In fiscal year 2009, over 9 million beneficiaries were eligible to receive health care and mental health care through DOD’s TRICARE program. Under TRICARE, beneficiaries have choices among various benefit options and may obtain care from either military treatment facilities or civilian providers. TRICARE beneficiaries fall into different categories: (1) active duty personnel and their dependents, (2) National Guard and Reserve servicemembers and their dependents, and (3) retirees and their dependents or survivors. 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, are eligible to obtain care under a separate program called TRICARE for Life. As shown in figure 1, active duty personnel and their dependents represented 32 percent of the beneficiary population, while National Guard and Reserve servicemembers and their dependents represented 14 percent. Ntionl Guard nd Reerve ervicememer nd dependentActive dty peronnel nd dependentRetiree nd their dependent or survivor(generlly nder ge 65) 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. TRICARE provides its benefits through several options for its non- Medicare-eligible beneficiary population. These options vary according to TRICARE beneficiary enrollment requirements, the choices TRICARE beneficiaries have in selecting civilian and military treatment facility providers, and the amount TRICARE beneficiaries must contribute toward the cost of their care. Table 1 provides additional information about these options. Claims data from fiscal years 2006 to 2009 show that the percentage of claims paid for using TRICARE Prime and TRICARE Extra has gradually increased, while the percentage of claims paid for using TRICARE Standard has declined 2 to 3 percentage points each year. (See fig. 2.) Moreover, in 2006 we reported that in fiscal year 2005 about 1.8 million beneficiaries who were eligible for TRICARE Standard or Extra elected not to use their benefits. In fiscal year 2009, about 926,000 beneficiaries who were eligible for TRICARE Standard, TRICARE Extra, and TRICARE Reserve Select elected not to use their benefits. In order for network and nonnetwork civilian providers to be authorized to provide care and be reimbursed under TRICARE, they must be licensed by their state, accredited by a national organization (if one exists), and meet other standards of the medical community. Individual TRICARE- authorized civilian providers can include health care providers, such as primary care physicians and specialists, as well as mental health care providers, including clinical psychologists. There are two types of authorized civilian providers—network and nonnetwork providers. Network providers are TRICARE-authorized providers who enter a contractual agreement with a managed care support contractor 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. 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. Nonnetwork providers are TRICARE-authorized providers who do not have a contractual agreement with a managed care support contractor to provide care to TRICARE beneficiaries. Nonnetwork civilian providers have the option of charging up to 15 percent more than the TRICARE reimbursement rate for their services on a case-by-case basis. The beneficiary is responsible for paying the extra amount billed in addition to required co-payments. The NDAA 2008 directed DOD to determine the adequacy of the number of health care and mental health care providers that currently accept nonenrolled beneficiaries as patients under TRICARE. Specifically, the mandate directed DOD to conduct surveys of beneficiaries and providers in at least 20 Prime Service Areas and 20 non-Prime Service Areas in each of fiscal years 2008 through 2011. The mandate also directed DOD to give a high priority to locations having high concentrations of Selected Reserve servicemembers. Additionally, the NDAA 2008 required DOD to consult with representatives of TRICARE beneficiaries and health care and mental health care providers to identify locations where nonenrolled beneficiaries have experienced significant access-to-care problems, and to survey health care and mental health care providers in these areas. The NDAA 2008 also required that specific types of information be requested in the surveys. For example, the mandate stated that the provider survey must include questions to determine whether providers are aware of TRICARE. Within DOD, TMA has primary responsibility for designing and implementing the beneficiary and provider surveys. In implementing the first year of the beneficiary and provider surveys, TMA followed the OMB standards for statistical surveys that we reviewed. However, TMA did identify an error in the geographic categorization of its participants for both surveys and has taken steps to correct it. In addition, TMA generally addressed the requirements outlined in the NDAA 2008 for both of its surveys but did not give a high priority to selecting areas with a high concentration of Selected Reserve servicemembers. Instead, for both surveys, TMA randomly selected geographic areas to produce results that can be generalized to the populations from which the survey samples were drawn. TMA plans to cover the entire United States at the end of the 4-year survey period, which will include any locations with higher concentrations of Selected Reserve servicemembers. In implementing its first round of beneficiary and provider surveys, TMA’s methodology for both of the multiyear surveys is consistent with the OMB standards for statistical surveys that we reviewed. (See app. I for our list of selected OMB standards.) These standards document the professional principles and practices that federal agencies are required to follow and the level of quality and effort expected in statistical activities. For example, OMB standards recommend that agencies develop a survey design that includes a methodology for identifying the target population. OMB standards also suggest that federal agencies ensure that the list of eligible survey participants representing the target population is evaluated for accuracy. In conducting its 2008 beneficiary and provider surveys, TMA representatives noted that they identified an error in the geographic categorization of eligible survey participants for both surveys. Specifically, TMA erroneously categorized some beneficiaries and providers as being located in 11 non-Prime Service Areas when in fact they were in Prime Service Areas. According to a TMA representative, this occurred as a result of a computer programming error. TMA identified this error after it began fielding the beneficiary survey in June 2008 but prior to fielding the provider survey, which began in December 2008. As a result, TMA surveyed approximately 9,000 fewer beneficiaries than intended in those 11 non-Prime Service Areas. TMA plans to correct this error in future years by surveying additional beneficiaries in the affected non-Prime Service Areas. TMA generally addressed the requirements outlined in the mandate during the implementation of its 2008 beneficiary and provider surveys, but because of methodological considerations TMA used a different approach for its selection of survey areas. (See app. II for a more detailed description of DOD’s survey methodology.) Overall, the mandate outlined specific survey requirements, including the number and priority of areas to be surveyed each year, the content for each type of survey, and the use of benchmarks, which can be used to assess survey results. (See table 2.) According to a TMA official responsible for implementing the surveys, TMA did not give a high priority to areas where higher concentrations of Selected Reserve servicemembers live, as specified in the mandate, because it decided to randomly select the areas to be surveyed in order to produce results that can be generalized to the populations from which the survey samples are selected. Moreover, at the end of the 4-year survey period for the beneficiary and provider surveys, TMA will have surveyed all areas of the United States, thereby including any locations with a higher concentration of Selected Reserve servicemembers. A TMA official also told us that TMA conducted additional analyses of the 2008 beneficiary survey results for TRICARE Reserve Select beneficiaries to obtain additional information about the Selected Reserve servicemembers, and plans to do so in the remaining 3 years of the survey. TMA found that its 2008 results indicate that TRICARE access is no different for the Selected Reserve servicemembers than for other beneficiaries in the surveyed areas. The first year’s results of TMA’s 4-year beneficiary survey are representative of the nonenrolled beneficiary population in the combined Prime Service Areas and combined non-Prime Service Areas that were selected for the 2008 survey. Based on our analysis of these results, we estimated that a higher percentage of nonenrolled beneficiaries in surveyed Prime Service Areas experienced problems accessing care from network or nonnetwork primary care physicians or nurses than beneficiaries in surveyed non-Prime Service Areas. However, we could not determine whether beneficiary access problems were related to TRICARE network providers because the survey did not ask beneficiaries to link problems accessing care with network or nonnetwork providers. However, we did find that the types of access problems beneficiaries experienced, such as providers not accepting TRICARE payments, were similar in Prime Service Areas and non-Prime Service Areas. In addition, we found that nonenrolled beneficiaries in both the surveyed Prime Service Areas and the surveyed non-Prime Service Areas rated their health care satisfaction similarly to each other and to beneficiaries of commercial health care plans, but slightly lower than Medicare beneficiaries. Despite an overall response rate of about 38 percent, TMA’s 2008 beneficiary survey results are representative of the nonenrolled beneficiary population for the combined Prime Service Areas and combined non-Prime Service Areas surveyed. (See fig. 3.) Because of the low response rate, TMA conducted a nonresponse analysis to determine whether the responses it received were representative of the surveyed population.