DEFENSE HEALTH 

CARE

TRICARE Surveys 

Indicate Nonenrolled 

Beneficiaries’ Access 

to Care Has Generally 

Improved

Report to Congressional Committees

March 2018

GAO-18-361

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO -18-361, a report to 

congressional committees

March 2018

DEFENSE HEALTH CARE

TRICARE Surveys Indicate Nonenrolled Beneficiaries’

Access to Care Has Generally Improved

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. View GAO-18-361. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.

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 feefor-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.
Page i GAO-18-361 DOD’s TRICARE Access Surveys

Letter 1

Background 7

Nonenrolled TRICARE Beneficiaries Reported Generally 

Experiencing Fewer Problems Accessing Care, and More 

Reported Obtaining Care when Desired 12

Nonenrolled Beneficiaries’ Positive Ratings of TRICARE Have 

Generally Increased over Time and Vary Compared to Other 

Federal Health Plans 21

Civilian Providers’ Reported Awareness of TRICARE Has 

Generally Increased over Time, While Mental Health Providers’ 

Acceptance of New TRICARE Patients Has Decreased 25

DOD’s Surveys of Nonenrolled Beneficiaries and Civilian 

Providers Collectively Indicate That Specific Geographic 

Locations May Have Access Problems 31

Agency Comments 33

Appendix I Comments from the Department of Defense 34

Appendix II GAO Contact and Staff Acknowledgments 35

Tables

Table 1: Summary of Basic TRICARE Options Prior to January 1, 

2018 8

Table 2: Locations with Both Potential Problems of Beneficiaries 

Not Finding Providers and Providers Not Accepting New

TRICARE Patients, 2012-2015 32

Figures

Figure 1: Percentage of Nonenrolled TRICARE Beneficiaries by 

Beneficiary Category, September 2016 (Number of 

Beneficiaries) 7

Figure 2: Percentage of Nonenrolled TRICARE Beneficiaries by 

Location, September 2016 (Number of Beneficiaries) 10

Figure 3: Nonenrolled TRICARE Beneficiaries Who Reported 

Experiencing Problems Finding a Civilian Provider over 

Time, by Provider Type 13

Contents
Page ii GAO-18-361 DOD’s TRICARE Access Surveys

Figure 4: Nonenrolled TRICARE Beneficiaries Who Reported 

Experiencing Problems Finding a Civilian Provider, by 

Provider Type and Location Type (2012-2015) 15

Figure 5: Nonenrolled TRICARE Beneficiaries Who Reported 

Experiencing Problems Finding a Civilian Provider, by 

Provider Type and Network Status (2012-2015) 17

Figure 6: Nonenrolled TRICARE Beneficiaries Who Reported 

Experiencing Problems Finding a Specialty or Mental 

Health Care Provider over Time, by Provider Type and 

Network Status 18

Figure 7: Comparison of Nonenrolled Beneficiaries’ Estimated 

Positive Ratings of Their TRICARE Experiences, over 

Time 22

Figure 8: Nonenrolled TRICARE Beneficiaries’ Estimated 

Experience Ratings Compared to Those of Medicare 

Fee-For-Service and Medicaid Beneficiaries 23

Figure 9: Civilian Providers’ Reported Awareness of TRICARE, by 

Provider Type and Network Status (2012-2015) 27

Figure 10: Civilian Providers’ Reported Acceptance of New 

TRICARE Patients, by Provider Type and Network Status 

(2012-2015) 30
Page iii GAO-18-361 DOD’s TRICARE Access Surveys

Abbreviations

CAHPS Consumer Assessment of Healthcare

 Providers and Systems

DOD Department of Defense

HHS Department of Health and Human Services

HSA Hospital Service Area

NDAA National Defense Authorization Act

NDAA 2008 National Defense Authorization Act for

 Fiscal Year 2008

NDAA 2012 National Defense Authorization Act for

 Fiscal Year 2012

NDAA 2017 National Defense Authorization Act for

 Fiscal Year 2017

PSA Prime Service Area

VA Department of Veterans Affairs

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Page 1 GAO-18-361 DOD’s TRICARE Access Surveys

441 G St. N.W.

Washington, DC 20548

March 29, 2018

The Honorable John McCain

Chairman

The Honorable Jack Reed

Ranking Minority Member

Committee on Armed Services

United States Senate

The Honorable Mac Thornberry

Chairman

The Honorable Adam Smith

Ranking Minority Member

Committee on Armed Services

House of Representatives

In fiscal year 2016, the Department of Defense (DOD) offered health care 

services, including mental health care, to more than 9 million eligible 

beneficiaries in the United States and abroad through TRICARE, DOD’s 

regionally structured health care program.1 Under TRICARE, 

beneficiaries may obtain care either from military hospitals and clinics, 

referred to collectively as military treatment facilities, or from civilian 

providers.2 However, since TRICARE’s inception in 1995, beneficiaries in 

some locations—particularly those who did not enroll in TRICARE’s 

managed care option—have raised concerns about difficulties finding 

civilian providers who will accept them as patients.

The number and type of civilian providers available to serve TRICARE 

beneficiaries can vary depending on a beneficiary’s location and choice of 

coverage—which prior to January 1, 2018, consisted of TRICARE’s three 

 1

Eligible beneficiaries include active duty personnel and their dependents, medically 

eligible National Guard and Reserve servicemembers and their dependents, and retirees 

and their dependents and survivors, among others. Active duty personnel include Reserve 

component members on active duty for at least 30 days. 

2

Through individual agreements between military treatment facilities and the Department 

of Veterans Affairs’ (VA) medical centers, eligible beneficiaries also may receive certain 

types of care from VA medical centers in some locations. 

Letter
Page 2 GAO-18-361 DOD’s TRICARE Access Surveys

basic plans: Prime, Extra, and Standard.3 Beneficiaries who used 

TRICARE Prime, a managed care option, had to enroll and could obtain 

care through military treatment facilities or TRICARE’s network of civilian 

providers.4 DOD uses contractors, called managed care support 

contractors, to develop networks of civilian providers (network providers) 

to ensure adequate access to care for all TRICARE beneficiaries in 

geographic areas called Prime Service Areas (PSA).5 Although some 

network providers may be located outside of PSAs, contractors are not 

required to develop networks in these areas (which we refer to as nonPSAs).

Beneficiaries did not need to enroll to receive care under TRICARE 

Standard, a fee-for-service option, or TRICARE Extra, a preferred 

provider organization option. These beneficiaries—referred to as 

nonenrolled beneficiaries—could choose to receive care either through 

TRICARE Standard when they saw nonnetwork civilian providers or 

through TRICARE Extra when they saw network civilian providers. The 

National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017) 

terminated both the TRICARE Standard and Extra options and 

established a self-managed preferred provider option called TRICARE 

Select beginning January 1, 2018.

In response to nonenrolled beneficiaries’ concerns about access to care, 

the National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) 

directed DOD to conduct a multi-year survey (2008-2011) of nonenrolled 

beneficiaries and a multi-year survey (2008-2011) of civilian providers to 

determine the adequacy of access to health care providers, including 

mental health care providers, for nonenrolled beneficiaries.6 The National 

Defense Authorization Act for Fiscal Year 2012 (NDAA 2012) directed 

 3

The National Defense Authorization Act for Fiscal Year 2017 included a number of 

changes to the TRICARE program, including the termination of TRICARE Standard and 

Extra and the establishment of a new option, TRICARE Select, which took effect on Jan. 

1, 2018.

4

Active duty personnel are required to use TRICARE Prime. 

5

PSAs are defined by a set of five-digit zip codes, usually within an approximate 40-mile 

radius of a military outpatient or inpatient treatment facility or a Base Realignment and 

Closure site, which is a military installation that has been closed or realigned as a result of 

decisions made by the Commission on Base Realignment and Closure. 

6

See Pub. L. No. 110-181, § 711(a), 122 Stat. 3, 190-191. (2008). 
Page 3 GAO-18-361 DOD’s TRICARE Access Surveys

DOD to continue both of these surveys for an additional 4-year period 

(2012-2015).7

The NDAA 2008 also included a recurring provision for us to review a 

series of issues related to the adequacy of access to care for nonenrolled 

TRICARE beneficiaries, including information gleaned from the 

beneficiary and civilian provider surveys, and to report on these issues on 

a biannual basis.8 We have issued a series of reports in response to this 

provision, including two reports that focused on DOD’s beneficiary and 

civilian provider surveys.9 In addition, the NDAA 2017 directed us to 

conduct a review of the network of civilian providers that provide care to 

nonenrolled beneficiaries under the TRICARE Extra option.10

This report addresses provisions in both the NDAA 2008, as amended, 

and the NDAA 2017 for us to report on the adequacy of access to care for 

nonenrolled TRICARE beneficiaries. Specifically, it describes

1. what the results of the most recent 4-year beneficiary survey indicate 

about access to care for nonenrolled beneficiaries;

2. what the results of the most recent 4-year beneficiary survey indicate 

about nonenrolled beneficiaries’ ratings of their experience with 

TRICARE;

 7

Pub. L. No. 112-81, § 721(a), 125 Stat. 1298, 1478 (2011).

8

This reporting time frame was amended in the NDAA 2012 to biennial reporting instead 

of biannual reporting. The National Defense Authorization Act for Fiscal Year 2015 

amended GAO’s reporting requirements to issue two remaining reports—one in 2017 and 

one in 2020.

9

For the reports on DOD’s surveys, see GAO, Defense Health Care: TRICARE Multiyear 

Surveys Indicate Problems with Access to Care for Nonenrolled Beneficiaries, 

GAO-13-364 (Washington, D.C.: Apr. 2, 2013) and Defense Health Care: 2008 Access to 

Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other 

Health Plans, GAO-10-402 (Washington, D.C.: Mar. 31, 2010). Other reports in response 

to this provision include Defense Health Care: More-Specific Guidance Needed for 

Assessing Nonenrolled TRICARE Beneficiaries’ Access to Care, GAO-14-384 

(Washington, D.C.: Apr. 28, 2014); Defense Health Care: DOD Lacks Assurance That 

Selected Reserve Members Are Informed About TRICARE Reserve Select, GAO-11-551 

(Washington, D.C.: June 3, 2011); and Defense Health Care: Access to Civilian Providers 

under TRICARE Standard and Extra, GAO-11-500 (Washington, D.C.: June 2, 2011).

10Pub. L. No. 114-328, § 701(g)(2), 130 Stat. 2000, 2188 (2016).
Page 4 GAO-18-361 DOD’s TRICARE Access Surveys

3. what the results of the most recent 4-year civilian provider survey 

indicate about civilian providers’ awareness and acceptance of 

TRICARE; and

4. what the collective results of the most recent 4-year beneficiary and 

civilian provider surveys indicate about access to care for nonenrolled 

beneficiaries by geographic area.

To determine what the results of the most recent 4-year beneficiary 

survey indicate about access to care for nonenrolled beneficiaries, we 

obtained and analyzed survey data from DOD’s TRICARE Standard 

Surveys of Beneficiaries for 2012-2015. Specifically, we analyzed these 

data to determine whether nonenrolled beneficiaries were able to obtain 

an appointment as soon as they wanted, how quickly they were able to 

get an appointment to see a provider, and if they had a problem finding a 

provider that would accept TRICARE.11 We compared these data across 

location types, provider types, and providers’ network status, where 

applicable. We also compared these results to DOD’s 2008-2011 survey 

results to identify any changes in beneficiaries’ access over time.

To determine what the results of the most recent 4-year beneficiary 

survey indicate about nonenrolled beneficiaries’ ratings of their 

experience with TRICARE, we obtained and analyzed the 2012-2015 

nonenrolled beneficiary survey data that indicated beneficiaries’ ratings of 

certain aspects of their TRICARE experiences, such as their ratings of 

health care, health plan, and primary, specialty, and mental health care 

providers.12 We compared these data by providers’ network status, where 

applicable. We also obtained and analyzed data from the Department of 

Health and Human Services’ (HHS) Consumer Assessment of Healthcare 

Providers and Systems (CAHPS) surveys for the 2013-2015 time period 

to compare nonenrolled TRICARE beneficiaries’ ratings to those of 

 11For mental health care, the survey question asked beneficiaries how much of a problem 

it was to get the “treatment or counseling you needed through your health plan,” and not 

necessarily to find a provider that would accept TRICARE.

12DOD reports beneficiaries’ ratings as positive if they are on an 8, 9, or 10 on a 0-10 

point scale. We did the same in our analysis. 
Page 5 GAO-18-361 DOD’s TRICARE Access Surveys

Medicare fee-for-service and Medicaid beneficiaries.13 Additionally, we 

compared the results of DOD’s 2012-2015 beneficiary surveys to DOD’s 

2008-2011 survey results to identify any changes in beneficiaries’ ratings 

of experiences over time.

To determine what the results of the most recent 4-year civilian provider 

surveys indicate about civilian providers’ awareness and acceptance of 

TRICARE, we obtained and analyzed survey data from DOD’s TRICARE 

Standard Surveys of Providers for 2012-2015. We compared these data 

by location type, provider type, and providers’ network status, where 

applicable. We compared these results to the results from DOD’s 2008-

2011 surveys to identify any changes in provider awareness and 

acceptance over time.

To determine what the collective results of the most recent 4-year 

beneficiary and civilian provider surveys indicate about access to care for 

nonenrolled beneficiaries, we compared the results of our analyses of the 

2012-2015 beneficiary and provider survey data by specific geographic 

regions, where possible, in order to identify locations with high 

percentages of nonenrolled beneficiaries who experienced problems 

finding civilian providers and low percentages of civilian providers who 

were accepting new TRICARE patients.14 We conducted this analysis by 

individual location type and provider type.

For each objective, we assessed the reliability of the data from the 

surveysincluding DOD’s 2012-2015 nonenrolled beneficiary and civilian 

provider surveys and HHS’s CAHPS surveyby speaking with 

knowledgeable officials and reviewing relevant documentation. DOD 

calculated the response rates for its 2012-2015 nonenrolled beneficiary 

surveys and civilian provider surveys to be about 25 percent and 39 

 13DOD based its nonenrolled beneficiary survey questions on HHS’s CAHPS survey, 

which allows for comparisons between the surveys. HHS’s CAHPS survey is an annual, 

national survey of beneficiaries of commercial health insurance, Medicare, Medicaid, and 

the Children’s Health Insurance Program. According to a CAHPS official, the CAHPS 

survey for Medicare and Medicaid beneficiaries was not conducted in 2012. Therefore, for 

each of the Medicare fee-for-service and Medicaid surveys, we combined the 2013-2015 

annual data into one point estimate in order to compare the results to DOD’s 4-year 

beneficiary surveys over a similar period. 

14Similar to our report on the prior 4-year surveys, we correlated survey results for which 

both (1) beneficiaries reported more problems finding civilian providers than the national 

average and (2) civilian providers reported less acceptance of new TRICARE patients 

than the national average. See GAO-13-364.
Page 6 GAO-18-361 DOD’s TRICARE Access Surveys

percent, respectively.15 We verified that the surveys’ results were 

representative of the areas surveyed by reviewing DOD’s nonresponse 

analyses for these surveys and by interviewing DOD officials.16 We 

determined that all data used in this report were sufficiently reliable for 

our purposes. However, our analyses have some limitations. In our 

collective analyses of DOD’s beneficiary and provider surveys, we were 

not able to compare survey results among all of the individual geographic 

locations due to low numbers of respondents in some areas. Specifically, 

we excluded individual locations that had less than 30 respondents to the 

beneficiary survey or less than 50 respondents to the provider survey, 

depending on the survey questions we analyzed. Due to the low numbers 

of respondents who indicated that they needed mental health care, we 

were unable to identify specific geographic locations in which nonenrolled 

beneficiaries experienced problems finding mental health providers.

We conducted this performance audit from March 2017 to March 2018 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

 15For the 4 years of the nonenrolled beneficiary survey, DOD mailed 146,125 surveys and 

received 35,242 complete and eligible responses, 19,415 of which were from nonenrolled 

TRICARE beneficiaries. DOD considered complete and eligible responses as those where 

TRICARE beneficiaries who answered at least half of the DOD-identified “key” questions. 

Over the 4 years of the 2012-2015 civilian provider survey, DOD mailed 192,129 surveys 

to physician and mental health providers, and received 50,331 complete and eligible 

responses. DOD considered the survey complete if the provider answered three DODidentified “key” questions that asked about the providers’ locations of practice and 

awareness and acceptance of TRICARE.

16DOD concluded that the results of the beneficiary survey nonresponse analyses 

suggested that although there were some differences in the demographic profiles between 

respondents and nonrespondents, they were not associated with systematic differences in 

satisfaction with care. 

From the results of the civilian provider survey nonresponse analyses, DOD concluded 

that there were only slight differences between respondents and nonrespondents in terms 

of the type of provider. For both the beneficiary and provider surveys, DOD officials also 

told us that the final post-survey weights used in their analyses accounted for the key 

characteristic differences in survey respondents compared with nonrespondents identified 

through the nonresponse analyses for both types of surveys.
Page 7 GAO-18-361 DOD’s TRICARE Access Surveys

In fiscal year 2016, DOD identified about 2.2 million nonenrolled 

TRICARE beneficiaries who fell into four categories: (1) retired 

servicemembers and their dependents, (2) inactive guard/reserve 

servicemembers and their dependents, (3) dependents of active duty, or 

of guard/reserve on active duty status, and (4) other beneficiaries, such 

as dependent survivors of deceased servicemembers. Retired 

servicemembers and their dependents made up the majority of 

nonenrolled beneficiaries at the end of fiscal year 2016 (approximately 60 

percent). (See fig. 1.)

Figure 1: Percentage of Nonenrolled TRICARE Beneficiaries by Beneficiary 

Category, September 2016 (Number of Beneficiaries)

Background

Composition of 

TRICARE’s Nonenrolled 

Beneficiary Population
Page 8 GAO-18-361 DOD’s TRICARE Access Surveys

Prior to January 1, 2018, TRICARE provided benefits through three basic 

options for its non-Medicare-eligible beneficiary population—TRICARE 

Prime, Standard, and Extra.17 These options varied by enrollment 

requirements, choices in civilian and military treatment facility providers, 

and the amount beneficiaries must contribute toward the cost of their 

care. (See table 1.) 

Table 1: Summary of Basic TRICARE Options Prior to January 1, 2018

TRICARE option Description

TRICARE Prime This is TRICARE’s managed care option and requires 

enrollment. All active duty servicemembers are 

required to use this option, while other TRICARE 

beneficiaries may choose it. Prime enrollees receive 

most of their care from providers at military treatment 

facilities and also may receive care from network 

civilian providers. This option has the lowest out-ofpocket costs for beneficiaries, as care provided at 

military treatment facilities does not have an 

associated copayment.

TRICARE Standard and Extra TRICARE beneficiaries who chose not to enroll in 

TRICARE Prime were able to obtain health care from 

nonnetwork providers (TRICARE Standard) or 

network civilian providers (TRICARE Extra). The 

TRICARE Standard option was designed to provide 

beneficiaries with maximum flexibility in selecting 

providers, but beneficiaries who obtained care from a 

network provider through TRICARE Extra paid lower 

copayments than they would if they had chosen a 

nonnetwork provider under the TRICARE Standard 

option. TRICARE Standard and Extra beneficiaries 

could also receive care from military treatment 

facilities, though they had a lower priority for receiving 

care than TRICARE Prime beneficiaries.

Source: GAO summary of Department of Defense TRICARE documentation. | GAO-18-361

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. 

 17TRICARE also offers TRICARE for Life to TRICARE beneficiaries who are eligible for 

Medicare and enroll in Part B. Under the TRICARE for Life program, TRICARE processes 

claims after they have been adjudicated by Medicare.

TRICARE’s Benefit 

Options
Page 9 GAO-18-361 DOD’s TRICARE Access Surveys

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.

Under TRICARE, DOD uses managed care support contractors to 

develop networks of civilian providers to serve all TRICARE beneficiaries 

in PSAs, which are typically within an approximate 40-mile radius of a 

military outpatient or inpatient treatment facility or Base Realignment and 

Closure sites. Although some network providers may be located in nonPSAs, contractors are not required to develop networks in these areas. 

Previously, contractors had the option of developing additional PSAs (and 

civilian provider networks) in areas that were not located near military 

treatment facilities or Base Realignment and Closure sites. However, on 

October 1, 2013, DOD eliminated these additional PSAs, referred to in 

the survey analyses as “former PSAs,” and as a result, the managed care 

support contractors were no longer required to develop and maintain 

networks of civilian providers in these areas.18

In fiscal year 2016, approximately 65 percent of the 2.2 million 

nonenrolled beneficiaries that were eligible for TRICARE Standard and 

Extra (1.47 million) lived in PSAs. Of the remaining nonenrolled 

beneficiaries (775,000), about 19 percent lived in former PSAs and about 

16 percent lived in non-PSAs. (See fig. 2.) Nonenrolled beneficiaries who 

live in former PSAs and non-PSAs may still have access to network 

providers, even though contractors are not required to develop networks 

in these areas. About 57 percent of these beneficiaries (445,000) filed at 

least one TRICARE claim with a network civilian provider during fiscal 

year 2016.

 18Managed care support contractor officials told us that they did not have plans to 

eliminate the networks of providers that were already established in those locations.

TRICARE Networks and 

Locations
Page 10 GAO-18-361 DOD’s TRICARE Access Surveys

Figure 2: Percentage of Nonenrolled TRICARE Beneficiaries by Location, 

September 2016 (Number of Beneficiaries)

Note: The Department of Defense requires its TRICARE contractors to develop networks of civilian 

providers (network providers) in geographic areas called Prime Service Areas, which are defined by a 

set of five-digit zip codes, usually within an approximate 40-mile radius of a military outpatient or 

inpatient treatment facility or a Base Realignment and Closure site. Contractors are not required to 

develop networks outside of these areas, which we refer to as non-Prime Service Areas. Previously, 

contractors had the option of developing additional Prime Service Areas (and civilian provider 

networks), in areas that were not located near military treatment facilities or Base Realignment and 

Closure sites. However, on Oct. 1, 2013, DOD eliminated these additional areas, which are referred 

to as “former Prime Service Areas”.

The NDAA 2008 directed DOD to survey nonenrolled beneficiaries and 

civilian providers in at least 20 PSAs in each of four fiscal years, 2008 

through 2011, as well as 20 non-PSAs. To do this, DOD divided the 

country into 80 distinct PSAs and 80 distinct non-PSAs and surveyed 20 

PSAs and 20 non-PSAs each year. At the end of the 4-year period, each 

year’s survey results were combined and weighted to develop estimates 

of access to health care, including mental health care, at the service area, 

state, and national levels. 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. Based on these 

DOD’s Implementation of 

Mandated Beneficiary and 

Civilian Provider Survey 

Requirements
Page 11 GAO-18-361 DOD’s TRICARE Access Surveys

consultations, DOD designated certain Hospital Service Areas (HSA) to 

include in its beneficiary and provider surveys.19

DOD used a similar methodology for determining its locations in the 2012-

2015 surveys. However, as a result of DOD’s changes to PSAs on 

October 1, 2013, 28 of the 80 non-PSAs surveyed were former PSAs. 

DOD also surveyed both nonenrolled beneficiaries and civilian providers 

in a total of 30 HSAs. As a result, DOD collectively surveyed 190 

geographic locations over the 4-year period.20 Furthermore, we previously 

reported that DOD’s implementation of its 2008-2011 nonenrolled 

beneficiary and civilian provider surveys generally addressed the 

requirements outlined in the NDAA 2008.21 DOD made several minor 

revisions to the methodologies of the 2012-2015 surveys, but we 

determined that none of those changes altered DOD’s compliance with 

the NDAA 2008, as amended.

 19According to DOD officials, representatives of TRICARE beneficiaries and health care 

providers suggested cities and towns where access should be measured, and DOD then 

identified HSAs corresponding to each city and town. HSAs, as defined by a Dartmouth 

University study, are collections of zip codes organized into more than 3,000 geographic 

regions in which Medicare beneficiaries seek the majority of their care from one hospital or 

a collection of hospitals. HSAs have non-overlapping borders and contain all U.S. zip 

codes without gaps in coverage. The HSAs included in the beneficiary and civilian 

provider surveys are within the PSAs or non-PSAs surveyed.

20The 80 PSAs, 52 non-PSAs, and 28 former PSAs covered the entire country. Even 

though the 30 HSAs are contained within the surveyed PSAs, non-PSAs, or former PSAs, 

DOD counts them as separate locations, totaling 190 surveyed areas.

21See GAO-10-402 and GAO-13-364. For more detailed information on DOD’s 

methodology for the surveys, see Appendix II in GAO-10-402 and Appendix I in 

GAO-13-364.
Page 12 GAO-18-361 DOD’s TRICARE Access Surveys

Nonenrolled beneficiary survey results over time. 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).22

Specifically, fewer nonenrolled beneficiaries reported that they 

experienced problems finding a primary care provider than in the prior 

survey (22 percent in 2012-2015 compared to 25 percent in 2008-2011).23

However, there was no significant statistical difference over time in the 

percentage of beneficiaries who reported experiencing problems finding a 

specialty care or mental health care provider. (See fig. 3.)

 22The margins of error for these estimates are within plus or minus 1 percentage point at 

the 95 percent confidence level. The difference in estimates is significant at the 95 percent 

confidence level.

23The margins of error for the estimates of beneficiary problems finding civilian primary 

care providers are within plus or minus 1 percentage point at the 95 percent confidence 

level. The difference in estimates is significant at the 95 percent confidence level. 

Nonenrolled 

TRICARE 

Beneficiaries 

Reported Generally 

Experiencing Fewer 

Problems Accessing 

Care, and More 

Reported Obtaining 

Care when Desired

Nonenrolled TRICARE 

Beneficiaries Reported 

Generally Experiencing 

Fewer Problems 

Accessing Care than in 

the Prior Survey
Page 13 GAO-18-361 DOD’s TRICARE Access Surveys

Figure 3: Nonenrolled TRICARE Beneficiaries Who Reported Experiencing Problems Finding a Civilian Provider over Time, by 

Provider Type

Notes: Bars display 95 percent confidence levels for estimates, rounded to a whole number.

Within provider types, the differences in estimates between the 2008-2011 survey and the 2012-2015 

survey are statistically different at the 95 percent confidence level for “any type of provider” and 

primary care providers.

a

Respondents answered “a big problem” or “a small problem” to the question that asked: In the last 

12 months, how much of a problem was it to find a personal doctor who would accept TRICARE? 

Answer choices were “a big problem,” “a small problem,” or “not a problem.”

b

Respondents answered “a big problem” or “a small problem” to the question that asked: “In the last 

12 months, how much of a problem was it to find a doctor with this specialty who would accept 

TRICARE? Answer choices were “a big problem,” “a small problem,” or “not a problem.”

c

Respondents answered “a big problem” or “a small problem” to the question that asked: “In the last 

12 months, how much of a problem, if any, was it to get the treatment or counseling you needed 

through your health plan? Answer choices were “a big problem,” “a small problem,” or “not a 

problem.”

Nonenrolled TRICARE beneficiaries who 

reported they experienced problems 

accessing a TRICARE provider were 

surveyed on the reasons for their problems. 

“Dr. was not accepting TRICARE payment” 

was the most-reported reason among all three 

provider types—primary care, specialty care, 

and mental health—and was reported by 

about 50 percent of respondents. 

Some of the other top reasons reported were 

that the

• doctor was not taking any new TRICARE 

patients;

• doctor was not taking any new patients; 

• travel distance was too long; or

• wait time for an appointment was too long

These top reasons were similar for both 

network and nonnetwork providers.

Source: GAO analysis of Department of Defense data. | 

GAO-18-361
Page 14 GAO-18-361 DOD’s TRICARE Access Surveys

Nonenrolled beneficiary survey results by type of location.

Nonenrolled beneficiaries in non-PSAs reported experiencing fewer 

problems finding primary and specialty providers than those in PSAs, 

which is similar to what we reported for the prior survey.24 For example, 

about 20 percent of beneficiaries in non-PSAs reported that they had 

problems finding specialty care providers compared to 24 percent in 

PSAs.25 Regarding beneficiaries in former PSAs, the only statistically 

significant difference among the three provider types was for problems 

finding a primary care provider. Specifically, fewer (about 19 percent) 

nonenrolled beneficiaries in non-PSAs reported experiencing problems 

finding a primary care provider to accept TRICARE, compared to 24 

percent in former PSAs.26 (See fig. 4.) DOD officials told us that they were 

unsure of the exact reasons for the difference between PSAs and nonPSAs. However, they explained that PSAs are often located in more 

populated areas, where TRICARE beneficiaries may not make up a large 

market share for local civilian providers, who may have a wide array of 

patients with other health plans.

 24See GAO-13-364. 

25The margins of error for these estimates are within plus or minus 2 percentage points at 

the 95 percent confidence level. The difference in estimates is significant at the 95 percent 

confidence level.

26The margins of error for these estimates are within plus or minus 3 percentage points at 

the 95 percent confidence level. The difference in estimates is significant at the 95 percent 

confidence level.
Page 15 GAO-18-361 DOD’s TRICARE Access Surveys

Figure 4: Nonenrolled TRICARE Beneficiaries Who Reported Experiencing Problems Finding a Civilian Provider, by Provider 

Type and Location Type (2012-2015)

Notes: Bars display 95 percent confidence levels for estimates, rounded to a whole number.

The Department of Defense requires its TRICARE contractors to develop networks of civilian 

providers (network providers) in geographic areas called Prime Service Areas, which are defined by a 

set of five-digit zip codes, usually within an approximate 40-mile radius of a military outpatient or 

inpatient treatment facility or a Base Realignment and Closure site. Contractors are not required to 

develop networks outside of these areas, which we refer to as non-Prime Service Areas. Previously, 

contractors had the option of developing additional Prime Service Areas (and civilian provider 

networks), in areas that were not located near military treatment facilities or Base Realignment and 

Closure sites. However, on October 1, 2013, DOD eliminated these additional areas, which are 

referred to as “former Prime Service Areas”.

Within provider types, the following differences in estimates between location types are statistically 

different at the 95 percent confidence level: within “any type of provider” and primary care providers, 

the estimates for non-Prime Service Areas are less than those for Prime Service Areas or former 

Prime Service Areas; within specialty care providers, the estimate for non-Prime Service Areas is less 

than Prime Service Areas.

a

Respondents answered “a big problem” or “a small problem” to the question that asked: In the last 

12 months, how much of a problem was it to find a personal doctor who would accept TRICARE? 

Answer choices were “a big problem,” “a small problem,” or “not a problem.”

b

Respondents answered “a big problem” or “a small problem” to the question that asked: “In the last 

12 months, how much of a problem was it to find a doctor with this specialty who would accept 

TRICARE? Answer choices were “a big problem,” “a small problem,” or “not a problem.”

c

Respondents answered “a big problem” or “a small problem” to the question that asked: Based on 

the following: In the last 12 months, how much of a problem, if any, was it to get the treatment or 
Page 16 GAO-18-361 DOD’s TRICARE Access Surveys

counseling you needed through your health plan? Answer choices were “a big problem,” “a small 

problem,” or “not a problem.”

Nonenrolled beneficiary survey results by network status.

Nonenrolled beneficiaries with network providers reported experiencing 

fewer problems finding civilian providers, compared to nonenrolled 

beneficiaries with nonnetwork providers. 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.27

(See fig. 5.)

 27The margins of error for the estimates of nonenrolled beneficiaries’ problems finding 

civilian primary care provider (by network status) at the 95 percent confidence level are 

within plus or minus 5 percentage points. These estimates are significantly different from 

each other at the 95 percent confidence level.
Page 17 GAO-18-361 DOD’s TRICARE Access Surveys

Figure 5: Nonenrolled TRICARE Beneficiaries Who Reported Experiencing 

Problems Finding a Civilian Provider, by Provider Type and Network Status (2012-

2015)

Notes: Bars display 95 percent confidence levels for estimates, rounded to a whole number.

Within each provider type, the differences in estimates between network and nonnetwork providers 

are statistically different at the 95 percent confidence level.

Due to the wording of the questions, we could not determine the problems finding “any type of 

provider” by network status.

a

For the providers’ network status, respondents answered either “yes” or “no” to the question that 

asked: Is your personal doctor part of the TRICARE civilian provider network? In addition, 

respondents answered either “a big problem” or “a small problem” to the question that asked: In the 

last 12 months, how much of a problem was it to find a personal doctor who would accept TRICARE? 

Answer choices were “a big problem,” “a small problem,” or “not a problem.”

b

For the providers’ network status, respondents answered either “yes” or “no” to the question that 

asked: In the last 12 months, was the civilian specialist you saw most part of the TRICARE civilian 

provider network? In addition, respondents answered “a big problem” or “a small problem” to the 

question that asked: “In the last 12 months, how much of a problem was it to find a doctor with this 

specialty who would accept TRICARE? Answer choices were “a big problem,” “a small problem,” or 

“not a problem.”

c

For the providers’ network status, respondents answered either “yes” or “no” to the question that 

asked: In the last 12 months, did you receive this treatment or counseling from a provider in 

TRICARE’s civilian network? In addition, respondents answered “a big problem” or “a small problem” 

to the question that asked: Based on the following: In the last 12 months, how much of a problem, if 

any, was it to get the treatment or counseling you needed through your health plan? Answer choices 

were “a big problem,” “a small problem,” or “not a problem.”
Page 18 GAO-18-361 DOD’s TRICARE Access Surveys

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.28 (See fig. 6.)

Figure 6: Nonenrolled TRICARE Beneficiaries Who Reported Experiencing Problems Finding a Specialty or Mental Health 

Care Provider over Time, by Provider Type and Network Status

Notes: Bars display 95 percent confidence levels for estimates, rounded to a whole number.

Within specialty health care and mental health care nonnetwork providers, the differences in 

estimates between the 2008-2011 and 2012-2015 surveys are statistically different at the 95 percent 

confidence level.

 28Changes over time for problems finding a primary care provider were not significant at 

the 95 percent confidence level. Twenty percent of nonenrolled beneficiaries with network 

primary care providers and 44 percent of those with nonnetwork primary care providers 

reported problems finding a primary care provider in the 2012-2015 survey. 
Page 19 GAO-18-361 DOD’s TRICARE Access Surveys

a

For the providers’ network status, respondents answered either “yes” or “no” to the question that 

asked: In the last 12 months, was the civilian specialist you saw most part of the TRICARE civilian 

provider network? In addition, respondents answered “a big problem” or “a small problem” to the 

question that asked: In the last 12 months, how much of a problem was it to find a doctor with this 

specialty who would accept TRICARE? Answer choices were “a big problem,” “a small problem,” or 

“not a problem.”

b

For the providers’ network status, respondents answered either “yes” or “no” to the question that 

asked: In the last 12 months, did you receive this treatment or counseling from a provider in 

TRICARE’s civilian network? In addition, respondents answered “a big problem” or “a small problem” 

to the question that asked: Based on the following: In the last 12 months, how much of a problem, if 

any, was it to get the treatment or counseling you needed through your health plan? Answer choices 

were “a big problem,” “a small problem,” or “not a problem.”

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.29 However, the most 

commonly reported length of time they waited between making an 

appointment and actually seeing a provider did not change from the 2008-

2011 surveys—most respondents in both surveys reported they were able 

to get appointments within 3 days (about 54 percent for both years’ 

surveys).30

The 2012-2015 survey also asked specific questions about how easy it 

was to get an appointment with specialty care providers and mental 

health care providers:31

• Of those nonenrolled beneficiaries who tried to make an appointment 

with a civilian specialty care provider, 84 percent reported it was 

 29The margins of error for these estimates are within plus or minus 1 percentage point at 

the 95 percent confidence level. The difference in estimates is significant at the 95 percent 

confidence level.

30The margins of error for these estimates are within plus or minus 1 percentage point at 

the 95 percent confidence level. Respondents had the option of picking time frames for 

how long they had to wait, such as “same day,” “1 day, or “2-3 days,” all the way up to “31 

days or longer.”

31The survey asked this question for specialty care providers and for mental health care 

providers, but did not ask about the ease in obtaining primary care appointments.

More Nonenrolled 

TRICARE Beneficiaries 

Reported Obtaining 

Appointments as Soon as 

Desired
Page 20 GAO-18-361 DOD’s TRICARE Access Surveys

“usually easy,” or “always easy,” to get appointments.32 These results 

also varied by network status, as a higher percentage of those who 

used a network specialty care provider reported that they found it 

“usually easy” or “always easy” to get appointments (85 percent) 

compared to those that used a nonnetwork specialty care provider (74 

percent).33

• Of those nonenrolled beneficiaries that received treatment or 

counseling from a civilian mental health care provider, 73 percent 

reported that when they needed treatment or counseling right away, 

they usually or always saw someone as soon as they wanted.34 We 

found that this result did not change since the prior survey, nor did we 

find any statistically significant differences between beneficiaries’ 

responses for seeing a network versus a nonnetwork mental health 

provider.

 32We could not compare this estimate to see how it has changed over time as the 

previous survey did not ask this question. The margin of error for this estimate is within 

plus or minus 1 percentage point at the 95 percent confidence level.

33The margins of error for these estimates are within plus or minus 7 percentage points at 

the 95 percent confidence level. The difference in estimates is significant at the 95 percent 

confidence level.

34The margin of error for this estimate is within plus or minus 10 percentage points at the 

95 percent confidence level.
Page 21 GAO-18-361 DOD’s TRICARE Access Surveys

Ratings of TRICARE over time. Nonenrolled beneficiaries’ positive 

ratings of TRICARE have generally increased since the previous survey. 

Specifically, over time, nonenrolled beneficiaries’ positive ratings of five 

different categories related to TRICARE have either increased (primary 

care rating, specialty care rating, and health plan rating) or remained the 

same (mental health care rating and health care rating).35 (See fig. 7.) 

Furthermore, nonenrolled beneficiaries’ positive ratings of their mental 

health care providers were lower than their ratings for their primary and 

specialty care providers. We also found that there were no significant 

differences at the 95 percent confidence level for nonenrolled 

beneficiaries’ ratings of primary care, specialty care, or mental health care 

providers based on their network status.36

 35We refer to “positive ratings” as those nonenrolled beneficiaries rated their experiences 

between an 8 and a 10 on an ascending 0-10 scale for each of these categories.

36Due to the survey questions’ wording for ratings with “health care” or “health plan,” we 

could not analyze these ratings by the nonenrolled beneficiaries’ reported providers’ 

network status. 

Nonenrolled 

Beneficiaries’ Positive 

Ratings of TRICARE 

Have Generally 

Increased over Time 

and Vary Compared 

to Other Federal 

Health Plans
Page 22 GAO-18-361 DOD’s TRICARE Access Surveys

Figure 7: Comparison of Nonenrolled Beneficiaries’ Estimated Positive Ratings of Their TRICARE Experiences, over Time

Notes: Percentages show the beneficiaries’ reported ratings of 8-10 on a 0-10 scale.

Bars display 95 percent confidence levels for estimates, rounded to a whole number.

Other than ratings of mental health care and health care, the differences in estimates between the 

2008-2011 and the 2012-2015 survey results are statistically significant at the 95 percent confidence 

level.

a

For the 2012-2015 survey, beneficiaries were asked “Using any number from 0 to 10, where 0 is the 

worst personal doctor possible, and 10 is the best personal doctor possible, what number would you 

use to rate your personal doctor?” The 2008-2011 survey question was the same, except it asked the 

beneficiary to rate the “personal doctor or nurse.” Our analysis is limited to nonenrolled beneficiaries 

who indicated that their personal doctor was a civilian.

b

Beneficiaries were asked “We want to know your rating of the specialist you saw most often in the 

last 12 months. Using any number from 0 to 10, where 0 is the worst specialist possible, and 10 is the 

best specialist possible, what number would you use to rate the specialist?” Our analysis is limited to 

nonenrolled beneficiaries who indicated that they had seen a civilian specialist in the last 12 months.

c

Beneficiaries were asked “Using any number from 0 to 10, where 0 is the worst treatment or 

counseling possible, and 10 is the best treatment or counseling possible, what number would you use 

to rate all your treatment or counseling in the last 12 months?” Our analysis is limited to nonenrolled 

beneficiaries who indicated that they had seen a civilian mental health care provider.

d

Beneficiaries were asked “Using any number from 0 to 10, where 0 is the worst health care possible, 

and 10 is the best health care possible, what number would you use to rate all your health care in the 

last 12 months?”

e

Beneficiaries were asked “Using any number from 0 to 10, where 0 is the worst health plan possible, 

and 10 is the best health plan possible, what number would you use to rate your health plan?”
Page 23 GAO-18-361 DOD’s TRICARE Access Surveys

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.37 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. (See fig.8.)

Figure 8: Nonenrolled TRICARE Beneficiaries’ Estimated Experience Ratings Compared to Those of Medicare Fee-For-Service 

and Medicaid Beneficiaries

Notes: Percentages show the beneficiaries’ reported ratings of 8-10 on a 0-10 scale.

 37We could not compare nonenrolled beneficiaries’ positive ratings of their mental health 

care provider to those of Medicare or Medicaid beneficiaries, as the latter two surveys did 

not contain a relevant question. See GAO-13-364 for previous trends. 
Page 24 GAO-18-361 DOD’s TRICARE Access Surveys

For the 2012-2015 nonenrolled beneficiary survey, margins of error were within 2 percentage points 

for each rating estimate, at the 95 percent confidence level. For the 2013-2015 Medicare and 

Medicaid surveys, margins of error were within 0.3 percentage points for each rating estimate, at the 

95 percent confidence level. Within rating categories, all differences in estimates between 2012-2015 

nonenrolled beneficiary survey results and 2013-2015 Medicare and Medicaid beneficiaries’ results 

are statistically significant at the 95 percent confidence level.

Estimates for Medicare and Medicaid beneficiaries are from the Department of Health and Human 

Services’ 2013 through 2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

surveys to Medicare and Medicaid beneficiaries. These surveys are administered to determine how 

beneficiaries rate their experiences in receiving care in the Medicare and Medicaid programs.

a

Beneficiaries were asked “Using any number from 0 to 10, where 0 is the worst personal doctor 

possible, and 10 is the best personal doctor possible, what number would you use to rate your 

personal doctor?” Our analysis is limited to nonenrolled beneficiaries who indicated that their personal 

doctor was a civilian.

b

TRICARE beneficiaries were asked “We want to know your rating of the specialist you saw most 

often in the last 12 months. Using any number from 0 to 10, where 0 is the worst specialist possible, 

and 10 is the best specialist possible, what number would you use to rate the specialist?” Medicare 

and Medicaid beneficiaries were asked the same question, but only in reference to the last 6 months. 

Our analysis is limited to nonenrolled beneficiaries who indicated that they had seen a civilian 

specialist in the last 12 months.

c

TRICARE Beneficiaries were asked “Using any number from 0 to 10, where 0 is the worst health 

care possible, and 10 is the best health care possible, what number would you use to rate all your 

health care in the last 12 months?” Medicare and Medicaid beneficiaries were asked the same 

question, but only in reference to the last 6 months.

d

Beneficiaries were asked “Using any number from 0 to 10, where 0 is the worst health plan possible, 

and 10 is the best health plan possible, what number would you use to rate your health plan?”
Page 25 GAO-18-361 DOD’s TRICARE Access Surveys

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).38 Specifically, since the previous survey, we found that 

awareness increased for specialty care providers (from 92 to 94 percent) 

and mental health care providers (from 68 to 74 percent).39

In addition, when we analyzed these results by location type, we found 

that civilian providers in both PSAs and non-PSAs reported higher 

awareness of TRICARE since the previous survey (from 79 to 82 percent 

in PSAs and from 87 to 89 percent in non-PSAs).40 Awareness among 

 38When rounded, the margins of error for civilian providers’ awareness of TRICARE are 

within plus or minus 1 percentage point at the 95 percent confidence level. The difference 

in estimates is significant at the 95 percent confidence level.

39Awareness among primary care providers remained unchanged since the last survey. 

When rounded, the margins of error for the specialty care and mental health care 

providers’ awareness of TRICARE are within plus or minus 2 percentage points at the 95 

percent confidence level. Within each provider type, the differences in estimates are 

significant at the 95 percent confidence level.

40When rounded, the margins of error for civilian providers’ awareness of TRICARE by 

location type are within plus or minus 1 percentage point at the 95 percent confidence 

level. Within each location type, the differences in estimates are significant at the 95 

percent confidence level. 

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
Page 26 GAO-18-361 DOD’s TRICARE Access Surveys

civilian providers in locations now designated as former PSAs remained 

statistically unchanged at the 95 percent confidence level (89 percent in 

2012-2015). However, despite some increases in awareness, civilian 

providers in PSAs reported lower awareness than those in non-PSAs and 

former PSAs in the 2012-2015 surveys.41

Provider awareness by network status. Providers within the TRICARE 

network reported higher awareness of TRICARE than nonnetwork 

providers, regardless of individual provider type. (See fig. 9.) Among 

individual provider types, the biggest difference in awareness between 

network and nonnetwork providers was for mental health care providers, 

with 96 percent of network mental health care providers reporting 

awareness of TRICARE compared with 72 percent of nonnetwork mental 

health care providers.42

 41We previously reported that civilian providers in PSAs had lower awareness of 

TRICARE than those in non-PSAs. See GAO-13-364. 

42When rounded, the margins of error for mental health care providers’ awareness of 

TRICARE are within plus or minus 2 percentage points at the 95 percent confidence level. 

The difference in estimates is significant at the 95 percent confidence level.
Page 27 GAO-18-361 DOD’s TRICARE Access Surveys

Figure 9: Civilian Providers’ Reported Awareness of TRICARE, by Provider Type and Network Status (2012-2015)

Notes: Bars display 95 percent confidence levels for estimates, rounded to a whole number.

Within provider types, the differences between the network and nonnetwork providers are statistically 

significant at the 95 percent confidence level.

Respondents answered “yes” to the survey question that asked “Is provider aware of the TRICARE 

health care program?”
Page 28 GAO-18-361 DOD’s TRICARE Access Surveys

Provider acceptance over time, by provider type and location type.

Nationwide, we found an overall decrease reported in civilian providers’ 

acceptance of new TRICARE patients in the 2012-2015 civilian provider 

survey (55 percent) compared to the 2008-2011 civilian provider survey 

(58 percent). 43 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.44

Specifically, mental health care providers’ TRICARE acceptance rate 

decreased from 39 to 36 percent.45 However, this low acceptance rate 

may not be an issue unique to TRICARE, as we have previously reported 

that there is a nationwide shortage of mental health professionals.46

In addition, when we analyzed results for all civilian providers by location 

type, we found that civilian providers in PSAs and non-PSAs reported 

lower acceptance rates of new TRICARE patients since the previous 

survey (from 55 to 53 percent in PSAs, and from 66 to 62 percent in nonPSAs).47 Acceptance among civilian providers in locations now 

designated as former PSAs remained statistically unchanged at the 95 

percent confidence level (60 percent in 2012-2015). Similar to our 

findings on providers’ awareness, we found that civilian providers in PSAs 

 43When rounded, the margins of error for all civilian providers’ acceptance of new 

TRICARE patients are within plus or minus 1 percentage point at the 95 percent 

confidence level. The difference in estimates is significant at the 95 percent confidence 

level.

44Primary care providers’ acceptance of new TRICARE patients was 67 percent in 2008-

2011 and 68 in 2012-2015, and specialty care providers’ acceptance of new TRICARE 

patients was 77 percent in 2008-2011 and 78 percent in 2012-2015. However, these 

differences for primary and specialty care were not statistically significant at the 95 

percent confidence level. 

45When rounded, the margins of error for civilian mental health providers’ acceptance of 

new TRICARE patients are within plus or minus 1 percentage point at the 95 percent 

confidence level. The difference in estimates is significant at the 95 percent confidence 

level.

46See GAO, VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data 

Needed, GAO-16-24 (Washington, D.C.: Oct. 28, 2015).

47When rounded, the margins of error for civilian providers’ acceptance of new TRICARE 

patients are within plus or minus 1 percentage point at the 95 percent confidence level. 

The difference in estimates is significant at the 95 percent confidence level. Acceptance 

rates of new TRICARE patients did not change for former PSAs.

Civilian Mental Health 

Care Providers’ 

Acceptance of New 

TRICARE Patients Has 

Decreased; Network 

Providers Reported Higher 

Acceptance than 

Nonnetwork Providers
Page 29 GAO-18-361 DOD’s TRICARE Access Surveys

reported lower acceptance rates than those in non-PSAs and former 

PSAs.48

Provider acceptance by network status. When we analyzed civilian 

providers’ acceptance of new TRICARE patients by providers’ network 

status, we found that network providers reported higher acceptance of 

new TRICARE patients than nonnetwork providers, regardless of provider 

type. (See fig. 10.) 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.49 Of those 

mental health care providers that were not accepting new TRICARE 

patients, one of the top reasons reported by those not in the network was 

a lack of awareness of TRICARE. Due to the relatively small number of 

network mental health providers who provided reasons for not accepting 

new TRICARE patients, it was not possible to identify one primary 

reason; however, some of the reasons they cited include reimbursement, 

not accepting new patients, and specialty was not covered.50

 48We previously reported that civilian providers in PSAs had lower awareness of 

TRICARE than those in non-PSAs. See GAO-13-364.

49When rounded, the margins of error for civilian mental health providers’ acceptance of 

new TRICARE patients are within 3 percentage points at the 95 percent confidence level. 

The difference in estimates is significant at the 95 percent confidence level.

50The relatively low number of responses that provided reasons for why they were not 

accepting new TRICARE patients resulted in large margins of error. 

Of the 17 percent of network providers who 

reported that they were not accepting new 

TRICARE patients, some of the top reasons 

cited were

• not accepting any new patients,

• reimbursement, and 

• do not know/no answer 

Of the 53 percent of nonnetwork providers 

who reported that they were not accepting 

new TRICARE patients, some of the top 

reasons cited were

• not aware of TRICARE/Not asked/Don’t 

know,

• miscellaneous, and

• specialty not covered 

A Department of Defense official told us that 

some examples of “miscellaneous” are “in a 

private practice”, and “not a preferred 

provider.”

Source: GAO analysis of Department of Defense data. | 

GAO-18-361
Page 30 GAO-18-361 DOD’s TRICARE Access Surveys

Figure 10: Civilian Providers’ Reported Acceptance of New TRICARE Patients, by Provider Type and Network Status (2012-

2015)

Notes: Bars display 95 percent confidence levels for estimates, rounded to a whole number.

Within provider types, the differences between the network and nonnetwork providers are statistically 

significant at the 95 percent confidence level.

Respondents answered “for all claims” or on a “claim-by-claim basis” to the survey question that 

asked “As of today, is the provider accepting new TRICARE Standard patients?”
Page 31 GAO-18-361 DOD’s TRICARE Access Surveys

Our analysis of the 2012-2015 nonenrolled beneficiary and civilian 

provider surveys indicated that beneficiaries may have difficulty accessing 

a primary care provider, a specialty care provider, or both in 6 out of the 

190 specific geographic locations that were surveyed. For the 6 locations 

we identified, beneficiaries reported higher levels of problems finding 

providers, and providers reported lower rates of accepting TRICARE 

patients.51

• Primary care. We identified two locations where access to primary 

care providers may be particularly problematic. (See table 2.) In these 

two locations, the percent of beneficiaries who reported that they had 

problems finding a primary care provider was at or above the 2012-

2015 beneficiary survey’s national average of 22 percent, and also 

where the percent of primary care providers who reported that they 

were accepting new TRICARE patients was at or below the 2012-

2015 civilian provider survey’s national average of 68 percent.52

• Specialty care. We identified five locations where access to specialty 

care providers may be particularly problematic. (See table 2.) In these 

five locations, the percent of beneficiaries who reported that they had 

problems finding a specialty care provider was at or above the 2012-

2015 beneficiary surveys’ national average of 23 percent, and also 

where the percent of specialty care providers who reported that they 

were accepting new TRICARE patients was at or below the 2012-

2015 civilian provider surveys’ national average of 78 percent.53

 51Because of the low numbers of survey responses for beneficiaries who said they 

needed civilian mental health care and responded to the question about whether they had 

a problem finding a civilian mental health care, we are unable to report correlated survey 

results for access problems to civilian mental health care providers.

52We excluded any individual locations that had less than (1) 30 respondents to the 

nonenrolled beneficiary survey questions about difficulties finding a specific type of 

provider, or (2) 50 respondents to the civilian providers’ survey question about acceptance 

of new TRICARE surveys.

53We excluded any individual locations that had less than (1) 30 respondents to the 

nonenrolled beneficiary survey questions about difficulties finding a specific type of 

provider, or (2) 50 respondents to the civilian providers’ survey question about acceptance 

of new TRICARE surveys.

DOD’s Surveys of 

Nonenrolled 

Beneficiaries and 

Civilian Providers 

Collectively Indicate 

That Specific 

Geographic Locations 

May Have Access 

Problems
Page 32 GAO-18-361 DOD’s TRICARE Access Surveys

Table 2: Locations with Both Potential Problems of Beneficiaries Not Finding Providers and Providers Not Accepting New 

TRICARE Patients, 2012-2015

Locations Potential access 

problems with primary 

carea

Potential access 

problems with specialty 

careb

Prime Service Areas (PSAs)

1. Bremerton/Seattle/Coupeville/Renton, Washington ✓ —

2. Brooklyn/Manhattan/Bronx/Jamaica, New York ✓ ✓

3. Fort Worth/Dallas/Arlington/Denton, Texas — ✓

4. Washington, DC/Rockville/Bethesda/Lanham, Maryland — ✓

Former PSAs

5. Dallas/McKinney/Amarillo/Rowlett, Texas — ✓

Hospital Service Area (HSA)

6. Dallas/Fort Worth, Texasc — ✓

Source: GAO analysis of Department of Defense data. | GAO-18-361

Note: We included locations where the percentage of nonenrolled beneficiaries who experienced 

problems finding a civilian provider was at or above the 2012-2015 beneficiary surveys’ national 

average and where the percentage of civilian providers who were accepting any new TRICARE 

patients was at or below the 2012-2015 civilian provider surveys’ national average. Both

determinations were made using the estimates’ margins of error at the 95 percent confidence level. 

We identified and excluded any areas that had fewer than 50 respondents for the civilian provider 

surveys or 30 respondents for the question nonenrolled beneficiary surveys.

a

Inclusion in this category was based on (1) nonenrolled beneficiaries’ responses of “a big problem” 

or “a small problem” to the question that asked “In the last 12 months, how much of a problem was it 

to find a personal doctor or nurse who would accept TRICARE?” and (2) civilian primary care 

providers’ responses of “for all claims” or a “claim-by-claim basis” to the question that asked “As of 

today, is the provider accepting new TRICARE Standard patients?”

b

Inclusion in this category was based on (1) nonenrolled beneficiaries’ responses of “a big problem” 

or “a small problem” to the question that asked “In the last 12 months, how much of a problem was it 

to find a doctor with this specialty who would accept TRICARE?” and (2) civilian specialty care 

providers’ responses of “for all claims” or a “claim-by-claim basis” to the question that asked “As of 

today, is the provider accepting new TRICARE Standard patients?”

c

The Dallas/Fort Worth, Texas, HSA is part of both the Dallas/McKinney/Amarillo/Rowlett, Texas 

Former PSA and the Fort Worth/Dallas /Arlington/Denton, Texas PSA.

When we compared this analysis to our analysis of the 2008-2011 

beneficiary and provider surveys, the “Dallas/Fort Worth, Texas” HSA 

was identified in both results. Using data from the prior survey, our 

analysis identified it as being potentially problematic for primary care, but 

using data from the more recent survey, we identified specialty care 

access as being potentially problematic.54 DOD officials told us that their 

 54See GAO-13-364.
Page 33 GAO-18-361 DOD’s TRICARE Access Surveys

past analysis of beneficiaries’ complaints in this location centered on 

appointment wait times exceeding beneficiaries’ preferences and on drive 

times to providers’ offices. Officials explained that although there was a 

wide range of network specialty care providers in this location, TRICARE 

beneficiaries were a very small percentage of the overall population. 

Furthermore, this location is home to a number of large corporations that 

have health care plans that reimburse providers more than TRICARE. 

DOD officials added that due to these factors, providers in this location do 

not give preference to TRICARE beneficiaries, and drive times in this 

location are often long due to the traffic patterns and overall congestion of 

a large urban area.

In reviewing a draft of this report, DOD concurred with our overall 

findings. DOD’s written response is reprinted in appendix I.

We are sending copies of this report to the Secretary of Defense and 

appropriate congressional committees. The report is also available at no 

charge on GAO’s website at http://www.gao.gov. 

If you or your staff has any questions regarding this report, please contact 

Debra A. Draper at (202) 512-7114 or draperd@gao.gov. Contact points 

for our Offices of Congressional Relations and Public Affairs may be 

found on the last page of this report. GAO staff who made key 

contributions to this report are listed in appendix II.

Debra A. Draper

Director

Health Care

Agency Comments
Appendix I: Comments from the Department of 

Defense

Page 34 GAO-18-361 DOD’s TRICARE Access Surveys

Appendix I: Comments from the Department 

of Defense
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 35 GAO-18-361 DOD’s TRICARE Access Surveys

Debra A. Draper at (202) 512-7114 or draperd@gao.gov.

In addition to the contacts named above, Bonnie Anderson, Assistant 

Director; Jeff Mayhew, Analyst-in-Charge; Amy Andresen; and Jennie 

Apter made key contributions to this report. Also contributing were Zhi 

Boon, Jacquelyn Hamilton, Vikki Porter, and Eric Wedum.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact:

Staff 

Acknowledgments:

(101917)
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