In 2013, when her father returned from a third deployment, Mia Martin was diagnosed with autism at 3 years old.

Autism is a bio-neurological developmental disability that impairs normal brain development and ultimately cognitive function and social interaction.

Mia was enrolled in public school for a while.

Her days started at about 5 a.m. to catch a bus.

She’d sit in a classroom until about 1 p.m. then head off to therapy for four hours, ending her day at about 6 p.m.

The 12-hour days were part of Mia’s routine for four years.

Mia’s father, Fort Bragg combat Veteran James Martin, knew it took a toll on Mia.

The public classroom setting was too rigid.

“Even in a classroom of 15 kids with a special education teacher and an assistant, my daughter is quite the handful,” Martin said.

Last year, they found New Leaf Academy in Fayetteville where lights and sounds are controlled and the environment and curriculum are tailored to children with Mia’s needs.

The school provides a special education teacher, a clinic and behavioral analysis technicians for each of the six children in the classroom.

It’s meant shorter days for Mia, who is now 11.

“In that environment, she thrives,” Martin said.

James Martin: My autistic daughter is excelling thanks to NC grant, scholarship

However, changes to TRICARE, the military’s medical insurance, are concerning. Martin worries that Mia will be removed from the school where he said she's improving.

It’s not only his own daughter who Martin worries about — it's all the other military children with autism he believes will be negatively impacted.

What’s changing?

In March, the Defense Health Agency, which oversees TRICARE, announced that by May, advanced behavioral analysis services outside of clinical settings will no longer be covered by the military insurance.

Applied behavioral analysis is a popular intervention for autism that teaches behaviors by breaking down asks into small steps and training in a precise way, according to the National Institutes of Health.

For Mia, who is nonverbal, it’s helped her communicate her wants and needs, while also helping her to get back on track if she has “a meltdown," Martin said.

Redirecting Mia's focus doesn’t come from a teacher but rather from the behavior technician at her side.

Registered behavior technicians help implement treatment and behavior plans that teach behaviors and skills universally used.

From April: Autism services for military families could be cut under DoD plan

Prior to the TRICARE changes, technicians could accompany children with autism to school and help facilitate the child’s learning.

According to a July news release from TRICARE, behavior technicians were reclassified as non-clinical, thus not covered by the insurance, and as a result, not accompanying children into the classroom.

The release states a TRICARE contractor may authorize board-certified behavior analysts to provide time-limited clinical advanced behavioral analysis services for a child in the school setting.

Martin compared the change to going to a doctor’s office that has no support staff, physician assistant or licensed practical nurse.

Community settings such as dental appointments or sporting events are no longer considered the space for behavior technician unless determined “clinically appropriate” based on a child’s treatment plan, the news release states.

“These changes are based on several years of research and development,” Dr. Krystyna Bienia, a clinical psychologist and senior policy analyst at the Defense Health Agency, said in the statement. “We used lessons learned during the demonstration, and also feedback from providers, advocates, and leading researchers. The updates will help children reach their full potential through clinically appropriate services.”

Martin disagrees.

“Shouldn’t kids get acclimated outside of a clinic setting,” he asked. “That makes no sense. How does it address behavior in a real-world environment?”

Martin said it leaves families who received the services to choose between going back to public school or home schooling their children.

Impact to Fayetteville autism school

The changes remind Amy Sparks of her own fight to take on the Fort Bragg school system in U.S. District Court in 1997.

Sparks’ husband served in the Air Force for 23 years. Their son Jarred, born in 1992, is autistic.

“I know the battles that these parents are having — not only do I have the experience of having a child with autism, but I also have that experience with TRICARE,” Sparks said.

When her son was young and she brought the lawsuit against the school, there were no local clinics. Her husband would often drive Jarred to Greensboro for services she'd fundraise to pay for.

Sparks said Jarred was likely one of the first autistic children in the Fayetteville area to start applied behavioral analysis therapy.

In 1997, the family sued the Fort Bragg school district to seek an appropriate education for Jarred.

“I said, ‘You’re not going to babysit my child. You're going to educate my child,’” Sparks said.

Jarred didn’t say “mama” until he was 5. He was mostly nonverbal until he worked with a speech pathologist in Greensboro at age 7.

While enrolled for two years at Fort Bragg schools, he was unable to master 40 objectives, Sparks said.

She removed her son from school and enrolled him in the Lovaas Learning Program, a form of applied behavior analysis.

Once switching programs, Jarred was able to master 400 objectives, Sparks said.

An example, she said, is Jarred’s therapist worked with him to build block structures — a task he couldn’t previously accomplish.

“We saw rapid growth,” she said.

After legal motions and appeals, the U.S. court ruled in 2004 in the family’s favor, ordering they be compensated for the educational services Sparks said her son didn’t receive at the military school.

Sparks views the latest changes to TRICARE through multiple lenses.

She’s a retired public school educator, and after Jarred’s unexpected death in 2011 at the age 19, she opened a school in his memory.

“With my own son, I never wanted to say, ‘What if’ — What if I’d done that treatment? What if we enrolled in a specialized school,” Sparks said.

The Fayetteville-based School of Hope serves only children diagnosed with autism.

Sparks said she does not think teachers in public school settings with larger class sizes and only one aide are always equipped.

At Fayetteville's School of Hope, co-founded by the Sparks family, each classroom has one teacher, one teacher’s assistant and no more than seven children; and each child has a behavior technician.

If a child enters the classroom anxious, the behavior technician would help redirect the student and provided feedback for the teacher on the child’s capabilities, Sparks said. A behavior technician can help a child improve from the one percentile to the 96th percentile, she said.

That is why Sparks is concerned the TRICARE changes will impact students at her school.

“TRICARE is definitely doing an injustice to the military men and women who serve this country...,” she said. "So many of them are having to be deployed... They don’t need to worry about what’s happening to their autistic child.”

Autism tool cited in DOD study is misused, researcher says

Parents and educators aren’t the only ones with concerns about the changes.

Ira Cohen, who has worked in the field of autism research since the 1970s and has a doctorate’s degree in psychobiology, is the principal author of an analysis tool that evaluates children with autism and treatments and interventions.

His research and autism tool was cited in six Department of Defense reports to Congress on autism in military children.

The DOD reports, using Cohen's tool to note behaviors of autistic children before and after applied behavior analyst services, questioned whether the services led to improvements for children with autism.

“The end result is that families could be deprived of an important service that they receive based on misuse of the instrument that they were using, which was my instrument, and they didn’t listen to me,” Cohen said.

Criteria for diagnosing autism has broadened, Cohen said.

Some children have IQs average or below average. Others have difficulty communicating or are nonverbal. Some engage in repetitive behaviors, Cohen said.

Cohen wrote a 40-page analysis of the DOD reports, where he questioned how it gathered data to make conclusions.

In his analysis, he wrote the autism rating instrument is designed in two forms — one for parents to analyze their child with autism, and another for professionals to analyze.

He wrote that the tool evaluates core behaviors seen in autism and behavioral concerns.

Among the behaviors evaluated that could generate a higher score are sensory behaviors, such as staring at objects, hand flapping and resistance to change; repetitive behavior such as turning pages back and forth, opening and closing doors and turning lights on and off; social interactions; sleeping problems; aggression toward self or others; fears; speaking abilities and learning; and memory.

Cohen said the rating scale he created is based on a zero to three format, with zero meaning a behavior is not seen, one means it’s rare, two means sometimes it’s seen and three means a behavior is often seen.

Each of the ratings is added for an overall score, with scores between 30 to 40 considered mild features of Autism Spectrum Disorder and scores greater than 60 typically deemed as being severely affected or likely to have an intellectual disability.

The misinterpretation in the DOD reports, Cohen said, is that the reports made a zero seem as if a behavior is missing when in reality it means the child is not engaging in the behavior.

“They assume that you can apply this one measure to all of those cases; and, in fact, if you talk to people who do ABA therapy, what they do depends upon the problems or the abilities of that individual child,” he said. “Often you’re dealing with severe problem behaviors that are impairing the child’s ability to benefit from therapy, and if they are not looking at what the goals of the therapy are and measuring what those things are, they’re providing a disservice to the field.”

Cohen found that 90% of 14,700 patient assessments were not used in a 2018 DOD report that analyzed only 1,577 children.

Cohen wrote that omitting the children who were not showing a behavior could be instances of children having improved.

Omitting those cases, he wrote, likely biased the data of cases that did not change.

His other concerns were the lack of demographics of the analyzed children, and whether both parents filled out the assessment of autistic behaviors in their children.

Age is important because “younger children often respond better to intervention for a variety of reasons,” Cohen wrote.

He said that a “more appropriate statistical analysis” would note factors such as gender, age, degree of impairment and health status among others.

He noted similar issues in other DOD reports, writing that “it is clear that the Department of Defense authors have not bothered to read the manual,” related to the autism scoring.

Analyzing the DOD's latest report to Congress in 2020, Cohen wrote that conclusions cannot be justified, because of a “lack of understanding" as to how the autism tool “is scored and interpreted and the obvious failure to read the manual.”

“The conclusions one draws from an analysis are only as good as the quality of the information that goes into the analysis,” Cohen wrote. “If the data are sloppy, so are the conclusions and their validity...”

Latest DOD report

In the Department of Defense’s latest autism report to Congress in June 2020, the DOD stated it had 15,928 TRICARE-eligible beneficiaries diagnosed with autism in fiscal year 2019.

Officials said program costs were $370.4 million that year. .

According to the report, the program which administers TRICARE funding for autism was set to expire Dec. 31, 2018, but extended to December 2023.

The report states that TRICARE-covered services for autism include speech and language pathology, occupational therapy, physical therapy, medication management, psychological testing, psychotherapy and applied behavior analysis.

According to the report, 54% of the beneficiaries diagnosed with autism did not receive applied behavior analysis services.

The report states that while there is limited research about whether early behavioral-analysis interventions can significantly affect the development of some children diagnosed with autism, not all children diagnosed with autism receiving the services show improvement.

The report states that officials analyzed 3,794 TRICARE beneficiaries receiving applied behavior analysis services for at least 18 months.

The report states that factors such as age, symptom severity, number of hours of services and other services were not factors considered.

The report found that some of the autism scores changed, and noted although improvements after a year and 18 months of applied behavior services, most of the changes were small “and may not be clinically significant.”

The report reached the conclusion that the delivery of applied behavioral analysis services in its current format “is not working for most TRICARE beneficiaries.”

Officials wrote that the DOD is concernedwhether applied behavioral analysis services provide the most effective services for beneficiaries diagnosed with autism.

“As of now, ABA services do not meet the TRICARE hierarchy of evidence standard for medical and proven care,” the report stated.

In a Defense Health Agency news release from March, Bienia, a clinical psychologist with the agency, said there isn't a "one size fits all” approach when it comes to autism care.

The news release stated that applied behavior analysis services for beneficiaries diagnosed with autism will continue but changes would go into effect start May 1 and a rollout plan for all changes goes into effect by Jan. 1.

A spokesman for the Defense Health Agency said changes were based on three years of work with industry stakeholders.

Previous instructions in the TRICARE Operations Manual allowed certain applied behavioral analysis services to be conducted in a school setting if approved in the patient's treatment plan, the spokesman said.

"The intent was that active (applied behavioral analysis) services would be provided and that treatment would be separate from any parallel educational task," he said.

The change eliminated the role of the behavioral technician from a classroom setting since applied behavioral analysis services authorized under the program "are designed to be delivered in a one-on-one treatment modality," the spokesman said.

Parents still concerned

Cumberland County attorney Jessica Flowers works with autism advocates to brief legislators on the House and Senate Armed Services Committees about how changes affect families.

Flowers said it concerns her that she doesn’t see funding for the services in National Defense Authorization Act proposals.

“It’s just been a nightmare trying to get the services that we’ve had before May 1,” she said.

Flowers thinks limiting the applied behavioral analysis services to clinical settings will create retention problems for the military, because of parents opting to home-school their children because they can't afford services no longer covered by insurance.

Flowers is a disabled Veteran whose husband is still in the military.

Their son Jacob, who turns 6 this August, is on the autism spectrum, she said.

She said the only language he has is copying others.

Flowers said Jacob previously tried a public school and a clinic setting.

“We tried. It didn’t work,” she said. “We went another route and found a place where he’s able to flourish, and now it’s being pulled out from under us.”

Flowers said her son, with behavioral assistance, is able to learn the same as other children who are not in special education.

Despite developmental delays, Flowers said, her son is smart and could identify colors by touching them in kindergarten and knows letters, shapes and sounds.

Her son has attended a private school with a disability grant, but she said TRICARE paid for his therapist to be in the classroom.

The school — which requires children with autism to be accompanied by a behavioral technician — won't allow her son to return without one.

With the first day of classes beginning Wednesday, Jacob has been left in limbo at home as his family waits to see if he can be placed in a clinic or decides whether to enroll him back in public school.

In public school, he'd be placed in a special needs classroom without therapy. In a clinical setting, he'd receive therapy without an education, his mother said.

Flowers is grappling with limited options for Jacob.

“Do I let my son continue his education where the only option is public school in an autism classroom, which was dreadful for him?”

In a public school, she said, Jacob was placed in an enclosed special needs classroom and would come home “throwing a tantrum or lying on the ground banging his head on the floor.”

Since attending the private school, she said, he has not had any of those aggressive tendencies.

She said a disability grant covered her son’s education, and TRICARE covered the therapist who worked 40 hours a week with him.

Her son thrived at the private school and made best friends.

“I was told, having a child with autism, that he wouldn’t show those kinds of emotions or have the ability to interact with peers like that,” she said.

She said her son was able to participate in a meaningful education.

Related reporting:N.C. bill seeks to expand residents' access to applied behavior analysis for autism

She said without a behavioral technician, he is unable to go to the school and receive therapy at the same time.

She said he’s not the type to raise his hand if he needs to go to the restroom, but his behavioral technician picks up on cues and voices his needs.

The therapist, she said, helped ensure he'd behave and meet goals that were in place for his individualized education plan.

"We love Jacob and would not change him for anything," Flowers said. "But we also want him to absolutely become the most independent, most productive version of Jacob he can possibly be."

To cover the costs of a technician outside of a clinical setting, 10 hours a week would be $8,000, Flowers was told.

Martin and Flowers said other insurance carriers cover applied behavioral analysis services that are being cut for military families.

Martin said it seems as if the Defense Health Agency is limiting services, which he said is causing applied behavioral analysis companies to leave Fayetteville.

“It feels like this new policy change was backdoored and was not in the best interest of the families concerned,” Martin said. “I know the government needs to budget, but going after services for disabled children with autism is a new low.”

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Sought TRICARE Beneficiaries to Receive Expensive Compounded Drugs

LITTLE ROCK-United States District Judge Brian S. Miller sentenced Bradley Fly, 36, of Germantown, Tenn., to 20 months in federal prison for violating the Anti-Kickback Statute. In July 2019, Fly pleaded guilty to offering two TRICARE beneficiaries’ money in exchange for signing up to receive expensive compounded drugs.

At sentencing, the United States introduced evidence that Fly bribed two people: his longtime friend (then a Marine reservist), plus an Army National Guardsman, whom Fly solicited while seated courtside at a Memphis Grizzlies game. Fly then facilitated prescriptions for both men and their wives, for which TRICARE paid over $500,000, earning himself over $180,000 in commission.

Judge Miller heard testimony from the Marine reservist and from a Special Agent with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) that the prescriptions were part of a larger network of prescription generation, including recruiters whom Fly paid for TRICARE beneficiary information and a group of doctors whom Fly used to sign prescriptions without consulting patients.

“There is no room for kickbacks in the healthcare marketplace,” said Acting United States Attorney Jonathan D. Ross. “Serious penalties and prison await those, like Mr. Fly, who fail to abide by the law. This office and its partners at the FBI and HHS-OIG are committed to rooting out such criminal conduct.”

“Mr. Fly paid kickbacks generating fraudulent claims to line his pockets without concern for the health and welfare of the patients,” said Miranda L. Bennett, Special Agent in Charge of the HHS-OIG Dallas Region. “We will continue working with our law enforcement partners to pursue individuals defrauding federal health care programs.”

“By defrauding TRICARE, Mr. Fly disgracefully cheated U.S. Veterans, their families, and American taxpayers,” said FBI Little Rock Acting Special Agent in Charge Jason Van Goor. “We are grateful for our state and federal partners who help us both investigate these cases and protect the financial integrity of our nation’s health care systems.”

In addition to the 20-month prison sentence, Fly was sentenced to three years of supervised release. The investigation was conducted by HHS-OIG and the FBI and prosecuted by Assistant United States Attorney Alexander D. Morgan.

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Two Florida residents have been charged with allegedly defrauding the federal government's largest health care programs, including a man linked to the American Mafia.

The Department of Justice announced Nov. 19 that Thomas Farese, 79, of Delray Beach, and Domenic Gatto, 47, of Palm Beach Gardens, have been charged with health care fraud, conspiracy to commit health care fraud and wire fraud and other crimes totaling $25 million in losses by Medicare, Tricare and CHAMPVA, the Department of Veterans Affairs’ health program for eligible Veterans' spouses and children.

The charges mark the second time in seven months the men have faced charges for allegedly engaging in health care fraud: in April, they and others were charged with conspiracy and committing fraud, allegedly bilking government health programs of $65 million.

According to court documents, Farese and Gatto hid their ownership of several medical equipment companies and arranged orders for medical devices, namely orthotic braces.

They then supposedly arranged and paid for orders, soliciting, bribing and receiving kickbacks from physicians for braces that weren't needed by patients -- orders that in turn were billed to the federal government, according to the Justice Department.

The pair also were involved in a related kickback scheme involving prescriptions for compounded medications -- prescriptions that are prepared for individual patients by specialty pharmacies that have been a frequent target of scammers for nearly the past decade.

Farese is no stranger to the U.S. legal system: he was charged and convicted in 1980 of running a multimillion-dollar marijuana smuggling and distribution operation through a Fort Lauderdale shipping company, sentenced to 30 years in prison and released in 1994.

Two years later, Farese was charged for laundering more than $1 million in drug money through several Florida coast strip clubs.

During his sentencing hearing in that case, federal prosecutor Jeffrey Slomar called Farese "a capo regime [captain] in the Colombo organized crime family" with "contacts throughout the world to facilitate money-laundering transactions," according to court documents.

He was sentenced to 10 years in prison and released in 2005, only to return seven years later, convicted again of money laundering.

He remained in prison until 2012, according to court documents.

Gatto is the developer of a West Palm Beach hotel complex, Banyan Cay Resort and Golf. He doesn’t appear to have a record of arrest prior to April.

Since at least 2013, the Justice Department has doggedly pursued companies and individuals that have profited from fraudulent orders for medical devices and compounded medications, which are personalized prescriptions crafted for patients who can't tolerate certain ingredients.

In the case of Tricare, the Justice Department has filed charges and convicted hundreds of persons involved in the schemes, including pharmacists, doctors, marketers and salesmen, including military troops.

Farese and Gatto face up to 20 years in prison if convicted of wire fraud and 10 years per count of conspiracy and health care fraud. The charge of violating the federal Anti-Kickback Statute carries a punishment of up to 5 years of prison, according to the Justice Department.

The men also face fines up to $250,000 for each count or twice the gross profit or loss caused by the offense, whichever is greater.

Both men have posted bonds of $700,000 and were released. According to the court, Farese's bail was paid by his wife Suzanne, daughter of Alphonse Persico, an alleged underboss in the Joseph Colombo crime family who died in prison in 1989.

Neither returned phone messages left by Military.com requesting comment on their cases.

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Military advocacy groups are calling for changes that give working-age retirees a longer grace period if they fail to set up a way to pay new fees for Tricare Select set to kick in Jan. 1.

As it is, if the retirees fail to set up their payments by Jan. 1, they’ll be kicked out of the health care program, and will have 90 days to apply for reinstatement.

Many advocacy organizations are hearing complaints about the new fees from angry members who may not have realized fees were coming, said Karen Ruedisueli, director of health affairs for the Military Officers Association of America. “Some of the angriest are the recent retirees who served almost their entire careers while our nation was at war and endured multiple combat deployments, only to face fee increases as they’re about to retire,” she said.

Starting Jan. 1, working-age retirees must pay an enrollment fee of $12.50 per month or $150 per year for individuals; and $25 per month or $300 a year for families.

MOAA and National Military Family Association want that 90-day grace period to be extended to 12 months, over concerns that retirees may lose health care coverage because they aren’t aware of the new requirement to pay enrollment fees. They also want retroactive coverage.

“We are seeking an extension to the grace period for Tricare reinstatement with retroactive coverage in the event someone misses the communication and fails to pay the enrollment fee by Jan. 1,” Ruedisueli said.

There were 407,431 military retirees and 764,936 retiree family members in Tricare Select at the end of 2019, according to a DoD report.

This doesn’t affect those in Tricare for Life. These fees affect retirees and their family members in the so-called Group A — the sponsor’s initial enlistment or appointment was before Jan. 1, 2018. The retirees in Group A are generally working-age retirees under age 65.

“Many beneficiaries understandably do not realize Congress passed this [Tricare Select] enrollment fee back with the [fiscal 2017 defense authorization act] and it is actually significantly lower than was proposed, thanks to the efforts of numerous associations who fought it,” Ruedisueli said. The provision was part of Tricare reform that was signed into law in 2016 by President Barack Obama.

MOAA and other organizations opposed the enrollment fee when it was proposed during the legislative process, she said. The Tricare reform was an 18-month process that began with a proposal to completely get rid of Tricare.

The 2016 law gave the Defense Health Agency discretion in deciding when to start charging working-age retirees enrollment fees for Tricare Select. But information was not immediately available from Defense Health Agency officials about whether it has the authority to extend the grace period to one year.

“There are sure to be retirees who don’t find out about the new fee by January 1,” said Eileen Huck, deputy director for health care for the National Military Family Association.

Advocates point to past transitions that were problematic, where despite the Defense Health Agency’s efforts, it was difficult to reach every beneficiary with updates about actions they needed to take to ensure their benefit continued. “Inevitably, some beneficiaries only learn about a new requirement when they try to use their benefit and find out they no longer have coverage,” Ruedisueli said.

In early 2019, officials with the Office of Personnel and Management extended the deadline by three months for beneficiaries to enroll in the Federal Employees Dental and Vision Insurance Program, known as FEDVIP, partly to help military retirees who were newly eligible for FEDVIP and missed the deadline to sign up. Some retirees didn’t realize they were losing their coverage in the Tricare Retiree Dental Program at the end of 2018.

MOAA also notes the disruption of the pandemic, “making it even more difficult to catch the attention of beneficiaries with critical enrollment fee information,” Ruedisueli said.

The communications from Tricare about open enrollment season may cause some confusion, as officials have told beneficiaries they don’t have to take any action if they want to stay in their same plan, and that message is still being conveyed on the Tricare website. But retirees who need to set up payments through allotment, electronic funds transfers, debit or credit card, must do so during the open enrollment period.

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FALLS CHURCH, Va. – There are changes coming soon to the TRICARE retail pharmacy network. Starting Dec. 15, 2021, CVS Pharmacy will join the TRICARE network. At the same time, Walmart, Sam’s Club, and some community pharmacies will leave the network.

Express Scripts is the TRICARE pharmacy contractor. They manage the TRICARE retail pharmacy network under a contract with the Department of Defense. Express Scripts reached a new agreement that adds CVS Pharmacy to the network of pharmacies.

“Beneficiaries will continue to have many convenient and nearby in-network options,” said U.S. Public Health Service Cmdr. Teisha Robertson, a pharmacist with the Defense Health Agency’s Pharmacy Operations Division. “Express Scripts’ partnership with CVS Pharmacy ensures most beneficiaries have a network pharmacy located near their home or work.”

The current TRICARE retail pharmacy network offers access to over 59,000 pharmacies. With this change, nearly 90% of beneficiaries will have access to a network pharmacy within five miles of their home.

Walmart and Sam’s Club have more than 5,300 locations nationwide. CVS Pharmacy has nearly 10,000 pharmacy locations. You can find CVS pharmacies inside many Target stores.

A group of around 3,000 community pharmacies will also leave the TRICARE network this year. But more than 14,000 community pharmacies will remain in the network.

Keep in mind that using home delivery or a military pharmacy are still lower cost options for you. You have to pay copayments when you use home delivery or any retail network pharmacy. Although these copayments are set to change next year, it isn’t because of this network change.

If you have a prescription at Walmart, Sam’s Club, or any other impacted pharmacy, you need to transfer it to a new network pharmacy before Dec. 15. If you filled a prescription at one of the impacted pharmacies, you’ll receive communication from Express Scripts. These communications will have recommendations on how you can fill your prescriptions at a new network pharmacy. You can also find a network pharmacy near you by visiting the Express Scripts website. CVS Pharmacy will be in the network starting Dec. 15.

Do you use specialty or limited distribution medications? If so, you’ll get a letter from Express Scripts detailing how you can transfer your prescriptions to a new specialty network pharmacy. You may also receive a phone call from an Express Scripts representative. They can help you move your medication to a new specialty network pharmacy that’s near you.

If you fill a prescription at Walmart, Sam’s Club, or community pharmacy leaving the network on or after Dec. 15, it will be a non-network pharmacy. This means you’ll have to pay the full cost of your prescription up front. You’ll also need to file a claim for partial reimbursement. Check out Filling Prescriptions to learn more. You can also refer to the TRICARE Pharmacy Program Handbook.

If you need to find a new network pharmacy, you can search for one on the Express Scripts website. You can also call Express Scripts at 1-877-363-1303 to help you find one close to you. Do you have questions about your pharmacy benefit? You can learn more by visiting Pharmacy on the TRICARE website.

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The FY 2021 National Defense Authorization Act (NDAA) stops the planned transition of active duty and National Guard/Reserve families who use the TRICARE Dental Program (TDP) to the Federal Employees Dental and Vision Insurance Program (FEDVIP). MOAA supports this move and will continue working to ensure Congress and the Defense Health Agency (DHA) remain committed to addressing known problems with TDP networks.

TDP is a voluntary dental plan available for purchase by active duty family members, transitional survivors, and Guard and Reserve members and their families. A similar move did take effect for the TRICARE Retiree Dental Program (TRDP): The FY 2017 NDAA sunsetted TRDP and made military retirees eligible for dental and vision coverage through FEDVIP as of Jan. 1, 2019. There are no changes to retiree dental and vision coverage – military retirees are still eligible for FEDVIP.

Administration of TDP transitioned to United Concordia in May 2017, and many military families complained their dentists left the network due to reimbursement rate cuts. Some high-concentration military areas such as Fort Leavenworth, Kan., and the Tidewater region of Virginia had few in-network providers.

MOAA and other advocacy groups took this issue to Capitol Hill, and Congress responded by including language in the FY 2019 NDAA that would have made TDP beneficiaries eligible for FEDVIP effective Jan. 1, 2022. The FY 2021 NDAA reverses these plans. The TRICARE Dental Program will remain in place.

Unlike TRDP, which was fully funded by military retirees through plan premiums, TDP includes a premium contribution from DoD. For most TDP beneficiaries, DoD pays 60% of the plan premium while the servicemember contributes 40%. Complications related to DoD’s premium contribution, among other issues, hampered efforts to transition TDP to FEDVIP.

MOAA supports this move by Congress to ensure all TDP beneficiaries have continued access to affordable dental coverage, and we are encouraged by recent steps the DHA has taken to address issues with TDP.

In September 2020, MOAA participated in a discussion on the way ahead for TDP hosted by DHA, sharing military family frustrations with the high number of dentists who have left the program and sparse provider networks in certain areas. We also shared military family concerns about reimbursement rate cuts potentially resulting in a lower quality of available dental care.

Last month, DHA released a request for information (RFI) on the next generation of TDP contracts, known as TDP6. The RFI seeks industry input on how to improve access, including recommendations on network adequacy standards to improve beneficiary satisfaction. It also addresses provider quality by seeking feedback on identifying higher quality providers that would result in better outcomes for beneficiaries.

As the TDP6 process moves ahead, MOAA will remain engaged to ensure military families continue to have affordable dental coverage that includes improved access to care and a greater emphasis on high quality providers.

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LITTLE ROCK, Ark. (News release)— A doctor and a medical sales representative have been charged in a scheme to pay and receive kickbacks to generate expensive prescriptions for compounded drugs. TRICARE, the military’s health insurer, paid over $12 million for the prescriptions, which the indictment alleges were rubber stamped without examining patients or regard to medical necessity. The 43-count indictment alleges the scheme also encompassed widespread efforts to obstruct the ensuing investigation.

Cody Hiland, U.S. Attorney for the Eastern District of Arkansas, Diane Upchurch, Special Agent in Charge of the FBI Little Rock Field Office, and Latisha Cleveland, Acting Special Agent in Charge of the Dallas Regional Office of the U.S. Department of Health and Human Services, Office of the Inspector General, announced the indictment, which was handed down yesterday by a federal grand jury and included charges for conspiracy, wire fraud, mail fraud, Anti-Kickback violations, aggravated identity theft, money laundering, lying to the FBI, falsifying records, and obstruction of justice.

The indictment alleges that recruiters sought TRICARE beneficiaries to receive the drugs, promising to secure their prescriptions (without any doctor consult) and, at times, offering them money to sign up. Upon receipt of TRICARE beneficiary information from recruiters, the ringleader of the scheme sent pre-filled prescriptions—with drugs to be dispensed, refills authorized, and patient names already listed—to medical professionals who signed without consulting patients or any regard to medical necessity. Prescriptions went to a Mississippi pharmacy, which shipped drugs nationwide and billed TRICARE for reimbursement.

According to the indictment, local doctor Joe David May, also known as Jay May, of Alexander, rubber stamped pre-filled prescriptions for over 100 beneficiaries for which TRICARE paid $4.5 million. May received pre-filled prescriptions from Derek Clifton, also of Alexander. The indictment alleges the ringleader paid Clifton to get May to sign the prescriptions despite knowing Clifton shared his payout with May. Clifton also had May sign pre-filled prescriptions for beneficiaries solicited by Clifton himself and his own recruiters. Clifton received over $740,000 tied to May’s prescriptions, which he used to buy a car, fund his retirement account, and purchase a home.

The indictment alleges Clifton, who previously coached high school basketball, began by recruiting three former players who joined the military. Each agreed to receive drugs after being offered money, and one later received $1,200 cash hidden inside a Stetson cowboy hat. Together they received nearly $500,000 in drugs prescribed by May.

According to the indictment, May used a cell phone app to electronically sign batch after batch of pre-filled prescriptions, including signing 8 pre-filled prescriptions within just 3 minutes of receipt, 10 within 5 minutes, and 13 within 13 minutes. In the final days before TRICARE reimbursements were expected to plummet, May rubber stamped more than 50 pre-filled prescriptions for which TRICARE paid $1.2 million. Many of those beneficiaries were recruited during a meeting at a North Little Rock National Guard facility where attendees were each offered $1,000 for receiving drugs.

The indictment alleges the only TRICARE beneficiary May actually treated before prescribing drugs was a 91-year-old widow suffering from dementia whom May noted neither “report[ed] any pain” nor appeared to be in pain. Nevertheless, he prescribed her $40,000 in pain cream off the books, failing to log the drugs in her official hospital chart.

According to the indictment May received cash kickbacks for signing, which participants openly discussed. When the ringleader joked about being hounded for payouts by texting Clifton “Hashtag for the day… [Ringleader], is my check ready? # Lol” Clifton replied “Haha! Meeeee toooo Jay already called asking this morning too…even the rich man[.]” Later, Clifton lamented falling TRICARE reimbursement rates by texting the ringleader “$210 minus half for tax$105 [sic] then dr’s cut then patients cut….. Yikes[.]” According to the indictment May deposited over $15,000 in cash in 2015 (compared to under $500 in 2014), including $10,000 during the same three-month period at the height of the scheme during which time Clifton withdrew over $15,000 in cash.

According the indictment, following a CBS News exposé and complaints of doctors signing prescriptions “on the down low” without seeing patients, recruiters were instructed to relay prescriber names to beneficiaries so beneficiaries could behave as if they “knew and saw their doctor” if they came into contact with the pharmacy.

The indictment alleges the ruse continued once federal agents began to investigate, with May and another prescriber both falsely claiming to have consulted patients before signing prescriptions and both producing phony medical records to make it appear patients had been consulted. Records produced by May related to beneficiaries never examined and cited made-up injuries and surgeries patients never experienced. Similarly, Clifton altered records produced to the Grand Jury to conceal the names of TRICARE beneficiaries who received drugs and withheld hundreds of prescriptions, emails, and other records from the Grand Jury that the FBI would later discover when searching his email account.

“Our healthcare system relies upon the integrity of those who practice in the field. It is our mission to root out those who would prey upon such vulnerability and prosecute them to the fullest extent of the law,” said U.S. Attorney Cody Hiland. “The assembly line alleged in this case of fraudulent prescriptions fueled by kickbacks was especially concerning because it attacked TRICARE, our military’s health insurer. Equally troubling are the allegations of a widespread campaign to throw investigators off the trail by lying to the authorities, falsifying medical records, tampering with evidence, and attempting to hide material from the Grand Jury. While such tactics may prolong an investigation, today’s indictment shows that they ultimately succeed only in bringing ever more serious charges upon the accused.”

“Unscrupulous medical professionals and fraudsters allegedly stole millions of dollars from the TRICARE program which serves our Veterans, military members and their families,” said FBI Special Agent in Charge Diane Upchurch. “In an effort to further pervert the course of justice, the defendants allegedly lied, obstructed justice, and falsified records in order to conceal their crimes. The deliberate targeting of a healthcare program which solely aids our military troops and their families is appalling, and the additional alleged attempts to cover up their criminal actions show the true nature of those indicted today. Alongside our partners at HHS-OIG, we will continue to aggressively investigate fraud within the healthcare industry and we urge anyone with information about suspected healthcare fraud to contact their local FBI Field Office.”

“Fraudulently submitting claims to any federally funded health care benefit program equates to robbing all American taxpayers” said HHS-OIG Acting Special Agent in Charge Latisha Cleveland. “Working closely with our law enforcement partners, our agents are determined to protect our nation’s health care systems. We are committed to ensuring that fraudsters pay for their crimes, especially those that target our military service members and Veterans.”

A vigilant public is indispensable to rooting out fraud, waste, and abuse within the healthcare industry. Please email This email address is being protected from spambots. You need JavaScript enabled to view it. if you or someone you know may have information about the compounded drug scheme targeting TRICARE. Please call 1-800-HHS-TIPS (1-800-447-8477) or the FBI with any other tips on suspected fraud, waste, or abuse within the healthcare industry.

This case is being investigated by the FBI and HHS-OIG, and prosecuted by Assistant United States Attorneys Alexander D. Morgan and Stephanie G. Mazzanti.

An indictment contains only allegations. A defendant is presumed innocent unless and until proven guilty.

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Miami, Florida -- A Georgia man was sentenced yesterday to over 11 years in federal prison for defrauding Tricare of approximately $12 million through a South Florida compounding pharmacy fraud scheme. Tricare is the health care benefit program covering military personnel and their dependents.

According to court documents, 51-year-old Erik Santos and his co-conspirators ran the scheme as follows: Santos paid recruiters to convince Tricare beneficiaries to fill prescriptions for expensive, supposedly tailor-made, compounded medications that the beneficiaries did not need. Santos paid doctors to approve pre-printed prescriptions for large amounts of these medications. The doctors did not see the beneficiaries or otherwise consider their medical needs before approving the prescriptions. Lastly, Santos steered the Tricare beneficiaries to fill their prescriptions with Patient Care America (PCA), a compounding pharmacy located in Broward County, Florida. PCA would bill Tricare for expensive drug formulations that had little to no therapeutic value. Many of the compounded medications were billed to Tricare at $10,000 to $15,000 for a month’s supply, even though the ingredients used in the mixtures were little more than common pain or scar creams. Santos’s fraudulent referrals caused an actual loss to the Tricare program of approximately $12 million. PCA pharmacy paid Santos over $7 million in prescription referral kickbacks.

In addition to the prison sentence, the Court imposed restitution in the amount of $11.8 million and entered a forfeiture judgement of approximately $7.6 million. On January 27, 2021, Santos pled guilty in federal district court in Ft. Lauderdale to one count of conspiring to commit health care fraud and wire fraud.

Acting U.S. Attorney Juan Antonio Gonzalez of the Southern District of Florida, Special Agent in Charge Cynthia A. Bruce of the Defense Criminal Investigative Service (DCIS), Southeast Field Office, and Special Agent in Charge George L. Piro of FBI Miami announced the sentence.

“Criminals steal exorbitant amounts of money from our government health programs through prescription medication fraud schemes. This significant sentence recognizes the seriousness of the crime,” said Acting U.S. Attorney Gonzalez. “Those who use kickbacks and other illegal activity to bilk taxpayer dollars from vital public programs will be held accountable.”

“Billing healthcare programs for medically unnecessary medications not only undermines the viability of those programs, it exploits all citizens,” said DCIS Special Agent in Charge Bruce. “I am pleased with the significant outcome of this investigation and would like to thank the U.S. Attorney’s Office and the investigative team for their tireless effort and great work to hold accountable those who fraudulently bill the Defense Health Agency.”

“Illegal kickbacks undermined the integrity of the Tricare health benefit program by putting profits in front of patient welfare,” said FBI Special Agent in Charge Piro. “The investigators who unraveled this scam are to be commended for their diligence and commitment. The FBI and our partners will continue to pursue those individuals who pay kickbacks and fraudulently bill for medical services that are not necessary.”

DCIS investigated the case with assistance from FBI Miami, and the Food and Drug Administration-Office of Criminal Investigation. The superseding indictment also named CHAMPVA (the Department of Veterans Affairs’ version of Tricare) as a fraud target and the Department of Veterans Affairs-Office of Inspector General assisted with the investigation.

Assistant U.S. Attorney Jon Juenger prosecuted the case. Assistant U.S. Attorney Daren Grove is handling the asset forfeiture component of the case.

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FALLS CHURCH, Va.  –  Will you soon be eligible for Medicare and TRICARE coverage? If yes, be sure to join the TRICARE webinar, “How to Get Started with Medicare and TRICARE,” on March 31, from 1 to 2 p.m. ET. This webinar will help you learn the basics of TRICARE For Life (TFL) and the steps to take to get TFL coverage. You must register to participate.

What is TFL? TFL provides Medicare-wraparound coverage to military retirees and their family members who are eligible for Medicare Part A, Part B, and TRICARE. As described in the TRICARE For Life Handbook, once you’re entitled to Medicare Part A, have Part B, and show as TRICARE eligible in the Defense Enrollment Eligibility Reporting System (DEERS), you automatically get TFL benefits.

“Medicare Part A and Part B are the two parts of Medicare that are critical for you to be eligible for TRICARE For Life,” said Anne Breslin, TRICARE For Life program manager with the Defense Health Agency. “Most of us become eligible for Medicare when we turn age 65.”

If you or a family member are turning age 65 soon, join the webinar for important information and resources. The webinar will highlight things you need to know, like when to sign up for Medicare so you don’t have a break in your TRICARE coverage and get your TFL benefits on time. It will also cover how you get care with TFL, Medicare providers, Medicare and TRICARE covered services, and TFL costs.

A Q&A will follow the presentation. Make sure to register for the March 31 TRICARE webinar for a chance to participate. Registration for the webinar is limited.

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JACKSON, Miss. — A pharmacy marketer has been sentenced to 30 months in prison for his role in a scheme to defraud a military health care program and private insurance companies, federal prosecutors said.

Thomas Wilburn Shoemaker, 57, of Rayville, Louisiana, was sentenced Tuesday for his role in a multimillion-dollar scheme to defraud Tricare and private insurance companies by paying kickbacks to distributors for the referral of medically unnecessary prescriptions. Tricare covers uniformed service members, retirees and their families.

The alleged conduct resulted in more than $180 million in fraudulent billings, including more than $50 million paid by federal health care programs, the U.S. Department of Justice said in a news release.

Shoemaker participated in the scheme by acting as a marketer for a network of pharmacies owned and operated by co-conspirators Mitchell Barrett and David Rutland. Shoemaker worked with the pharmacies to use his Tricare insurance to adjust prescription formulas to ensure the highest reimbursement without regard to efficacy, and he recruited doctors to procure prescriptions for high margin compounded medications. Shoemaker also obtained numerous fraudulent prescriptions using the personal information of military acquaintances.

Shoemaker pleaded guilty on Aug. 12 to conspiracy to defraud the United States and solicit, receive, offer, and pay illegal kickbacks.

In addition to the prison sentence, Shoemaker was ordered to pay restitution and forfeit all assets resulting from the scheme.

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A Georgia man has been sentenced to more than 11 years in federal prison and ordered to pay $11.8 million in restitution to Tricare for his role in a massive health care fraud scheme.

Erik Santos, 51, of Braselton, Ga., was sentenced May 27 in federal district court in Fort Lauderdale, Fla. He had pleaded guilty on Jan. 27 to one count of conspiring to commit health care fraud and wire fraud, according to court documents. In addition to the $11.8 million in restitution to Tricare, Santos must forfeit $7.6 million in personal gains from the scheme, which charged Tricare thousands of dollars for “compounded medications” that were little more than common pain creams or scar creams, according to Justice Department officials.

Investigators alleged that Santos, owner of two marketing companies, and his co-conspirators, ran a compounding pharmacy fraud scheme in 2014 and 2015. They allege Santos paid recruiters to convince Tricare beneficiaries to fill prescriptions for expensive, supposedly tailor-made compounded medications that the beneficiaries didn’t need. Santos also paid doctors to approve pre-printed prescriptions for large amounts of these medications, and the doctors didn’t see the beneficiaries or otherwise consider their medical needs before approving the prescriptions, according to court documents.

Then Santos would steer the Tricare patients to Patient Care America, a compounding pharmacy in Broward County, Fla. PCA would bill Tricare for these expensive drug compounds — many of which cost $10,000 to $15,000 for a one-month supply, according to Justice Department officials.

Santos’ fraudulent referrals caused an actual loss to Tricare of about $12 million; and the PCA pharmacy paid Santos more than $7.6 million in referral kickbacks, according to Justice officials.

“This significant sentence recognizes the seriousness of the crime,” said Juan Antonio Gonzalez, acting U.S. Attorney of the Southern District of Florida, in a statement announcing the sentencing. “Those who use kickbacks and other illegal activity to bilk taxpayer dollars from vital public programs will be held accountable,” he said.

“Billing healthcare programs for medically unnecessary medications not only undermines the viability of those programs, it exploits all citizens,” said Cynthia A. Bruce, Defense Criminal Investigative Service Special Agent in Charge, in the announcement. DCIS investigated the case with assistance from FBI Miami, and the Food and Drug Administration’s Office of Criminal Investigation.

Overall, the co-conspirators participated in the scheme to defraud Tricare out of tens of millions of dollars, Justice officials said in an announcement in 2018. Two named co-conspirators employed at the time by Patient Care America are awaiting trial, according to court documents. They are Matthew Smith, a licensed pharmacist and vice president of PCA in charge of non-sterile compounding operations; and Alisa Catoggio, a licensed pharmacy technician and executive assistant to Smith. At least eight additional co-conspirators in the overall case have pleaded guilty to federal criminal charges arising out of the scheme, according to Justice officials. It is not known if any doctors are among those.

In addition, Monty Ray Grow, 49, of Tampa, a former college and professional football player, was convicted by a jury in 2018 of 18 criminal charges in connection with the case, including conspiracy to commit health care fraud, conspiracy to pay and receive health care kickbacks, money laundering and others. Justice officials said Grow received nearly $20 million in kickbacks. Grow was ordered to pay about $18 million in restitution, and was sentenced to more than 20 years in federal prison.

In October, 2020, an appeals court upheld Grow’s conviction, but sent the case back to the lower court because the sentence exceeded the statutory maximum allowed by the jury’s general verdict.

Tricare’s costs for compounded medications ballooned in 2014 and 2015, causing a budget shortfall in 2015. In the first four months of 2015, the Defense Health Agency spent nearly $1 billion on compounded prescriptions. Aggressive marketing campaigns by some compounded pharmacies directly targeted Tricare beneficiaries to sell them prescriptions such as pain creams, wound ointments and erectile dysfunction medications.

A Tricare policy change that took effect May 1, 2015 called for screening all ingredients in the prescriptions and rejecting any that contained non-FDA approved ingredients.

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The Biden administration's plan to cover the cost of home COVID-19 tests does not apply to Tricare beneficiaries.

Beginning Saturday, private and group health insurers will be required to reimburse the cost of eight take-home COVID tests per month under an initiative announced by President Joe Biden on Jan. 10.

But as a federal health program, Tricare's nearly 8 million beneficiaries who aren't on active duty will not have the same access, although the military health system is reviewing its policies, according to a Defense Health Agency spokesman.

Under Tricare, tests are covered only when ordered by a doctor for patients with symptoms; who have had prolonged exposure but no symptoms; are having surgery; or are overseas and need to be tested.

All other reasons -- personal concern, workplace safety, returning to work or school, travel or access to services -- are not covered.

In a major effort to broaden access to testing across the U.S., Biden ordered insurers to cover the cost of eight COVID-19 test kits per month for people with health insurance starting Jan. 15.

The initiative requires insurers to reimburse for the full cost of take-home tests at their network pharmacies and at out-of-network retailers for a $12 copayment per test.

And under the directive, patients with an underlying health condition or other factors will not be limited on the number of tests they can be reimbursed for if they have a doctor's order.

Since the beginning of the COVID-19 pandemic, Tricare beneficiaries have been able to have their COVID-19 tests covered only if they have symptoms or have been in contact with a person who has tested positive and they have a doctor's order.

Tricare spokesman Peter Graves said Thursday that policy remains in place but the Department of Defense is reexamining its rules.

"The Defense Health Agency is reviewing the latest guidance on at-home testing kits in order to identify whether any changes to the current policy are warranted," Graves said in an email to Military.com.

The new insurance reimbursement plan also does not apply to Medicare, which provides the primary coverage for military beneficiaries who use Tricare For Life – meaning those patients are also excluded under the initiative.

Despite not being covered under the federal program's reimbursement plan, Tricare users should still be able to get access to free tests.

As part of the announcement, the government will establish "thousands of locations," according to Biden, to distribute free take-home tests and will create a website for anyone to order free rapid antigen tests for delivery.

Beginning Jan. 19, anyone can order free tests for home delivery at www.COVIDTests.gov.

Some states like Vermont already have programs in place that require insurers to reimburse for tests. Other states, including Colorado, Connecticut, Iowa, Maryland, Massachusetts, New Hampshire, New Jersey and Washington, as well as the District of Columbia, already have been giving away free tests at COVID-19 test sites, community centers, libraries and community health clinics.

With the spread of the Omicron variant of the illness, test kits have remained in short supply at retailers and via community distribution.

Earlier this month, the Defense Department awarded contracts to a number of rapid antigen test makers, including Abbott, maker of the BinaxNOW test; iHealth Lab; and Roche Diagnostics for the purchase of 380 million over-the-counter tests, and to Goldbelt Security for distribution of a planned 500 million tests.

The DoD is the contracting agency because it has the infrastructure and capability to "acquire goods and services as rapidly and effectively as possible for the federal government in support of the American public," according to Pentagon spokeswoman Jessica Maxwell.

There have been more than 460,000 cases of COVID-19 diagnosed in the military community since the beginning of the pandemic, including military personnel, family members, civilian employees and contractors.

Nearly 650 have died, including 88 troops, 34 dependents, 394 civilians and 133 contractors, according to the DoD.

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MOBILE, Ala. (WPMI) — Heritage Compounding Pharmacy, based in Mobile on Midtown Park East, has settled a federal fraud case for more than $1.9 Million.

A federal complaint filed in October alleged that Heritage and its owners Christopher and Marti Burgess defrauded TRICARE and CHAMPVA, both of which provide healthcare benefits for U.S. Military members, of more than $2.8 Million between January 2013 and May 2015.

The settlement agreement filed in November requires Heritage and the Burgesses to pay $450,000 within 10 days of the agreement being accepted and $2,500 per month beginning in December until the settlement amount of $1,910,392 is fulfilled.

Online records indicate that Heritage Compounding Pharmacy closed in June 2018 and that in 2015 Christopher Burgess formed Rockwell Pharmaceuticals, LLC located in Daphne.

Marti Burgess’ Facebook page indicates she has been a pharmacist for Walmart since July 2016.

According to the Alabama Board of Pharmacy website, both Burgesses have valid state licenses with no disciplinary actions listed.

Federal prosecutors allege that between January 2013 and Mid-2015 the defendants would submit “false claims to TRICARE and CHAMPVA that were tainted by illegal kickbacks.”

Court documents also show that federal authorities believe that the defendants used pre-printed prescriptions for Ketamine, a Schedule III controlled substance, that “were not medically necessary or prescribed by a physician who had a legitimate physician-patient relationship.”

U.S. Magistrate Judge Sonja Bivens signed the Stipulation of Settlement and Consent Judgement Monday.

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Native American Veteran care and benefits were at the center of a Nov. 20 Senate Committee on Indian Affairs hearing on Capitol Hill.

Secretary Robert Wilkie told Congress there are two areas that can help Native American Veterans – expanding telehealth and more benefits events.

“One solution we have pursued is telehealth,” he said. “VA has its own telehealth facilities in the western states – Alaska, Montana, Oklahoma and Wyoming – and they are helping us to get care to Veterans who don’t live that short drive away from a VA facility.”

On the benefits side, Wilkie said VA hosted 30 claims events, assisting more than 1,000 Native American Veterans from 24 tribes in the past year.

Wilkie said one of his priorities is reaching out to rural and Native populations, who make up 31,000 active duty and 140,000 Veterans.

“Our pledge at VA is to continue to work with tribal governments to face the unique challenges that accompany life of America’s Native communities,” he said.

Wilkie said VA works with Indian Health Services to make sure Native American Veterans get the care they need.

“It’s our mission to make sure all Native Americans know that this VA belongs to them as well,” he said.

Native American Veterans can access the VA-IHS Consolidated Mail Order Pharmacy Program, which sends prescription medications directly to Native homes, Wilkie said. Last year, the program processed 840,000 prescriptions for Native Veterans, up 17 percent from the previous year.

Native American Veterans also receive VA care through benefits, helping them on issues like job training and housing. Additionally, Wilkie said the National Cemetery Administration is a key partner in the Library of Congress’ Warrior Spirit Project. This yearlong curriculum development project honors American Indian Veterans by profiling the sacrifice and patriotism of Native Americans who are memorialized across the country.

Improving care

Wilkie encouraged Congress to take two steps that would help VA connect with Native America. The first was to consider a bipartisan bill that will help VA directly fund state and local groups that are in a position to help prevent Veteran suicide, VA’s number one clinical priority.

“It’s something we believe can make an immediate difference in Veterans’ lives,” he said.

Wilkie said VA also supports legislation to establish a VA Advisory Committee on Tribal and Indian Affairs, which he said would help Native American Veterans.

“We believe that this would provide a formal structure and forum for VA to engage with tribal leadership and create many opportunities for collaboration to improve VA services to Native American Veterans.”

As VA secretary, Wilkie has traveled to the Dakotas, Montana, Oklahoma, Alaska and Wyoming to meet with Native American Veterans, tribal leaders and caregivers. He also has trips planned to Kansas, Arizona and New Mexico.

Wikie is the first VA secretary to testify before the committee. Veterans Health Administration Executive in Charge Dr. Richard Stone also testified in front of the committee.

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Final Co-Defendant Awaits Trial in December

LITTLE ROCK—A ninth defendant has pleaded guilty in connection with a $12 million scheme to generate prescriptions for expensive compounded drugs paid for by TRICARE. Kenneth Myers Jr., 43, of Alpharetta, Georgia (formerly of Little Rock), pled guilty to conspiring to violate the Anti-Kickback Statute today before United States District Judge Kristine G. Baker.

Myers collected nearly $70,000 for recruiting TRICARE beneficiaries to receive expensive compounded drugs, for which TRICARE paid over $340,000. Myers acknowledged offering TRICARE beneficiaries money to receive the drugs and that medical providers, including co-defendant Joe David May a.k.a. Jay May, 40, of Alexander, rubber stamped prescriptions without consulting the TRICARE beneficiaries.

Upon learning a federal agent planned to interview a TRICARE beneficiary about his prescription, Myers instructed the man to lie by claiming he had been examined by a doctor before getting his prescription. When Myers was later interviewed, he lied to the FBI by claiming he played no role in securing prescriptions and instead directed beneficiaries to consult their own doctor.

In pleading guilty to the kickback conspiracy, Myers joins Albert Glenn Hudson, 40, of Sherwood; Derek Clifton, 39, of Alexander; Donna Crowder, 66, of North Little Rock; Jennifer Crowder (formerly Bracy), 38, of Little Rock; Keith Benson, 50, of North Little Rock; Keith Hunter, 52, of Little Rock; Angie Johnson, 50, of North Little Rock; and Blake Yoder, 40, of Scott.

Conspiring to violate the Anti-Kickback Statute is punishable by up to five years in federal prison, three years of supervised release, and a $250,000 fine.

Trial of the 10th and final defendant, May, is set for December 6, 2021, before Judge Baker. May faces charges of conspiracy, wire fraud, mail fraud, violating the anti-kickback statute, aggravated identity theft, lying to the FBI, and falsifying records in a federal investigation.

Jonathan D. Ross, Acting United States Attorney for the Eastern District of Arkansas, James A. Dawson, Special Agent in Charge of the FBI Little Rock Field Office, and Miranda Bennett, Special Agent in Charge of the Dallas Regional Office of the U.S. Department of Health and Human Services announced the guilty plea.

The investigation was conducted by the FBI and HHS-OIG. The case is being prosecuted by Assistant United States Attorney Alexander D. Morgan.

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A San Diego psychiatrist has been sentenced to prison for fraudulent claims to Tricare, and ordered to pay $783,764 in restitution.

Marco Antonio Chavez “used these ill-gotten gains to buy himself luxuries including a red 2016 Jaguar and thousands of dollars’ worth of David Yurman jewelry,” stated a press release from the U.S. Attorney’s Office in the Southern District of California.

The 40-year-old Chavez was sentenced in federal court to 21 months in prison. The maximum penalty for health care fraud is 10 years in prison and a $250,000 fine. In August, 2019, Chavez pleaded guilty to felony health care fraud.

Over time, Chavez submitted about $928,800 in false and fraudulent claims to Tricare , and Tricare paid $783,764 on those claims.

Chavez became a Tricare network provider in April, 2013, providing psychiatry services, including therapy and prescription medications for children and adults. According to prosecutors, he used his access to the web-based system to submit fraudulent claims to Tricare using his unique personal security code to avoid review by other billing staff, according to the release. He then arranged for those federal funds to be paid directly into his personal account.

Chavez used information from patients to submit claims for nonexistent care, according to prosecutors. In one example, he billed Tricare for 80 dates of service, when he actually saw the patient on just three different occasions. His office staff submitted the claims for those three occasions; Chavez submitted the other 77 claims directly, according to the release. Of those claims, 21 included dates for service before that patient’s initial visit. Another patient saw Chavez on five occasions, yet Chavez submitted another 71 claims for service when he didn’t actually see the patient. Those two incidents cited by prosecutors happened in 2013 and 2014.

Prosecutors said Chavez tried to avoid detection through a variety of means. He told patients that they might see entries on their Explanation of Benefits forms from Tricare that they wouldn’t recognize.

When the Tricare contractor conducted an audit and asked for certain patient files, he claimed he had already sent the files, when he knew the files didn’t exist, according to the release.

In addition to Assistant U.S. Attorney Valerie Chu, the FBI and Defense Criminal Investigative Service worked on the case.

“Dr. Chavez’ conduct is a particularly egregious example of fraud against the TRICARE program in that his greed clearly took priority over his patients’ trust and well-being,” said Bryan D. Denny, Special Agent in Charge of the Defense Criminal Investigative Service, Western Field Office, in a statement in the release.

“The doctor’s sentencing should serve notice to other unscrupulous healthcare providers that any unprincipled actions that corrupt the integrity of the Tricare program and ultimately degrade the quality of health care provided to military service members and their families will be vigorously investigated by DCIS and its law enforcement partners.”

In a separate action on June 23, the Medical Board of California issued an order revoking Chavez’s medical license, related to allegations that Chavez was treating patients while under the influence of a drug or alcohol, according to Board documents.

In May, 2018, NBCSanDiego.Com reported that a judge had suspended Chavez’s license after he admitted to drinking a pint of vodka before treating patients.

In Board documents, an investigator who visited Chavez’s office stated Chavez had told him he drank two eight ounce glasses of vodka mixed with cloves at 6 a.m. and 7 a.m. that morning, because it was his mother’s home remedy to stop his drinking. There were patients in the waiting room when the investigator visited.

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About 75,000 Tricare customers were overcharged for monthly premiums on Thursday, in some cases 100 times more than the actual amount owed.

The Defense Health Agency, which manages the Tricare system, said in a statement Friday that it was working closely with Humana Military, the Defense Department contractor that administers the Tricare health program for the East Region, the area affected by the overcharges. The region includes 32 states and the District of Columbia.

Tricare provides civilian health benefits for service members, military retirees and their families.

“While this is an unfortunate error, I am confident this will be resolved quickly,” Army Lt. Gen. Ron Place, director of the Defense Health Agency, said in the statement. “I am personally in touch with the president of Humana Military, and his team has taken immediate steps to correct this error.”

The root cause of the processing error is still under investigation, the statement said.

Health care coverage for affected Tricare customers will be uninterrupted, the statement said.

A recorded message on Humana Military’s customer service line promises callers that their credit cards will be credited “within 24 to 48 hours.”

The overcharges were an unwelcome surprise as Americans gearing up for holiday spending.

“So @Humana,” tweeted a former Coast Guard member in Virginia with the Twitter handle Devin’s Cyberz Cow on Thursday, “my wife and I are two of the Vets that got TriCare charges multiplied by 100 times their normal amount this month. How soon will you be reversing them? For now you’ve effectively bricked my credit card during Christmas shopping season … ”

In a post on its website, Humana Military said the glitch was affecting recurring credit and debit card premiums and that the company was working to correct the problem.

“We pledge that we will do everything we can to ensure that beneficiaries are not adversely affected by this error, including covering overdraft and related fees,” the post said.

Humana Military’s customer service at 800-444-5445 expanded its weekend hours to 8 a.m. to 6 p.m. Eastern Time to handle urgent inquiries.

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TRICARE recipients who want to change their plan during open season will need to take an old school approach for the rest of the period due to a glitch in the computer system.

The Defense Department says the glitch will not be fixed by the end of open season on Dec. 9. The season started on Nov. 11. This open season is for beneficiaries who want to change their plans starting Jan. 1, 2020.

“We realize some individuals will be inconvenienced by this situation and we ask for their understanding,” Pentagon spokeswoman Jessica Maxwell told Federal News Network. “There are two other options for changing health plans, and we encourage beneficiaries who wish to do so to take full advantage of those options.”

The other two options are to enroll by phone or mail. To enroll by phone, beneficiaries can call:

• Humana Military (TRICARE East): 1-800-444-5445
• Health Net Federal Services (TRICARE West): 1-844-866-9378
• Overseas beneficiaries go to TRICARE-overseas.com/contact-us for country specific phone numbers

To enroll by mail, download TRICARE Prime or Select enrollment forms at www.tricare.mil/openseason2019 and send the forms to the contractor address on the forms.

Insight by Dell Technologies and Intel: Federal technologists explore the challenges with the handling and analysis of video data in this exclusive executive briefing.

Maxwell said DoD does not have any intention of extending open season due to the online issues. The Defense Manpower Data Center will conduct a sweep of all web “change of enrollment plan transactions” initiated during open season to make sure there is no gap in TRICARE coverage for those who already changed their plans online.

This year marks TRICARE’s second open season enrollment.

“This is the one extended period of time where you have the opportunity to change your TRICARE plan from Prime to Select or Select to Prime,” Francine Forestell, chief of TRICARE customer communications, said during a September webinar hosted by Military OneSource. “If you have any intention to change your plan this would be the time to do it.”

Members can also change from individual plans to family plans or vice versa.

TRICARE Prime offers a lower cost, but fewer options for providers. TRICARE Select, on the other hand, can be more expensive, but offers more providers and patients do not need referrals.

We want to “give our patients the opportunity to select the plan that best works for them,” then- Defense Health Agency Director Vice Adm. Raquel Bono said last year as to why TRICARE adopted open season. “Some of our folks, depending on where they are or what family members they are covering — if they have children in school or young kids at home — may find certain benefits to being part of TRICARE Prime program or moving to TRICARE Select.”

Along with open season last year, dental and vision care for TRICARE retiree beneficiaries were transferred to the Federal Employees Dental and Vision Insurance Program. Retirees can choose from 10 different dental carriers and four vision carriers. Signing up for vision and dental is a completely separate open season and not through the TRICARE system.

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In the wake of a widespread glitch that auto-billed 25,000 beneficiaries in Tricare's East region with monthly fees 100 times the amount owed on Thursday, the contractor in charge said it is working with banks to block the charges.

"We are actively working to correct this billing error, and the payment process has been stopped," Mark Mathis, a spokesman for Humana, told Military.com in an email late Thursday.

The issue impacted all users in the East region who automatically pay monthly enrollment fees by credit or debit card, including military retirees on Tricare Prime and those enrolled in Tricare Reserve Select, Tricare Retired Reserve and Tricare Young Adult. It did not affect retirees and others who pay premiums through paycheck allotment or Tricare for Life enrollees.

The incorrectly billed amounts ranged from just over $4,000 to a whopping $110,000, depending on the set monthly premiums, according to a Military.com calculation. While some beneficiaries reported that their credit card companies blocked the charge, those using checking accounts may not have been so lucky, with the automatically billed amount sparking overdraft fees and potentially cleaning out their savings.

Mathis said Humana plans to work directly with banks to cover any fees caused by the error.

"We are working directly with banks to reverse charges before they occur," he said. "We pledge that we will do everything we can to ensure that beneficiaries are not adversely affected by this error, including covering overdraft and related fees."

Enrollees won't experience interrupted Tricare coverage, he said. Customers who are experiencing problems can call Humana at 1-800-444-5445 during normal business hours.

In 2018, the same group of users affected by Thursday's error was at risk of using their health coverage entirely when Humana in the East and HealthNet Federal Services in Tricare's West region did not inherit billing information as part of a contractor change. Users were first told to update their information by late December 2017, but many of those who did so by the required deadline ultimately had their information lost anyway thanks to an enrollment blackout put in place that month.

Humana's problems during the transition did not end there. Retirees who pay fees to Humana by allotment were caused extra confusion when they received a payment change letter even though it did not apply to them. Then, a second system glitch about a month later failed to process the January enrollment allotment payments from more than 4,000 of the retirees who received the initial incorrect mailing.

Additionally, a recent report from the Government Accountability Office found that the company only recently started meeting Tricare's standards for timely claims processing.

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With a new year on the horizon, Tricare enrollment fees and copays will be changing in 2020.

By law Tricare fees go up slightly every year. For retirees the cost bump is tied to the annual cost of living increase (COLA), while other fee increases are set ahead of time by Congress.

While the changes are small, the costs do go up for many Tricare recipients. Here’s a break down.

Tricare Prime

While active duty family members pay no enrollment fee for Tricare Prime, the annual fee for retirees who entered the service before 2018 and their dependents will increase from $297 annually to $300 for individual coverage while family coverage will go from $594 to $600.

For those retirees who entered the service after Jan. 1, 2018 and their beneficiaries the annual premium for individual coverage will go from $360 to $366 while the family plan will increase from $720 to $732.

Some copayments will increase as well; specialty and urgent care visits will cost $1 more in 2020.

Tricare Prime users who are medically retired or survivors do not see an increase.

Read more about 2020 Tricare Prime costs.

Tricare Select

Just like Tricare Prime, active duty family members enrolled in Tricare Select pay no enrollment fees. All others will see a slight fee increase in 2020.

While retirees who entered service before 2018 pay no enrollment fee, retirees who joined the service in 2018 or later will see an increase from $462 to $471 for individual coverage and $924 to $942 for family coverage.

Some copayments will see slight increases as well. Active duty family members of those who entered before 2018 as well as all Tricare Reserve Select participants will see primary care visits go up by $1 - from $21 to $22, and specialist visits will increase $2 each, from $31 to $33. Those who entered in 2018 or later will see a $1 increase in specialist visits.

Full details on 2020 Tricare Select costs.

Tricare Reserve Select

Reservists enrolled in Tricare Reserve Select will see their monthly payments increase from $42.83 to $44.17 for individual coverage and from $218.01 to $228.27 for family coverage.

Tricare Retired Reserve

Retired reservists who haven't turned 60 and are covered under the Tricare Retired Reserve program will benefit from a rate decrease in 2020. The monthly premium for an individual retiree will decrease from $451.51 to $444.37, and those with family coverage will see a monthly decrease from $1,083.40 to $1,066.26.

Tricare Young Adult

College-age dependents enrolled in the Tricare Young Adult program will see an increase in their monthly premiums; however, the amounts vary depending on which option they are covered under. For those using Tricare Young Adult Select, the monthly payment will go from $214 to $228, and those using Tricare Young Adult Prime will see the monthly payment increase from $358 to $376.

Continued Health Care Benefit Program (CHCBP)

Recently discharged members with temporary health insurance under the Continued Health Care Benefit Program (CHCBP) will see their premiums increase by the largest amount. Those who have single coverage will be hit with a premium increase from $484.33 to $517.67 each month, and those electing family coverage will pay an additional $75.67 each month, increasing their premiums from $1,091 to $1,166.67.

Tricare Pharmacy Costs

Prescription drug costs for Tricare users are also set to rise Jan. 1, some by as much as 42%. The pharmacy fee increases impact all Tricare users who utilize off-base pharmacies, including those on Tricare for Life.

Effective Jan. 1, 2020, a 90-day supply of generic drugs received through the program's Express Scripts mail-order pharmacy will increase from $7 to $10. Co-pays on brand-name drugs received through the mail will go from $24 to $29; the price rises from $53 to $60 for non-formulary drugs.

Generic drug prescriptions filled at retail pharmacies will see the cost rise from $11 to $13 for a 30-day supply, while the same supply of brand-name medications will increase from $28 to $33. Non-formulary drugs -- those not on Tricare's list of fully covered medications -- will go up from $53 to $60.

Prescriptions filled on base will continue to have no cost to members.

Read more about 2020 Tricare pharmacy fees.

Keep Up with Changes to Tricare and Your Other Benefits

Want to know about changes in military benefits as they happen? Sign up for a free Military.com membership to get the latest benefits news delivered directly straight to your inbox.

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Did you know your TRICARE deductible and catastrophic cap reset every Jan. 1? As always, TRICARE costs depend on who you are as well as your health plan (for example, TRICARE Prime or TRICARE Select). So take a few minutes to re-familiarize yourself with the deductible and catastrophic cap associated with your plan.

A deductible is a fixed amount you pay out of pocket for covered health care services each calendar year before TRICARE pays anything. Enrollment fees aren’t included in your deductible.

Your deductible varies by health plan. If you have TRICARE Select, your deductible depends on your sponsor’s status and rank, and whether they’re in Group A or Group B. There’s no deductible with TRICARE Prime. But you may have to pay a deductible if you see a provider without a referral using the point-of-service option. If you have TRICARE For Life (TFL), you only have to pay an annual deductible for services not covered by both Medicare and TRICARE. Download the TFL Cost Matrix from the TFL page to see what Medicare and TRICARE pay.

Your deductibles reset to $0 every Jan. 1. You can find your deductible on the TRICARE Costs and Fees Sheet.

The catastrophic cap is the most you or your family may pay out of pocket for covered TRICARE health care services each calendar year. This protects you because it sets a limit for the amount you’ll pay annually for TRICARE covered medical services. Each year, your TRICARE Prime or TRICARE Select enrollment fees along with all other out-of-pocket expenses count toward your catastrophic cap. Each Jan. 1, this amount resets to $0.

Once you reach your catastrophic cap, you don’t pay any more of the TRICARE-allowable charge for covered services. This includes enrollment fees for TRICARE Prime and TRICARE Select, costs paid toward annual deductibles, pharmacy copayments, and other cost-shares based on TRICARE-allowable charges. But you’ll have to pay for services that don’t fall under the catastrophic cap protection.

The catastrophic cap doesn’t apply to:

• Services not covered by TRICARE
• Any amount that non-participating providers may charge above the TRICARE-allowable charge (up to 15% above the allowable charge)
• TRICARE Prime point-of-service charges
• Monthly premiums for TRICARE Reserve Select, TRICARE Retired Reserve, or TRICARE Young Adult

Visit the Cost Terms page to help you better understand your deductible, catastrophic cap, and other TRICARE costs. Then use the TRICARE Compare Cost tool to find your health plan costs, including costs related to TRICARE For Life. For a detailed overview of most costs and fees for TRICARE programs, you can also check out the 2020 TRICARE Costs and Fees Sheet. This is your benefit—take command of your health care by learning about your plan.

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The Tricare Dental Plan (TDP) is giving its policyholders an extra $300 to spend on dental care this year as a result of the COVID-19 national emergency.

The dental plan is available to active duty family members, eligible National Guard and Reserve members and their family members.

Since many people were unable to receive necessary dental procedures as a result of social-distancing requirements and state medical office restrictions, the $300 increased coverage is designed "to compensate for the downtime when services weren't available,” Tricare officials said in a release.

United Concordia, the administrator of the program, made the announcement on their website.

Normally, the annual maximum benefit amount under the plan is limited to $1,500 per person. As a result of this change, the program will pay an annual maximum benefit of $1,800 per person. The additional coverage is automatic and requires no action on your part. It does not increase the max lifetime coverage for orthodontics.

The increased maximum benefit will remain in effect through April 30, 2021.

The Tricare Dental plan is a voluntary insurance program available worldwide to family members of active duty and eligible Guard and Reserve members, as well as inactive Guard and Reserve members. The program covers dependent children until age 21, or age 23 if full-time students. For the current contract year (May 1 - April 30) the monthly premium is $11.60 for an individual and $30.15 for a family.

Retirees are covered under the FEDVIP dental insurance program.

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Thousands of TRICARE beneficiaries are losing coverage for their medication as more drugs are dropped from the list of those approved for TRICARE coverage.

The Defense Health Agency has been excluding some prescription drugs from TRICARE coverage after the fiscal year 2018 National Defense Authorization Act included a provision allowing DHA to do so.

Previously, all medications were categorized in one of three tiers – Generic, Brand Name and Non-Formulary – with varying copays for beneficiaries.

Now, drugs that DHA categorizes as “Tier 4/non-covered” are excluded from coverage under TRICARE. These Tier 4 drugs cannot be obtained at pharmacies at military treatment facilities. They also aren’t available through the TRICARE Pharmacy Home Delivery Program.

Tier 4 drugs are only available at retail pharmacies at full out-of-pocket cost to the beneficiary. Costs for Tier 4 drugs do not apply to the annual TRICARE catastrophic cap.

For the last year, the DHA has been identifying and reviewing drugs to potentially remove them from coverage. The first round of Tier 4/non-covered drugs was announced in August 2019 and included Glumetza, Vimovo, and Lexette. Excluding these drugs had little impact on beneficiaries since very few TRICARE patients were using these prescription drugs and alternative agents were available for them.

However, nearly 19,000 beneficiaries taking Dexilant to treat gastroesophageal reflux disease (GERD) were impacted when that drug was dropped from TRICARE coverage effective Nov. 28, 2019.

We also recently learned that DHA is considering adding brand-name erectile dysfunction drugs Viagra and Cialis to Tier 4/non-covered status, although this decision is pending approval from the DHA director.

While MOAA understands the rationale for establishing Tier 4 to improve formulary management, we are concerned about where this process is headed. We are monitoring Tier 4 drug reviews closely to ensure DHA follows congressional intent and moves to Tier 4 only those medications that “provide very little to no clinical effectiveness” per the FY 2018 NDAA legislative language.

MOAA is also pressing DHA to establish an appeals process for Tier 4 determinations.

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A Facebook post from Tricare celebrating April as “Autism Acceptance Month” has struck a nerve, with hundreds of military families criticizing the Defense Department for its health care coverage of autism treatment for military families.

Families complained that recent DoD policy changes have resulted in cuts in coverage for autism treatment.

“What a gross post from a group that has made getting services so difficult for hundreds of people,” wrote Meigan Toland, commenting on Tricare’s simple April 8 post.

At last look on April 11, there were 690 comments to the post, which reads: “We can all work to make room for more inclusivity and tolerance with just a little patience, understanding and education. Learn more about Tricare coverage of Autism treatment: www.tricare.mil/autism.

The post “immediately, albeit unintentionally, highlighted the concerns and limitations with the changes in autism care that many military families encounter,” stated a press release from the organization Exceptional Families of the Military.

The responses to the post “are eye-opening, underscoring a problem that needs to be addressed in the military community,” said Austin Carrigg, CEO and founder of the group.

In spring 2021, defense officials announced an expansion of the Tricare Comprehensive Autism Care Demonstration program to provide more support to meet families’ needs. There are nearly 16,000 military children diagnosed with autism involved in that program, which began in 2014 and is currently authorized to continue through Dec. 31, 2023.

In response to Military Times’ request for comment, Defense Health Agency officials said the Tricare benefit is unique in its coverage. “Unlike commercial plans, Tricare is defined in statue and regulation, whereas commercial plans tend to have flexibility for various coverage determinations,” said Peter Graves, spokesman for DHA.

“Tricare’s autism benefit is one of the most robust available and provides coverage for occupational therapy, physical therapy, physician services, psychological services, psychological testing, prescription drugs and speech therapy.”

Changes in the demonstration program “focus on providing enhanced beneficiary and family support, improving outcomes, encouraging parental involvement and improving utilization management controls to truly provide a comprehensive benefit,” he said.

Military families have said that among other things, the changes curtailed coverage of Applied Behavioral Analysis, or ABA, services provided in community and school settings, where therapists help children develop skills to deal with real world situations when they may experience sensory overload. Registered behavior technicians are not covered in community or school settings. Board-certified behavior analysts are allowed but only if approved by the Tricare contractor for a limited time.

Unpredictable stressors in community settings can’t be replicated at home, and therapy can’t address behaviors until the behaviors happen, families contend.

“I can recreate a grocery store at home, with a cashier … but I can’t recreate the 80-plus people in the store,” Holly Duncan, an Air Force wife and mother of two children on the autism spectrum, told Military Times. If therapists are allowed to work with students at school, they can reinforce the proper behavior for the child who may not want to sit in her seat and do the work. This also allows the teacher to continue to teach the class.

“We also want to make sure everyone is on the same page” so that the behavior is reinforced to better help the child, said Duncan, co-director of the Autism Family Advocacy Committee for the Exceptional Families of the Military organization.

“Our children already have enough hoops to jump through,” commented Lana Lazar-Amaro on the Tricare page. “Limiting ABA to clinic settings only makes it nearly impossible for our children to receive the necessary therapy hours when they are school age.”

Graves said “Tricare is consistent with commercial and Medical plans regarding the exclusion of ABA services in the school setting,” and cited as examples the Federal Employee Health Benefits plans, Texas Medicaid and Cigna.

In a Dec. 21 letter to the Defense Department, Sens. Jeanne Shaheen of New Hampshire and Kirsten Gillibrand of New York said they began hearing from families about the adverse consequences of the changes shortly after they took effect. They requested more information about the changes and the steps DoD is taking to support military families with beneficiaries diagnosed with Autism Spectrum Disorder.

Military families on Facebook repeatedly cited problems with bureaucratic processes that often cause disruptions in a child’s treatment. Treatment plans have to be submitted to Tricare every six months now. Waiting lists for appointments compound the difficulties.

“I’m on edge, wondering if we’ll be able to be approved,” said Dr. Jennifer Bittner, an Army spouse who, with Duncan, is co-director of the Autism Family Advocacy Committee.

Bittner, who was previously a practicing child and adolescent therapist, wants to ensure that her child receives a quality treatment plan that supports his needs, not just one that “checks the boxes” for Tricare, she said. “I can’t tell you the amount of stress I go through every six months wondering if services are going to be stopped” if the plan isn’t approved, she told Military Times.

Some commenters called for coverage of additional alternate therapies. “There are therapies that families want for their children that aren’t being offered through the autism care demonstration,” Duncan said. “Those who don’t choose ABA for their families are left behind. That’s not okay. ABA is not a one-size-fits-all therapy. We need other therapies offered for families.”

For example, she’d like Tricare to also cover social skills groups, which is not covered under the autism care demonstration.

“Tricare, please stop with the acceptance and awareness spiel until you put together accessible, meaningful coverage that addresses issues instead of making families’ lives so much more difficult,” commented Kristin Proffitt on the Tricare Facebook page. “After 10 years with 2 children on the spectrum, your callous and arbitrary changes to their services and the steps you have actively taken to make therapy less accessible … has caused our family more stress and harm than their diagnosis ever would.”

Kira Barrett-Voelker called the Tricare post “a slap in the face.

“As a health-care provider with a child on the spectrum, all you’ve done is reinforce society’s negative view of autistic individuals,” she wrote. “It’s not just ABA that’s the issue. It’s becoming increasingly more difficult to find any therapy or provider, even in big cities, that will work with Tricare.”

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A Mississippi man described as the “mastermind of the largest health care fraud scheme” in that state’s history has been sentenced to 18 years in prison and ordered to pay nearly $350 million in connection to his role in a scheme to defraud Tricare, Justice officials said.

Wade Ashley Walters, 54, of Hattiesburg, Miss., who earlier pleaded guilty to one count of conspiracy to commit health care fraud and one count of conspiracy to commit money laundering, was sentenced Jan. 15 in federal court in Mississippi, according to an announcement from the Justice Department. He is co-owner of numerous pharmaceutical distributors and compounding pharmacies — companies that make individualized medications for people.

He was ordered to pay nearly $288 million in restitution, and to pay an additional $57 million to forfeit his personal profit from the scheme, officials stated.

The sentencing “is another mile marker on the long road to justice for victims, our Veterans, our military, and all American taxpayers, as the mastermind of the largest health care fraud scheme in Mississippi history has been held to answer for his crimes,” said Mike Hurst, U.S. Attorney for the Southern District of Mississippi, in the Justice Department announcement.

Since 2007, federal officials have been engaged in a coordinated, large-scale investigation of health care fraud. Some involve schemes to submit claims to Medicare, Medicaid and Tricare for treatments that weren’t medically necessary, and sometimes never provided. Some schemes resulted in convincing Tricare beneficiaries to fill prescriptions for pain creams, ointments and other topical medicines they didn’t necessarily need, resulting from illegal kickback schemes.

Between 2012 and 2016, Walters ran a scheme to defraud Tricare and other health care benefits programs by distributing compounded medications that weren’t medically necessary, officials stated.

According to Justice officials, Walters and his co-conspirators:

*adjusted prescription formulas to ensure the highest reimbursement without regard to effectiveness; and solicited recruiters to get prescriptions for high-margin compounded medications, *paid those recruiters commissions based on the percentage of reimbursements paid, including claims reimbursed by Tricare, and set up a system to make it appear that the pharmacies were collecting copayments, while waiving or reducing copayments paid by beneficiaries.

*solicited medical practitioners to authorize prescriptions for high-profit compounded medications, and sometimes paid kickbacks to those practitioners.

The investigation into this specific scheme began in the FBI’s Jackson, Miss., field office. Among the federal agencies that investigated are the Defense Criminal Investigative Service’s southeast field office, the Internal Revenue Service’s Atlanta field office, and the Mississippi Bureau of Narcotics.

The Justice Department Criminal Division’s Fraud Section leads the Health Care Fraud Strike Force, formed in 2007. That has resulted in charging more than 4,200 defendants who have collectively billed Medicare for about $19 billion, according to Justice officials.

In May, 2015, a Tricare policy change required screening of all ingredients in the compounded prescriptions and rejecting any that contained non-FDA approved ingredients. These prescriptions were increasingly costly to the Defense Health Agency, which spent nearly $1 billion on compounded prescriptions in the first four months of 2015 alone.

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Some military families and retirees can add Tricare to their list of costs that are increasing in the current economic environment.

Generally speaking, if a Tricare beneficiary paid out of pocket for Tricare before, that cost will be going up. Active-duty families in Tricare Select will see some increases in co-payments, generally by a few dollars, starting Jan. 1, 2022. There are also increases coming in co-payments and annual enrollment fees for retirees, their families and others, according to fee schedules just released by the Defense Health Agency.

These cost increases don’t apply to active-duty families in Tricare Prime, who only pay when they get care without a referral, use non-network providers without authorization, or use a pharmacy other than a military pharmacy. There are no charges to active-duty members for any type of health care.

The Tricare open season began Monday and ends Dec. 13. This is the only time of year when you can make changes to — or enroll in — Tricare Prime or Tricare Select, outside of a qualifying life event such as marriage, birth of a baby, or retirement from active duty. You can also switch plans entirely. Changes you make go into effect Jan. 1, 2022. Visit www.tricare.mil/openseason for more information and to make changes.

If you’re not already in a plan and don’t enroll during open season, you’ll only be eligible for care at a military hospital or clinic — if space is available. Defense health officials advise that even if you don’t plan to make changes in your Tricare coverage for next year, you should check for any cost changes that could affect you.

By law, DoD is required to raise certain beneficiary out-of-pocket cost shares by an amount based on the annual cost of living adjustment for retirees, which is 5.9 percent for 2022. Cost increases also reflect changes in the cost of health care services and drugs, and other factors, according to the Defense Health Agency.

There are also differences in some costs based on when the sponsor entered the military. Those who entered before Jan. 1, 2018, are part of Group A, while those who entered on or after Jan. 1, 2018, are part of Group B.

For active-duty families in Tricare Select, co-payments generally increase by a few dollars for various services. For example, in-network primary care outpatient visits for families in Group A increase by $2, from $22 to $24. For this group, co-pays for outpatient specialty care will increase by $4, to $38. Outside of the Tricare network, the patient pays 20 percent of the cost.

Enrollment fees

There are no yearly enrollment fees for active-duty service members and their family members or for retirees enrolled in the Tricare for Life plan, but there are enrollment fees for other retirees and their families, and those are increasing in 2022.

A working-age retiree in Tricare Prime will pay a $323 annual enrollment fee for an individual, an increase of $20 per year, and $647 for a family, an increase of $41. In Tricare Select, a working-age retiree generally will pay an annual enrollment fee of $158 per individual and $317 per family, increases of $8 and $17, respectively.

Annual deductibles

There are no annual deductibles in Tricare Prime. But there are deductibles for those in Tricare Select, and those costs are also going up for some members. Example: For active-duty family members and Tricare Reserve Select members who entered the military after Jan. 1, 2018, the annual deductible for those in paygrades E-4 and below has increased by $4, to $56, for an individual; and by $7, to $112, for a family. The annual deductible is the amount you must spend before the Tricare cost-sharing begins.

Catastrophic cap

The catastrophic cap is the maximum amount of money you pay out of pocket each year for covered services before Tricare will start picking up 100 percent of the cost. It’s increasing for beneficiaries in most Prime and Select programs, except for active-duty families in Prime and Select who are in Group A, where it remains at $1,000; and retirees in Tricare Prime, Group A, where it remains at $3,000. For active-duty families in Group B, the catastrophic cap has increased by $62, to $1,120.

The catastrophic cap for Group A retirees and their families in Tricare Select increases from $3,500 to $3,706.

Premium plans

Monthly premium costs will increase for the Tricare Retired Reserve plan (about 4 percent) and the Tricare Young Adult plans (12 percent for TYA Prime and 3 percent for TYA Select.) They will decrease slightly for the Tricare Reserve Select plan.

Who can participate in Tricare open season?

Anyone enrolled in or eligible for Tricare Prime, Tricare Prime Remote, Tricare Select, Tricare Overseas Program Prime, Tricare Overseas Program Select and U.S. Family Health Plan are eligible to participate in the open season.

Open season doesn’t apply to active-duty members, who have full health coverage, and it doesn’t apply to retirees who are in Tricare for Life. Coverage is automatic if you have Medicare Part A and Part B.

Those who have premium-based plans — Tricare Young Adult, Tricare Retired Reserve and Tricare Reserve Select — can buy these plans at any time. But those in Tricare Young Adult with the Prime and Select plan options can only change plans during an open enrollment season or qualifying life event.

Tricare Prime is a health maintenance organization-style plan, where you get most of your care from a primary care manager, and referrals are required for specialty care. There is no deductible. Active-duty service members and their family members, and transitional survivors don’t pay enrollment fees or out-of-pocket costs for covered services. Retirees, their families and all others pay enrollment fees and out-of-pocket costs for covered services except for preventive care.

Tricare Select is a preferred provider organization-style plan where you choose your Tricare-authorized provider and don’t have to get referrals for most services. There are deductibles, co-payments and cost-shares.

Drug costs

As previously reported, pharmacy costs will increase in 2022, with co-payment increases ranging from $1 to $8. The increase doesn’t affect active-duty service members, who pay nothing for their covered medications through military pharmacies, retail network pharmacies and through the home delivery benefit. The increase also doesn’t apply to survivors of active-duty service members, or to medically retired service members and their family members.

The military pharmacy is still the lowest cost option for military beneficiaries; there’s no cost for covered generic and brand-name drugs at these pharmacies.

Dental

Family members of active duty, National Guard and Reserve — as well as Guard and Reserve members who aren’t on active duty — are eligible for the Tricare Dental Program, which requires separate enrollment.

Most retirees and their family members are eligible for dental and vision coverage under the Federal Employees Dental and Vision Insurance Program, or FEDVIP, which is administered by the Office of Personnel Management.

The open season for FEDVIP also runs from Nov. 8 to Dec. 13. The same number of vision and dental insurance options are offered for 2022; the cost for the options will increase, on average, by less than 1 percent. There are 23 dental plans offered by 12 carriers, seven of which provide nationwide coverage, while the remaining five offer regional coverage.

If you’re already enrolled in a FEDVIP dental and/or vision plan and don’t want to make a change, your enrollment will automatically continue.

Vision

You must be enrolled in a Tricare health plan to be eligible for FEDVIP vision coverage. Those eligible include active-duty family members, retirees and their eligible family members, and Selected Reserve members and their family members. There are 10 vision insurance plans available from five national providers.

Visit www.benefeds.com to enroll in FEDVIP and to get more information.

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Tricare would only cover the generic versions of Viagra and Cialis under a new policy passed by a Defense Health Agency (DHA) panel Wednesday.

The DHA Beneficiary Advisory Panel, which provides advice and recommendations on what Tricare should cover, voted 6 to 2 for a policy that would also require physicians to prescribe new users generic Viagra before trying generic Cialis to treat erectile dysfunction.

Viagra, generic name sildenafil, tablets are for short-term use, while Cialis, or tadalafil, is considered "long-acting" and can be used to treat an enlarged prostate.

The panel's discussion was mostly about how physicians choose which drug to prescribe first.

"But [physicians] said they need them both," said Charles Hostettler, a panel member representing AMSUS, an organization for military health care professionals, "and yet you're forcing them to use the short-acting first in all cases and which to me just seems to be a little bit strange."

The recommendation to change Tricare's coverage came from the Department of Defense Pharmacy & Therapeutics Committee, which voted last year to modify it after determining that generic and brand-name erectile dysfunction drugs have the same efficacy.

If approved, this policy would also move erectile dysfunction drugs Stendra, Staxyn, Levitra and all their generics to Tier 4 status, meaning they won't be covered under Tricare.

Under the policy change, men who are more than 40 years old will no longer need prior authorization from their doctor for Tricare to cover generic drugs to treat erectile dysfunction; those younger than 40 or who have enlarged prostates will still need authorization.

The recommendation now goes to the DHA's deputy director, who will review and sign off on the new policy on behalf of the DHA director.

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Two U.S. senators have introduced legislation that would let Tricare waive prescription drug copayments for the duration of the COVID-19 pandemic or other national emergency.

Sens. Kyrsten Sinema, D-Ariz., and Roger Wicker, R-Miss., proposed the Tricare Prescriptions Relief Act bill Wednesday to provide financial help for active-duty and retiree families experiencing unexpected increases in prescription drug costs during the pandemic.

Military families and retirees who use on-base pharmacies have no copayments for prescriptions at those facilities. But they do share the cost of their prescriptions at civilian retail stores and through Tricare's mail-order system.

The bill would let DoD waive those fees, which range from $10 to $60 for a 90-day drug supply by mail, and from $11 to $60 for a 30-day prescription at a retail pharmacy. That waiver would stay in effect during the pandemic or other national emergency as declared by the federal government.

"In the wake of a widespread disaster like a hurricane or global pandemic, our military service members, Veterans, and their families should not have to worry about how they will continue to afford life saving treatments," Wicker said in a release.

"Ensuring Arizona Tricare recipients can receive their prescriptions outside of military clinics at no added cost helps keep Arizona military families and retirees safe during the ongoing coronavirus pandemic," said Sinema.

A similar bill has been introduced in the House by two Democrats, Reps. Elaine Luria of Virginia and Lisa Blunt Rochester of Delaware.

At the height of social distancing measures during the coronavirus pandemic, Defense Health Agency officials encouraged Tricare beneficiaries to switch to mail order, which carries lower copayments than retail stores and offers the convenience of home delivery.

Base restrictions and reduced staffing also made it more difficult for some beneficiaries to pick up prescriptions at military pharmacies. Although some established temporary drive-up or curbside service or changed hours to accommodate patients, some limited operations only to active-duty personnel or closed temporarily.

Beneficiaries who also take medications needed for COVID-19 patients and use mail order also saw some of their copayments triple when Tricare limited prescriptions of certain drugs to a 30-day supply. Previously, beneficiaries could receive a 90-day supply of these medications for the same copay.

Defense officials announced in May that it would limit prescriptions of albuterol and levalbuterol, also known by the brand names ProAir, Proventil, Ventolin and Xopenex, as well as hydroxychloroquine, also known as Plaquenil, to prevent shortages.

Tricare beneficiaries also told Military.com that other medications were on the limited supply list, such as fluticasone, also known as Flovent or Flonase. The corticosteroid reduces inflammation of the nasal passages.

Retired Marine Corps Maj. Mike Snyder said he received a 60-day supply, rather than his usual 90-day supply, without warning.

"I only get a two-month supply and then I have to renew in 30 days for another two-month supply as long as this restriction is in place. What that means is that I will pay two copays and only get half the product I'm supposed to," Snyder said.

The bills circulating in the House and Senate would give DoD the "flexibility they need to waive cost sharing requirements," since the department is not allowed by law to change Tricare copayments.

But they would not require the DoD to waive the fees, and, if made into law and the Pentagon decided to institute the copayment waiver, would not be retroactive.

Still, with no end in sight for the national emergency and when planning for future disasters, DoD should have the ability to change the copays if needed, the lawmakers said.

"Forcing our service men and women to make the decision between saving money and their health is wrong," Blunt Rochester said. "This is the least we can do for those who have served our nation."

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Service members will no longer need a waiver to get laser treatments for severe razor bumps at a civilian facility.

The Defense Department announced Dec. 17 that Tricare will cover claims filed by active-duty personnel who require laser therapy for pseudofolliculitis barbae, or PFB, from a non-military provider.

The change, which is backdated to July 17, 2019, follows the Navy’s termination earlier this year of its permanent no-shave chits for sailors with the condition.

Sailors had been allowed to request a waiver to a military requirement that all personnel be clean-shaven, but Navy leadership decided to scrap the practice, citing two Naval Safety Center reviews that found beard growth can obstruct the seal of face masks, potentially exposing service members to hazardous and lethal conditions.

“We are ensuring that all our sailors will remain safe in the operational, maintenance and training environment that they’re under,” said Rear Adm. Jeff Jablon, director of the military personnel, plans and policy division within the Office of the Chief of Naval Operations.

Under the new Tricare policy, active duty service members with PFB who have not responded to conventional treatment and receive a recommendation from a military dermatologist may be able to receive laser therapy off-base.

PFB is an inflammatory condition caused by ingrown hairs and irritation stemming from the process of shaving. It is more common in men of African and Asian descent, and an estimated 60 percent of African-Americans have the condition.

Several studies estimate the prevalence of PFB among black recruits and soldiers to be between 45 percent and 83 percent.

Roughly 6,000 sailors have sought medical treatment for the condition; data for members of the other military services was not readily available during the holiday break.

While the condition can be treated with topical ointments, chemical peels and steroids, removal of the hair follicle is considered to be among the most effective treatments, but therapies, including waxing and electrolysis, can be painful, expensive and cause unwanted side effects.

Laser treatments can thin and destroy the hair, reducing the chance of recurrence.

The new policy only applies to service members on active duty; Tricare does not cover most laser treatments, including those for hair removal and skin care, for other beneficiaries, including retirees and family members.

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Military families are worried that with changes coming to the military health system that include outsourcing some care to community providers, they won't be able to find quality providers or access decent care.

In some locations, families already are facing problems, said members of the Defense Department's Military Family Readiness Council Wednesday. For example, at Newport, R.I., military personnel face difficulties finding good pediatricians for their children, while in Europe, service members and their dependents have had trouble accessing mental health services, including via telemedicine.

They also worry that as the Defense Department pursues plans to restructure the military health system, the problems will get worse.

"We are having difficulty finding quality providers that are in the network. Is there anything being done to encourage civilian providers to participate with Tricare, or is there any real incentive for them to work with Tricare?" asked Jill Waters, a pediatric nurse and wife of an Army recruiter in Michigan, speaking to Defense Health Agency Director Lt. Gen. Ronald Place.

"We're just not sure what the future will hold," added Carolyn Stevens, director of DoD's office of Military Family Readiness Policy.

Since 2013, the Defense Department has undertaken efforts to restructure what was once a $50 billion health care system. The stated goal of the effort is to improve services while reducing costs by cutting redundant programs and systems that existed in triplicate under separate Army, Navy and Air Force medical commands.

But that effort grew substantially under the fiscal 2017 National Defense Authorization Act, which gave administrative authority of military hospitals and clinics to the Defense Health Agency and subsequently realigned the service medical commands to shift their focus toward caring primarily for active-duty personnel.

The transformation plans call for reducing the number of civilian beneficiaries, including retirees and their family members, seen at military hospitals in locations where comparable health care services are available in the local community under Tricare.

But as DHA and the services pursue these sea changes, troops and families are trying to sort out what health care services will be available down the road.

Sergeant Major of the Marine Corps Troy Black said Wednesday that changes at Naval Hospital Beaufort, S.C., which serves Marine Corps Recruit Depot Parris Island, have put the Marine Corps in the position of relying on community care for its recruits.

The aging hospital facility had already closed its emergency room and urgent care facilities. Under the DHA transformation plans, it’s slated to become an outpatient ambulatory care clinic with no overnight beds.

Marine officials have been concerned that personnel will face long wait times for emergency care at the local hospital or recruits will need to be transported to major medical centers farther away.

"I use [the recruit depot] as one example to highlight some of the challenges we're looking at with network care... having to rely on a civilian facility, there are challenges," Black said. "As we go through this over time, as we develop, how do we see this as being a priority? How does the military leadership influence the civilian leadership of those hospitals? How do we balance out major level training as a priority, accessions as a priority?" Black said.

Families also said they not only had questions about access to care but how they were supposed to meet military medical requirements such as being cleared for travel for overseas orders or qualifying for the Exceptional Family Member Program under a new system.

Place sought to assuage concerns, first noting that he, his wife, children and grandchildren are all beneficiaries in the military and Tricare systems.

"When I look at quality in our system, safety in our system, access or transparency, everywhere I look, I look at it as a surgeon, but I look at it as a patient, as a husband, as a parent and as a grandparent... I also understand the stress the entire family bears," he said.

He added that medical requirements for families will be improved once the process for meeting them is standardized across the services -- one of the goals of transformation.

"We're not there yet, but I fully understand the requirements to the Defense Health Agency standardize the process,'' Place said.

Regarding concerns over the availability and quality of providers in the Tricare networks, Place said several regulations restrict DoD's ability to recruit doctors or work with hospital systems directly, including on the contracts for managed care with Humana Military and Health Net Federal Services, the companies that oversee Tricare, and reimbursement rates linked to Medicare rates.

"In general, Those hospitals and doctors... that are in our networks are doing it out of a sense of patriotism. They are not making huge cash off of us," Place said. "We try to extol the virtues of our patient populations, that they are generally healthy, that they are motivated, that they are patriotic themselves. [And] in many areas of the country that's actually a successful marketing tool for which we are able to get high quality hospitals and practitioners. The limitations [are] where the market is tight, [the rates] can harm us."

How the COVID-19 pandemic will affect the system's overhaul has yet to be determined. On March 25, Defense Health Agency officials said they decided to delay the next step in the reforms -- establishing administrative markets responsible for military treatment facilities in five regions across the U.S.

But Place said he wishes the transformation could move more quickly and the plan will maintain "greater access to high quality care for every single beneficiary."

After the meeting -- the first Military Family Readiness Council meeting held virtually -- Patty Barron, a council member and director of the family readiness directorate at the Association of the United States Army, said she appreciated Place's overview but said military families are craving specifics.

She added that the "'What's next?' was not answered."

"Military families will deal with what you tell them if you can be as specific as possible," she said, saying she was speaking as a spouse and not for the council. "What we need is a FAQ on this. We have one for COVID-19, why not for this?."

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“Plan for what is difficult while it is easy” is an apt quote regarding healthcare in general and Tricare in particular. If you’re transitioning out of the military, it’s important to know your responsibilities and form a strategy well in advance of your separation date.

Plan ahead before you leave

It’s recommended to start scheduling you and your family’s Tricare coverage planning at least six months before retiring. Necessary medical exams, researching different coverage options and plans that may be a better fit due to a new location are part of the prep-work. Re-enrolling in an existing plan, changing plans, and paying enrollment fees are just some of the changes you should be prepared to meet.

Schedule your exit medical exam as early as possible

To ensure proper healthcare after you separate, it’s essential to be on top of your Separation Health Assessment while you’re still active duty. The exam must be performed at a military hospital, military clinic, or VA facility 90 days before retirement and terminal leave. If you plan on filing claim with the Department of Veterans Affairs, calendar the exam earlier than 90 days. While the VA refers to the exam as the “disability exam,” all active duty are required to take it on the way out.

The separation health assessment tracks your medical history and your current health. Prior to the exam is the time to prepare and review your medical history and check to see it’s complete and correctly notated in your file, specifically injuries and medical concerns identified during your military career. You’ll need to complete a “Report of Medical History” or DD Form 2807-1 form before your exam.

You must re-enroll in Tricare

Upon retirement, you and your family’s status and plan options change; use vigilance to avoid a break in coverage. Re-enrollment in your chosen Tricare plan is usually required within 90 days after your retirement date from active duty — whether you’re planning to keep the same type of plan or not.

Even if you’ve already enrolled in Tricare Prime or Tricare Select, you must re-enroll. You and your family will need to arrange for new ID cards, and some beneficiaries may have to begin paying an annual enrollment fee.

If you miss the 90-day deadline, retroactive enrollment can be requested within 12 months of your retirement date. If approved for retroactive coverage, your enrollment fee or fees are also calculated retroactively to your retirement date.

If you miss the 12-month deadline, you may only re-enroll during Tricare Open Enrollment Season or if you or a family member experience a Qualifying Life Event, such as moving, marriage, or the birth of a child. Know you plan, in some plans the move must be relocation to a new country.

Expect changes in your Tricare when you retire

While on active duty, there are no out-of-pocket expenses, and family costs are minimal. But a retiree should expect to encounter costs. Depending on your current Tricare plan, they may include:

• Annual enrollment fees and copayments for Tricare Prime.
• Higher copayments and cost-shares for Tricare Select.
• Possible higher prescription costs.
• Catastrophic cap increases.

Be advised that hearing aids and chiropractic care are not covered under Tricare. However, an additional premium-based dental plan may be available to most military retirees thru the Federal Employees Dental and Vision Insurance Program (FEDVIP). Eligibility can be determined through the FEDVIP website.

The five Tricare plans for retirees and their families

There are five Tricare health plans available to Veterans and their families after retirement; each fulfills different needs and operates under different qualifying parameters. The five plans are Tricare Prime, Tricare Select, US Family Health Plan, Tricare for Life, and Tricare Select Overseas.

The Tricare Prime plan is a managed care option available in what is called a prime service area. These are areas where military hospitals and clinics are within specific geographic proximity to the sponsor or beneficiary. DriVetime and distance relative to the Primary Care Manager (PCM) determine your eligibility for this plan. Some exceptions allow a waiver of the distance requirements. Tricare Prime is further divided into three programs, Prime Remote, Prime Overseas, and Prime Remote Overseas. These plans cover rural areas and areas over a certain distance from providers, here and abroad.

The Tricare Select plan is a self-managed, preferred provider organization plan available only in the United States. An enrollment fee and annual deductible are required, and cost shares apply for covered services.

The US Family Health Plan is an additional Tricare Prime option available through community-based networks in not-for-profit health care systems. The plan is only available in six specific areas of the United States. The areas range from the Northeast to Texas and Louisiana, but only those geographical areas are covered.

The Tricare For Life plan is for eligible beneficiaries who have both Medicare Part A and B. Coverage is automatic. There is no enrollment form required. You’re covered under the Tricare for Life plan if you already qualify for Tricare in DEERS and are entitled to Medicare Part A and Medicare Part B. However, it is crucial that you routinely monitor your DEERs information to keep it updated and current

The Tricare Select Overseas plan provides comprehensive coverage in all overseas areas.

To access this plan, you must first register with the Tricare Select plan and then move on from there. Enrollment is required.

Special programs designed to fill Veteran healthcare gaps

The Transitional Assistance Management Program (TAMP) covers those facing involuntary separation. Sponsors and family members who are eligible can choose from any of the five Tricare plans under TAMP and also have access to military hospitals and clinics. The program’s coverage is limited to 180 days.

The Continued Health Care Benefit Program (CHCBP) is a premium-based plan that straddles the interim period between military benefits end and civilian health plans begin. The CHCBP provides temporary health care coverage that lasts from 18 to 36 months after you lose eligibility for Tricare. It offers the same coverages as Tricare select.

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