In fiscal year 2016, DOD identified about 2.2 million nonenrolled TRICARE beneficiaries who fell into four categories: (1) retired servicemembers and their dependents, (2) inactive guard/reserve servicemembers and their dependents, (3) dependents of active duty, or of guard/reserve on active duty status, and (4) other beneficiaries, such as dependent survivors of deceased servicemembers. Retired servicemembers and their dependents made up the majority of nonenrolled beneficiaries at the end of fiscal year 2016 (approximately 60 percent). (See fig. 1.) Prior to January 1, 2018, TRICARE provided benefits through three basic options for its non-Medicare-eligible beneficiary population—TRICARE Prime, Standard, and Extra. These options varied by enrollment requirements, choices in civilian and military treatment facility providers, and the amount beneficiaries must contribute toward the cost of their care. (See table 1.) The NDAA 2017 made specific changes to the TRICARE program that became effective on January 1, 2018. These changes included terminating the TRICARE Standard and Extra options, establishing a new option called TRICARE Select, and ensuring that 85 percent of TRICARE Select beneficiaries are covered by the network of civilian providers. TRICARE Select has similar benefits to TRICARE Standard and Extra for obtaining care from nonnetwork and network providers, but unlike these options, TRICARE Select requires enrollment. Under TRICARE, DOD uses managed care support contractors to develop networks of civilian providers to serve all TRICARE beneficiaries in PSAs, which are typically within an approximate 40-mile radius of a military outpatient or inpatient treatment facility or Base Realignment and Closure sites. Although some network providers may be located in non- PSAs, contractors are not required to develop networks in these areas. Previously, contractors had the option of developing additional PSAs (and civilian provider networks) in areas that were not located near military treatment facilities or Base Realignment and Closure sites. However, on October 1, 2013, DOD eliminated these additional PSAs, referred to in the survey analyses as “former PSAs,” and as a result, the managed care support contractors were no longer required to develop and maintain networks of civilian providers in these areas. In fiscal year 2016, approximately 65 percent of the 2.2 million nonenrolled beneficiaries that were eligible for TRICARE Standard and Extra (1.47 million) lived in PSAs. Of the remaining nonenrolled beneficiaries (775,000), about 19 percent lived in former PSAs and about 16 percent lived in non-PSAs. (See fig. 2.) Nonenrolled beneficiaries who live in former PSAs and non-PSAs may still have access to network providers, even though contractors are not required to develop networks in these areas. About 57 percent of these beneficiaries (445,000) filed at least one TRICARE claim with a network civilian provider during fiscal year 2016. The NDAA 2008 directed DOD to survey nonenrolled beneficiaries and civilian providers in at least 20 PSAs in each of four fiscal years, 2008 through 2011, as well as 20 non-PSAs. To do this, DOD divided the country into 80 distinct PSAs and 80 distinct non-PSAs and surveyed 20 PSAs and 20 non-PSAs each year. At the end of the 4-year period, each year’s survey results were combined and weighted to develop estimates of access to health care, including mental health care, at the service area, state, and national levels. Additionally, the NDAA 2008 required DOD to consult with representatives of TRICARE beneficiaries and providers of health care, including mental health care, to identify locations where nonenrolled beneficiaries have experienced significant access-to-care problems and to survey both beneficiaries and health care providers, including mental health care providers, in these areas. Based on these consultations, DOD designated certain Hospital Service Areas (HSA) to include in its beneficiary and provider surveys. DOD used a similar methodology for determining its locations in the 2012- 2015 surveys. However, as a result of DOD’s changes to PSAs on October 1, 2013, 28 of the 80 non-PSAs surveyed were former PSAs. DOD also surveyed both nonenrolled beneficiaries and civilian providers in a total of 30 HSAs. As a result, DOD collectively surveyed 190 geographic locations over the 4-year period. Furthermore, we previously reported that DOD’s implementation of its 2008-2011 nonenrolled beneficiary and civilian provider surveys generally addressed the requirements outlined in the NDAA 2008. DOD made several minor revisions to the methodologies of the 2012-2015 surveys, but we determined that none of those changes altered DOD’s compliance with the NDAA 2008, as amended. Nonenrolled beneficiary survey results over time. Nationwide, a lower percentage of nonenrolled beneficiaries reported that they experienced problems finding any type of provider in the 2012-2015 survey (29 percent) when compared to the prior 2008-2011 survey (31 percent). Specifically, fewer nonenrolled beneficiaries reported that they experienced problems finding a primary care provider than in the prior survey (22 percent in 2012-2015 compared to 25 percent in 2008-2011). However, there was no significant statistical difference over time in the percentage of beneficiaries who reported experiencing problems finding a specialty care or mental health care provider. (See fig. 3.) Nonenrolled beneficiary survey results by type of location. Nonenrolled beneficiaries in non-PSAs reported experiencing fewer problems finding primary and specialty providers than those in PSAs, which is similar to what we reported for the prior survey. For example, about 20 percent of beneficiaries in non-PSAs reported that they had problems finding specialty care providers compared to 24 percent in PSAs. Regarding beneficiaries in former PSAs, the only statistically significant difference among the three provider types was for problems finding a primary care provider. Specifically, fewer (about 19 percent) nonenrolled beneficiaries in non-PSAs reported experiencing problems finding a primary care provider to accept TRICARE, compared to 24 percent in former PSAs. (See fig. 4.) DOD officials told us that they were unsure of the exact reasons for the difference between PSAs and non- PSAs. However, they explained that PSAs are often located in more populated areas, where TRICARE beneficiaries may not make up a large market share for local civilian providers, who may have a wide array of patients with other health plans. Nonenrolled beneficiary survey results by network status. Nonenrolled beneficiaries with network providers reported experiencing fewer problems finding civilian providers, compared to nonenrolled beneficiaries with nonnetwork providers. For example, 20 percent of the nonenrolled beneficiaries who used a network civilian primary care provider reported that they had a problem finding a primary care provider that would accept TRICARE compared with the 44 percent of nonenrolled beneficiaries who used a nonnetwork civilian primary care provider. (See fig. 5.) In addition, when compared with the results of the last survey (2008- 2011), the percentages of nonenrolled beneficiaries who reported that they experienced problems finding a specialty care or mental health care provider increased in the most recent survey (2012-2015) for beneficiaries who used nonnetwork providers, but there were no changes over time if their specialty care or mental health care providers were in the network. (See fig. 6.) Compared to the prior survey, a higher percentage of nonenrolled beneficiaries reported that they were able to obtain appointments as soon as they desired. Specifically, the percentage of nonenrolled beneficiaries who made non-urgent appointments for health care and reported that they were able to usually or always obtain an appointment as soon as they thought they needed increased from 87 percent in the 2008-2011 survey to 90 percent in the 2012-2015 survey. However, the most commonly reported length of time they waited between making an appointment and actually seeing a provider did not change from the 2008- 2011 surveys—most respondents in both surveys reported they were able to get appointments within 3 days (about 54 percent for both years’ surveys). The 2012-2015 survey also asked specific questions about how easy it was to get an appointment with specialty care providers and mental health care providers: Of those nonenrolled beneficiaries who tried to make an appointment with a civilian specialty care provider, 84 percent reported it was “usually easy,” or “always easy,” to get appointments. These results also varied by network status, as a higher percentage of those who used a network specialty care provider reported that they found it “usually easy” or “always easy” to get appointments (85 percent) compared to those that used a nonnetwork specialty care provider (74 percent). Of those nonenrolled beneficiaries that received treatment or counseling from a civilian mental health care provider, 73 percent reported that when they needed treatment or counseling right away, they usually or always saw someone as soon as they wanted. We found that this result did not change since the prior survey, nor did we find any statistically significant differences between beneficiaries’ responses for seeing a network versus a nonnetwork mental health provider. Ratings of TRICARE over time. Nonenrolled beneficiaries’ positive ratings of TRICARE have generally increased since the previous survey. Specifically, over time, nonenrolled beneficiaries’ positive ratings of five different categories related to TRICARE have either increased (primary care rating, specialty care rating, and health plan rating) or remained the same (mental health care rating and health care rating). (See fig. 7.) Furthermore, nonenrolled beneficiaries’ positive ratings of their mental health care providers were lower than their ratings for their primary and specialty care providers. We also found that there were no significant differences at the 95 percent confidence level for nonenrolled beneficiaries’ ratings of primary care, specialty care, or mental health care providers based on their network status. Ratings of TRICARE compared to other federal health plans. When we compared these results to those of the 2013-2015 CAHPS surveys, we found that nonenrolled TRICARE beneficiaries’ positive experience ratings for primary care providers and specialty care providers were lower than those of Medicare fee-for-service beneficiaries and higher than those of Medicaid beneficiaries, which is similar to what we found for the previous survey. We also found that TRICARE beneficiaries’ positive experience ratings for their health care were higher than that of both Medicare fee-for-service beneficiaries and Medicaid beneficiaries, but TRICARE beneficiaries’ positive experience ratings for their health plan were lower than both of these groups. (See fig.8.) Provider awareness over time, by provider type and by location type. Nationwide, a higher percentage of civilian providers reported that they were aware of TRICARE in the 2012-2015 civilian provider survey (84 percent) than those from the 2008-2011 civilian provider survey (82 percent). Specifically, since the previous survey, we found that awareness increased for specialty care providers (from 92 to 94 percent) and mental health care providers (from 68 to 74 percent). In addition, when we analyzed these results by location type, we found that civilian providers in both PSAs and non-PSAs reported higher awareness of TRICARE since the previous survey (from 79 to 82 percent in PSAs and from 87 to 89 percent in non-PSAs). Awareness among civilian providers in locations now designated as former PSAs remained statistically unchanged at the 95 percent confidence level (89 percent in 2012-2015). However, despite some increases in awareness, civilian providers in PSAs reported lower awareness than those in non-PSAs and former PSAs in the 2012-2015 surveys. Provider awareness by network status. Providers within the TRICARE network reported higher awareness of TRICARE than nonnetwork providers, regardless of individual provider type. (See fig. 9.) Among individual provider types, the biggest difference in awareness between network and nonnetwork providers was for mental health care providers, with 96 percent of network mental health care providers reporting awareness of TRICARE compared with 72 percent of nonnetwork mental health care providers. Provider acceptance over time, by provider type and location type. Nationwide, we found an overall decrease reported in civilian providers’ acceptance of new TRICARE patients in the 2012-2015 civilian provider survey (55 percent) compared to the 2008-2011 civilian provider survey (58 percent). However, when we analyzed acceptance by provider type, we found that the overall decrease was mainly attributable to a decrease in mental health care providers’ acceptance rates, as primary and specialty care providers’ acceptance rates remained unchanged. Specifically, mental health care providers’ TRICARE acceptance rate decreased from 39 to 36 percent. However, this low acceptance rate may not be an issue unique to TRICARE, as we have previously reported that there is a nationwide shortage of mental health professionals. In addition, when we analyzed results for all civilian providers by location type, we found that civilian providers in PSAs and non-PSAs reported lower acceptance rates of new TRICARE patients since the previous survey (from 55 to 53 percent in PSAs, and from 66 to 62 percent in non- PSAs). Acceptance among civilian providers in locations now designated as former PSAs remained statistically unchanged at the 95 percent confidence level (60 percent in 2012-2015). Similar to our findings on providers’ awareness, we found that civilian providers in PSAs reported lower acceptance rates than those in non-PSAs and former PSAs. miscellaneous, and A Department of Defense official told us that some examples of “miscellaneous” are “in a private practice”, and “not a preferred provider.” Provider acceptance by network status. When we analyzed civilian providers’ acceptance of new TRICARE patients by providers’ network status, we found that network providers reported higher acceptance of new TRICARE patients than nonnetwork providers, regardless of provider type. (See fig. 10.) Among individual provider types, the biggest difference in acceptance between network and nonnetwork providers was for mental health care providers with 79 percent of network mental health care providers reporting acceptance of new TRICARE patients compared with 30 percent of nonnetwork mental health care providers. Of those mental health care providers that were not accepting new TRICARE patients, one of the top reasons reported by those not in the network was a lack of awareness of TRICARE. Due to the relatively small number of network mental health providers who provided reasons for not accepting new TRICARE patients, it was not possible to identify one primary reason; however, some of the reasons they cited include reimbursement, not accepting new patients, and specialty was not covered. Our analysis of the 2012-2015 nonenrolled beneficiary and civilian provider surveys indicated that beneficiaries may have difficulty accessing a primary care provider, a specialty care provider, or both in 6 out of the 190 specific geographic locations that were surveyed. For the 6 locations we identified, beneficiaries reported higher levels of problems finding providers, and providers reported lower rates of accepting TRICARE patients. Primary care. We identified two locations where access to primary care providers may be particularly problematic. (See table 2.) In these two locations, the percent of beneficiaries who reported that they had problems finding a primary care provider was at or above the 2012- 2015 beneficiary survey’s national average of 22 percent, and also where the percent of primary care providers who reported that they were accepting new TRICARE patients was at or below the 2012- 2015 civilian provider survey’s national average of 68 percent. Specialty care. We identified five locations where access to specialty care providers may be particularly problematic. (See table 2.) In these five locations, the percent of beneficiaries who reported that they had problems finding a specialty care provider was at or above the 2012- 2015 beneficiary surveys’ national average of 23 percent, and also where the percent of specialty care providers who reported that they were accepting new TRICARE patients was at or below the 2012- 2015 civilian provider surveys’ national average of 78 percent. When we compared this analysis to our analysis of the 2008-2011 beneficiary and provider surveys, the “Dallas/Fort Worth, Texas” HSA was identified in both results. Using data from the prior survey, our analysis identified it as being potentially problematic for primary care, but using data from the more recent survey, we identified specialty care access as being potentially problematic. DOD officials told us that their past analysis of beneficiaries’ complaints in this location centered on appointment wait times exceeding beneficiaries’ preferences and on drive times to providers’ offices. Officials explained that although there was a wide range of network specialty care providers in this location, TRICARE beneficiaries were a very small percentage of the overall population. Furthermore, this location is home to a number of large corporations that have health care plans that reimburse providers more than TRICARE. DOD officials added that due to these factors, providers in this location do not give preference to TRICARE beneficiaries, and drive times in this location are often long due to the traffic patterns and overall congestion of a large urban area. In reviewing a draft of this report, DOD concurred with our overall findings. DOD’s written response is reprinted in appendix I. We are sending copies of this report to the Secretary of Defense and appropriate congressional committees. The report is also available at no charge on GAO’s website at http://www.gao.gov. If you or your staff has any questions regarding this report, please contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. Debra A. Draper at (202) 512-7114 or draperd@gao.gov. In addition to the contacts named above, Bonnie Anderson, Assistant Director; Jeff Mayhew, Analyst-in-Charge; Amy Andresen; and Jennie Apter made key contributions to this report. Also contributing were Zhi Boon, Jacquelyn Hamilton, Vikki Porter, and Eric Wedum.

Summary: DOD provides health care, including mental health care, to eligible beneficiaries through TRICARE. Beneficiaries who use TRICARE Prime, a managed care option, must enroll to receive care. Prior to Jan. 1, 2018, beneficiaries did not need to enroll for TRICARE Standard, a fee-for-service option, or TRICARE Extra, a preferred provider organization option (referred to as nonenrolled beneficiaries). Although the TRICARE Standard and Extra options were terminated effective Jan. 1, 2018, the new TRICARE Select option has similar benefits for obtaining care from network and nonnetwork providers. The National Defense Authorization Act (NDAA) for Fiscal Year 2008 directed DOD to conduct surveys of nonenrolled beneficiaries and civilian providers about access to care under the TRICARE Standard and Extra options. It also directed GAO to review the surveys' results. Additionally, the NDAA for Fiscal Year 2017 included a provision for GAO to review access to care under TRICARE Extra. This report addresses both provisions. GAO analyzed DOD's surveys to determine (1) nonenrolled beneficiaries' access to care, (2) nonenrolled beneficiaries' ratings of TRICARE, (3) civilian providers' awareness and acceptance of TRICARE, and (4) nonenrolled beneficiaries' access by individual geographic area. GAO interviewed agency officials, analyzed the 2012-2015 surveys, and compared them to DOD's 2008-2011 surveys and to surveys of Medicare and Medicaid beneficiaries. In commenting on a draft of this report, DOD concurred with GAO's findings. The Department of Defense's (DOD) most recent surveys of TRICARE beneficiaries and civilian health care providers show that access to care has generally improved for nonenrolled beneficiaries who used the TRICARE Standard and Extra options. Specifically, GAO found the following: Nonenrolled beneficiaries reported improved access to care in the most recent 4-year survey (2012-2015), compared to the prior survey (2008-2011). For example, a lower percentage of nonenrolled beneficiaries reported that they experienced problems finding a civilian provider in the most recent survey (29 percent) than those in the prior survey (31 percent). In addition, a higher percentage of nonenrolled beneficiaries (90 percent) reported that they were usually or always able to obtain a non-urgent appointment as soon as they thought they needed compared to the prior survey (87 percent). The percentage of nonenrolled beneficiaries who reported positive experience ratings of TRICARE ranged from 71 to 83 percent over five categories, including ratings of primary, specialty, and mental health care providers. These ratings were generally higher than the prior survey. When compared to other federal health plans, nonenrolled TRICARE beneficiaries' positive experience ratings of primary and specialty care providers were lower than those of Medicare fee-for service beneficiaries, but higher than those of Medicaid beneficiaries. The percentage of civilian providers who were aware of TRICARE increased from 82 percent in the prior survey to 84 percent. However, the percentage who accepted new TRICARE patients decreased from 58 percent to 55 percent. According to GAO's analysis of survey data, this overall decrease was mainly attributable to a decrease in mental health care providers' acceptance rates, as the acceptance rates for primary and specialty care providers remained unchanged. Network providers reported both higher awareness and acceptance of TRICARE than providers not in the network (referred to as nonnetwork providers). The biggest gap in both awareness and acceptance between network and nonnetwork providers was for mental health care providers: About 96 percent of network mental health care providers reported awareness of TRICARE compared to 72 percent of nonnetwork mental health care providers. About 79 percent of network mental health care providers reported accepting new TRICARE patients compared to 30 percent of nonnetwork mental health care providers. GAO's analysis of both the beneficiary and provider surveys identified locations in New York, Washington, Texas, and Washington, D.C. where access to providers may be particularly problematic. Specifically, in these locations, beneficiaries reported more problems finding providers who accepted TRICARE and providers reported lower acceptance of TRICARE, compared to national averages.