1.) TRICARE’s Benefit Options

Prior to January 1, 2018, TRICARE provided benefits through three basic  options for its non-Medicare-eligible beneficiary population—TRICARE  Prime, Standard, and Extra. The NDAA 2017 made specific changes to the TRICARE program that  became effective on January 1, 2018. These changes included  terminating the TRICARE Standard and Extra options, establishing a new  option called TRICARE Select, and ensuring that 85 percent of TRICARE  Select beneficiaries are covered by the network of civilian providers. TRICARE Select has similar benefits to TRICARE Standard and Extra for  obtaining care from nonnetwork and network providers, but unlike these  options, TRICARE Select requires enrollment. 2.) Additionally, the NDAA 2008 required DOD to  consult with representatives of TRICARE beneficiaries and providers of  health care, including mental health care, to identify locations where  nonenrolled beneficiaries have experienced significant access-to-care  problems and to survey both beneficiaries and health care providers,  including mental health care providers, in these areas. Nationwide, a lower  percentage of nonenrolled beneficiaries reported that they experienced  problems finding any type of provider in the 2012-2015 survey (29  percent) when compared to the prior 2008-2011 survey (31 percent). 3.) 4.) Nonenrolled beneficiary survey results by network status. For example, 20 percent of the  nonenrolled beneficiaries who used a network civilian primary care  provider reported that they had a problem finding a primary care provider  that would accept TRICARE compared with the 44 percent of nonenrolled  beneficiaries who used a nonnetwork civilian primary care provider. In addition, when compared with the results of the last survey (2008- 2011), the percentages of nonenrolled beneficiaries who reported that  they experienced problems finding a specialty care or mental health care  provider increased in the most recent survey (2012-2015) for  beneficiaries who used nonnetwork providers, but there were no changes  over time if their specialty care or mental health care providers were in  the network. More Nonenrolled TRICARE Beneficiaries Reported Obtaining Appointments as Soon as Desired

Compared to the prior survey, a higher percentage of nonenrolled  beneficiaries reported that they were able to obtain appointments as soon  as they desired. Specifically, the percentage of nonenrolled beneficiaries  who made non-urgent appointments for health care and reported that  they were able to usually or always obtain an appointment as soon as  they thought they needed increased from 87 percent in the 2008-2011  survey to 90 percent in the 2012-2015 survey. Ratings of TRICARE compared to other federal health plans. When  we compared these results to those of the 2013-2015 CAHPS surveys,  we found that nonenrolled TRICARE beneficiaries’ positive experience  ratings for primary care providers and specialty care providers were lower  than those of Medicare fee-for-service beneficiaries and higher than those  of Medicaid beneficiaries, which is similar to what we found for the  previous survey. We also found that TRICARE beneficiaries’ positive  experience ratings for their health care were higher than that of both  Medicare fee-for-service beneficiaries and Medicaid beneficiaries, but  TRICARE beneficiaries’ positive experience ratings for their health plan  were lower than both of these groups. Civilian Providers’ Reported Awareness of TRICARE Has Generally Increased over Time, While Mental Health Providers’ Acceptance of New TRICARE Patients Has Decreased

		Civilian Providers’ Awareness of TRICARE Has Generally Increased over Time, with Network Providers Reporting Higher Awareness than Nonnetwork Providers

Provider awareness over time, by provider type and by location  type. Nationwide, a higher percentage of civilian providers reported that  they were aware of TRICARE in the 2012-2015 civilian provider survey  (84 percent) than those from the 2008-2011 civilian provider survey (82  percent). However, when we analyzed acceptance by provider  type, we found that the overall decrease was mainly attributable to a  decrease in mental health care providers’ acceptance rates, as primary  and specialty care providers’ acceptance rates remained unchanged. Among individual provider types, the biggest  difference in acceptance between network and nonnetwork providers was  for mental health care providers with 79 percent of network mental health  care providers reporting acceptance of new TRICARE patients compared  with 30 percent of nonnetwork mental health care providers. We identified five locations where access to specialty  care providers may be particularly problematic. Agency Comments

In reviewing a draft of this report, DOD concurred with our overall  findings.
Why GAO Did This Study

DOD provides health care, including mental health care, to eligible beneficiaries through TRICARE. Beneficiaries who use TRICARE Prime, a managed care option, must enroll to receive care. Prior to Jan. 1, 2018, beneficiaries did not need to enroll for TRICARE Standard, a fee-for-service option, or TRICARE Extra, a preferred provider organization option (referred to as nonenrolled beneficiaries). Although the TRICARE Standard and Extra options were terminated effective Jan. 1, 2018, the new TRICARE Select option has similar benefits for obtaining care from network and nonnetwork providers.
The National Defense Authorization Act (NDAA) for Fiscal Year 2008 directed DOD to conduct surveys of nonenrolled beneficiaries and civilian providers about access to care under the TRICARE Standard and Extra options. It also directed GAO to review the surveys' results. Additionally, the NDAA for Fiscal Year 2017 included a provision for GAO to review access to care under TRICARE Extra. This report addresses both provisions.
GAO analyzed DOD's surveys to determine (1) nonenrolled beneficiaries' access to care, (2) nonenrolled beneficiaries' ratings of TRICARE, (3) civilian providers' awareness and acceptance of TRICARE, and (4) nonenrolled beneficiaries' access by individual geographic area. GAO interviewed agency officials, analyzed the 2012-2015 surveys, and compared them to DOD's 2008-2011 surveys and to surveys of Medicare and Medicaid beneficiaries. In commenting on a draft of this report, DOD concurred with GAO's findings.

What GAO Found

The Department of Defense's (DOD) most recent surveys of TRICARE beneficiaries and civilian health care providers show that access to care has generally improved for nonenrolled beneficiaries who used the TRICARE Standard and Extra options. Specifically, GAO found the following:
Nonenrolled beneficiaries reported improved access to care in the most recent 4-year survey (2012-2015), compared to the prior survey (2008-2011). For example, a lower percentage of nonenrolled beneficiaries reported that they experienced problems finding a civilian provider in the most recent survey (29 percent) than those in the prior survey (31 percent). In addition, a higher percentage of nonenrolled beneficiaries (90 percent) reported that they were usually or always able to obtain a non-urgent appointment as soon as they thought they needed compared to the prior survey (87 percent).
The percentage of nonenrolled beneficiaries who reported positive experience ratings of TRICARE ranged from 71 to 83 percent over five categories, including ratings of primary, specialty, and mental health care providers. These ratings were generally higher than the prior survey. When compared to other federal health plans, nonenrolled TRICARE beneficiaries' positive experience ratings of primary and specialty care providers were lower than those of Medicare fee-for service beneficiaries, but higher than those of Medicaid beneficiaries.
The percentage of civilian providers who were aware of TRICARE increased from 82 percent in the prior survey to 84 percent. However, the percentage who accepted new TRICARE patients decreased from 58 percent to 55 percent. According to GAO's analysis of survey data, this overall decrease was mainly attributable to a decrease in mental health care providers' acceptance rates, as the acceptance rates for primary and specialty care providers remained unchanged. Network providers reported both higher awareness and acceptance of TRICARE than providers not in the network (referred to as nonnetwork providers). The biggest gap in both awareness and acceptance between network and nonnetwork providers was for mental health care providers:
About 96 percent of network mental health care providers reported awareness of TRICARE compared to 72 percent of nonnetwork mental health care providers.
About 79 percent of network mental health care providers reported accepting new TRICARE patients compared to 30 percent of nonnetwork mental health care providers.
GAO's analysis of both the beneficiary and provider surveys identified locations in New York, Washington, Texas, and Washington, D.C. where access to providers may be particularly problematic. Specifically, in these locations, beneficiaries reported more problems finding providers who accepted TRICARE and providers reported lower acceptance of TRICARE, compared to national averages.