DOD and VA Health Care
Access for Dual Eligible Beneficiaries
Gao ID: GAO-03-904R June 13, 2003
The Department of Defense (DOD) reported that under its current policy, beneficiaries eligible for both TRICARE and the Department of Veterans Affairs' (VA) health care (dual eligible beneficiaries) are not allowed to utilize the services offered by both health care systems for treatment for the same episode of care. For example, if a beneficiary experiences back pain and seeks treatment from VA, the beneficiary must then receive all care related to that back pain from VA. Should the beneficiary then decide to seek treatment for the back pain from TRICARE, any claims related to that care would be denied. According to DOD, this policy was established to ensure continuity of care for beneficiaries and to ensure that there was no duplication of care or of payments from TRICARE or VA. Under the policy, if beneficiaries are dissatisfied with the care provided by VA, they are unable to switch to TRICARE to receive services for the same episode of care. On April 16, 2003, DOD reported to the Congress on a proposal to change its policy and promulgate regulations for coordinating care between DOD and VA. As agreed, we focused our review on the reasonableness of DOD's process. To do so, we reviewed the report submitted to the Congress and TRICARE policies, and interviewed agency officials from DOD and VA. Our work was conducted in June 2003 in accordance with generally accepted government auditing standards.
DOD proposes to change its basic policy to enable dual eligible beneficiaries to access both systems for the same episode of care, thus ensuring full freedom of choice. DOD also proposes to pay for medically necessary care to the extent that such care would be covered by TRICARE. DOD's proposal appears reasonable, and it is in the process of developing regulations to implement it.
GAO-03-904R, DOD and VA Health Care: Access for Dual Eligible Beneficiaries
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June 13, 2003:
The Honorable John Warner:
Chairman:
The Honorable Carl Levin:
Ranking Minority Member:
Committee on Armed Services:
United States Senate:
The Honorable Duncan Hunter:
Chairman:
The Honorable Ike Skelton:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives:
Subject: DOD and VA Health Care: Access for Dual Eligible
Beneficiaries:
The Department of Defense (DOD) reported that under its current policy,
beneficiaries eligible for both TRICARE and the Department of Veterans
Affairs' (VA) health care (dual eligible beneficiaries) are not allowed
to utilize the services offered by both health care systems for
treatment for the same episode of care.[Footnote 1] For example, if a
beneficiary experiences back pain and seeks treatment from VA, the
beneficiary must then receive all care related to that back pain from
VA. Should the beneficiary then decide to seek treatment for the back
pain from TRICARE, any claims related to that care would be denied.
According to DOD, this policy was established to ensure continuity of
care for beneficiaries and to ensure that there was no duplication of
care or of payments from TRICARE or VA. Under the policy, if
beneficiaries are dissatisfied with the care provided by VA, they are
unable to switch to TRICARE to receive services for the same episode of
care.
Section 708 of the Bob Stump National Defense Authorization Act for
Fiscal Year 2003[Footnote 2] directed the Secretary of Defense to
establish a process for resolving issues related to patient safety and
continuity of care for beneficiaries who are concurrently eligible for
health care through DOD's TRICARE program and through VA. It also
required that the Comptroller General review and report on issues
related to dual eligibility.
On April 16, 2003, DOD reported[Footnote 3] to the Congress on a
proposal to change its policy and promulgate regulations for
coordinating care between DOD and VA. As agreed, we focused our review
on the reasonableness of DOD's process. To do so, we reviewed the
report submitted to the Congress and TRICARE policies, and interviewed
agency officials from DOD and VA. Our work was conducted in June 2003
in accordance with generally accepted government auditing standards.
DOD proposes to change its basic policy to enable dual eligible
beneficiaries to access both systems for the same episode of care, thus
ensuring full freedom of choice. DOD also proposes to pay for medically
necessary care to the extent that such care would be covered by
TRICARE. DOD's proposal appears reasonable, and it is in the process of
developing regulations to implement it.
An official with the TRICARE Management Activity reviewed a draft of
this letter and agreed the information in it is correct. We are sending
copies of this letter to the Secretary of Defense, appropriate
congressional committees, and other interested parties. We will provide
copies of it to others upon request. In addition, it is available at no
charge on the GAO Web site at http://www.gao.gov. If you or your staff
have any questions, please contact me at (202) 512-7101 or Michael T.
Blair, Jr., at (404) 679-1944.
Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
Signed by Cynthia A. Bascetta:
(290272):
FOOTNOTES
[1] According to DOD, an episode of care is generally accepted to be
all care related to a single injury or illness.
[2] Pub. L. No. 107-314, § 708, 116 Stat. 2458, 2585 (2002).
[3] Report to Congress: Department of Defense Plan for Coordinating
Care Between TRICARE and the Department of Veterans Affairs
(Washington, D.C.: April 2003).
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