintains a national network of retail pharmacies that beneficiaries may use without having to file a claim for reimbursement. Beneficiaries may also use non-network pharmacies. However, at non-network pharmacies, beneficiaries pay the full price of the medication up front and then file a claim for reimbursement.

DOD requires prescriptions to be filledfil ed with generic drugs when available.6272 These are defined as medications approved by the Food and Drug Administration that are clinicallyclinical y the same as brand- name medications. Brand-name drugs that have a generic equivalent are only dispensed after the prescribing health care provider completes a clinical assessment that indicates the brand-name drug should be used in place of the generic medication and ESI grants approval.

a prior authorization. Prescriptions Filled by Mail Order

TRICARE beneficiaries may arrange for home delivery of prescription drugs through the mail by registering with ESI. DOD negotiates drug prices with pharmaceutical manufacturers. The prices for drugs dispensed by mail order are considerably lower than drugs dispensed through retail pharmacies. Use of home deliveryIn recent years, use of home delivery as compared to retail pharmacies by TRICARE beneficiaries decreased from 65% in FY2017 to 49% in FY2020.73 DOD attributes this decrease in use of the home delivery program to congressional y directed co-payment increases.74 69 Assistant Secretary of Defense (Health Affairs) Memorandum, “T RICARE Pharmacy Benefit Program Formulary Management ,” December 22, 2004, https://www.health.mil/Reference-Center/Policies/2005/12/19/Clarification-to-HA-Policy-04-032--TRICARE-Pharmacy-Benefit -Program-Formulary-Management--December-2. 70 T he VA has authority delegated from the General Services Administration to manage the medical care sections of the Federal Supply Schedule, which includes pharmaceuticals. For more information on the delegation of authority authorized in Federal Acquisition Regulation Subpart 8.402(a), see https://www.acquisition.gov/far/8.402. https://www.acquisition.gov/far/8.402. 71 ESI was awarded the T RICARE pharmacy benefit manager contract, which includes a base year, seven one -year option periods, and options for a phase-out period. T he estimated value of the contract is $4.3 billion. For more on the contract award, see https://www.defense.gov/Newsroom/Contracts/Contract/Article/2721522/ and https://sam.gov/opp/abe6e87ba52841ad814589f30934c63c/view. 72 32 C.F.R. §199.21(j). 73 DOD, Evaluation of the TRICARE Program: Fiscal Year 2021 Report to Congress, February 26, 2021, p. 52. 74 Ibid. Congressional Research Service 21 link to page 26 link to page 26 Military Medical Care: Frequently Asked Questions Co-payment Adjustments beneficiaries increased by 23% from FY2013 to FY2017.63 DOD attributes this increase to the education campaign it launched in 2009, copayment adjustments that incentivize the mail order program, and a pilot program that requires TFL beneficiaries to obtain brand-name maintenance medication refills through home delivery or MTF pharmacies.64

Copayment Adjustments

Section 702 of the NDAA for FY2018 (P.L. 115-91) adjusted pharmacy copaymentco-payment amounts. The copaymentco-payment amounts for 2018 to 2027 are codified in 10 U.S.C. §1074g(a) and are listed inin Table 4.5. After 2027, the Secretary of Defense is authorized to set and adjust cost sharing amounts to "reflect changes in the costs of pharmaceutical agents and prescription dispensing, rounded to the nearest dollar."65

”75 Table 45. TRICARE Pharmacy Copayments, 2018-2027 Retail Retail Mail Order Mail Order Mail Order Generic Brand Generic Brand Nonformulary (30-day supply) (30-day supply) (90-day supply) (90-day supply) (90-day supply) 2018 $11 $28 $7 $24 $53 2019 $11 $28 $7 $24 $53 2020 $13 $33 $10 $29 $60 2021 $13 $33 $10 $29 $60 2022 $14 $38 $12 $34 $68 2023 $14 $38 $12 $34 $68 2024 $16 $43 $13 $38 $76 2025 $16 $43 $13 $38 $76 2026 $16 $48 $14 $44 $85 2027 $16 $48 $14 $44 $85 Source: 10 U.S.C. §1074g(a)(6)(A). Notes: Retail pharmacy co-payments. TRICARE Pharmacy Copayments, 2018-2027

 

Retail

Generic

(30-day supply)

Retail

Brand

(30-day supply)

Mail Order

Generic

(90-day supply)

Mail Order

Brand

(90-day supply)

Mail Order

Non-Formulary

(90-day supply)

2018

$11

$28

$7

$24

$53

2019

$11

$28

$7

$24

$53

2020

$13

$33

$10

$29

$60

2021

$13

$33

$10

$29

$60

2022

$14

$38

$12

$34

$68

2023

$14

$38

$12

$34

$68

2024

$16

$43

$13

$38

$76

2025

$16

$43

$13

$38

$76

2026

$16

$48

$14

$44

$85

2027

$16

$48

$14

$44

$85

Source: 10 U.S.C. §1074g(a)(6)(A).

Notes: Retail pharmacy copayments are applicable when using a network pharmacy. Additional cost sharing is applied when using a non-network pharmacy.

9. What is the Extended Care Health Option (ECHO) Program?

The Extended Care Health Option (ECHO) program provides supplemental health care and non-medical services and supplies for military families with special needs.66 ECHO pays for services and supplies designed to reduce the disabling effects of a qualifying condition and would generally not be covered under a TRICARE health plan. Qualifying conditions include:

  • Autism Spectrum Disorder;
  • Moderate or severe intellectual disability;
  • Serious physical disability;67
  • Extraordinary physical or psychological conditions causing the beneficiary to be homebound;
  • Diagnosis in an infant or toddler (under age 3) of a neuromuscular developmental condition or other condition expected to precede a diagnosis of moderate or severe mental retardation or serious physical disability; and
  • Multiple disabilities, which may qualify if there are two or more disabilities impacting separate body systems.68

There are three distinct categories of ECHO benefits: general services and supplies, ECHO Home Health Care (EHHC), and applied behavioral analysis for autism spectrum disorder. In general, beneficiaries are required to access federal, state and local services, such as Medicaid's Home and Community-Based Services, prior to utilizing ECHO.

Table 5. ECHO-Covered Services & Supplies

Assistive interpreter or translation services

Rehabilitative services

Transportation to/from institutions or facilities

Durable equipment, including adaptation and maintenance equipment

Short-term relief for primary care givers (respite care)

Institutional care

Applied Behavioral Analysis

Training for special education and assistive technology devices

Expanded in-home respite care, such as home health care, physical/occupational/speech therapy, or medical case management (EHHC)

Source: Defense Health Agency, TRICARE Fact Sheet, Extended Care Health Option, March 2018.

Dependents of active duty servicemembers are the only category of DOD beneficiaries eligible for ECHO. Neither reservists and their dependents nor retirees and their dependents are eligible. To participate in ECHO, the dependent must be enrolled in a TRICARE health plan (e.g., Prime, Select, or the Uniformed Services Family Health Plan), enrolled in their service's Exceptional Family Member Program69, and have a qualifying physical or mental disability/condition. Eligible dependents register for ECHO through their respective TRICARE contractor's case management program.

There are no costs to register in ECHO. For months in which beneficiaries use the ECHO benefit, cost shares are required. Monthly cost shares are based on the sponsor's pay grade and the benefit is capped at $36,000 per beneficiary, per fiscal year. Annual service and supply costs exceeding this amount are the responsibility of the beneficiary. Respite care provided under EHHC does not count towards the general benefit cap, however it is limited to what TRICARE would pay if a dependent resided in a skilled nursing facility.

Table 6. ECHO Monthly Cost Share

Sponsor Pay Grade

Monthly Cost Share

E-1 to E-5

$25

E-6

$30

E-7, O-1

$35

E-8, O-2

$40

E-9, W-1, W-2, O-3

$45

W-3, W-4, O-4

$50

W-5, O-5

$65

O-6

$75

O-7

$100

O-8

$150

O-9

$200

O-10

$250

Source: 32 C.F.R. §199.5.

Notes: Adapted by CRS.

10 10. Who Pays First When a Beneficiary is Enrolled in TRICARE and Other Health Insurance (OHI)? In general, TRICARE is a secondary payer of health care claims when beneficiaries are dual y enrolled in other health insurance (OHI) programs (e.g., employer-sponsored insurance, private health insurance, Medicare), or covered by liability insurance policies or third-party payers. Section 1079(i)(1) of Title 10, U.S. Code and 32 C.F.R. §199.8 general y prohibits TRICARE from serving as the primary payer for health care claims of beneficiaries with OHI. Typical y, when a health care provider bil s for services rendered, the beneficiary’s OHI policy wil first pay a specified amount according to their benefit plan. TRICARE then pays the remaining cost of TRICARE-covered services other than specified out-of-pocket costs (e.g., co-payments). In certain instances, TRICARE serves as the primary payer when a beneficiary is:  enrolled in Medicaid;  enrolled in certain federal health programs (e.g., Indian Health Service); or 75 10 U.S.C. §1074g(a). Congressional Research Service 22 link to page 31 link to page 31 Military Medical Care: Frequently Asked Questions  eligible for a State Crime Victims Compensation program.76 11. How Are Priorities for Care in Military Treatment Facilities Assigned?

Title 10 of the U.S. Code assigns general priorities for MTF care. "A member of the uniformed services on active duty" is the only TRICARE beneficiary group entitled to care in any MTF. 7077 Dependents of active duty personnel are also entitled to receive MTF care on a space-available basis.71 basis.78 Military retirees and their dependents do not have an entitlement or right to MTF care, although they may receive care on a space-available basis (see question "15“17. Have Military Personnel Been Promised Free Medical Care for Life?").72

”).79 DOD issued regulations and implementation policy to clarify the basic priorities for MTF care:

Priority 1: Active-duty servicemembers;

Priority 2: Active-duty family members enrolled in TRICARE Prime;

Priority 3: Retirees, their family members and survivors enrolled in TRICARE Prime;

Priority 4: Active-duty family members not enrolled in TRICARE Prime and TRICARE Reserve Select enrollees; and

Priority 5: All other eligible persons.73

80 MTF commanders are also authorized to grant certain exceptions to these priority groups. These may include care required by law or DOD policy (e.g., employees exposed to health hazards, occupational health, workplace injuries, medical emergencies), patients needed to support the clinical case mix of a Graduate Medical Education program, overseas or remote geographic location, or other extraordinary cases.

11 12. What are DOD's Access to Care Standards?

In 1995, DOD established access to care standards to ensure beneficiaries enrolled in TRICARE Prime receive timely care in an MTF or from a civilian health care provider. The current access to care standards, outlined in DOD regulation and implementation policy, include:

  • the following:  Urgent/Acute Care: Beneficiary must be offered an appointment to visit an appropriate health care provider within 24 hours and within a 30-minute drive-time from the beneficiary's residence;
  • Routine Care: Beneficiary must be offered an appointment to visit an appropriate health care provider within one week and within a 30-minute drive-time from the beneficiary'beneficiary’s residence;
  • Well-Patient Visit/Preventative 76 32 C.F.R. §199.8. For more on State Crime Victims Compensation programs, see https://www.benefits.gov/benefit/4416 and CRS Report R42672, The Crim e Victim s Fund: Federal Support for Victim s of Crim e, by Lisa N. Sacco. 77 10 U.S.C. §1074. 78 10 U.S.C. §1076. 79 10 U.S.C. §1074. 80 DOD clarified the basic priorities for MT F care in 32 C.F.R. §199.17(d) and Department of Defense, Health Affairs Policy 11-005, TRICARE Policy for Access to Care, February 23, 2011. Congressional Research Service 23 Military Medical Care: Frequently Asked Questions Well-Patient Visit/Preventive Care: Beneficiary must be offered an appointment Care: Beneficiary must be offered an appointment to visit an appropriate health care provider within four weeks;
  • Specialty Care: Beneficiary must be offered an appointment to visit an appropriate health care provider within four weeks and within a 1one-hour drive-time from the beneficiary's residence;
  • Office Wait Times: In non-emergency circumstances, office waiting times shall shal not exceed 30 minutes; and
  • Access to Primary Care Manager: Beneficiary must have access to their primary care manager or designee by telephone, 24 hours a day, 7 days a week.74

1281 13. How Does the Patient Protection and Affordable Care Act Affect TRICARE?

In general, the Patient Protection and Affordable Care Act (ACA)7582 does not directly affect TRICARE administration, health care benefits, eligibility, or cost to beneficiaries.76

83 Section 3110 of the ACA did open a special Medicare Part B enrollment window to enable certain individuals to gain eligibility for TFL.7784 The ACA also waived the Medicare Part B late enrollment penalty during the 12-month special enrollment period (SEP) for military retirees, their spouses (including widows/widowers), and dependent children who are otherwise eligible for TRICARE and are entitled to Medicare Part A based on disability or end-stage renal disease, but had previously declined Part B. The ACA required the SECDEF to identify and notify individuals of their eligibility for the SEP. Section 3110 of the ACA was amended by the Medicare and Medicaid Extenders Act of 201078201085 to clarify that Section 3110 applies to Medicare Part B elections made on or after the date of enactment of the ACA, which was on March 23, 2010.

13 14. How does TRICARE Determine itsDOD Determine What Health Care Services are Covered by TRICARE? Chapter 55 of Title 10, U.S. Code authorizes TRICARE coverage of specific health care services.86 For health care services not specified in statute, TRICARE may only cover services that are: medically or psychologically necessary to prevent, diagnose, or treat a mental or physical illness, injury, or bodily malfunction as assessed or diagnosed by a physician, dentist, clinical psychologist, certified marriage and family therapist, optometrist, podiatrist, 81 DOD access to care standards are stipulated in 32 C.F.R. §199.17(p)(5) and further elaborated in Department of Defense, Health Affairs Policy 11-005, TRICARE Policy for Access to Care, February 23, 2011. 82 P.L. 111-148. 83 CRS Report R41198, TRICARE and VA Health Care: Impact of the Patient Protection and Affordable Care Act (ACA), by Sidath Viranga Panangala and Don J. Jansen . 84 P.L. 111-148 §3110. 85 P.L. 111-309 §201. 86 Various statutes in Chapter 55 of T itle 10, U.S. Code require T RICARE coverage of specific health care servic es (e.g., certain preventive services, hospice care, forensic examinations following a sexual assault or domestic violence, wigs for patients with chemotherapy-induced alopecia). Congressional Research Service 24 Military Medical Care: Frequently Asked Questions certified nurse-midwife, certified nurse practitioner, certified clinical social worker, or other class of provide as designated by the Secretary of Defense...87 Periodical y, DOD reviews certain non-covered health care services to determine whether “safety and efficacy have been proven to be comparable or superior to conventional therapies.”88 DOD uses a “hierarchy of reliable evidence” to review and determine whether a non-covered health care service has shifted from “unproven” to a “national y accepted medical practice.”89 TRICARE coverage policy is revised once DOD determines a health care service is “proven.”90 15. How does DOD Determine the TRICARE Reimbursement Rates?

In general, DOD utilizes reimbursement methods similar to those of Medicare for inpatient care, outpatient care, and other related services. 10 U.S.C. §1079(h) and (j) Sections 1079(h) and 1079(i) of Title 10, U.S. Code require that payment levels for health care services provided under TRICARE be aligned with Medicare'Medicare’s fee schedule "to the extent practicable." DOD” DHA has the authority to grant exceptions to deviate from Medicare'Medicare’s fee schedule when "adequate access to care would be impaired."79

” or when an existing Medicare rate does not exist.91 Reimbursement for Inpatient Care

The CHAMPUS Diagnosis Related Groups (DRG)-based payment system is used to reimburse civilian civilian hospitals and other health care facilities for providing inpatient care to TRICARE beneficiaries. To ensure standardization with U.S.-based medical coding and reimbursement classifications, DOD adopted the same DRG coding scheme and nomenclature as Medicare.80’s Inpatient Prospective Payment System.92 Reimbursement rates assigned to each DRG are determined by DOD and updated annuallyannual y. In general, rates are calculated in a similar manner as those published by the Centers for Medicare and Medicaid Services (CMS).81

93 87 10 U.S.C. §1079(a)(12). 88 32 C.F.R. §199.2 and §199.4(g)(15); and DOD, T RICARE Policy Manual 6010.60-M, “Unproven Drugs, Devices, Medical T reatments, and Procedures,” Chapter 1, Section 2.1, updated August 13, 2021, https://manuals.health.mil/pages/DisplayManualHtmlFile/2021-08-13/AsOf/T P15/C1S2_1.html. 89 Ibid. T he “Hierarchy of Reliable Evidence” includes published literature on “well controlled studies of clinically meaningful endpoints” and formal technology assessments, national professional medical associations’ reports or policy positions, and report s of national expert opinion organizations. 90 DOD, T RICARE Policy Manual 6010.60-M, “Unproven Drugs, Devices, Medical T reatments, and Procedures,” Chapter 1, Section 2.1, updated August 13, 2021. 91 32 C.F.R. §199.14(j)(1)(iv)(C). 92 32 C.F.R. §199.14(a)(1)(i)(A). Diagnosis Related Groups (DRGs) is a method of assigning a predetermined cost of inpatient care for a specific diagnosis. Costs assigned to each DRG are determined prospectively by the U.S. Centers for Medicare and Medicaid Services (CMS), and accounts for severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity. Additional cost adjustments may be made for geographic or other factors impacting wage differences. T he DRG-based payment system is required by 42 U.S.C. §1395ww for all civilian health care facilities that participate in Medicare. For more information about DRGs, see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software. 93 When calculating T RICARE rates, various provisions in 32 C.F.R. §199.14 and §199.17 direct the same or similar methodologies used by CMS for the Medicare program. For more on how CMS calculates DRG rates, see Medicare Payment Advisory Commission (MEDPAC), “Hospital Acute Inpatient Services Payment System,” Payment Basics, October 2016, http://www.medpac.gov/docs/default -source/payment -basics/medpac_payment_basics_16_hospital_final.pdf. T RICARE DRG rates are available at Congressional Research Service 25 link to page 31 Military Medical Care: Frequently Asked Questions Reimbursement for Hospital-based Outpatient Care Reimbursement for Hospital-based Outpatient Care

Hospital-based outpatient services are reimbursed using the TRICARE outpatient prospective payment system (OPPS).94 Modeled after Medicare's OPPS program, TRICARE pays for hospital-based outpatient services on a rate-per-service basis.8295 Each service is assigned a Health Care Procedure Coding System (HCPCS) code and descriptor, then categorized into an Ambulatory Payment Classification (APC) group based on clinical and cost similarities. A reimbursement rate is assigned to each group, which applies to any service in the APC. DOD publishes quarterly updates for TRICARE APC reimbursement rates, which are consistent with those published by the CMS.83

96 Reimbursement for Outpatient Care and Health Care-relatedRelated Services

Other outpatient care and services provided in a non-hospitalnonhospital setting are reimbursed using the allowable charge method.8497 By law (P.L. 102-39610 U.S.C. §1097b) and federal regulation (32 C.F.R. §199.14), civilian health care providers treating TRICARE patients cannot billbe reimbursed more than 115% of charges authorized by the DOD fee schedule, also known as the CHAMPUS Maximum Allowable Charge (CMAC). CMAC rates are updated annuallyannual y, calculated on a national basis, and then adjusted for locality differences.85

98 TRICARE reimburses health care providers at the CMAC rate or the billed bil ed charge, whichever is lower. In some instances, TRICARE may reimburse above the CMAC rate in localities where excessive balance billing86 bil ing” occurs or to ensure "adequate beneficiary access to care."87

14”99 16. What DOD Health Benefits are Available to Reservists?

In recent years, especiallyespecial y as members of the Reserve Component88Component100 have had a larger role in combat operations overseas, Congress has enlarged the health benefits available for members of the Reserve Component. TypicallyTypical y, DOD health benefits for members of the Reserve Component vary based on their duty status, which are outlined inin Table 7.

Members of the National Guard,6. https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Diagnosis-Related-Group-Rates. 94 32 C.F.R. §199.14(a)(6)(ii). 95 For more information on Medicare’s Outpatient Prospective Payment System (OPPS), see http://www.medpac.gov/docs/default -source/payment -basics/medpac_payment_basics_16_opd_final.pdf. 96 Quarterly T RICARE APC reimbursement rate updates are available at https://health.mil/Military-Health-T opics/Business-Support/Rates-and-Reimbursement/Outpatient -Prospective-Payment-System. Reimbursement rates for T RICARE-specific APCs are updated on an annual basis instead of quarterly. 97 Outpatient care and services provided in a nonhospital setting can include laboratory services, rehabilitation therapy, radiology, durable medical equipment, certain drugs, professional provider services, facility charges, and ambulance services. 98 Locality configurations and adjustments are made in the same man ner as Medicare’s Fee Schedules. For more information on Medicare’s Fee for Service localities, see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Locality.html. CMAC rates are available at https://health.mil/Military-Health-T opics/Business-Support/Rates-and-Reimbursement/CMAC-Rates. 99 32 C.F.R. 199.14(j)(1)(iv). Balance billing occurs when a health care provider or facility bills a patient for the difference between what was charged and the allowed reimbursement rate. 100 For additional information on Reserve Component pay and benefits, see CRS Report RL30802, Reserve Component Personnel Issues: Questions and Answers, by Lawrence Kapp and Barbara Salazar T orreon . Congressional Research Service 26 Military Medical Care: Frequently Asked Questions Health benefits for members of the National Guard who are activated by their governor for state active duty (e.g., disaster response duty), may also be eligible for their state' varies from state to state and may include eligibility for their state’s employee health insurance program.

Table 76. DOD Health Benefits Available to Members of the Reserve Component

Duty Status of Reserve Component Member

DOD Health Benefit

Statutory Reference

Serving on active duty ≥30 consecutive days

Duty Status of Reserve Statutory Component Member DOD Health Benefit Reference Same health benefits as regular active component members members (i.e., TRICARE Prime)

10 U.S.C. §1074 Serving on active duty ≥30 consecutive days TRICARE Prime §1074

 

TRICARE Prime coverage up to 180 days prior to activation if orders are in support of a contingency operation

10 U.S.C. §1074 operation Eligible to enrol in TRICARE Reserve §1074

Selected Reservist in an inactive duty training status (i.e., "drilling reservist")

Eligible to enroll in TRICARE Reserve Select, a premium-based, preferred preferred provider organization- structured health plan

10 U.S.C. §1076d Selected Reservist (i.e., dril ing structured health plan reservist) Eligible to enrol in the premium-based §1076d

 

Eligible to enroll in the premium-based TRICARE Dental Plan 10 U.S.C. §1076a Il ness or injury during inactive duty 10 U.S.C. §1074 training, including travel to/from dril Il ness or injury-specific care at an MTF or TRICARE- site authorized provider 10 U.S.C. §1074a Transitional Assistance Management Program—180 Separating from a period of >30 days of eligibility for premium-free TRICARE Prime consecutive days of active duty while or TRICARE Select, beginning on the day of 10 U.S.C. §1145 supporting a contingency operation separation from active duty Eligible to enrol in TRICARE Retired Reserve, a premium-based, preferred provider organization- 10 U.S.C. §1086 Retired Reservist (not yet eligible to structured health plan receive retirement pay) Eligible to enrol Dental Plan

 

Illness or injury during inactive duty training, including travel to/from drill site

Illness or injury-specific care at an MTF or TRICARE-authorized provider

10 U.S.C. §1074a

Separating from a period of >30 consecutive days of active duty while supporting a contingency operation

Transitional Assistance Management Program – 180 days of eligibility for premium-free TRICARE Prime or TRICARE Select, beginning on the day of separation from active duty

10 U.S.C. §1145

Retired Reservist (not yet eligible to receive retirement pay)

Eligible to enroll in TRICARE Retired Reserve, a premium-based, preferred provider organization- structured health plan

10 U.S.C. §1086

 

Eligible to enroll a dental plan offered by the Federal Employee Dental and Vision Program (FEDVIP) 10 U.S.C. (FEDVIP)

10 U.S.C. §1076c

§1076c Same health benefits as retirees of the active Retired Reservist (eligible to receive retirement pay, but component who are not yet eligible for Medicare 10 U.S.C. §1097 retirement pay, but not yet eligible (e.g., TRICARE Prime for Medicare)

Same health benefits as retirees of the active component who are not yet eligible for Medicare (e.g., TRICARE Prime or TRICARE Select)

10 U.S.C. §1097

 

Eligible to enroll or TRICARE Select) for Medicare) Eligible to enrol a dental plan offered by the Federal Employee Dental and Vision Program (FEDVIP) 10 U.S.C. (FEDVIP)

10 U.S.C. §1076c

§1076c Retired Reservist (eligible to receive retirement pay and Medicare)

TRICARE for Life

10 U.S.C. §1086

15retirement pay and enrol ed in TRICARE for Life 10 U.S.C. §1086 Medicare Part B) 17. Have Military Personnel Been Promised Free Medical Care for Life?

Some military personnel and retirees maintain that they and their dependents were promised "free medical care for life" at the time of their enlistment. Such promises may have been made by military recruiters and in recruiting brochures; however, if they were made, they were not based upon laws or official regulations.89101 In 1993, the Deputy Assistant Secretary of Defense for Health 101 Under current laws and federal regulations only active duty personnel are entitled to military health care. Active duty dependents also have an entitlement to care, however, may be seen in an MT F on a space -available basis. Retirees Congressional Research Service 27 link to page 27 Military Medical Care: Frequently Asked Questions Affairs acknowledged this notion in a statement to the House Committee on Armed Services and attempted to clarify that an entitlement to free medical care for life does not exist:

We have a medical care program for the life of our beneficiaries, and it is pretty well wel defined in the law. That easily gets interpreted to, or reinterpreted into, free medical care for the rest of your life. That is a pretty easy transition for people to make in their thinking, and it is pervasive. We spend an incredible amount of effort trying to reeducate people that that is not their benefit.90

102 Federal courts have held that current statutes or regulations do not grant a right or promise for free medical care for retirees and their dependents.91103 In Sebastian v. U.S., the U.S. Court of Appeals for the Eleventh Circuit ruled that:

as follows: Nothing in these regulations provided for unconditional lifetime free medical care or free medical care or authorized recruiters to promise such care as an inducement to joining or continuing in the armed forces. While the Retirees argue that the above mentioned section 4132.1 gave those of them who served as officers in the Navy and Marine Corps the right to free unconditional medical care, we cannot agree. The [1922 Manual of the Medical Department of the United States Navy] Manual provided guidelines for the Navy's Medical Department, but did not create any right in such officers to the free unconditional lifetime medical care they claim. It It related only to hospital care, not the broader services that these Retirees seek, and covered only the period when it was in effect. In any event, in view of the general pattern of the military regulations that provides medical care to retirees only when facilities and personnel were available, we decline to read into the creation of such an enduring and broad right to unconditional free lifetime medical care.

In sum, we conclude that the Retirees have not shown that they have a right to the health care they say was "taken"“taken” by the government. Since the basic premise of their claim fails, their taking claim necessarily also fails.92

104 In 2002, an appeal of Schism v. U.S. also held that a legal, contractual right to free health care for life does not exist:

The promise of such health care was made in good faith and relied upon. Again, however, because no authority existed to make such promises in the first place, and because Congress has never ratified or acquiesced to this promise, we have no alternative but to uphold the judgement against the retirees'’ breach-of-contract claim.105 18 breach-of-contract claim.93

16. What is the Congressionally Directed Medical Research Program?

The Congressionally Directed Medical Research Program (CDMRP) is a congressional appropriation to the DOD, explicitly for peer-reviewed biomedical research in congressionally specified health matters. In general, Congress inserts CDMRP funding in the Defense Health Program's Research, Development, Test, and Evaluation (RDT&E) account in the annual DOD appropriation. CDMRP funding is not part of the President's budget request for overall RDT&E. In FY2019, 67% ($1.47 billion) of the Defense Health Program's RDT&E appropriation was for the CDMRP.94 Biomedical research conducted by the Defense Advanced Research Projects Agency or other military research agencies are funded through separate accounts and are not reflected in the CDMRP. Table 8 depicts appropriations for selected CDMRP programs in the past five years.

The U.S. Army Medical Research and Material Command (USAMRMC) administers the CDMRP and is responsible for awarding and managing competitive grants. USAMRMC solicits CDMRP grant opportunities through Program Announcements or Broad Agency Announcements, which are posted on their website or through http://www.grants.gov.

Members of Congress may request funding for medical research during the annual defense appropriations process. The appropriations committees typically send Members a memorandum with instructions for submitting requests.

Table 8. Appropriation Levels for Selected CDMRP Research Areas, FY2014-FY2019

(in millions of dollars)

 

FY2015a

FY2016b

FY2017c

FY2018d

FY2019e

Alcohol and Substance Abuse Disorders

4

4

4

4

4

Alzheimer's Disease

12

15

15

15

15

Amyotrophic Lateral Sclerosis

7.5

7.5

7.5

10

10

Autism

6

7.5

7.5

7.5

7.5

Bone Marrow Failure

3.2

3

3

3

3

Breast Cancer

120

120

120

130

130

Chronic Pain Management

-

-

-

-

10

Combat Readiness

-

-

-

-

15

Duchenne Muscular Dystrophy

3.2

3.2

3.2

3.2

3.2

Epilepsy

7.5

7.5

7.5

7.5

7.5

Global HIV/AIDS

8

8

8

8

8

Gulf War Illness

20

20

20

21

21

Hearing Restoration

-

-

10

10

10

HIV/AIDS

12.9

12.9

12.9

12.9

12.9

Joint Warfighter Medical

50

50

50

50

50

Kidney Cancer

-

-

10

15

15

Lung Cancer

10.5

12

12

14

14

Lupus

-

-

5

5

5

Melanoma

-

-

-

-

10

Multiple Sclerosis

5

6

6

6

6

Orthotics and Prosthetics Outcomes

10

10

10

10

10

Ovarian Cancer

20

20

20

20

20

Peer-Reviewed Cancer

50

50

60

80

80

Peer-Reviewed Medical

247.5

278.7

300

330

330

Peer-Reviewed Orthopedic

30

30

30

30

30

Prostate Cancer

80

80

90

100

100

Psychological Health/Traumatic Brain Injury

125

125

125

125

125

Reconstructive Transplant

15

12

12

12

12

Spinal Cord Injury

30

30

30

30

30

Therapeutic Service Dog Training

3

-

-

-

-

Tick-Borne Disease

-

5

5

5

5

Trauma Clinical

-

10

10

10

10

Tuberous Sclerosis

6

6

6

6

6

Vision

10

10

15

15

15

Core Program Funding

179.8

207.5

264.6

291

291

Notes: The CDMRP website (http://cdmrp.army.mil/) also provides specific descriptions and funding histories of the different research programs. The "Peer-Reviewed Medical" and "Peer-Reviewed Cancer" research categories typically include multiple research areas that are eligible for funding. Eligible research areas are outlined in the explanatory statement accompanying the Defense Appropriations bill for that year.

a. Funds appropriated by P.L. 113-235. See Congressional Record, December 11, 2014, p. H9604.

b. Funds appropriated by P.L. 114-113. See House Committee on Appropriations Explanatory Statement, Division C, p. 87B.

c. Funds appropriated by P.L. 115-31. See House Committee on Appropriations Explanatory Statement, Division C, p. 76B.

d. Funds appropriated by P.L. 115-91. See House Committee on Appropriations Explanatory Statement, Division C, p. 94B.

e. Funds appropriated by P.L. 115-245. See House Committee on Appropriations Explanatory Statement, Division C, p. 96C.

17. Does TRICARE Cover Abortion?

. Does TRICARE Cover Abortion? 10 U.S.C. §1093 provides that "Funds available to the Department of Defense may not be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term or in a case in which the pregnancy is the result of an act of rape or incest.”106 and their dependents have no such entitlement, but may be seen in an MT F on a space-available basis. See question “11. How Are Priorities for Care in Military T reatment Facilities Assigned?” 102 H.Rept. 103-13. 103 See Coalition of Retired Military Veterans, et al. v. United States of America, U.S. Dist. of South Carolina, C.A.#2:96-3822-23, Dec. 10, 1997: 11-12; Sebastian v. United States, 185 F.3d 1368, 1372 (Fed. Cir. 1999); or Schism and Reinlie v. United States, 2002 WL 31549178 (Fed.Cir. (Fla.)), November 18, 2002. 104 Sebastian v. U.S., 185 F.3d 1368 (11th Cir. 2002). 105 Schism and Reinlie v. U.S., 239 F.3d 1280 (11th Cir. 2001). 106 T he clause “or in a case in which the pregnancy is the result of an act of rape or incest” was added by Section 704 of the National Defense Authorization Act for Fiscal Year 2013 ( P.L. 112-239). Congressional Research Service 28 Military Medical Care: Frequently Asked Questions 19. What is DOD’s policy on Use Animals in Medical Research or Training? Yes. DOD policy is that live animals wil not be used for training and education or medical research purposes except where, after exhaustive analysis, no alternatives are available.107 The policy also requires that training or research procedures used “cause the least pain or distress to the minimum number of animals” and include a “non-terminal disposition,” when possible.108 107 DOD, DOD Instruction 3216.01, Use of Animals in DoD Programs, March 20, 2019, https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/321601p.pdf. 108 Ibid, p.4. “Non-terminal disposition” refers to the repurposing of an animal subject through adoption, retirement, or interagency transfer when it is no longer needed for training or research. Congressional Research Service 29 Military Medical Care: Frequently Asked Questions Appendix. Glossary of Acronyms Glossary of Acronyms ACA Affordable Care Act MHS Military Health System ADFM Active Duty Family Member MHSER Military Health System Executive Review ADSM Active Duty Service Member MILCON Military Construction AFMRA Air Force Medical Readiness Agency MILPERS Military Personnel APC Ambulatory Payment Classification MTF Military Treatment Facility ASD(HA) Assistant Secretary of Defense (Health Affairs) NDAA National Defense Authorization Act BAP Beneficiary Advisory Panel O&M Operations & Maintenance BUMED Navy Bureau of Medicine and Surgery OHI Other Health Insurance CBO Congressional Budget Office OPPS Outpatient Prospective Payment System CDMRP Congressional y Directed Medical Research PAC Policy Advisory Council Program Civilian Health and Medical Program of the Principal Deputy Assistant Secretary of Defense CHAMPUS Uniformed Services PDASD(HA) (Health Affairs) CMAC CHAMPUS Maximum Al owable Charge QLE Qualifying Life Event CRS Congressional Research Service RDT&E Research, Development, Testing, and Evaluation CSA Combat Support Agency SECDEF Secretary of Defense DEERS Defense Enrol ment Eligibility Reporting System SEP Special Enrol ment Period DEPSECDEF Deputy Secretary of Defense SMMAC Senior Military Medical Action Council DHA Defense Health Agency TAMP Transitional Assistance Management Program DHB Defense Health Board TFL TRICARE for Life DHP Defense Health Program TRR TRICARE Retired Reserve DOD Department of Defense TRS TRICARE Reserve Select DSCP Defense Supply Center Philadelphia TYA TRICARE Young Adult Under Secretary of Defense (Personnel and ESI Express Scripts, Inc. USD(P&R) Readiness) FEHBP Federal Employee Health Benefits Program USFHP Uniformed Services Family Health Plan FY Fiscal Year GAO Government Accountability Office HCPCS Healthcare Common Procedure Coding System IPPS Inpatient Prospective Payment System JMOC Joint Medical Oversight Council MEDCOM Army Medical Command MERHCF Medicare-Eligible Retiree Health Care Fund Congressional Research Service 30 Military Medical Care: Frequently Asked Questions Author Information Bryce H. P. Mendez Analyst in Defense Health Care Policy Insert Acknowledgments Here Disclaimer This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress. Information in a CRS Report should n ot be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you wish to copy or otherwise use copyrighted material. Congressional Research Service R45399 · VERSION 6 · UPDATED 31 carried to term or in a case in which the pregnancy is the result of an act of rape or incest."95

18. Does DOD Use Animals in Medical Research or Training?

Yes. DOD policy is that live animals will not be used for training and education except where, after exhaustive analysis, no alternatives are available.96 Currently approved uses include pre-deployment training for medical personnel and include infant intubation (ferrets), microsurgery (rodents), and combat trauma training (goats and swine).

Appendix. Glossary of Acronyms

Glossary of Acronyms

ACA

Affordable Care Act

MBOG

Medical Business Operations Group

ADFM

Active Duty Family Member

MDAG

Medical Deputies Action Group

ADSM

Active Duty Service Member

MEDCOM

Army Medical Command

AFMS

Air Force Medical Service

MERHCF

Medicare-Eligible Retiree Health Care Fund

APC

Ambulatory Payment Classification

MHS

Military Health System

ASD(HA)

Assistant Secretary of Defense (Health Affairs)

MHSER

Military Health System Executive Review

BAP

Beneficiary Advisory Panel

MILCON

Military Construction

BUMED

Navy Bureau of Medicine and Surgery

MILPERS

Military Personnel

CBO

Congressional Budget Office

MOG

Medical Operations Group

CDMRP

Congressionally Directed Medical Research Program

MPOG

Manpower and Personnel Operations Group

CHAMPUS

Civilian Health and Medical Program of the Uniformed Services

MTF

Military Treatment Facility

CMAC

CHAMPUS Maximum Allowable Charge

NDAA

National Defense Authorization Act

CRS

Congressional Research Service

O&M

Operations & Maintenance

CSA

Combat Support Agency

OPPS

Outpatient Prospective Payment System

DEERS

Defense Enrollment Eligibility Reporting System

PAC

Policy Advisory Council

DEPSECDEF

Deputy Secretary of Defense

PDASD(HA)

Principal Deputy Assistant Secretary of Defense (Health Affairs)

DHA

Defense Health Agency

QLE

Qualifying Life Event

DHP

Defense Health Program

RDT&E

Research, Development, Testing, and Evaluation

DOD

Department of Defense

SECDEF

Secretary of Defense

DSCP

Defense Supply Center Philadelphia

SEP

Special Enrollment Period

ECHO

Extended Care Health Option

SMMAC

Senior Military Medical Action Council

EFMP

Exceptional Family Member Program

TAMP

Transitional Assistance Management Program

EHHC

ECHO Home Health Care

TFL

TRICARE for Life

eMSM

Enhanced Multi-Service Market

TRR

TRICARE Retired Reserve

ESI

Express Scripts, Inc.

TRS

TRICARE Reserve Select

FEHBP

Federal Employee Health Benefits Program

TYA

TRICARE Young Adult

FY

Fiscal Year

USAMRMC

United States Army Medical Research and Materiel Command

GAO

Government Accountability Office

USD(P&R)

Under Secretary of Defense (Personnel and Readiness)

HCBS

Home and Community-Based Services

USFHP

Uniformed Services Family Health Plan

HCPCS

Healthcare Common Procedure Coding System

VA

Department of Veterans Affairs

Author Contact Information

[author name scrubbed], Analyst in Defense Health Care Policy ([email address scrubbed], [phone number scrubbed])

Acknowledgments

This product was originally prepared by [author name scrubbed], former CRS Specialist in Defense Health Care Policy.

Footnotes

1.

David J. Smith, Raquel C. Bono, and Bryce J. Slinger, "Transforming the Military Health System," Journal of the American Medical Association, vol. 318, no. 24 (2017), pp. 2427-2428.

2.

For more information about the Military Health System's mission and strategic initiatives, see https://health.mil/About-MHS.

3.

10 U.S.C. §1071.

4.

10 U.S.C. §1073d.

5.

10 U.S.C. §2358.

6.

10 U.S.C. §401. Humanitarian and civic assistance activities includes medical, surgical, dental, and veterinary care, among others.

7.

Department of Defense, Evaluation of the TRICARE Program: Fiscal Year 2018 Report to Congress, April 5, 2018, p. 17, https://www.health.mil/Reference-Center/Reports/2018/05/09/Evaluation-of-the-TRICARE-Program-Fiscal-Year-2018-Report-to-Congress.

8.

The "TRI" in "TRICARE" originally referred to its initial three main benefit plan options: a health maintenance organization option (TRICARE Prime), a preferred provider option (formerly known as "TRICARE Extra"), and a fee-for-service option (formerly known as "TRICARE Standard").

9.

Department of Defense, Plan for Reform of the Administration of the Military Health System, October 25, 2013, p. 3, https://health.mil/Reference-Center/Reports/2013/11/25/Plan-for-Reform-of-the-Administration-of-the-Military-Health-System.

10.

ibid.

11.

ibid.

12.

ibid, p. 4.

13.

ibid, p. 4.

14.

ibid, p. 4. The Human Resources and Manpower Workgroup (HR&MANPOWER WG) was the name identified in the planning process, however DOD chartered the group as the Manpower and Personnel Operations Group (MPOG).

15.

eMSM Market Managers are authorized to manage the respective market's budget, standardize clinical and business functions, support medical readiness activities, and direct the movement of manpower and workload between MTFs within the market. For more information about eMSM management, see Department of Defense, Deputy Secretary of Defense Memorandum, Implementation of Military Health System Governance Reform, March 11, 2013, p. 3, https://www.health.mil/Reference-Center/Policies/2013/03/11/Implementation-of-Military-Health-System-Governance-Reform.

16.

ibid, p. 4.

17.

ibid, p. 4.

18.

A Combat Support Agency (CSA) is defined in DOD Directive 3000.06 as an organization, designated by 10 U.S.C. §193 or the Secretary of Defense, to "provide and plan for the optimum support capabilities attainable within existing and programmed resources to the operational commanders within the parameters of the CSA's statutory responsibility and its chartering DOD Directive."

19.

MTFs in the National Capital Region include Walter Reed National Military Medical Center, Fort Belvoir Community Hospital, DiLorenzo TRICARE Health Clinic, Tri-Service Dental Clinic, Family Health Center Fairfax, and Family Health Center Dumfries.

20.

Department of Defense, DOD Directive 5136.13, Defense Health Agency, September 30, 2013.

21.

Department of Defense, Deputy Secretary of Defense Memorandum, Implementing Congressional Direction for Reform of the Military Health System, September 28, 2018, https://health.mil/Reference-Center/Policies/2018/09/28/Implementing-Congressional-Direction-for-Reform-of-the-Military-Health-System.

22.

P.L. 115-232 §711.

23.

Service Surgeons General are typically general or flag officers in the grade of Lieutenant General/Vice Admiral.

24.

Statutory duties assigned to the Service Surgeons General are described in 10 U.S.C. §§3036, 5136, 8036.

25.

Additional duties assigned to the Service Surgeons General were included in Section 712 of the John S. McCain National Defense Authorization Act for FY2018 (P.L. 115-232).

26.

See question "3. What is the Medicare-Eligible Retiree Health Care Fund (MERHCF)?" for a discussion of the MERHCF.

27.

Third-party collections are funds collected from additional health insurance payers for beneficiary care delivered by an MTF.

28.

Department of Defense, FY 2019 Budget Request Overview, February 2018, p. 5-4, Figure 5.2, https://comptroller.defense.gov/Portals/45/Documents/defbudget/fy2019/FY2019_Budget_Request_Overview_Book.pdf.

29.

P.L. 106-398 §712.

30.

Federal agencies that contribute to the MERHCF are DOD (Air Force, Army, Marine Corps, Navy), Department of Health and Human Services (Public Health Service), Department of Homeland Security (Coast Guard), and Department of Commerce (National Oceanic and Atmospheric Administration).

31.

Department of Defense, Valuation of the Medicare-Eligible Retiree Health Care Fund, December 2017, p. 4, https://media.defense.gov/2018/Apr/12/2001902556/-1/-1/0/MERHCF%20VAL%20RPT%202016.PDF.

32.

P.L. 103-337 §738.

33.

Department of Defense, Request for Proposals – Section C: Description/Specifications/Work Statement (HT9402-15-R-0002), November 3, 2014, https://www.fbo.gov/notices/157d8d11c7087ac0a3bb5f2fe10a7b83.

34.

U.S. Government Accountability Office, GAO Decision in the Matter of UnitedHealth Military & Veteran Services LLC; WellPoint Military Care Corporation; Health Net Federal Services, LLC, B-411837.2, November 9, 2016, https://www.gao.gov/assets/690/681207.pdf.

35.

Dependents of active duty servicemembers who have died are deemed transitional survivors. This status is granted for the first three years after the sponsor dies. After the third year, dependents are then deemed as survivors of active duty servicemembers and are subject to the cost sharing requirements for retirees.

36.

The catastrophic cap is an annual maximum limit that a beneficiary pays out of pocket for TRICARE cost sharing. In general, point of service charges, TRS, TRR, and TYA premiums, non-TRICARE covered benefits, and balance billing charges do not apply to the catastrophic cap.

37.

32 C.F.R. §199.17(b)(1) authorizes the DHA Director to designate geographic locations in which TRICARE Prime may be offered. Health Affairs Policy 11-008 requires PSAs to be established within a 40-mile radius from an MTF or BRAC installation. 32 C.F.R. §199.17(b)(1) also authorizes active duty servicemembers and their dependents assigned to remote locations outside of a PSA to participate in TRICARE Prime Remote (TPR), a similar option to TRICARE Prime. For more information about TPR, see https://tricare.mil/primeremote.

38.

10 U.S.C. §1076d.

39.

For more on the Ready Reserve and Selected Reserve see CRS Report RL30802, Reserve Component Personnel Issues: Questions and Answers, by [author name scrubbed] and [author name scrubbed], Question 2.

40.

The Transitional Assistance Management Program (TAMP) provides an additional 180 days of premium-free coverage for TRICARE Prime or TRICARE Select. Beneficiaries are eligible for TAMP if their sponsor is subject to certain transitional events, such as involuntary separation under honorable conditions, demobilizing member of the Reserve Component, sole survivorship discharge, or transition from the Active Component to the Reserve Component. For more information about TAMP, see https://tricare.mil/tamp.

41.

10 U.S.C. §1076d specifies that members of the Selected Reserves who are "eligible to enroll in a health benefits plan under chapter 89 of title 5" are not eligible to enroll in TRICARE Reserve Select.

42.

Department of Defense, Assistant Secretary of Defense (Health Affairs) Memorandum, Policy Memorandum to Establish 2019 Monthly Premium Rates for TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult, August 29, 2018, https://health.mil/Reference-Center/Policies/2018/08/29/2019-Monthly-Premium-Rates-for-TRS-TRR-and-TYA.

43.

10 U.S.C. §1076e.

44.

For more on military retirement, see CRS Report RL34751, Military Retirement: Background and Recent Developments, by [author name scrubbed].

45.

Department of Defense, Assistant Secretary of Defense (Health Affairs) Memorandum, Policy Memorandum to Establish 2019 Monthly Premium Rates for TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult, August 29, 2018, https://health.mil/Reference-Center/Policies/2018/08/29/2019-Monthly-Premium-Rates-for-TRS-TRR-and-TYA.

46.

10 U.S.C. §1110b.

47.

P.L. 111-383 §702.

48.

Department of Defense, Assistant Secretary of Defense (Health Affairs) Memorandum, Policy Memorandum to Establish 2019 Monthly Premium Rates for TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult, August 29, 2018, https://health.mil/Reference-Center/Policies/2018/08/29/2019-Monthly-Premium-Rates-for-TRS-TRR-and-TYA.

49.

Medicare Part B is covers medically necessary outpatient services and equipment (e.g., physicians' and non-physician services, outpatient hospital services, durable medical equipment, clinical laboratory tests, ambulance services, and limited prescription drugs and biologics). Participation in Medicare Part B is voluntary, however enrollment and monthly premiums are required for those who opt-in. For more information on Medicare Part B, see CRS Report R40425, Medicare Primer, coordinated by [author name scrubbed].

50.

10 U.S.C. §1086(d).

51.

CRS Report R40082, Medicare: Part B Premiums, by [author name scrubbed].

52.

Department of Defense, "TRICARE Open Season Begins November 12," press release, August 1, 2018, https://www.health.mil/News/Articles/2018/08/01/TRICARE-Open-Season-Begins-November-12.

53.

10 U.S.C. §1074g.

54.

Express Scripts, Inc., "Express Scripts Awarded TRICARE Pharmacy Program Contract," press release, June 27, 2008, https://globenewswire.com/news-release/2008/06/27/380555/145445/en/Express-Scripts-Awarded-TRICARE-Pharmacy-Program-Contract.html.

55.

10 U.S.C. §1074g(a)(2)(A).

56.

10 U.S.C. §1074g(b). The Pharmacy and Therapeutics Committee meets at least quarterly and its minutes are publicly available at the Defense Health Agency Pharmacy Operations Division website: https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/Operations/Pharmacy-Division/DoD-Pharmacy-and-Therapeutics-Committee.

57.

The Beneficiary Advisory Panel (BAP) is a federal advisory committee established by 10 U.S.C. §1074g(c). For more information on the BAP, see https://health.mil/bap.

58.

DHA provides a publicly-available list of MTF pharmacies that accept electronic prescriptions from civilian providers. See https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Access-to-Healthcare/Pharmacy-Program/Electronic-Prescribing.

59.

Office of the Assistant Secretary of Defense (Health Affairs), Memorandum subject "TRICARE Pharmacy Benefit Program Formulary Management" dated December 22, 2004. Accessed August 7, 2018, at https://www.health.mil/Reference-Center/Policies/2005/12/19/Clarification-to-HA-Policy-04-032--TRICARE-Pharmacy-Benefit-Program-Formulary-Management--December-2.

60.

The VA has authority delegated from the General Services Administration to manage the medical care sections of the Federal Supply Schedule, which includes pharmaceuticals. For more information on the delegation of authority authorized in Federal Acquisition Regulation Subpart 8.402(a), see https://www.acquisition.gov/far/current/html/Subpart%208_4.html.

61.

ESI was awarded the TRICARE pharmacy benefit manager contract, which includes a base year, seven one-year option periods, and options for a phase-out period. The estimated value of the contract is $5.3 billion. For more information, see https://www.fbo.gov/notices/7701a811be0214a23f04b4e284f8b13b.

62.

32 C.F.R. §199.21(j).

63.

Department of Defense, "Evaluation of the TRICARE Program: Fiscal Year 2017 Report to Congress," April 5, 2018, p. 35, https://www.health.mil/Reference-Center/Reports/2018/05/09/Evaluation-of-the-TRICARE-Program-Fiscal-Year-2018-Report-to-Congress.

64.

ibid.

65.

10 U.S.C. §1074g(a).

66.

For additional information please see the ECHO web page at http://www.tricare.mil/echo.

67.

"Serious physical disability" is defined in 32 C.F.R. §199.2 as a "physiological disorder or condition or anatomical loss affecting one or more body systems which has lasted, or with reasonable certainty is expected to last, for a minimum period of 12 contiguous months, and which precludes the person with the disorder, condition or anatomical loss from unaided performance of at least one major life activity as defined in this section."

68.

Qualifying conditions are outlined in 32 C.F.R. §199.5(b)(2).

69.

EFMP is a program for active duty family members with special medical or education needs. The program coordinates support services from the MHS and DOD education systems. Each military service mandates enrollment in EFMP if a family member has special needs. Additional information on EFMP can be found at https://www.militaryonesource.mil/-/the-exceptional-family-member-program-for-families-with-special-needs.

70.

10 U.S.C. §1074.

71.

10 U.S.C. §1076.

72.

10 U.S.C. §1074.

73.

DOD clarified the basic priorities for MTF care in 32 C.F.R. §199.17(d) and Department of Defense, Health Affairs Policy 11-005, TRICARE Policy for Access to Care, February 23, 2011.

74.

DOD access to care standards are elaborated in Department of Defense, Health Affairs Policy 11-005, TRICARE Policy for Access to Care, February 23, 2011. There are stipulated in 32 C.F.R. §199.17(p)(5).

75.

P.L. 111-148.

76.

CRS Report R41198, TRICARE and VA Health Care: Impact of the Patient Protection and Affordable Care Act (ACA), by [author name scrubbed] and [author name scrubbed].

77.

P.L. 111-148 §3110.

78.

P.L. 111-309 §201.

79.

32 C.F.R. §199.14(j)(iv)(C).

80.

Diagnosis Related Groups (DRGs) is a method of assigning a predetermined cost of inpatient care for a specific diagnosis. Costs assigned to each DRG are determined prospectively by the U.S. Centers for Medicare and Medicaid Services (CMS), and accounts for severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity. Additional cost adjustments may be made for geographic or other factors impacting wage differences. The DRG-based payment system is required by 42 U.S.C. §1395ww for all civilian health care facilities that participate in Medicare. For more information about DRGs, see https://www.cms.gov/ICD10Manual/version34-fullcode-cms/fullcode_cms/Design_and_development_of_the_Diagnosis_Related_Group_(DRGs)_PBL-038.pdf.

81.

TRICARE DRG rates are available at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Diagnosis-Related-Group-Rates.

82.

For more information on Medicare's Outpatient Prospective Payment System (OPPS), see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf.

83.

Quarterly TRICARE APC reimbursement rate updates are available at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Outpatient-Prospective-Payment-System. Reimbursement rates for TRICARE-specific APCs are updated on an annual basis instead of quarterly.

84.

Outpatient care and services provided in a non-hospital setting can include laboratory services, rehabilitation therapy, radiology, durable medical equipment, certain drugs, professional provider services, facility charges, and ambulance services.

85.

Locality configurations and adjustments are made in the same manner as Medicare's Fee Schedules. For more information on Medicare's Fee for Service localities, see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Locality.html. CMAC rates are available at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/CMAC-Rates.

86.

Balance billing occurs when a health care provider or facility bills a patient for the difference between what was charged and the allowed reimbursement rate.

87.

32 C.F.R. 199.14(j)(1)(iv).

88.

For additional information on Reserve Component pay and benefits, see CRS Report RL30802, Reserve Component Personnel Issues: Questions and Answers, by [author name scrubbed] and [author name scrubbed].

89.

Under current laws and federal regulations only active duty personnel are entitled to military health care. Active duty dependents also have an entitlement to care, however, may be seen in an MTF on a space-available basis. Retirees and their dependents have no such entitlement, but may be seen in an MTF on a space-available basis. See question "10. How Are Priorities for Care in Military Treatment Facilities Assigned?".

90.

H.Rept. 103-13

91.

See Coalition of Retired Military Veterans, et al. v. United States of America, U.S. Dist. of South Carolina, C.A.#2:96-3822-23, Dec. 10, 1997: 11-12; Sebastian v. United States, 185 F.3d 1368, 1372 (Fed. Cir. 1999); or Schism and Reinlie v. United States, 2002 WL 31549178 (Fed.Cir. (Fla.)), November 18, 2002.

92.

Sebastian v. U.S., 185 F.3d 1368 (11th Cir. 2002).

93.

Schism and Reinlie v. U.S., 239 F.3d 1280 (11th Cir. 2001).

94.

U.S. Congress, House Committee on Appropriations, Explanatory Statement to P.L. 115-245, 115th Cong., 2018.

95.

The clause "or in a case in which the pregnancy is the result of an act of rape or incest" was added by Section 704 of the National Defense Authorization Act for Fiscal Year 2013 (P.L. 112-239).

96.

Department of Defense, Department of Defense Instruction 3216.01, Use of Animals in DoD Programs, at http://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/321601p.pdf?ver=2017-10-03-131649-680.