Question

This week we are studying Health Programs, I need assistance with the below:

Choose a health program:

Tricare Prime

Address the following questions:

Briefly describe the program

Summarize the experience you or a person you know had with the program.

*you may cover a long period of experience or focus on one or two specific that stand out.

Based on personal experience, what are the advantages of the program?

Based on personal experience, what are the disadvantages of the program?

If you were eligible for the program, and you had a choice, would you use the program now for your own health care?

Why or why not?

Answer 1

Tricare Prime is a health insurance program offered to active duty members, retirees, activated guard & reserve members, and families. If you're on active duty, you have to enroll in Tricare Prime, all others can choose to enroll or use TRICARE Select. TRICARE Prime offers fewer out-of-pocket costs than Tricare Select, but less freedom of choice for providers.

There are four Tricare Prime Plans:

Tricare Prime

Tricare Prime Remote

Tricare Prime Overseas

Tricare Prime Remote Overseas

Each plan is generally the same, differing only in the geographical area that it covers.

Tricare Categories

There are two separate categories of Tricare beneficiaries:

Group A: where the service member entered active duty before 2018

Group B: where the service member entered active duty in 2018 or later

Tricare Prime for Families of Active Duty Members

Family members of active duty personnel will pay:

Minimal out-of-pocket-costs

No enrollment fees

No network copayments

No point-of-service fees unless using the point-of-service option

Tricare Prime for Families of Retirees

All other people using Tricare Prime will pay an annual enrollment fee of $297.00 for a single member and $594.00 for a family for those in group A, and $360.00 for a single member and $720.00 for a family for those in group B.

Catastrophic Cap

The catastrophic cap is the maximum amount you will pay out-of-pocket annually for all healthcare. The catastrophic cap resets each year.

Active duty recipients have a catastrophic cap of $1,000. Retired recipients have a catastrophic cap of $3,000 for Group A or $3,598 for Group B.

Copay Amounts

In addition to an enrollment fee, you also may pay a copayment for various services received at network providers, these fees are:

Tricare Prime Copayments

Service    Active Duty Cost Retiree Cost

Annual Deductible $0 $0

Primary Care $0 $20

Specialist $0 $30

Urgent Care $0 $30

Emergency Room $0 $61

Hospital $0 $154

Outpatient Services $0 $61

Ambulance $0 $41

Medical Equipment $0 20%

Maternity $0 $150*

*For retirees the copay for maternity services varies according to location of services performed.

If I were eligible for the program, and I had a choice, I would use the program now for my own health care.
Alternative 1: Require a one-time or annual enrollment in TRICARE Standard, but without an enrollment fee, while making no adjustment to any other part of the TRICARE program beneficiary fee structure: Under this alternative, beneficiaries must first indicate in an enrollment process that they intend to use that health plan option in order to obtain TRICARE Standard benefits. Advantages: Would be viewed by beneficiaries as imposing only a small increase in their administrative requirement for using TRICARE. Would not give beneficiaries participating in any TRICARE option a basis for objecting to an increase in the TRICARE cost-sharing structure. Provides at least a limited basis for targeting some TRICARE beneficiaries not enrolled in TRICARE Prime for population health management services. Would provide an opportunity to make an annual update in DEERS record of address and OHI information for enrolling beneficiaries. Disadvantages: Does not require an effective commitment by beneficiaries to use TRICARE Standard. Many might enroll to preserve their future options but have no intent for near-term reliance on TRICARE. Provides at most, a limited increase in information required to support reliable TRICARE budget estimates, and at worst, very misleading information upon which to base such estimates. Would require an extensive communication effort to ensure beneficiaries become aware that satisfying the enrollment requirement is prerequisite for obtaining TRICARE Standard coverage of their medical costs. • Does not provide a reliable basis for planning potential future provision of population health management services to TRICARE Standard reliants. Provides no increased incentive for beneficiaries to rely on OHI as primary payer.

Does not make an equitable adjustment in beneficiaries' contribution through cost-sharing to sustaining the TRICARE benefit. By once again highlighting the very low cost of participating in TRICARE this might attract even more eligible beneficiaries who do not currently use the MHS, but rely on OHI. Would increase cost of the TRICARE program because it provides no offset to the administrative costs of implementing this alternative. Alternative 2: Require annual enrollment in TRICARE Standard, with only a nominal enrollment fee required, while making no adjustment to any other part of the TRICARE program beneficiary fee structure: Under this alternative, beneficiaries must first pay an annual, nominal TRICARE Standard enrollment fee (e.g., $25-$50) in order to obtain TRICARE Standard benefits. Advantages: Because only a nominal enrollment fee would be charged, beneficiaries would view this as the least objectionable implementation of a fee-based, annual enrollment requirement for TRICARE Standard. Would not give beneficiaries participating in TRICARE Prime a basis for objecting to an increase in the TRICARE cost-sharing structure. Provides at least a limited basis for targeting some TRICARE beneficiaries, no enrolled in TRICARE Prime, for population health management services. Would provide an opportunity to make an annual update in DEERS records of address and OHI information for enrolling beneficiaries. Disadvantages: Compared to Alternative 1, limiting the enrollment fee to just a "nominal" amount only marginally increases the probability that enrollees have made an effective commitment to using TRICARE Standard. Many might still enroll to preserve their future options but have no real intent of near-term reliance on TRICARE. Provides, at most, a limited increase in information required to support reliable TRICARE budget estimates and, at worst, very misleading information upon which to base such estimates. 10

There would likely be beneficiary objection to the introduction of even a "nominal" TRICARE Standard enrollment fee. Would require an extensive communication effort to ensure beneficiaries become aware that satisfying the enrollment requirement is prerequisite for obtaining TRICARE Standard coverage of their medical costs. A "nominal” enrollment fee might not offset the associated administrative costs to the TRICARE program. Does not make an equitable adjustment in beneficiaries' contribution through cost-sharing to sustaining the TRICARE benefit. By once again highlighting the very low cost of participating in TRICARE, this might attract even more eligible beneficiaries who do not currently use the MHS but rely on OHI. Alternative 3: Require annual enrollment in TRICARE Standard, with payment of an enrollment fee related to the current TRICARE Prime enrollment fee (e.g., 40-50 percent of Prime enrollment fee), while making no adjustment to any other part of the TRICARE program beneficiary fee structure: Under this alternative TRICARE Standard beneficiaries, in addition to remaining responsible for their historic deductible and copayment costs, would pay an annual enrollment fee, just as participants in TRICARE Prime. Advantages: By requiring that beneficiaries desiring to use TRICARE Standard pay a greater than "nominal" enrollment fee, would increase the likelihood their enrollment decisions are based on intent to be TRICARE-reliant. Might induce current and potential TRICARE Standard users to be totally reliant on OHI. Provides increase in information useful for making reliable TRICARE budget estimates. TRICARE Standard enrollment fees likely would offset the associated administrative costs to the TRICARE program. 11

Provides an improved basis for targeting some TRICARE beneficiaries not enrolled in TRICARE Prime for population health management services. Would provide an opportunity to make an annual update in DEERS records of address and OHI information for enrolling beneficiaries. Disadvantages: • Would likely elicit significant objection from TRICARE beneficiaries. Would increase costs to TRICARE for beneficiaries who decide, as a result of introduction of a TRICARE Standard enrollment fee, to shift from reliance on TRICARE Standard to enrollment in TRICARE Prime. Does not provide any disincentive, such as raising TRICARE Prime enrollment fees, to dissuade beneficiaries from making such shifts. By keeping constant all other aspects of the TRICARE program fee structure, does not make the comprehensive changes necessary to optimize the MHS's ability to sustain the TRICARE benefit. Would require an extensive communication effort to ensure beneficiaries become aware that satisfying the enrollment requirement is prerequisite for obtaining TRICARE Standard coverage of their medical costs. Alternative 4: Require annual enrollment in TRICARE Standard with payment of an enrollment fee that is indexed to inflation and related to the current TRICARE Prime enrollment fee (e.g., 40-50 percent of Prime enrollment fee), while making adjustments to certain other parts of the TRICARE program beneficiary fee structure: Under this alternative, the MHS would take a "systems approach" to implementing a TRICARE Standard enrollment fee requirement. Such an approach recognizes that, in total, the various elements of the current fee structure interact to affect the contribution that TRICARE costs and beneficiary choices make to MHS operational and financial outcomes. These interactions must be controlled, to the extent possible, to produce a complementary mix that optimizes the MHS's ability to sustain the TRICARE benefit. Advantages: Makes a number of the comprehensive and interrelated changes necessary to optimize the MHS's ability to sustain the TRICARE benefit.

12 By requiring that beneficiaries desiring to use TRICARE Standard pay a greater than “nominal” enrollment fee, would increase the likelihood their enrollment decisions are based on intent to be TRICARE-reliant. Might motivate TRICARE beneficiaries who have not used the benefit to remain reliant on OHI. Provides increase in information useful for making reliable TRICARE budget estimates. TRICARE Standard enrollment fees likely would offset the associated administrative costs to the TRICARE program. Provides an improved basis for targeting some TRICARE beneficiaries, not enrolled in TRICARE Prime, for population health management services. Would provide an opportunity to make an annual update in DEERS records of address and OHI information for enrolling beneficiaries. Disadvantages: Of the four alternatives considered for introducing TRICARE Standard enrollment, this one will elicit the greatest beneficiary dissatisfaction. Would require an extensive communication effort to convince beneficiaries that increasing a number of costs in the TRICARE beneficiary fee structure is necessary component for ensuring sustainment of the benefit. Would require an extensive communication effort to ensure beneficiaries become aware that satisfying the enrollment requirement is prerequisite for obtaining TRICARE Standard coverage of their medical costs.

• For Advantages and disadvantages of Tricare Prime refer the images added with this write-up.