Military Health
Increased TRICARE Eligibility for Reservists Presents Educational Challenges Gao ID: GAO-07-195 February 12, 2007Since 2001, the number of reservists mobilized for active duty has increased dramatically. Congress has expanded reservists' and their dependents' eligibility for TRICARE, the Department of Defense's (DOD) health insurance program. The National Defense Authorization Act (NDAA) for Fiscal Year 2004 directed GAO to examine the health insurance coverage of reservists and their dependents. This report (1) identifies the extent to which reservists have civilian health insurance, (2) examines DOD's efforts to educate reservists and their dependents about TRICARE, and (3) describes reservists' level of satisfaction with TRICARE and the types of problems reservists and their dependents experienced when using it. To do this, GAO relied on interviews with DOD and DOD's survey data. GAO also administered a survey of TRICARE benefit assistance coordinators.
Eighty percent of mobilized reservists have civilian health insurance--a rate similar to that of the U.S. population between 18 and 64 years old. The number of reservists with civilian health insurance varies among reservists, with older reservists and reservists of higher rank having a greater rate of insurance than younger reservists and reservists of more junior rank, and reservists with dependents being more likely to have insurance than reservists without dependents. Reservists and their dependents obtained coverage through a variety of sources and over half of all reservists kept their civilian health insurance during mobilizations, even though they were eligible to enroll in TRICARE. Many reservists reported that they maintained their civilian coverage to avoid disruptions associated with a change to TRICARE and to ensure that their dependents could continue seeing their current providers who might not accept TRICARE. Increased mobilizations of reservists and successive legislative changes that have increased reservists' and their dependents' eligibility for TRICARE have complicated DOD's efforts to educate reservists about TRICARE. DOD's primary educational tools are the TRICARE briefings provided at mobilization sites and demobilization sites. According to DOD officials, these days of training are often so full of critical information that it is difficult for reservists to absorb all of the details of TRICARE. These briefings also occur at a time when a reservist may have already been eligible for TRICARE for up to 90 days without realizing it. These briefings are supplemented by family support programs, Web sites, toll-free customer assistance numbers, and print materials. DOD officials recognize the need to improve TRICARE education, but do not plan to provide additional TRICARE briefings for reservists and their dependents. When reservists used TRICARE, most reported that they were satisfied with TRICARE, although some reported experiencing difficulties. Over 60 percent of reservists who used TRICARE reported being satisfied. In addition, 70 percent of reservists thought TRICARE was either equal to or better than their civilian health insurance. However, according to DOD's and GAO's surveys, when reservists and their dependents did experience problems with TRICARE, a few of the most frequently reported problems include difficulties understanding TRICARE, establishing TRICARE eligibility, obtaining TRICARE assistance, and finding a health care provider that accepts TRICARE.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-195, Military Health: Increased TRICARE Eligibility for Reservists Presents Educational Challenges
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
February 2007:
Military Health:
Increased TRICARE Eligibility for Reservists Presents Educational
Challenges:
TRICARE Education for Reservists:
GAO-07-195:
GAO Highlights:
Highlights of GAO-07-195, a report to congressional committees
Why GAO Did This Study:
Since 2001, the number of reservists mobilized for active duty has
increased dramatically. Congress has expanded reservists‘ and their
dependents‘ eligibility for TRICARE, the Department of Defense‘s (DOD)
health insurance program. The National Defense Authorization Act (NDAA)
for Fiscal Year 2004 directed GAO to examine the health insurance
coverage of reservists and their dependents. This report (1) identifies
the extent to which reservists have civilian health insurance, (2)
examines DOD‘s efforts to educate reservists and their dependents about
TRICARE, and (3) describes reservists‘ level of satisfaction with
TRICARE and the types of problems reservists and their dependents
experienced when using it. To do this, GAO relied on interviews with
DOD and DOD‘s survey data. GAO also administered a survey of TRICARE
benefit assistance coordinators.
What GAO Found:
Eighty percent of mobilized reservists have civilian health insurance”a
rate similar to that of the U.S. population between 18 and 64 years
old. The number of reservists with civilian health insurance varies
among reservists, with older reservists and reservists of higher rank
having a greater rate of insurance than younger reservists and
reservists of more junior rank, and reservists with dependents being
more likely to have insurance than reservists without dependents.
Reservists and their dependents obtained coverage through a variety of
sources and over half of all reservists kept their civilian health
insurance during mobilizations, even though they were eligible to
enroll in TRICARE. Many reservists reported that they maintained their
civilian coverage to avoid disruptions associated with a change to
TRICARE and to ensure that their dependents could continue seeing their
current providers who might not accept TRICARE.
Increased mobilizations of reservists and successive legislative
changes that have increased reservists‘ and their dependents‘
eligibility for TRICARE have complicated DOD‘s efforts to educate
reservists about TRICARE. DOD‘s primary educational tools are the
TRICARE briefings provided at mobilization sites and demobilization
sites. According to DOD officials, these days of training are often so
full of critical information that it is difficult for reservists to
absorb all of the details of TRICARE. These briefings also occur at a
time when a reservist may have already been eligible for TRICARE for up
to 90 days without realizing it. These briefings are supplemented by
family support programs, Web sites, toll-free customer assistance
numbers, and print materials. DOD officials recognize the need to
improve TRICARE education, but do not plan to provide additional
TRICARE briefings for reservists and their dependents.
When reservists used TRICARE, most reported that they were satisfied
with TRICARE, although some reported experiencing difficulties. Over 60
percent of reservists who used TRICARE reported being satisfied. In
addition, 70 percent of reservists thought TRICARE was either equal to
or better than their civilian health insurance. However, according to
DOD‘s and GAO‘s surveys, when reservists and their dependents did
experience problems with TRICARE, a few of the most frequently reported
problems include difficulties understanding TRICARE, establishing
TRICARE eligibility, obtaining TRICARE assistance, and finding a health
care provider that accepts TRICARE.
What GAO Recommends:
GAO recommends that DOD provide additional TRICARE briefings to
reservists and their dependents during regular training or when they
are first notified of mobilization. DOD partially concurred, agreeing
that briefings should occur when members are first informed of
mobilization, but disagreeing that briefings are needed during other
periods. GAO continues to believe that such briefings would be
effective.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-195].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marcia Crosse at (202)
512-7119 or crossem@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Most Reservists Have Civilian Health Insurance, and Many Reservists
Choose to Maintain Their Civilian Insurance When Mobilized:
DOD Is Challenged by the Task of Educating Reservists and Their
Dependents about TRICARE:
Most Reservists Are Satisfied with Their TRICARE Benefits, but Some
Reservists Experience Difficulties Using TRICARE:
Conclusions:
Recommendation:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Selected Legislation Pertaining to TRICARE Eligibility for
Reservists:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Selected TRS Eligibility Criteria and Premiums for Selected
Reservists as of October 1, 2006:
Table 2: TRICARE Options Available to Reservists and Their Dependents:
Figures:
Figure 1: Periods of TRICARE Eligibility for Mobilized Reservists and
their Dependents, as of July 2006:
Figure 2: Sources of Reservists' and Their Dependents' Health
Insurance, Prior to Mobilization, 2003:
Figure 3: Reservists' Knowledge about Various Aspects of TRICARE:
Figure 4: Comparison of Specific Aspects of Reservists' TRICARE Health
Insurance to Civilian Health Insurance:
United States Government Accountability Office:
Washington, DC 20548:
February 12, 2007:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Minority Member:
Committee on Armed Services:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable Duncan L. Hunter:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives:
Since the September 11, 2001, terrorist attacks, the Department of
Defense (DOD) has increased its reliance on reservists to support the
global war on terrorism, and particularly Operations Enduring Freedom
and Iraqi Freedom.[Footnote 1],[Footnote 2] This has increased the
number of reservists supporting DOD's current operations and the
duration of reservists' active-duty service. In recent years, Congress
has increased the health care benefits available to mobilized
reservists and their dependents, which generally include family members
such as spouses and dependent children. Although all active-duty
military personnel must enroll in TRICARE, the military health
insurance program, reservists and their dependents have historically
been eligible for TRICARE only while the reservist was serving on
active duty for an extended period of time following
mobilization.[Footnote 3] The National Defense Authorization Acts
(NDAA) for Fiscal Years 2004, 2005, 2006, and 2007 expanded the number
of reservists and their dependents who are eligible for TRICARE, and
the duration of their eligibility. These expansions in eligibility
increased the number of reservists that DOD, working through the
reserve components, is required to educate about TRICARE. Reservists
who are mobilized for a period of more than 30 days become eligible for
TRICARE, as do their dependents. Those who have private health
insurance that covers their dependents may choose to cancel that
coverage and switch to TRICARE or continue that coverage.
The increased dependence on reservists in recent years has raised
questions by some members of Congress as to whether reservists and
their dependents have adequate health insurance when they are not on
active duty and whether they have difficulty using TRICARE when they
are eligible for it. The NDAA for Fiscal Year 2004 directed that we
study the health insurance coverage of reservists and their dependents,
DOD's efforts to provide assistance specifically to reservists and
their dependents to facilitate their access to and use of TRICARE
benefits, and reservists' and their dependents' experiences using
TRICARE.[Footnote 4] Specifically, as discussed with the committees of
jurisdiction, we (1) identified the extent to which reservists have
civilian health insurance, (2) examined DOD's efforts to educate
reservists and their dependents about TRICARE, and (3) described
reservists' level of satisfaction with TRICARE and the types of
problems reservists and their dependents experienced when using
TRICARE.
To determine the extent to which reservists have civilian health
insurance coverage, we relied on the results of DOD's 2003 and 2004
Status of Forces Surveys of Reserve Component Members, the most recent
surveys that include questions about reservists' insurance
coverage.[Footnote 5] Through our review of the relevant documentation
and our discussion with DOD officials, we determined that the data
presented in the surveys were sufficiently reliable for our purposes.
We interviewed representatives from DOD's Office of Reserve Affairs,
the TRICARE Management Activity (TMA), Defense Manpower Data Center,
and each of the seven reserve components. We also reviewed reports from
the Congressional Research Service and Congressional Budget Office as
well as GAO's prior work on reservists and defense health care.
To examine DOD's efforts to educate reservists and their dependents
about TRICARE and to describe reservists' level of satisfaction with
TRICARE and the types of problems reservists and their dependents
experienced when using TRICARE, we interviewed over 100 reservists from
the Army National Guard and Navy Reserve. We selected these two groups
because they had large numbers of reservists demobilizing that we were
able to interview during the course of our work. We used these
interviews to validate and update information that we gathered from
DOD's 2003 and 2004 Status of Forces Surveys of Reserve Component
Members, the 2002 Survey of Spouses of Activated National Guard and
Reserve Component Members, and the 2000 Survey of Reserve Component
Members. We also developed and conducted our own survey of TRICARE
benefit counseling and assistance coordinators (BCAC). With the
assistance of DOD officials, we identified BCACs who had direct
experience providing TRICARE counseling and assistance to reservists
and their dependents. DOD officials said that because BCACs assist
reservists and their dependents with problems using TRICARE, they could
provide us with perspective on the types of problems that reservists
experience.
For a complete discussion of our scope and methodology, see appendix I.
We conducted our work from October 2005 through December 2006 in
accordance with generally accepted government auditing standards.
Results in Brief:
Most reservists have civilian health insurance and many of them choose
to maintain this insurance for their dependents during mobilizations.
Prior to being mobilized, 80 percent of reservists had civilian health
insurance--a rate similar to that of comparable groups within the U.S.
population between 18 and 64 years old. Reservists higher in age and
rank are more likely to have health insurance than their junior
counterparts. Reservists with dependents are also more likely to have
insurance than those that do not have dependents. Reservists obtained
coverage through a variety of sources, and some reservists had more
than one source of coverage. The most common sources of health
insurance were the reservists' employer-based health plans and their
spouses' employer-based health plans. Over half of all reservists kept
their civilian health insurance for their dependents during their most
recent mobilizations, even though they were eligible to receive
coverage under TRICARE with no associated premiums.
DOD is challenged by the task of educating reservists and their
dependents about TRICARE, and many reservists and dependents consider
themselves to be ill-informed about it. Increased mobilizations of
reservists and successive legislative changes that have increased
reservists' eligibility for TRICARE have complicated DOD's efforts to
educate reservists about TRICARE. According to the 2003 Status of
Forces Survey, fewer than 20 percent of all reservists said that they
and their dependents are well informed about TRICARE. In the 2004
Survey, approximately 41 percent of reservists reported that their
dependents did not use TRICARE because of its complexity. Fifty-eight
percent of TRICARE BCACs that responded to our survey said that
reservists' ability to understand TRICARE is the biggest problem they
face. DOD's primary educational tools are TRICARE briefings provided to
reservists at mobilization sites just prior to being deployed to the
location of their active-duty service, and at demobilization sites when
they return. These briefings are supplemented by family support
programs, Web sites, toll-free customer assistance numbers, and print
materials. TRICARE officials have noted that education could be
improved for reservists by providing additional TRICARE briefings at
times when reservists are not being mobilized or demobilized because
reservists are distracted by other concerns during these times. They
have also suggested targeting additional TRICARE education to
dependents. DOD officials recognize the need to improve TRICARE
education, but do not plan to provide additional TRICARE briefings for
reservists and their dependents.
A majority of reservists report that they are satisfied with their
TRICARE benefits; however, some reservists have experienced
difficulties when using TRICARE. When we interviewed reservists, over
half reported satisfaction with TRICARE, which was consistent with data
from DOD's 2003 Status of Forces Survey in which over 60 percent of the
reservists who used TRICARE reported being satisfied with it.
Additionally, the 2004 Status of Forces Survey showed that 70 percent
of reservists thought TRICARE was either equal to or better than their
civilian health insurance. However, the survey also showed that when
reservists and their dependents experienced problems related to
TRICARE, among the most commonly reported difficulties was a general
lack of understanding about TRICARE. Other difficulties included
establishing TRICARE eligibility, obtaining TRICARE assistance, and
finding a health care provider that accepts TRICARE. DOD officials we
interviewed said they believed that some of these difficulties stemmed
from problems with the recording of reservists' eligibility for
TRICARE, which is done by reserve component administrative personnel
rather than TMA personnel. Therefore, a reservist who was not properly
registered in DOD's system for recording eligibility might seek
assistance from a TRICARE BCAC, who would be unable to assist the
reservist with his or her problem, rather than the administrative
personnel who could assist with such problems.
In light of the increasing number of reservists that are eligible for
TRICARE, and reservists' continued concerns that they are ill-informed
about TRICARE, we recommend that the Secretary of Defense improve
TRICARE education for reservists and their dependents by providing
additional TRICARE briefings at times other than at mobilization and
demobilization, or at the time that reservists are first informed of
their impending mobilization. In commenting on this recommendation, DOD
agreed that TRICARE information should be provided to reservists and
their dependents when they are first informed of a pending mobilization
of the member; however, it disagreed that TRICARE briefings should be
provided at other times. DOD stated that training time is limited
during training periods not associated with mobilization and must be
prioritized to maximize its value. We understand the importance for DOD
to effectively use limited training time. However, we continue to
believe that providing TRICARE briefings whenever time becomes
available during reservist training periods--a time when reservists are
not distracted by other concerns associated with mobilization--would be
an effective way to help ensure that reservists are aware of the most
current information about TRICARE.
Background:
Since the end of the cold war, there has been a change in the way
reserve forces have been used in military operations. During the cold
war era, the reserve components were a manpower tool that was rarely
tapped. For example, from 1945 to 1989, reservists were mobilized by
the federal government only four times, an average of less than once
per decade. Since 1990, reservists have been mobilized by the federal
government six times, an average of nearly once every 3 years, and have
been used extensively to support operations in the global war on
terrorism. Since September 11, 2001, about 500,000 reservists have been
mobilized, primarily to support operations in Afghanistan and
Iraq.[Footnote 6] This increased use of the reserves has led to greater
congressional interest in the types of benefits provided to reservists,
including the health insurance provided to reservists and their
dependents under TRICARE. Specifically, advocates for expanding TRICARE
have suggested that increasing reservists' access to TRICARE could
improve the medical readiness of reservists by facilitating early
detection and treatment of medical conditions which otherwise might
disqualify a reservist from deploying. Additionally, increased access
to TRICARE could smooth the transition to and from active duty for
reservists and their dependents, an important factor given the
increased mobilizations of reservists.
Health Insurance Protections for Reservists:
Reservists' private health insurance coverage is protected by the
Servicemembers Civil Relief Act (SCRA)[Footnote 7] and the Uniformed
Services Employment and Reemployment Rights Act of 1994
(USERRA).[Footnote 8] Included in these acts are protections for
reinstating and maintaining reservists' health insurance. Specifically,
when a reservist whose individual coverage was terminated while the
reservist was on active duty returns from that duty, SCRA requires
private insurance companies to reinstate coverage at the premium rate
the reservist would have been paying had coverage not been
terminated.[Footnote 9] It also requires insurance companies to cover
most preexisting conditions after a reservist's insurance is
reinstated.[Footnote 10] USERRA allows reservists to elect to keep
employer-provided health benefits while the reservists are absent from
employment due to active duty, up to a maximum period of 24 months. For
absences of 30 days or less, the employer must continue to pay its
share of the premium. For absences of 31 days or more, the reservist
may elect to continue the civilian coverage, but the employer may
charge the reservist the full premium, including the employer
contributions.[Footnote 11] In addition, under USERRA, employers must
generally reinstate reservists' health coverage upon their reemployment
and no waiting period or exclusions may be imposed in connection with
that reinstatement.[Footnote 12] The protections found in SCRA and
USERRA also apply to the health benefits of a reservist's dependents,
if those dependents were covered under the reservist's policy prior to
his or her active-duty service.
Expanded TRICARE Eligibility for Reservists and Their Dependents:
Prior to fiscal year 2004, reservists that were not on active duty had
limited eligibility for TRICARE. Specifically, they were entitled to
receive treatment through TRICARE at a military medical facility for
illnesses or injuries incurred during training or periods of active
duty. Family members of reservists had generally not been entitled to
use TRICARE, but became eligible if the reservist was serving on active
duty for more than 30 days.
Beginning in fiscal year 2004, Congress made successive changes to
TRICARE that included several provisions which significantly expanded
access to TRICARE for reservists that are not on active duty, and their
dependents. (For a detailed description of the legislative changes that
expanded the TRICARE eligibility of reservists, see app. II.) The NDAA
for Fiscal Year 2004[Footnote 13] included a temporary provision in
which Congress authorized members of the Selected Reserve and the
Individual Ready Reserve to enroll in TRICARE if the reservists were
eligible for unemployment compensation or ineligible for health care
coverage from their civilian employer.[Footnote 14] Another temporary
provision allowed reservists who had received their active-duty orders
to use TRICARE for up to 90 days before their active-duty service
began. A third temporary provision extended the length of time that
service members could use TRICARE under the Transitional Assistance
Management Program (TAMP) to 180 days after they were released from
active duty.[Footnote 15]
The NDAA for Fiscal Year 2005[Footnote 16] indefinitely extended the
provisions that provided up to 90 days of TRICARE coverage to
reservists prior to the beginning of active-duty service and 180 days
after.[Footnote 17] It also authorized the program that DOD has named
TRICARE Reserve Select (TRS), which makes TRICARE coverage available
for purchase by certain reservists after their TAMP coverage ends. As
originally authorized, TRS provided the option of purchasing TRICARE
coverage to members of the Selected Reserve who were mobilized since
September 11, 2001, and who continuously served on active duty for 90
days or more in support of a contingency operation.[Footnote 18] To
qualify for TRS, reservists had to enter into an agreement with their
respective reserve components to serve in the Selected Reserve for the
number of years that they wished to participate in TRS. They could
receive 1 year of coverage for each 90-day period of this qualifying
service.[Footnote 19] Electing to enroll in this TRS program was a one-
time opportunity, and as originally authorized, the program required
reservists to sign the new service agreement and register for TRS
before leaving active duty.[Footnote 20] Figure 1 describes the various
periods of TRICARE eligibility for mobilized reservists and their
dependents.
Figure 1: Periods of TRICARE Eligibility for Mobilized Reservists and
their Dependents, as of July 2006:
[See PDF for image]
Source: GAO.
[A] For a reservist to qualify for TRICARE, the active-duty order must
be for a period of over 30 days.
[B] The reserve component will validate eligibility.
[End of figure]
The NDAA for Fiscal Year 2006[Footnote 21] further expanded the number
of reservists and dependents eligible to participate in the TRS
program. Under the expanded program, which became effective on October
1, 2006, almost all reservists and dependents--regardless of the
reservist's prior active-duty service--have the option of purchasing
TRICARE coverage. Similar to the original TRS program, members of the
Selected Reserve and dependents choosing to enroll in the expanded TRS
program must pay a monthly premium to receive TRICARE coverage. The
premium paid by reservists and their dependents for coverage varies
based on certain qualifying conditions that must be met, such as
whether the reservist has access to an employer-sponsored health plan.
Those who would have been eligible under the original TRS program
because they have qualifying service in support of a contingency
operation pay the lowest premium. In addition, those reservists with
qualifying service in support of a contingency operation would now have
up to 90 days after leaving active duty to sign the new service
agreement required to be eligible for this lowest premium tier. Table 1
describes the Selected Reservists who are eligible to purchase TRS and
the associated premiums.
Table 1: Selected TRS Eligibility Criteria and Premiums for Selected
Reservists as of October 1, 2006:
Eligibility criteria: Tier 1: Reservist must have qualifying active-
duty service in support of a contingency operation on or after
September 11, 2001, for at least 90 days, and must maintain Selected
Reserve[C] status for each year of TRS coverage purchased;
Percentage of TRICARE premium paid by the reservist[A]: 28;
Monthly TRICARE premium cost for calendar year 2006[B]: TRS member
only: $81.00;
Monthly TRICARE premium cost for calendar year 2006[B]: TRS member and
family: $253.00;
Duration of coverage: 1 year of coverage for each continuous 90 days of
qualifying service.
Eligibility criteria: Tier 2: Reservist must not be eligible for
employer-sponsored health insurance; or must be eligible for
unemployment compensation, or self-employed; must renew service
agreement and maintain Selected Reserve status for each year of TRS
coverage purchased;
Percentage of TRICARE premium paid by the reservist[A]: 50;
Monthly TRICARE premium cost for calendar year 2006[B]: TRS member
only: $145.29;
Monthly TRICARE premium cost for calendar year 2006[B]: TRS member and
family: $451.42;
Duration of coverage: Up to 1 year of coverage with an annual option to
renew.
Eligibility criteria: Tier 3: Reservist not eligible for Tier 1 or 2;
may be eligible for employer-sponsored insurance, but must renew
service agreement and maintain Selected Reserve status for each year of
TRS coverage purchased;
Percentage of TRICARE premium paid by the reservist[A]: 85;
Monthly TRICARE premium cost for calendar year 2006[B]: TRS member
only: $247.00;
Monthly TRICARE premium cost for calendar year 2006[B]: TRS member and
family: $767.41;
Duration of coverage: Up to 1 year of coverage with an annual option to
renew.
Source: GAO.
[A] The total amount of the premium is the amount determined by the
Secretary of Defense for Health Affairs, based on an appropriate
actuarial basis.
[B] DOD plans to recalculate the monthly premiums annually.
[C] The Selected Reserve component contains those units and individuals
considered essential to wartime missions. In 2005, 88 percent of
reservists were a part of the Selected Reserve.
[End of table]
The NDAA for Fiscal Year 2007 significantly restructured the TRS
program by eliminating the three-tiered premium structure.[Footnote 22]
This law provides that members of the Selected Reserve will be eligible
to purchase TRICARE coverage for themselves and their dependents at the
28 percent premium rate regardless of whether they have served on
active duty in support of a contingency operation.[Footnote 23] In
addition, eligibility at the 28 percent premium rate will not depend on
the length of a service agreement entered into following a period of
active-duty service. Instead, reservists will be eligible for TRS for
the duration of their service in the Selected Reserve. The law requires
DOD to implement these changes no later than October 1, 2007.
Defense Enrollment Eligibility Reporting System:
In order to use TRICARE, reservists must establish their own and their
dependents' eligibility in the Defense Enrollment Eligibility Reporting
System (DEERS)--the computerized database which DOD uses to store the
identity of active-duty members and reservists, and their dependents.
Proper registration in DEERS is necessary to use TRICARE. Reservists
are automatically registered in DEERS by reserve component
administrative personnel, but reservists must register their dependents
and ensure that those dependents are correctly entered into the
database. Although TRICARE is administered by TMA, reserve components'
administrative personnel record reservists' enrollment in DEERS and
resolve any DEERS-related problems.
TRICARE Options for Mobilized Reservists and Their Dependents:
Once determined to be eligible for TRICARE, mobilized reservists and
their dependents are able to choose among several TRICARE options.
These beneficiaries may obtain health care through DOD's direct care
system of military hospitals and clinics, commonly referred to as
military treatment facilities (MTF), or through DOD's system of
civilian providers. DOD uses managed care support contractors to
develop networks of civilian providers to complement the care available
in MTFs. Upon arriving at their final duty station, mobilized
reservists must enroll in TRICARE Prime, TRICARE's managed care option.
Their dependents may enroll in TRICARE Prime. If they do not enroll in
TRICARE Prime, they may receive care through TRICARE Standard,
TRICARE's fee-for-service option, or TRICARE Extra, TRICARE's preferred
provider option. While all beneficiaries may receive care on a space-
available basis at MTFs, TRICARE Prime enrollees have priority for care
at these facilities. Under TRICARE, the dependents of mobilized
reservists do not pay premiums for their health care coverage; however,
depending on the option chosen, they may be responsible for co-payments
and deductibles. Table 2 provides an overview of these options.
Table 2: TRICARE Options Available to Reservists and Their Dependents:
TRICARE plan option: Prime (managed care);
Providers[A]: Network providers;
Copayments: None;
Yearly deductible: None.
TRICARE plan option: Extra (preferred provider);
Providers[A]: Network providers;
Copayments: 15 percent of negotiated rate[B];
Yearly deductible: Annual deductibles may apply.
TRICARE plan option: Standard (fee-for-service);
Providers[A]: Non- network providers who will accept TRICARE rates;
Copayments: 20 percent of allowable charge[C];
Yearly deductible: Annual deductibles may apply.
Source: GAO analysis of TRICARE Web data.
[A] All beneficiaries may receive care at MTFs as space and
capabilities are available, but TRICARE Prime enrollees have priority
for care in MTFs.
[B] A negotiated rate is the rate that TRICARE has agreed to pay the
preferred provider.
[C] An allowable charge is the maximum amount TRICARE is allowed to
authorize for each procedure or service and is tied by law to
Medicare's allowable charges. See 10 U.S.C. § 1079(h). Non-network
providers are prohibited from billing beneficiaries more than 115
percent of the TRICARE allowable charge for a given procedure or
service.
[End of table]
Most Reservists Have Civilian Health Insurance, and Many Reservists
Choose to Maintain Their Civilian Insurance When Mobilized:
Most reservists have civilian health insurance, and over half of all
reservists choose to maintain their civilian health insurance during
mobilization. Prior to being mobilized, 80 percent of reservists had
civilian health insurance--a rate which is similar to that of the U.S.
population between 18 and 64 years old. Insurance coverage varies by
rank and age, with officers and senior personnel more likely to have
coverage than junior personnel. Reservists with dependents are also
more likely to have coverage than those that do not have dependents.
Reservists obtained coverage through a variety of sources, and some
reservists had more than one source of coverage. Even when reservists
were mobilized and eligible for TRICARE, over half opted to keep their
civilian health insurance for their dependents during their most recent
mobilization. As of December 2006, less than 3 percent of eligible
reservists had opted to enroll in TRS.
Reservists Covered by Health Insurance at Rates Similar to Those Found
in the General Population:
The percentage of reservists with health insurance--80 percent--is
similar to that of the U.S. population between 18 and 64 years old.
Insurance coverage for reservists varies by rank and age. According to
the 2003 Status of Forces Survey, officers and senior-enlisted
reservists were more likely to have health insurance than junior-
enlisted personnel. Ninety-one percent of officers and 87 percent of
senior-enlisted personnel, both of whom have an average age of over 37
years, reported having health insurance; 67 percent of junior-enlisted
reservists, with an average age of 25 years, reported having health
insurance.[Footnote 24]
Insurance coverage for reservists also varies between those with
dependents and those without dependents. For example, 87 percent of
reservists with dependents reported having civilian health insurance
prior to their most recent activation, while only 65 percent of
reservists without dependents reported having civilian health
insurance. Similarly, 91 percent of senior-enlisted reservists with
dependents had such insurance prior to their most recent mobilization,
compared with 70 percent of senior-enlisted personnel without
dependents.
The percentage of reservists with health insurance has remained
relatively consistent over time. In prior work we reported that in
2000, nearly 80 percent of all reservists had health insurance, and 60
percent of junior enlisted reservists had health insurance. Eighty-six
percent of reservists with dependents had health insurance and 63
percent of reservists without dependents reported having
insurance.[Footnote 25] Within the general population, there has been a
slight decrease in the number of individuals with health insurance over
the past 6 years: In 2000, 82 percent of the 18 to 64 year old
population had health insurance, as compared with 80 percent in 2005.
Reservists and their dependents obtained health insurance through a
variety of sources, and some had more than one source of insurance
coverage. Figure 2 shows the sources of reservists' and their
dependents' health insurance prior to mobilization. The primary source
of health insurance was civilian employers. About three-quarters of
reservists and their dependents were covered by their civilian
employers' health plan, and over one-quarter were also covered by their
spouses' civilian employer's health plan.
Figure 2: Sources of Reservists' and Their Dependents' Health
Insurance, Prior to Mobilization, 2003:
[See PDF for image]
Source: DOD's 2003 Status of Forces Survey.
Note: Margin of error within ± 2 percent.
Percentages total more than 100 because some survey respondents
reported more than one source of health insurance for themselves or
their dependents.
[End of figure]
Many Mobilized Reservists Choose to Maintain Civilian Coverage:
Although reservists are required to enroll in TRICARE and their
dependents become eligible for TRICARE when the reservists are
mobilized, most opt to maintain their civilian insurance for their
dependents during their active-duty service. According to the 2003
Status of Forces Survey, 52 percent of reservists maintained their
civilian employer's health insurance during their most recent
mobilization. The 2004 Status of Forces Survey found that 85 percent of
reservists reported that their civilian employer continued to pay at
least a portion of their insurance premium. According to the survey and
our interviews with DOD officials, many reservists maintained their
civilian health insurance to avoid disruptions associated with changing
to TRICARE and to ensure that their dependents could continue seeing
their current providers who may not accept TRICARE.
Relatively Few Reservists Have Enrolled in TRS:
On April 27, 2005, TRS became available to certain reservists returning
from active duty on contingency operations. In October 2006, TRS became
available to an expanded number of reservists based upon their health
insurance status. As of December 2006, less than 3 percent of eligible
reservists had enrolled in TRS. DOD officials reported that more than
485,000 reservists were eligible to enroll in TRS, and as of December
2006, over 11,000 reservists had enrolled themselves or their
dependents in TRS.[Footnote 26] DOD officials said that one reason for
the low enrollment rate may be the result of an enrollment process
which, until passage of the NDAA for Fiscal Year 2006, required
reservists to take the first step toward enrollment while they were
still on active duty. To become eligible to purchase coverage in TRS, a
reservist had to execute a service agreement to remain in Selected
Reserve status while still serving on active duty. This usually
occurred at a demobilization site. Officials told us that they believe
that a primary reason that reservists did not take this first step in
the enrollment process was that reservists were generally more focused
on returning to their families during this period than they were on
making decisions about their health insurance. The NDAA for Fiscal Year
2006 changed this requirement so that reservists have up to 90 days
from the end of their active-duty service to execute the service
agreement and the length of the agreement determines the time period of
their eligibility for TRS at the 28 percent premium. The NDAA for
Fiscal Year 2007 eliminated the service agreement requirement and,
under this law, eligibility for TRS will end only upon the termination
of the reservist's service in the Selected Reserve. Finally, some DOD
officials said that a lack of education about the program may also have
resulted in low participation rates.
DOD Is Challenged by the Task of Educating Reservists and Their
Dependents about TRICARE:
The increased number of reservists being mobilized and changing TRICARE
eligibility requirements for reservists have challenged DOD in its
efforts to educate reservists and their dependents about TRICARE.
Reservists have reported that they and their dependents are not well
informed about TRICARE, with less than 20 percent saying they were well
informed. The primary educational resources DOD relies on are the
TRICARE briefings provided by each reserve component to mobilized
reservists just prior to deployment, and those given at demobilization
sites when reservists return from deployment. These briefings are
supplemented by family support programs, Web sites, toll-free customer
assistance numbers, and print materials. DOD officials said that
education could be improved for reservists and their dependents by
providing TRICARE briefings to reservists at times not associated with
mobilization or demobilization, targeting TRICARE education for
dependents, and improving other existing educational resources. DOD has
worked to improve several of its tools for educating reservists about
TRICARE, but it currently has no plans to require that the reserve
components provide additional TRICARE briefings.
DOD Is Educating an Increased Number of Reservists and Dependents about
TRICARE:
Increased mobilizations of reservists and continuing changes to TRICARE
eligibility have increased the number of reservists and dependents that
DOD must educate about TRICARE. The terrorist attacks of September 11,
2001, marked the beginning of a substantial increase in the number of
reservists being mobilized and therefore eligible for TRICARE. From
1996 to 2001, DOD provided TRICARE education to approximately 10,000
mobilized reservists annually. Since the beginning of fiscal year 2002,
DOD has provided TRICARE education to about 125,000 mobilized
reservists annually, according to DOD officials.
Steadily expanding TRICARE eligibility for reservists has also placed
new challenges on DOD to continually update its educational programs.
These expansions (described in app. II) have required DOD to revise its
training materials, update its Web site, and retrain benefits
counseling and assistance coordinators to provide more current
information to reservists and their dependents. For example, the pre-
active duty benefits discussed earlier were expanded, from 30 days to
up to 90 days prior to the date active-duty service begins. TAMP, which
provides continued TRICARE coverage to reservists separating from
active duty, was extended from 60 days to 180 days. In fiscal year
2005, with the initial implementation of TRS, DOD developed new
educational materials to inform reservists and their dependents of
their new benefits. The NDAA for Fiscal Years 2006 and 2007 each
revised the provisions of TRS. In response to these requirements, DOD
updated its educational tools because the tools describing who is
eligible, what premiums they pay, and when they must register changed
with each revision.
Most Reservists and Their Dependents Are Not Well-Informed about
TRICARE:
Reservists reported that they and their dependents are not well
informed about TRICARE. TRICARE BCACs that responded to our survey in
2006 reported that the most commonly experienced problem that
reservists and their dependents face when using TRICARE is a poor
understanding of the program. According to DOD's 2003 Status of Forces
Survey, the last time DOD surveyed reservists about their knowledge of
TRICARE, less than 20 percent of all reservists believed that they were
well-informed about their TRICARE benefits.
These findings are consistent with our past work on civilian health
coverage of reservists and their dependents, and they indicate that DOD
has been challenged by the task of educating reservists about TRICARE
since at least 2000. In past work, we found that reservists and their
dependents that had dropped their private health insurance for TRICARE
reported problems understanding TRICARE. We concluded that they could
benefit from improved TRICARE education.[Footnote 27] Figure 3
illustrates data from DOD's 2003 Status of Forces Survey showing
reservists' opinions of how well-informed they felt about various
aspects of TRICARE. Reservists' two most frequently cited areas of
confusion included knowing which doctors participated in the TRICARE
provider network, and which services are covered by TRICARE.[Footnote
28]
Figure 3: Reservists' Knowledge about Various Aspects of TRICARE:
[See PDF for image]
Source: DOD's 2003 Status of Forces Survey.
Note: Margin of error within ± 2 percent.
[End of figure]
Surveys indicate a lack of awareness about DOD programs designed to
assist family members in learning about and using TRICARE. DOD
officials said that they were interested in reaching out to reservists'
dependents because they recognize that reservists' dependents,
specifically spouses, often play a major role in the family's
understanding and use of TRICARE. However, DOD's 2000 Survey of Reserve
Component Members indicated that fewer than 50 percent of the spouses
of mobilized reservists were aware of the family support programs
designed to assist them in understanding and using TRICARE. The 2002
survey showed that fewer than 10 percent of spouses used these
programs.
DOD Uses a Variety of Tools to Educate Reservists and Their Dependents
about TRICARE:
DOD relies on a several methods to educate reservists and their
dependents about TRICARE. TRICARE briefings by each reservist's reserve
component are the primary tool DOD uses to educate reservists about
TRICARE. The briefings generally occur when a reservist is mobilized
and when the reservist returns from a mobilization. However, many DOD
officials and TRICARE BCACs have said that this is not an ideal time
for reservists to initially learn about TRICARE. According to DOD
officials, these days of training are often so full of critical
information that it is difficult for the reservist to absorb all of the
details of TRICARE. These briefings also occur at a time when a
reservist may have already been eligible for TRICARE for up to 90 days
without realizing it.[Footnote 29] Similarly at demobilization sites,
where reservists are debriefed upon returning from theater, officials
tell us that many reservists are focused on returning home to their
families rather than learning the details of their TRICARE benefits. In
addition, briefings at mobilization and demobilization sites typically
do not include reservists' dependents.
Family support programs designed to educate reservists' dependents
about TRICARE are used by most of the reserve components, including the
National Guard, Air Force, Army, Navy, and the Marines. DOD officials
said that these programs are important because reservists' dependents
often play a major role in understanding and using reservists' TRICARE
benefits. Family support programs are intended to increase knowledge
about a variety of military benefits, including TRICARE. For example,
the Air Force Reserve Command provides TRICARE information and
assistance at family support offices. In order to provide the most
current information to reservists and their dependents, personnel at
these locations are educated regularly about new programs that affect
reservists. Similarly, the National Guard Bureau has established family
assistance centers that provide support for dependents of deployed
soldiers in the National Guard and other reserve components, as well as
assistance for demobilizing soldiers. However, reservists have reported
a lack of awareness about these programs and fewer than 10 percent of
reservists' spouses said they took advantage of these programs.
DOD relies on other educational resources such as the TRICARE Web site,
toll-free customer assistance phone numbers, the use of BCACs, and
print materials sent directly to reservists and their dependents.
However, most of these resources are helpful only to reservists and
their dependents that actively seek TRICARE information; they do not
reach out to reservists that are not already pursuing the information.
In a survey administered by DOD in 2005, a third of reservists cited
the TRICARE Web site as their primary source of information when they
seek assistance. However, DOD officials acknowledged that the site was
cumbersome, with a satisfaction rate of less than 60 percent. DOD
reported in January 2006 that its TRICARE Web site contained over
538,000 pages of content and over 300 subsites.[Footnote 30]
In DOD's 2005 survey, close to 13 percent of reservists cited a
preference for obtaining assistance from toll-free customer assistance
numbers. However, as of December 2006, the TRICARE Web Site listed at
least 25 different toll-free customer assistance numbers. This doesn't
include any toll-free numbers that each reserve component might have
available. This large number of TRICARE customer service numbers
confuses beneficiaries. TRICARE users ranked phone and electronic
sources of information as the most difficult to use. DOD's
Communications and Customer Service Group acknowledged that such a
multitude of customer assistance numbers is sometimes not helpful.
Finally, less than 3 percent of reservists said that they rely on print
materials such as newspapers and newsletters. Although DOD has updated
some of its print materials with information about TRS, these materials
are not reaching all reservists. DOD said that the reserve components'
administrative personnel update the file of reservists' addresses in
DEERS when notified by the member, but incorrect addresses remain for
approximately 10 percent of reservists. According to DOD officials,
this results in approximately 10 percent of TRICARE mailings being
returned to sender as misdirected mail.
Individual reserve units also provide TRICARE education to their
members. This is sometimes a reservist's primary source of information
about his or her TRICARE benefits. However, DOD officials said the
quality of this information can vary greatly across units and depends
largely on the individuals charged with providing the information.
DOD Officials Recognize the Need for Improved TRICARE Education:
DOD officials recognize that TRICARE education could be improved, but
they currently do not plan to require that the reserve components
provide additional TRICARE briefings. DOD officials have suggested that
TRICARE education could be made more effective by supplementing the
TRICARE briefings provided at mobilization and demobilization sites
with annual briefings during training periods when reservists are not
being mobilized and are therefore better able to focus on the material
covered in the briefing. DOD officials said that briefings at
mobilization sites are a logical time to remind reservists of their
available TRICARE benefits, but this is not the best time to expose
reservists to TRICARE information for the first time. However, as of
July 2006, DOD had no plans to require reserve components to increase
the number of TRICARE briefings they provide to reservists or change
the time that they provide them.
Half of the TRICARE BCACs that responded to our survey said that
education should be improved. Some suggested targeting additional
education to dependents of mobilized reservists. Other DOD officials
agreed and said that the spouses of reservists are generally
responsible for the family's health care decisions when the member is
mobilized, so dependents should therefore be a focus of DOD's
educational efforts. However, DOD officials we interviewed noted that
when dependents are invited to briefings they often do not attend. They
said that publicizing information to families could be a challenge, but
suggested that reservists and their families also bear some
responsibility for being aware of these programs.
In November 2006, DOD launched a redesigned TRICARE Web site and TMA
has plans to reduce the number and redundancy of pages on the Web site.
DOD officials acknowledge that they have inaccurate addresses on file
for some reservists. They continue to send reminders to reservists to
keep the information in DEERS current, but they expect there will
always be a number of incorrect addresses on file.
Most Reservists Are Satisfied with Their TRICARE Benefits, but Some
Reservists Experience Difficulties Using TRICARE:
A majority of reservists report that they are satisfied with their
TRICARE benefits; however, some reservists have experienced
difficulties when using TRICARE. According to our interviews with
reservists and DOD's most recently available data, over half of the
reservists who used TRICARE were satisfied with it. Additionally, 70
percent of reservists thought that TRICARE was either equal to or
better than their civilian health insurance. However, when reservists
did experience problems with TRICARE, the most commonly reported
difficulties were (1) a general lack of understanding about the TRICARE
program, (2) establishing TRICARE eligibility, (3) obtaining TRICARE
assistance, and (4) finding a health care provider. DOD officials said
they believed that some of these problems stemmed from difficulties
reservists encounter in establishing their eligibility in DEERS, which
is done through reserve component administrative personnel.
Registration in DEERS is necessary for reservists and their dependents
to use TRICARE. The officials we interviewed observed that helping
reservists understand their benefits, establishing reservists'
eligibility for TRICARE, and addressing specific concerns is
complicated because responsibility for resolving problems is divided
across organizational units. TRICARE is administered by TMA, but
recording reservists' eligibility in DEERS is managed by each reserve
component's administrative personnel.
Most Reservists Are Satisfied with TRICARE:
In our interviews with over 100 reservists, we found that over half
reported that they were satisfied with their TRICARE benefit. This was
also supported by DOD's 2004 Status of Forces Survey, which showed that
70 percent of reservists thought TRICARE was either equal to or better
than their civilian health insurance plans. DOD's 2003 Status of Forces
Survey showed that over 60 percent of the reservists who used TRICARE
reported being satisfied with their own TRICARE benefits and with their
dependents' TRICARE benefits. Only 20 percent of reservists reported
dissatisfaction with the benefits in the 2003 Status of Forces Survey.
Figure 4 illustrates how specific aspects of TRICARE compared with
reservists' civilian health insurance.
Figure 4: Comparison of Specific Aspects of Reservists' TRICARE Health
Insurance to Civilian Health Insurance:
[See PDF for image]
Source: DOD's 2004 Status of Forces Survey.
Note: Margin of error within ± 2 percent.
Percentages may not total 100 due to rounding.
[End of figure]
Some Reservists and Their Dependents Experienced Difficulties When
Using TRICARE:
Some reservists and their dependents experienced difficulties when they
used TRICARE. Our surveys of BCACs and interviews with reservists and
DOD officials indicated that when reservists experienced difficulties
using TRICARE, the most common difficulties included a lack of
knowledge about TRICARE benefits, problems establishing TRICARE
eligibility, obtaining TRICARE assistance, and finding medical
providers. These findings were consistent with data from DOD's 2003
Status of Forces Survey.
Understanding Benefits:
Fifty-eight percent of the TRICARE BCACs that responded to our survey
reported that the biggest problem reservists and their dependents faced
when using TRICARE is their ability to understand TRICARE. Many
reservists and their dependents lack a basic understanding of TRICARE.
According to the 2004 Status of Forces Survey, about 41 percent of
reservists reported that their dependents did not use TRICARE insurance
because of the complexity of TRICARE. Some BCACs said that reservists
and their dependents continue to experience difficulties understanding
the complexity of the various options, knowing which benefits are
covered, understanding the referral process and authorizations
required, and the changing enrollment requirements. For example,
enrollment requirements change throughout the periods before, during,
and after a reservist's active-duty service. Dependents of reservists
who have been ordered to active duty for a period of more than 30
consecutive days may enroll in TRICARE Prime if they wish to be covered
by that option. Dependents enrolled in TRICARE Prime must then re-
enroll to continue TRICARE Prime coverage during their TAMP period when
the reservist returns from active duty. However, dependents using
TRICARE Extra and TRICARE Standard are not required to re-enroll to
receive TAMP benefits. Access to TRICARE could be impaired if
reservists and their dependents fail to adhere to the changing
enrollment requirements.
Establishing Eligibility:
Establishing eligibility for TRICARE in the DEERS database--DOD's
computerized database used to record TRICARE eligibility--has been
problematic for many reservists and their dependents. Almost half of
the BCACs that responded to our survey said that the process for
establishing TRICARE eligibility in DEERS needed to be improved. DEERS
stores the identity of reservists, dependents, and others who are
entitled to TRICARE benefits as well as their dates of eligibility.
BCACs that we surveyed and other DOD officials said that many
reservists and their dependents are incorrectly entered into DEERS when
the reservists are mobilized. When reservists return from a
mobilization, they are required to update their status in DEERS and to
keep their dependents' information updated as well in order to receive
the benefits for which they are eligible. Reservists sometimes do not
do this. When DEERS is not properly updated, reservists or their
dependents might be denied medical care, or be charged incorrectly for
medical services. According to DOD officials we interviewed, dependents
of active-duty members also have problems with DEERS, but these
problems are accentuated for dependents of reservists because their
eligibility status can change more frequently.
DOD does not collect data on how many reservists and their dependents
experience problems with the information entered into the DEERS system.
However, DOD officials said that they believe that some of the problems
reservists face in using TRICARE, including the other problems
described in this report, stem from problems in their DEERS enrollment.
This problem is exacerbated by the fact that BCACs and other TMA staff
are not able to resolve reservists' problems with DEERS because each
reserve component's administrative personnel, rather than TMA, record
reservists' eligibility information in DEERS. Reservists often do not
realize that they need to seek assistance with DEERS from a different
office than that from which they would seek benefits assistance. For
example, a reservist who was not properly registered in DEERS might
seek assistance from a TRICARE BCAC, who would be unable to assist the
reservist with his or her problem, rather than the administrative
personnel who could assist with these problems.
Finding Assistance:
Almost a third of the BCACs that responded to our survey said that many
reservists and their dependents experience difficulties in obtaining
TRICARE assistance when problems or questions about TRICARE arise. Many
reservists do not have a designated TRICARE expert within their unit
and are not aware of the many resources available to assist them with
their TRICARE benefits. BCACs we surveyed also reported that when
reservists call for information, sometimes even unit-designated TRICARE
representatives are confused by reservists' benefits and cannot answer
beneficiary questions. Some BCACs responsible for assisting reservists
in using TRICARE do not have access to DEERS and are therefore unable
to provide accurate information about TRICARE eligibility to reservists
and their dependents.
Finding Medical Providers:
Over a quarter of the BCACs that responded to our survey reported that
finding a medical provider is one of the problems most commonly
experienced by reservists and their dependents when using TRICARE
benefits. Some DOD officials we spoke with also said that reservists
and their dependents experience difficulties finding medical providers
that accept TRICARE. However, other work we have done reviewing access
to care for TRICARE beneficiaries indicates that there are a large
number of TRICARE providers accepting new patients except where there
are few practicing providers in general, such as in geographically
remote areas.[Footnote 31] We could not determine whether reservists
that experienced difficulty finding TRICARE providers lived in
geographically remote areas.
Conclusions:
Changes to reservists' TRICARE eligibility have resulted in DOD having
to educate a growing number of reservists and their dependents about
their eligibility requirements and benefits under TRICARE. Despite
DOD's use of a variety of tools to educate reservists about TRICARE,
reservists, BCACs, and DOD officials continue to suggest that TRICARE
education could be improved by providing TRICARE briefings at times
other than when reservists are being mobilized or returning from
mobilizations. For example, reservists have other required training
periods during the year where a discussion of TRICARE benefits could be
a part of the program. In addition, while reservists and their
dependents become eligible for TRICARE up to 90 days before the
reservists' active-duty service begins, they might not learn of this
eligibility until the TRICARE briefing they receive at the mobilization
site. Despite this shortcoming, DOD has no plans to add additional
TRICARE briefings during times other than mobilization and
demobilization.
Recommendation:
We recommend that the Assistant Secretary of Defense for Health Affairs
improve TRICARE education for reservists and their dependents by
providing additional TRICARE briefings to reservists and their
dependents. These briefings could be provided to reservists during
training periods not associated with mobilizations or at the time that
reservists are first informed of their impending mobilization.
Agency Comments and Our Evaluation:
DOD provided written comments on a draft of this report. DOD partially
concurred with our recommendation, agreeing that information about
TRICARE should be provided to reservists and their family members when
they are first informed of a pending mobilization of the member or any
time a member is ordered to active duty or full-time National Guard
duty for more than 30 days. However, DOD did not agree that providing
additional briefings during periods not associated with mobilizations
would be beneficial. DOD's comments are reprinted in appendix III.
DOD noted that reservists' training time is limited and must be
prioritized to maximize its value. DOD further noted the difficulty in
holding the interest of an audience to describe a benefit for which
they are not yet eligible. DOD stated that it has provided an abundance
of information about TRICARE to reservists and their family members.
As we noted earlier, DOD has revised its training materials and updated
its Web site to provide more current information to reservists and
their dependents. However, our surveys and interviews with BCACs and
reservists indicate that these materials are not reaching all
reservists, but instead reach only those that actively seek TRICARE
information. Furthermore, we understand the importance for DOD to
effectively use limited training time. However, we continue to believe
that providing TRICARE briefings whenever time becomes available during
reservist training periods--a time when reservists are not distracted
by other concerns associated with mobilization--would be an effective
way to help ensure that reservists are aware of the most current
information about TRICARE.
DOD also provided technical comments, which we have incorporated where
appropriate.
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties. We
will also make copies available to others upon request. In addition,
the report is available at no charge on the GAO Web site at [Hyperlink,
http://www.gao.gov].
If you or your staff have questions about this report, please contact
me at (202) 512-7119. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
report. Another contact and staff acknowledgments are listed in
appendix III.
Signed by:
Marcia Crosse:
Director, Health Care:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
The National Defense Authorization Act (NDAA) for Fiscal Year 2004
directed that we study the health insurance coverage of reservists and
their dependents, DOD's efforts to provide assistance specifically to
reservists and their dependents to facilitate their access to and use
of TRICARE benefits, and reservists' and their dependents' experiences
using TRICARE.[Footnote 32] To do this, we (1) identified the extent to
which reservists have civilian health insurance, (2) examined DOD's
efforts to educate reservists and their dependents about TRICARE, and
(3) described reservists' level of satisfaction with TRICARE and the
types of problems reservists and their dependents experienced when
using TRICARE.
To determine the extent to which reservists had civilian health
insurance, we obtained data from the Department of Defense's (DOD) 2003
and 2004 Status of Forces Surveys of Reserve Component Members and
DOD's 2000 Survey of Reserve Component Members. We discussed the
limitations of the surveys with DOD officials and determined that the
survey data were reliable for our purposes. We did not independently
assess the reliability of DOD's data. To learn about the extent of
TRICARE benefits available to reservists and their dependents, we
reviewed pertinent legislation, regulations, documents, reports, and
information related to the TRICARE health benefits available to
activated reservists and their dependents. In addition, we interviewed
officials in the offices of the Assistant Secretary of Defense for
Reserve Affairs, the TRICARE Management Activity (TMA), the Defense
Manpower Data Center, and representatives of the seven reserve
components.[Footnote 33] We also interviewed members of selected
reserve military service organizations: the Enlisted Association of the
National Guard of the United States; the Reserve Officers Association
of the United States; and the Military Officers Association of America.
Finally, we reviewed and evaluated reports from the Congressional
Research Service and Congressional Budget Office as well as prior GAO
reports.
To examine DOD's efforts to educate reservists and their dependents
about TRICARE, we interviewed representatives from DOD's TMA, the
Office of Reserve Affairs, and each of the seven reserve components
about their efforts to educate reservists about TRICARE. We also
interviewed officials from outside stakeholder groups. We interviewed
over 100 reservists from the Army National Guard and the Navy Reserves.
We selected these two groups because they had large numbers of
reservists demobilizing that we were able to interview during the
course of our work. We used these interviews to validate and update
information that we had gathered from the various surveys that we used
as the basis of our work. We also reviewed DOD TRICARE Web sites and
other materials designed to inform servicemembers and their dependents
about TRICARE. We developed and administered a Web-based survey of
benefit counseling and assistance coordinators (BCAC) who respond to
problems encountered by reservists and their dependents when they use
TRICARE. With the assistance of DOD officials, we identified BCACs who
had direct experience providing TRICARE counseling and assistance to
reservists and their dependents. We received survey responses from 226
BCACs who were currently engaged in providing TRICARE counseling and
assistance. Because these 226 respondents were not selected at random
from a larger population of known BCACs, the information they provided
cannot be projected to any other BCACs. In addition, we reviewed our
prior work on reservists and military health care. We also used DOD's
2003 and 2004 Status of Forces Surveys of Reserve Component Members,
DOD's 2002 Survey of Spouses of Activated National Guard and Reserve
Component Members, and DOD's 2000 Survey of Reserve Component Members
to provide us with information about reservists' opinions about
TRICARE.
To describe reservists' level of satisfaction with TRICARE and the
types of problems reservists and their dependents experienced when
using TRICARE, we interviewed DOD officials as mentioned above, and we
relied on our own survey of BCACs. We used information from the
interviews of reservists as described above. We also obtained and
analyzed the results of the DOD's 2003 and 2004 Status of Forces
Surveys of Reserve Component Members.
Finally, the NDAA for Fiscal Year 2004 mandated that we describe DOD's
options for continuing civilian health care coverage while reservists
are mobilized. We did not address this part of the mandate in this
report because it was addressed in our October 19, 2005 report, Defense
Health Care: Health Insurance Stipend Program Expected to Cost More
Than TRICARE But Could Improve Continuity of Care for Dependents of
Activated Reserve Component Members (GAO-06-128R).
We performed our work from October 2005 through December 2006 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Selected Legislation Pertaining to TRICARE Eligibility for
Reservists:
Laws: National Defense Authorization Act for Fiscal Year 2004, Pub. L.
No. 108-136, §§ 702-704, 117 Stat. 1392, 1525-28 (2003);
Description: Contained a provision which allowed nonactivated members
of the Selected Reserve and the Individual Ready Reserve and their
family members to enroll in TRICARE if the member was eligible for
unemployment compensation or was ineligible for health care coverage
from his or her civilian employer.[A] Another provision allowed
reservists who had pending active-duty orders to use TRICARE for up to
90 days before their active-duty service began. A third provision
extended the length of time which service members, including
demobilized reservists, could use TRICARE after they had been released
from active duty to 180 days. These provisions were set to expire on
December 31, 2004.
Laws: Ronald W. Reagan National Defense Authorization Act for Fiscal
Year 2005, Pub. L. No. 108-375, §§ 701, 703, 706, 118 Stat. 1811, 1980-
84 (2004);
Description: Indefinitely extended the temporary provision passed in
2003 which allowed reservists with pending active-duty orders to use
the military health care system up to 90 days before their active-duty
service began. It also indefinitely extended the temporary provision
which extended the length of time which service members could use
TRICARE after they had been released from active-duty service to 180
days. This legislation did not extend the provision which authorized
TRICARE access for reservists who were eligible for unemployment
compensation or were ineligible for health care coverage from their
civilian employer; Another provision provided TRICARE Standard coverage
through a new program that DOD named TRICARE Reserve Select (TRS). This
was made available to reservists who had been activated for a period of
more than 30 days in support of a contingency operation on or after
September 11, 2001, and who agreed to continue serving in the Selected
Reserves after release from active duty. Under this provision,
reservists are eligible to purchase TRICARE coverage for themselves and
their family members for up to 1 year for each 90 days of active duty
served, or the number of full years for which they agreed to continue
service, whichever is less.[B] Reservists pay a monthly premium of 28
percent of the total amount determined by the Secretary of Defense on
an appropriate actuarial basis as being reasonable for coverage.
Laws: National Defense Authorization Act for Fiscal Year 2006, Pub. L.
No. 109-163, §§ 701-702, 119 Stat. 3136, 3339-42 (2006);
Description: Extended eligibility for TRICARE Standard to all Selected
Reserve component personnel. Those reservists who meet TRS requirements
established in the NDAA for Fiscal Year 2005 will continue to pay the
28 percent premium. Those who are eligible for unemployment
compensation, are self-employed, or who are not eligible for insurance
through an employer-sponsored plan will pay 50 percent. Those who do
not qualify for the two lower premium levels, such as those who are
eligible for employer-based insurance but prefer to enroll in TRICARE,
will pay 85 percent.
Laws: John Warner National Defense Authorization Act for Fiscal Year
2007, Pub. L. No. 109-364, §§ 701-702, 120 Stat. 2083 (2006);
Description: Restructures the TRS program by eliminating the three-
tiered premium structure. Establishes that reservists who are eligible
for the Federal Employees Health Benefit Plan are not eligible to
purchase TRICARE coverage. Under this provision, members of the
Selected Reserve will be eligible to purchase TRICARE coverage for
themselves and their dependents at the 28 percent premium rate
regardless of whether they have served on active duty in support of a
contingency operation. In addition, eligibility will not depend on the
length of a service agreement entered into following a period of active
duty; instead, reservists will be eligible for TRS for the duration of
their service in the Selected Reserve. DOD is required to implement
these changes by October 1, 2007.
Source: GAO.
[A] Under this temporary provision, eligible reservists would have been
required to pay a premium equivalent to 28 percent of the total amount
determined by the Secretary of Defense on an appropriate actuarial
basis as being reasonable for coverage. DOD did not implement this
provision before it expired on December 31, 2004, citing a lack of
authorized funds.
[B] Reservists who were ordered to active duty for a period of more
than 30 days, but served less than 90 continuous days due to an injury,
illness, or disease incurred or aggravated while deployed are eligible
for 1 year of TRICARE coverage under this provision.
[End of table]
[End of section]
Appendix III: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
1200 Defense Pentagon:
Washington, DC 20301-1200:
Health Affairs:
Jan 26 2001
Ms. Marcia Crosse:
Director, Defense Health Care:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
This is the Department of Defense (DoD) response to the GAO draft
report, "GAO-07-195, `Military Health: Increased TRICARE Eligibility
for Reservists Presents Educational Challenges,' dated December 22,
2006 (GAO Code 290492)."
Thank you for the opportunity to review and comment on the draft
report. The report provides an accurate summary of the new benefits now
offered to Reserve Component (RC) members and their families and
describes the Department's ongoing efforts to ensure that RC
beneficiaries are educated on their benefits and in a position to make
the best decisions regarding their health care coverage. The GAO offers
one recommendation in its report. The recommendation and the DoD
response are enclosed.
We agree that TRICARE information should be provided to RC members and
their families upon initial entry into the RC. Furthermore, we agree
that TRICARE information is essential when members are notified of
pending mobilization and they and their families soon become eligible
for TRICARE. We respectfully disagree, however, with the GAO comments
that TRICARE education could be provided during additional training
periods not associated with mobilization. There are numerous RC
training requirements, and annual training time is at a premium. Other
important training requirements must take priority during these
sessions. Also enclosed are several technical comments.
Again, thank you for the opportunity to provide these comments. My
points of contact for additional information are Lt Col James Whitton
at (703) 681-0039 and Mr. Gunther Zimmerman (Audit Liaison) at (703)
681-3492.
Sincerely,
Signed by:
William Winkenwerder, Jr., MD:
Enclosures:
As stated:
GAO CODE 290492/GAO-07-195:
"Military Health: Increased TRICARE Eligibility for Reservists Presents
Educational Challenges"
Department Of Defense Comments To The Recommendation:
Recommendation 1: The GAO recommended that the Assistant Secretary of
Defense for Health Affairs improve TRICARE education for Reservists and
their family members by providing additional TRICARE briefings to
Reservists and their family members. Such briefings could be provided
to Reservists during training periods not associated with mobilizations
or at the time that Reservists are first informed of their impending
mobilization. (Page 36/GAO Draft Report):
DOD Response: The Department partially concurs with this
recommendation. We concur that information about TRICARE should be
provided to Reservists and their family members when they are first
informed of the pending mobilization of the member. Moreover, this same
requirement should apply any time a member is ordered to active duty or
full-time National Guard duty for more than 30 days. These briefings
would be timed to coincide with the member and family becoming eligible
for TRICARE.
Because Guard and Reserve members perform duty infrequently, training
time is at a premium and any training must be prioritized in order to
maximize the limited training time available. Moreover, it is difficult
to hold the interest of an audience to describe a benefit for which
they are not eligible. An initial briefing upon entry into the Guard or
Reserve and when the member and family will soon be eligible for
TRICARE are appropriate.
There is an abundance of information about TRICARE that is available to
Reservists and their family members. The Department will continue to
support the ongoing education efforts by the Reserve Components and
their parent military departments by producing and providing current
and timely educational materials. The Department continues to explore
the most effective and efficient avenues to use in delivering this
information. In addition, DoD is exploring approaches to notify
Reservists if they become eligible for TRICARE up to 90 days before the
Reservist's active-duty service begins.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia Crosse, (202) 512-7119 or crossem@gao.gov:
Acknowledgments:
In addition to the contact named above, Thomas Conahan, Assistant
Director; Cathleen Hamann; Adrienne Griffin; Carolina Morgan; and
Suzanne Worth made key contributions to this report.
FOOTNOTES
[1] For the purposes of this report, the term reservist includes all
members of the seven reserve components. These reserve components are
the Army National Guard and the Air National Guard, as well as the Army
Reserve, the Naval Reserve, the Marine Corps Reserve, the Air Force
Reserve, and the Coast Guard Reserve.
[2] Operation Enduring Freedom, which began in October 2001, supports
combat operations in Afghanistan and other locations, and Operation
Iraqi Freedom, which began in March 2003, supports combat operations in
Iraq and other locations.
[3] Mobilization is the process by which the armed forces are brought
into a state of readiness for war or national emergency or to support
some other operational mission. In this report, we use the term
mobilization to refer to the process of calling up reserve components
for active-duty service. We use the term mobilized reservist to refer
to a reservist that has received his or her order to active duty.
[4] Pub. L. No. 108-136, § 705, 117 Stat. 1392, 1528-29 (2003).
[5] The Status of Forces Surveys are a series of surveys of reserve and
active-duty personnel that provide DOD with information for evaluating
and monitoring existing programs and policies. Each year, the Status of
Forces Survey includes different questions covering different issues.
The 2003 and 2004 surveys each asked reservists a different set of
health-related questions. We did not use the 2005 Status of Forces
Survey because it did not contain any health-related questions. The
2006 Survey was not available when we performed this work.
[6] In 2005, 88 percent of reservists were a part of the Selected
Reserve, which is one category of reservists. The Selected Reserve
contains those units and individuals considered essential to wartime
missions. The other reserve categories are the Individual Ready
Reserve, the Inactive National Guard, Standby Reserve, and Retired
Reserve.
[7] Pub. L. No. 108-189, 117 Stat. 2835 (2003) (codified at 50 U.S.C.
App. §§ 501-596). National Guard members are eligible for SCRA
protection only when they have been called to active duty for more than
30 days to respond to a national emergency declared by the President
and that active duty is supported by federal funds.
[8] Pub. L. No. 103-353, 108 Stat. 3149 (codified as amended at 38
U.S.C. §§ 4301-4334).
[9] The reservist's individual insurance premium may be increased
during the period between termination and reinstatement, but only to
the extent it would have been increased for other persons covered by
that insurance during that period.
[10] Preexisting conditions that are service connected are excluded
from coverage. For example, individual policies would not have to cover
injuries incurred in the line of duty that could be covered first by
DOD and then by the Department of Veterans Affairs. In addition,
preexisting conditions excluded during the original period of coverage
may also be excluded after reinstatement.
[11] For deployments of 31 days or more, USERRA permits the employer to
assess an additional 2 percent administrative fee if reservists elect
to continue with civilian insurance and pay the full premium, including
the employer share. The employer is not required to charge the full
premium or the 2 percent administrative fee and some employers continue
to pay some or all of the premium during the reservist's absence.
[12] Waiting periods or exclusions are permitted in cases where they
would have been in effect had coverage not been interrupted by the
reservist's absence and in cases where the illness or injury has been
incurred during or aggravated by the reservist's service.
[13] Pub. L. No. 108-136, 117 Stat. 1392 (2003).
[14] We use the term temporary provision to refer to statutory
requirements that are effective for a limited amount of time or have a
set expiration date.
[15] These three temporary provisions expired on December 31, 2004.
[16] Pub. L. No. 108-375, 118 Stat. 1811 (2004).
[17] Both the preactive-duty benefit and TAMP coverage are also
available for dependents of the reservists. See 32 C.F.R. §§
199.3(b)(5) and 199.3(e).
[18] A contingency operation is generally defined as an operation
designated by DOD as one in which members of the armed forces are or
may become involved in military actions against an enemy of the United
States or against an opposing military force, or an operation that
results in the call to active duty of members of the uniformed services
under any applicable provision of law during a war or national
emergency declared by the President or Congress. See 10 U.S.C. §
101(a)(13). Examples of contingency operations include Operations
Enduring Freedom and Iraqi Freedom.
[19] Reservists who were ordered to active duty for a period of more
than 30 days, but served less than 90 continuous days due to an injury,
illness, or disease incurred or aggravated while deployed, were
eligible for 1 year of TRICARE coverage under TRS as originally
authorized.
[20] Reservists who qualified could also obtain coverage for their
dependents by paying the appropriate premium.
[21] Pub. L. No. 109-163, 119 Stat. 3136 (2006).
[22] See Pub. L. No. 109-364, § 706, 120 Stat. 2083, (to be codified at
10 U.S.C. § 1076(d)).
[23] The law lists one exception. Members of the Selected Reserve who
are eligible for coverage under the Federal Employees Health Benefit
Plan will not be eligible to purchase TRICARE for themselves or for
their dependents.
[24] Age data provided by DOD as of October 2006. DOD categorizes
enlisted personnel as either junior enlisted (classified as E-1 to E-4)
or senior enlisted (classified as E-5 to E-9). The average age of
junior-enlisted Selected Reservists is 25 years old; the average age of
senior-enlisted Selected Reservists is 37 years old. The average age
for officers in Selected Reserve status is 39 years old.
[25] GAO, Defense Health Care: Most Reservists Have Civilian Health
Coverage but More Assistance Is Needed When TRICARE Is Used, GAO-02-829
(Washington, D.C.: Sept. 6, 2002).
[26] As of the end of April 2006, over 485,000 reservists had been
mobilized for a contingency operation. About 19 percent have served
more than once.
[27] GAO-02-829, p. 19.
[28] In 2005, DOD consolidated its TRICARE regions from 12 to 3, with a
similar reduction in the number of contractors responsible for
maintaining the network of physicians in each region. We did not
specifically assess the impact, if any, this has had on reservists but
it represents one more change that TRICARE has faced in educating
reservists about TRICARE.
[29] DOD officials said that while pre-active-duty benefits give
reservists up to 90 days of TRICARE coverage prior to the date their
active duty begins, reservists are rarely given 90 days notice of
upcoming active duty.
[30] TRICARE Conference, "Military Medicine: Transforming the Future"
(Washington, D.C.: Jan. 30-Feb. 2, 2006).
[31] GAO, Defense Health Care: Access to Care for Beneficiaries Who
Have Not Enrolled in TRICARE's Managed Care Option, GAO-07-48
(Washington, D.C.: Dec. 22, 2006).
[32] See Pub. L. No. 108-136, § 705, 117 Stat. 1392, 1528-29 (2003).
[33] The seven reserve components include the Army National Guard and
the Air National Guard, as well as the Army Reserve, the Naval Reserve,
the Marine Corps Reserve, the Air Force Reserve, and the Coast Guard
Reserve.
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