TRICARE Prime: Move or lose it

By Tom Philpott: CNJ columnist

Retired Navy Corpsman Lloyd Tilch Sr., his wife Debbie and their chronically-ill son Cody pulled up roots last month in Blythe, Calif. They moved into a rented house 110 miles away, near to the Marine Corps base hospital at Twentynine Palms, Calif.

The Tilch family had to move — and had only 11 days to do so after opening a letter from their TRICARE support contractor — to remain eligible for TRICARE Prime, the military’s managed care network, said Debbie Tilch.

As many as 190,000 TRICARE Prime enrollees across the United States have received similar letters.

They advise TRICARE is enforcing a rule requiring beneficiaries enrolled in Prime at a military treatment facility (MTF) to seek a waiver, either from the MTF commander or TRICARE Regional Office, if they live more than a 30-minute drive, or 40 miles, from the base.

Debbie sought a waiver for her family but was turned down. Suddenly she faced a difficult choice: move her family within 30 minutes of Twentynine Palms by July 20 or see Prime coverage end effective Oct. 1.

Without Prime, the family would have to rely on TRICARE Standard, the military’s more costly fee-for-service insurance option.

Many families who received these letters did get a waiver. Others were denied waivers but have decided to allow Prime enrollment to end rather than move families nearer to a base. But Debbie said her family has so many health problems that retaining Prime coverage outweighed her desire to stay in Blythe near to other family member and friends. Three older children have careers there or have started their own families nearby.

But given that her youngest, Cody, has been hospitalized 19 times in the past year alone, and that husband Lloyd, 50, can’t work because of his own fragile health, Debbie worried that staying in Blythe under TRICARE Standard would be both unaffordable and dangerous.

With TRICARE Standard, her family’s out-of-pocket costs every year quickly would hit the $3,000 catastrophic cap that protects retirees.

But more worrisome was the prospect that 11-year-old Cody, coping with “three life-threatening health issues,” might lose access to Prime specialists who have been treating his epilepsy, diabetes and weakened heart for years.

No TRICARE policy official was available to discuss the wholesale enforcement this year of the 30-minute rule across the TRICARE system.

Austin Camacho, spokesman for the TRICARE Management Activity in Falls Church, Va., did explain in an e-mail that the decision, which was made in January, flowed out of a concern for assuring quality care to beneficiaries.

“The change was made after research confirmed a direct correlation between proximity of medical care and quality of medical care,” Camacho wrote. “We determined that to optimize their health care, our beneficiaries need to have a primary care physician near their homes.”