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Tricare Snafus Cause Medical Shortfalls For Military Families

An Army wife was notified last week that her son wouldn't be able to go to his appointment with the pediatric pulmonologist he'd been seeing for the last two years. The medical practice could no longer accept his Tricare insurance under the Defense Department's new Tricare contract with TriWest Healthcare Alliance.

Her elementary-age son has a heart condition, and asthma, and is prone to pneumonia. He is required to see the pulmonologist every six months and can't get a refill for his critical medication until he sees that doctor.

"This is one of the extremely important doctors he needs," she said, crying during a telephone interview Feb. 13, the day she learned her son wouldn't be able to see the provider. "He can't go without this medicine."

The wife, who asked to remain anonymous out of fear of retaliation against her active-duty husband, thought Defense Health Agency officials had provided a solution when they announced beneficiaries in Tricare West would be able to see the specialists if they obtained referrals from their primary care doctors and a waiver letter provided by Tricare officials. The temporary policy change, made in late January, said beneficiaries would not have to wait for TriWest to approve the referral.

But the medical group contacted her on Feb. 13 to say they couldn't see her son for his Feb. 21 appointment without an authorization number from Tricare. They refused the waiver.

She called TriWest again Feb. 18, and after being on the phone from 8:00 a.M. Until about 1:30 p.M. – including being on hold for several hours – she was able to get a referral authorized for her son because of his critical need. The Army wife said the representative took extraordinary measures to get the referral through. It would take at least four months to get another appointment, she said.

Her family has endured a series of problems since the new contract started with TriWest in January, and they are among an untold number of military families and health care providers who have experienced issues.

TriWest HealthCare Alliance took over the Tricare West Region contract on Jan. 1. In December 2022, defense officials announced the awarding of the two new Tricare contracts worth a potential combined $136 billion over eight one-year option periods. Humana Military's contract is worth a potential $70.8 billion, while TriWest's is worth a potential $65.1 billion.

After protest hurdles were cleared, the work on transitioning to the new contracts started in January 2024.

Last year, Defense Health Agency officials assured military families there would be no interruptions to their health care with the new contracts, and they promised the contracts would bring some improvements in their care.

"We are committed to keeping all of our military families informed about your health plan, your choices, and ensuring a seamless transition to new contractors," DHA Director Army Lt. Gen. Telita Crosland said in a May 2024 press release.

But the transition to TriWest from Health Net Federal Services has been anything but seamless, according to multiple military families and health care providers who have contacted Military Times. Those problems have affected patients' ability to get needed care — including a terminal cancer patient whose referrals were lost somewhere in the system.

Since Jan.1, beneficiaries and providers alike have had problems with TriWest's online portal, and many have waited hours on hold with the TriWest call center for multiple days.

Families dropped from coverage

On Jan. 24, when the Army wife took her children to their appointment at their military clinic near Fort Cavazos, Texas, she found out they'd been kicked out of Tricare Prime as of Jan. 1. While she is happy with the care they've continued to receive at the military clinic, she and her sons need to see a variety of specialists.

"They advised us at the appointment that we are no longer Tricare Prime, and we were on direct care, which is almost like not having insurance at all," she said.

Direct care is run on a space-available basis at military clinics. So far, the family has been able to get their primary care at the clinic. Prior to the doctor's visit on Jan. 24, they hadn't been notified of the loss of coverage.

"In November, we were told everyone would be automatically ported over from Tricare East to Tricare West," she said. "For us, and many others, that wasn't the case."

Texas is one of six states that were transferred from coverage under the Tricare East Region to the Tricare West Region under the new contracts. It took three days and multiple phones with TriWest and Tricare for the family to get back into Tricare Prime, the Army wife said.

Getting kicked out of Tricare was only the beginning of the Army family's problems, which have reached a crisis level. Though she received authorization for her son to see his specialist, she also needs surgery for a new condition but is unable to find a doctor who will accept her insurance because of the TriWest problems, the wife said.

The Defense Health Agency announced several steps to help military families deal with the problems, including the waiver that is intended to allow families to see specialists without waiting for TriWest to approve a referral. But as the Army wife and others have found, an unknown number of specialists won't accept the waiver – even for existing patients – because of the difficulties the providers are having with TriWest.

In addition to widespread problems with TriWest's web portal and call-center wait times, other problems reported to Military Times include: receiving incorrect information from TriWest; TriWest taking months to approve contracts for Tricare providers; and providers not being reimbursed for the care they've provided to Tricare beneficiaries.

Because the providers are having these difficulties, some of them are not taking new Tricare patients – and dropping the ones they did have.

"We've been really concerned about all the issues that both providers and beneficiaries are encountering in the East and West regions," said Eileen Huck, acting director of government relations for the National Military Family Association. "We're concerned about the the impact the issues are having on families' access to care, and we're concerned about the impact on the network if providers are not receiving timely reimbursement."

Many providers in the network are small businesses, Huck noted, including some run by veterans and military spouses.

"It's not realistic to expect they can go weeks without receiving reimbursement," Huck said. "We've heard from multiple providers who are either contemplating leaving the Tricare network or having to close their doors."

Problems in the East and West

In statements provided to Military Times, Defense Health Agency officials and TriWest officials said they are aware of the issues. DHA "is very concerned about the issues that have been reported in both the East and West regions regarding provider reimbursements, patient wait times with the call centers and web portal challenges, among others … We understand these challenges and are working hand in hand with both TriWest in the West and Humana in the East to resolve these issues," officials stated.

In the East region, the problems appear to center around providers' lack of payment since Jan. 1. Some providers have told Military Times they are in danger of having to stop seeing Tricare patients, or even shutter their businesses. Humana Military remains the Tricare East contractor, but the company has a new claims processor.

DHA is "aware of the issues Humana has had with their claims processor. They have assured us this is being fixed and we are holding them to the terms of their contract with us," officials said in their statement to Military Times.

Humana officials told Military Times a "small percentage" of providers' records in the claims administration system contained outdated or incorrect data, despite loading all providers' current data into the system in preparation for the new contract.

Claims have started flowing through the processing systems, and payments have begun, officials said. Humana also made the decision to send advance payments "to the most vulnerable providers who have submitted claims," they added.

"Humana Military has identified the root cause of this issue and is working to resolve it and prevent it from recurring," they said Feb. 7. "At this time, we anticipate those remaining issues will be fixed in the next couple of weeks."

Humana officials said providers can submit claims through a clearinghouse, mail, email or fax – if they can't submit them through the provider portal at Humana.Military.Com.

As for the plethora of problems in the West region, DHA officials told Military Times they are monitoring TriWest's performance daily, and are "taking appropriate steps and contract actions to facilitate resolution of all performance issues in the West Region."

In a Feb. 5 response to concerns and questions raised by Rep. Marilyn Strickland, D-Wash., DHA officials said they have have issued a Corrective Action Request for the West region's referral and authorization issues and are considering additional requests.

"We will continue to leverage all available avenues of redress, including negative incentives, under the contract to bring TriWest into compliance with its contractual obligations," officials wrote in their response to Strickland.

TriWest acknowledged the problems in a statement to Military Times.

The company "recognizes there have been a number of challenges associated with this transition, and our sole focus is solving these issues expeditiously and achieving the excellent service our nation's heroes deserve," TriWest officials said. "While some issues will take time to resolve, we are confident in our ability to deliver a successful outcome for America's service members, and we deeply appreciate the Tricare beneficiaries and providers who are working through these issues with us."

For the patient with terminal cancer whose referrals were lost, her referral waiver came in time for her to get the test she needed. But by that time, the patient – a military retiree's wife – had spent 28 hours on the phone with TriWest, much of it spent on hold or in a loop that resulted in no answers, she told Military Times. On Jan. 23 alone, she was on the phone from 9 a.M. To 4:30 p.M.

Medical providers left in limbo

Many medical providers are struggling to get their contracts approved by TriWest to participate in Tricare, despite having completed the necessary paperwork months ago, said Kristi Cabiao, CEO of Mission Alpha Advocacy, an organization that works to improve the quality of life for families in the Exceptional Family Member Program.

And difficulties with getting paid have taken a toll on health care providers in the East region since Jan. 1, Cabiao said. Some providers have had to take out loans to continue operating, while others have been forced to close their doors.

Gabrielle Griffith said her clinic is hanging on by a thread. She owns 850Therapy clinic in Crestview, Florida, which serves the special needs children of service members stationed at Eglin Air Force Base, Hurlburt Field, Camp Bull Simons and other installations in the area.

Unless the payments start coming in on a regular basis, Griffith will be forced to close, she said. Previously, she accepted only Tricare patients, prioritizing serving military families. But recently, she's applied to join the networks of other insurance companies.

"I'm not prioritizing Tricare any more … We're going to have to prioritize the insurance companies that pay consistently and take care of the providers as well," Griffith said.

She fought all through January to get paid for claims, but "when we submit claims they're sitting there in the queue forever," Griffith said.

Under the previous contract, reimbursements for claims typically were deposited in 850Therapy's bank account within a few days after. Now, Griffith said, she's being told the claims are going to take 30 to 90 days to process.

Humana posted on its provider web page that the company is actively working to fix the delay, and it anticipates returning to its standard turnaround time within the next several weeks.

"We don't have several weeks," Griffith said.

Griffith has dropped about 40% of 850Therapy's patients, who numbered more than 400 at the end of last year. She opened the practice in December 2023 and had built her staff to a team of 17 therapists. She now owes the therapists back pay for all of January. She was frank with them about the situation and their options, and some have had to leave for other jobs.

While some money has trickled in for claims for services in 2025 – and Humana sent 850Therapy an advance payment of $15,000 toward unpaid claims – it's not enough, Griffith said. Her overhead costs, including rent and payroll, total between $40,000 to $50,000 each month.

"We do have some movement, but we still don't have answers," she said.

Griffith woke up on Feb. 13 to find another $7,900 deposited into the clinic's bank account after she complained on social media.

In order to keep her doors open, Humana must "completely resume normal payments," Griffith said. "Sending us a little bit is not going to stop me from continuing to fight to get this fixed." With some payments starting to come in on Feb. 18, she said, "I'm hoping this is a move in a positive direction."

Some things are working

Experiences have varied among both beneficiaries and providers. One provider was able to get credentialed by TriWest and negotiate a higher rate of payment than they received under Health Net, the provider told Military Times.

And Army retiree Karl Lamberth said he and his wife found an advocate in the managed-care team at their military clinic at Fort Johnson, Louisiana, who helped them work through the process to get the treatments they needed.

In January, Lamberth's neurologist considered dropping his Tricare patients. Lamberth needed to get treatment for his back, and when he told the head of managed care at the military clinic about the situation, "she lobbied him not to drop his Tricare patients," Lamberth said.

"There isn't a lot of specialized care here, and they don't want to lose the specialists they rely on," he said.

When Lamberth told his neurologist about the waiver letter offered by Tricare officials, the doctor didn't want to accept it.

"He said, 'Oh, no, no, no,'" Lamberth said. "I think part of their hesitation is that they don't know if they're going to get paid."

The leader of the managed-care team somehow got a referral through, and Lamberth was able to receive his back treatment.

"I don't know how she did it, because we had been dead in the water for over two weeks and couldn't get any response from anybody or anything," Lamberth said. "This whole thing with TriWest, it just seems off, the way it's broken. How in in the world did something like this happen?"

Defense officials and the managed-care contract providers had at least one year to prepare for the transition.

"Once this all get sorted, there has to be some kind of review into what happened and where things fell apart," said Huck, with the National Military Family Association. "At some point, there will be another contract transition, and DHA needs to figure out what went wrong so that it doesn't happen again."

Karen has covered military families, quality of life and consumer issues for Military Times for more than 30 years, and is co-author of a chapter on media coverage of military families in the book "A Battle Plan for Supporting Military Families." She previously worked for newspapers in Guam, Norfolk, Jacksonville, Fla., and Athens, Ga.

What Troops And Retirees Need To Know About Tricare In 2025

Note: Whether it's health care, retirement benefits, family support and child care, VA benefits or other programs, getting smart about the rewards you have earned is worth your time. Although it is not yet clear to what extent federal cuts will affect DOD programs — including quality-of-life initiatives — these benefits were in place as of this writing.

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The 9.6 million Tricare beneficiaries have seen changes in the Department of Defense health care program, with new Tricare contracts that were implemented starting on Jan. 1, 2025. The new contractor for the West Region is TriWest Healthcare Alliance. The incumbent contractor for the East Region, Humana Government Business, has continued in that role.

An additional 1.5 million beneficiaries were transferred to the West Region from six states in the East Region: Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin. The West Region now covers 26 states.

The new contracts are designed to bring improvements for beneficiaries, according to defense health officials, such as more efficient health care referral transfers between the two regions; greater provider network flexibility; improved beneficiary choice; and enhanced telehealth appointments.

However, as of March 1, Tricare beneficiaries and medical providers in both regions were still having widespread problems, affecting beneficiaries' access to the health care they need. Defense Health Agency and the Tricare contractors have been working to fix the problems.

Meanwhile, after years of forcing some military beneficiaries to seek medical care in the Tricare private sector network, the Defense Department wants to attract patients back to military treatment facilities.

Citing problems that have led to "chronically understaffed military treatment facilities and dental treatment facilities," then-Deputy Secretary of Defense Kathleen Hicks in 2024 directed sweeping changes to boost staffing at medical facilities and increase access to care for beneficiaries.

A patient undergoes an exam at the Atlanta VA Medical Center. (Atlanta VA Medical Center)

Hicks laid out a plan to grow the number of patients who receive care in a military treatment facility by 7% by the end of 2026, compared to the number of beneficiaries in December 2022. That would mean 3.3 million people would be using the MTFs in three years, according to calculations.

For example, officials are conducting a comprehensive review of all medical manpower and staffing; and plan to shuffle medical personnel to boost capacity at some locations.

Beneficiaries' increased costs in 2025

Some military families saw a rise in their health care costs in 2025. Active duty service members don't have any out-of-pocket costs.

Generally, those who have been paying out-of-pocket for health care under Tricare in 2024 will pay extra in 2025, according to fee schedules released by the Defense Health Agency. For those who make co-payments for covered services such as primary care visits, specialty care outpatient visits and emergency room visits, some co-pays will go up by $1 to $3 a visit.

Family members may have costs, depending on the Tricare health plan they are enrolled in, their sponsor's pay grade and when the sponsor entered active duty, the type of care they get and where they get it.

There are no costs for covered preventive care visits.

Those who pay annual enrollment fees will also see increases. For example, retirees who entered the military before 2018 will pay $744 to enroll their family in Tricare Prime, up from $726 in 2024.

Annual deductibles will increase for some, which means the families will pay more out of pocket before Tricare kicks in. For example, active duty families in Tricare Select whose service member is E-4 and below and entered the military on or after Jan. 1, 2018, will pay $128 out of pocket before Tricare kicks in, an increase of $3 compared to 2024.

Pharmacy costs did not increase in 2025 for Tricare beneficiaries who get their prescriptions filled at a retail pharmacy or through the mail-order program. There aren't co-payments for prescriptions filled at military pharmacies. In February, 2025, Kroger rejoined the Tricare retail pharmacy network.

Wanda Ward, a pharmacy tech at Naval Hospital Pensacola, fills a prescription for TRICARE beneficiaries. (Jason Bortz/Navy)

Active duty members pay nothing for their covered medications through military pharmacies, retail pharmacies in the Tricare network and through the home delivery benefit. The military pharmacy is still the lowest cost option for all military beneficiaries, because there's no cost for covered generic and brand-name drugs at these pharmacies.

Under the Tricare Pharmacy Home Delivery policy, those enrolled in the automatic refill program must approve each refill so that they only receive the medications they need. Express Scripts, the administrator of the program, will let them know by phone, email or text that they have a refill coming up. Enrollees will then log into their account to confirm the prescription.

Tricare expanded the telehealth program during the pandemic to make it easier for military beneficiaries to get care. It now covers telehealth visits over the phone as a permanent benefit. While there was a temporary waiver on patient costs for telehealth during the pandemic, patients now pay cost-shares and co-pays. Telehealth costs are similar to costs for in-person care.

Tricare also covers the use of secure video conferencing to provide medically necessary services, allowing patients to connect with a provider using a computer or smartphone.

Who's eligible?

Tricare offers 11 different options, with choices depending on the status of the military sponsor and the geographic location.

It is open to active duty members; military retirees; National Guard and reserve members; spouses and children registered in the Defense Enrollment Eligibility Reporting System; and certain others, including some former military spouses and survivors, as well as Medal of Honor recipients and their immediate families.

Those entering the military or changing status — for example, from active duty to retired — should make sure they and their eligible family members are enrolled in the Tricare program of their choice. Those who do not enroll may only receive care at a military clinic or hospital on a space-available basis; medical care by civilian providers would not be covered.

The one-month open season begins on the Monday of the second full week in November. During that time, you can enroll in a new Tricare Prime or Tricare Select plan or change your enrollment. If you're satisfied with your current Tricare health plan you don't have to take action.

Nurse practitioner Tiffany Holm performs a routine physical on Willie Benjamin at the Tricare Outpatient Clinic-Clairemont Mesa operated by Naval Medical Center San Diego. (PO2 Chelsea A. Blom/Navy)

By law, there's a strict limitation on switching Tricare plans outside of open season. The exception to that rule is if there is a qualifying life event, such as the birth or adoption of a child, a move to a new duty station, a marriage or retirement. Open season does not apply to active duty members, who have full health coverage, or to retirees who are in Tricare for Life.

Tricare beneficiaries fall into one of two categories set by law:

Group A: Sponsors who entered the military before Jan. 1, 2018, and their dependents;

Group B: Sponsors who entered the military on or after Jan 1, 2018, and their dependents.

Those in Group A and Group B have different enrollment fees and out-of-pocket costs.

Families of active duty, National Guard and reserve service members — as well as Guardsmen and reservists who aren't on active duty — are eligible for the Tricare Dental Program, which requires separate enrollment.

Most retirees and their family members are eligible for dental and vision coverage under the Federal Employees Dental and Vision Insurance Program, or FEDVIP, which is administered by the Office of Personnel Management and also requires separate enrollment.

What are the options?

Tricare offers two core health care options: Tricare Prime and Tricare Select.

All active duty members are required to enroll in Tricare Prime; they pay nothing out of pocket. Active duty families can also enroll in Tricare Prime without an enrollment fee.

Prime beneficiaries are assigned a primary care manager, or PCM, at their local military treatment facility, or, if one is not available, they can select a PCM within the Tricare Prime civilian network. Specialty care is provided on referral by the PCM, either to specialists at a military facility or a civilian provider.

Tricare Select is similar to a traditional fee-for-service health plan. Patients can see any authorized provider they choose, but must pay a deductible and co-pays for visits. Patients pay lower out-of-pocket costs when they receive care from a provider within the Tricare network.

All Tricare programs have a cap on how much a family pays out of pocket each fiscal year, depending on the sponsor's status and the type of Tricare program used.

The plans

Tricare Prime. Similar to a health maintenance organization, Tricare Prime has lower out-of-pocket costs but requires enrollees to use network providers and coordinate care through a primary care manager — a doctor, nurse practitioner or medical team.

It's free to active duty members. Families enrolled in a Tricare Prime plan do not have to pay enrollment fees or co-payments unless they use the point-of-service option or fill a prescription outside of a military pharmacy. Retirees must pay an annual enrollment fee. Co-payments for medical visits are lower than other programs.

Tricare Prime Remote. Service members who live and work more than 50 miles or an hour's drive from the nearest military treatment facility must enroll in Tricare Prime Remote. Family members are eligible if they live with an enrolled service member in a qualifying location, or they may use Tricare Select.

Tricare Prime Overseas. This is a managed-care option for active duty members and their command-sponsored family members in nonremote locations. They have assigned primary care managers at a military treatment facility who provide most care and referrals for and coordination of specialty care.

Tricare Prime Remote Overseas is a managed care option in designated remote overseas locations, with most care from an assigned primary care manager in the local provider network who provides referrals for specialty care. Activated National Guard and reserve members and their families may also enroll in these options while the sponsor is on active duty. Retirees and their families are not eligible.

Tricare Select. This is a preferred provider plan — authorized doctors, hospitals and other providers are paid a Tricare-allowable charge for each service performed. Costs are higher for out-of-network providers, and certain procedures require pre-authorization.

There is no enrollment fee for active duty families. Group A working age retirees are required to pay monthly enrollment fees. Co-pays vary by status and type of care.

Tricare Reserve Select. Qualified Selected Reserve members can buy Tricare coverage when they are in drilling status — not mobilized. The program offers coverage similar to Tricare Select.

Tricare Retired Reserve. "Gray area" National Guard and reserve retirees who have accumulated enough service to qualify for military retirement benefits but have not reached the age at which they can begin drawing those benefits (usually age 60) can purchase this insurance, which offers coverage similar to Tricare Select.

Tricare for Life. This wraparound program is for retirees and family members who are eligible for Tricare and Medicare. The provider files the claims with Medicare; Medicare pays its portion and then sends the claim to the Tricare for Life claims processor. Enrollees must enroll in Medicare Part A — free for those who paid Medicare taxes while working — and Part B — monthly premium required — to receive Tricare for Life.

Tricare Young Adult. Unmarried dependent children who do not have private health insurance through an employer may remain in Tricare until age 26 under a parent's coverage via TYA Select or TYA Prime. Premiums are required for both.

U.S. Family Health Plan. Beneficiaries who live in one of six designated areas can enroll in this as a Prime option. Those enrolled get all their care, including prescription drugs, from a primary care provider that the beneficiary selects out of a network of private doctors affiliated with one of the not-for-profit health care systems in the plan.

Beneficiaries do not get care at military hospitals or clinics, or from Tricare network providers when enrolled in the U.S. Family Health Plan.

Action items

Beneficiaries enroll in a Tricare plan in order to be covered for civilian health care. Those who don't enroll will only be able to get health care at a military clinic or hospital on a space-available basis.

To be eligible for any of the Tricare plans, beneficiaries must first be enrolled in the Defense Enrollment Eligibility Reporting System.

Active duty members are automatically registered in DEERS when they join the military, but they must register eligible dependent family members.

Service members should make sure the information is correct for their family members. Only military members can add or remove family members. This can be done through the local ID card office.

Florida Military Families Fight For Medical Reimbursements Through TRICARE

Congressman Gus Bilirakis tells 10 Tampa Bay TRICARE is undergoing a "major system transition" which has delayed their "usual" claims processing time frame.

LAND O' LAKES, Fla — Changes with Humana TRICARE, the primary healthcare program used by active duty military, have left some local military families fighting for their medical reimbursements.

A 10 Tampa Bay media affiliate confirmed that on Jan. 1, 2025, Humana Military switched the company it uses for claims processing from WPS Health Insurance to PGBA.

Retired U.S. Airman Kevin Sellers dutifully tracks his wife's medical expenses. Kim Sellers was diagnosed with multiple sclerosis in 2016 and sees multiple doctors at USF Health and through Tampa General.

Kevin Sellers said he had never faced any issues with her TRICARE health insurance until this past January, when a special test was flagged as "NOT APPROVED," leaving them with a nearly $1,500 unexpected bill and many questions.

"When I go through it I can't get a whole lot of information about it, it doesn't tell me why," Sellers said. "I submitted the appeal. It should just show up here to show they have the appeal and that they're working on it, but it still shows up as 'not approved.'"

Sellers also said he's sent several unanswered emails to TRICARE about the issue.

Florida Congressman Gus Bilirakis, a state leader in veteran healthcare, is now looking into the situation on behalf of the Sellers family and others who have brought similar issues to his attention.

Bilirakis tells 10 Tampa Bay that TRICARE is undergoing a "major system transition" which has delayed their "usual" claims processing time frame. Now, he's filing a formal congressional inquiry with TRICARE.

For the Sellers family, this is a matter of transparency.

"If they need time, or if they need to get systems up in place, then help us, let us know that," Sellers said. "I don't want to spend my days playing hospital administrator, I'd like to spend my days with my wife."

10 Tampa Bay has reached out directly to TRICARE several times this week for comment about its system transition and issues it has caused for patients. We have not yet heard back.

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