Tag Archives: TRICARE

Sick and Tired: Military Kids Need Better Access to Same-Day Care at MTF

Child-at-MTFRecently, when a military spouse at our Association told me she had to take her baby to the emergency room when there were no appointments at their Military Treatment Facility (MTF), I thought my head was going to explode.

I flashed back to one of many similar situations I faced when we were on TRICARE Prime, and my daughter, Kate, was in her ‘ear infection phase.’ On one memorable occasion, Kate started a fever on a Friday night (of course, after the MTF was closed for the weekend). By Saturday, the telltale ear tugging and crankiness were in full swing. I kept my fingers crossed that we could keep things under control with Motrin and Tylenol until the clinic reopened on Monday. Unfortunately, by Sunday she had a 104 degree fever, obvious signs of a ruptured ear drum (I’ll spare you the details), and was crying inconsolably.

I knew we couldn’t wait until Monday for an MTF appointment, so with a newborn crying to be fed and a 20 month old wailing in pain, I braced myself for an uphill battle to find medical care that TRICARE would cover.

I consulted the TRICARE website where it seemed like our only option was the emergency room. This concerned me; did a ruptured ear drum constitute a threat to life, limb, or eyesight? I was terrified of having to foot the bill for an ER visit.

Not willing to risk it, I called TRICARE. They told me to take Kate to a network urgent care and call our primary care manager (PCM) on Monday to request a referral.

I think you know where this story is going…

On Monday, I called our PCM, who refused to give me a referral because the appointment had already taken place. When I called TRICARE back, their hands were tied. Without a referral, they could not pay the urgent care provider. We were at an impasse, and eventually paid out of pocket for that visit.

The reason this particular incident is burned into my memory is because it occurred while I was recovering from a c-section, and we were about a week away from PCSing. My husband’s new unit had orders to Iraq, but the departure date kept moving, causing second and third order effects… most notably on our temporary housing plans. Oh, and we had just learned (from CNN – surprise!) that Army deployments were being extended to 15 months.

Military families lead complicated lives full of uncertainty. Getting a sick child appropriate medical attention should NOT be complicated.

The National Military Family Association has advocated for years to fix this problem.

And, in fairness, things have improved.

Sometimes.

At certain locations.

For instance, our old MTF in Virginia, the Woodbridge Clinic, is gone now. It’s replaced with the Dumfries Clinic, which has improved appointment access by adding Saturday hours.

Yet, we still hear of too many instances where families can’t get same-day appointments at the MTF, are refused referrals to urgent care, and are left with no option but the emergency room for their sick kids.

This is just wrong.

As the health care subject matter expert for our Association, this issue is not only my job, it’s personal. Now is the time to fix this problem once and for all. Military families deserve access to the best care, including same-day appointments for urgent issues.

Please help us by signing our petition and sharing your experience with access to same day appointments in the comments below.

karen-rPosted by Karen Ruedisueli, Government Relations Deputy Director

Since When Does MTF Mean ‘Might Take Forever?’

MMC-GR-Military-Kids-Deserve-the-Best-Care-(3)

Did you know garlic is a powerful antibiotic?

I didn’t either, until I had lived in Germany on an Army post for a couple months.

One day, my daughter woke up with a fever. It was just high enough to have me worried, so I waited for the appointment line to open for the day, and called as soon as the clock rolled over to 7:30am.

We know how this goes, so of course, I had the number programmed in my phone. All the better to dial quickly. By 7:31am I had navigated (like a pro) through the menu options and found myself on hold, waiting to talk to a representative.

“There are seven calls ahead of you.”

Seven.

My heart sank. Seven isn’t great. Seven means it’s likely that the appointments for the day will be filled before they get to me. But, being the optimist I am, I hung on the line.

After all, my baby daughter had a fever. She’s never sick, and even after being trained as a nurse, fevers in infants worry me. The hold music starts playing, and I pulled out the thermometer again. I held my breath and hoped.

Nope, the fever was still there. She’s was flushed, and clammy, and crying, again, because I just had to take her temperature one more time.

“There are four calls ahead of you.”

It’s now 7:45am and I am losing hope. I’m bouncing the baby and waiting.

Finally, a representative comes on the line, gets my husband’s social security number, and asks me to explain the problem. I do, and the baby screams, filling in the gaps of my story with her own frantic song.

“The earliest we can get you in is Friday. There is an appointment at two.”

Today is Monday, and we need seen now. Friday won’t work. On Friday, she’ll be fine. Or, as my overly worried Momma brain starts thinking, she’ll be dead.

The only other option is to take her to the emergency room. Germany doesn’t have an urgent care system, and other than the small clinic on post, there isn’t an American facility to go to. However, the German children’s hospital is amazing, if your child needs a hospital; if you have an infant with a fever, it’s really not that great. What I needed was antibiotics for an ear infection, and the reassurance that I was doing the best I could by hydrating and comforting my child at home. What I got was excessive testing in the German hospital, hours of waiting, the stress of not being unable to understand the system, and the flu (probably from the arm rests in the waiting room).

Unfortunately, this situation happened to me again, and again, for the three years we were stationed in Germany.

During our tour there, I was only seen ONE time for an urgent matter in the pediatrician’s office, and that was because I sat in the office and refused to leave until someone could help me.

I learned quickly the best I could do was attempt to help myself. I learned that garlic is a powerful antibiotic… in large doses. And believe me: you really haven’t lived until you’ve tried to get your five year old to swallow four cloves of fresh garlic to treat a suspected ear infection.

I learned Germany has an extensive alternative medicine culture, and in a pinch, I could go to a pharmacy off post and communicate my problems (in terrible German) to their pharmacists. I learned essential oils can help, and sometimes, you just have to suck it up and spend two nights in the German hospital for an issue American doctors would treat as urgent care, and send you home.

This has to change. Our military children deserve better. As wonderful as alternative medicine and emergency rooms are, we shouldn’t be forced to use them because there aren’t enough appointments, or doctors, to go around.

In the meantime, I’m stocking up on garlic.

Have you had problems making an MTF appointment for a sick family member? Please tell us about it and include the approximate time frame (we are most interested in recent situations to show this is a current problem). We will compile your stories and share with Congress and senior DoD leadership.

heatherPosted by Heather Aliano, Social Media Manager

Storming the Hill Since 1969! #WayBackWednesday

It’s the 1990s, and our Association is making waves on Capitol Hill. During this decade, we released an innovative health care plan for military families, which included recommendations that were later incorporated into TRICARE.

Twenty years later, we are still on the forefront of TRICARE issues, including those controversial topics that your military family needs answers to. Not finding the answers you need? Leave us a comment and let us know how we can help!

Sydney-testifying

Navigating the TRICARE maze: Prime vs. Standard

tricare-prime-vs-standardCo-pays.

Cost-shares.

In-network vs. out-of-network.

I’ll have a whole new vocabulary once I master the TRICARE maze!

For the past 9 years, I’ve used TRICARE Prime. I’ve seen doctors at Military Treatment Facilities (MTFs) and in town. I thought I scored big time when I was assigned a Primary Care Manager (PCM) out in town because the base was too full to take new patients. When we were stationed outside of Washington D.C., I navigated between multiple MTFs to get the care I needed.

It’s not a perfect system and there are some glitches. For example, accessing records between an Army hospital and a Navy hospital…let’s just say it doesn’t work as well as it should. The different systems don’t always “talk” to each other, which means you may need to hand-carry records, especially ultrasounds, MRIs, or other digital images between MTFs. And if you do see a civilian provider off the installation you’ll also need to carry records between providers.

With Prime, one thing I never had to worry about was cost. As long as I had referrals and pre-authorizations – I had minimal co-pays, if any at all. In fact, I had our first son while covered under Prime and don’t recall paying anything for my prenatal care, labor, delivery, or post-partum care. I attended child birth classes, met with a lactation consultant, took an infant CPR class, and even left the hospital with a bag full of goodies for our newborn.

Four years later, we are expecting our second and I decided to switch to TRICARE Standard. Why? Because when I got pregnant, I was recalled by the MTF, even though I live more than 30 miles from an MTF and was already seeing a civilian provider in town. And, unfortunately, the MTF I was recalled to doesn’t have the providers I need. I didn’t want to navigate appointments in opposite directions driving 30 miles one way to the MTF and 30 miles in the opposite direction to specialists.

I thought I understood the deductible, co-pays, and cost-shares under TRICARE Standard. Yet, maternity care has its own set of cost-shares, too. I’ve learned to keep copies of my Explanation of Benefits (EOBs) and any bills I receive directly from a provider. I call my regional contractor frequently to review claims and ask questions. I discovered my OB’s billing office isn’t an expert on TRICARE billing, and as a result, I was being overcharged. I had the same problem with overcharges for lab work, too.

And I discovered the hospital education benefits I enjoyed at the MTF with my first pregnancy aren’t covered. There is a fee to take a child birth refresher class or meet with a lactation consultant.

Our second baby is due in a few short weeks and overall I’m happy with the quality of care we are receiving under TRICARE Standard. I’ve learned I have a role to play in keeping costs down by asking questions about coverage, reviewing bills, reading the TRICARE website, and talking to my regional contractor to understand our benefit. TRICARE Standard has given me the flexibility to see the providers I prefer, but it comes at a cost.

What are your experiences with TRICARE Prime vs. TRICARE Standard? What would you recommend to other military families?

katie2Posted by Katie Savant, Government Relations Information Manager

Middle of the Night Hero – The Nurse Advice Line

mom-with-sick-babyNew mom. Husband is out of town. 4 month-old with a raging fever and barky cough. It’s 3:00 A.M. Oh, and there’s a blizzard dumping buckets of snow.

I haven’t heard this cough before and it sounds like he’s having trouble breathing. Why does my husband have to be gone when I’m in the middle of a crisis? I don’t want to risk our lives taking our infant-son to the emergency room in this weather. So, what should I do?

Medical Advice Is Only a Phone Call Away
Thankfully, the Nurse Advice Line was up and running that night my son came down with pneumonia. And, the good news is that the Nurse Advice Line is back. Stateside military families, including those in Alaska and Hawaii, can call 1.800.TRICARE (874.2273) 27/4 and reach a licensed nurse. This was a godsend when my son was an infant. The nurse was able to ask me questions about my son’s condition. She also offered some at-home remedies to help sooth his symptoms and scheduled an appointment for me the very next morning.

I was very thankful to have a medical professional to call in the middle of the night. Her tips helped calm my son (and his nervous momma, too) and I was able to safely make it to my son’s pediatrician’s office in the morning when the roads were cleared.

Who Can Use the Nurse Advice Line?
The Nurse Advice Line is available to all TRICARE beneficiaries including Prime, Network Prime, Standard, TRICARE for Life, TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult. And if you use Prime and are enrolled at a Military Treatment Facility – the nurse can help you schedule an appointment. Score!

But do you still need a referral from your Primary Care Manager?  Find out here.

Do you think your military family will use the Nurse Advice Line?

KatiePosted by Katie Savant, Government Relations Information Manager

Navigating Urgent Care as a Military Family

urgent-careMy family has fairly extensive experience with urgent care. We have been very fortunate to avoid major medical issues and emergencies, but, like most people with kids, we’ve had our share of strep throat, stomach viruses, and recurrent ear infections. In true Murphy’s Law fashion, these situations tend to crop up at the most inconvenient times.

When my daughter was a toddler, I could predict her ear infections with remarkable accuracy based on the federal holiday weekend schedule when our Military Treatment Facility (MTF) would be closed for 3-4 days straight. Many times, I was faced with a decision on where and when to seek care that did not fit the category of emergency, but seemed quite necessary to me.

When you or a family member need unexpected medical care, it can sometimes be difficult to know who to call or where to go. Urgent medical conditions are those that do not threaten life, limb, or eyesight, but need attention to prevent them from becoming a serious health risk. Your options differ based on whether you have TRICARE Prime or Standard but, in both cases, your primary care manager (PCM), family doctor, or pediatrician is your best place to start.

For TRICARE Prime Beneficiaries
If you reach your PCM but they cannot provide an appointment within 24 hours, you can request a referral to a local network urgent care clinic. You can find a network urgent care clinic by using the Find a Provider tool on your regional managed care support contractor’s website: HealthNet Federal Services in the North Region, Humana in the South Region, and UnitedHealthcare in the West Region or by calling the customer service line.

If you are unable to reach your PCM, call your managed care support contractor to discuss your options.

A TRICARE Prime beneficiary who uses an urgent care clinic without a referral is choosing the TRICARE Point of Service option which results in higher out of pocket costs. The Point of Service option has a $600 family deductible. This means that your family has to pay $600 out of pocket before TRICARE cost sharing begins. If your trip to urgent care is your family’s first time using the Point of Service option, the entire fee will be applied against the deductible and you will be responsible for paying the urgent care clinic out of pocket.

For TRICARE Standard Beneficiaries
TRICARE Standard does not require a referral for urgent care. If you reach your family doctor or pediatrician but they cannot provide an appointment – or – if you are unable to reach your regular doctor, you can find a network urgent care clinic using the same options listed above. Your usual deductible and cost shares will apply.

This spring, TRICARE plans to introduce a Nurse Advice Line that will give beneficiaries another option for getting an Urgent Care referral. We will release details on the Nurse Advice Line as soon as they are available to us.

What questions do you have about TRICARE? Let us know in the comment section below and we’ll do our best to answer them!

karen-rPosted by Karen Ruedisueli, Government Relations Deputy Director

FAQ Series: Affordable Care Act and TRICARE – Dental, Vision, Breast Pumps

tricare-patientWith the roll-out of the Affordable Care Act (ACA), many TRICARE beneficiaries have questions about specific ACA provisions and whether those provisions will impact TRICARE. Specifically, military families have contacted us with questions about dental, pediatric vision coverage, and breast pumps for new moms.

General Information
The ACA defines “10 essential health benefits.” All insurance plans sold to individuals and small businesses (e.g., those sold on the exchanges) will have to cover items and services in the “10 essential health benefits” categories. Self-insured employers (large employers such as Apple, Home Depot, Yahoo, etc. who choose to pay claims from their own money vs. purchase a typical insurance policy for their employees) are exempt from the essential benefit requirement. More than half of Americans who have health insurance provided by their employers are in self-insured health benefit plans. Additionally, most large employer plans already cover most of the 10 broad essential benefits categories.

The ACA also requires most health plans to cover preventative services at no cost to the patient.

The ACA requires dental coverage for children. How does this compare to TRICARE?
Pediatric dental coverage is one of the ACA’s “10 essential health benefits.” The ACA gives states wide latitude to decide what specific “essential benefits” insurers must offer in their policies. According to the American Dental Association, most states will require plans to provide an adequate array of dental services (Utah is the only state to offer only preventative services).

TRICARE offers three dental programs for service members and military families: the TRICARE Dental Program, the TRICARE Retiree Dental Program, and the TRICARE Active Duty Dental Program. The dental programs offer coverage to active duty service members and their families, Guard and Reserve members (activated or not) and their families, retirees and their families, and surviving spouses and their children. TRICARE’s dental programs already cover children and the services included in the ACA mandated pediatric dental plans.

The ACA requires pediatric vision coverage. How does this compare to TRICARE?
Pediatric vision coverage is one of the “10 essential health benefits” the ACA requires. However, there is limited information on the healthcare.gov website regarding vision benefit specifics. According to the American Academy of Ophthalmology, individual and small group health insurance plans (such as those sold on the exchanges) will be required to include full coverage of childhood comprehensive eye exams and glasses or contact lenses for vision correction.

TRICARE offers coverage for routine eye exams for both children and adults. They will also cover treatment for medical conditions of the eye. TRICARE does not, however, cover contact lenses or eyeglasses for vision correction except under very limited circumstances. Visit the TRICARE website to read their Vision Benefits Fact Sheet (located on the right side of the page under “Related Downloads”) for details.

The ACA requires insurance plans to cover breast pump rental or provide breast pumps for new moms. How does this compare to TRICARE?
The ACA requires most health plans to cover preventative health services specifically for women, including breastfeeding comprehensive support and counseling. As part of breastfeeding support, the ACA requires insurers to cover breast pumps. However, plans that are grandfathered are exempt from this requirement.

TRICARE will only cover a breast pump if the baby is premature and meets certain criteria.

Will TRICARE’s coverage change to include these additional benefits the ACA requires?
TRICARE operates completely independently of the ACA which is concerned only with commercial insurers. Since TRICARE is not a health insurance policy or company, but a federal health benefits program, it is not subject to the laws that govern the insurance industry either at the federal or state level. As such, TRICARE is not required to adhere to the provisions in the ACA.

This does not mean that TRICARE will never change policy to enhance coverage. For example, to bring TRICARE in line with the ACA provision extending parents’ health insurance to their children up to age 26, the FY11 National Defense Authorization Act gave the Defense Department the authority to extend TRICARE coverage to young adults. Something similar would be required to provide pediatric vision and breast pump coverage to TRICARE beneficiaries, but no legislation or policy changes regarding these benefits have been introduced to date.

Do you have additional questions about how the ACA provisions impact TRICARE? Post a comment or send us an email at info@militaryfamily.org.

Posted by Karen Ruedisueli and Katie Savant, Government Relations Department