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Insurance News and Issues


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Higher Premiums,Fewer Insurers Mar 2000 Federal Health Plan

They should be so lucky.  Most people who are fortunate enough to have
insurance at all pay a heck of a lot more for a heck of lot less.  Gee, wanna
bet all of a sudden we'll start hearing about "medical reform" now that the
fat republicans suddenly have to pay a few dollars more?  Gouge and
gouge until they finally squeeze the the hands that feed them. Then maybe
the rest of us will some relief from the massive health costs we've been
enduring for the past few decades.

ellis

October 29, 1999
Higher Premiums, Fewer Insurers Mar 2000 Federal Health Plan
  By Douglas J. Gillert
  American Forces Press Service

  WASHINGTON -- The Office of Personnel Management hasn't been
  able to keep the lid on cost increases to the Federal Employees
  Health Benefits Program, which will rise an average of 9.3
  percent this year.

  As OPM frets over how to control the rising cost of health
  insurance for the nations' millions of federal employees, it
  also has seen 43 insurers from last year's plan drop out.
  Officials said the dropouts will affect more than 40,000
  civilian employees who will have to find a new carrier for 2000.

  These changes were announced as the FEHBP open season, which
  runs Nov. 8-Dec. 13, drew near.

  "It is clear that competition in the marketplace has not
  effectively slowed the growth in FEHBP premiums," said OPM
  Director Janice R. Lachance. OPM administers the health plan for
  federal employees and retirees. "We must consider new and bold
  approaches so we can continue providing affordable, high-quality
  health care to our employees, retirees and their families."

  Lachance said the increases this year and the past two years are
  unacceptable. This year's rate increase follows a 9.5 percent
  increased in 1999 and a 7.2 percent increase in 1998. To control
  future increases and improve the program overall, Lachance said
  OPM will submit legislative proposals early next year to improve
  the quality and cost effectiveness of health plans by raising
  the standards for participating health insurers. She also hopes
  to make the plan more efficient.

  Lachance was scheduled to discuss improvements during a panel
  discussion at the American Association of Health Plans quality
  and information conference in Palm Springs, Calif., Oct. 29. She
  was expected to address customer service, quality care and
  value-based purchasing with association members. Based in
  Washington, the association represents more than 1,000 health
  maintenance organizations, preferred provider organizations and
  other network-based plans.

  No reason was given for the 43 insurers that dropped out of the
  plan for 2000. However, OPM said the insurers were required to
  notify their members that they need to select a new plan during
  the open season.

  "Military Report," an on-line newsletter posted a list of the
  dropouts on the Internet its Sept. 23 edition at
  www.militaryreport.com/healthins.htm.

  In 2000, biweekly premiums will average $30.10 for individuals
  and $64.67 for families. All participating insurers and premiums
  are listed on the OPM Web site at
  www.opm.gov/insure/00rates/index.htm.

************

October 27, 1999
TRICARE Puts Remote Locales on Prime Time
  By Douglas J. Gillert
  American Forces Press Service

  WASHINGTON -- More than 80,000 active duty service members
  previously excluded from TRICARE Prime health care benefits
  because of their duty location now have Prime access.

  Enrollment in TRICARE Prime Remote began Oct. 1, and by Jan. 1,
  2000, officials expect to have reached most active duty service
  members not covered by Prime benefits. This includes recruiters,
  ROTC instructors and staff, communications specialists, officers
  enrolled in education programs with industry, acquisition
  specialists and others assigned away from military installations.

  Fiscal 1998 legislation mandated development of the Prime Remote
  benefit to bring all active duty service members under the Prime
  umbrella. A key issue is ensuring remotely assigned individuals
  meet fit-for-duty requirements and are qualified for worldwide
  deployment, said Air Force Col. Rich Bannick, deputy chief
  operating officer of the TRICARE Management Activity.

  To qualify for TRICARE Prime Remote, service members must reside
  and work more than 50 miles from a military medical treatment
  facility. Once they enroll, TRICARE Prime Remote will provide
  active duty service members with a TRICARE Prime-like benefit
  when they're stationed away from traditional sources of military
  health care.

  The benefit also includes complete dental care equal to what
  service members assigned to military installations receive.

  Enrollees in Prime Remote have a couple of choices of where to
  get their health and dental care, Bannick said.

  "We want to be unobtrusive in ensuring they have unencumbered
  access to primary care," he said. "If TRICARE network providers
  are available, that's where we'd like them to go first. But
  there are probably going to be a lot of locations where there
  are no network providers. Then, they can choose any TRICARE-
  authorized primary care provider they wish."

  Bannick added that it's important for new enrollees to select
  health care providers who participate in TRICARE; they'll
  process claims on behalf of the beneficiary.

  Like others in Prime, Remote enrollees will need authorization
  to see a specialist or be hospitalized, Bannick said. They'll
  get that by calling their regional health care finder, listed in
  "Remote Controller," the TRICARE Prime Remote guide issued with
  enrollment forms and also on the <a
href="http://www.tricare.osd.mil/remote"TRICARE Remote Web site</a.

  "By law, this program applies only to active duty members,"
  Bannick said. "Our line leadership asked us to evaluate how this
  program might be extended to family members, and Congress asked
  us to report on how DoD might expand coverage to remote family members."

  That's not to say family members at remote locations don't have
  access to health care, Bannick cautioned.

  "They still have TRICARE Standard (CHAMPUS) coverage, as well as
  access to TRICARE Extra networks in some locations, including
  network retail pharmacies. Also, since July 1998, they've had
  the National Mail Order Pharmacy program for chronic
  medications." TRICARE managed care support contractors also have
  developed Prime networks in heavily populated areas, and these,
  too, are open to family members, he said.

  So, despite base closures and fewer military medical facilities
  in the United States today, Bannick believes health care options
  actually have expanded for family members. "The only thing they
  don't have is a Prime Remote benefit, and we're working on the
  presentation of the issues and options, now," he said.

  Enrollment guides and forms initially were sent to
  geographically separated units, which will continue to be the
  central point of contact for new enrollees. However, individuals
  can also request assistance directly from TRICARE regional
  offices, whose locations and telephone numbers are listed in the
  guidebook and on the Web.

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TRICARE PRIME REMOTE ENROLLMENT OPENS


  = N  E  W  S      R  E  L  E   A  S  E
  =
  = OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE
  = (PUBLIC AFFAIRS)
  = WASHINGTON, D.C. 20301
  =
  = PLEASE NOTE DATE
  ====================================================

  No. 463-99
  (703) 695-0192(media)
  IMMEDIATE RELEASE
  October 5, 1999
  (703)697-5737(public/industry)
  TRICARE PRIME REMOTE ENROLLMENT OPENS
  Dr. Sue Bailey, assistant secretary of defense for Health Affairs,
announced today that thousands of active duty servicemembers who live in the
United States but far from military hospitals and clinics can immediately
enroll in a new program, known as TRICARE Prime Remote.
  TRICARE Prime Remote facilitates access to primary medical care in the
local areas where servicemembers live and work.  Active duty personnel who
live and work more than 50 miles from a military hospital or clinic must
enroll in TRICARE Prime Remote.  In areas where there are TRICARE network
providers, servicemembers can select a primary care provider from the
network as their Primary Care Manager (PCM).  If there are no network
providers, servicemembers may select any local, TRICARE-certified provider.
Servicemembers will no longer need to call the nearest military hospital or
clinic in order to schedule an appointment for primary care services.
  "Our approach in designing the Prime Remote benefit is to focus on the
needs of the servicemembers and their commanders," says Bailey. "We
understand that duty in a remote area brings its own hardships.  So when our
servicemembers are sick, we want them to see their doctors without the
hassle of long-distance phone calls or requirements to travel unreasonable
distances."
  "When specialty care is needed, either the primary care doctor or service
member must call and get an authorization," continued Bailey. "Additionally,
there will be instances when we will need to determine if the medical
condition will impact a member's fitness for duty." Authorization for
specialty care is obtained from the regional contractor.
          "I want to stress, however, that in the event of an emergency,
servicemembers should seek medical care immediately," Bailey emphasized.  In
these cases, pre-authorization is not required, but authorization must be
obtained within 24 hours following the emergency.
  The most important action that servicemembers must take is to enroll in
the program. Units will be receiving enrollment packets that include an
enrollment form for each assigned member. In the event a unit or service
member does not receive an enrollment packet, the service member or
commander should call the regional contractor to get enrollment forms and
other information on TRICARE Prime Remote. These toll-free phone numbers are
listed at the end of this release.
  If servicemembers live in remote areas and have not yet enrolled, they
still have their medical benefits. When they need non-emergency medical
care, they should call the regional contractor at the number below to get an
authorization. The regional contractor will also ensure the service member
receives an enrollment form and other information on TRICARE Prime Remote.
  Under TRICARE Prime Remote, pharmacy and mental health services are
covered benefits.  Pre-authorization for mental health care is required and
may be obtained by calling the toll-free contractor number.  Services such
as toll-free health care information lines, access to preferred provider
networks, utilization of regional Health Care Finders are all services
available to military members in remote areas.  The same TRICARE contractors
that handle family member claims will now handle medical claims processing
services for all active duty servicemembers.
  TRICARE Prime Remote includes dental care benefits.  Servicemembers in
remote areas may obtain care from any licensed dentist (or VA facility where
dental care is available to servicemembers).  Specialty dental care, like
medical care, must be approved before treatment.  However, unlike medical
care, the Military Medical Support Office (MMSO), Great Lakes Naval Station,
Ill., will approve dental specialty care.  The MMSO will also process and
pay all military claims for dental care.
  DoD established the MMSO, a joint service office, as part of the TRICARE
Prime Remote initiative.  The Navy serves as executive agent with medical
representatives from the Army, Navy, Air Force and Coast Guard on the staff.
The MMSO, like the regional contractors, provides 24-hour, 7-day a week
service to military members who have questions about obtaining civilian
health care or who experience an emergency hospitalization.  The MMSO will
help guide callers to the appropriate regional contractor.  The MMSO can be
reached at 1-888-MHS-MMSO (1-888-647-6676) or at their website,
http://navymedicine.med.navy.mil/mmso/ .
  At this time, family members are not eligible for TRICARE Prime Remote.
However, there are some programs for family members in remote areas in
Regions 1 (Northeast), 2 (Mid-Atlantic), 5 (Heartland) and 11 (Northwest).
The Department is studying various options for expanding family member
choices in the coming year.  In the meantime, family members continue to
have TRICARE Standard, and they may use TRICARE Extra in areas where network
providers are available.
  Personnel serving in remote areas overseas will continue to be served by
the TRICARE Overseas Lead Agents (Europe, Pacific, and Latin America) in the
same manner as previously arranged for remote units.
  Additional information about TRICARE Prime Remote can be obtained by
calling the following toll-free numbers, or by visiting the TRICARE Prime
Remote website: http://www.tricare.osd.mil/remote .
  Northeast (Region 1)
  1-888-999-5195
  Mid-Atlantic (Region 2)
  1-800-931-9501
  Southeast (Region 3)
  1-877-249-9179
  Gulfsouth (Region 4)
  1-877-249-9179
  Heartland (Region 5)
  1-800-941-4501
  Southwest (Region 6)
  1-800-406-2832
  Central (Regions 7/8)
  1-877-554-2224
  Southern California (Region 9) and Golden Gate (Region 10)
  1-800-242-6788
  Northwest (Region 11)
  1-800-404-2042
  Pacific (Region 12), Alaska and Hawaii
  1-800-242-6788;
  -END-

  NOTE: This is a plain text version of a web page.
  If your mail program did not properly format this
  information, current News Releases are online at
  http://www.defenselink.mil/news/#BLUETOPS
  ====================================================
  Virtual tour of the Pentagon
       http://www.defenselink.mil/pubs/pentagon/

*************

MILITARY FAMILIES AND DEPENDENTS STRUGGLE WITH MEDICAL INSURANCE

June 9

Just back from Washington D.C. Carrie Sap sends this update. There is nothing more pathetic then a Government that reneges on the families of the men and women who defend it. How cheap and low can it stoop.

ellis

From: Care6211@aol.com

June 1-4, 1999 a small group of military families came to DC to plea for help from the injustices of Military Health Care to the disabled (mostly children) have been refused medically necessary doctor ordered care by Tricare. We met with Tricare and Congressional and Senate staffers. The basis for the refusal was Tricare's custodial care policy. Custodial Care by most guidelines is assistance with activities of daily living (ADL's) Tricare tells us our children and other family members can be refused medically necessary skilled care (defined in their policies) on the basis that they are unable to perform ADL'S for themselves. No matter how medically necessary or how many doctors order the care they are limited to 1 hour a day of nursing and 1 doctor visit a month, medications and supplies. No other group is limited like this. There are 25 cases whom Tricare has made the decision to pay for this care for they are seeking to give these 25 care for life for a service they say isn't a covered benefit because they are "special cases" not necessarily because they need skilled care while they deny doctor ordered skilled care to medically complex children. They continue to say Congress made this decision and they can't pay for custodial care the truth is that

Congress gave the Department of Defense the authority to define the definition of custodial care and the current definition is not consistent with the common definition of custodial care. If you look in DOD and Tricare publication's it is defined in many different ways. Tricare officials have testified to Congress on many occasions and misrepresented this fact. Tricare recipients do not get the same protection those who have employer based health care.

With more than 8 million currently eligible for Tricare who will protect us? We only use the custodial care policy as an example of the injustices. We are being cost shifted to Medicaid being told we need to find other funding for therapy and the list goes on. In a time when retention and are down the families with special needs (expensive care) are told to handle their careers and the family situation or get out. Many families have been threatened if they speak up about the injustices. We need help.

______________________________________________________________________

______________________________________________________________________

Carrie Sapp, Spokesperson for "Casualties of Tricare" is going to Washington D.C. this June in order to lobby congress into abiding by their responsiblities to the U.S. Military's families and dependents regarding Medical Care. She has fought a long and hard personal battle and has now resorted to forming an alliance of other Military Dependents to get the Healthcare and Medical Care they are owed and most certianly deserve.

While their family members are off in a shooting war they should not have to worry about the Medical needs of their families on home front. Please read through the updated issues below and email/fax your Senators and Congressmen to insure they meet with this lady and properly address her concerns. There is no excuse for this kind of treatment to those who are putting their lives on the line for the rest of us.

Ellis

___________

Updated Issues to address

(1) The Military Health Care System (TRICARE/CHAMPUS to contractor to MTF) is focused on doing the minimum to support our Exceptional Family Members (EFMs), rather than giving the maximum support to families that the system allows.

(2) TRICARE management and the contractors hide behind definitions that allow them to give this minimum of care (custodial care definition, therapy limits). Some of these policies allow TRICARE to deny or limit benefits to an EFM because he or she is disabled, or "too sick to get well."

(3) The TRICARE management and contractors ignore definitions in Title 32 that show a clear intent to categorize home nursing care (skilled nursing) as a benefit that TRICARE can (not just should) provide. They do not provide this benefit equally. The squeaky wheel gets the care; those that do not protest get less, or none.

(4) The fight for benefits is an individual responsibility. There is no ombudsman, no government person to intervene, represent, or advocate for the military family with the TRICARE contractor. Families become experts, or they suffer. Complaints about TRICARE are investigated by TRICARE, at its leisure. No agency is available to intervene for families fighting for urgently needed, life sustaining care.

(5) TRICARE benefits are incomprehensible. It is difficult to determine which TRICARE option best serves each family. Families suffer under the mistaken belief that Prime is best - the "Prime propaganda." Some are completely shut out of the MTF because they have little choice but to use Standard because of the specialists they need to see on a regular basis. Special needs military families need the support of the MTF and they need the easy access to outside providers without having to jump through hoops to get referrals or other needs taken care of.

(6) TRICARE wrongly defers treatments and other benefits to Medicaid, making Medicaid a primary provider instead of a provider of last resort. This sometimes leaves families trapped in the state system for care and makes transferring to another state difficult, and sometimes impossible, for families. Families are being separated because they cannot transfer state benefits and they cannot go to a new home with no services for their EFM. Some states have lengthy waits for Medicaid waivers.

(7) No military office or activity provides assistance or liaison for the families when coordinating with other providers or services from federal, state, or local agencies. When moving, this makes it very hard on families. It can take months to get our EFM into the needed network for services.

(8) The military medical community has advised service members to get out of the military to provide better care for their EFMs at a time when retention is critical. Also, some service members have had their careers threatened when they continue to demand their health benefits. Families have been told by their doctors that they were ordered to back off from advocating for their EFM patient or face being discontinued as a provider for TRICARE. Most doctors don't have the time or resources to fight an uphill battle with TRICARE, and so they back off.

(9) Standards of care are being sacrificed in the name of cost effective medical care. It is wrong to deny medical care because it is not cost effective. Many families see case management as money management, with little concern for the patient. The case manager should not be required to show that medical care is cost effective. They should be looking to the best interests of the patient, and not to the cost of necessary, medically apppropriate care. If we used cost effective as the standard of medical care, no one would get appropriate medical care.

(10) TRICARE has used policies to limit or deny medically necessary covered services that have been ordered by the primary physician (TRICARE Authorized) with little accountability to patient well being. Who is responsible if the doctor orders covered services and TRICARE refuses to provide the care? Families are being financially devastated and TRICARE has very little accountability.

(11) Many TRICARE representatives are very uninformed about the benefits available to us and, therefore, many families are not getting the services for which they qualify. We need better trained benefits representatives who are qualified to answer our questions. If the TRICARE representatives don't know what the benefits are, then how are those being served by the system going to get needed information?

______________________________________________________________________

My letter to Congressional offices to request meeting

Dear Honorable Congressperson:

I am writing on behalf of Special Needs Military Families. We have a small group of families who will be coming to inform and educate our representatives and military leaders about how the DOD and its Tricare system are not meeting the medical needs of these special needs children and spouses. Some of us are facing problems obtaining medical care for our families under the Tricare system. In many cases the DOD refuses to provide our families with doctor prescribed, medically necessary and life sustaining care.

We have been told that this limited care is the benefit that Congress had intended for us. We find that hard to believe. Some of us are being pushed to the Medicaid system to obtain medical care. We do not believe it was the intent of Congress for military members who have served and are serving honorably to be left to the “better health care coverage of Medicaid” or for Tricare to be the payer of last resort. Some families are being pressured to put their special needs family members in institutions. Others are being told to get out of the military if they can't handle both their careers and their families demanding medical needs. We will be in the Washington D.C. area from June 1-4, 1999. We would appreciate just a few minutes out of what I know is an extremely busy schedule to discuss with you our specific concerns.

Sincerely,

Carrie Sapp Spokesperson for "Casualties of Tricare" 28103 East 61 Street Broken Arrow, Oklahoma 74014 phone-918-357-5463

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Ellis Smith

smithorg@bellatlantic.net
AMERI - ADVOCATE
Santa Cruz California
AOL-IM SMITHNET2K - ICQ# 22499125
United States



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