Health Care Committee Goals
Top Legislative/Policy Goals
119th Congress
(As of 12/5/2024)
Principles, Positions and Goals
The military healthcare benefit is a commitment a grateful nation makes to service members, their families, retirees and survivors. For the currently serving, TRICARE is vital to servicemember and military family readiness. For military retirees, decades of service and sacrifice constitute a large, pre-paid, in-kind premium that warrants low cost-sharing for a top-tier benefit.
Disproportionate out-of-pocket cost increases that reduce the value of TRICARE after service members have fulfilled their commitments are unacceptable. Similarly, TRICARE must maintain robust provider networks and keep pace with coverage offered by top commercial plans to deliver the world class health care promised to service members, retirees, their families and survivors.
Specific positions and goals include:
Control TRICARE Fees
Improve Access to Care
1. DoD Statement to SASC Personnel Subcommittee – FY 2025 Defense Personnel Posture Hearing, page 5 – May 8, 2024
2. Disproportionate = greater than military retired pay COLA
TRICARE Pharmacy Program
119th Congress
(As of 12/5/2024)
- Improve access to care within the destabilized military health system (MHS) by securing more effective beneficiary resources for reporting and getting assistance with barriers to access; TRICARE policy flexibility to seek care where it is available; and greater visibility on access metrics.
- Align TRICARE coverage with new technology/evolving treatment protocols and benchmarks established by top commercial plans/other government payers.
- Ensure the TRICARE Pharmacy retail network is on par with top health care plans and meets both the acute and maintenance medication needs of all TRICARE beneficiary segments including rural families, long-term care facility residents, and patients who rely on specialty, compound, or infusion medications.
- Block any legislation or policy change that would impose new TRICARE fees or disproportionately increase enrollment fees, deductibles, copays/cost shares or the catastrophic cap without grandfathering current service members and uniformed services retirees.
- Monitor the beneficiary experience and provide feedback to managed care support contractors and the Defense Health Agency (DHA) to ensure T-5 transition disruptions are addressed quickly and effectively.
Principles, Positions and Goals
The military healthcare benefit is a commitment a grateful nation makes to service members, their families, retirees and survivors. For the currently serving, TRICARE is vital to servicemember and military family readiness. For military retirees, decades of service and sacrifice constitute a large, pre-paid, in-kind premium that warrants low cost-sharing for a top-tier benefit.
Disproportionate out-of-pocket cost increases that reduce the value of TRICARE after service members have fulfilled their commitments are unacceptable. Similarly, TRICARE must maintain robust provider networks and keep pace with coverage offered by top commercial plans to deliver the world class health care promised to service members, retirees, their families and survivors.
Specific positions and goals include:
Control TRICARE Fees
- Maintain TRICARE Prime as a zero out-of-pocket cost option for active duty families.
- Grandfather current servicemembers and retirees to protect against new TRICARE fees or disproportionate fee increases, including:
- Unprecedented TRICARE for Life enrollment fees or cost sharing proposals
- Disproportionate increases to TRICARE fixed dollar cost sharing including enrollment fees, deductibles, copays, and the catastrophic cap
- Higher percent cost shares or new deductibles specific to non-network care
- Urge DoD to implement a tiered specialty care copayment structure that reduces TRICARE copays for mental health and physical/speech/occupational therapy visits.
Improve Access to Care
- Align TRICARE coverage with new technology/evolving treatment protocols and benchmarks established by top commercial plans/other government payers including:
- Premium free TRICARE coverage for young adult dependents up to age 26 to align with - Affordable Care Act (ACA) requirements
- Non-pharmaceutical pain management treatments including chiropractic and acupuncture
- Assisted reproductive technology (ART), including in vitro fertilization (IVF)
- Zero copays for pharmaceutical contraception to align with ACA requirements and CHAMPVA coverage policy
- LEQEMBI, an FDA-approved treatment for Alzheimer's disease covered by Medicare and FEP Blue since July 2023
- Lab developed tests, including diagnostic genetic testing
- Expanded eating disorder treatment coverage
- Omnipod 5 for Type 2 diabetics
- Litfulo/JAK inhibitors for the treatment of alopecia areata
- Chronic Care Management (CCM) services
- Extend coverage for eligible children of veterans’ families until age 26 under CHAMPVA to align with ACA requirements.
- Expand TRICARE Qualifying Life Events to include pregnancy and dissatisfaction with the military treatment facility (MTF) to allow pregnant beneficiaries and/or those dissatisfied with the MTF to seek care in the civilian network by switching to TRICARE Select.
- Require DoD to establish a well-publicized digital access assistance system allowing TRICARE beneficiaries to report access challenges and receive help navigating the MHS. Mandate an annual report to Congress on the number and types of beneficiary access complaints (disaggregated by MTF/Prime Service Area to provide actionable data) and steps taken to address systemic access problems.
- Drive greater congressional oversight and DHA accountability through visibility on access-to-care metrics including:
- Increased MTF-level transparency data, starting with pediatric primary and prenatal care access measures
- A GAO evaluation of TRICARE network adequacy at the market level for pediatric and adult primary care, including OB/GYN
- Monitor the beneficiary experience and provide feedback to DHA to ensure T-5 transition disruptions are addressed.
- Protect TRICARE Prime referral-free urgent care that has served as a critical primary care relief valve for the destabilized MHS (FY2017 NDAA Sec 702).
- Mental Health Care Access: Urge Congress to request more information on the ”notable disconnect between the positive assessments given by DHA and TRICARE representatives and concerns expressed by the DoDIG and by TRICARE patient advocate groups” as reported by the Defense Health Board’s 2023 Beneficiary Mental Health Care Access Report.
- Ensure service members and their families stationed in isolated, remote and rural locations have an adequate TRICARE network and/or sufficient MTF presence to ensure access to care.
- Monitor competitive plan demonstrations and the move to alternative payment models, including value-based care, to prevent negative impacts on access, cost, or quality of care for TRICARE beneficiaries.
- Advocate for improvement of case management services for medically complex beneficiaries or those with serious or chronic medical conditions.
- Address recommendations made by the Defense Health Board’s Pediatric Health Care Services Report including:
- Urge TRICARE to adopt a pediatric definition of “medical necessity” to address pediatric care within the MHS/TRICARE that is variable and not always aligned with accepted best practices
- Establish accurate and consistent tracking and reporting of metrics across the system to ensure delivery of cost effective, quality care to all pediatric beneficiaries
- Ensure health care benefits pertain equally to all eight federal uniformed services, including the USPHS Commissioned Corps and NOAA Commissioned Corps, and all sponsor segments including retirees.
1. DoD Statement to SASC Personnel Subcommittee – FY 2025 Defense Personnel Posture Hearing, page 5 – May 8, 2024
2. Disproportionate = greater than military retired pay COLA
TRICARE Pharmacy Program
- Prevent disproportionate TRICARE Pharmacy copay increases by achieving legislation limiting DoD’s authority to increase pharmacy copays (FY2018 NDAA, Sec 702) or blocking proposals for disproportionate pharmacy copay increases.
- Ensure the TRICARE Pharmacy retail network is on par with top health care plans and meets both the acute and maintenance medication needs of all TRICARE beneficiary segments including rural families, long-term care facility residents, and patients who rely on specialty, compound, or infusion medications.
- Protect the MTF pharmacy benefit by opposing any effort to charge fees or copays at MTF pharmacies or reduce eligibility to use MTF pharmacies.
- Require DoD to track beneficiary satisfaction and prescription drug availability with the TRICARE Pharmacy Home Delivery program.
- Advocate for copay flexibility when TRICARE Pharmacy Home Delivery cannot fill a prescription or provide a full supply due to out-of-stocks or other limitations.
- Ensure TRICARE utilization management policies (prior authorization/step therapy, medical necessity, quantity limits) are in line with commercial plan best practices and allow beneficiaries to access essential medications.
- Provide oversight on DoD implementation of appeals process for TRICARE Tier 4 drugs required by FY 2022 NDAA SASC report language.
- Provide oversight of updated TRICARE Dental Program implementation (FY2023 NDAA, Sec 701) to ensure robust networks and at least one plan aligned with current premium, cost-sharing, and coverage options.
- Seek legislation to reinstate TRICARE benefits for remarried survivors when the subsequent marriage ends consistent with CHAMPVA policy.
- Simplify TRICARE for retirement eligible National Guard and Reserve service members:
- Provide an affordable TRICARE option for Reserve Component retired service members at the same subsidized premium rate as other retired members.
- Provide premium-free, zero cost-sharing medical and dental coverage for Selected Reserve service members eligible for TRICARE Reserve Select (TRS).
- Expand TRS for USPHS Ready Reserve regardless of duty status by replacing the term “Selected Reserve” with “Uniformed Services”. (10 USC 1076d(a))
- Fund TRS for federal employees who are Ready Reservists earlier than fiscal year 2030 (10 USC 1076d).
- Authorize Individual Ready Reservists the option to enroll in TRS as an opportunity to maintain medical readiness for recall/activation. (10 USC 1076d).
- Provide an option for RC service members and families to retain private health coverage under active duty orders in lieu of switching to TRICARE.
- Authorize National Guard members separating from full-time duty (32 USC 502(f)) Transitional Assistance Management Program coverage (10 USC 1145).
- Ensure the new TRICARE Dental Program (TDP) construct includes a provision for activated members as a life event or reenrollment.(10 USC 1076a)
- Ensure the new TDP construct includes continued subsidized premiums currently available to TDP beneficiaries (10 USC 1076a)
- Ensure any proposed changes to the direct care system of military hospitals and clinics – including medical billet cuts, any other uniformed/civilian/contracted medical personnel reductions and/or military treatment facility downsizing or closures – allow the MHS to fulfill its dual mission of readiness (ready medical force/medically ready force) and beneficiary care provision.
- Seek full implementation and interoperability between VA and DoD electronic health records, including exchange of digital images and imaging studies.
- Require DoD to conduct a pilot program offering cryopreservation of service member gametes prior to a combat deployment.
- Advocate for continued expansion to non-medical counseling through programs such as Military Family Life Counselors and Military OneSource. Support funding for the Uniformed Services University of Health Sciences as the prime educator of military health providers, which is essential to the uniformed provider pipeline and increases the number of culturally competent providers for military beneficiaries.