Access to Care

Beginning February 20, 2009, the Government mandated new rules regarding “access to care” for all Prime enrollees except Active Duty Service Members.   The new rules indicate Prime enrollees should expect to drive no more than 30 minutes for primary care and no more than 60 minutes for specialty care.

Under the new rules, each Military Treatment Facility (MTF) is authorized to determine if they want to accept enrollments from beneficiaries residing greater than a 30 minute drive time from the MTF.  For those MTFs willing to accept enrollments (outside the 30 minute drive time), the MTFs may specify mileage limits beyond the 30 minutes or may identify specific zip codes.  For those MTFs that are willing to accept enrollment beyond 100 miles, the TRICARE Regional Office must approve. 

If the MTF is an available choice for enrollment, those beneficiaries requesting enrollment to that MTF must sign the Access to Care waiver section of the enrollment form.  When this section is signed, the beneficiary is acknowledging that their drive time to primary care may exceed 30 minutes and drive time to specialty care may exceed 60 minutes.

Access-to-care standards differ for the level of care sought.  For access to primary care, the drive time for TRICARE Prime beneficiaries should not exceed 30 minutes.  For access to specialty care, the drive time should not exceed 60 minutes.

As a new enrollee, how does this impact my ability to choose assignment to the Military Treatment Facility (MTF) if I live greater than 30 minutes drive time?

Each MTF has made a decision on whether or not they will accept enrollees who live outside the 30 minute drive time.  Some MTFs will accept beneficiaries outside the 30 minutes, but residing within a specific mileage from the MTF.  Many of these requests need individual approval.  Some of the MTFs will not accept enrollees outside the 30 minute drive time, thus you will need to choose assignment to a civilian PCM.  Check with your local TRICARE Service Center to determine if assignment to the MTF is possible.

As an existing enrollee, how does this impact my ability to continue assignment to the Military Treatment Facility (MTF) if I live greater than 30 minutes drive time?

If you live within 100 miles of the MTF, you may continue your MTF enrollment if you have signed the Access to Care (ATC) section on the enrollment form (section V).  If you have not signed the ATC section, you will be getting a request from HMHS to sign and return that portion of the enrollment form before your annual renewal of October 1.

What happens if I live greater than 100 miles from the Military Treatment Facility (MTF)?

If you live greater than 100 miles from the MTF, you may or may not be able to continue your enrollment to the MTF.  Each MTF and the TRICARE Regional Office (TRO) will decide whether you will be able to continue your MTF enrollment.  If the MTF and TRO do not approve the MTF assignment, you will need to select a civilian Primary Care Manager (PCM).  If you do not select a civilian PCM, one will be selected for you and you will be automatically assigned.

What happens if I no longer reside in the South region, but I want to continue my enrollment in the South?

You will not be able to continue your enrollment in the South.  You should check with the contractor for your region to see if Prime is available where you live.  If so, you should transfer your enrollment to that region.  If you are unable to transfer your enrollment, you will be automatically disenrolled at renewal time (September 30, 2009).