Presidential Security: Vetting of Individuals and Secure Areas at Mar-a-Lago

The President has made numerous trips to the Mar-a-Lago property in Palm Beach, Florida, during which he met with foreign leaders and conducted presidential activities.

GAO was asked to review the establishment of secure areas for use by the President at Mar-a-Lago. This report provides information on, among other things, (1) vetting of individuals expected to be near the President; (2) efforts to establish secure areas for handling classified information; and (3) regulations and processes for agency expenditures on employees who travel with the President. This is a public version of a sensitive report that GAO issued in October 2018. Information that the Secret Service and DOD deemed sensitive has been omitted.

GAO analyzed laws, regulations, policies, and procedures; reviewed agreements between federal agencies and trip after-action reports; and interviewed DOD and Secret Service officials. GAO also reviewed vouchers from the four presidential trips to Mar-a-Lago from February 3, 2017 through March 5, 2017.GAO also reviewed documentation and descriptions of specific security practices with DOD and Secret Service officials. The Executive Office of the President has not responded to requests regarding its role in assisting DOD and the Secret Service in carrying out their responsibilities.

The U.S. Secret Service (Secret Service) vets individuals differently depending on the person's expected proximity to the President when he travels, including during his visits to Mar-a-Lago. According to Secret Service officials, vetting may include using physical screening (measures to detect physical threats to the president and secure the property) and background checks intended to identify individuals who have prior criminal activity or present other types of threats. Individuals at Mar-a-Lago who are not expected to meet with the President or enter spaces the President may visit pass through an outer layer of security consisting of physical screening checkpoints surrounding the property. The Secret Service physically screens all individuals who will access areas where the President will be present, such as a dining room. According to Secret Service officials, individuals who have a meeting with the President generally undergo both physical screening and enhanced background checks.

The Department of Defense (DOD) and the Secret Service coordinate to establish and secure several areas that are suitable for handling classified information when the President travels to Mar-a-Lago. These areas include a conference center, spaces used by staff of the National Security Council and the Executive Office of the President, and presidential transportation vehicles. Details associated with these areas and facilities are sensitive and have been omitted from this report.

The Secret Service and DOD are subject to regulations that govern the reimbursement of employees for official travel expenses. Both organizations have processes to review these travel-related expenses when their personnel travel with the President and try to acquire lodging at the General Services Administration's per diem lodging rate. When the Secret Service is not able to acquire rooms at the per diem lodging rate, including when it needs rooms for operational purposes that exceed 300 percent of the per diem rate (a threshold set by the General Services Administration), employees must submit a waiver request. DOD personnel must also obtain approval when costs exceed the General Services Administration's lodging rate. Our review of DOD vouchers and Secret Service documentation confirmed that personnel did not exceed the 300 percent threshold for lodging during the Mar-a-Lago trips examined in this review. We assessed the costs of Presidential travel in a separate report.

The President has made numerous trips to the Mar-a-Lago property in  Palm Beach, Florida. The President has hosted a foreign head of state  and head of government and conducted other presidential  responsibilities, including addressing matters of national concern, while at  Mar-a-Lago, which may render the property a location of potential interest  to foreign actors. Because members of the public are able to mingle with  the President when he is at Mar-a-Lago, members of Congress and  others have raised questions about the protection of classified information  at the property. Questions have also been raised with regard to potential  conflicts of interest that could arise as a result of foreign government  patronage at The Trump Organization’s properties.

You asked us to review issues pertaining to the establishment of secure  areas where classified information can be handled by the President when  he travels to Mar-a-Lago. You also asked us to identify payments made to  the U.S. Department of the Treasury (Treasury) that result from foreign  government patronage at The Trump Organization properties. This  report provides information on (1) processes taken to vet individuals who  will be in close proximity to the President when he visits Mar-a-Lago; (2)  processes to provide the President with secure areas for handling  classified and other sensitive information while at Mar-a-Lago; (3)  regulations and processes governing agency expenditures on employee  per diem expenses for travel and operational space for personnel who  travel with the President; and (4) the Treasury’s processes for receiving  payments from The Trump Organization or the President and payments  that the Treasury has received through these processes. This is a public  version of a sensitive GAO report that we issued in October 2018. DOD  and the Secret Service deemed some of the information in our October  report as sensitive, which must be protected from public disclosure.

Therefore, this report omits sensitive information on vetting individuals  and providing secure areas for handling classified information. Although  the information provided in this report is more limited, the report  addresses the same objectives as the sensitive report and uses the same  methodology.

To address our first objective, we analyzed guidance and documents  related to protective operations from the U.S. Secret Service (Secret  Service) and reviewed agreements between federal agencies to identify  the measures that agencies are expected to take to vet individuals during  the President’s domestic trips. We interviewed officials from the Secret  Service and the Federal Bureau of Investigation to ascertain how they  partner to vet individuals during the President’s trips. We reviewed final  survey reports that summarize security measures and actions taken by  the Secret Service during the President’s four trips to Mar-a-Lago  between February 3, 2017 and March 5, 2017 and other documentation.  A GAO engagement assessing Presidential travel costs selected the first  four trips to Mar-a-Lago after the President’s inauguration, because those  trips were completed shortly before the date of the Congressional request  letter. To stay consistent with concurrent work on Presidential travel  costs, the same time frame was selected. We interviewed officials from  the Secret Service who were tasked with protecting the President to  determine how agreements, policies, and procedures are used to vet  individuals when the President is at Mar-a-Lago.

To address our second objective, we reviewed security-related guidance  from the Secret Service and the Department of Defense (DOD) to  determine the roles that these organizations have in establishing secure  areas that may be used to handle classified information when the  President travels. We also reviewed Office of the Director of National  Intelligence policies and procedures that are to be used when  establishing temporary secure areas, such as those used at Mar-a-Lago,  for handling classified information. We also reviewed the details of  specific security practices for the site with agency officials. We relied on  DOD and Secret Service documentation and descriptions of these  practices. We discussed with DOD officials after-action reports they  prepare to identify vulnerabilities related to information security and steps  that have been taken to address these vulnerabilities. We requested from  DOD the after-action reports examining areas that may have been used  by its personnel, the National Security Council, and the Executive Office  of the President during the President’s trips. DOD officials provided us  with a March 2017 after-action report for the President’s March 3-5, 2017  visit to Mar-a-Lago. We reviewed the report to understand the types of  information included and assessed by DOD. DOD officials stated that  similar reports were developed after each of the President’s February  2017 trips to Mar-a-Lago. In addition, we discussed and reviewed with  Secret Service officials specific security practices at Mar-a-Lago related  to protection of the property, the presidential suite, the dining room, and  public areas, among others. We further reviewed the Secret Service’s  after-action reports for each of the four trips to Mar-a-Lago within our  scope. Each report included specific information on what had occurred  during the trip and identified what security personnel did in securing each  segment of the site. Secret Service personnel made themselves available  to answer our questions regarding the report.

To address our third objective, we reviewed laws, regulations, and  policies to identify the rules and processes governing agency  expenditures on operational spaces and per diem for employees who  accompany the President when he is traveling domestically. We reviewed  documentation about DOD’s and the Secret Service’s travel processes,  such as policies and agency guidance. In addition, we reviewed the  vouchers from the presidential trips to Mar-a-Lago that were completed  between February 3, 2017 and March 5, 2017. We also interviewed  knowledgeable officials from DOD and the Secret Service. We reviewed  relevant policies and spoke with agency officials regarding policies and  processes that are in place for when individuals on travel need to exceed  the General Services Administration per diem rate. We also reviewed  Secret Service documentation regarding waiver requests submitted when  individuals traveling with the President exceeded the General Service’s  Administration per diem rate. In addition to this work, we assessed the  costs of Presidential travel, which we published in a second report in  January 2019.

To address our fourth objective, we reviewed Treasury’s website and  interviewed Treasury officials to identify processes for receiving gifts to  the federal government and gifts to reduce the public debt. To identify  payments received by Treasury from the President or The Trump  Organization that were made through the Treasury’s donation processes,  we reviewed Treasury accounts and interviewed officials to determine if  any payments had been received from January 2017 through August  2018. We also reviewed The Trump Organization’s written policy, which  provides its definition of foreign government patronage, explains how it  will calculate profits from foreign government patronage, and specifies  when The Trump Organization intends to make payments to the Treasury  under this policy. Finally, we interviewed attorneys representing The  Trump Organization.

Additionally, we contacted the White House Counsel’s Office in May 2017  and January 2018 to solicit the perspective of the Executive Office of the  President, including the National Security Council, on efforts to establish  secure areas and vet individuals at Mar-a-Lago and manage costs  associated with personnel traveling with the President, and on any  payments The Trump Organization has made to the U.S. Treasury of  profits realized from foreign government patronage of The Trump  Organization’s properties. As of January 2019, the White House  Counsel’s Office had not responded to our requests for information.

We conducted this performance audit from April 2017 to October 2018 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. We subsequently worked with  DOD and the Secret Service, from September 2018 to January 2019 to  prepare this unclassified version of the original sensitive report for public  release. This public version was also prepared in accordance with these  standards.

Secret Service has Processes to Vet Individuals Based on Their Expected Proximity to the President

The Secret Service has processes to vet individuals differently depending  on the person’s expected proximity to the President, using a combination  of physical screening and background checks, as illustrated in figure 1.

According to Secret Service officials, physical screening includes the use  of equipment such as wands and magnetometers to secure the property.  Background checks assess in part whether an individual has a history of  criminal activity. In some cases, enhanced background checks identify  other types of threats.

The Secret Service develops and executes a security plan to ensure that  the outer, middle, and inner layers at the travel location are secure.  Officials from the Secret Service confirmed that agency policies aim to  provide comprehensive planning guidance for their agents’ activities but  are not meant to be all inclusive.

Outer Layer: The Secret Service uses physical screening measures  to establish a layer of security around the Mar-a-Lago property.  According to Secret Service officials, state and local law enforcement  and the U.S. Coast Guard may monitor entry onto the property or  perform visual checks of individuals entering the property and  surrounding waterways. Depending on where the President is, guests  may be required to pass through a physical security checkpoint that  employs magnetometers, wands, and visual checks to assess  physical threats.

Middle Layer: Officials from the Secret Service said that they use  physical screening measures for individuals and any rooms that the  President may access during his visit. Officials told us that if they are  notified of the President’s planned arrival to a specific room, they will  secure that room.

Inner Layer: In advance of the President’s arrival, the Secret Service  has a process requiring vetting of individuals who are expected to be  within close proximity to the President for a planned purpose or in  certain secure areas. According to Secret Service officials, individuals  who need access to secure areas but who are not expected to interact  directly with the President, such as wait staff and other workers, are to  undergo a background check in addition to physical screening.  Individuals who are expected to meet the President are to undergo a  background check and an enhanced background check. Officials from  the Secret Service said that they are responsible for collecting the  findings from these checks and making recommendations to the  Executive Office of the President on whether individuals with  derogatory findings should be allowed to access a space. According  to officials from the Secret Service, staff at Mar-a-Lago routinely  undergo background checks.

In order to conduct the background check, the Secret Service is to use  personally identifiable information for each individual, and those  Individuals’ names may be checked against indexes maintained by the  Secret Service and other federal, state, and local law enforcement  organizations. The Secret Service’s guidance notes that submission of  the requested information to run a background check is based on  individuals voluntarily providing the needed information. In order to  conduct an enhanced background check, the Secret Service collaborates  with the Federal Bureau of Investigation and other federal agency  partners. According to officials from the Secret Service, the Executive  Office of the President is responsible for identifying individuals who are  expected to meet with the President and providing the Secret Service with  the names and the personally identifiable information needed to complete  these checks.

According to Secret Service guidance, White House staff is expected to  submit all names to the Secret Service at least 72 hours in advance of the  President’s arrival. Advance agents are also responsible for setting  deadlines for completing background checks. Officials from the Secret  Service said that, based on the information received from these checks,  the Secret Service will make a recommendation to the Executive Office of  the President on whether an individual should be granted access to the  President. According to these officials, the Executive Office of the  President ultimately determines whether or not an individual will have  access. However, the Secret Service is responsible for ensuring that the  area is safe and that the individual is physically screened.

DOD and the Secret Service Provide Secure Areas for the Handling of Classified Information When the President Travels to Mar-a-Lago

DOD’s White House Communications Agency and the Secret Service  each have specific responsibilities for establishing secure  communications and secure areas for handling classified information  when the President travels to domestic locations, such as Mar-a-Lago.

DOD’s White House Communications Agency: This organization is  an information technology unit within DOD that supports the President  and his staff during presidential trips. This organization’s mission is to  provide information services to the President, Vice President, National  Security Staff, Secret Service, and others when directed. According  to agency guidance and officials, the White House Communications  Agency is responsible for installing secure communications equipment  that enables the exchange of classified information in areas that may  be used by these entities.

Secret Service: According to officials from the Secret Service, they  send an advance team that coordinates with the White House  Communications Agency to set up a conference center for the  President where classified information may be exchanged, among  other things. These officials stated that they provide security at the  entrance of this conference center and perform security sweeps to  ensure that it is safe and secure.

DOD and the Secret Service coordinate to establish and secure several  areas that are available for handling classified information when the  President travels to locations such as Mar-a-Lago, as shown in figure 2.  These areas include a conference center, spaces used by staff of the  National Security Council and Executive Office of the President, and  presidential transportation vehicles. Details associated with these areas  and facilities are sensitive and have been omitted from this report.

Regulations and Processes Governing Secret Service and DOD Expenditures on Employee Per Diem Expenses for Travel and Operational Space in Support of the President

The Secret Service and DOD are subject to regulations governing  reimbursements to employees for official travel. Processes exist to review  these travel-related expenses when personnel from these agencies  travel. These processes are the same when personnel accompany the  President to Mar-a-Lago.

Federal Regulations Govern Agencies’ Policies for Paying Or Reimbursing Employees’ Official Duty Travel Expenses

Two regulations implement statutory requirements and executive branch  policies for travel, allowing agencies to pay for or reimburse their  employees’ per diem expenses (lodging, meals and incidental expenses)  and other travel-related expenses:

The Federal Travel Regulation (FTR), issued by the General  Services Administration applies to the Secret Service’s personnel.

The Joint Travel Regulations (JTR), issued by the Department of  Defense apply to DOD personnel.

Both regulations allow agencies to pay for employees’ daily expenses  when they are traveling within the continental United States, based on  allowances set by the General Services Administration for the applicable  location and date (per diem rates) or the actual expense of travel. Under  the Federal Travel Regulation, the maximum amount that a civilian  employee may be reimbursed is 300 percent of the applicable per diem  rate. The Joint Travel Regulations allow uniformed service members to  be reimbursed up to 300 percent of the per diem rate when they are  traveling in the continental United States, but they can be reimbursed  more than 300 percent of the per diem rate for lodging when traveling  outside the continental United States.

The Secret Service Has a Standard Process for Overseeing Costs for Lodging, Meals and Incidental Expenses, and Operational Space during Presidential Travel

Officials from the Secret Service stated that they apply the same cost  oversight processes for all presidential travel. Expenses for lodging and  operational space are centrally billed to the agency, and employee meals  and incidental expenses are reimbursed to the traveler. In accordance  with policy, the Secret Service tries to acquire lodging at the General  Services Administration’s per diem lodging rate and must submit a waiver  request for any room that exceeds this designated rate by any amount.  The Secret Service field office closest to the travel destination is  responsible for arranging for these spaces, negotiating rates, and if  necessary submitting a waiver request to officials in the Secret Service’s  Logistics Resource Center. The Logistics Resource Center is to review  the waiver request, determine whether a more cost effective method  exists to meet the need, and approve or reject the request.

In some cases, the Secret Service may not be able to acquire rooms at  the per diem lodging rate, or agents may need rooms for operational  purposes that exceed 300 percent of the per diem rate, which is more than is allowed for lodging under the Federal Travel Regulation. For  example, the Secret Service may use a room for operational purposes or  reserve rooms adjacent to the President to better protect him. In addition,  to meet operational demands, the Secret Service may require a certain  number of agents to stay at the hotel in which the President is staying, so  that they are within a certain proximity of the President at all times.  Furthermore, officials from the Secret Service said that members of the  Secret Service canine teams must stay at hotels that allow animals, and  rooms at these hotels may exceed the General Services Administration  lodging rate.

The authorities the Secret Service has relied on to pay for hotel rooms  needed to meet its operational requirements do not limit how much the  agency can pay. Further, Congress passed a law in May of 2017  excepting the Secret Service from regulatory caps on room rentals,  regardless of room purpose. Nevertheless, consistent with the Secret  Service waiver process, personnel are still required to submit waiver  requests for operational spaces to justify the need to book rooms during  the President’s trips to Mar-a-Lago at prices higher than the General  Service Administration lodging rates. We confirmed that a blanket waiver  request was submitted and approved for all rooms at Mar-a-Lago that  exceeded the General Services Administration per diem lodging rate  during the President’s trips to Mar-a-Lago that are covered by this  review. Additionally, we reviewed Secret Service documentation and confirmed that Secret Service personnel did not exceed the 300 percent  threshold for lodging.

For meals and incidental expenses, the Secret Service’s employees who  are on official duty are to submit a claim for reimbursement electronically  or by paper and receipts, as applicable, at the conclusion of the trip.  Approving officials are to approve (or deny) expenses, and the Secret  Service’s Financial Management Division authorizes reimbursement for  approved travel.

DOD Has a Standard Process to Oversee Costs for Lodging, Meals and Incidental Expenses, and Operational Space during Presidential Travel To Mar- A-Lago

DOD personnel use the same processes for travel to Mar-a-Lago as they  do for other Presidential trips to oversee costs for lodging, meals, and  incidental expenses. According to officials from DOD’s Defense Travel  Management Office, their office establishes travel policy that applies to  the four organizations that travel in support of the President’s trips. DOD  personnel use the Defense Travel System to submit travel documents,  including vouchers and receipts, as applicable. According to officials,  lodging may be booked and reimbursed on an individual basis or centrally  billed if a block of rooms is needed over the same period. Meals and  incidental expenses are reimbursed to the traveler. Like Secret Service’s  personnel, DOD personnel must obtain approval from an authorizing  official prior to the trip to exceed the General Services Administration per  diem lodging rate, consistent with the Federal Travel Regulation and Joint  Travel Regulations. According to officials from the Defense Travel  Management Office, DOD typically would not reimburse expenses above  the approved lodging rate if lodging at the approved rate was available  within the region. However, officials from the Defense Finance and  Accounting Service indicated that presidential trips may require such a  deviation. These approvals are to be tracked in the Defense Travel  System.

The White House Military Office, which includes the White House  Communications Agency, also sends personnel with the President when  he travels. White House Communications Agency officials told us that its  lodging and operational space for these personnel are typically  coordinated by the White House Travel Office and that DOD personnel  pay for the associated costs and seek reimbursement from DOD after the  trip is complete.

According to officials from the White House Communications Agency,  some personnel are required to remain at, or near, the Mar-a-Lago  property. If they are not required to stay at or near the property, they will  try to obtain lodging at hotels in the area at the General Services  Administration’s per diem rate for lodging. DOD officials told us that  according to the Joint Travel Regulations, DOD is not authorized to pay or  reimburse daily expenses above the 300 percent ceiling. In connection  with the President’s travel to Mar-a-Lago between February 3, 2017 and  March 5, 2017, DOD personnel exceeded the General Services  Administration per diem rate but did not exceed the 300 percent  threshold.

According to officials from the Defense Travel Management Office,  operational space used for official business is governed by the Federal  Acquisition Regulation. White House Communications Agency officials  told us that they have generally used space near the Mar-a-Lago property  but leased property, effective September 2017, near Mar-a-Lago to  reduce the cost of supporting the President’s trips to the property.

Payments Received by the U.S. Treasury Department from The Trump Organization through Treasury’s Donation Processes

Treasury has regular processes for receiving payments designated as  gifts to the United States and gifts to reduce the public debt. Treasury  officials stated that any payments received from The Trump Organization  or the President that are designated as gifts would be handled using  these processes. Under federal law, Treasury may receive general gifts to  the U.S. Government and may also receive gifts to reduce the public  debt. Treasury has developed processes to accept these types of  payments, as shown in figure 3.

Treasury officials said there are three accounts available to receive  payments as gifts—a general gift account, a general fund receipts  account, and an account for gifts to reduce the public debt. Any of these  accounts could receive payments designated as gifts by the President or  The Trump Organization. Treasury officials told us they would deposit  such payments into the account for gifts to the U.S. Government unless  the payment source specified that the funds should be used to reduce the  public debt.

Treasury received one payment from The Trump Organization, for  $151,470 that was submitted through Treasury’s processes on February  22, 2018. In May 2017, The Trump Organization issued a policy  addressing profits generated from foreign government patronage at its  businesses. The Trump Organization’s policy states that it will make a  single lump-sum payment annually after the end of its fiscal year, which  ends on December 31st. We did not identify any other payments that  Treasury received from The Trump Organization or the President  between January 21, 2017, and August 1, 2018.  In September 2018,  an attorney for The Trump Organization confirmed that the organization  had not made any payments since February 22, 2018.

We provided copies of this draft report to DOD, DHS, the Department of  Justice, the General Services Administration, the Department of Treasury,  and the Executive Office of the President for comment. We also provided  a section to the Trump Organization for comment.  DHS provided written  comments, which are reprinted in their entirety in appendix I. DHS, DOD,  the Department of Treasury and the Department of Justice also provided  technical comments, which we incorporated into this report as  appropriate. The Executive Office of the President and the Trump  Organization provided no comments.

As agreed with your offices, unless you publicly release this report earlier,  we will not issue the report until 30 days from the report date. At that time,  we will also provide copies to the Secretary of Defense, the Director of  the Secret Service, the Secretary of Homeland Security, the Attorney  General, the Director of the Federal Bureau of Investigation, the  Administrator of the General Services Administration, and the Secretary  of the Treasury. In addition, this report will be available at no charge on  the GAO website at www.gao.gov.

If you or your staff have any questions about this report, please contact  Joseph (Joe) Kirschbaum at (202) 512-9971 or at KirschbaumJ@gao.gov  or Diana Maurer at (202) 512-9627 or at MaurerD@gao.gov. Contact  points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this report. GAO staff who made key  contributions to this report are listed in Appendix II.

Appendix I: Comments from the Department of Homeland Security

Appendix II: GAO Contacts and Staff Acknowledgments

In addition to the contacts named above, Gina R. Hoffman, Assistant  Director; Joseph P. Cruz, Assistant Director; Tracy Barnes, Nicholas  Benne, Jennifer Kamara, Joanne Landesman, Amie Lesser, Thomas  Lombardi, Carol Petersen, Michael Silver, Janet Temko-Blinder,  Christopher Turner, Kayli Westling, and Alex Winograd made key  contributions to this report.

The President has made numerous trips to his Mar-a-Lago property in Palm Beach, Florida, where he has hosted foreign leaders and conducted other presidential duties.

We reviewed several aspects of security and expenses for personnel traveling with the President. We found that

Secret Service has processes to vet and physically screen visitors

Secret Service personnel coordinated with Department of Defense personnel to establish secure areas that could be used to handle classified information

Both Secret Service and Department of Defense personnel adhered to federal travel regulations and did not exceed the allowable rate for lodging


Defense Health Care: DOD Surveys Indicate Beneficiary Experience Generally Unchanged in First Year of TRICARE Select

DOD provided health care to more than 9 million eligible beneficiaries through TRICARE in fiscal year 2018. Most of these beneficiaries were enrolled in TRICARE's managed care plan—TRICARE Prime. However, about 2 million beneficiaries received care primarily from civilian providers through TRICARE's non-Prime options: TRICARE Standard and Extra. Effective January 1, 2018, these two options were eliminated and TRICARE Select was implemented. TRICARE Select has similar benefits for provider choice and obtaining care from civilian providers as TRICARE Standard and Extra, but includes access standards to ensure at least 85 percent of enrollees are covered by TRICARE's network of civilian providers, among other things.

The National Defense Authorization Act (NDAA) for Fiscal Year 2008 included a provision for GAO to review results of DOD surveys of non-Prime beneficiaries and civilian providers. Additionally, the NDAA for Fiscal Year 2017 included a provision for GAO to review access to care after implementation of TRICARE Select in 2018. This report addresses both provisions.

GAO analyzed DOD's survey results to determine changes after implementation of TRICARE Select in (1) non-Prime beneficiaries' ratings of TRICARE, (2) non-Prime beneficiaries' reported ability to find providers and obtain appointments, and (3) civilian providers' reported acceptance of TRICARE. GAO analyzed the results of the 2017-2019 surveys, and interviewed agency officials and DOD contractors.

DOD provided technical comments, which GAO incorporated as appropriate.

On January 1, 2018, the Department of Defense (DOD) implemented a new health plan option—TRICARE Select—for beneficiaries who primarily obtain care from civilian providers rather than through TRICARE's managed care plan—TRICARE Prime. DOD surveys indicate few changes in these non-Prime beneficiaries' satisfaction and access to care during the first year following the implementation of TRICARE Select, though GAO cannot directly attribute these differences to implementation due, in part, to other changes in the TRICARE program during the same time frame. Specifically, GAO found the following:

There was no change in the percent of beneficiaries reporting positive ratings of their TRICARE health care and health plans—80 percent and 68 percent, respectively—in the first year of TRICARE Select.

There was an increase in the percent of beneficiaries reporting problems accessing specialty providers from 18 to 24 percent in the first year of TRICARE Select. However, as the figure shows, there was no statistically significant change in the percent of beneficiaries reporting they received care as soon as needed for primary and specialty care appointments.

There was no change in the percent of providers that reported accepting new TRICARE patients if they were also accepting any new patients—about 90 percent of primary care and specialty care providers, and 47 percent of mental health care providers—in the first year of TRICARE Select.

In fiscal year 2018, the Department of Defense (DOD) offered health care  services to more than 9 million eligible beneficiaries in the United States  and abroad through TRICARE. Prior to 2018, beneficiaries primarily had  a choice between three health plan options—TRICARE Prime, TRICARE  Standard, and TRICARE Extra—to obtain care either from military  hospitals and clinics, referred to as military treatment facilities, or from  civilian providers. Most beneficiaries were enrolled in TRICARE Prime,  TRICARE’s managed care plan. However, about 2 million beneficiaries  received care primarily from civilian providers through TRICARE’s non- Prime options—TRICARE Standard and TRICARE Extra. The National  Defense Authorization Act (NDAA) for Fiscal Year 2017 terminated  TRICARE Standard and Extra beginning on January 1, 2018, and introduced TRICARE Select—a new plan option for beneficiaries to obtain  care primarily from civilian providers.

Since TRICARE’s inception in 1995, beneficiaries have raised concerns  about difficulties finding civilian providers who will accept them as  patients. In response to these concerns about access to care, the NDAA  for Fiscal Year 2008 directed DOD to conduct a multi-year survey (2008- 2011) of non-Prime beneficiaries and a multi-year survey (2008-2011) of  civilian providers to determine the adequacy of beneficiaries’ access to  health care providers. The multi-year surveys were continued for 2012- 2015, and most recently from 2017-2020. The NDAA for Fiscal Year  2008 also included a provision for us to conduct recurring reviews of a  series of issues related to the adequacy of non-Prime TRICARE  beneficiaries’ access to care, including a review of information gleaned  from the beneficiary and civilian provider surveys, and to report on these  issues on a biannual basis.

Since TRICARE Select’s implementation, there also have been  complaints from some non-Prime beneficiaries that they did not know  about this new plan and that their ability to find certain types of  providers—particularly mental health providers—that accept TRICARE  has decreased. The NDAA for Fiscal Year 2017 directed us to review  TRICARE Select beneficiary access and satisfaction, civilian provider  acceptance of new TRICARE patients, and how these have changed  since the implementation of TRICARE Select in 2018.

This report addresses provisions in the NDAA for Fiscal Year 2008, as  amended, and the NDAA for Fiscal Year 2017 for us to report on the  adequacy of non-Prime TRICARE beneficiaries’ access to care.  Specifically, this report describes the extent to which  1.  non-Prime TRICARE beneficiaries’ ratings of TRICARE have changed  since the implementation of TRICARE Select;  2.  non-Prime TRICARE beneficiaries’ reported ability to find providers  and obtain appointments has changed since the implementation of  TRICARE Select; and  3.  civilian providers’ reported acceptance of TRICARE patients has  changed since the implementation of TRICARE Select.

To determine the extent to which non-Prime TRICARE beneficiaries’  ratings of TRICARE changed since the implementation of TRICARE  Select, we obtained and analyzed 3 years of survey results from DOD’s  TRICARE Survey of Beneficiaries for 2017-2020. Specifically, we  analyzed data related to beneficiaries’ ratings of certain aspects of their  TRICARE experiences, such as their ratings of health care, health plan,  and primary, specialty, and mental health care providers. To compare  how these ratings had changed after the TRICARE Select  implementation, we compared combined data from the first 2 completed  years of the survey (2017 and 2018)—which reflects beneficiary  experiences under TRICARE Standard and Extra—to the most recent  completed year of the survey (2019)—which reflects beneficiary  experiences in the first year under TRICARE Select.

To determine the extent to which non-Prime TRICARE beneficiaries’  reported access to care has changed since the implementation of  TRICARE Select, we analyzed data from DOD’s beneficiary survey. We  analyzed these data to determine if non-Prime beneficiaries indicated that  they had problems finding providers that would accept TRICARE, that  they were able to obtain appointments as soon as they wanted, and how  quickly they were able to see providers. We compared the combined  data from the 2017 and 2018 beneficiary surveys to data from the 2019  survey to identify changes since the implementation of TRICARE  Select. We then compared these data between different geographic  location types and provider types, where applicable. In addition, we met  with DOD’s two managed care support contractors to determine how they  were ensuring access to care for these beneficiaries.

To determine the extent to which civilian providers’ reported acceptance  of TRICARE patients has changed since the implementation of TRICARE  Select, we obtained and analyzed survey data from DOD’s TRICARE  Survey of Providers for 2017-2020. Specifically, we analyzed the data to  determine whether civilian providers were accepting any new TRICARE  patients, and accounted for whether they were accepting any other new  patients. We compared the combined data from the 2017 and 2018  provider surveys to data from the 2019 survey to identify changes since  the implementation of TRICARE Select. We also compared these data  between different geographic location types, provider types, and whether  a provider was participating in the TRICARE network of providers.

For each objective, we assessed the reliability of the data from DOD’s  surveys by speaking with knowledgeable officials, conducting statistical  testing, and reviewing relevant documentation. We previously reported  that DOD’s implementation of its 2008-2011 and 2012-2015 beneficiary  and civilian provider surveys generally addressed the requirements  outlined in the NDAA 2008. DOD made several minor revisions to the  methodologies of the 2017-2020 surveys, but we determined that the  surveys continue to address the requirements outlined in the NDAA 2008,  as amended. DOD calculated the response rates for its 2017-2019  beneficiary surveys and civilian provider surveys to be about 19 percent  and 29 percent, respectively. We verified that the surveys’ results were  representative of the areas surveyed by reviewing DOD’s nonresponse  analyses for these surveys and by interviewing DOD officials.

Two factors affect our ability to directly attribute differences in survey  results to the implementation of TRICARE Select: 1) There were other  significant changes to the TRICARE health plans between 2017/2018 and  2019 survey years—on January 1, 2018, the TRICARE regions were  restructured and a new contractor began managing the program in the  West region. 2) Each individual year of the DOD multi-year survey is not  nationally generalizable; the survey is designed so that 4 years of results  create a nationally representative sample and are analyzed collectively.  However, at the time of our analysis, only 1 year of data reflecting  beneficiary and provider experiences after the implementation of  TRICARE Select was available. As a result of these limitations, reported  differences from the 2017/2018 surveys to the 2019 survey may be due to  changes in the TRICARE program, differences in the geographic areas  sampled, or other factors rather than the implementation of TRICARE  Select. After consideration of these limitations, we determined that all  data used in this report were sufficiently reliable for our audit objectives— to describe changes in beneficiary experience and provider acceptance of  TRICARE patients before and after TRICARE Select was implemented on  January 1, 2018.

We conducted this performance audit from March 2019 to February 2020  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Prior to January 1, 2018, TRICARE provided benefits through three main  plan options for its non-Medicare-eligible beneficiary population— TRICARE Prime, Standard, and Extra. These options varied by  enrollment requirements, choices in civilian and military treatment facility  providers, and the amount beneficiaries must contribute toward the cost  of their care. (See table 1.) The NDAA for Fiscal Year 2017 terminated  the TRICARE Standard and Extra plans beginning on January 1, 2018,  and introduced TRICARE Select. Beneficiaries who had used the  TRICARE Standard and Extra plans as of December 31, 2017 were  automatically enrolled in TRICARE Select for the first year of the new  plan, but as of January 1, 2019, beneficiaries were required to actively  enroll in TRICARE Select.

TRICARE’s Regional Structure and Contracts

DOD uses two regional managed care support contractors to develop  networks of civilian providers to serve all TRICARE beneficiaries. Within  the regions, contractors are required to develop these networks of  providers in areas called Prime Service Areas (PSA), which are  geographic areas usually within an approximate 40-mile radius of a  military inpatient treatment facility, as well as in areas outside of PSA  locations, or non-PSAs. To develop the networks, the contractors enter  into contracts with some providers—referred to as network providers—to  treat TRICARE patients at an agreed upon reimbursement rate.  Beneficiaries can also receive care from certified nonnetwork providers.  However, beneficiaries visiting a nonnetwork provider may have to pay for  the care at the time of the visit and later file a claim for reimbursement,  whereas beneficiaries visiting a network provider are only responsible for  paying a copayment or cost-sharing amount.

The NDAA for Fiscal Year 2017 also mandated that DOD ensure at least  85 percent of the TRICARE Select beneficiary population be covered by  the TRICARE network of providers by January 1, 2018, and that DOD  determine access standards and ensure the program meets or exceeds  access standards of “high-performing health care systems in the United  States” for health care appointments. DOD has contracted both of these  efforts to the two contractors.

Surveys Indicate Beneficiary Ratings of TRICARE Were Generally Unchanged in the First Year of Select, but Ratings of Primary Care Providers Decreased

Non-Prime beneficiaries’ ratings of TRICARE were generally unchanged  during the first year following the transition from TRICARE Standard and  Extra to TRICARE Select. Specifically, there was no statistically  significant change from the 2017/2018 surveys to the 2019 survey in the  percent of beneficiaries who positively rated their health care and their  health plans—defined as giving responses of 8 or higher (out of 10) on  each survey question. In the 2019 survey, 80 percent of beneficiaries  rated their health care positively, and 67 percent rated the TRICARE  health plan positively. (See fig. 1.)

Non-Prime TRICARE beneficiaries also rated three different types of  providers and of the three, ratings of primary care providers decreased  from the 2017/2018 to 2019 surveys. The percent of beneficiaries who  positively rated their primary care providers decreased from 85 to 80  percent in the 2019 survey. We found no statistically significant  differences from the 2017/2018 surveys to the 2019 survey in  beneficiaries’ positive ratings of specialty care and mental health care  providers, with 83 and 73 percent of beneficiaries reporting positive  ratings of their specialty care and mental health care providers,  respectively in 2019. (See fig. 2.)

Beneficiary Surveys Indicate More Problems Finding Providers in First Year of TRICARE Select, but No Change in Ability to Get Appointments

Beneficiaries Were More Likely to Report Problems Finding Providers in the First Year of Select

In the first year of TRICARE Select, a higher percentage of non-Prime  beneficiaries reported experiencing problems finding civilian health care  providers who accepted TRICARE than before the transition, particularly  for specialty care. We found there was a statistically significant increase  in the percentage of beneficiaries who reported problems finding a  provider that would accept TRICARE from 27 to 32 percent from the  2017/2018 surveys to the 2019 survey. In particular, there was a  statistically significant increase in the percentage of beneficiaries who  reported problems finding a specialty care provider in the 2019 survey (24  percent) compared to the 2017/2018 surveys (18 percent). The percent of  beneficiaries who reported problems accessing primary care or mental  health care remained statistically unchanged with 26 and 31 percent  reporting problems, respectively, in the 2019 survey. (See fig. 3.)

We also found that a higher percentage of beneficiaries located in PSAs  reported experiencing problems finding providers, whereas there was no  change for beneficiaries located in non-PSA areas. Specifically, from  the 2017/2018 surveys to the 2019 survey, there was a statistically  significant increase in the percentage of beneficiaries located in PSAs  who reported problems finding any type of civilian provider (27 to 34  percent), primary care providers (21 to 29 percent), and specialty care  providers (18 to 25 percent). There was no statistically significant change  among beneficiaries in PSAs reporting problems finding mental health  care providers or among beneficiaries in non-PSAs for any provider  types. (See fig. 4.)

To help beneficiaries find providers that accept TRICARE patients,  managed care support contractors develop networks of providers in PSAs  and some non-PSA locations. Each month, these contractors report to  DOD the percent of Select beneficiaries who were covered by the  TRICARE network of providers, according to contractor-developed  measures of adequate access to care. Although nearly one-third of  beneficiaries reported experiencing problems finding a civilian provider,  DOD officials told us that nearly 100 percent of beneficiaries in the East  have had adequate access to a network provider since January 1, 2018,  exceeding the 85 percent requirement. For the West, DOD officials said  the contractor reported that more than 85 percent of beneficiaries had  adequate access to a network provider as of August 2018.

According to DOD officials, the two contractors used different methods to  ensure adequate access to a network provider:  In the East region, the contractor decided to develop networks of  civilian providers in the entire region.

In the West region, the spread-out geography of the region made it  difficult to develop networks of civilian providers throughout the entire  region. Therefore, the contractor used mapping software to determine  areas within non-PSAs which had large populations of TRICARE  Select beneficiaries. As a result, the contractor identified 12 areas in  the West region—which it called Select Areas—to develop additional  networks of civilian providers in order to meet the requirement.

Contractors also provide resources to beneficiaries to help them identify  providers that accept TRICARE patients. Contractors maintain lists of  network and other TRICARE-certified providers that accept TRICARE  patients, and monitor and report on the accuracy of these lists to DOD  monthly. However, contractor representatives noted that providers can  decide to accept or not accept TRICARE patients at any time, and these  changes are not always reflected in the lists. Contractor representatives  explained that if a beneficiary cannot find a provider to accept TRICARE  for needed care, the beneficiary can submit a complaint to the contractor.  Contractor representatives said that they can address beneficiary  complaints by attempting to identify and certify new providers, but noted  that some subspecialty providers are not available in all areas.  Representatives from one contractor told us that they have identified  alternative sources of care when providers are not available. For  example, when no civilian psychiatrists were accepting new patients in a  remote area, the contractor offered beneficiaries telehealth services from  a military treatment facility.

Beneficiaries’ Reported Ability to Obtain an Appointment When Needed Was Unchanged in First Year of TRICARE Select

There was no statistically significant change after the transition to  TRICARE Select in the percent of non-Prime beneficiaries who reported  being able to get an appointment as soon as they needed. In the 2019  survey, 88 percent of beneficiaries reported that they could usually or  always obtain an appointment for primary care as soon as they needed  and 86 percent reported being able to do so for specialty care. (See fig.  5.) Similarly, about 65 percent of beneficiaries reported waiting a week or  less between scheduling an appointment for non-urgent care and meeting  with their doctor in the 2019 survey, and 83 percent of beneficiaries  reported waiting 2 weeks or less.

Surveys Indicate Few Changes in Civilian Providers’ Acceptance of TRICARE Patients in First Year of Select

There was no change in the percent of civilian providers nationwide who  reported accepting new TRICARE patients if they were also accepting  other new patients after the transition to TRICARE Select. Across all  provider types, 67 percent of providers in the 2019 survey reported  accepting new TRICARE patients if they were also accepting other new  patients; this percentage was not statistically significantly different from  the 2017/2018 surveys. There was also no statistically significant change  among specific provider types—in the 2019 survey, 47 percent of mental  health care providers and about 90 percent of primary care and specialty  care providers reported accepting new TRICARE patients if they were  accepting any new patients.

When we analyzed provider responses by network status and specialty,  the surveys indicated a decrease in the percentage of network mental  health providers who were accepting new TRICARE patients if they were  also accepting other new patients. The percent of these network mental  health providers decreased a statistically significant amount from 91  percent in the 2017/2018 surveys to 84 percent in the 2019 survey. (See  fig. 6.) However, there was no change in the overall percentage of all  network or all nonnetwork providers that were accepting new TRICARE  patients if they were also accepting any new patients—93 percent of  network and 58 percent of nonnetwork providers in the 2019 survey.

When we analyzed provider responses by location, we found that  provider acceptance of new TRICARE patients decreased by a  statistically significant amount in non-PSAs. Specifically, a lower  percentage of providers located in non-PSAs reported accepting new  TRICARE patients if they were accepting other new patients, decreasing  from 72 percent in the 2017/2018 surveys to 68 percent in the 2019  survey. This percentage did not significantly change for providers in  PSAs. (See fig. 7.)

There were few changes in the reasons providers gave for not accepting  TRICARE patients in the first year of TRICARE Select. (See Table 2 for a  list of reasons providers offered in the 2019 survey.) Of 14 categories of  reasons that providers gave, there was a statistically significant change in  two categories between the 2017/2018 surveys to the 2019 survey.  Specifically, the percentage of providers who listed reimbursement as a  reason for not accepting new TRICARE patients declined from 11 percent  to 8 percent, and the percentage of providers who listed that the doctor  was not available or too busy increased from 4 percent to 8 percent.

DOD provided technical comments on a draft of this report, which we  incorporated as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, and other interested parties. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found  on the last page of this report.

Appendix I: GAO Contact and Staff Acknowledgments

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov.

In addition to the contact named above, individuals making key  contributions to this report include Tom Conahan (Assistant Director), A.  Elizabeth Dobrenz and Jeffrey Mayhew (Analysts-in-Charge), Jennie  Apter, Alexander Cattran, Jacquelyn Hamilton, Vikki Porter, and Jeffrey  Tamburello.

Defense Health Care: TRICARE Surveys Indicate Nonenrolled  Beneficiaries’ Access to Care Has Generally Improved, GAO-18-361  (Washington, D.C.: Mar. 29, 2018).

Defense Health Care: More-Specific Guidance Needed for Assessing  Nonenrolled TRICARE Beneficiaries’ Access to Care, GAO-14-384  (Washington, D.C.: Apr. 28, 2014).

Defense Health Care: TRICARE Multiyear Surveys Indicate Problems  with Access to Care for Nonenrolled Beneficiaries, GAO-13-364  (Washington, D.C.: Apr. 2, 2013).

Defense Health Care: DOD Lacks Assurance That Selected Reserve  Members Are Informed About TRICARE Reserve Select, GAO-11-551  (Washington, D.C.: June 3, 2011).

Defense Health Care: Access to Civilian Providers under TRICARE  Standard and Extra, GAO-11-500 (Washington, D.C.: June 2, 2011).

Defense Health Care: 2008 Access to Care Surveys Indicate Some  Problems, but Beneficiary Satisfaction Is Similar to Other Health Plans,  GAO-10-402 (Washington, D.C.: Mar. 31, 2010).

More than 9 million active-duty military servicemembers and their families rely on TRICARE health plans. In January 2018, the Department of Defense offered a new plan—TRICARE Select—for beneficiaries who primarily get care from civilian doctors.

We looked at beneficiary surveys from before and after the new plan. These survey results were similar after the switch to TRICARE Select. However, more beneficiaries reported problems finding some types of civilian doctors who accepted TRICARE after the switch.