HEIDELBERG, Germany - There's a long-time, Department of Defense mandated system in place for determining beneficiary priority at military health care facilities: active-duty first, their family members second, other TRICARE-enrolled beneficiaries next and then space available for all others eligible for care within the DOD system.

While that established process hasn't changed, the declining number of health care providers and available appointments at the Heidelberg Health Center has made it more difficult for many of the other TRICARE-enrolled and space available patients to be seen on a regular basis.

In fact, even Soldiers and their family members are also being increasingly referred to host-nation facilities for treatment, said George Sherman, Chief of the Europe Regional Medical Command Care Call Center, which books all patient appointments at HHC, in addition to other outlying clinics.

"Our priority is to take care of our TRICARE Prime enrollees (active duty and their family members), but we know that off-post care may be necessary in certain cases for this category as well," he said. "Appointments are getting very tight now and we're just as frustrated as our patients that we can't get everybody in."

Due to the Army's transformation of its European footprint and the pending closures of the Heidelberg and Mannheim communities, the lack of access for the space available population is a situation that won't be resolved, and will in fact only increase.

"The affects are starting to be felt and appointments with MTF providers will be harder to come by as we meet our obligations of reducing staff in line with the community's overall troop reductions," explained Col. Lance Raney, deputy commander for clinical services with the Heidelberg Medical Department Activity.

That doesn't mean that quality health care is no longer available to all beneficiaries, Raney emphasized, only that the source of that care will come more through the TRICARE network in the form of local national providers at off-post medical facilities.

The transition to these providers and services is already evident to space-available patients.

"Anybody that is not enrolled in TRICARE Prime or Plus at our facility is considered space available," said Sherman citing as examples Department of Defense civilians, contractors, DOD Dependents Schools employees, TRICARE Standard retirees and all of these groups' respective family members.

Space available patients may call the ERMC Care Call Center after 11 a.m. Monday-Friday to try and schedule a same-day appointment based on cancellations and acute care openings.

The center has 15 booking clerks who cover two shifts from 6:30 a.m. - 5 p.m. The numbers are toll-free civ. 00800-3762-2273, DSN 371-2622, civ. 06221-17-2622.

"By 11 a.m., however, same-day appointments are usually gone," said Sherman. "Space available is all luck, based on timing. Our enrollees have priority and there are hardly any space As getting into our system. As a result, emotions are rising and people calling our clerks sometimes get irate. Our appointment clerks take a beating each day, so I'd like to ask that callers please don't take out their frustrations on our clerks."

Besides, not getting a space available slot isn't necessarily a bad thing, according to Sherman, who explained that utilizing host-nation providers has advantages.

"For effective, long-term health care, you want to be able to have continuity with your provider," he said. "You want a provider who knows you, knows your background and can provide consistency in care. That's why it might actually be better to establish a relationship with a provider downtown."

Developing a consistent care plan with the same host-nation provider will eventually be a necessity for retirees who plan to stay in the area after the health center closes its doors in June 2013.

At that time, a small clinic on Patrick Henry Village will provide limited care for Soldiers and their families, but retirees once enrolled at HHC in TRICARE Plus with a primary care manager will then fall under TRICARE Standard for off-post care.

The primary differences patients see on the local economy are not in the level of care or quality of service, which are compatible with the standards at military treatment facilities, but in the payment options, said Elfinesh Worku, a beneficiary counseling and assistance coordinator with the TRICARE Service Center at the health center.

"Nowadays, many German providers are strict in demanding upfront payments, requiring patients to pay a deposit that can be up to ,2,500 for admission and in-patient care depending on the estimated length of stay," Worku said. "For retirees, they need to file those receipts to receive their 75 percent reimbursement from TRICARE."

Worku mentioned that there is sometimes room for negotiation on the deposit before being admitted and that some hospitals accept Value Added Tax, or VAT, forms.

Private facilities charge the 19 percent VAT, but government hospitals don't, she added.

"Also, patients (space available or TRICARE referrals) filling prescriptions at host nation pharmacies will have to pay up front and then settle the claim through their respective insurance carriers.

Retirees in TRICARE Plus or Standard will need to get a cash register receipt to file with their reimbursement claim for the 75-percent coverage of costs, after their $150 deductible," she said.

In addition, she noted that TRICARE Standard for retirees does not cover the costs of routine eye exams (unless the patient has cataracts or some form of eye disease) or hearing aids. Both of those expenses are out of pocket for the full amount.

But just as with adhering to the priority system for appointments, these health care issues are not new. The difference is that beneficiaries are having to deal with them more so than in the past based on the circumstances of transformation and closure.

"We understand that this is a cultural shift for our community and will be stressful for some, so we will work diligently with all of our beneficiaries and our host-nation partners to ensure this transition of health care services is as seamless as possible," said Raney.

"Our TRICARE Beneficiary Counseling and Assistance Coordinators, along with our Host Nation Patient Liaisons, will work one-on-one with our beneficiaries to help them choose the right treatment facility, book the appointment and offer interpretation services as needed," he said.

"The bottom line is that we will remain focused on ensuring our beneficiaries continue to receive safe, quality health care throughout our transition to closure," Raney said.