	Background

DOD’s health care program—TRICARE—provides health care services to active duty military members and their dependents and military retirees and their dependents. Also, Medicare-eligible uniformed services retirees age 65 and over and their spouses, dependents and survivors are entitled to TRICARE benefits as of October 1, 2001—referred to as TRICARE For Life (TFL). Number of Program Participants and Program Costs Differ Significantly

As of June 2001, there were a total of 38 participants in ICMP-PEC whose services for the fiscal year were projected to cost about $6 million. PFPWD Is Accessible but Changes May Reduce Caseloads

Regional program managers generally agreed that PFPWD is meeting its goal of financially assisting disabled ADFMs with their special health care service and equipment needs. The 2001 Defense Authorization Act eliminated copayments for TRICARE Prime but not for PFPWD participants, effective April 1, 2001. Data are not available, however, on how many PFPWD participants are affected by the program’s $1,000 monthly benefit limit. ICMP-PEC and PFPWD Benefits Are Better Than or Comparable to Other Programs and Plans

Comparing ICMP-PEC’s unlimited home health and SNF benefits with Medicare and Medicaid showed that ICMP-PEC’s benefits are more generous. ICMP-PEC’s home benefit is up to 24 hours a day of skilled nursing care, 7 days a week. Currently, ICMP-PEC lacks a clearly enunciated purpose, well-defined eligibility criteria and benefits, and an efficient application process thereby impeding beneficiary access. Recommendations

To ensure that DOD’s active duty and retired beneficiaries and dependents with seriously disabling conditions can readily access needed services and equipment,we recommend that the Secretary of Defense direct the Assistant Secretary of Defense for Health Affairs to take the following actions aimed at improving ICMP-PEC:   clarify ICMP-PEC’s purpose, eligibility criteria, and service coverage and provide guidance to better equip regional program managers in administering the program and target groups in understanding it;   provide guidance on how the legislative changes made to ICMP-PEC since its inception are to be implemented; and   make needed improvements to TMA’s ICMP-PEC records to ensure that they capture the actual case-by-case cost data needed to properly plan and manage the current program.
What GAO Found

The military's health program--TRICARE--provides medical care to about 8.3 million active duty service members and retired beneficiaries and their dependents and survivors. The Department of Defense (DOD) also provides benefits for persons severely disabled by physical or mental problems through its Individual Case Management Program for Persons with Extraordinary Conditions (ICMP-PEC) and for less severely disabled active duty dependents through its Program for Persons with Disabilities (PFPWD). Recently, military families and advocacy groups have raised concerns about accessing ICMP-PEC benefits. Also, the DOD Authorization Act for 2001 entitled military retirees age 65 and older and their dependents and survivors to TRICARE benefits for life which may have caseload and cost effects on ICMP-PEC. As of June 2001, 38 ICMP-PEC participants were projected to receive $6 million in services in fiscal year 2001, Their annual per-case costs were projected to range from $13,000 to $382,000. ICMP-PEC now lacks a clear purpose, well-defined eligibility criteria and benefits, and an efficient application process. In contrast, PFPWD is an established program with well defined criteria and benefits that assist thousands of ADFMs with their special health care service and equipment needs. Also, before April 2001, PFPWD provided many services and equipment at modest cost to ADFMs with severe disabilities that were also available at higher copayments to less seriously disabled ADFMS under TRICARE Basics. Data are unavailable on how many PFPWD participants are affected by the program's $1,000 monthly benefit limit. A comparison of ICMP-PEC's home care benefit of up to 24 hours of skilled nursing care per day, seven days per week-and unlimited skilled nursing facility coverage with Medicare and selected Medicaid programs showed that ICMP-PEC's benefits are more generous.