Military update: Some patients moving to keep Prime coverage
Stars and Stripes August 22, 2009
Retired Navy Corpsman Lloyd Tilch Sr., his wife, Debbie, and their chronically ill son, Cody, pulled up roots last month in Blythe, Calif., and moved into a rented house 110 miles away, closer to the Marine Corps base hospital at Twentynine Palms, Calif.
The Tilch family had to move — and had only 11 days to do so after opening a letter from their Tricare support contractor — to remain eligible for Tricare Prime, the military’s managed care network, said Debbie Tilch.
As many as 190,000 Tricare Prime enrollees across the United States have received similar letters. They advise that Tricare is enforcing a rule requiring beneficiaries enrolled in Prime at a military treatment facility (MTF) to seek a waiver, either from the MTF commander or Tricare Regional Office, if they live more than a 30-minute drive, or 40 miles, from the base.
Debbie sought a waiver for her family but was turned down. She faced a difficult choice: move her family within 30 minutes of Twentynine Palms by July 20 or see Prime coverage end on Oct. 1. Without Prime, the family would have to rely on Tricare Standard, the military’s more costly fee-for-service insurance option.
Many families who received these letters did get a waiver. Others were denied waivers but have decided to allow Prime enrollment to end rather than move families closer to a base. Debbie said her family has so many health problems that retaining Prime coverage outweighed her desire to stay in Blythe.
With Tricare Standard, her family’s out-of-pocket costs every year quickly would hit the $3,000 catastrophic cap that protects retirees. But more worrisome was the prospect that 11-year-old Cody, coping with "three life-threatening health issues," might lose access to Prime specialists who have been treating his epilepsy, diabetes and weakened heart for years.
No Tricare policy official was available to discuss the enforcement of the 30-minute rule across the Tricare system. Austin Camacho, spokesman for the Tricare Management Activity in Falls Church, Va., did explain in an e-mail that the decision, which was made in January, flowed out of a concern for assuring quality care to beneficiaries.
"The change was made after research confirmed a direct correlation between proximity of medical care and quality of medical care," Camacho wrote. "We determined that to optimize their health care, our beneficiaries need to have a primary care physician near their homes."
Debbie Tilch said that until last year she did have a primary care physician in Blythe. But this doctor and others she knows of, both in Blythe and in surrounding small towns, had their status as Prime care managers revoked by Tricare, in this case by the TriWest Health Alliance, managed care support contractor for the West Region. The company disputes this.
Tilch said last year she was forced to join a managed care network out of Twentynine Palms. At the time she got a waiver from the 30-minute commute rule. But last month, after getting the TriWest letter, she sought another waiver. This time it was denied. The Tricare support office on base told Tilch she would have to get a new address within 40 miles of base by July 20 or access to Prime would end Oct. 1. Tilch said she offered a nearby Post Office Box address but Tricare insisted on an actual residence.
Scott K. Celley, vice president of external affairs at TriWest, said enforcement of the waiver rule for commutes longer than 30 minutes are occurring across all Tricare regions. The purpose, as Tricare policy officials explained, "is to ensure that beneficiaries are accessing care within a reasonable distance of where they live so they are getting good quality care and can reach their providers in a reasonable period of time," Celley said.
Tilch said her Prime providers on base are terrific. But she doesn’t accept the notion that forcing beneficiaries to live nearer to base will result in more timely care or higher quality care. Cody still is being referred to specialists for his various ailments as far away as San Diego and Los Angeles, long commutes from either Blythe or Twentynine Palms.
In her view, Tricare is enforcing its 30-minute commute rule now to save money by forcing more retirees to use Standard.
It’s just not fair now for Tricare to force long-settled retirees to move nearer to base or lose access to promised benefits, Tilch said.
She said Cody is having three seizures a day, related in part to the stress of moving to a new community. Their rent in Twentynine Palms is double what it was in Blythe, she said. Moving expenses totaled $5,000 last month. Yet she still has to drive Cody to specialists more than 200 miles away.
Military beneficiaries, she said, deserve better than this.