Under TRICARE, beneficiaries have choices among various benefit options and may obtain care from either military treatment facilities or civilian providers. When nonenrolled beneficiaries receive care from civilian providers, they have the option of seeing either network or nonnetwork providers. The NDAA 2008 directed DOD to conduct surveys of beneficiaries and civilian providers to assess nonenrolled beneficiaries’ access to care. TRICARE provides benefits through several basic options for its non- Medicare-eligible beneficiary population. These options vary by enrollment requirements, choices in civilian and military treatment facility providers, and the amount beneficiaries must contribute toward the cost of their care. Table 1 provides a summary of some of these benefit options. Claims data from fiscal years 2008 to 2011 show that the percentages of the number of outpatient claims paid for TRICARE Prime and TRS have gradually increased, while the percentage of claims paid for TRICARE Standard has declined. (See fig. 1.) The percentage of claims paid for TRICARE Extra has remained steady over the same period. Starting on September 30, 2013, the number of PSAs will be reduced, and as a result, the TRICARE Prime option will be available to fewer beneficiaries. The targeted PSAs are those that are not in close proximity to existing MTFs or BRAC locations and will predominantly affect retirees and their dependents. According to a TMA official, this change is expected to affect about 171,000 retirees and dependents (37,000 in the North region, 36,000 in the West region, and 98,000 in the South region), with an estimated savings to DOD of $45 million to $56 million annually. In fiscal year 2011, TMA identified about 2 million nonenrolled beneficiaries (approximately one-fourth of the total eligible TRICARE population), who fell into three main categories: (1) retirees and their dependents or survivors, (2) active duty dependents, and (3) National Guard and Reserve servicemembers and their dependents. (See fig. 2.) Overall, during 2008-2011, an estimated one in three nonenrolled beneficiaries (about 31 percent) experienced problems finding any type of civilian provider—primary, specialty, or mental health care provider—who would accept TRICARE. Specifically: an estimated 25 percent of nonenrolled beneficiaries experienced problems finding a civilian primary care provider; an estimated 25 percent of nonenrolled beneficiaries experienced problems finding a civilian specialty care provider; and an estimated 28 percent experienced problems accessing a civilian mental health care provider. Overall, access to civilian primary care and specialty care providers differed for nonenrolled beneficiaries located in PSAs compared to those in non-PSAs. Specifically, we found that more nonenrolled beneficiaries in PSAs experienced problems finding civilian primary care and specialty care providers compared to those in non-PSAs. (See fig. 6.) However, access to civilian mental health care providers did not differ for nonenrolled beneficiaries in PSAs and non-PSAs. TMA also surveyed beneficiaries in HSAs in response to access concerns about these specific areas. We found that more nonenrolled beneficiaries in HSAs experienced problems accessing civilian specialty care than those in the areas outside of the surveyed HSAs. (See fig. 7.) However, there were no statistical differences in the estimated percentages of nonenrolled beneficiaries who experienced problems finding civilian primary or mental health care providers between the HSAs and the locations surveyed outside of these areas. The top two reasons reported by nonenrolled beneficiaries—regardless of type of care—for why they believed they experienced problems accessing a provider included “doctors not accepting TRICARE payments” and “doctors not accepting new TRICARE patients.” (See fig. 8.) Our analysis of the 4-year survey data showed that nonenrolled beneficiaries’ ratings for specific satisfaction measures were similar when compared between PSAs and non-PSAs, and between surveyed HSAs and the areas outside of the surveyed HSAs. Specifically, our analysis of beneficiaries’ ratings for four measures—satisfaction with primary care providers, specialty care providers, health care, and health plan— indicated no substantial differences between area types. For example, we found that about 80 percent of nonenrolled beneficiaries in both PSAs and non-PSAs rated their primary care provider as an 8 or higher on a scale from 0 to 10. Nationwide, an estimated 82 percent of civilian providers indicated they were aware of the TRICARE program, but only an estimated 58 percent were accepting new TRICARE patients, according to our analysis of the 2008 through 2011 civilian provider survey results. When compared to a national provider survey, civilian providers’ acceptance of new TRICARE patients was less than providers’ acceptance of other types of beneficiaries. Specifically, a survey of physicians in 2008 by the Center for Studying Health System Change found that about 96 percent of physicians accepted new commercially insured beneficiaries, about 86 percent accepted new Medicare beneficiaries, and about 72 percent accepted new Medicaid beneficiaries. According to the TRICARE survey results, when asked the reasons for not accepting new TRICARE patients, the most-cited category by those civilian providers who were not accepting any new TRICARE patients was that the provider “was not aware of the TRICARE program/not asked/don’t know about TRICARE.” (See fig. 10 for the top 7 categories of reasons for why civilian providers were not accepting new TRICARE patients.) Additionally, while nonenrolled beneficiaries cited that providers were not accepting TRICARE for payment as the top reason why any providers were unwilling to accept them as patients, the providers cited it as the third highest reason in addition to “don’t know/no answer.” When we compared the results of TMA’s 2008-2011 civilian provider survey (excluding nonphysician mental health providers) to the results of its 2005-2007 civilian physician survey, we found that although civilian physicians’ awareness has increased over time, their acceptance of new TRICARE patients has decreased over time. This was also true whether they were accepting any new patients or new Medicare patients. For example, civilian physicians’ acceptance of any new TRICARE patients has decreased from about 76 percent in 2005-2007 to an estimated 70 percent in 2008-2011. (See fig. 11.) When analyzed further by provider type, we found that civilian primary and specialty care providers had higher awareness and acceptance of TRICARE than civilian mental health care providers. (See fig. 12.) Specifically, only an estimated 39 percent of civilian mental health providers were accepting new TRICARE beneficiaries, compared to an estimated 67 percent of civilian primary care providers and an estimated 77 percent of civilian specialty care providers. The categories of reasons cited for not accepting new TRICARE patients also differed by provider type. For example, civilian mental health care providers more often cited “not aware of TRICARE/not asked/don’t know about TRICARE” than civilian primary or specialty care providers. Additionally, the top category of reasons cited by civilian primary care providers was that they were “not accepting patients” while the top category of reasons cited by specialty providers was “reimbursement.” (See fig. 13 for the top categories of reasons for civilian providers not accepting new TRICARE patients, by provider type.) We also found that providers’ awareness and acceptance of TRICARE differed by type of area. Similar to TMA’s nonenrolled beneficiary survey, which showed that nonenrolled beneficiaries in PSAs generally experienced more problems finding providers than their counterparts in non-PSAs, our analysis of the 2008 through 2011 civilian provider survey indicated that civilian providers in PSAs were less aware of TRICARE and less accepting of new TRICARE patients than civilian providers in non- PSAs. Specifically, an estimated 81 percent of civilian providers in PSAs were aware of the TRICARE program, compared to an estimated and an estimated 87 percent of civilian providers in non-PSAs, 56 percent of civilian providers in PSAs were accepting any new TRICARE patients, compared to an estimated 66 percent of those providers in non-PSAs. (See fig. 14.) An analysis of the collective results of the multiyear beneficiary and civilian provider surveys indicated particular geographic areas where nonenrolled beneficiaries are experiencing considerable access problems. These locations are defined as areas where (1) the percentage of nonenrolled beneficiaries who experienced difficulties finding a civilian provider was at least the national estimate and (2) the percentage of civilian providers who were accepting any new TRICARE patients was at or below the national estimate. Using these criteria, we identified a number of areas where beneficiaries were having access problems, mostly in Texas. (See app. IV for detailed information about these areas and how they were determined.) In determining areas where nonenrolled beneficiaries were experiencing access problems to any type of civilian provider, we first identified 24 individual areas (out of the 215 individual areas surveyed by the 2008- 2011 beneficiary surveys) where the estimated percentage of nonenrolled beneficiaries who experienced difficulties finding any type of civilian provider met or exceeded the national estimate (31 percent). Of these, we identified 2 PSAs where the estimated percentage of civilian providers who were accepting any new TRICARE patients was at or below the national estimate (58 percent)—Central/Southern-Central Coastal California and Northeastern Texas. Additionally, we identified 2 HSAs that also met these criteria, one of which is contained within the Northeastern Texas PSA. Table 4 shows each of these areas with the estimated percentage of (1) nonenrolled beneficiaries who experienced problems finding any type of civilian provider and (2) civilian providers who were accepting any new TRICARE patients. For the overlapping PSA and HSA (Northeastern Texas and Dallas/Fort Worth), we found that although a high percentage of civilian providers were accepting new patients (between 95 and 97 percent), only about half of these providers were accepting any new TRICARE patients. (See table 5.)