United States Government Accountability Office

GAO Report to Congressional Committees

DEFENSE HEALTH 

CARE 

Access to Care for 

Beneficiaries Who 

Have Not Enrolled in 

TRICARE’s Managed 

Care Option 

December 2006 

 

GAO-07-48 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

December 2006

DEFENSE HEALTH CARE 

Access to Care for Beneficiaries Who 

Have Not Enrolled in TRICARE’s Managed 

Care Option 

Highlights of GAO-07-48, a report to 

congressional committees 

The Department of Defense (DOD)

provides health care through its 

TRICARE program. Under 

TRICARE, beneficiaries may obtain 

care through a managed care 

option that requires enrollment and 

the use of civilian provider 

networks, which are developed and 

managed by contractors. 

Beneficiaries who do not enroll 

may receive care through TRICARE 

Standard, a fee-for-service option, 

using nonnetwork civilian 

providers or through TRICARE 

Extra, a preferred provider 

organization option, using network 

civilian providers. Nonenrolled 

beneficiaries in some locations 

have reported difficulties finding 

civilian providers who will accept 

them as patients. 

The National Defense

Authorization Act (NDAA) for 

fiscal year 2004 directed GAO to

provide information on access to 

care for nonenrolled TRICARE 

beneficiaries. This report describes

(1) how DOD and its contractors 

evaluate nonenrolled beneficiaries’ 

access to care and the results of 

these evaluations; (2) impediments 

to civilian provider acceptance of 

nonenrolled beneficiaries, and how 

they are being addressed; and

(3) how DOD has implemented the 

NDAA fiscal year 2004

requirements to take actions to

ensure nonenrolled beneficiaries’ 

access to care. To address these

objectives, GAO examined DOD’s 

survey results and DOD and

contractor documents and

interviewed DOD and contractor

officials. 

DOD and contractor officials use various methods to evaluate access to care, 

and according to these officials, their methods indicate that access is 

generally sufficient for nonenrolled beneficiaries. For example, in its 2005 

survey of civilian providers DOD found that 14 percent of civilian providers 

surveyed in 20 states were not accepting new patients from any health plan. 

Of those accepting new patients, about 80 percent would accept nonenrolled 

TRICARE beneficiaries as new patients. DOD’s contractors use various 

methods to monitor access to care. While these methods were not designed 

specifically to evaluate access for nonenrolled beneficiaries, they provide 

information that allows contractors to monitor the availability of both 

network and nonnetwork civilian providers for this population. According to

contractor officials, their measures indicate that nonenrolled beneficiaries’ 

access to care is sufficient overall. 

DOD, its contractors, and beneficiary and provider representatives cited 

various factors as impediments to network and nonnetwork civilian 

providers’ acceptance of nonenrolled TRICARE beneficiaries and ways to 

address them. These impediments include concerns specific to TRICARE, 

including reimbursement rates and administrative issues, as well as issues 

not specific to TRICARE, such as providers without sufficient practice 

capacity for additional patients. DOD and its contractors have specific ways 

to address impediments related to reimbursement rates and administrative 

issues, but issues that are not specific to TRICARE are more difficult to 

resolve. For example, DOD has authority to increase reimbursement rates 

for network and nonnetwork civilian providers in areas where access to care 

has been impaired. Furthermore, other impediments not specific to 

TRICARE, such as provider practices at capacity and few providers in 

geographically remote locations, cannot be readily resolved and create 

access difficulties for all local residents, including TRICARE beneficiaries. 

Various DOD offices as well as DOD’s contractors are already carrying out 

the responsibilities outlined by the NDAA for fiscal year 2004—such as 

educating civilian providers and recommending reimbursement rate 

adjustments—actions that help ensure nonenrolled beneficiaries’ access. 

However, a senior official was not formally designated to have responsibility 

for these mandated actions. 

DOD commented on the report, stating that GAO’s approach was insightful, 

but disagreeing with GAO’s finding that a senior official was not formally 

designated to be responsible for taking actions to ensure TRICARE 

beneficiaries’ access to care as outlined in the NDAA. DOD said that an 

existing directive designating a senior official to serve as program manager

for TRICARE met this requirement. However, the directive does not 

specifically designate an official responsible for ensuring access as specified 

in the NDAA. Nor did DOD take other actions to designate that a senior 

official have such responsibilities. 

www.gao.gov/cgi-bin/getrpt?GAO-07-48.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marcia Crosse 

at (202) 512-7119 or crossem@gao.gov. 
Contents 

Letter 1

Results in Brief 4

Background 6

TMA and Its MCSCs Use Various Methods to Evaluate Access to 

Care That Indicate Sufficient Access for Nonenrolled TRICARE 

Beneficiaries 18

Various Factors Impede Providers’ Acceptance of Nonenrolled 

TRICARE Beneficiaries, and TMA and MCSCs Have Different 

Ways to Address Them 29 

NDAA Responsibilities for Nonenrolled TRICARE Beneficiaries’ 

Access to Care Are Being Carried Out by TMA and the MCSCs, 

but Were Not Formally Designated to a Senior Official 41 

Agency Comments and Our Evaluation 44 

Appendix I Scope and Methodology 47 

Appendix II Methodology Used for TMA’s Civilian Provider 

Survey 51 

Appendix III Civilian Provider Survey Instrument 56 

Appendix IV Categorized Responses to the Civilian Provider 

Survey’s Open-ended Question 59 

Appendix V TRICARE Reimbursement Rates That Remain 

Higher than Medicare Reimbursement Rates 60 

Appendix VI Comments from the Department of Defense 63 

Appendix VII GAO Contacts and Staff Acknowledgments 65 

Page i GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Tables 

Table 1: Summary of the Three Main TRICARE Options 10 

Table 2: TMA’s 2005 Civilian Provider Survey Results Showing 

Percent of Surveyed Providers Accepting Nonenrolled 

TRICARE Beneficiaries (of Those Accepting New Patients) 

by State 20 

Table 3: TMA’s 2005 Civilian Provider Survey Results Showing 

Percent of Surveyed Providers Accepting Nonenrolled 

TRICARE Beneficiaries (of Those Accepting New Patients) 

by Hospital Service Area 22 

Table 4: Applications for Locality Waivers and Approval Results 33 

Table 5: Applications for Network Waivers and Approval Results 35 

Table 6: Responsibilities Outlined in the NDAA for Fiscal Year 2004 

and the Entities Covering Them 42 

Table 7: “What are the reasons Doctor X is Not Accepting New

TRICARE [Nonenrolled] Patients?” 59 

Figures 

Figure 1: TRICARE Beneficiaries in Fiscal Year 2005 7 

Figure 2: Location of Prime Service Areas in Each TRICARE 

Region 13

Figure 3: All Nonenrolled TRICARE Beneficiaries by Region 15 

Figure 4: Percent of Claims Paid for TRICARE Standard and Extra 

for Each TRICARE Region for Fiscal Years 2001-2005 16 

Page ii GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Abbreviations 

ART Assistance Reporting Tool 

ASD Assistant Secretary of Defense 

CAHPS Consumer Assessment of Healthcare Providers and 

 Systems 

CPT current procedural terminology 

DOD Department of Defense 

HSA hospital service area 

MCSC managed care support contractor 

MTF military treatment facility 

NDAA National Defense Authorization Act 

OMB Office of Management and Budget 

TFL TRICARE for Life 

TMA TRICARE Management Activity 

TRO TRICARE regional office 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page iii GAO-07-48 Access to Care for Nonenrolled Beneficiaries
United States Government Accountability Office

Washington, DC 20548 

December 22, 2006 

The Honorable John Warner 

Chairman 

The Honorable Carl Levin 

Ranking Minority Member 

Committee on Armed Services 

United States Senate 

The Honorable Duncan L. Hunter 

Chairman 

The Honorable Ike Skelton 

Ranking Minority Member 

Committee on Armed Services 

House of Representatives 

The Department of Defense (DOD) offers health care to almost 10 million 

beneficiaries, including active duty personnel, retirees, and their 

dependents, through its regionally structured TRICARE program, which is 

expected to cost about $37 billion in fiscal year 2006. Under TRICARE, 

health care is available through the military services’ system of military 

hospitals and clinics, referred to as military treatment facilities (MTFs) 

and through civilian providers. Although DOD and the military services 

strive to maximize the use of MTFs, TRICARE beneficiaries have received 

an increasing amount of care through civilian providers. Between fiscal 

years 2000 and 2005, the percent of inpatient care delivered to TRICARE 

beneficiaries by civilian providers increased from about 50 percent to an 

estimated 75 percent. During the same time frame, the percent of 

outpatient care delivered by civilian providers increased from 39 percent 

to an estimated 65 percent.1

TRICARE has three options for its beneficiaries:2 Prime, Standard, or 

Extra. These options vary according to enrollment requirements, the 

 1

Fiscal year 2005 data are estimates by the TRICARE Management Activity (TMA) because 

providers and TRICARE beneficiaries have up to a year to file health care claims. 

2

TRICARE beneficiaries who are eligible for Medicare and enroll in Part B are eligible to 

receive care under TRICARE for Life. Under this program, TRICARE processes claims after 

they have been adjudicated by Medicare. 

Page 1 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
choices beneficiaries have in selecting civilian and MTF providers, and the 

amount they must contribute towards the cost of their care. Prime, a 

program in which beneficiaries receive care in a managed care provider 

network similar to a health maintenance organization, is the only option 

requiring enrollment and has the lowest copayments. Beneficiaries who 

enroll in Prime usually obtain health care from the MTF, but they may also

obtain care from a network civilian provider when MTF care is not 

available. Beneficiaries do not need to enroll to receive care under 

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

organization option. Under Standard, nonenrolled beneficiaries can obtain 

health care from civilian providers who do not belong to the TRICARE 

network but agree to accept TRICARE beneficiaries as patients. 

Beneficiaries have the highest copayments under Standard. Under Extra, 

nonenrolled beneficiaries may obtain health care from network civilian 

providers. Nonenrolled beneficiaries cannot be categorized as belonging to

an Extra or Standard group because each time they seek care, they can 

choose to see either a network or nonnetwork civilian provider, and this 

choice determines whether they receive coverage under Extra or 

Standard. Under any option, TRICARE beneficiaries may receive care at 

an MTF when space is available. Priority for MTF usage is given first to 

active duty personnel and then to beneficiaries enrolled in Prime. 

DOD’s TRICARE Management Activity (TMA) uses managed care support 

contractors (MCSC) to develop networks of civilian providers and perform 

other customer service functions, such as claims processing, and to ensure 

that all beneficiaries—including nonenrolled beneficiaries—receive

satisfactory service under TRICARE, such as assistance with finding 

providers. Currently, there is one MCSC for each of TRICARE’s three 

regions—North, South, and West. For each region, TMA has established a 

TRICARE Regional Office (TRO) and has designated the TRO directors as 

the health plan managers for their regions with responsibilities such as 

monitoring provider network quality and adequacy, overseeing the MCSCs, 

and monitoring customer satisfaction. 

Since TRICARE began in 1995, nonenrolled TRICARE beneficiaries in 

some locations have complained about difficulties finding nonnetwork 

civilian providers who will accept them as patients. In addition, TRICARE

beneficiaries have cited concerns that TMA has focused more attention on

the Prime option, which allows TMA to manage beneficiaries’ care, and 

has given less attention to the options available for nonenrolled TRICARE 

beneficiaries. In response to these concerns, the National Defense 

Authorization Act (NDAA) for fiscal year 2004 directed DOD to monitor 

nonenrolled TRICARE beneficiaries’ access to care through a survey of 

Page 2 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
civilian providers.3

 In addition, the NDAA required DOD to designate a 

senior official to take actions to ensure access to care for nonenrolled 

TRICARE beneficiaries. 

The NDAA for fiscal year 2004 also directed GAO to review the processes, 

procedures, and analysis used by DOD to determine the adequacy of the 

number of network and nonnetwork civilian providers and the actions 

taken to ensure access to care for nonenrolled TRICARE beneficiaries. 

Specifically, as discussed with the committees of jurisdiction, this report 

describes (1) how TMA and its MCSCs evaluate nonenrolled TRICARE 

beneficiaries’ access to care and the results of these evaluations; (2) the 

impediments to civilian provider acceptance of nonenrolled TRICARE 

beneficiaries, and how they are being addressed; and (3) how DOD has 

implemented the fiscal year 2004 NDAA requirements to take actions to 

ensure nonenrolled TRICARE beneficiaries’ access to care. 

To determine how TMA evaluates nonenrolled TRICARE beneficiaries’ 

access to care, we interviewed and obtained documentation from TMA 

officials about the civilian provider survey, which included a random, 

representative sample of civilian providers in selected geographic 

locations and therefore included both network and nonnetwork civilian 

providers. We also reviewed information from TMA’s annual beneficiary 

health care survey, which includes information on beneficiaries’ access to 

care. In addition, we met with TRO and MCSC officials for each of the 

three regions, TMA officials, and representatives from each of the services’

Surgeons General to identify and evaluate the tools used for monitoring 

access to care. To identify the impediments to network and nonnetwork 

civilian providers’ acceptance of nonenrolled TRICARE beneficiaries and 

how these impediments are being addressed, we obtained information 

from TMA, TRO, and MCSC officials. We also met with representatives of 

TRICARE beneficiaries and the American Medical Association to discuss 

their concerns about impediments to health care access for nonenrolled 

TRICARE beneficiaries. In addition, we obtained and analyzed data related 

to TMA’s implementation of reimbursement rate increases in specific 

locations for the purpose of improving access to care. However, we did 

not evaluate the extent to which the rate increases improved civilian

providers’ acceptance of TRICARE beneficiaries as patients. To examine 

how DOD has implemented the fiscal year 2004 NDAA requirements to 

 3

See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003) and S. Rep. No. 108-46, at 330 

(2003). 

Page 3 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
take actions to ensure nonenrolled TRICARE beneficiaries’ access to care, 

we obtained information from TMA, TRO, and MCSC officials. Through 

our review of the relevant documentation and our discussions with TMA, 

TRO, and MCSC officials, we determined that the data presented in this 

report were sufficiently reliable for our purposes. We conducted our work 

from July 2005 through December 2006 in accordance with generally 

accepted government auditing standards. Appendix I contains more details 

about our scope and methodology, and appendix II contains more detail 

about the scope and methodology of DOD’s civilian provider survey. 

TMA and its MCSCs use various methods to evaluate access to care, and 

according to TMA and MCSC officials, the resulting measures indicate that

nonenrolled TRICARE beneficiaries’ access to care is generally sufficient 

and that access problems appear to be minimal. Among methods used by 

TMA to evaluate access to care are its recently implemented civilian

provider survey and an annual beneficiary health care survey. The survey 

of civilian providers, which includes network and nonnetwork providers, 

is designed to measure access to care by identifying how many civilian 

providers are willing to accept nonenrolled TRICARE beneficiaries as new 

patients. The first round of this survey, implemented in 2005, focused on 

20 states and found that 14 percent of civilian providers were not 

accepting new patients from any government or commercial health plan. 

Of those accepting new patients, about 80 percent would accept 

nonenrolled TRICARE beneficiaries as new patients. In addition, the 

results of each of TMA’s annual beneficiary health care surveys for 2003 

through 2005 show that nonenrolled TRICARE beneficiaries’ satisfaction 

with access to care was similar to satisfaction reported by participants in 

commercial health plans. TMA and the TROs also receive anecdotal 

information through beneficiary feedback, and, according to these 

officials, complaints about access to care are infrequent. Each of the 

MCSCs also has its own methods of monitoring access to care, including 

analyzing provider and beneficiary locations as part of their responsibility 

for ensuring sufficient network capacity for all TRICARE beneficiaries 

residing in locations with civilian provider networks. While the MCSCs’ 

methods were not designed specifically to evaluate access for nonenrolled 

TRICARE beneficiaries, they do provide helpful information that allows 

the MCSCs to monitor the availability of both network and nonnetwork 

civilian providers for this population. According to MCSC officials, their 

measures indicate that nonenrolled TRICARE beneficiaries’ access to care 

is sufficient overall. 

Results in Brief 

Page 4 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
TMA, MCSCs, and beneficiary and provider representatives cited various 

factors as impediments to network and nonnetwork civilian providers’ 

acceptance of nonenrolled TRICARE beneficiaries and different ways to 

address them. These impediments include concerns that are specific to the 

TRICARE program, including reimbursement rates and administrative 

issues, as well as issues that are not specific to TRICARE, such as 

providers not having sufficient capacity in their practices for additional 

patients and provider shortages in geographically remote areas. TMA and 

the MCSCs have specific ways to respond to impediments related to 

TRICARE reimbursement rates and administrative issues, while the others 

are more difficult to address. For example, TMA has the authority to 

increase reimbursement rates for network and nonnetwork civilian 

providers in locations where TMA determines that access to care is 

impaired. Using this authority, TMA has increased reimbursement rates for 

specific services for network and nonnetwork civilian providers in 15 

locations, including two waivers covering the state of Alaska. To respond 

to network and nonnetwork civilian providers’ concerns about 

administrative issues, such as problems with claims processing, MCSCs 

are working to educate providers on TRICARE requirements. However, 

while MCSCs and TMA believe that efforts to increase reimbursement 

rates and assist providers with administrative issues have improved access 

to care, the actual extent to which these efforts have improved access is 

unclear. Nonetheless, other impediments that are not specific to TRICARE 

are more difficult for TMA and MCSCs to resolve. For example, some 

network and nonnetwork civilian providers do not accept nonenrolled 

TRICARE beneficiaries as new patients because their practices are already 

at capacity. In addition, there are few practicing civilian providers, either 

network or nonnetwork, in some geographically remote areas, impairing 

access for all local residents, including TRICARE beneficiaries. Recently 

TMA has adopted two bonus payment systems similar to those used by 

Medicare for locations with provider shortages. 

Various TMA offices, including the TROs, and the MCSCs are carrying out 

the responsibilities outlined by the NDAA for fiscal year 2004—such as 

educating civilian providers and recommending reimbursement rate 

adjustments—actions that help ensure nonenrolled beneficiaries’ access to

care. For example, in some locations, the TROs have recommended 

adjustments to reimbursement rates when access to care was impaired. 

Other activities, such as educating nonnetwork civilian providers, are 

shared by the TROs, other TMA offices, and the MCSCs. However, a senior 

official was not formally designated to have responsibility for these 

actions as required in this mandate. 

Page 5 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
DOD said our approach used to address issues in this report was 

thoughtful and insightful, but DOD disagreed with our finding that a senior 

official was not formally designated to take actions to ensure adequate 

access to care for nonenrolled TRICARE beneficiaries, including ensuring

adequate participation by nonnetwork providers, as outlined by the NDAA 

for fiscal year 2004. DOD stated that the agency has an existing directive 

that designates a senior official to serve as program manager for 

TRICARE, which meets the NDAA mandate for nonenrolled beneficiaries. 

However, we do not agree that DOD has adequately addressed the 

mandate. First, during our audit work we found that no specific actions 

had been taken to designate a senior official. Second, while the 

responsibilities of the TMA Director and the TROs under the directive 

generally encompass provision of care to nonenrolled beneficiaries, the 

directive does not task any one official with identifying the specific actions

necessary to ensure adequate provider participation in each market area,

as the law required. 

In fiscal year 2005, almost 10 million beneficiaries were eligible to receive 

health care under TRICARE, DOD’s regionally structured health care 

program. Under TRICARE, beneficiaries have choices among three 

different benefit options and may obtain care from either MTFs or civilian 

providers. The NDAA for fiscal year 2004 directed DOD to conduct a 

survey to monitor access to care for beneficiaries who chose not to use 

TRICARE’s managed care option and to appoint a senior official to take

actions to ensure that these beneficiaries have adequate access to care. 

TRICARE beneficiaries fall into various categories, including active duty 

personnel and their dependents and retirees and their dependents. 

Retirees and certain dependents and survivors who are entitled to 

Medicare Part A and enrolled in Part B, and who are generally age 65 and

older,4

 are eligible to obtain care under a separate program called 

Background 

Composition of TRICARE’s 

Beneficiary Population 

 4

TRICARE beneficiaries under 65 years of age who are eligible for Medicare Part A on the 

basis of disability or end stage renal disease are eligible for TRICARE for Life if they enroll 

in Medicare Part B. 

Page 6 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
TRICARE for Life (TFL).5

 As shown in figure 1, active duty personnel and 

their dependents represent 42 percent of the beneficiary population. 

Retirees and their dependents who are not entitled to Medicare (generally

under age 65) comprised 44 percent of the TRICARE beneficiary 

population while retirees and dependents over 65 represented 14 percent

of the beneficiary population. 

Figure 1: TRICARE Beneficiaries in Fiscal Year 2005 

Source: GAO analysis of DOD data.

Active duty personnel and dependentsb

Retirees and dependents

(generally under age 65)a

TRICARE for Life retirees and

dependents (generally age 65 and older)a 14%

42%

44%

a

TRICARE beneficiaries under 65 years of age who are eligible for Medicare Part A on the basis of 

disability or end stage renal disease are eligible for TRICARE for Life if they enroll in Medicare Part B.

b

National Guard and reservists who have been activated are included as active duty personnel and 

their family members are included as dependents. 

 5

TRICARE for Life is a program for Medicare-eligible beneficiaries enrolled in Medicare

Part B, which covers charges from licensed practitioners, as well as clinical laboratory and 

diagnostic services, surgical supplies and durable medical equipment, and ambulance 

services. TRICARE for Life pays expenses remaining after Medicare has paid its share of 

claims and also pays for certain skilled nursing and inpatient hospitalization services that 

Medicare does not cover. 

Page 7 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
TRICARE beneficiaries can choose to obtain health care through MTFs or 

through civilian providers, which includes providers who belong to the 

TRICARE provider network as well as nonnetwork providers who agree to

accept TRICARE beneficiaries as patients. Individual civilian providers 

must be licensed by their state, accredited by a national organization, if 

one exists, and meet other standards of the medical community to be 

authorized to provide care under TRICARE. Individual TRICAREauthorized civilian providers can include attending physicians, certified 

nurse-practitioners, clinical nurse specialists, dentists, clinical 

psychologists, physician assistants, podiatrists, and optometrists, among 

others. There are two types of authorized civilian providers—network and 

nonnetwork providers. Network civilian providers are TRICAREauthorized providers who enter a contractual agreement with the regional 

MCSC to provide health care to TRICARE beneficiaries. By law, TRICARE 

maximum allowable reimbursement rates must generally mirror Medicare 

rates, but network providers may agree to accept lower reimbursements 

as a condition of network membership. In some cases, they agree to 

accept negotiated reimbursement rates, which are usually discounts off of 

the TRICARE reimbursement rates, as payment in full for medical care or

services. Network civilian providers are reimbursed at their negotiated 

rate regardless of whether they are providing care to enrolled TRICARE 

beneficiaries under the Prime option or nonenrolled TRICARE 

beneficiaries under the Extra option. Network civilian providers file claim 

forms for TRICARE beneficiaries and follow other contractually required 

processes, such as those for obtaining referrals. However, network civilian 

providers are not obligated to accept all TRICARE beneficiaries seeking 

care. For example, a network civilian provider may decline to accept 

TRICARE beneficiaries as patients because the provider’s practice does 

not have sufficient capacity or for other reasons.6

Network and Nonnetwork 

Civilian Providers Under 

TRICARE 

Nonnetwork civilian providers are TRICARE-authorized providers who do 

not have a contractual agreement with an MCSC to provide care to 

TRICARE beneficiaries.7

 Nonnetwork civilian providers may accept 

TRICARE beneficiaries as patients on a case-by-case basis. These 

providers may choose to accept the TRICARE reimbursement rate as 

 6

For example, network providers may determine that only a set amount of their practice—

such as 10 or 20 percent—will be allocated to TRICARE patients. When this percentage is 

met, providers may decline to accept any new TRICARE patients. 

7

TRICARE beneficiaries who choose to receive medical care from providers who are not 

TRICARE-authorized may be responsible for all billed charges. 

Page 8 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
payment in full for their services on a case-by-case basis. This practice is 

referred to as “participating” or accepting assignment on a claim. 

Nonnetwork civilian providers also have the option of charging up to 

15 percent more than the TRICARE reimbursement rate for their services 

on a case-by-case basis—a practice referred to as “non-participating.” 

However, when a nonnetwork civilian provider bills more than the 

TRICARE reimbursement rate, TRICARE beneficiaries are responsible for 

paying the extra amount billed in addition to their required copayments. 

TROs and MCSCs told us that this authority is infrequently used, in part, 

because when providers bill the additional 15 percent, they usually collect 

their total reimbursement from the TRICARE beneficiaries, who may not 

always pay promptly.8

 When nonnetwork civilian providers “participate”

on a claim and agree to accept the TRICARE reimbursement amount as 

payment in full, the MCSCs usually pay them directly, ensuring timely 

payment of the claim. 

TRICARE’s Benefit 

Options 

TRICARE provides its benefits through three main options for its nonMedicare eligible beneficiary population that vary according to TRICARE 

beneficiary enrollment requirements, the choices TRICARE beneficiaries 

have in selecting civilian and MTF providers, and the amount TRICARE 

beneficiaries must contribute towards the cost of their care. However, 

while there are three main options, there are only two types of TRICARE

beneficiaries—enrolled and nonenrolled—and two types of civilian 

providers—network and nonnetwork. (See table 1.) All beneficiaries may 

also obtain care at MTFs although priority is given to active duty 

beneficiaries and Prime enrollees. 

 8

Between fiscal years 2001 and 2005 the percent of nonnetwork civilian providers who 

billed TRICARE beneficiaries an additional 15 percent over the TRICARE reimbursement 

rate on some of their claims decreased from 10 percent to 6.3 percent. Similarly, the

percent of nonnetwork civilian providers who billed an additional 15 percent over the

TRICARE reimbursement rate on all of their claims decreased from 7.4 percent in fiscal 

year 2001 to 4.4 percent in fiscal year 2005. 

Page 9 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Table 1: Summary of the Three Main TRICARE Options 

TRICARE 

option Type of option

Enrollment 

required Enrollment fee

Civilian 

provider statusa

Deductible

Beneficiary 

copayment 

(outpatient care)b

Prime Managed care Yes YescNetwork None $0–$12d

Standard Fee-for-service No No Nonnetwork $50-$150 per

individual; 

$100-$300 per 

familyf

20–25% of the 

TRICARE 

reimbursement ratee

Extra Preferred provider

organization 

No No Network $50-$150 per

individual; 

$100-$300 per 

familyf

15–20% of the 

TRICARE 

reimbursement rate 

Source: GAO analysis of DOD data. 

a

Beneficiaries may also use MTF providers. Priority for MTF usage is given to active duty personnel 

and beneficiaries enrolled in Prime. 

b

The lower range of copayments apply to active duty dependents while higher copayments apply to 

retirees and their dependents. There is no charge for outpatient care received at MTFs. 

c

There is no enrollment fee for active duty servicemembers and their dependents. However, retirees 

and their dependents under 65 years must pay an annual enrollment fee of $230 per individual or 

$460 per family. 

d

Inpatient care and other types of service require different levels of copayment for retirees. Active duty

family members who enroll in Prime never incur a copayment. 

e

On a case-by-case basis, nonnetwork civilian providers may charge up to 15 percent more than the 

TRICARE reimbursement rate. In these instances, the TRICARE beneficiaries are also responsible 

for this amount in addition to copayments. 

f

Dependents of lower-ranked enlisted personnel pay lower deductible amounts. Dependents of 

higher-ranked military personnel, as well as retirees and their dependents, pay the higher deductible 

amounts. 

The three main options with their corresponding enrollment requirements 

and provider categories are as follows: 

• TRICARE Prime: This managed care option is the only TRICARE option 

requiring enrollment. Active duty servicemembers are required to enroll in

this option while other TRICARE beneficiaries may choose to enroll.9

Prime enrollees receive most of their care from providers at MTFs, 

augmented by network civilian providers who have agreed to meet 

specific access standards for appointment wait times among other 

 9

To use the TRICARE Prime option, eligible TRICARE beneficiaries must reside in 

locations where TRICARE Prime is offered. 

Page 10 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
requirements.10 Prime enrollees have a primary care manager who either 

provides care or authorizes referrals to specialists. Beneficiaries can be

assigned to a primary care manager at the MTF or, if the MTF is at 

capacity or no MTF is available, Prime enrollees may select a civilian 

primary care manager. Prime offers lower out-of-pocket costs than the 

other TRICARE options. Active duty personnel and their dependents do 

not pay enrollment fees, annual deductibles, or copayments for care 

obtained from network civilian providers. Retirees and their dependents 

who are not entitled to Medicare pay an annual enrollment fee and small 

copayments for care obtained from network civilian providers. 

• TRICARE Standard: TRICARE beneficiaries who choose not to enroll in

Prime may obtain health care using this fee-for-service option, which is 

designed to provide maximum flexibility in selecting providers. Under 

Standard, nonenrolled TRICARE beneficiaries may obtain care from 

TRICARE-authorized nonnetwork civilian providers of their choice. 

TRICARE beneficiaries using this option do not need a referral for most 

specialty care. Under Standard, all TRICARE beneficiaries must pay an 

annual deductible and copayments, which vary among active duty 

dependents and retirees and their dependents, and there is no annual 

enrollment fee.11 In addition, nonnetwork providers are not required to 

meet access standards, such as those for appointment wait times. 

• TRICARE Extra: Similar to a preferred-provider organization, 

nonenrolled TRICARE beneficiaries may also obtain health care from a 

TRICARE network civilian provider for lower copayments than they would 

have under the Standard option—about 5 percent less. TRICARE 

beneficiaries choosing to use Extra must pay towards the same annual 

deductible as Standard and are responsible for copayments. Similar to 

Standard, there is no annual enrollment fee. Additionally, network civilian 

providers caring for nonenrolled TRICARE beneficiaries must adhere to 

the same access standards for appointment wait times that they use for 

enrolled TRICARE beneficiaries under Prime. 

 10Prime enrollees may also receive care from nonnetwork providers; however, such care is

subject to deductibles and copayments of 50 percent of the TRICARE reimbursement rate

unless the enrollee has a referral for the care from the Primary Care Manager. 

11The annual deductible also varies from $50 to $150 per person or from $100 to $300 per 

family. Dependents of lower-ranked active duty enlisted personnel pay the lower 

deductible amounts. Dependents of high-ranked personnel and retirees and their

dependents pay the higher deductible amounts. 

Page 11 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Among TRICARE beneficiaries who were not Medicare eligible in fiscal 

year 2005, about 5.5 million or 65 percent of TRICARE’s beneficiaries were 

enrolled in Prime and thereby declared their intent to use their TRICARE 

benefit. In contrast, TMA does not know whether nonenrolled 

beneficiaries intend to use their TRICARE benefit. In fiscal year 2005, 

claims data showed that about 1.2 million or 14 percent of nonenrolled 

TRICARE beneficiaries obtained care with 66 percent of this care being 

delivered through the Standard option and 34 percent delivered through 

the Extra option. The remaining 1.8 million or 21 percent of nonenrolled 

beneficiaries were eligible for TRICARE benefits but did not use them 

during this time period.12 At any time, this population of eligible nonusers 

could elect to use Standard or Extra, and DOD would reimburse claims 

submitted for their health care after annual deductibles are met. 

TMA uses three MCSCs to provide civilian health care under the TRICARE 

program. Each MCSC is responsible for the delivery of care to TRICARE 

beneficiaries in one of three geographic regions—North, South, and West. 

The MCSCs are contractually required to establish and maintain networks 

of civilian providers in designated locations within these regions that are 

referred to as Prime Service Areas. (See fig. 2 for the location of Prime 

Service Areas in each of the three TRICARE regions.) Prime Service Areas

include all MTF enrollment areas,13 Base Realignment and Closure sites,14

and additional areas where either TMA or the MCSC deems networks to be 

cost effective. As a result, each region may contain multiple Prime Service

Areas. In these areas, civilian provider networks are required to be large 

enough to provide access for all TRICARE beneficiaries regardless of 

enrollment status or Medicare-eligibility. TMA contractually requires that 

MCSCs’ civilian provider networks meet specific access standards, such as

travel times or wait times, for both primary and specialty care. For 

example, TRICARE beneficiaries seeking primary care should not have to

drive more than 30 minutes to get to their appointment locations. In 

TRICARE Contracts and 

Regional Structure 

 12About 1.3 million additional beneficiaries were eligible for TRICARE for Life in fiscal year 

2005. 

13MTF enrollment areas are geographic areas determined by the ASD for Health Affairs that 

are defined by five-digit zip codes, usually within an approximate 40-mile radius of MTFs 

with inpatient care. In areas encompassing MTFs, the civilian provider networks are

expected to complement the clinical services provided in MTFs. 

14Base Realignment and Closure sites are military installations that have been closed or 

realigned as a result of decisions made by the Commission on Base Realignment and 

Closure. 

Page 12 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
addition to contractual requirements, the MCSCs can add additional 

access standards that they strive to meet. 

Figure 2: Location of Prime Service Areas in Each TRICARE Region 

Source: GAO analysis of DOD data. 

Prime service area

TRICARE 

North Region 

TRICARE 

South Region 

TRICARE 

West Region 

Note: Shaded areas represent counties in which there was a TRICARE network of civilian providers

available to serve both enrolled and nonenrolled beneficiaries. 

Page 13 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
MCSCs are also responsible for performing other customer service 

functions, such as processing claims and helping TRICARE beneficiaries 

locate providers. They also are required to operate TRICARE Service 

Centers, which are frequently located within MTFs, to provide TRICARE 

beneficiaries with information on the different TRICARE options, 

information on benefit coverage, assistance with finding network and 

nonnetwork civilian providers, determining eligibility status, and other 

activities. MCSCs provide customer service to any TRICARE beneficiary 

who requests assistance, regardless of their enrollment status. 

In each of the three regions, TMA uses a TRO to manage health care 

delivery. TRO directors are considered the health plan managers for the 

regions and are responsible for overseeing the MCSCs, including 

monitoring network quality and adequacy, monitoring customer 

satisfaction outcomes, and coordinating appointment and referral 

management policies. TRO directors and staff also provide customer 

service to all TRICARE beneficiaries who request assistance regardless of 

their enrollment status. 

Although they vary in the size of the geographic area covered, each

TRICARE region has approximately the same number of TRICARE 

beneficiaries. However, the number of nonenrolled TRICARE beneficiaries 

varies by region as does their access to network providers under the Extra 

option depending on their proximity to a Prime Service Area. (See fig. 3 for 

the number and distribution of nonenrolled beneficiaries by region.) 

Page 14 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Figure 3: All Nonenrolled TRICARE Beneficiaries by Region 

Source: GAO analysis of DOD data. 

Number of Non-Enrolled Beneficiaries

0 

1 to 80 

81 to 300 

301 or more 

TRICARE 

North Region 

(1,493,136) 

TRICARE 

South Region 

(830,638) 

TRICARE 

West Region 

(668,054) 

Note: Shaded areas represent counties where nonenrolled beneficiaries resided. 

Page 15 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Throughout the three regions, about 16 percent of nonenrolled TRICARE 

beneficiaries reside outside of Prime Service Areas. In the North region, 

23 percent of nonenrolled TRICARE beneficiaries live outside of Prime 

Service Areas, and in the West Region, 21 percent of nonenrolled 

TRICARE beneficiaries live outside of Prime Service areas. Because the 

South Region has extensive Prime Service Areas, no TRICARE 

beneficiaries live in locations without a civilian provider network. 

Although most nonenrolled TRICARE beneficiaries nationwide live in a 

Prime Service Area, making Extra a readily available option, nonenrolled 

TRICARE beneficiaries have used Standard more frequently than Extra for 

each fiscal year from 2001 through 2005. (See fig. 4.) 

Figure 4: Percent of Claims Paid for TRICARE Standard and Extra for Each TRICARE Region for Fiscal Years 2001-2005 

Source: GAO analysis of TMA data.

0 

5 

10

15 

20 

25 

30 

35 

40 

45 

2001 2002 2003 2004 2005 

Extra

Standard

2001 2002 2003 2004 2005 2001 2002 2003 2004 2005 

Percentage

North

Fiscal year 

South West

TRICARE claims paid

Note: In 2004, TMA consolidated its 11 TRICARE regions into 3 TRICARE regions. TMA officials 

reallocated the data from the 11 regions to correspond to the current regional structure. 

Page 16 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
The NDAA for fiscal year 2004 directed DOD to monitor nonenrolled 

TRICARE beneficiaries’ access to care under the TRICARE Standard 

option and to designate a senior official to take the actions necessary to 

ensure access to care for nonenrolled TRICARE beneficiaries.15

Specifically, the NDAA required surveys to be done in 20 market areas16

each fiscal year until all markets were surveyed to determine how many 

civilian providers17 were accepting nonenrolled TRICARE beneficiaries as 

new patients. Although the law focused on Standard, TMA officials told us

that since nonenrolled TRICARE beneficiaries can receive care through 

both the Standard and Extra options, they designed the survey to monitor 

access to care from both network and nonnetwork providers. 

Requirements in the NDAA 

for Fiscal Year 2004 

Related to Nonenrolled 

TRICARE Beneficiaries 

When developing the survey’s methodology, TMA defined market areas as 

individual states and determined that all states could be surveyed within a 

3-year period. TMA implemented its survey in fiscal year 2005 for the first 

20 states.18 The survey collected data from the billing and insurance 

specialists of selected civilian providers, both network and nonnetwork, to 

determine how many were accepting nonenrolled TRICARE beneficiaries 

as new patients and to identify the reasons providers cite for not accepting

these TRICARE beneficiaries. About 17 percent of the providers in the 

sample belonged to a TRICARE network while the remaining 83 percent of 

providers in the sample were nonnetwork providers. Because about 

14 percent of all civilian providers belong to the TRICARE network, TMA’s 

sample of civilian providers is fairly representative of the network and 

nonnetwork civilian provider population serving all TRICARE 

beneficiaries, including nonenrolled beneficiaries who can use the 

Standard and Extra options. TMA’s four-question survey focused on a 

given provider’s awareness of TRICARE, whether the provider was 

accepting nonenrolled beneficiaries as new patients, and if not, the 

 15See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003) and S. Rep. No. 108-46, at 330 

(2003). 

16Neither the NDAA nor any congressional reports accompanying the legislation provided a

definition for ‘market areas.’ 

17The NDAA did not specify network or nonnetwork providers for the survey, but both

types of providers can accept nonenrolled TRICARE beneficiaries as patients. Network 

providers see nonenrolled TRICARE beneficiaries under TRICARE’s Extra option.

18TMA obtained clearance to distribute its Survey of Continued Viability of TRICARE 

Standard (the civilian provider survey) from the Office of Management and Budget on 

May 16, 2005. This clearance is required by the Paperwork Reduction Act. See 44 U.S.C. §§

3507 and 3508. 

Page 17 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
reasons why they were not. (See app. II for a detailed discussion of the 

methodology used for this survey and app. III for the complete survey 

instrument.) 

The NDAA for fiscal year 2004 also required DOD to designate a senior 

official to take actions necessary for achieving and maintaining the 

participation of nonnetwork civilian providers in a number adequate to 

ensure care for nonenrolled TRICARE beneficiaries in each market area.

According to this legislation, the senior official would have the following 

responsibilities: 

• educating nonnetwork civilian providers about TRICARE, 

• encouraging nonnetwork civilian providers to accept nonenrolled 

TRICARE beneficiaries as patients, 

• ensuring that nonenrolled TRICARE beneficiaries have the information 

necessary to locate nonnetwork civilian providers readily, and 

• recommending adjustments in reimbursement rates that the official 

considers necessary to ensure adequate availability of nonnetwork civilian 

providers for nonenrolled TRICARE beneficiaries. 

TMA and its MCSCs use various methods for evaluating access to care, 

and according to TMA and MCSC officials, the resulting measures indicate 

that access to care is generally sufficient for nonenrolled TRICARE 

beneficiaries. TMA is administering the civilian provider survey required

by the NDAA for fiscal year 2004, which is designed to obtain information 

on network and nonnetwork civilian providers’ willingness to accept 

nonenrolled TRICARE beneficiaries as new patients. TMA also obtains 

information about access to care through its annual health care survey of 

all TRICARE beneficiaries and through the anecdotal beneficiary feedback 

they receive from the TROs, which monitor access in their respective

regions. MCSCs also use a variety of approaches to evaluate access to 

care, including inquiries from beneficiaries, analyses of claims data, and

monitoring of the capacity of civilian provider networks. 

TMA uses multiple methods of evaluating access to care for its 

nonenrolled TRICARE beneficiaries, including the recently implemented 

survey of civilian providers and its annual health care survey of TRICARE 

beneficiaries. In addition, TMA monitors centrally received beneficiary

TMA and Its MCSCs 

Use Various Methods 

to Evaluate Access to 

Care That Indicate 

Sufficient Access for 

Nonenrolled 

TRICARE 

Beneficiaries 

TMA Uses Various 

Methods for Evaluating 

Access to Care 

Page 18 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
complaints and inquiries, and each TRO monitors access to care in its 

respective region. 

In fiscal year 2005, TMA completed the first phase of its mandated survey

of civilian health care providers.19 (See app. II for discussion of technical 

aspects of this survey’s methodology.) Although the survey was designed 

to determine the extent to which providers were willing to accept 

nonenrolled TRICARE beneficiaries as new patients, it is premature to 

interpret the results because this is the first of three rounds of the survey, 

and TMA does not have an established benchmark for determining the 

number of civilian providers that are needed for nonenrolled beneficiaries. 

During this initial round, TMA randomly selected a representative sample 

of over 40,000 providers in 20 states. TMA found that the majority of the 

providers surveyed were accepting new patients, including nonenrolled 

TRICARE beneficiaries.20 Specifically, only 14 percent of providers 

reported that they were not accepting new patients, including TRICARE 

patients, privately insured patients, or patients who were paying for their 

own care. Of the remaining 86 percent accepting new patients, the percent 

that would accept nonenrolled TRICARE beneficiaries as new patients 

averaged 80 percent for all 20 states.21 (See table 2 for overall results by 

state.) An additional comparison of the acceptance rate for two categories 

of providers—primary care providers22 and specialists23—in each of these 

20 states revealed very little difference between the two categories.24 Of 

those accepting new patients, 78 percent of primary care providers and 

TMA’s Survey of Civilian 

Providers 

 19In accordance with the law, TMA plans to conduct a survey of civilian health care

providers using a 3-year phased approach, surveying 20 states in each year for 2 years, and

10 states plus the District of Columbia during the final year. 

20In fiscal year 2004 TMA piloted this survey in 20 cities where TRICARE beneficiary 

advocacy groups anecdotally identified problems with access to care for nonenrolled 

TRICARE beneficiaries. 

21This ranged from a low of 68 percent in New York to a high of 93 percent in South Dakota.

22The primary care provider category consists of providers whose specialties include family 

or general practice, internal medicine, obstetrics and gynecology, or pediatrics. 

23The specialist category consists of all other medical specialties not captured in the

primary care category. 

24TMA did not subdivide primary care and specialist providers into network and 

nonnetwork categories. 

Page 19 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
81 percent of specialists would accept nonenrolled TRICARE beneficiaries 

as new patients.25

Table 2: TMA’s 2005 Civilian Provider Survey Results Showing Percent of Surveyed 

Providers Accepting Nonenrolled TRICARE Beneficiaries (of Those Accepting New 

Patients) by State 

Surveyed states 

Percent of surveyed providers accepting

nonenrolled TRICARE beneficiaries 

(of those accepting new patients)

South Dakota 93

Maine 92

Idaho 91

Kansas 90

Mississippi 89

Nebraska 89

Wyoming 88

Alaska 87

Wisconsin 87

Massachusetts 87

New Mexico 86

Indiana 84

South Carolina 84

Illinois 83

California 81

Washington 79

Delaware 78

Texas 76

New Jersey 70

New York 68

Total 80

Source: GAO analysis of DOD data. 

 25Indiana is the only state, among those surveyed, with a statistically significant difference

in acceptance rates between primary care and specialist providers. However, both primary

care and specialist acceptance rates in Indiana are relatively high, with 89 percent of

specialists and 78 percent of primary care providers accepting new nonenrolled TRICARE 

beneficiaries. 

Page 20 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
In addition to the statewide sample, TMA also sampled civilian providers 

in several smaller geographic locations, defined as hospital service areas

(HSA),26 in order to respond to concerns about access to care that were 

specific to certain locations. TMA selected 29 HSAs—12 that were 

randomly selected from within the 20 states evaluated for fiscal year 2005 

and 17 based on beneficiary concerns about specific locations.

27 As in the 

20-state survey, TMA found that most providers in the selected HSAs were 

accepting new patients, including nonenrolled TRICARE beneficiaries. 

Specifically, only 13 percent of surveyed providers reported that they were

not accepting new patients. Of the remaining 87 percent accepting new 

patients, 81 percent were accepting nonenrolled TRICARE beneficiaries as 

new patients. (See table 3.) An additional comparison of the acceptance 

rates for primary care providers and specialists who were accepting new 

patients revealed that 75 percent of the surveyed primary care providers 

and 85 percent of the surveyed specialists would accept nonenrolled 

TRICARE beneficiaries as new patients.28 A further comparison of 

providers accepting nonenrolled TRICARE beneficiaries as new patients 

between the HSAs selected based on TRICARE beneficiaries’ concerns 

and the HSAs randomly selected from the 20 surveyed states showed 

minimal difference in acceptance rates—80 percent and 83 percent, 

respectively.

 26HSAs are collections of zip codes organized into over 3,000 geographic regions in which 

Medicare beneficiaries seek the majority of their care from one hospital or a collection of 

hospitals. HSAs have nonoverlapping borders and contain all U.S. zip codes without gaps in 

coverage. 

27Four of the HSAs selected by TRICARE beneficiaries—two in Florida and two in 

Michigan—were located outside of the selected states. 

28In one community, Arlington, Texas, the survey found a sizeable difference in the rate of 

acceptance between primary care providers (47 percent) and specialists (73 percent). 

Page 21 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Table 3: TMA’s 2005 Civilian Provider Survey Results Showing Percent of Surveyed 

Providers Accepting Nonenrolled TRICARE Beneficiaries (of Those Accepting New 

Patients) by Hospital Service Area

Hospital Service Areasa

Percent of surveyed providers accepting

nonenrolled TRICARE beneficiaries 

(of those accepting new patients)

Peoria, Illinoisb96

Fort Wayne, Indianab94

Battle Creek, Michiganb93

Watertown, New York 92

Santa Fe, New Mexicob90

Eau Claire, Wisconsinb90

Belleville, Illinois 87

Waukegan, Illinois 87

Evansville, Indiana 89

Charleston, South Carolinab87

Lafayette, Indianab87

Syracuse, New York 86

Corpus Christi, Texasb84

Killeen, Texas 84

Spokane, Washington 84

San Diego, California 83

Tallahassee, Floridab83

Kalamazoo, Michiganb80

San Antonio, Texas 80

Boca Raton, Floridab 79

Indianapolis, Indiana 79

Columbia, South Carolina 79

Sacramento, Californiab77

Olympia, Washington 72

Houston, Texasb68

Monterey, Californiab67

Arlington, Texas

b

62

Brooklyn, New Yorkb60

Seattle, Washingtonb60

Total 81

Source: GAO analysis of DOD data. 

Page 22 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
a

Hospital Service Areas are collections of zip codes organized into geographic regions in which 

Medicare TRICARE beneficiaries seek the majority of their care from one hospital or a collection of 

hospitals. Hospital Service Areas have nonoverlapping borders and contain all U.S. zip codes without

gaps in coverage. 

b

Locations requested by TRICARE beneficiary groups and TRICARE Regional Offices for 

assessment of access to care. These locations were not randomly selected. 

In both the states and HSAs, civilian providers who indicated that they 

were not accepting nonenrolled TRICARE beneficiaries as new patients 

were asked to identify why they made this decision in their own words, 

and were permitted to provide as many reasons as they wanted. More than 

half of both network and nonnetwork respondents cited not having a 

provider available or reimbursement issues as reasons. For providers 

citing nonavailability as a reason, many explained that they were either in

the process of retiring or were too busy to accept any new patients at this 

time. Providers citing reimbursement issues most often stated an opinion 

that TRICARE’s reimbursement rates were low and that claims payment 

was slow. (See app. IV for TMA’s summary of the aggregate results by 

category.) 

Although there is no benchmark with which to compare the results of the 

initial civilian provider survey effort, TMA officials stated that their 

analysis of the 2005 survey results did not indicate widespread problems 

with nonenrolled TRICARE beneficiaries’ access to care. Nonetheless, 

TRO officials used the survey results to identify specific cities in their 

regions where civilian providers’ acceptance of nonenrolled TRICARE 

beneficiaries and knowledge about TRICARE were low in comparison to 

the other locations surveyed.29 To assist in this effort, the Assistant 

Secretary of Defense (ASD) for Health Affairs directed TMA’s 

Communications and Customer Service Directorate to work with the 

TROs and other TMA officials to develop a strategic marketing plan for 

these locations.30 The cities selected by the TROs are as follows: 

• West region: Olympia, Washington (2,732 nonenrolled beneficiaries), 

Monterey, California (1,180 nonenrolled beneficiaries), Seattle, 

 29Eight of the locations were surveyed as HSAs in the 2005 civilian provider survey. One

additional location, Anchorage, Alaska, was previously identified as an area with low 

civilian provider acceptance of nonenrolled beneficiaries during TMA’s pilot of the survey 

in 2004. 

30TMA has not specified a timeline for this task. 

Page 23 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Washington ( 2,358 nonenrolled beneficiaries), and Anchorage, Alaska 

(3,381 nonenrolled beneficiaries); 

• North region: Brooklyn, New York (4,276 nonenrolled beneficiaries) and 

Eau Claire, Wisconsin (902 nonenrolled beneficiaries); and 

• South region: Arlington, Texas (3,025 nonenrolled beneficiaries), Houston,

Texas (6,415 nonenrolled beneficiaries), and Boca Raton, Florida (447 

nonenrolled beneficiaries). 

TMA officials and TRICARE beneficiaries have stated that additional 

survey questions could have yielded useful information. For example, the 

survey did not ask providers whether they are accepting new Medicare 

patients—an important proxy because TRICARE reimbursement rates are 

established using Medicare reimbursement rates, and a comparison of the 

two programs could provide information on whether providers are more 

concerned with the amount of reimbursement or other issues.31

Furthermore, the survey did not ask providers how much of their current 

practice consists of TRICARE beneficiaries, to capture whether or not 

providers may already have TRICARE beneficiaries in their practices. 

However, a provision in the NDAA for fiscal year 2006 instructs TMA to 

add the following questions to its civilian provider survey: 

1. What percentage of Dr. X’s current patient population uses any form of 

TRICARE? 

2. Does Dr. X accept patients under the Medicare program? 

3. Would Dr. X accept additional Medicare patients?32

In addition to its civilian provider survey that covered 20 states, TMA 

gathers worldwide information on nonenrolled TRICARE beneficiaries’ 

access to care through its annual Health Care Survey of DOD 

Beneficiaries, which covers all TRICARE beneficiaries and all TRICARE 

TMA’s Beneficiary Health Care 

Survey 

 31In Medicare Fee-for-Service Beneficiary Access to Physician Services: Trends in

Utilization of Services, 2000 to 2002, GAO-05-145R (Washington, D.C.; Jan. 12, 2005), we

evaluated two indicators of beneficiary access to Medicare physician services and found 

that although Medicare physician fees had been reduced by 5.4 percent in 2002, the

indicators we evaluated suggested an increase in access to care. 

32See Pub. L. No. 109-163, § 711, 119 Stat. 3136, 3343. 

Page 24 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
options.33 According to survey results from 2003 through 2005, about 

77 percent of nonenrolled TRICARE beneficiaries who obtained care 

reported that “getting needed care” was not a problem for them. Similarly, 

over 80 percent of these TRICARE beneficiaries reported that they could 

“get care quickly.” For the same time period, TMA compared its survey 

results with the results of a civilian health plan survey, the Consumer 

Assessment of Healthcare Providers and Systems (CAHPS®),34 which 

asked participants the same questions on access to care under their plans. 

From this comparative analysis, TMA found that a similar percentage of 

civilian health plan participants—about 80 percent—responded that 

“getting needed care” was not a problem and that they could “get care

quickly.” TMA uses this survey as a benchmark to compare TRICARE 

against civilian plans. 

Anecdotal information about access to care is available through TMA’s 

centralized Beneficiary and Provider Services office, which collects and 

monitors information on TRICARE beneficiaries’ complaints and general 

inquiries, including issues about access to care. TRICARE beneficiaries 

may contact this office by telephone, e-mail, written correspondence, or 

through their congressional representatives. TMA officials broadly 

categorize each contact by issue and use this information to monitor 

trends in the feedback they receive through these contacts. A TMA official 

stated that if the number of contacts they receive related to an issue rises, 

the appropriate program officials—such as the TROs—are notified and 

encouraged to investigate the issue. Furthermore, TMA maintains a record

of TRICARE beneficiary and provider contacts that have been addressed 

and those that remain open and continue to require attention. Although 

the Beneficiary and Provider Services office does not specifically track 

access-to-care issues as a separate issue, one of the TMA officials 

responsible for tracking the contacts told us that TRICARE beneficiary 

Beneficiary Feedback 

 33The Health Care Survey of DOD Beneficiaries was implemented in response to a 

requirement in the NDAA for fiscal year 1993 to annually survey beneficiaries of DOD’s

health care programs about their ability to access health care services and their satisfaction 

with the services they received, among other things. See 10 U.S.C. § 1071, note. TMA 

conducts this survey on a yearly basis using a representative sample of all TRICARE 

beneficiaries worldwide. 

34CAHPS is a registered trademark of the Department of Health and Human Services’ 

Agency for Healthcare Research and Quality. CAHPS refers to a family of surveys that asks 

consumers and patients to evaluate their health care using a standardized set of questions. 

The Centers for Medicare & Medicaid Services conducts a CAHPS survey of both the

Medicare fee-for-service population and the Medicare Advantage population. Throughout 

this report we refer to the fee-for-service CAHPS® survey as the CAHPS survey. 

Page 25 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
complaints and inquiries relating to access issues have been minimal. 

Overall, concerns and inquiries for the “contractor service complaint” 

category, which could include access-to-care issues for both enrolled and 

nonenrolled TRICARE beneficiaries, represented about 1 percent of about 

6,900 total contacts about the MCSCs for 2005. 

In addition, on a regional level, the TROs collect and monitor TRICARE 

beneficiary feedback gathered from e-mails and phone calls, as well as 

correspondence they receive from TRICARE beneficiary groups. However, 

the TROs told us that detailed information on each of these contacts is not 

routinely maintained. For example, one TRO told us that when a TRICARE 

beneficiary contacts them for assistance in locating a provider, they track 

the general reason for the call, but do not document the specific concerns. 

TRO officials told us that they receive only a small number of contacts 

from nonenrolled TRICARE beneficiaries who are unable to obtain care 

from nonnetwork civilian providers.35 For example, one TRO told us that 

they received approximately 34 requests for assistance locating a provider 

in calendar year 2005 from the over 600,000 nonenrolled TRICARE 

beneficiaries in this region. TRO officials indicated that sometimes these 

requests are due to TRICARE beneficiaries’ inability to obtain care from a 

specific provider at a specific time and are not necessarily indicative of 

access problems because that provider may be available at another time or 

other providers may be available. The TROs told us that they also monitor 

nonenrolled TRICARE beneficiaries’ access to care retrospectively by

evaluating claims data as a record of health care usage. For example, the 

TROs use these data to identify how many network and nonnetwork 

providers have accepted nonenrolled TRICARE beneficiaries as patients 

and to evaluate the use of the different TRICARE options. 

Finally, the TROs and military services are in the process of implementing 

a new method of monitoring TRICARE beneficiary feedback. The 

Assistance Reporting Tool (ART) is a computer database that when fully 

operational will be used to archive and manage TRICARE beneficiary 

feedback on all aspects of health care. Currently each of the three TROs, 

all Army MTFs, and a portion of Navy and Air Force MTFs use this system 

as either their primary or one of several tools for managing and archiving

TRICARE beneficiary feedback.36 Because ART is not mandatory for all 

 35The TROs acknowledge that the majority of TRICARE beneficiaries direct their concerns

and inquiries to the MCSCs and not to the TRO. 

36The office of the Army Surgeon General has mandated that all Army MTFs use the ART. 

Page 26 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
MTFs, the TROs also rely on other feedback mechanisms to capture the 

most complete record of TRICARE beneficiary concerns and questions. 

These other mechanisms include e-mails from TRICARE beneficiaries to 

MTFs and data requests that the TROs periodically make to MTFs. In 

addition, while the MCSCs are not required to use ART because it was 

introduced after TRICARE’s current health care delivery contracts were 

awarded, one of the MCSCs is currently using it. In the next cycle of 

TRICARE contracts, TMA officials told us that they plan to require that all

MCSCs use this system. TMA officials who have reviewed the preliminary 

information captured by ART told us that the tool has obtained very little 

feedback that would indicate nonenrolled TRICARE beneficiaries are 

having problems with access to care.

Each of the three MCSCs has developed its own methods for monitoring 

whether TRICARE beneficiaries in its region have access to care both in 

Prime Service Areas and in areas where provider networks do not exist. 

According to the MCSCs, while their methods for evaluating access to care 

were not designed to evaluate access specifically for nonenrolled 

TRICARE beneficiaries, they do provide some information that they use to 

monitor the availability of both network and nonnetwork civilian 

providers for this population, which is one component of access to care. 

The MCSCs also monitor access to care through beneficiary inquiries. 

Each maintains a data system to archive and tabulate anecdotal TRICARE 

beneficiary feedback received through some or all of the following 

methods: telephone, e-mail, congressional correspondence, or walk-in 

visits to a TRICARE Service Center. The MCSCs organize TRICARE 

beneficiary feedback into subject categories and then monitor changes in 

the frequency of contacts in these categories to identify trends and 

important issues. At our request, each of the MCSCs reviewed their most 

recent TRICARE beneficiary complaint data and found very small numbers 

of comments pertaining to health care access. The MCSCs told us this was 

an indication that TRICARE beneficiaries—both enrolled and 

nonenrolled—were not experiencing any widespread problems with 

access to care. For example, one MCSC identified fewer than 40 

complaints related to access out of one million contacts with TRICARE 

beneficiaries in a 1-month period. The second MCSC reported that for the 

last two quarters of 2005 they received an average of 355 inquiries and 

complaints each month about access to care. Officials from this MCSC told 

us that while their TRICARE beneficiary feedback system could not 

quantify the total number of inquiries received, these 355 inquiries 

represented a small percentage of all contacts. The third MCSC reported 

MCSCs Have Approaches 

for Monitoring Access to 

Care Though They Are Not 

Specific to Nonenrolled 

TRICARE Beneficiaries 

Page 27 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
that out of more than 250,000 phone calls and walk-in visits to TRICARE 

Service Centers during the month of December 2005, 71 contacts, or less 

than 1 percent of the total contacts, were related to access. 

The MCSCs also determine how many civilian providers have accepted at

least one TRICARE beneficiary by analyzing claims data to examine the 

extent to which both network and nonnetwork civilian providers are 

accepting TRICARE beneficiaries as patients. Each MCSC has concluded 

that more than half of all licensed civilian providers—both network and 

nonnetwork—in their respective regions have accepted at least one 

TRICARE beneficiary, regardless of enrollment status, as a patient in the 

last year.37 According to MCSCs, access to care appears to be generally

sufficient because the percentage of all licensed civilian providers in each

region who have submitted at least one TRICARE claim during the past 

year are as follows: 90 percent in the South region, where TRICARE 

beneficiaries represent 3.7 percent of the entire region’s population; 

56 percent in the West region, where TRICARE beneficiaries represent 

3.1 percent of the region’s population; and 52 percent in the North region, 

where all TRICARE beneficiaries represent an estimated 2.1 percent of the 

region’s population.38

Each MCSC told us that one of the primary ways they ensure sufficient 

access to care for both enrolled and nonenrolled TRICARE beneficiaries is 

by monitoring whether their civilian provider networks have the capacity 

to provide care to all beneficiaries in their Prime Service Areas. 

Throughout the three regions, the majority of nonenrolled TRICARE 

beneficiaries—84 percent—live within Prime Service Areas, making the 

choice of using a civilian network provider through Extra a readily 

available option for them. In the South region, all TRICARE beneficiaries 

reside in Prime Services Areas. In this region, the MCSC monitors access 

to care through geographic analyses of provider and TRICARE beneficiary 

locations to determine whether its networks meet the needs of both 

enrolled and nonenrolled TRICARE beneficiaries using TRICARE’s access 

standards. In another region, where not all TRICARE beneficiaries live in 

Prime Service Areas, the MCSC will assist nonenrolled TRICARE 

beneficiaries in finding nonnetwork civilian providers on an as-needed 

 37TRICARE beneficiaries did not seek care from all licensed civilian providers because in 

some areas TRICARE serves a small percentage of the general population. 

38Our estimate excluded the census population of residents living in small portions of Iowa, 

Missouri, and Tennessee that are part of the North Region. 

Page 28 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
basis. In the third region where the Prime Service Areas also do not 

encompass all TRICARE beneficiaries, the MCSC recruits and contracts

with providers outside of Prime Service Areas who are available and 

willing to deliver care to nonenrolled TRICARE beneficiaries living there. 

Network providers who deliver care in locations outside of Prime Service 

Areas currently account for 25 percent of this MCSCs’ network providers. 

TMA, MCSCs, and provider representatives have cited various factors as 

impediments to civilian providers’ willingness to accept nonenrolled 

TRICARE beneficiaries as patients, and TMA and its MCSCs have different 

ways to address them. Some impediments are specific to TRICARE, 

including concerns about reimbursement rates and administrative issues, 

and TMA and its MCSCs have specific ways to address these issues. For 

example, TMA has the authority to increase reimbursement rates in 

certain circumstances, and both TMA and MCSCs conduct outreach efforts 

targeted to assist civilian providers with administrative issues. Other 

impediments—such as providers’ practices being at maximum patient 

capacity and provider shortages in certain locations—are not specific to 

TRICARE and are therefore inherently more difficult for TMA and the 

MCSCs to address. 

Since TRICARE was implemented in 1995, some civilian providers—both 

network and nonnetwork—have complained that TRICARE’s 

reimbursement rates tend to be lower than those of other health plans, and 

as a result, some of these providers have been unwilling to accept 

nonenrolled TRICARE beneficiaries as patients. According to the results 

of the initial round of TMA’s civilian provider survey, concern about 

reimbursement amounts was one of the primary reasons that both 

network and nonnetwork civilian providers cited for not accepting 

nonenrolled TRICARE beneficiaries as new patients. In the 2005 civilian

provider survey, of those who gave reasons for not accepting nonenrolled 

TRICARE beneficiaries as new patients, 20 percent of network providers 

and 25 percent of nonnetwork providers cited concerns about 

reimbursement amounts. However, TMA has the authority to adjust 

reimbursement rates in areas where it determines that reimbursement rate 

amounts have been negatively impacting TRICARE beneficiaries’ ability to 

obtain care.

One of providers’ main reasons for not accepting nonenrolled TRICARE 

beneficiaries as patients is providers’ concern about low reimbursement 

amounts. TRICARE’s reimbursement rates generally mirror 

Various Factors 

Impede Providers’ 

Acceptance of 

Nonenrolled 

TRICARE 

Beneficiaries, and 

TMA and MCSCs 

Have Different Ways 

to Address Them 

Providers Cite Concerns 

about TRICARE’s

Reimbursement Rates as a 

Reason for Denying 

Nonenrolled TRICARE 

Beneficiaries’ Access to 

Care, but TMA Has 

Authority to Adjust Rates 

When Needed 

Providers’ Concerns about 

TRICARE Reimbursement 

Rates 

Page 29 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
reimbursement rates paid by the Medicare program. Beginning in fiscal 

year 1991,39 in an effort to control escalating health care costs, Congress 

instructed DOD to gradually lower its reimbursement rates for individual 

civilian providers to mirror those paid by Medicare40—an adjustment that 

has saved hundreds of millions of dollars since the conversion.41 As of 

January 2006, the transition to Medicare rates was nearly complete, and 

reimbursement rates for only 48 services remain higher than Medicare 

reimbursement rates. (See app. V for a list of these services.) 

According to TMA and MCSC officials, civilian providers, including both 

network and nonnetwork, generally seek to develop a practice that 

includes patients with higher-paying private insurers to compensate for 

the acceptance of patients with lower-paying health plans, including 

Medicare, Medicaid, and TRICARE. However, according to TMA and 

MCSC officials, TRICARE generally has little leverage to encourage 

network and nonnetwork civilian provider acceptance of its patients 

because the TRICARE population is small and transient. Further, in 

locations where the demand for providers’ services exceeds the supply—

such as in Alaska—providers can be selective about who they accept as 

patients. 

TMA and MCSC officials have also cited providers’ concerns that 

TRICARE’s pediatric and obstetric rates are lower than Medicaid rates for 

these services. To investigate these concerns, TMA conducted a 

comparative analysis that found TRICARE’s reimbursement rates for 

selected pediatric and obstetric procedures were generally higher than 

Medicaid’s rates in many states for March 2006. TMA compared the 

TRICARE reimbursement rate for the service most commonly billed by 

pediatricians—an office visit for an established patient—with Medicaid 

rates for this service and found that in 41 of the 45 states for which 

Medicaid data were available, the TRICARE reimbursement rate exceeded 

 39Prior to the implementation of TRICARE, DOD provided civilian health care to eligible 

beneficiaries under the Civilian Health and Medical Program of the Uniformed Services to 

supplement health care provided through MTFs. 

40Congress specified that reductions were not to exceed 15 percent in a given year. See

Department of Defense Appropriations Act for Fiscal Year 1991, Pub. L. No. 101-511, § 8012

104 Stat. 1856, 1877 (1990). This instruction was eventually codified at 10 U.S.C. § 1079(h). 

41We previously evaluated the methodology used to transition to Medicare level of payment 

and concluded this methodology complies with statutory requirements and generally 

conformed with accepted actuarial practice in Reimbursement Rates Appropriately Set; 

Other Problems Concern Physicians, GAO/HEHS-98-80 (Washington, D.C.: Feb. 26, 1998).

Page 30 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Medicaid’s rate for this service. In addition, TMA compared its 

reimbursement rates for 14 commonly used maternity and delivery 

services with Medicaid rates and found that in 35 of the 45 states for which 

Medicaid data were available,42 TRICARE reimbursement rates for these 

services exceeded the Medicaid payment rates. 

TMA also analyzed reimbursement rates for pediatric immunizations based 

on MCSCs’ concerns that providers viewed these rates as too low. 

However, when TMA compared TRICARE’s reimbursement rates with the 

cost of the vaccine for the 10 most frequently used pediatric vaccines and 

for the hepatitis A vaccine, TMA’s analysts concluded that the TRICARE 

reimbursement rates were generally reasonable and not undervalued in 

relation to what a provider might actually pay to obtain them. Only one 

vaccine—the pediatric hepatitis A vaccine—appeared to be priced lower 

than the reasonable cost of obtaining the vaccine. In this instance, the

TRICARE reimbursement rate was $22.64, while pediatricians were paying 

between $27.41 and $30.37 for the vaccine. As a result of this discrepancy,

TMA used its general authority to deviate from Medicare rates,43 and 

starting May 1, 2006, TMA instructed the MCSCs to reimburse pediatric

hepatitis A vaccines nationally at a new reimbursement rate of $30.40. 

TMA has the authority to increase TRICARE reimbursement rates for 

network and nonnetwork civilian providers to ensure that all beneficiaries, 

including nonenrolled beneficiaries, have adequate access to care. TMA’s 

authorities include (1) waiving reimbursement rate reductions for both 

network and nonnetwork providers that resulted when TRICARE 

reimbursement rates were lowered to Medicare levels,44 (2) issuing locality 

waivers that increase rates for specific procedures in specific localities,45

and (3) issuing network-based waivers that increase some network civilian 

providers’ reimbursements.46 Once implemented, waivers remain in effect

indefinitely until TMA officials determine they are no longer needed. As of 

August 2006, TMA had approved 15 waivers in total—2 waiving 

TMA Has Authority to Use 

Waivers to Adjust 

Reimbursement Rates 

 42Two states do not have fee-for-service Medicaid programs. The remaining three states and 

the District of Columbia did not provide data on Medicaid reimbursements.

43See 10 U.S.C. § 1079(h)(1). 

4432 C.F.R. § 199.14(j)(1)(iv)(C). 

4532 C.F.R. § 199.14(j)(1)(iv)(D). According to a TMA official, TMA usually defines a locality 

using one or more zip codes.

4632 C.F.R. § 199.14(j)(1)(iv)(E). 

Page 31 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
reimbursement rates reductions that resulted when TRICARE 

reimbursement rates were lowered to Medicare levels, 7 locality waivers, 

and 6 network waivers. 

TMA can use its authority to waive reimbursement rate reductions to 

restore TRICARE reimbursement rates in specific localities to the levels 

that existed before a reduction was made to align TRICARE rates with 

Medicare rates. On two occasions, TMA has used this authority in Alaska 

to encourage both network and nonnetwork civilian providers to accept 

TRICARE beneficiaries as patients in an effort to ensure adequate access 

to care. In 2000, TMA used this waiver authority to uniformly increase 

reimbursement rates for network and nonnetwork civilian providers in 

rural Alaska, and in 2002 TMA implemented this same waiver for network 

and nonnetwork civilian providers in Anchorage. The use of these waivers 

resulted in an average reimbursement rate increase of 28 percent for all of

Alaska. However, in 2001, we studied the effect of the 2000 waiver on 

access to care in rural Alaska and found that it did not increase TRICARE 

beneficiaries’ access to care.47

Locality waivers may be used to increase rates for specific medical 

services in specific areas where access to care has been severely impaired. 

Reimbursement rate increases for this type of waiver can be established in 

one of three ways: by adding a percentage factor to the existing TRICARE 

reimbursement rate, by calculating a prevailing charge,48 or by using 

another government reimbursement rate, such as rates used by the 

Department of Veterans Affairs to purchase health care from civilian 

providers. The resulting rate increase would be applied to both network 

and nonnetwork civilian providers for the medical services identified in 

the areas where access is severely impaired. A total of nine applications 

for locality-based waivers have been submitted to TMA between January

2003 and August 2006. (See table 4.) Of these, seven locality waivers have

been approved by TMA and two are still pending. Six of the approved 

locality waivers as well as one pending application are for locations in 

Alaska. This includes one approved waiver to adjust the reimbursement 

rates for obstetric services to match Medicaid rates in Alaska and nine 

 47See Across-the-Board Physician Rate Increases Would be Costly and Unnecessary, 

GAO-01-620 (Washington, D.C.: May 24, 2001). 

48Prevailing charges are commonly used charges that fall within the range of charges most 

frequently and widely used by providers in a locality for a particular procedure or service.

Page 32 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
additional states based on TMA’s comparative analysis of reimbursement 

rates for 14 obstetrical procedures. 

Table 4: Applications for Locality Waivers and Approval Results 

Date submitted Affected location Affected services 

Amount of increase

requested Status 

1/23/03 Juneau, AK All gynecological procedures or 

services delivered by one 

provider 

600 percenta3/26/03—Approved for 

nonroutine gynecological 

procedures or services 

8/2004 Fairbanks, AK All inpatient internal medicine 

procedures or services 

delivered by providers 

employed by Fairbanks 

Memorial Hospital 

Veterans Administration 

ratesb

10/28/04—Approved 

6/08/05 Anchorage, AK All medical procedures or 

services delivered by 

perinatologists

40 percent 11/21/05—Approved for 

perinatologists who are 

participating providersc

6/08/05 Fairbanks, AK Four medical procedures or 

services delivered by two 

plastic surgeons

175-253 percent 5/18/06—Approved to 

increase rates to the rate 

paid by the Veterans 

Administration for 

professional services 

provided by plastic 

surgeons in Alaska 

3/03/05 Puerto RicodAll medical procedures or 

services delivered by 

neurosurgeons

40 percent 10/26/05—Approved 

10/19/05 Alaska, Arizona,

Connecticut, Montana, 

Nevada, Oregon, South 

Carolina, Washington, 

West Virginia, 

Wyoming.e

14 obstetrical procedures or 

services 

Medicaid reimbursement 

amounts 

03/20/06—Approved 

2/23/06 Fairbanks, AK All anesthesia or pain 

management and treatment 

services delivered by 

anesthesiologists 

200 percent 6/02/06—Approved to 

increase rates by 

252 percentf

3/06/06 Puerto RicodFive high-risk medical

procedures or services 

delivered by obstetricians; 

multiple medical procedures or 

services delivered by 

orthopedists and urologists 

Various: Between 

160 percent and 

460 percent for

obstetricians; 300 percent 

for orthopedists; and 

162 percent for urologists 

Pending 

7/2006 All of Alaska All medical services or 

procedures 

Veterans Administration 

ratesb

Pending 

Source: DOD. 

a

Request did not include a specific increase amount. The approved waiver was for the lesser of billed 

charges or 600 percent of the TRICARE reimbursement rate. 

Page 33 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
b

TMA agreed to match the Department of Veterans Affairs reimbursement rates for these procedures. 

c

Participating providers submit claims for reimbursement and are not permitted to bill TRICARE 

beneficiaries an additional 15 percent above the TRICARE reimbursement rate. 

d

The TROs are not responsible for managing TRICARE in Puerto Rico because it operates under a 

different contract than used for the threeTRICARE regions. 

e

When reviewing the need for this rate adjustment, TMA compared TRICARE reimbursement rates 

with Medicaid rates in 45 states for which data were available. The 10 states listed were identified as 

needing a rate adjustment based on this analysis. Each year when the TRICARE reimbursement 

rates are adjusted, TMA intends to similarly determine where this adjustment is needed. 

f

Because the TRICARE reimbursement rate changed during the period between the application and 

the approval of this waiver, TMA raised the percentage of the increase. 

Network waivers are used to increase reimbursement rates for network 

providers up to 15 percent above the TRICARE reimbursement rate in an 

effort to ensure an adequate number and mix of primary and specialty care 

network civilian providers for a specific location. Between January 2002 

and August 2006, 10 applications for network waivers have been submitted 

to TMA. Of these, 6 network waivers have been approved by TMA and 4 

have been denied. (See table 5.) 

Page 34 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Table 5: Applications for Network Waivers and Approval Results 

Date submitted Affected location Affected services 

Amount of

increase requested Status 

1/29/02 Fredricksburg, VA 33 varied medical 

procedures or services, 

encompassing various 

specialties 

28 percentaDenied—Application did not 

substantiate an access to care 

problem 

3/07/02 Great Falls, MT All medical procedures or 

services delivered by a 

specific clinic representing 

32 specialties 

200 percentaDenied—Application did not directly 

request a network waiver and 

increase could be handled under 

TRICARE Prime Remoteb

8/13/02 Idaho All medical procedures and 

services 

15 percent 1/15/03—Approved for nine 

specialties in the Mountain Home Air 

Force Base Prime Service Area 

12/20/02 Bozeman, MT All obstetrical or

gynecological medical

procedures or services 

15 percent Denied—Increase available under 

TRICARE Prime Remoteb

4/08/03 Cheyenne, WY Three newborn inpatient 

medical procedures or 

services 

To match civilian 

insurers’ rates

7/16/03—Approved increase to 

15 percent above TRICARE 

reimbursement rates 

2/03 and 3/03 Watertown, NY

Norwich, CT

Deliveries provided by nurse 

midwives in NY and 

emergency gynecological 

services in CT

Not specified Denied–Incomplete application 

package submitted 

9/26/03 Ft. Leonard Wood and 

Springfield, MO

All medical procedures and 

services delivered by 

network providers 

15 percent 12/24/03—Approved for 11 

specialties in Ft. Leonard Wood 

Prime Service Area Denied for 

Springfield

1/05/05 Delta Junction and Tok, 

AK 

All primary care medical 

procedures and services 

15 percent 3/30/05—Approved for nonmental 

health medical care services, 

excluding laboratory services 

6/10/05 Norfolk, VA All medical procedures and 

services for three specialties 

delivered by a group of 

pediatric specialists 

15 percent 7/08/05—Approved 

3/06/06 Rapid City, SD All obstetrical or

gynecological services 

delivered by a group of 

specialists 

Not specified 5/16/2006—Approved a 15 percent 

increase for one group of 

obstetricians and gynecologists 

Source: DOD. 

a

According to TMA, the waiver requesters did not understand that the maximum network waiver is 

15 percent over TRICARE reimbursement rates. If the waiver had been granted it would have been 

limited to 115 percent of the TRICARE reimbursement rate. 

Page 35 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
b

TRICARE Prime Remote is a specialized version of TRICARE Prime available for active duty 

members when they are assigned to duty stations in areas not served by the military health care 

system. Under this program, civilian network providers can be reimbursed up to 15 percent above the 

TRICARE reimbursement rate. Family members who reside with service members who are enrolled 

in TRICARE Prime Remote are eligible to enroll in and receive care under TRICARE Prime Remote 

for Active Duty Family Members. 

Providers, TRICARE beneficiaries, MCSCs, as well as TRO directors may 

apply for a reimbursement rate waiver by submitting written requests 

supporting the need for reimbursement rate increases on the grounds that 

access to health care services is impaired due to low reimbursement rates. 

These requests must contain specific justifications to support the claim 

that access problems are related to reimbursement rates and must include 

information such as the number of providers and TRICARE beneficiaries 

in a location, the availability of MTF providers, geographic characteristics, 

and cost effectiveness of granting the waiver. All waiver requests are 

submitted to the TRO directors, who review the application and make a 

decision whether to forward the request to the Director of TMA through 

TMA’s contracting officers, who are responsible for administering the 

MCSCs’ contracts. According to a TMA official, the contracting officers 

work with TMA analysts to review the submitted requests and verify 

whether there is an insufficient number of providers in the area and 

conduct a cost-benefit analysis before making a recommendation to the 

Director of TMA that the waiver be accepted or denied. Each analysis is 

tailored to the specific concerns outlined in the waiver requests. 

According to this official, TMA conducts these additional analyses to 

ensure that an increase in reimbursement rates would actually alleviate

access problems and that access was not impaired due to such things as 

administrative problems or providers’ unhappiness with claims payment 

timeliness or accuracy. 

Once a waiver is granted, there is no mechanism that automatically 

terminates it. According to a TMA official, there was an expectation within 

TMA that the continued need for existing waivers would be evaluated on 

an annual basis.49 However, waivers have been reviewed on a periodic, ad 

hoc basis rather than on an annual basis as expected. When TMA 

implemented new MCSC contracts in fiscal years 2004 and 2005, TMA and 

 49The regulation authorizing locality waivers based on severe impairment of access states 

that those decisions are “subject to review and determination or modification at any time 

... if circumstances change so that adequate access to health care services would no longer

be severely impaired.” See 32 C.F.R. § 199.14(j)(1)(iv)(D)(1). The regulations for the other 

two waivers do not specifically address review. 

Page 36 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
the MCSCs discussed existing waivers and mutually agreed to extend all of 

them because they continued to believe that these waivers were necessary 

to ensure access to care. However, without a formal analysis of how these 

waivers have impacted access in the areas in which they were

implemented, the actual extent of their effect is unclear. 

Providers Cite Concerns 

About TRICARE’s 

Administrative Issues as 

Reasons for Not Accepting 

Nonenrolled TRICARE 

Beneficiaries, but MCSCs 

Use Various Methods to 

Address These Concerns 

Since the inception of TRICARE, both network and nonnetwork civilian 

providers have expressed concerns about administrative issues or 

“hassles” associated with the program, which, when combined with low 

reimbursement rates, make them less likely to accept nonenrolled 

TRICARE beneficiaries as patients. TMA and MCSC officials stated that 

because TRICARE beneficiaries usually represent only a small percentage 

of a provider’s practice, both network and nonnetwork civilian providers 

may not be as knowledgeable about the program and its unique 

administration requirements. Adding to the potential for confusion, while 

some administrative requirements apply to all TRICARE beneficiaries, the 

TRICARE program also has separate and distinct administrative 

requirements for enrolled and nonenrolled TRICARE beneficiaries. For 

example, network providers must meet specific time frame and 

documentation requirements when referring enrolled TRICARE 

beneficiaries for specialty care or when delivering specialty care to 

enrolled TRICARE beneficiaries. However, referral standards usually do 

not apply to nonenrolled TRICARE beneficiaries. Additionally, according 

to the initial round of TMA’s civilian provider survey, 15 percent of 

network respondents and 7 percent of nonnetwork respondents who gave 

explanations for why they were not accepting nonenrolled TRICARE 

beneficiaries as new patients cited administrative inconveniences as a 

reason. These administrative inconveniences included too much 

paperwork, problems understanding the benefits and policies, and a 

lengthy referral process. 

MCSC and TMA officials also told us that providers’ past experiences with 

TRICARE administrative issues may have biased their opinion of the 

program, while, in some cases, there have been improvements. For 

example, according to MCSCs and TMA officials, some providers perceive

that previously identified claims processing problems persist and cite 

problems with timeliness and claims payment decisions as reasons for not 

accepting TRICARE patients. While claims processing problems plagued

the TRICARE program in its early years, we reported in 2003 that efforts 

Page 37 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
had been made to improve claims processing efficiency, and as a result, 

claims were being processed in a more timely manner, though some 

inefficiencies remained.50 In addition, some TRO officials and providers 

said that TRICARE claims payment decisions sometimes are not always 

clear to providers and, as a result, they may believe problems with claims 

processing exist. This is due in part to the fact that TRICARE’s claims 

processing outcomes may differ from Medicare’s—despite the programs’ 

similarities in reimbursement rates—due to different benefit structures 

and different claims processing tools that are used to prevent 

overpayment. Furthermore, because they do not always understand the 

program, providers and TRICARE beneficiaries may complain about 

adjudication decisions on claims that have been processed correctly. 

Problems may also occur because providers and TRICARE beneficiaries 

may make mistakes when filing their claims. 

In efforts to address problems related to administrative issues, MCSCs 

conduct a variety of outreach efforts to educate nonnetwork civilian 

providers on TRICARE requirements and assist with both actual and 

perceived administrative concerns. For example, MCSCs provide on-line 

tools and toll-free telephone support to mitigate administrative issues. 

Also, one MCSC works with state medical associations to address provider 

concerns and to ensure that information about TRICARE requirements is 

included in medical association newsletters. Each of the MCSCs has 

provider relations representatives located in areas throughout the region

outside of their central office. These provider relations representatives 

schedule opportunities to meet with nonnetwork civilian providers that 

include booths or speaking engagements at health fairs, conferences, and

other provider events and, when necessary, work one-on-one with 

network and nonnetwork civilian providers to provide instructions on 

ways to respond to TRICARE’s administrative requirements and to help 

eliminate the burden of unnecessary paperwork. According to MCSCs, 

these efforts have been helpful because they are not experiencing 

widespread problems with TRICARE beneficiaries’ access to care. 

However, similar to the use of waivers, the actual extent to which these 

efforts have improved access to care is unclear. 

 50See GAO, Defense Health Care: TRICARE Claims Processing Has Improved but 

Inefficiencies Remain, GAO-04-69 (Washington, D.C.: Oct. 15, 2003). 

Page 38 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
TMA and MCSCs attempt to address impediments to network and 

nonnetwork provider acceptance of nonenrolled TRICARE beneficiaries 

that are not specific to the TRICARE program. However, TMA and MCSCs 

cannot always resolve access problems related to these impediments. 

Some network and nonnetwork civilian providers may be unwilling to 

accept TRICARE beneficiaries as patients because their practices are 

already at capacity. For example, the initial round of TMA’s civilian 

provider survey found that 14 percent of providers in the 20 states 

surveyed were not available to accept any new patients, including 

TRICARE patients, privately insured patients, or patients who were paying 

for their own care. According to the MCSCs, access problems related to 

practice capacity are more likely to occur in geographically remote areas 

that have few providers than in more densely populated areas with more 

providers. However, one MCSC stated that access problems related to 

practice capacity can also occur in urban areas where the medical needs

of the population exceed the supply of specific specialties, such as 

dermatology. 

Though TMA and MCSCs 

Attempt to Address 

Impediments That Are Not 

Specific to TRICARE, 

These Issues Cannot 

Always be Resolved 

TRICARE beneficiaries’ access to care is also impeded in areas where 

there are insufficient numbers and types of civilian providers, both 

network and nonnetwork, to cover the local demand for health care. In 

these locations, the entire community is impacted by provider shortages. 

Consequently, TRICARE beneficiaries, as well as all other local residents, 

must sometimes travel long distances to obtain health care. MCSC officials 

stated that each TRICARE region includes areas with civilian provider 

shortages. For example, in TRICARE’s North Region, Watertown, New 

York, has an insufficient number of certain specialty providers for its 

population, which includes TRICARE beneficiaries stationed at a nearby 

military installation whose MTF is too small to handle all of their health 

care needs. TRICARE’s South Region contains many rural areas with few 

providers, including multiple locations in Oklahoma and Texas. Likewise, 

in TRICARE’s West Region, MCSC officials stated that there are provider 

shortages in various locations, including Cheyenne, Wyoming, and 

Mountain Home, Idaho.

TMA and the MCSCs have limited means of responding to access-to-care 

impediments in areas with network and nonnetwork civilian provider 

shortages, although TMA has adopted two bonus payment systems that 

Page 39 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
mirror those used by Medicare for these areas.51 In June 2003, TMA began 

paying providers a 10 percent bonus payment for the services rendered in 

Health Professional Shortage Areas, which the Department of Health and

Human Services has identified as having a shortage of primary care, 

dental, or mental health providers.52 Also, in January 2005, TMA followed 

Medicare in initiating payment of a 5 percent bonus for services rendered 

by primary care providers in geographic areas designated by the 

Department of Health and Human Services as Physician Scarcity Areas,53 a 

program that is only operational through 2007.54 Providers who are eligible 

for and wish to receive either of these bonus payments must include a 

specific code on every claim they submit to obtain these additional 

payments. According to a TMA official, TMA does not know the extent to

which these payments have been used and has not evaluated the 

effectiveness of these bonus payments on access to care. 

TMA and the MCSCs have attempted to overcome obstacles related to 

practice capacity and provider shortages by using high-ranking military 

personnel and field provider relation representatives to make personal 

appeals to network and nonnetwork civilian providers. In August 2004, the 

ASD for Health Affairs wrote a letter to providers appealing to their 

patriotism and asking them to accept TRICARE beneficiaries as patients. 

One MCSC official claimed that this letter has resulted in additional 

providers accepting both enrolled and nonenrolled TRICARE beneficiaries 

as patients. In addition, in certain areas where access is problematic, 

MCSC provider relations representatives or TRO officials personally call

on providers to solicit their support of military personnel through 

TRICARE. 

 51TMA has the authority to implement bonus payment programs for physicians in areas

determined to be medically underserved areas by the Department of Health and Human 

Services for Medicare purposes. TMA is required to make the bonus payments in the same 

amounts as authorized for Medicare. See 32 C.F.R. § 199.14(j)(2).

52See 42 U.S.C. § 1395l(m). Health Professional Shortage Area designations are based on 

shortages of primary medical care, dental, or mental health providers and may be rural or

urban areas, population groups, or medical or other public facilities. 

53Physician Scarcity Area designations are based on the calculation of the ratios of active 

providers of primary and specialty care to Medicare beneficiaries in every county in the 

United States. See 42 U.S.C. § 1395l(u). 

54The Medicare bonus payment program for Physician Scarcity Areas expires at that time. 

Page 40 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Various TMA offices, including the TROs, and the MCSCs are carrying out 

the responsibilities that are outlined in the NDAA for fiscal year 2004 to 

take actions to ensure nonenrolled beneficiaries’ access to care, such as 

educating civilian providers and recommending reimbursement rate 

adjustments—though these responsibilities were not formally designated 

to a single, senior official. For example, TMA’s Communications and 

Customer Service Directorate has primary responsibility for education and 

marketing activities for all civilian providers—including nonnetwork 

providers—although the TROs and MCSCs also share this responsibility. 

(See table 6.) This office oversees a national contract for marketing and

education materials with input from the TROs and the MCSCs. As part of 

this responsibility, this office designs and prepares marketing and 

education materials in conjunction with its contractor. On a regional level, 

the TROs and MCSCs also have responsibilities for educating both 

network and nonnetwork civilian providers. As part of these efforts, each 

TRO works with its region’s MCSC to host town-hall meetings and to 

provide briefings for network and nonnetwork civilian providers. In 

addition, the MCSCs contact, support, educate, and market to both 

network and nonnetwork civilian providers. For example, one MCSC 

distributes its monthly provider newsletter or bulletin to nonnetwork 

civilian providers who submit 25 or more TRICARE claims in 1 year. 

MCSCs also provide educational materials to civilian providers, including 

nonnetwork providers, and, in some instances, schedule provider seminars 

for nonnetwork providers. 

NDAA 

Responsibilities for 

Nonenrolled 

TRICARE 

Beneficiaries’ Access 

to Care Are Being 

Carried Out by TMA 

and the MCSCs, but 

Were Not Formally 

Designated to a 

Senior Official

Page 41 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Table 6: Responsibilities Outlined in the NDAA for Fiscal Year 2004 and the Entities

Covering Them 

Responsibilities Entities

Educate nonnetwork civilian providers about 

Standard 

• TMA’s Communications and 

Customer Services Directorate 

• TROs 

• MCSCs 

Encourage nonnetwork civilian providers to accept 

nonenrolled TRICARE beneficiaries as patients 

under Standard 

• MCSCsa

Ensure that nonenrolled TRICARE beneficiaries 

have information necessary to locate nonnetwork 

providers readily 

• TMA 

• TROs 

• MCSCs 

Recommend adjustments in provider reimbursement 

rates to ensure adequate availability of nonnetwork 

providers for nonenrolled TRICARE beneficiaries 

• TROsb

Source: GAO analysis of DOD information. 

a

MCSCs solicit nonnetwork providers to accept TRICARE beneficiaries when nonenrolled TRICARE 

beneficiaries cannot locate providers in a specific location. 

b

Although the TROs are responsible for preparing and submitting justification for payment waivers, 

other interested parties, including MCSCs, providers, and TRICARE beneficiaries can submit 

requests for payment adjustments through the TROs. 

Actions to encourage both network and nonnetwork civilian providers to 

accept nonenrolled TRICARE beneficiaries as patients are currently being 

addressed by the MCSCs. First, in areas with network civilian providers, 

MCSCs are required by contract to ensure that the networks are robust 

enough to provide health care to both enrolled and nonenrolled TRICARE 

beneficiaries in that location. As a result, MCSCs strive to ensure adequate 

numbers of network civilian providers who could also provide care to 

nonenrolled TRICARE beneficiaries. In addition, when nonenrolled 

TRICARE beneficiaries request assistance with finding providers, MCSCs 

work to encourage civilian providers, who could be either network or 

nonnetwork, to accept these TRICARE beneficiaries as patients. In some 

instances when a provider cannot be easily identified for a TRICARE 

beneficiary, MCSCs told us their provider relations representatives, who 

are knowledgeable about providers in their regions, will call on individual 

providers to encourage them to accept these TRICARE beneficiaries as 

patients. Nonetheless, as contractually required, MCSCs are focused on 

recruiting civilian providers for their networks and do not proactively 

recruit nonnetwork civilian providers to accept TRICARE beneficiaries as 

patients. Efforts to obtain nonnetwork civilian providers for nonenrolled 

Page 42 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
TRICARE beneficiaries using the Standard option are initiated on an asneeded basis. 

Additionally, TMA, its TROs, and the MCSCs all have procedures and tools 

in place aimed at ensuring that nonenrolled TRICARE beneficiaries can 

readily locate both network and nonnetwork civilian providers. A central 

TMA office maintains an online directory of both network and nonnetwork 

civilian providers who have accepted TRICARE beneficiaries as patients in 

the last 2 years. MCSCs’ Web sites provide a link to this TMA directory and 

also provide a directory of network civilian providers in their regions. 

Also, the TROs provide services, including assistance with locating civilian 

providers, to any TRICARE beneficiary who contacts them. Among other 

services they provide, Beneficiary Service Representatives at MCSCoperated TRICARE Service Centers assist “walk-in” TRICARE

beneficiaries—regardless of their enrollment status—to locate providers. 

In addition, all MCSCs are contractually required to have representatives 

available by phone 24 hours a day, 7 days a week to assist with locating a 

network provider. One MCSC told us that if a network provider is not 

available, the phone representatives will help locate nonnetwork providers 

in the area. 

Finally, the TROs currently are responsible for recommending 

reimbursement rate adjustments—that have been initiated by their offices, 

MCSCs, providers, and TRICARE beneficiaries—to increase provider 

reimbursement rates in areas where access to care is impaired for both 

enrolled and nonenrolled TRICARE beneficiaries. Since the TROs were 

established in 2004, two of the three TROs have recommended such 

increases to provider reimbursement rates in their regions.55

Nonetheless, TMA has not formally designated a senior official to take

responsibilities for nonenrolled TRICARE beneficiaries and nonnetwork 

civilian providers as outlined in the NDAA for fiscal year 2004. According 

to TMA officials, this role was assumed by the ASD for Health Affairs, who 

is responsible for overseeing DOD’s health programs and resources, 

because these responsibilities are included in the official directive for this 

position.56 According to senior TMA officials, the ASD for Health Affairs 

 55Prior to the establishment of the TROs, regional offices, referred to as Lead Agents, were

responsible for coordinating and submitting waiver request packages.

56DOD Directive 5136.1, which describes the responsibilities, functions, relationships, and 

authorities of the ASD for Health Affairs, would include these responsibilities. 

Page 43 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
intended to delegate these responsibilities to the TRO directors. However, 

while this intent was communicated verbally, the delegation was never 

formalized in writing. TRO officials told us that while they were aware of

the ASD for Health Affairs’ intent, they never received official notification 

or designation outlining these responsibilities and expectations. As a 

result, at the time of our site visits, the TROs had not undertaken any 

efforts beyond the level of assistance they were already providing to 

nonenrolled TRICARE beneficiaries and nonnetwork civilian providers.57

Nonetheless, during the time of our review, each TRO was in the process 

of assigning responsibilities for nonenrolled beneficiaries to a specific 

staff member in accordance with the staffing plan TMA established for the 

TROs. Additionally, officials at each of the TROs told us that they provide 

services and assistance to all TRICARE beneficiaries regardless of 

enrollment status. 

To more directly assign responsibilities for nonenrolled beneficiaries’ 

access to care to the TROs, the NDAA for fiscal year 2006 specifically

instructs the TROs to (1) identify nonnetwork providers who will accept 

nonenrolled TRICARE beneficiaries as patients; (2) communicate with 

nonenrolled TRICARE beneficiaries; (3) conduct outreach to nonnetwork 

providers, encouraging their acceptance of TRICARE beneficiaries as 

patients; and (4) publicize which nonnetwork providers in each region 

accept nonenrolled TRICARE beneficiaries as patients.58 It also requires 

that DOD submit annual reports to Congress on efforts to implement these 

activities. 

We received comments on a draft of this report from DOD (see app. VI). In

its comments DOD stated that it appreciated the collaborative, insightful, 

and thorough approach that was taken with this important issue. However, 

DOD disagreed with our finding that it had not formally designated a 

senior official to ensure nonenrolled beneficiaries’ access to care, 

including adequate participation by nonnetwork providers, as required by

the NDAA for fiscal year 2004. DOD stated that DOD directive 5136.12 

assigned these duties to the TMA director and the TROs by designating the 

TMA Director as the program manager for TRICARE health and medical 

Agency Comments 

and Our Evaluation 

 57Since the NDAA for 2006, which tasked the TROs with responsibility for monitoring,

oversight, and improvement of the Standard option within their respective regions, all three 

TROs have undertaken a number of new initiatives to meet these responsibilities. 

58See Pub. L. No. 109-163, § 716, 119 Stat. 3136, 3345. 

Page 44 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
resources and other responsibilities. DOD stated that this responsibility 

clearly encompasses provision of care to nonenrolled beneficiaries and 

therefore meets the NDAA requirement. 

We continue to believe that DOD has not adequately addressed the 

requirement in the mandate. First, in multiple interviews and e-mail 

exchanges during our audit work, senior DOD officials told us that no 

specific actions had been taken to designate a senior official and that, by

default, the duties fell to the ASD for Health Affairs who is responsible for 

overseeing DOD’s health programs and resources. Further, during our site 

visits, TRO officials told us they had never been officially notified of their

responsibilities and expectations for nonenrolled beneficiaries and 

nonnetwork providers. As a result, at the time of our site visits the TROs 

told us they had not undertaken any efforts beyond the level of assistance 

they had already been providing to nonenrolled beneficiaries and 

nonnetwork civilian providers. Second, we do not agree with DOD that the 

terms of the pre-existing directive satisfy the requirements of the mandate.

Contrary to the requirement in the law that one official be designated, the 

directive generally assigns responsibilities to TMA, as well as to multiple 

TROs on a geographic basis. While part of the TROs’ responsibilities 

include developing a plan for the delivery of healthcare within the 

geographic region, the mandate contemplated a more global approach to 

addressing provider participation, specifically requiring one senior official 

to ensure provider participation in each market area. 

DOD also provided technical comments that we incorporated where 

appropriate.

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

appropriate congressional committees, and other interested parties. We 

will also make copies available to others upon request. In addition, the 

report is available at no charge on the GAO Web site at 

http://www.gao.gov. If you or your staff have questions about this report, 

please contact me at (202) 512-7119. Contact points for our Office of 

Page 45 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions are listed in 

appendix VII. 

Marcia Crosse 

Director, Health Care 

Page 46 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix I: Scope and Methodology 

Page 47 GAO-07-48 

Appendix I: Scope and Methodology 

The National Defense Authorization Act (NDAA) for fiscal year 2004 

directed GAO to review the processes, procedures, and analysis used by 

the Department of Defense (DOD) to determine the adequacy of the 

number of network and nonnetwork civilian providers and the actions 

taken to ensure access to care for nonenrolled TRICARE beneficiaries. 

Specifically, this report describes (1) how TRICARE Management Activity 

(TMA) and its managed care support contractors (MCSC) evaluate 

nonenrolled TRICARE beneficiaries’ access to care and the results of these 

evaluations; (2) the impediments to civilian provider acceptance of 

nonenrolled TRICARE beneficiaries, and how they are being addressed; 

(3) how DOD has implemented the fiscal year 2004 NDAA requirements to 

take actions to ensure nonenrolled TRICARE beneficiaries’ access to care. 

TMA and MCSCs’ 

Evaluation of Nonenrolled 

Beneficiaries’ Access to 

Care and the Status of 

Access 

To describe how TMA evaluates nonenrolled TRICARE beneficiaries’ 

access to care, we interviewed and obtained documentation from officials 

in TMA’s Health Program Analysis and Evaluation Directorate about its 

civilian provider survey, called the Survey on Continued Viability of 

TRICARE Standard. Although DOD was required to conduct a survey to 

assess nonenrolled beneficiaries’ access to care under the Standard 

option, the survey was administered to both network and nonnetwork 

civilian providers since nonenrolled beneficiaries can receive care from 

these providers under both the Extra and Standard options. We reviewed 

the survey methodology, including the methods for selecting respondents, 

the survey’s response rate,1

 the designation of TRICARE market areas, and 

the survey instrument itself. We also reviewed TMA’s methods for 

randomly sampling market areas and providers and their administration of 

the survey instrument and found these decisions methodologically sound 

and statistically valid. In addition, we reviewed the survey results, 

including the published results and analysis. While we did not

independently validate the survey data, we did assess the reliability of the 

data by reviewing survey documentation and internal controls and by 

interviewing knowledgeable agency officials and found that the data were 

sufficiently reliable for our purposes. To obtain information on how the 

civilian provider survey was developed, we interviewed officials at the 

Office of Management and Budget (OMB) because the Paperwork 

Reduction Act required OMB approval before it could administered. We 

also interviewed TRICARE beneficiary group representatives who had 

recommended sites for inclusion in the survey where nonenrolled 

 1

The survey had a 55 percent response rate. 

 Access to Care for Nonenrolled Beneficiaries
Appendix I: Scope and Methodology 

TRICARE beneficiaries’ access to health care may be impaired. To identify

how the civilian provider survey results would be used to evaluate access 

to care, we met with officials of TMA’s Office of Health Plan Operations, 

the director of TMA’s Standard Programs Division, and officials from the 

three TRICARE Regional Offices (TROs). 

We also reviewed TMA’s annual Health Care Survey of Defense 

Beneficiaries and compared it with a survey conducted by the Department 

of Health and Human Services’ Consumer Assessment of Health Care 

Providers and System of individuals who received health care through 

civilian health insurers. These surveys include identical questions on 

access-to-care issues that allowed for comparative analysis of the opinions 

expressed by TRICARE beneficiaries and civilian health plan users. Using 

data from the 2003-2005 surveys we analyzed nonenrolled TRICARE 

beneficiaries’ responses to access to care and compared them with results 

from the Consumer Assessment of Health Care Providers and Systems. We 

did not independently verify the data from each of these surveys; however, 

we did assess the reliability of these data by reviewing related 

documentation and interviewing knowledgeable agency officials and 

found that they were sufficiently reliable for our purposes. 

To further identify and describe other methods TMA and MCSCs used to 

evaluate care access for nonenrolled TRICARE beneficiaries, we met with

officials of TMA, the TROs, MCSCs, and each of the services’ Office of the 

Surgeon General to obtain information on the systems they use for 

monitoring TRICARE beneficiary feedback and conducting other types of 

analyses, such as monitoring health care claims. The TROs and military 

services provided information on the Assistance Reporting Tool, a system 

that is being developed to monitor and archive TRICARE beneficiary 

feedback. The MCSCs also shared information about their independent 

systems for maintaining TRICARE beneficiary feedback. TMA, MCSC, and 

military service officials provided us with examples of TRICARE 

beneficiary feedback reports and health care claims data for nonenrolled 

TRICARE beneficiaries that TMA uses to evaluate access to care for this 

population. We did not independently verify data from the MCSCs’ 

TRICARE beneficiary feedback systems and TMA’s claims data files; 

however, we did assess the reliability of these data by interviewing 

knowledgeable officials and reviewing previous GAO work using these 

data and found that they were sufficiently reliable for our purposes. To 

identify how the MCSCs monitor access to care both in Prime Service 

Areas and in areas where networks have not been established, we 

obtained information about their techniques for network development and 

for civilian provider recruitment. 

Page 48 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix I: Scope and Methodology 

To identify and describe the impediments to providers’ acceptance of 

nonenrolled TRICARE beneficiaries, we obtained information from TMA 

Health Plan Operations, TMA Health Program Analysis and Evaluation 

Directorate, TRO, and MCSC officials on the possible reasons that 

providers were unwilling to accept nonenrolled TRICARE beneficiaries as 

patients. We also met with representatives of TRICARE beneficiary groups 

and the American Medical Association to obtain anecdotal information 

about impediments to health care access and to supplement our data on 

possible access-to-care problems. 

To identify and describe how impediments, such as TRICARE

reimbursement rates and administrative issues, are being addressed, we 

reviewed TRICARE’s reimbursement policies and authorities as well as 

provider outreach strategies and marketing and education efforts of TMA 

and its MCSCs. We also reviewed the procedures for issuing waivers used 

to increase reimbursement rates in areas where TMA determines that 

access to care is impaired, including the application, review, and decision 

process. We then obtained information from TMA’s Office of Medical 

Benefit and Reimbursement Systems on all of the completed and pending 

requests for reimbursement waivers. Finally, we interviewed MCSC and 

TRO officials to identify the administrative issues that impact provider 

acceptance of TRICARE beneficiaries and how they conduct outreach 

efforts to alleviate problems and/or educate providers about these issues. 

However, we did not assess the extent to which these efforts improved 

civilian providers’ acceptance of nonenrolled beneficiaries as patients. 

To examine how DOD has implemented the NDAA fiscal year 2004 

requirements for oversight of nonenrolled TRICARE beneficiaries’ access 

to care, we reviewed pertinent sections of this legislation outlining the 

tasks that DOD must perform to comply with the law. We interviewed 

officials in TMA’s office of Health Plan Operations, the director of the 

TRICARE Standard Programs Division, and officials in each of the TROs. 

To identify whether and how the oversight responsibilities outlined in the 

NDAA were being managed, we obtained information from TRO and 

MCSC officials for each of the three regions and TMA’s Communications 

and Customer Service Directorate to identify activities in place to educate

network and nonnetwork providers about TRICARE Standard, to 

encourage network and nonnetwork providers to treat nonenrolled 

TRICARE beneficiaries, and to ensure that nonenrolled TRICARE 

beneficiaries have the information necessary to locate providers readily. 

Impediments to Provider 

Acceptance of 

Nonenrolled TRICARE 

Beneficiaries and How 

They Are Being Addressed 

DOD Implementation of 

NDAA Fiscal Year 2004 

Requirements for 

Oversight of Nonenrolled 

Beneficiaries’ Access to 

Care 

Page 49 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix I: Scope and Methodology 

We conducted our work from July 2005 through December 2006 in 

accordance with generally accepted government auditing standards. 

Page 50 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix II: Methodology Used for TMA’s Appendix II: Methodology Used for TMA Civilian Provider Survey

’s 

Civilian Provider Survey 

The National Defense Authorization Act (NDAA) for fiscal year 2004 

required that the TRICARE Management Activity (TMA) conduct surveys

in TRICARE market areas within the United States to determine how many 

health care providers are accepting new patients under TRICARE 

Standard in each market area. The NDAA did not stipulate how TMA 

should define a market area but specified that 20 market areas should be 

completed each fiscal year until all market areas in the United States have

been surveyed. Although the mandate focused on Standard, TMA officials 

designed the survey to monitor access to care from both network and 

nonnetwork providers since nonenrolled TRICARE beneficiaries can 

receive care through both the Standard and Extra options. 

Before TMA could begin administering the civilian provider survey, it 

required review and clearance from the Office of Management and Budget

(OMB) under the Paperwork Reduction Act.1

 Subsequent to this review, 

OMB approved a four-item questionnaire for the study administered in 

fiscal year 2005.2

 (See app. III for the approved questionnaire.) 

In designing the Survey on Continued Viability of TRICARE Standard (the 

civilian provider survey), TMA defined the individual states and the 

District of Columbia as 51 market areas—a definition that will allow TMA 

to complete the survey of all markets within a 3-year period and to develop 

estimates of access to health care at both the state and national levels. 

However, in order to provide information on smaller geographic areas 

where nonenrolled TRICARE beneficiaries may be having problems 

finding either network or nonnetwork providers, TMA supplemented the 

statewide samples by oversampling3 from submarkets within each state

 1

The Paperwork Reduction Act requires that all federal agency activities that involve 

collecting information from the public involving 10 or more people be approved by OMB to

ensure that collection of this information will have a minimum burden on the public. See 44

U.S.C. §§ 3507 and 3508. 

2

DOD’s submission package to OMB included additional questions that OMB did not

approve for inclusion in the fiscal year 2005 survey because they did not directly respond to

the NDAA for fiscal year 2004. The excluded questions that did not satisfy OMB’s clearance

criteria included the percentage of a provider’s current patient population that uses any

form of TRICARE, a provider’s willingness to accept new Medicare patients, and if a 

provider is not accepting new Medicare patients, the reasons why. 

3

The purpose of oversampling is to increase the sample size of some target subpopulation. 

In this case the target subpopulation is several defined geographic locations within each 

state that were randomly selected for analysis. Oversampling this subpopulation provides 

TMA with reliable information about health care providers at the local level to supplement

what they learn about providers in each state as a whole. 

Page 51 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix II: Methodology Used for TMA’s 

Civilian Provider Survey

called Hospital Service Areas (HSA). The HSA geographic designation is 

derived from a Dartmouth University study that groups zip codes into 

distinct sets based on the analysis of patient travel patterns to the hospital 

or hospitals they use most often. TMA endorsed the HSA submarket 

methodology because these areas are nonoverlapping and encompass all 

of the United States. In addition, nonenrolled TRICARE beneficiaries 

reside in almost all of the 3,436 HSAs. TMA’s methodology asks for 

oversamples from HSAs in the 24 states where 80 percent of nonenrolled 

TRICARE beneficiaries reside. When the study is complete in fiscal year 

2007, TMA will have survey data from 2 HSAs selected randomly from 

each of the 24 states where the majority of nonenrolled TRICARE 

beneficiaries live, as well as information from HSAs purposively selected 

because TRICARE beneficiaries or TROs were concerned with access in 

these areas.

To select the market areas that would be surveyed in fiscal year 2005, TMA 

randomly selected sites from the individual states and the District of 

Columbia and randomly selected 12 submarket HSAs within the 20 market 

areas. In addition, in order to be able to respond to TRICARE beneficiary 

concerns that access in some locations was impaired, TMA selected 17 

additional submarket HSAs that TRICARE beneficiaries had identified as 

problem areas in terms of access to health care. Four of these 17 sites 

were outside the 20 selected state-wide market areas because TRICARE 

beneficiaries had raised concerns about access issues in these locations.

TMA selected its sample for the civilian provider survey from the 

American Medical Association Masterfile, a data set of U.S. providers that 

includes data on all providers who have the necessary educational and 

credentialing requirements. This Masterfile did not differentiate between 

TRICARE’s network and nonnetwork civilian providers. However, TMA 

selected this file because it is widely recognized as one the best 

commercially available lists of providers in the United States and contains

over 600,000 active providers along with their addresses, phone numbers, 

and information on practice characteristics, such as their specialty.

4

Although the Masterfile is considered to contain most providers, 

deficiencies in coverage and inaccuracies in detail remain. Therefore, TMA 

attempted to update providers’ addresses and phone numbers and to 

ensure that providers were eligible for the survey. 

 4

The providers in the American Medical Association’s Masterfile are both medical doctors

and doctors of osteopathy.

Page 52 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix II: Methodology Used for TMA’s 

Civilian Provider Survey

From this Masterfile, TMA expected to randomly sample about 1,000 

providers from each market and submarket area—a sample size that 

would achieve TMA’s desired margin of error.5

 However, in some 

instances, a sample of 1,000 exceeded the number of providers in the 

market or submarket area, in which case TMA attempted to contact all 

providers in that area. Overall, TMA initially sampled about 41,000 

providers, including both network and nonnetwork civilian providers. 

After verifying phone numbers and eliminating ineligible providers,6

 TMA 

attempted to contact about 33,000 office-based providers in the 20 states 

and 29 HSAs evaluated in fiscal year 2005. When analyzing provider 

responses, TMA weighted each response so that the sampled providers 

represented the population from which they were selected. 

To administer the civilian provider survey TMA hired a contractor, who 

conducted the fieldwork for this project. The contractor mailed a 

combined cover letter and questionnaire to the billing managers for all 

providers in their sample. If the provider did not respond to the mailed 

questionnaire, TMA followed up with a second mailing 3 weeks later and 

conducted a telephone interview within 30 days of the first mailing for 

those who did not respond to the mailed survey.7

 During the survey period, 

telephone interviewers called each provider’s office up to 10 times in an 

attempt to obtain a completed survey. 

Because the overall response rate to the survey was 55 percent, TMA 

conducted an analysis of their findings to determine whether the results 

were biased by a high percentage of providers not responding. Although 

TMA officials told us that OMB’s approval for the fiscal year 2005 survey

did not specify a required response rate, OMB’s public guidance specifies 

that if response rates are lower than 80 percent, agencies need to conduct 

a nonresponse analysis.8

 Such an analysis is used to verify that

 5

TMA ultimately dropped the sample size for each market and submarket area to about 800 

providers in each location in order to accommodate both randomly and judgmentally 

selected sites and remain within its resourced and OMB-approved overall sample of about 

40,000 physicians. According to TMA officials, the reduction in sample size did not affect

the sample outcomes and their ability to project results. 

6

According to TMA officials, providers were ineligible for such reasons as being employed

by the military or the government. 

7

The questionnaire or phone interview was directed to an administrative staff person in the

provider’s office. 

8

According to OMB officials, this is a common industry practice when there is potential for 

concern about the reliability of survey results due to a low response rate. 

Page 53 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix II: Methodology Used for TMA’s 

Civilian Provider Survey

nonrespondents to the survey would not answer differently from those 

who did respond and that the respondents are representative of the target 

population, thus ensuring that the data are statistically valid. When 

conducting this analysis, TMA interviewed a sample of providers who did 

not respond to the original survey and compared their responses and 

demographics with the original survey respondents.9

 TMA also compared 

nonrespondents’ demographics with those of the target population of 

health care providers. The results of TMA’s nonresponse analysis indicate 

that the survey respondents are representative of the target population of 

providers. 

The nonresponse analysis provided additional useful information for TMA. 

First, it did not show a difference in the rate that responding and 

nonresponding network civilian providers were aware of the TRICARE 

program. However, it did show a statistically significant difference in the 

rate of awareness between responding and nonresponding nonnetwork 

civilian providers. These results indicate that having a familiarity with 

TRICARE increases a provider’s incentive to respond to the survey. In 

order to adjust for this bias, TMA could have calculated an adjustment to 

the sampling weights—an adjustment that has not been applied to the 

survey results. As a result, the unweighted survey results tend to overstate 

civilian providers’ awareness and acceptance of TRICARE.10 Nonetheless, 

TMA’s survey contractor noted that the survey results are not problematic 

if the survey is used to compare changes in awareness and acceptance 

from year to year. Further, TMA’s use of the unadjusted results of the 

initial survey phase as indicators of areas in which to focus marketing and 

outreach efforts is appropriate because TMA is using it to make relative

comparisons of the areas surveyed. 

TMA’s survey of civilian providers continues, and their analysts expect to 

complete data collection for the nation over a 3-year period ending in 

fiscal year 2007. Although TMA’s efforts meet the mandate’s requirement 

of surveying 20 market areas each fiscal year until all market areas were 

surveyed, collecting survey results over this period may limit TMA’s stated

goal of deriving an overall national estimate because the national estimate 

will combine data collected over several years rather than during one 

 9

For example, TMA compared provider specialty and network status between the original 

respondents and the nonrespondents in bias analysis. 

10According to TMA officials, TMA expects to provide post-survey weighting to account for

differential response rates. 

Page 54 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix II: Methodology Used for TMA’s 

Civilian Provider Survey

relatively short time period, as well as the likelihood different instruments 

will be used over time. For example, four additional questions may be 

added to the fiscal year 2006 survey. TMA officials told us that the time lag 

could potentially impact the results used to derive a national estimate, but 

that their limited resources for this study prevent them from conducting a 

nationwide survey under a shorter time frame. 

Page 55 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix III: Civilian Provider Survey Appendix III: Civilian Provider Survey Instrument 

Instrument 

The National Defense Authorization Act (NDAA) for fiscal year 2004 directed the 

Department of Defense (DOD) to monitor nonenrolled TRICARE beneficiaries’ access 

to care under the TRICARE Standard option.1

 Although the mandate focused on 

Standard, nonenrolled TRICARE beneficiaries can receive care from both 

nonnetwork civilian providers through the Standard option and from network civilian 

providers through the Extra option. Beneficiaries can move freely between these 

options depending on their choice of civilian provider each time they receive care. 

Therefore, DOD’s survey was designed to monitor nonenrolled beneficiaries’ access 

to care from both network and nonnetwork providers. As each cycle of the survey is 

completed, TMA will be able to project survey results to the sampled market areas. 

When all cycles of the survey are complete, TMA will be able to project the survey 

data at the national level.

Following is the actual survey instrument that was used to obtain information from 

civilian providers. The staff administering this survey were not aware of whether the 

civilian providers they contacted were network or nonnetwork, and the same survey 

questions, which specifically mentioned the Standard option, were asked of all 

respondents. Nonetheless, if network civilian providers were to deliver care to 

nonenrolled beneficiaries, the responding providers’ staff would likely understand 

that this care would be provided under the Extra option. Therefore, for the purposes 

of the survey, the term “Standard” referred to both the Standard and Extra option. 

 1

See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003) and S. Rep. No. 108-46, at 330 (2003). 

Page 56 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix III: Civilian Provider Survey 

Instrument 

Page 57 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix III: Civilian Provider Survey 

Instrument 

Page 58 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix III: Civilian Provider

Survey Appendix IV Instrument : Categorized Responses to the 

Civilian Provider Survey’s Open-ended 

Question 

Table 7: “What are the reasons Doctor X is Not Accepting New TRICARE 

[Nonenrolled] Patients?” 

Percent of providers who cited this reason 

Reason for not accepting new

TRICARE patients 

Network (Extra) 

providers 

Nonnetwork

(Standard) 

providers

All 

providers

Doctor not available 31 29 29

Reimbursement 20 25 24

Other/miscellaneous 12 11 12

Administrative inconveniences 15 7 8

Takes other forms of TRICARE 7 8 8

Specialty not covered 6 6 6

Insurance/image problems 3 6 5

Not aware of TRICARE 1 3 3

Only takes certain insurance 0 3 3

Customer service 4 2 2

Application in process 0 1 1

Total percent 99a101a101a

Total responses 378 3837 4215

Source: GAO analysis of DOD data. 

a

Total does not equal 100 percent due to rounding errors. 

Page 59 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix V: TRICARE Reimbursement Rates 

That Remain Higher than Medicare 

Reimbursement Rates 

CPT codeaProcedure or service performed

Ratio of TRICARE to 

Medicare reimbursement

20250 Biopsy, vertebral body, open; thoracic 1.007

38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic 2.980

38241 Bone marrow or blood-derived peripheral stem cell transplantation; autologous 2.954

52355 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or 

renal pelvic tumor 1.090

58600 Litigation or transaction of fallopian tube(s), abdominal or vaginal approach, unilateral or 

bilateral 1.084

58605 Litigation or transaction of fallopian tube(s), abdominal or vaginal approach, postpartum, 

unlaterial or bilateral, during same hospitalization (separate procedure) 1.024

58615 Occlusion of fallopian tube(s) by device (eg. Band, clip, Galope ring) vaginal or suprapubic 

approach 1.040

59012 Cordocentesis (intrauterine), any method 1.137

59020 Fetal contraction stress test 1.427

59025 Fetal non-stress test 1.184

59030 Fetal scalp blood sampling 1.210

59050 Fetal monitoring during labor by consulting physician (ie, non-attending physician) with 

written report; supervision and interpretation 1.324

59051 Fetal monitoring during labor by consulting physician (ie, non-attending physician) with 

written report; interpretation only 1.219

59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or 

oophorectomy, abdominal or vaginal approach 1.016

59135 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total 

hysterectomy 1.017

59140 Surgical treatment of ectopic pregnancy; cervical, with evacuation 1.161

59320 Cerciage of cervix, during pregnancy; vaginal 1.122

59325 Cerciage of cervix, during pregnancy; abdominal 1.094

59350 Hysterorrhaphy of ruptured uterus 1.205

59409 Vaginal delivery only (with or without episiotomy and/or forceps) 1.184

59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum car 1.156

59412 External cephalic version, with or without tocolysis 1.139

59414 Delivery of placenta (separate procedure) 1.190

59514 Cesarean delivery only 1.175

59515 Cesarean delivery only; including postpartum care 1.126

59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or 

forceps) 1.118

59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or 

forceps); including postpartum care 1.104

Appendix V: TRICARE Reimbursement Rates 

That Remain Higher than Medicare 

Reimbursement Rates 

Page 60 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix V: TRICARE Reimbursement Rates 

That Remain Higher than Medicare 

Reimbursement Rates 

CPT codeaProcedure or service performed

Ratio of TRICARE to 

Medicare reimbursement

59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean

delivery 1.127

59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean

delivery; including postpartum care 1.078

59812 Treatment of incomplete abortion, any trimester, completed surgically 1.044

59840 Induced abortion, by dilation and curettage 1.217

59850 Induced abortion, by one or more intra-amniotic injuctions (amniocentesis-injections), 

including hospital admission and visits, delivery of fetus and secundines 1.021

59851 Induced abortion, by one or more intra-amniotic injuctions (amniocentesis-injections), 

including hospital admission and visits, delivery of fetus and secundines; with dilation and 

curettage and/or evacuation 1.019

59855 Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without 

cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus 

and secudines 1.015

59856 Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without 

cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus 

and secudines; with dilation and curettage and/or evacuation 1.046

59857 Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without 

cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus 

and secudines; with hysterotomy (failed medical evacuation) 1.058

59866 Multifetal pregnancy reduction(s) (MPR) 1.151

63091 Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or 

retroperitoneal approach with decompression of spinal cord, cauda equine or nerve 

root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in 

addition to code for primary procedure) 1.003

67334 Strabismus surgery by posterior fixation suture technique, with or without muscle 

recession (List separately in addition to code for primary procedure) 1.025

92953 Temporary transcutaneous pacing 2.965

93541 Injection procedure during cardiac catheterization; for pulmonary angiography 1.624

93542 Injection procedure during cardiac catheterization; for selective right ventricular or right 

atrial angiography (eg.internal mammary), whether native or used for bypass. 1.216

93543 Injection procedure during cardiac catheterization; for selective left ventricular or left atrial 

angiography 1.558

93544 Injection procedure during cardiac catheterization; for aortography 1.979

93545 Injection procedure during cardiac catheterization; for selective coronary angiography 

(injection of radiopaque material may be by hand) 1.833

93616 Esophageal recording of atrial electrogram with or without ventricular electrogram(s); with

pacing 1.198

93660 Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG

monitoring and intermittent blood pressure monitoring, with or without pharmacological 

intervention 1.320

94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination 1.901

Source: GAO analysis of DOD data. 

Page 61 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix V: TRICARE Reimbursement Rates 

That Remain Higher than Medicare 

Reimbursement Rates 

a

Current Procedural Terminology (CPT) is a set of codes, descriptions, and guidelines intended to 

describe procedures and services performed by physicians and other health care providers. 

Page 62 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix VI: Comments from the Department of Defense Appendix VI: Comments from the 

Department of Defense 

Page 63 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix VI: Comments from the Department of Defense 

Page 64 GAO-07-48 Access to Care for Nonenrolled Beneficiaries
Appendix VII: 

and Staff A

GAO Contacts

cknowledgments 

Page 65 GAO-07-48

Appendix VII: GAO Contacts and Staff 

Acknowledgments 

Marcia Crosse (202) 512-7119 or crossem@gao.gov

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

Director, Kevin Dietz, Cathleen Hamann, Lois Shoemaker, Robert Suls, 

and Suzanne Worth made key contributions to this report. 

Access to Care for Nonenrolled Beneficiaries

GAO Contact 

Acknowledgments 

(290398) 
GAO’s Mission The Government Accountability Office, the audit, evaluation and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “Subscribe to Updates.” 

The first copy of each printed report is free. Additional copies are $2 each. 

A check or money order should be made out to the Superintendent of 

Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. Orders 

should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, D.C. 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER