TRICARE Standard vs. TRICARE Prime For Pregnancy

November 3, 2015

Pregnant military spouses who live within the 40-mile catchment area of base hospitals have been a captive population for base obstetricians for years. If the woman is enrolled in TRICARE Prime, the military’s managed care network, prenatal care, delivery, and postnatal care, by definition, are managed by TRICARE to take full advantage of available base obstetric staff and resources.

If the woman isn’t enrolled in Prime but instead uses TRICARE Standard, the military’s fee-for-service insurance, she still can be pulled into the military hospital for obstetric care, even if her reason for choosing Standard, with its higher out-of-pocket costs on most services, was to be able to choose her own civilian doctor.

Why does this happen? Under TRICARE rules, Standard patients residing near a base must get a non-availability statement (NAS) from the base hospital confirming that the care they seek for major procedures is not available from the military. Otherwise, Standard coverage can be denied.

This NAS requirement has angered many beneficiaries, but it can be particularly irksome for expectant mothers because military hospitals, in general, have done of a lousy job staffing and modernizing their female health care facilities. The NAS requirement can interrupt continuity of care, generally prized for patient health, when it’s more efficient for the military to assume obstetric care.

Congress heard enough complaints that in 2001 it changed the law, setting a two-year fuse. Effective December 2003, expectant mothers who use Standard no longer will have to seek care first from the base hospital. They can stay with their civilian physician of choice.

The military obstetrics community is worried, not only about losing access to Standard patients but by the real possibility that many pregnant Prime patients also will drop out of the managed care network to receive care instead from civilian physicians.

Why would they do that when Standard costs so much more than Prime coverage? Wouldn’t these women have to pay the usual Standard annual deductible plus 20 percent of allowable charges?

The answer for active duty family members is no.

Those who use Standard for prenatal care face no co-payments and pay only $25 of the cost of delivering a baby in a civilian hospital. Congress set up this special deal for spouses of active duty members several years ago. The goal was to protect families of recruiters, ROTC instructors, and other members on remote stateside assignments from hundreds of dollars in out-of-pocket Standard costs resulting from pregnancies and childbirth.

The discounted Standard rates for pregnancy coverage are not limited to remote assignments. Indeed, they remain in effect for active duty dependents at any location, even though Congress has approved a TRICARE Prime Remote program extending managed care benefits to remote families.

If this doesn’t change and the NAS requirement ends, the military obstetrics community fears losing one-third to one-half of their current patient load, which will adversely impact on doctor skills, female health care, and medical readiness. The surgeons general are pressing for relief from Congress. They hope lawmakers either will extend the NAS requirement on obstetric care for another year to give base hospitals more time to modernize and staff up to compete with civilian doctors for expectant mothers, or lawmakers will “level the playing field” on Standard costs by re-imposing the routine co-pays on off-base obstetric care to active duty families.

Meanwhile, base hospitals are scrambling to improve prenatal care and other female care programs. That’s what they should have done years ago, says Joyce Wessel Raezer, director of government relations for the National Military Family Association in Alexandria, VA.

“They’ve had a lot of problems with how they treat women,” Raezer says. “They yank you in when you’re pregnant, but I’ve got women telling me they can’t get routine appointments.”

At some base hospitals, she says, obstetrics facilities “are awful” with four women and their babies sharing one room and without the benefit of private showers.

That’s changing, finally, now that military obstetrics programs are at risk.

By Tom Philpott

Devin Joy
djoy@incharge.org

Devin is a graduate of Valencia College in Graphic and Interactive Design. Devin has over ten years of experience designing educational and inspiring materials for print, web and other media.