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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
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.
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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
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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
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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
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
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 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
....”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”).
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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.
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.
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.
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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.
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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
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:
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:
Reporting to the MDAG are four supporting governing bodies:
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
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Source: Department of Defense, 2018. Notes: Adapted by CRS. |
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:
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.
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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:
The transfer of these responsibilities is required to be completed no later than September 30, 2021.22
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
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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
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Source: Department of Defense, 2018. Notes: Adapted by CRS. |
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.
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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:
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
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.
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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.
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).
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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
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
Figure |
![]() |
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.
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.
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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.
|
![]() |
|
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.
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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.
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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
|
| |
Annual Enrollment Fee |
ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $297/single $594/family | ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $360/single $720/family |
|
$0 |
$0 |
Preventive Care Visit |
ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $0 | ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $0 |
Primary Care Outpatient Visit |
ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $20 | ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $20 |
Specialty Care Outpatient Visit |
ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $30 | ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $30 |
Urgent Care Center Visit |
ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $30 | ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $30 |
Emergency Room Visit |
ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $61 | ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $61 |
Inpatient Admission (Hospitalization) |
ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $154/admission | ADSMs, ADFMs, Transitional Survivors:
Retirees, their families, others: $154/admission |
Maximum Annual Out-of-Pocket Charge (Catastrophic Cap) |
ADSMs
ADFMs, Transitional Survivors:
Retirees, their families, others: $3,000 per family | ADSMs
ADFMs, Transitional Survivors:
|
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 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).
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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.
|
| |
| ADFMs, Transitional
Retirees, their families, others: $0 | ADFMs, Transitional Survivors:
Retirees, their families, others: $462/single $924/family |
Annual Deductible |
Sponsor is E-4 and below $50 (Individual)
Sponsor is E-5 and above $150 (Individual)
Retirees, their families, others: $150 (Individual) $300 (Family) | Sponsor is E-4 and below $51 (Individual)
$154 (Individual)
Retirees, their families, others:
|
Preventive Care Visit |
Care Visit
ADFMs, Transitional Survivors:
ADFMs, Transitional
Retirees, their families, others: $0 | ADFMs, Transitional Survivors:
Retirees, their families, others: $0 |
Primary Care Outpatient Visit |
ADFMs, Transitional Survivors: $21 Network
Retirees, their families, others: $29 Network
| ADFMs, Transitional Survivors: $15 Network
Retirees, their families, others: $25 Network
|
Specialty Care Outpatient Visit |
ADFMs, Transitional Survivors: $31 Network
Retirees, their families, others: $41 Network
| ADFMs, Transitional Survivors: $25 Network
Retirees, their families, others: $41 Network
|
Urgent Care Center Visit |
ADFMs, Transitional Survivors: $21 Network
Retirees, their families, others: $29 Network
| ADFMs, Transitional Survivors: $20 Network
Retirees, their families, others: $41 Network
|
Emergency Room Visit |
ADFMs, Transitional Survivors: $83 Network
Retirees, their families, others: $111 Network
| ADFMs, Transitional Survivors: $41 Network
Retirees, their families, others: $82 Network
|
Inpatient Admission (Hospitalization) |
ADFMs, Transitional Survivors: $19.05/day or $25/admission
Retirees, their families, others:
| ADFMs, Transitional Survivors: $61/admission Network
Retirees, their families, others: $179/admission Network
|
Inpatient Admission (MTF Hospitalization) |
$19.05/day (subsistence charge) |
|
Maximum Annual Out-of-Pocket Charge (Catastrophic Cap) |
ADSMs
ADFMs, Transitional Survivors:
Retirees, their families, others: $3,000 per family | ADSMs
ADFMs, Transitional Survivors:
Retirees, their families, others:
|
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.
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
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.
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
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
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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
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 |
|
|
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.
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:
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.
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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.
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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.
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:
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.
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.
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.
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.
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:
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.
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
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
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
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
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 .
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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.
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 |
10 U.S.C. |
|
10 U.S.C. | |
Selected Reservist in an inactive duty training status (i.e., "drilling reservist") |
|
10 U.S.C. |
| ||
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 |
|
10 U.S.C. §1076c |
|
§1076c
Same health benefits as retirees of the active
Retired Reservist |
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 |
|
10 U.S.C. §1076c |
|
§1076c
Retired Reservist |
TRICARE for Life |
10 U.S.C. §1086 |
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
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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
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)
|
|
|
|
| |
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.
. 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).
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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.
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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
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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
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).
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
Acknowledgments
This product was originally prepared by [author name scrubbed], former CRS Specialist in Defense Health Care Policy.
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. | |
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. | |
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. |