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Report to Congressional Requesters:

February 2005:

MILITARY PAY:

Gaps in Pay and Benefits Create Financial Hardships for Injured Army 
National Guard and Reserve Soldiers:

GAO-05-125:

GAO Highlights:

Highlights of GAO-05-125, a report to congressional requesters

Why GAO Did This Study:

In light of the recent mobilizations associated with the Global War on 
Terrorism, GAO was asked to determine if the Army’s overall environment 
and controls provided reasonable assurance that soldiers who were 
injured or became ill in the line of duty were receiving the pay and 
other benefits to which they were entitled in an accurate and timely 
manner. GAO’s audit used a case study approach to provide perspective 
on the nature of these pay deficiencies in the key areas of (1) overall 
environment and management controls, (2) processes, and (3) systems. 
GAO also assessed whether recent actions the Army has taken to address 
these problems will offer effective and lasting solutions.

What GAO Found:

Injured and ill reserve component soldiers—who are entitled to extend 
their active duty service to receive medical treatment—have been 
inappropriately removed from active duty status in the automated 
systems that control pay and access to medical care. The Army 
acknowledges the problem but does not know how many injured soldiers 
have been affected by it. GAO identified 38 reserve component soldiers 
who said they had experienced problems with the active duty medical 
extension order process and subsequently fell off their active duty 
orders. Of those, 24 experienced gaps in their pay and benefits due to 
delays in processing extended active duty orders. Many of the case 
study soldiers incurred severe, permanent injuries fighting for their 
country including loss of limb, hearing loss, and back injuries. 
Nonetheless, these soldiers had to navigate the convoluted and poorly 
defined process for extending active duty service.

Examples of Injured Soldiers with Gaps in Pay and Benefits: 

[See PDF for image]

[End of figure]

The Army’s process for extending active duty orders for injured 
soldiers lacks an adequate control environment and management 
controls—including (1) clear and comprehensive guidance, (2) a system 
to provide visibility over injured soldiers, and (3) adequate training 
and education programs. The Army has also not established user-friendly 
processes—including clear approval criteria and adequate infrastructure 
and support services. Many Army locations have used ad hoc procedures 
to keep soldiers in pay status; however, these procedures often 
circumvent key internal controls and put the Army at risk of making 
improper and potentially fraudulent payments. Finally, the Army’s 
nonintegrated systems, which require extensive error-prone manual data 
entry, further delay access to pay and benefits. 

The Army recently implemented the Medical Retention Processing (MRP) 
program, which takes the place of the previous process in most cases. 
MRP, which authorizes an automatic 179 days of pay and benefits, may 
have resolved many of the processing delays experienced by soldiers. 
However, MRP has some of the same issues and may also result in 
overpayments to soldiers who are released early from their MRP orders. 
Out of 132 soldiers the Army identified as being released from active 
duty, 15 received pay past their release date—totaling approximately 
$62,000. 

What GAO Recommends:

GAO makes 20 recommendations for immediate actions including 
(1) establishing comprehensive policies and procedures, (2) providing 
adequate infrastructure and resources, and (3) making process 
improvements to compensate for inadequate, stovepiped systems. In 
addition, GAO recommends 2 actions, as part of longer term system 
improvement initiatives, to integrate the Army’s order writing, pay, 
personnel, and medical eligibility systems. In its written response to 
our recommendations, DOD briefly described its completed, ongoing, and 
planned actions for each of our 22 recommendations. 

www.gao.gov/cgi-bin/getrpt?GAO-05-125.

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Gregory D. Kutz at (202) 
512-9095 or kutzg@gao.gov.

[End of section]

Contents:

Letter:

Results In Brief:

Background:

Injured and Ill Reserve Component Soldiers Experience Gaps in Pay and 
Benefits, Creating Financial Hardships for Soldiers and Their Families:

The Army Lacks an Effective Control Environment and Management Controls:

Lack of Clear Processes Contributed to Pay Gaps and Loss of Benefits:

Nonintegrated Systems Contribute to Processing Delays:

The Army's New Medical Retention Program Will Not Solve All the 
Problems Associated with ADME:

Conclusion:

Recommendations of Executive Action:

Agency Comments and Our Evaluation:

Appendixes:

Appendix I: Objective, Scope, and Methodology:

Appendix II: Comments From the Department of the Army:

GAO Comments:

Appendix III: GAO Contact and Staff Acknowledgments:

GAO Contact:

Acknowledgments:

Table:

Table 1: Audited Installations:

Figures:

Figure 1: Overview of the Army's ADME Application Process--When 
Operating as Planned:

Figure 2: Effects of Disruptions in Pay and Benefits:


Figure 3: Illustration of Retroactive Rescission of Orders and 
Resulting Impact on Soldiers:

Figure 4: Transaction Flow Between the Army's Order Writing, Pay, 
Personnel, and Medical Eligibility Systems:


Letter February 17, 2005:

The Honorable Tom Davis: 
Chairman, Committee on Government Reform: 
House of Representatives:

The Honorable Christopher Shays: 
Chairman, Subcommittee on National Security, Emerging Threats, and 
International Relations: 
Committee on Government Reform: 
House of Representatives:

The Honorable Todd Russell Platts: 
Chairman, Subcommittee on Government Management, Finance, and 
Accountability: 
Committee on Government Reform: 
House of Representatives:

In response to the September 11, 2001, terrorist attacks, the Army 
National Guard and Army Reserve mobilized and deployed soldiers in 
support of Operations Noble Eagle and Enduring Freedom. When mobilized 
for up to 2 years at a time,[Footnote 1] these soldiers performed 
search and destroy missions against Taliban and al Qaeda members 
throughout Asia and Africa, fought on the front lines in Afghanistan 
and guarded al Qaeda prisoners held at Guantanamo Bay, Cuba. Similarly, 
reserve component soldiers fought on the front lines in Iraq and are 
now assisting in peace-keeping and reconstruction operations in Iraq 
under Operation Iraqi Freedom. In November 2003 and August 2004, we 
reported[Footnote 2] that the existing processes and controls used to 
provide pay and allowances to mobilized reserve component soldiers were 
so cumbersome and complex that neither DOD nor the mobilized Army Guard 
and Reserve soldiers could be reasonably assured of timely and accurate 
pay. During the Army National Guard audit, we identified several 
instances in which injured Guard soldiers experienced gaps in entitled 
active duty pay and associated medical benefits due to problems with 
the Army's process for extending their active duty orders. Mobilized 
reserve component soldiers who are injured or become ill are released 
from active duty and demobilized when their mobilization orders expire 
unless the Army takes steps, at the soldier's request, to extend their 
active duty service--commonly referred to as an active duty medical 
extension (ADME).

Concerned that these soldiers' problems were symptomatic of a broader 
problem in providing timely and accurate pay and related health and 
other benefits to mobilized reserve component soldiers that were 
injured in the line of duty, you asked us to determine if the Army's 
ADME process provided reasonable assurance that injured soldiers 
returning from operations associated with the Global War on 
Terrorism[Footnote 3] were receiving the pay and other benefits to 
which they were entitled in an accurate and timely manner. As such, we 
are reporting on (1) problems experienced by selected injured or ill 
Army Reserve and National Guard soldiers, (2) weaknesses in the overall 
control environment and management, (3) the lack of clear processes, 
and (4) the lack of integrated pay, personnel, and medical eligibility 
systems. During the course of our audit, the Army implemented the 
Medical Retention Processing (MRP) program, which takes the place of 
ADME for soldiers returning from operations in support of the Global 
War on Terrorism.[Footnote 4] Therefore, we also assessed whether the 
MRP program had resolved deficiencies associated with ADME and would 
provide effective and lasting solutions.

To achieve our objectives, we performed work at 10 Army installations 
throughout the country that either mobilized reserve component soldiers 
or, according to Army data, had significant injured or ill reserve 
component populations. To determine what impact these problems were 
having on soldiers and their families and provide perspective on the 
nature of pay deficiencies, we interviewed 38 reserve component 
soldiers who served in the Global War on Terrorism and had experienced 
problems with the active duty medical extension order process at four 
military installations. Using Army pay and administrative records, we 
corroborated information provided by soldiers about disruptions in pay 
and benefits. We were not always able to validate other statements 
injured soldiers made about other types of problems they experienced. 
We also interviewed and obtained relevant documentation from officials 
at the Army Manpower Office[Footnote 5] at the Pentagon, all four of 
the Army's Regional Medical Commands (RMC) in the continental United 
States, and the Army Human Resource Command (HRC) in Alexandria, 
Virginia.

We relied on a case study and selected site visit approach for this 
work, principally because the many previously identified flaws in the 
existing pay processes had not yet been resolved. Compounding this, the 
Army did not maintain reliable, centralized data on the number, 
location, and disposition of mobilized reserve component soldiers who 
had requested to extend their active duty service because they had been 
injured or become ill in the line of duty.[Footnote 6] Therefore, it 
was not possible to statistically test controls or the impact control 
breakdowns had on soldiers and their families.

We performed this work between February 2004 and October 2004 in 
accordance with generally accepted government auditing standards. The 
investigative portion of our work was completed in accordance with 
investigative standards established by the President's Council on 
Integrity and Efficiency. We also reviewed written and technical 
comments provided by the Principal Deputy Under Secretary of Defense 
for Personnel and Readiness, which we have incorporated as appropriate. 
DOD's comments are reprinted in appendix II. Further details on our 
scope and methodology are included in appendix I.

Results In Brief:

The Army lacks an effective control environment and the management 
controls needed to provide reasonable assurance that injured and ill 
reserve component soldiers receive the pay and benefits to which they 
are entitled without interruption. For some soldiers, this resulted in 
being removed from active duty status in the automated systems that 
control pay and access to benefits, including medical care. In 
addition, because these soldiers no longer had valid active duty 
orders, they did not have access to the post exchange--which allows 
soldiers and their families to purchase groceries and other goods at a 
discount. While the Army does not know how many soldiers have 
experienced problems receiving their pay and benefits, of the 38 
reserve component soldiers we interviewed, 24 said that they had 
experienced gaps in their pay and benefits due to delays in processing 
extended active duty orders. Although we did not verify the claims of 
all 24 soldiers, we further developed 10 case studies and verified that 
they had indeed experienced problems receiving their pay and benefits. 
For example, while attempting to obtain care for injuries sustained 
from a helicopter crash in Afghanistan, one Special Forces soldier we 
interviewed fell off his active duty orders four times. During the 
times he was off-orders, he was not paid and he and his family 
experienced delays in receiving medical treatment. In all, he missed 10 
pay periods--totaling $11,924. Although the Army eventually paid him, 
each time he fell off orders and was not paid, he and his family 
struggled financially. Many of the soldiers we interviewed had incurred 
severe, permanent injuries fighting for their country including loss of 
limb, hearing loss, and ruptured disks. Nonetheless, we found that the 
soldier carries a large part of the burden when trying to understand 
and successfully navigate the Army's poorly defined requirements and 
processes for obtaining extended active duty orders.

The Army lacks an adequate control environment and management controls 
over ADME, which is one of the mechanisms[Footnote 7] it uses to 
provide medical treatment for injured or ill reserve component soldiers 
returning from Iraq and Afghanistan when their mobilization orders had 
expired. ADME, as opposed to other means the Army uses to provide 
health care, places soldiers on active duty orders, which then entitles 
soldiers to pay and other active duty benefits.

* First, the Army's guidance for processing ADME orders does not 
clearly define organizational responsibilities or standards for being 
retained on active duty orders, how soldiers will be identified as 
needing an extension, and how and to whom ADME orders are to be 
distributed. Without clear and comprehensive guidance, the Army is 
unable to establish straightforward, user-friendly processes that 
provide reasonable assurance that injured and ill reserve component 
soldiers receive the pay and benefits to which they are entitled 
without interruption. In addition, the guidance erroneously requires 
the personnel cost associated with soldiers on ADME orders to be 
accounted for as a base operating expense, rather than charged to 
contingency operations. We believe the cost of treating injured and ill 
soldiers--including their pay and benefits--who fought in operations 
supporting the Global War on Terrorism should be recorded as an expense 
associated with contingency operations to accurately capture the total 
cost of these operations.

* Second, the Army lacks an integrated personnel system to provide 
visibility over injured or ill reserve component soldiers and as a 
result, sometimes loses track of these soldiers. For example, according 
to one soldier we interviewed, after he was injured in Iraq by a hand- 
detonated land mine and medically evacuated back to the United States 
for treatment, the Army called his wife to attempt to locate him. 
According to the soldier, the Army apparently had no record of his 
injury and transport out of theater and thought he might be absent 
without leave, when in fact, he was in an Army hospital in the United 
States making appointments with Army physicians.

* Finally, the Army has not adequately educated reserve component 
soldiers about ADME or trained Army personnel responsible for helping 
soldiers apply for ADME orders. As a result, many of the soldiers we 
interviewed said that neither they nor the Army personnel responsible 
for helping them clearly understood the process. This confusion 
resulted in delays in processing ADME orders and for some, meant that 
they fell from their active duty orders and lost pay and medical 
benefits for their families.

The Army lacks customer-friendly processes for injured or ill soldiers 
who are trying to extend their active duty service through the ADME 
process--including clear approval criteria and adequate infrastructure 
and support services. Although the Army's procedural guidance, 
discussed previously, describes what forms and documents must be 
submitted as part of an ADME application, the guidance lacks clear 
criteria on the specific information that must be contained in each 
document and well-defined procedures for providing feedback on the 
status of application packages. As a result, soldiers often had to 
submit their applications numerous times before obtaining approval. 
This delay, in turn, caused these soldiers to fall off their active 
duty orders and, at times, interrupted their pay and benefits. For 
example, one Special Forces soldier we interviewed, who lost his leg 
when a roadside bomb destroyed the vehicle he was riding in while on 
patrol for Taliban fighters in Afghanistan, missed three pay periods 
totaling $5,000 because he fell off his active duty orders. Although 
this soldier was clearly entitled to a medical extension, according to 
approving officials at Army Manpower, his application was not 
immediately approved because it did not contain sufficiently current 
and detailed information to justify this soldier's qualifications for 
an active duty medical extension. In addition, at some installations 
the Army did not have adequate support services to help soldiers 
complete their ADME applications and obtain the required medical 
documentation in an efficient and timely manner. For example, one 
injured soldier we interviewed whose original mobilization orders 
expired in January 2003 said that he made over 40 trips to various 
sites at Fort Bragg during the month of January to complete his ADME 
application.

The financial hardships experienced by injured or ill reserve component 
soldiers would have been more widespread had individuals within the 
Army not taken extraordinary steps to keep soldiers in pay status. In 
fact, 7 of the 10 Army installations we visited had created their own 
ad-hoc procedures or workarounds to keep soldiers in pay status. One 
installation we visited issued legitimate, official mobilization orders 
locally to keep soldiers in pay status. However, in doing so, they 
created additional problems--which ultimately resulted in garnishing 
soldiers' pay to straighten out Army accounting and funding issues. In 
most other cases, the installations we visited made unauthorized, 
unsupported adjustments to a soldier's pay records. While effectively 
keeping a soldier in pay status in the pay system, this workaround 
circumvented key internal controls--putting the Army at risk of making 
improper and, as explained later, potentially fraudulent payments. In 
addition, because these soldiers are not on official active duty 
orders, they are not eligible to receive other benefits to which they 
are entitled, including health coverage for their families. For some of 
the soldiers we interviewed, this created significant problems. For 
example, according to one soldier we interviewed, when he was off 
active duty orders due to delays in processing his extension and 
required treatment for nausea and vomiting blood, he was initially 
refused treatment because he was not on active duty orders. His wife 
also lost access to health care each time he was off his active duty 
orders. At the time, his wife was pregnant and was relying on coverage 
through the military's dependent care insurance for her prenatal visits.

Manual processes and non-integrated pay and personnel systems affect 
the Army's ability to generate timely active duty medical extension 
orders and ensure that soldiers are paid correctly. Overall, we found 
the current stovepiped, nonintegrated systems were labor intensive and 
require extensive error-prone manual data entry and reentry. For 
example, the Army's order-writing system does not directly interface 
with the personnel, pay, or medical eligibility systems, which all need 
to be updated in order for soldiers and their families to receive the 
pay and medical benefits to which they are entitled. Instead, once 
approved, hard copy or electronic copy ADME orders are distributed and 
used to manually update the appropriate systems. However, as discussed 
previously, the Army's ADME guidance does not address the distribution 
of ADME orders or clearly define who is responsible for ensuring that 
the appropriate pay, personnel, and medical eligibility systems are 
updated. As a result, ADME orders are not sent directly to the 
individuals responsible for data input but instead, are distributed via 
e-mail and forwarded throughout the Army and the Department of Defense-
-eventually reaching individuals with access to the pay, personnel, and 
medical eligibility systems. For example, once an ADME order is 
processed, it is e-mailed to nine different individuals--four at the 
National Guard Bureau (NGB), four at the Army Manpower office, and one 
HRC in Alexandria Virginia--none of which are responsible for updating 
the appropriate pay and benefit systems. Not only is this process 
vulnerable to input errors, but not sending a copy of the orders 
directly to the individual responsible for input further delays a 
soldier's ability to receive the pay and benefits to which he or she is 
entitled.

The Army's new MRP program, which went into effect May 1, 2004, and 
takes the place of ADME for soldiers returning from operations in 
support of the Global War on Terrorism, should resolve many of the 
processing delays experienced by soldiers applying for ADME by 
simplifying the application process. In addition, unlike ADME, the 
personnel costs associated with soldiers on MRP orders are 
appropriately linked to the contingency operation for which they 
served, and therefore will more appropriately capture these costs 
related to the Global War on Terrorism. While the front-end approval 
process appears to be operating more efficiently than the ADME approval 
process, due to the fact that the first wave of 179-day MRP orders did 
not expire until October 27, 2004, after the completion of our work, we 
were unable to assess how effectively the Army identified soldiers that 
required an additional 179 days of MRP and whether those soldiers will 
experience pay problems or difficulty obtaining new MRP orders. In 
addition, because the Army does not maintain reliable data on the 
current status and disposition of injured soldiers, we could not test 
or determine whether all soldiers who should be on MRP orders were 
applying and getting into the system. Further, MRP has not resolved the 
underlying management control problems that plague ADME--including 
problems associated with the lack of guidance, visibility over 
soldiers, adequate training and education, and manual processes and non-
integrated pay and personnel systems--and in some respects has worsened 
problems associated with the Army's lack of visibility over injured 
soldiers. For example, in September and October of 2004 the Army did 
not know with any certainty how many soldiers were currently on MRP 
orders, how many had returned to active duty, or how many had been 
released from active duty early.

In addition, although MRP authorizes 179 days and eliminates the need 
to reapply for new orders every 30 days, as was sometimes the case with 
ADME, it also presents new challenges. If the Army treats and releases 
soldiers from active duty in less than 179 days, our previous work has 
shown that weaknesses in the Army's process for releasing soldiers from 
active duty and stopping the related pay before their orders have 
expired--in this case before their 179 days is up--often resulted in 
overpayments to soldiers. Although the Army did not have a complete or 
accurate accounting of soldiers who were treated and released from MRP 
early, of the 132 soldiers that the Army identified as released from 
active duty, we found that 15 received pay past their release date-- 
totaling approximately $62,000. For example, one soldier who was 
released from active duty on July 9, 2004 after 43 days on MRP orders 
was overpaid $10,595 between July and November. As of the date of this 
report, we are continuing to investigate soldiers who were overpaid by 
the Army. Finally, because ADME will continue to be used for soldiers 
who are not activated or mobilized as part of the Global War of 
Terrorism--such as soldiers injured in Bosnia or Kosovo or during 
training exercises--it is still important that the ADME problems we 
identified are resolved.

We are making 20 recommendations for immediate actions including (1) 
establishing comprehensive policies and procedures for managing 
programs for treating reserve component soldiers with service-connected 
injuries or illnesses--including MRP and ADME, (2) providing adequate 
infrastructure and resources, and (3) making process improvements to 
compensate for inadequate, stove-piped systems. In addition, GAO 
recommends 2 actions, as part of longer term system improvement 
initiatives, to integrate the Army's order writing, pay, personnel, and 
medical eligibility systems.

We are encouraged that the Army has begun to take action to address the 
problems we identified and are hopeful that it will continue to work 
toward comprehensive, effective solutions for addressing the 
recommendations in this report dealing with reserve component soldiers 
with service-connected injuries or illnesses.

Background:

The Army has several mechanisms for providing needed health care 
services for reserve component soldiers who become injured or ill while 
mobilized on active duty or during military training. Some soldiers 
choose to be released from duty and seek care through their private 
insurers. Eligible soldiers may also seek care through the Veterans 
Administration (VA) or the military's transitional medical assistance 
program.[Footnote 8] Finally, soldiers may also request to remain on 
active duty for medical evaluation, treatment, and/or processing 
through the Army disability evaluation system. Remaining on active duty 
entitles soldiers to continue receiving full pay and allowances as well 
as health care without charge to the soldiers and their dependents.

Until recently, mobilized reserve component soldiers who were receiving 
medical treatment or evaluations for conditions that made them unfit 
for duty have fallen into two groups. The first comprises soldiers who 
are being treated on mobilization orders and is referred to as "medical 
holdover" soldiers. The second group comprises soldiers whose 
mobilization orders have expired and who have applied and been approved 
to be extended on active duty for medical treatment or evaluation 
through ADME orders. Regardless of the classification, the Army's goals 
are the same--to ensure that the soldier attains the optimal level of 
physical or mental condition and to determine whether he or she can be 
returned to duty, released from active duty, or released from military 
service. To facilitate this process the Army relies on (1) case 
managers located at Army Military Treatment Facilities (MTF) who are 
responsible for helping both active and reserve component soldiers 
schedule medical appointments and understand what steps he or she needs 
to take to progress through the treatment or evaluation process (for 
reserve component soldiers this might include applying for ADME) and 
(2) garrison support units and medical hold units located at each 
installation that are responsible for, among other things, helping 
soldiers apply for ADME.

* Medical holdover. This group comprises two categories: ( 1) soldiers 
who were mobilized to active duty, but who for medical reasons were non-
deployable[Footnote 9] and (2) soldiers who were mobilized and deployed 
but sustained line of duty injuries, which make them not fit to return 
to duty. These soldiers are being medically treated while on their 
original mobilization orders. If treatment is not completed and 
soldiers have not been returned to duty or released from duty at the 
end of their orders, these soldiers may apply for an ADME order.

* Active duty medical extension. This group comprises three categories: 
(1) soldiers who were previously in medical holdover, either because 
they were medically non-deployable or had sustained line of duty 
injuries, but whose medical treatment was not completed before their 
mobilization orders expired, (2) soldiers identified during 
demobilization as being not fit for duty due to illnesses or injuries 
sustained or aggravated while on active duty, and (3) soldiers who 
sustained injuries during annual training, weekend drills, or other 
activities associated with their Army National Guard or Army Reserve 
duties. This third group of soldiers, however, falls outside the scope 
of our audit.

Mobilized reserve component soldiers who are in medical holdover are 
attached to a medical hold unit[Footnote 10] and would typically apply 
for ADME orders through that unit.[Footnote 11] If identified during 
demobilization, injured or ill soldiers would typically apply for ADME 
orders through the garrison support unit, which handles the 
mobilization and demobilization of reserve component soldiers. However, 
similar to soldiers injured during weekend drills or annual training, 
mobilized soldiers may also apply for ADME orders through their reserve 
component home state units.

As shown in figure 1, reserve component soldiers wishing to be extended 
on active duty for medical treatment or evaluation are to submit an 
active duty medical extension order application packet to Army Manpower.

Figure 1: Overview of the Army's ADME Application Process--When 
Operating as Planned:

[See PDF for image] 

[A] Soldiers are identified as needing medical treatment through (1) 
mobilization, (2) demobilization, or (3) when the soldier is medically 
evacuated out of theater.

[B] Army Manpower will not begin processing a medical extension order 
request packet until it deems that the packet is complete. Army 
Manpower does not give notice to the requesting installation if more 
detailed information is required to begin the evaluation and approval 
process.

[End of figure] 

Officials in that office evaluate the application packet and make a 
determination of (1) whether the soldier will be approved for medical 
extension orders, (2) the length of medical extension orders, if 
approved, and (3) the military medical treatment facility to which the 
soldier will be attached. The officials make these determinations based 
on the data included in the application packets. According to the 
medical extension procedural guidance, all application packets are to 
include:

* An application form that includes demographic information about the 
soldier and identifies the closest military medical treatment facility 
to the soldiers home to which the soldier will be attached for 
treatment;[Footnote 12]

* A physician's statement describing the soldier's diagnosis, 
prognosis, and care needed, including length of care needed;[Footnote 
13]

* A physical profile, if available;[Footnote 14]

* A commander's statement that the soldier's illness or injury was 
incurred or aggravated in the line of duty; and:

* A letter of consent to remain on active duty.

Army Manpower officials also told us that soldiers must submit a copy 
of their original orders, although we did not find that to be 
explicitly stated in the Procedural Guidance or the Field Operating 
Guide. Figure 1 depicts the design of the ADME process as it was 
intended to be implemented. As discussed later in this report, we found 
numerous breakdowns in the process.

As shown in figure 1, all medical extension application packets were to 
be transmitted to Army Manpower officials in the Pentagon. If a 
soldier's application is not approved, the soldier was to be released 
from active duty and, as discussed previously, was eligible for the 
Army's transitional medical assistance program or possibly VA benefits. 
Once Army Manpower officials approve an ADME application, they e-mail a 
memorandum requesting the extension to the HRC location in St. Louis, 
Missouri, which processes the ADME orders. HRC-St. Louis, the entity 
that ultimately forwards copies of the orders to personnel responsible 
for updating the Army's pay, personnel, and medical eligibility 
systems, then transmits, via e-mail, a copy of the order back to Army 
Manpower and the Army National Guard. Army Manpower distributes copies 
to the medical hold unit, the regional medical command and the soldier. 
This process, as described by Army Manpower officials, was not set 
forth in either the ADME Procedural Guidance or the MEDCOM Field 
Operating Guide.

According to DOD directive, if a soldier--active duty or reserve 
component, including reserve component soldiers mobilized to active 
duty--remains medically unfit for duty for a year, the Army is to 
examine whether the soldier can be returned to duty (RTD), released 
from active duty (REFRAD), or put before a medical evaluation board and 
entered into the physical disability evaluation process to determine 
the likelihood of return to duty.[Footnote 15] The exceptions are 
soldiers who have not yet reached an optimal level of medical care and 
for whom the possibility of return to duty may still be realistic.

The procedural guidance and the field operating guide for ADME do not 
limit the number of times or the number of total days that soldiers may 
be on medical extension orders for the purpose of medical treatment or 
evaluation. Individual medical extension orders can be written for up 
to 179 days or for shorter periods, as appropriate. They may also be 
extended beyond the original end date by providing an updated 
physician's statement detailing the revised healing plan and associated 
timeframe.

Effective May 1, 2004, the Army implemented its new MRP program, which 
takes the place of ADME for soldiers returning from operations in 
support of the Global War on Terrorism, and transferred the approval 
process from the Army Manpower office to HRC - Alexandria. ADME will 
still exist, but only for Army reserve component soldiers who become 
injured or ill during annual training, weekend drills, other activities 
associated with Army National Guard or Army Reserve duty, and military 
operations not associated with the Global War on Terrorism. Eligible 
soldiers who were on ADME orders when MRP was implemented were not 
transferred to MRP orders but if necessary, can apply for MRP when 
their ADME orders expire. Soldiers eligible for MRP are also eligible 
to participate in the Army's new Community Based Health Care Initiative 
(CBHCI) pilot program. The purpose of the initiative is to allow 
selected reserve component soldiers to return to their homes and 
receive medical care in their community rather than remaining at the 
demobilization site. To be selected for the program, soldiers must 
volunteer to remain on active duty, reside in a state participating in 
the pilot program, and reside in a community where appropriate medical 
care is available.

MRP is for soldiers who become injured or ill while on mobilization 
orders in support of the Global War on Terrorism. Soldiers who are 
identified within the first 25 days of mobilization as being medically 
non-deployable for non-service-connected medical conditions will be 
released from active duty. Soldiers who are injured in the line of duty 
or become ill during pre-deployment training or while deployed may 
apply for MRP once the Army has established that (1) the soldier will 
not return to duty within 60 days or (2) the soldier could return to 
duty within 60 days, but will not have at least 120 days remaining on 
his mobilization orders. Soldiers meeting these criteria will be 
reassigned to the installation Medical Retention Processing Unit 
(MRPU). Soldiers are to remain assigned to the MRPU until a medical 
determination is made concerning whether they will return to duty, 
enter the CBHCI program, be released from active duty, retire, or be 
discharged. All MRP orders are cut for 179 days, and the Army's 
implementing instructions state that soldiers will not be extended past 
365 days without being entered into the physical disability evaluation 
process. Further, MRP orders state that separation or REFRAD is 
required upon completion of medical evaluation or treatment, or for 
disability separation.

Injured and Ill Reserve Component Soldiers Experience Gaps in Pay and 
Benefits, Creating Financial Hardships for Soldiers and Their Families:

Poorly defined requirements and processes for extending injured and ill 
reserve component soldiers on active duty have caused soldiers to be 
inappropriately dropped from their active duty orders. For some, this 
has led to significant gaps in pay and health insurance, which has 
created financial hardships for these soldiers and their families. 
Based on our analysis of Army Manpower data during the period from 
February 2004 through April 7, 2004, almost 34 percent of the 867 
soldiers who applied to be extended on active duty orders fell off 
their orders before their extension requests were granted. This placed 
them at risk of being removed from active duty status in the automated 
systems that control pay and access to benefits, including medical care 
and access to the post exchange--which allows soldiers and their 
families to purchase groceries and other goods at a discount.

While the Army Manpower office began tracking the number of soldiers 
who have applied for ADME and fell off their active duty orders during 
that process, the Army does not keep track of the number or soldiers 
who have lost pay or other benefits as a result. Although, logically, a 
soldier who is not on active duty orders would also not be paid, as 
discussed later, many of the Army installations we visited had 
developed ad hoc procedures to keep these soldiers in pay status even 
though they were not on official, approved orders. However, many of the 
ad hoc procedures used to keep soldiers in pay status circumvented key 
internal controls in the army payroll system--exposing the Army to the 
risk of significant overpayment, did not provide for medical and other 
benefits for the soldiers dependents, and sometimes caused additional 
financial problems for the soldier.

Further, because the Army did not maintain any centralized data on the 
number, location, and disposition of mobilized reserve component 
soldiers who had requested ADME orders but had not yet received them, 
we were unable to perform statistical sampling techniques that would 
allow us to estimate the number of soldiers affected. However, through 
our case study work, we identified 38 reserve component soldiers who 
said they had experienced problems with the active duty medical 
extension order process and subsequently fell off their active duty 
orders. Of those, 24 said that they had experienced gaps in their pay 
and benefits. We did not verify the claims of all 24 soldiers; however, 
based on the information that we obtained from these soldiers, we 
further developed 10 case studies and verified that they had indeed 
experienced problems receiving their pay and benefits.

Figure 2 provides an overview of the pay problems experienced by the 10 
case study soldiers we interviewed and the resulting impact the 
disruptions in pay and benefits had on the soldiers and their families. 
According to the soldiers we interviewed, many were living paycheck to 
paycheck, therefore, missing pay for even one pay period created a 
financial hardship for these soldiers and their families.

Figure 2: Effects of Disruptions in Pay and Benefits:

[See PDF for image] 

[A] Missed pay only includes base pay, however, depending on the 
soldiers location and circumstances, they may be entitled to more than 
base pay. There is not a direct correlation between the number of days 
off orders and the amount of pay missed. This occurs for a variety of 
reasons, including differences in soldier rank and pay structure.

[End of figure] 

During our fieldwork, the 10 soldiers described in figure 2 experienced 
pay problems. While the Army ultimately addressed these soldiers' 
problems, absent our efforts and consistent pressure from the 
requesters of the report, it would likely have taken longer for the 
Army to address these soldiers' problems. To illustrate the tremendous 
hardships faced by injured and ill reserve component soldiers applying 
for active duty medical extensions, we have chronicled the experiences 
of three soldiers who were mobilized to active duty for military 
operations in Afghanistan and Iraq. Each of these soldiers had an 
illness and/or injury that was incurred or aggravated while mobilized.

* Case Study #1. As a Staff Sergeant with the Virginia Army National 
Guard, B Company, 3rd Battalion, 20th Special Forces, this soldier was 
called to active duty in January 2002 for a 1 year tour of duty in 
Afghanistan, including search and destroy missions seeking Taliban 
organizations and operatives. In July 2002, while in combat in 
Afghanistan, he was injured in a helicopter crash and sustained 
injuries to both knees and suffered kidney problems. He returned to 
Fort Bragg in October 2002 with his unit to demobilize. As part of this 
process, he first applied for an active duty medical extension in 
November--hoping that his orders would be approved before his original 
mobilization orders expired on January 3, 2003. However, the order to 
extend him on active duty was not approved until approximately a month 
after his original mobilization orders expired, resulting in two missed 
pay periods. Although the nature and extent of his injuries required 
months of treatment, his original medical extension was only approved 
for 90 days. As a result, he had to apply for three additional 
extensions. Each time, delays in processing caused him to fall off 
orders--during which time he missed an additional 8 pay periods. In 
all, he missed 10 pay periods totaling approximately $12,000. Although 
the Army eventually paid him, each time he fell off orders and was not 
paid, he and his family struggled financially. According to the 
soldier, the late pay caused his credit to be negatively affected. He 
was delinquent on 10 payments with four creditors, all coinciding with 
missed pay periods. In addition, because he was often in between 
orders, on several occasions the soldier's medical treatment was 
delayed. For example, according to the soldier, he went to an Army 
medical treatment facility after experiencing nausea and vomiting 
blood, but because he was off orders and his identification card was 
not active, he was initially refused medical treatment. His family also 
suffered each time he fell off orders. Specifically, his wife lost 
access to her dependent insurance benefits from the Army's health care 
contractors. At the time, his wife was pregnant and was relying on the 
dependent insurance coverage for her prenatal visits. According to the 
soldier, the stress caused by these circumstances created so much 
anxiety that he ultimately sought counseling to help him cope with the 
strain. This soldier's ADME problems were resolved as of April 2004.

* Case Study #2: As a Sergeant with the Army National Guard, 72nd 
Military Police Company in Las Vegas, Nevada, this soldier was 
mobilized and deployed with his unit in February 2003 for Operation 
Iraqi Freedom. While in Iraq, he and his unit were responsible for 
guarding and transporting prisoners to and from Baghdad and Abu Ghraib 
prison, securing the courthouse and the surrounding perimeter during 
trials, and suppressing prison riots. In June 2003, during a prison 
riot, he severely injured his left knee and later sustained a head 
injury and had to be medically evacuated for treatment. When he arrived 
at Madigan Army Medical Center at Fort Lewis, Washington, he had 
surgery on his knee and cervical disk. Because his injuries required 
treatment beyond February 2004, the date his mobilization orders would 
expire, he applied for an active duty medical extension in December 
2003. However, his application was not approved until April 2004. 
During most of the time he was off orders, the medical hold unit 
personnel at Fort Lewis were able to keep him in pay status by working 
with the local finance staff to manipulate key fields in the Army's pay 
system. Nonetheless, these ad-hoc workarounds were not always 
effective, and he missed about three pay periods totaling almost 
$3,900. In addition, because he did not have official active duty 
orders, he and his family did not have access to military base benefits 
such as the Post Exchange, precluding them from buying groceries and 
other necessities at a discount, and he was unable to show proof of 
employment in order to receive a home loan or even rent a house for his 
family. As a result, the soldier said that he and his wife and three 
daughters lived in the basement of his father-in-law's house and 
borrowed $10,000 from his mother for living expenses. This soldier's 
ADME problems were resolved as of April 2004. Case Study #10. As a 
Specialist with the Army National Guard, 306 Engineers, located in 
Amityville, New York, this soldier was activated in January 2002 as 
part of Operation Noble Eagle. She initially reported to Fort Dix, New 
Jersey, to be mobilized and deployed but was later sent to Fort 
Stewart, Georgia, to assist that installation's engineering unit with 
vehicle repairs. In April 2002, while at Fort Stewart, she injured her 
left foot during training exercises. While still on her original 
mobilization orders, she had surgery on her foot. However, a year 
later, in January 2003, her original mobilization orders were about to 
expire but she was still having problems walking so she applied for an 
active duty medical extension. Although her original request was 
approved on January 18, 2003, for 30 days, her subsequent request was 
not approved. According to the soldier, she had to reapply for 
extensions numerous times before finally being approved. During this 
time she was off orders for a total of 101 days, totaling $13,475 in 
late pay. According to the soldier, she depleted her savings and had to 
use money saved for her retirement to pay her bills. According to the 
soldier, the 14 pay periods she missed while applying for active duty 
medical extension orders caused her to pay many of her bills late. This 
soldier's ADME problems were resolved as of April 2004.

The Army Lacks an Effective Control Environment and Management Controls:

The Army lacks an effective control environment and the management 
controls needed to provide reasonable assurance that injured and ill 
reserve component soldiers receive the pay and benefits to which they 
are entitled without interruption. Specifically, the Army has not 
provided (1) clear and comprehensive guidance needed to develop 
effective processes to manage and treat injured and ill reserve 
component soldiers, (2) an effective means of tracking the location and 
disposition of injured and ill soldiers, and (3) adequate training and 
education programs for Army officials and injured and ill soldiers 
trying to navigate their way through the ADME process.

Clear and Complete Guidance Lacking:

The Army's implementing guidance related to the extension of active 
duty orders is sometimes unclear or contradictory--creating confusion 
and contributing to delays in processing ADME orders. For example, the 
guidance states that the Army Manpower Office is responsible for 
approving extensions beyond 179 days but does not say what organization 
is responsible for approving extensions that are less than 179 days. In 
practice, we found that all applications were submitted to Army 
Manpower for approval regardless of number of days requested. At times, 
this created a significant backlog at the Army Manpower Office and 
resulted in processing delays. The guidance also is confusing regarding 
where applications for extensions are to be forwarded. It specifies 
sending them to either the National Guard Bureau or the Army Manpower 
office but provides no further explanation for why an application would 
be sent to one organization versus the other.

The Army's regulations[Footnote 16]for addressing the needs of injured 
and ill active component soldiers are intended to also address the 
needs of mobilized injured and ill reserve component soldiers because 
once a reserve component soldier has been on active duty orders in 
excess of 30 days, he or she is entitled to the same health and other 
benefits as active component soldiers. Army regulations[Footnote 17] 
also state that for soldiers on active duty orders for 30 consecutive 
days or more, their active duty orders may be extended for the purpose 
of receiving medical treatment. However, the Army's implementing 
guidance does not clearly define organizational responsibilities, how 
soldiers will be identified as needing an extension, how ADME orders 
are to be distributed, and to whom they are to be distributed. As 
discussed later, the lack of clear guidance has contributed to the 
Army's difficulties in (1) maintaining visibility over the status of 
these soldiers and their applications, (2) training and educating 
soldiers and Army personnel on the procedures for applying for 
extensions, and (3) efficiently updating the appropriate pay, 
personnel, and medical eligibility systems. In addition, according to 
the guidance, the personnel costs associated with soldiers on ADME 
orders should be tracked as a base operating cost. However, we believe 
the cost of treating injured and ill soldiers--including their pay and 
benefits--who fought in operations supporting the Global War on 
Terrorism should be accounted for as part of the contingency operation 
for which the soldier was originally mobilized. This would more 
accurately capture the total cost of these wartime operations.[Footnote 
18]

The Army Lacks an Effective Means of Tracking the Location and 
Disposition of Injured and Ill Soldiers:

As we have reported in the past, the Army's visibility over mobilized 
reserve component soldiers is jeopardized by stovepiped systems serving 
active and reserve component personnel.[Footnote 19] Therefore, the 
Army has had difficulty determining which soldiers are mobilized and/or 
deployed, where they are physically located, and when their active duty 
orders expire. In the absence of an integrated personnel system that 
provides visibility when a soldier is transferred from one location to 
another, the Army has general personnel regulations that are intended 
to provide some limited visibility over the movement of soldiers. 
However, when a soldier is on ADME orders, the Army does not follow 
these or any other written procedures to document the transfer of 
soldiers from one location to another--thereby losing even the limited 
visibility that might otherwise be achievable. Further, although the 
Army has a medical tracking system, the Medical Operational Data System 
(MODS) that could be used to track the whereabouts and status of 
injured and ill reserve component soldiers, we found that, for the most 
part, the installations we visited did not use or update that system. 
Instead, each of the installations we visited had developed its own 
stovepiped tracking system and databases.

According to Army officials, when a soldier departs from one unit or 
installation to another, the Army requires the losing unit to notify 
the gaining unit about the transfer and provide the gaining unit with a 
copy of the soldier's orders. However, these procedures are not 
followed when ADME orders are used to attach a soldier to an MTF for 
treatment. As a result, the receiving MTF is routinely not notified 
about the transfer and therefore, has no knowledge that it is now 
responsible for the injured soldier. Such knowledge is necessary to 
ensure that the soldier is assigned a case manager and receives the 
needed medical attention.

Instead, Army Manpower sends a copy of the soldier's ADME orders to the 
RMC and, according to Army Manpower officials, they expect the RMC to 
forward a copy of the orders to the gaining MTF. However, as discussed 
previously, the Army's procedural guidance does not clearly define how 
ADME orders are to be distributed and does not direct the RMC to 
further distribute the orders. Further, according to officials at Army 
RMCs, they are often inundated with e-mails containing multiple ADME 
order attachments, making it impractical for them to sort through and 
distribute all of them. As a result, we found that ADME orders did not 
routinely make it to the gaining MTF. According to Army officials at 
some of the MTFs we visited, this, combined with the fact that some 
soldiers on ADME orders never report to their new unit, make it 
difficult to ensure that these soldiers get the treatment they need. As 
discussed later, nonintegrated systems and a lack of clear guidance on 
how, to whom, and for what purpose ADME orders are to be distributed 
have also created delays in updating the Army's pay, personnel, and 
medical eligibility systems once a soldier's ADME order is approved.

Case Study Illustration: Army Loses Track of Wounded National Guard 
Soldier: 

A Specialist with the Nevada Army National Guard, 72nd MP Company, was 
mobilized on February 10, 2003, to active duty as part of Operation 
Iraqi Freedom. He and his unit were mobilized through Fort Lewis, 
Washington, and sent to Iraq. His unit provided security for Abu Ghraib 
prison, including reopening the prison and securing Iraqi detainees; 

On June 27, 2003, while on duty outside the prison near Baghdad, the 
vehicle in which the soldier was riding was struck by a hand-detonated 
land mine. The soldier and others in his vehicle were injured. He was 
medically evacuated from the scene of the attack for treatment of 
multiple injuries including a blown ear drum with complete hearing loss 
in his right ear and partial hearing loss in the left, large cuts and 
bruises over his left eye and forehead, fracture to the left elbow and 
left wrist, crushed (deformed) right index finger, and shrapnel on the 
left side of his upper body; 

He was flown from Iraq to Kuwait and then to Lundsthul Hospital in 
Germany for additional care. After a week or so at the hospital in 
Germany, the soldier was cleared to go back to the United States to 
continue his medical care. According to the soldier, he was told that 
he must have "closed toe shoes" in order to take the flight home or he 
would be strapped down to a gurney the entire flight. The soldier only 
had flip-flops since at the time of the attack, it was necessary to cut 
off his clothing and shoes to care for his wounds; 

After being told by the hospital chaplain that shoes were not 
available, he was given permission to leave the hospital to obtain 
shoes and clothing. He proceeded to take the hospital shuttle bus to 
Ramstien Air Base, approximately 15 minutes away. The soldier told us 
that he walked approximately 2 miles to the Post Exchange, wearing flip-
flops and torn clothing from the attack, along with stitches and 
slings. Further, he was severely hearing impaired and in pain. After 
purchasing shoes and toiletry items, at his own expense, he took a cab 
back to Lundstuhl Hospital; 

Once he got to Fort Lewis, Washington, he was transported by bus to 
Madigan Army Hospital. On or about July 7, 2003, the soldier's wife 
told us that personnel from Fort Lewis contacted her at their home in 
Las Vegas. The Army could not locate the soldier and wanted to know if 
his spouse knew his location. Personnel from Fort Lewis thought he 
might be AWOL. He was in fact at the Army hospital at Fort Lewis making 
medical appointments with physicians. Eventually he was placed on 
remote care at Nellis Air Force base located near his home in Las 
Vegas; 

On or about July 25, 2003 while on convalescent leave in Las Vegas the 
family was contacted by a member of the U.S. Army stating that the 
soldier had been injured in Baghdad and was in a hospital in Germany. 
The soldier had been in the States for 20 days.


Although MODS, if used and updated appropriately, could provide some 
visibility over injured and ill active and reserve component soldiers-
-including soldiers who are on ADME orders, 8 of the 10 installations 
we visited did not routinely use MODS. MODS is an Army Medical 
Department (AMEDD) system that consolidates data from over 15 different 
major Army and Department of Defense data bases. The information 
contained in MODS is accessible at all Army MTFs and is intended to 
help Army medical personnel administer patient care. For example, as 
soldiers are approved for ADME orders, the Army Manpower office enters 
data indicating where the soldier is to receive treatment, to which 
unit he or she will be attached, and when the soldier's ADME orders 
will expire. However, as discussed previously, the Army has not 
established written standard operating procedures on the transfer and 
tracking of soldiers on ADME orders. Therefore, the installations we 
visited were not routinely looking to MODS to determine which soldiers 
were attached to them through ADME orders. When officials at one 
installation did access MODS, the data in MODS indicated that the 
installation had at least 105 soldiers on ADME orders. However, 
installation officials were only aware of 55 soldiers who were on ADME 
orders. According to installation officials, the missing soldiers never 
reported for duty and the installation had no idea that they were 
responsible for these soldiers.

Further, although MODS will generate reports that show when a reserve 
component soldier's orders are within 30, 60, or 90 days of expiration, 
only two of the locations we visited said that they used MODS for this 
purpose--noting that they used other local systems in conjunction with 
MODS. Officials at the other installations discounted the utility of 
MODS for managing soldiers on ADME orders because the data were often 
inaccurate or incomplete. Further, MODS does not contain information on 
who has applied for ADME or the status of ADME applications. Therefore, 
all of the installations we visited used their own local systems and/or 
spreadsheets to track the status of soldiers who were nearing the end 
of their mobilization orders, were applying for ADME, and were on ADME 
orders.

The Army Lacks Adequate Training and Education Programs:

The Army has not adequately trained or educated Army staff or reserve 
component soldiers about ADME. The Army personnel responsible for 
preparing and processing ADME applications at the 10 installations we 
visited received no formal training on the ADME process. Instead, these 
officials were expected to understand their responsibilities through on-
the-job training. However, the high turnover caused by the rotational 
nature of military personnel, and especially reserve component 
personnel who make up much of the garrison support units that are 
responsible for processing ADME applications, limits the effectiveness 
of on-the-job training. Once these soldiers have learned the 
intricacies of the ADME process, their mobilization is over and their 
replacements must go through the same on-the-job learning process. For 
example, 9 of the 10 medical hold units at the locations we visited 
were staffed with reserve component soldiers.

In addition, the Army has not developed nor implemented any ADME 
training or education for soldiers and their commanders. In the absence 
of education programs based on sound policy and clear guidance, 
soldiers have established their own informal methods--using Internet 
chat rooms and word-of-mouth--to educate one another on the ADME 
process. Unfortunately, the information they receive from one another 
is often inaccurate and instead of being helpful, further complicates 
the process. For example, one soldier was told by his unit commander 
that he did not need to report to his new medical hold unit after 
receiving his ADME order. While this may have been welcome news at the 
time, the soldier could have been considered absent without leave. 
Instead, the soldier decided to follow his ADME order and reported to 
his assigned case manager at the installation.

Case Study Illustration: Guard Soldier Loses Pay and Medical Benefits:  

A Sergeant First Class mobilized on June 23, 2002, under Operation 
Enduring Freedom orders and was deployed to Afghanistan in August 2002. 
On September 17, 2002, he was injured and suffered a torn rotator cuff, 
broken shoulder blade, and torn ligaments in his shoulder. He was 
medically evacuated back to Fort Bragg and assigned to the 2125th 
Garrison Support Unit while he was on his original set of mobilization 
orders. The Sergeant told us that he received very little support from 
unit officials and had great difficulty getting appointments to see a 
doctor to get the proper medical forms completed. For example, he did 
not get to see a doctor for 6 months after surgery to repair his 
shoulder. He was given guidelines by the unit to use in preparing his 
ADME packet, but the unit rejected his packet and he was told he used 
the wrong form--even though he had used the request form included in 
their own guidelines. The Sergeant indicated that the civilian in 
charge of the ADME process at the Fort Bragg medical holding unit did 
not have a real understanding of the process. Further, the soldier 
stated that the commander of the medical holding company was also 
unfamiliar with the process; 

As a result of these problems, the Sergeant's orders lapsed and he 
missed one pay period before he was granted ADME. Further, because his 
active duty orders had expired, according to the soldier, he was not 
admitted to the base and missed several medical appointments. He also 
said that, because he was off his active duty orders, his wife had to 
pay for treatment for an illness out of her own pocket.

Lack of Clear Processes Contributed to Pay Gaps and Loss of Benefits:

The Army lacks customer-friendly processes for injured and ill soldiers 
who are trying to extend their active duty orders so that they can 
continue to receive medical care. Specifically, the Army lacks clear 
criteria for approving ADME orders, which may require applicants to 
resubmit paperwork multiple times before their application is approved. 
This, combined with inadequate infrastructure for efficiently 
addressing the soldiers' needs, has resulted in significant processing 
delays. Finally, while most of the installations we reviewed took 
extraordinary steps to keep soldiers in pay status, these steps often 
involved overriding required internal controls in one or more systems. 
In some cases, the stop gap measures ultimately caused additional 
financial hardships for soldiers or put the Army at risk of 
significantly overpaying soldiers in the long run.

The Army Lacks Criteria for Approving ADME Orders:

Although the Army Manpower office issued procedural guidance in July of 
2000 for ADME and the Army Office of the Surgeon General issued a field 
operating guide in early 2003, neither provides adequate criteria for 
what constitutes a complete ADME application package. The procedural 
guidance lists the documents that must be submitted before an ADME 
application package is approved; however, the criteria for what 
information is to be included in each document is not specified. In the 
absence of clear criteria, officials at both Army Manpower and the 
installations we visited blamed each other for the breakdowns and 
delays in the process.

Soldiers applying for ADME orders are required to submit an application 
package to the Army Manpower office that includes, among other things, 
(1) evidence that the soldier's injury was sustained in the line of 
duty and (2) a physician's statement outlining the diagnosis, 
prognosis, and treatment plan. Officials at the Army Manpower office 
and many of the Army installations we visited agree that problems with 
this documentation create one of the greatest barriers to processing 
ADME orders in a timely manner and ensuring that soldiers do not fall 
off their active duty orders. However, this is where their agreement 
ends.

According to Army Manpower officials, delays in processing have 
resulted for two reasons: (1) soldiers do not apply for ADME until 
their orders have expired or are about to expire and (2) soldiers do 
not submit complete application packages. According to Army Manpower 
statistics, in February 2004, the first month they began tracking 
application statistics, 34 percent of the applications submitted were 
received after the soldier's active duty orders had expired and another 
47 percent were received within 30 days of expiration. In addition, 
they claimed that 87 percent of ADME applications they reviewed were 
incomplete and therefore could not be processed without additional 
information.

In contrast, according to officials at the 10 installations we visited, 
soldiers applying for ADME fall off their active duty orders because 
(1) Army Manpower does not begin processing application packages until 
a soldier's active duty orders are set to expire and (2) it is not 
clear exactly what medical documentation is required for approval and 
the requirements often change without notice. Officials at the 10 
installations we visited said that, generally, they could compile the 
information needed for an ADME application packet in about a week, but 
it typically took the Army Manpower office 60 to 90 days to process the 
application. Further, once the package was submitted, they would 
receive nothing from Army Manpower indicating that the packet had been 
received or was being evaluated. Instead, installations would 
periodically inquire as to the status of the application. It was often 
only upon inquiry that installation officials would learn that the 
medical documentation provided was inadequate or that the package was 
never received.

Case Study Illustration: ADME Extension Denied to Soldier who Lost Leg 
in Roadside Attack:  

A Sergeant First Class with B Company, 20th Special Forces, Alabama, 
was deployed to Afghanistan in September 2002. On February 19, 2003, 
while on patrol for Taliban fighters, the soldier's vehicle was 
destroyed by a roadside bomb. He and other members of his unit suffered 
serious injuries. He lost a leg and was immediately transferred to 
Germany and then on to Walter Reed Army Medial Center. He had about 15 
surgeries on his leg and was receiving physical therapy for his 
prosthetic leg. When his mobilization orders expired on January 3, 
2004, he had to apply for ADME. As with many of the soldiers we 
interviewed, the Sergeant had difficulty navigating the ADME process, 
despite the assistance of the Special Forces Liaison. After missing 
three pay periods and over $5,000 in pay, ADME was approved through May 
31, 2004. While waiting for his medical examination board, which had 
been cancelled four times, the Sergeant applied for an ADME extension. 
On June 2, 2004, an e-mail was received from Army Manpower stating that 
"current and more detailed medical documents were needed to evaluate 
this soldier's qualifications for ADME." As a result, according to this 
soldier, who incurred a grave injury in service to his country, he was 
denied health insurance for his family for over 1 month and had to 
borrow money from his brother to pay his mortgage. According to the 
soldier, in July 2004, he completed the medical board process to 
receive his disability pay, was released from active duty, and returned 
home.

According to installation officials, the Army Manpower office will not 
accept ADME requests that contain documentation older than 30 days. 
However, because it often took Army Manpower more than 30 days to 
process ADME applications, the documentation for some applications 
expired before approving officials had the opportunity to review it. 
Consequently, applications were rejected and soldiers had to start the 
process all over again. Although officials at the Army Manpower office 
denied these assertions, the office did not have policies or procedures 
in place to ensure that installations were notified regarding the 
status of soldiers' applications or clear criteria on the sufficiency 
of medical documentation. For example, one soldier we interviewed at 
Fort Lewis had to resubmit his ADME applications three times over a 3- 
month period--each time not knowing whether the package was received 
and contained the appropriate information. According to the soldier, 
weeks would go by before someone from Fort Lewis was able to reach the 
Army Manpower office to determine the status of his application and 
when they did, he was told each time that he needed more current or 
more detailed medical documentation. Consequently, it took over 3 
months to process his orders during which time he fell off his active 
duty orders and missed 3 pay periods totaling nearly $4,000.

In an environment that lacks clear criteria on what constitutes a 
complete application package and well-defined processes for providing 
feedback on the status of application packages, it is not surprising 
that soldiers have fallen out of pay status because their current 
orders--mobilization or ADME--expired before their ADME orders or ADME 
extensions came through.

The Army Has Not Consistently Provided the Infrastructure Needed to 
Support Injured and Ill Soldiers:

The Army has not consistently provided the infrastructure needed-- 
including convenient support services--to accommodate the needs of 
soldiers trying to navigate their way through the ADME process. This, 
combined with the lack of clear guidance discussed previously and the 
high turnover of the personnel who are responsible for helping injured 
and ill solders through the ADME process, has resulted in injured and 
ill soldiers carrying a disproportionate share of the burden for 
ensuring that they do not fall off their active duty orders to thereby 
receive the pay and benefits to which they are entitled. This has left 
many soldiers disgruntled and feeling like they have had to fend for 
themselves.

As the mobilization orders for the first wave of injured and ill 
reserve component soldiers coming back from Iraq and Afghanistan began 
to expire in 2003, according to Army officials, the Army was not 
prepared and lacked the infrastructure to process their ADME 
applications. For instance, case managers now play an important role in 
ensuring that both reserve component and active Army soldiers receive 
the medical care they need so that they can return to duty, be released 
from active duty, or separate from military service. However, in 
January 2003, the Army had very few case managers to deal with the 
thousands of injured and ill soldiers--both active duty and reserve 
component--returning to the Army's 14 demobilization sites. This 
mirrors the comments of some of the soldiers we interviewed, who found 
the ADME application process in disarray and not organized in a fashion 
that made it easy for soldiers to obtain all the appropriate documents 
and medical appointments needed to successfully apply for and obtain 
ADME orders. For example, one injured soldier we interviewed whose 
original mobilization orders expired in January 2003 recalls making 
over 40 trips to various sites at Fort Bragg during the month of 
January to complete his ADME application.

Case Study Illustration: Army Reserve and National Guard Liaisons 
Assume Responsibility for ADME in the Absence of an Established 
Infrastructure:  

In July 2002, one Army Reserve National Guard liaison at Walter Reed 
Medical Center observed that numerous injured and ill soldiers were 
falling off orders and were losing pay and benefits. He advised his 
commander of the problem and unofficially began assisting soldiers with 
ADME issues; 

There wasn't any funding or furniture for work space because this was 
not an official office. Therefore, he and a couple of other soldiers 
rummaged through the trash and found some old office furniture, which 
they used to establish an operating base from which to work. Since that 
time, these soldiers have used their own money and own time--making 
frequent trips to local office supply stores to purchase supplies and 
keep the office running. According to the soldier who started the 
office, they have spent about three hundred dollars out of pocket for 
office supplies; 

The soldier who started the office had received some information on the 
process in a related workshop he had taken but no formal training was 
provided to any of the soldiers working in the office as to how the 
ADME process worked. Instead, they learned through trial and error. 
Further, in 2002, there were no case managers at Walter Reed. 
Consequently, soldiers were responsible for making medical appointments 
and managing their own care. If soldiers were severely injured they 
were not capable of preparing an ADME packet and there was no one 
assigned to assist them. The case manager system, which was established 
in May of 2004, has helped considerably in this regard. However, the 
process, and the amount of time it takes to process ADME orders have 
not improved.

At the time of our site visits some installations were still 
experiencing difficulties, particularly those that handle mobilization 
and demobilization of soldiers. For instance, at Fort Lewis, one of the 
Army's largest mobilization/demobilization sites, the medical hold unit 
to which ADME soldiers are attached has had to move its soldiers on 
three occasions to different barracks to make room for demobilizing 
soldiers.

Case Study Illustration: Injured Guard Soldier Sent to Two Bases Where 
No Medical Treatment Was Available:  

A Sergeant with G Company, 140th Aviation unit, California, was 
deployed to Iraq on March 6, 2003. On or about March 27, 2003, the 
soldier injured his back when he was thrown to the ground during a 
sandstorm. He re-injured his back in April 2003 loading a helicopter. 
He was diagnosed with two bulging discs and curvature of the spine. The 
soldier was medically evacuated to Andrews Air Force Base, Maryland, 
for medical treatment. While being transported, his stretcher was 
dropped, further compounding his injuries. After 2 weeks at Andrews, 
the soldier told us that he received pain medication but no medical 
treatment. He was then transported to Travis Air Force Base in 
California to continue his treatment. In October 2003, because he was 
an Army soldier being treated at an Air Force facility, he was ordered 
to report to the Army hospital at Fort Lewis, Washington, for further 
treatment. Upon arrival, he turned over his medical records to Fort 
Lewis personnel. The records were lost and never found. According to 
the soldier, he was housed in World War II era barracks. The mess hall 
was about a one-half mile walk from the barracks--difficult for him to 
navigate with a cane and even harder for other soldiers with more 
severe injuries. The barracks were not wheelchair accessible and the 
more able-bodied soldiers eventually built a wheelchair ramp. During 
his 3 weeks at Fort Lewis, the soldier received pain medication but no 
medical treatment. The doctors at Fort Lewis determined that it would 
be in his best interest to return to Travis for treatment and he was 
reassigned there. Although this ordeal took place while the soldier was 
on his original mobilization orders, it illustrates the inadequacies of 
the infrastructure used to house and treat injured soldiers and the 
difficulty faced by injured soldiers when they are transferred from one 
location to another.

Over time, the Army has begun to make some progress in addressing its 
infrastructure issues. At the time of our visit, we found that some 
installations had added new living space or upgraded existing space to 
house returning soldiers. For example, Walter Reed has contracted for 
additional quarters off base for ambulatory soldiers to alleviate the 
overcrowding pressure and Fort Lewis had upgraded its barracks to 
include, among other things, wheelchair accessible quarters. Also, 
installations have been adding additional case managers to handle their 
workload. Case managers are responsible for both active and reserve 
component soldiers, including injured and ill active duty soldiers, 
reserve component soldiers still on mobilization orders, reserve 
component soldiers on ADME orders, and reserve component soldiers who 
have inappropriately fallen off active duty orders. As of June 2004, 
according to the Army, it had 105 case managers, and maintained a 
soldier-to-case-manager-ratio of about 50-to-1 at 8 of the 10 locations 
we visited while conducting fieldwork. Finally, to the extent possible, 
several of the sites we visited co-located administrative functions 
that soldiers would need--including command and control functions, case 
management, ADME application packet preparation, and medical treatment. 
They also made sure that Army administrative staff, familiar with the 
paperwork requirements, filled out all the required paperwork for the 
soldier. Centralizing document preparation reduces the risk of 
miscommunication between the soldier and unit officials, case managers, 
and medical staff. It also seemed to reduce the frustration that 
soldiers would feel when trying to prepare unfamiliar documents in an 
unfamiliar environment.

Ad Hoc Procedures to Keep Soldiers in Pay Status Circumvented Key 
Internal Controls and Created Additional Problems for Soldiers:

The financial hardships discussed previously that were experienced by 
some soldiers would have been more widespread had individuals within 
the Army not taken it upon themselves to develop ad hoc procedures to 
keep these soldiers in pay status. In fact, 7 of the 10 Army 
installations we visited had created their own ad-hoc procedures or 
workarounds to (1) keep soldiers in pay status and (2) provide soldiers 
with access to medical care when soldiers fell off active duty orders. 
In many cases, the installations we visited made adjustments to a 
soldiers pay records. While effectively keeping a soldier in pay 
status, this work-around circumvented key internal controls--putting 
the Army at risk of making improper and potentially fraudulent 
payments. In addition, because these soldiers are not on official 
active duty orders they are not eligible to receive other benefits to 
which they are entitled, including health coverage for their families. 
Conversely, one installation we visited issued official orders locally 
to keep soldiers in pay status. However, in doing so, they created a 
series of accounting problems that resulted in additional pay problems 
for soldiers when the Army attempted to straighten out its accounting.

Many of the installations we visited made informal agreements with 
staff at the installation's payroll office to keep solders in pay 
status until their ADME orders could be approved. When a soldier's ADME 
packet was submitted to Army Manpower, the case manager or medical hold 
unit commander would ask a trusted coworker at the installation's 
payroll department to extend the soldier's orders. Installation payroll 
personnel, who have authorized access to the Army's payroll system, 
then enter an unauthorized transaction. Specifically, payroll personnel 
manually adjust the soldier's original mobilization order end date and, 
in effect, circumvented key controls which are intended to ensure that 
only valid transactions supported by valid active duty orders are 
entered into the pay system. While these soldiers are technically not 
on active duty orders, they continue to be paid as if they were. 
Subsequently, when the ADME order was issued and sent to the soldier, 
it was backdated to the original mobilization order end date. 
Backdating the ADME order makes it appear as if the soldier has been on 
orders the entire time. This ad-hoc workaround has three drawbacks. 
First, the practice of routinely altering pay records without support 
creates an environment that increases the risk of improper or 
fraudulent payments. For example, in such an environment, payroll 
personnel could arrange to extend the order end dates for numerous 
soldiers, allowing them to receive pay after they have been released 
from active duty, and, in return, ask for a portion of the fraudulent 
payment. Second, although soldiers have rarely been denied ADME, if 
this were to happen, the soldier would then be responsible for repaying 
the amounts received after the mobilization orders expired--assuming 
that the case manager or medical hold unit commander tells the finance 
office that a soldier's ADME packet was denied. Finally, while the 
soldier has access to medical care on the installation, his family 
would not be able to use civilian providers under the Army's contractor 
health provider network. For example, if a soldier's family relies on 
TRICARE-Remote--DOD's health care plan intended to treat eligible 
beneficiaries through private sector health care providers--as their 
primary health insurance, the family's benefits cannot be extended 
without a copy of valid active duty orders. Similarly, without valid 
active duty orders the family would not have access to other benefits 
such as the Post Exchange for reduced price groceries.

According to Army officials at the installations we reviewed, they 
understood that exploiting the weaknesses in the Army's payroll systems 
was not in line with Army procedures, but, understandably, told us that 
they were not left with many choices. According to these officials, 
they were motivated, in part, because it was the right thing to do for 
the soldier, and, in part, because they feared retribution. They noted 
that soldiers who fell out of pay status frequently complained to their 
congressmen or the Inspector General or the installation commander. 
Such complaints could result in an investigation where installation 
officials, who were the ones with the most direct contact with the 
disgruntled soldiers, would be called on to explain the reasons for 
soldiers' orders not being processed. Since order processing and 
approval are actions over which the installation officials had no 
control, but which they feared they would have to explain, medical hold 
unit commanders began keeping logs of what specific information was 
sent to Army Manpower and when it was sent. They also began looking for 
ways to keep soldiers from falling out of pay status, even if those 
actions involved circumventing internal controls, in an attempt to 
forestall the possibility of undergoing an investigation if someone 
fell off orders.

In contrast, the installation commander at one installation was 
unwilling to override key controls in the pay system and instead issued 
new orders locally to extend the soldiers' mobilization. While this 
kept the soldier in active duty pay status, it created accounting 
problems for the installation finance office that ultimately caused pay 
problems for soldiers. As injured and ill reserve component soldiers 
requiring ADME neared the end of their original mobilization order end 
date, the installation's Adjutant General's office would issue new 
orders to extend soldiers' mobilization. The extension was typically 90 
days long, the average amount of time based on their experience that it 
took to receive ADME orders. However, as discussed previously, the 
personnel costs associated with soldiers on mobilization orders are 
recorded in accounts related to contingency operations, whereas, the 
personnel costs for soldiers on ADME orders are recorded in accounts 
related to base operations costs. Therefore, when soldiers received 
their backdated ADME orders, installation payroll and accounting 
personnel would reallocate costs previously charged to a contingency 
operations account to the base operating account.

To do this, as shown in figure 3, the payroll office retroactively 
rescinded the local order used to keep the soldier in pay status, which 
created a debt in the amount of pay that the soldier received while on 
that order. Because the soldier then owed the government money, albeit 
from a contrived debt, a significant portion of the soldier's wages 
were garnished to pay back the debt as he or she began receiving ADME 
paychecks, which are accounted for as a base operations expense.

Figure 3: Illustration of Retroactive Rescission of Orders and 
Resulting Impact on Soldiers:

[See PDF for image] 

[End of figure] 

Figure 3 shows that 66 percent of this soldier's paycheck was garnished 
until the monies owed from pay received and accounted for as a 
contingency operations expense were repaid in full. For example, one 
soldier's paycheck suddenly dropped to $1,550 from $3,625 without 
explanation. Upon repayment, the soldier then began receiving 166 
percent of his pay until he was compensated for the amount previously 
garnished. As he later found out, the Army was garnishing his pay to 
reimburse the contingency operations account. Not surprisingly, this 
creates serious confusion and a significant cash flow problem for most 
soldiers until the Army reconciles the two amounts. In addition, the 
effort required to correct the Army's accounting creates an 
administrative burden that could have been avoided had the Army 
adequately addressed its processes to efficiently process soldiers' 
ADME orders. Finally, as discussed previously, we believe that the cost 
of treating and paying soldiers whose injuries resulted in support of 
the Global War on Terrorism should be linked to the contingency 
operation for which the soldier was originally mobilized. This would 
more accurately capture the total cost of the operation.

Nonintegrated Systems Contribute to Processing Delays:

Manual processes and nonintegrated order writing, pay, personnel, and 
medical eligibility systems also contribute to processing delays which 
affect the Army's ability to update these systems and ensure that 
soldiers on ADME orders are paid in an accurate and timely manner. 
Overall, we found that the current stove-piped, nonintegrated systems 
were labor-intensive and require extensive error-prone manual data 
entry and re-entry. Therefore, once Army Manpower approves a soldiers 
ADME application and the ADME order is issued, the ADME order does not 
automatically update the systems that control a soldier's access to pay 
and medical benefits. In addition, as discussed previously, the Army's 
ADME guidance does not address the distribution of ADME orders or 
clearly define who is responsible for ensuring that the appropriate 
pay, personnel, and medical eligibility systems are updated, so 
soldiers and their families receive the pay and medical benefits to 
which they are entitled. As a result, ADME orders were sent to multiple 
individuals at multiple locations before finally reaching individuals 
who have the access and authority to update the pay and benefits 
systems, which further delays processing.

As shown in figure 4, once Army Manpower officials approve a soldier's 
ADME application, they e-mail a memorandum to HRC-St. Louis authorizing 
the ADME order. The Automated Order Resource System (AORS), which is 
used to write the order, does not directly interface nor automatically 
update the personnel, pay, or medical eligibility systems. Instead, 
once HRC-St. Louis cuts the ADME order it e-mails a copy of the order 
to nine different individuals--four at the Army Manpower office, four 
at the NGB headquarters, and one at the HRC in Alexandria Virginia-- 
none of which are responsible for updating the pay, personnel, or 
medical eligibility systems.

Figure 4: Transaction Flow Between the Army's Order Writing, Pay, 
Personnel, and Medical Eligibility Systems:

[See PDF for image] 

[End of figure] 

As shown in figure 4, Army Manpower, upon receipt of ADME orders, e- 
mails copies to the soldier, the medical hold unit to which the soldier 
is attached, and the RMC. Again, none of these organizations has access 
to the pay, personnel, or medical eligibility systems. Finally, NGB 
officials e-mail copies of National Guard ADME orders to one of 54 
state-level Army National Guard personnel offices and HRC-Alexandria e- 
mails copies of Reserve ADME orders to the Army Reserve's regional 
personnel offices. HRC-Alexandria also sends all Reserve orders to the 
medical hold unit at Walter Reed Army Hospital. When asked, the 
representative at HRC-Alexandria who forwards the orders did not know 
why orders were sent to Walter Reed when many of the soldiers on ADME 
orders were not attached or going to be attached to Walter Reed. The 
medical hold unit at Walter Reed that received the orders did not know 
why they were receiving them and told us that they filed them.

At this point in the process, of the eight organizations that receive 
copies of ADME orders, only two--the ANG personnel office and the Army 
Reserve personnel office--use the information to initiate a pay or 
benefit-related transaction. Specifically, the Guard and Reserve 
personnel offices initiate a transaction that should ultimately update 
the Army's medical eligibility system, Defense Enrollment Eligibility 
System (DEERS). To do this, the Army National Guard personnel office 
manually inputs a new active duty order end date into the Army National 
Guard personnel system, Standard Installation Division Personnel 
Reporting System (SIDPERS). In turn, the data from SIDPERS are batch 
processed into the Total Army Personnel Database-Guard (TAPDB-G), and 
then batch processed to the Reserve Components Common Personnel Data 
System (RCCPDS). The data from RCCPDS are then batch processed into 
DEERS--updating the soldier's active duty status and active duty order 
end-date. Once the new date is posted to DEERS, soldiers and family 
members can get a new ID card at any DOD ID Card issuance 
facility.[Footnote 20] The Army Reserve finance office initiates a 
similar transaction by entering a new active duty order end date into 
the Regional Level Application System (RLAS), which updates Total Army 
Personnel Database-Reserve (TAPDB-R), RCCPDS, and DEERS through the 
same batch process used by the Guard.

As discussed previously, the Army does not have an integrated pay and 
personnel system. Therefore, information entered into the personnel 
system (TAPDB) is not automatically updated in the Army's pay system, 
Defense Joint Military Pay System-Reserve Component (DJMS-RC).

Instead, as shown in figure 4, after receiving a copy of the ADME 
orders from Army Manpower, the medical hold unit and/or the soldier 
provide a hard copy of the orders to their local finance. Using the 
Active Army pay input system, Defense Military Pay Office system (DMO), 
installation finance office personnel update DJMS-RC. Not only is this 
process vulnerable to input errors, but also, not sending a copy of the 
orders directly to the individual responsible for input further delays 
a soldier's ability to receive the pay and benefits to which the 
soldier is entitled.

The Army's New Medical Retention Program Will Not Solve All the 
Problems Associated with ADME:

The Army's new MRP program, which went into effect May 1, 2004, and 
takes the place of ADME for soldiers returning from operations in 
support of the Global War on Terrorism, has resolved many of the 
processing delays experienced by soldiers applying for ADME by 
simplifying the application process. In addition, unlike ADME, the 
personnel costs associated with soldiers on MRP orders are 
appropriately linked to the contingency operation for which they 
served, and, therefore, will more appropriately capture the costs 
related to the Global War on Terrorism. While the front-end approval 
process appears to be operating more efficiently than the ADME approval 
process, due to the fact that the first wave of 179-day MRP orders did 
not expire until October 27, 2004, after we completed our work, we were 
unable to assess how effectively the Army identified soldiers that 
required an additional 179 days of MRP and whether those soldiers will 
experience pay problems or difficulty obtaining new MRP orders. In 
addition, the Army has no way of knowing whether all soldiers that 
should be on MRP orders are actually applying and getting into the 
system. Further, MRP has not resolved the underlying management control 
problems that plagued ADME, and, in some respects, has worsened 
problems associated with the Army's lack of visibility over injured 
soldiers. Finally, because the MRP program is designed such that 
soldiers may be treated and released from active duty before their MRP 
orders expire, weaknesses in the Army's processes for updating its pay 
system to reflect an early release date have resulted in overpayments 
to soldiers.

According to Army officials at each of the 10 installations we visited, 
unlike ADME, they have not experienced problems or delays in obtaining 
MRP orders for soldiers in their units. In fact some installation 
officials have said that the process now takes 1 or 2 days instead of 1 
or 2 months. Because there is no mechanism in place to track 
application processing times, we have no way of substantiating these 
assertions. Conversely, we are not aware of any soldier complaints 
regarding the process, which were commonplace with ADME.

The MRP application and approval process, which rests with HRC- 
Alexandria, instead of the Army Manpower office, is a simplified 
version of the ADME process. As with ADME orders, the soldier must 
request that this process be initiated and voluntarily request an 
extension on active duty orders. Both the MRP and ADME request packets 
include the soldier's request form, a physician's statement, and a copy 
of the soldier's original mobilization orders. However, with MRP, the 
physician's statement need only state that the soldier needs to be 
treated for a service-connected-injury or illness and does not require 
detailed information about the diagnosis, prognosis, and medical 
treatment plan as it does with ADME. As discussed previously, 
assembling this documentation was one of the primary reasons ADME 
orders were not processed in a timely manner. In addition, because all 
MRP orders are issued for 179 days, MRP has alleviated some of the 
workload on officials who were processing AMDE orders and who were 
helping soldiers prepare application packets by eliminating the need 
for a soldier to reapply every 30, 60, or 90 days as was the case with 
ADME.

While MRP has expedited the application process, MRP guidance, like 
that of ADME, does not address how soldiers who require MRP will be 
identified in a timely manner, how soldiers requiring an additional 179 
days of MRP will be identified in a timely manner, or how soldiers and 
Army staff will be trained and educated about the new process. Further, 
because the Army does not maintain reliable data on the current status 
and disposition of injured soldiers, we could not test or determine 
whether all soldiers that should be on MRP orders are actually applying 
and getting into the system. In addition, because MRP authorizes 179 
days of pay and benefits regardless of the severity of the injury, the 
Army faces a new challenge--to ensure that soldiers are promptly 
released from active duty or placed in a medical evaluation board 
process upon completion of medical care or treatment and avoid 
needlessly retaining and paying these soldiers for the full 179 days. 
However, MRP guidance does not address how the Army will provide 
reasonable assurance that upon completion of medical care or treatment 
soldiers are promptly released from active duty or placed in a medical 
evaluation board process.

MRP has also contributed to the Army's difficulty maintaining 
visibility over injured reserve component soldiers. Although the Army's 
MRP implementation guidance requires that installations provide a 
weekly report to HRC-Alexandria that includes the name, rank, and 
component of each soldier currently on MRP orders, according to HRC 
officials, they are not consistently receiving these reports. 
Consequently, the Army cannot say with certainty how many soldiers are 
currently on MRP orders, how many have been returned to active duty, or 
how many soldiers have been released from active duty before their 179- 
day MRP orders expired. As discussed previously, if the Army used and 
appropriately updated the agency's medical tracking system, MODS, the 
system could provide some visibility over injured and ill active and 
reserve component soldiers--including soldiers on ADME or MRP orders. 
However, the Army MRP implementation guidance is silent on the use of 
MODS and does not define responsibilities for updating the system. 
According to officials at HRC-Alexandria, they do not update MODS or 
any other database when they issue MRP orders. They also acknowledged 
that the 1,800 soldiers reflected as being on MRP orders in MODS, as of 
September 2004, was probably understated given that, between May 2004 
and September 2004, HRC-Alexandria processed approximately 3,300 MRP 
orders. Further, as was the case with ADME, 8 of the 10 installations 
we visited did not routinely use or update MODS but instead maintained 
their own local tracking systems to monitor soldiers on MRP orders.

Not surprisingly, the Army does not know how many soldiers have been 
released from active duty before their 179-day MRP orders had expired. 
This is important because our previous work has shown that weaknesses 
in the Army's process for releasing soldiers from active duty and 
stopping the related pay before their orders have expired--in this case 
before their 179 days is up--often resulted in overpayments to 
soldiers. According to HRC-Alexandria officials, as of October 2004, a 
total of 51 soldiers had been released from active duty before their 
179-day MRP orders expired. At the same time, Fort Knox, one of the few 
installations that tracked these data, reported it had released 81 
soldiers from active duty who were previously on MRP orders--none of 
whom were included in the list of 51 soldiers provided by HRC- 
Alexandria. Concerned that some of these soldiers may have 
inappropriately continued to receive pay after they were released from 
active duty, we verified each soldier's pay status in DJMS-RC and found 
that 15 soldiers were paid past their release date--totaling 
approximately $62,000. For example, one soldier was released from 
active duty on July 9, 2004, after 43 days on MRP orders but, as of 
November 5, 2004, the soldier was still being paid as if he were on 
active duty. Between July and November he was overpaid $10,595. 
Further, if we had not alerted the Army, he may have continued to be 
paid until November 21, 2004--the date his 179-day MRP orders would 
have expired--an additional $1,246, for a total of $11,841. According 
to Army finance officials, they rely on the soldier to bring them a 
copy of their Certificate of Discharge or Release from Active Duty (DD 
form 214) so that they can change the order end date in the pay system 
and stop the soldier's pay. However, when the installation finance 
personnel do not receive a soldier's DD214, the soldier will continue 
to be paid until the order end date recorded in the pay system--in this 
case, the original date on the soldier's MRP orders. In another 
example, a soldier who was released from active duty on October 7, 
2004, continued to receive active duty pay and may have continued to 
receive pay until January 10, 2005, if we had not brought the issue to 
the Army's attention--for a total of $4,500.

Finally, because ADME will still exist for soldiers who are not 
mobilized in support of the Global War on Terrorism--such as soldiers 
injured in Bosnia or Kosovo or during annual training exercises--it is 
still important that the problems we identified related to it are 
resolved.

Conclusion:

The recent mobilization and deployment of Army National Guard and 
Reserve soldiers in connection with the Global War on Terrorism is the 
largest activation of reserve component troops since World War II. As 
such, in recent years, the Army's ability to take care of these 
soldiers when they are injured or ill has not been tested to the degree 
that it is being tested now. Unfortunately, the Army has failed this 
test and the brave soldiers fighting to defend our nation have paid the 
price. The personal toll that the pay problems experienced by these 
soldiers and their families and what they have endured cannot be 
readily measured. But clearly, the hardships they have endured are 
unacceptable given the substantial sacrifices they have made and the 
injuries they have sustained. To its credit, the Army's new streamlined 
medical retention application process has alleviated many of the 
immediate problems experienced by soldiers under ADME but it also has 
many of the same limitations. A complete and lasting solution to the 
pay problems and overall poor treatment of injured soldiers that we 
identified will require that the Army address the underlying problems 
associated with its all around control environment for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses and deficiencies associated with its automated systems.

Recommendations of Executive Action:

We recommend that the Secretary of the Army direct the Deputy Chief of 
Staff, Army G-1 to take the following 22 actions:

Control Environment and Management Controls. Develop and promulgate-- 
with appropriate input from the Regional Medical Commands, hospital 
commanders, medical hold unit commanders, and case managers-- 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses. At a minimum, standard operating procedures, and guidance 
should be developed that address:

* Specific organizational responsibilities for managing programs that 
deal with injured or ill reserve component soldiers, including 
specifying which officials have the ultimate responsibility for the 
success of these programs.

* Where orders that extend a soldier's active duty status are to be 
issued, how they are to be distributed, and to whom they are to be 
distributed--for both command and control purposes and to update the 
Army's pay, personnel, and medical eligibility systems.

* Standards for being retained on active duty orders, including time 
frames and criteria for extension or retention beyond one year.

* Criteria that clearly establishes priorities for where a soldier may 
be attached for medical care (i.e. medical facility has the specialties 
and the capacity needed to treat the soldier, proximity to soldier's 
residence).

* Minimum eligibility criteria for soldiers applying for such programs 
as ADME and MRP.

* Avenues through which soldiers may apply for such programs.

* Specific documentation required to retain or extend active duty 
orders for medical treatment or evaluation.

* Entitlements of each program for both the soldier and his/her 
dependents.

* Correctly link the cost of these programs to the mission or operation 
in which the soldier was involved.

Require that the officials designated with the responsibility for 
managing these programs develop performance measures to evaluate the 
program's success. Such performance measures should be sufficient to 
enable the Army to:

* Evaluate the efficiency and effectiveness of these programs-- 
including timeliness of application processing, soldier satisfaction, 
and the length of time soldiers are in the program.

* Take any corrective actions needed to address documented shortcomings 
in program performance.

Infrastructure, resources, and process improvement. Provide the 
infrastructure and resources needed to support these programs and make 
needed process improvements to provide reasonable assurance that:

* Officials responsible for managing and treating injured and ill 
reserve component soldiers are adequately trained on program 
requirements, benefits, and processes.

* Reserve component soldiers and unit commanders will be educated on 
these programs, their requirements, and their benefits.

* The administrative burden on the soldier is alleviated through 
coordinated, customer-friendly processes and easy access to staff 
responsible for both the administrative and medical treatment aspects 
of the programs.

* Paper-intensive application processes are replaced with user-friendly 
automated processes, to the extent possible, through which soldiers are 
notified or have easy access to the current status of their application.

* The practice of garnishing soldiers' wages to resolve accounting 
problems created by the use of retroactive rescissions of soldiers' 
orders is ended.

Automated systems. In the near term, require that:

* The gaining MTF is notified and receives a copy of the solder's 
orders when a soldier is transferred from one MTF to another for 
treatment.

* The information in MODS is routinely updated and utilized to the 
maximum extent possible to provide visibility over and manage injured 
and ill reserve component soldiers.

* New orders extending active duty for injured or ill soldiers are sent 
directly to the staff responsible for updating the appropriate pay, 
personnel, and medical eligibility systems.

* Controls are put in place to provide assurance that the order end 
date in the pay system is changed to reflect the actual date the 
soldier was released from active duty when soldiers are released from 
active duty before their orders expire.

In the long term, design and implement integrated order writing, pay, 
personnel, and medical eligibility systems that:

* Provide visibility over injured and ill reserve component soldiers.

* Ensures that the order writing system automatically updates the pay, 
personnel, and medical eligibility systems.

Agency Comments and Our Evaluation:

In its written response to a draft of this report, DOD briefly 
described its completed, ongoing, and planned actions to implement all 
22 of our recommendations.

We are encouraged that the Army has begun to take action to address the 
problems we identified and are hopeful that it will continue to work 
toward comprehensive, effective solutions for addressing the 
recommendations in this report dealing with reserve component soldiers 
with service-connected injuries or illnesses.

Separately in its technical comments, reprinted in appendix II, DOD 
disagreed with several of the facts and circumstances presented in the 
report related to non-pay issues and challenged our use of certain case 
studies. We continue to believe that the information we presented 
offers valid perspective on the Army's management and treatment of 
injured reserve component soldiers.

As agreed with your offices, unless you announce its contents earlier, 
we will not distribute this report further until 30 days from its date. 
At that time, we will send copies to interested congressional 
committees, the Secretary of the Army, and the Director of the Office 
of Management and Budget. We will make copies available to others upon 
request. In addition, the report will be available at no charge on the 
GAO Web site at [Hyperlink, http://www.gao.gov].

If you or your staffs have any questions concerning this report, please 
contact me at (202) 512-9095 or [Hyperlink, kutzg@gao.gov], or Diane 
Handley at (404) 679-1986 or [Hyperlink, handleyd@gao.gov]. Key 
contributors to this report are acknowledged in appendix III.

Signed by: 

Gregory D. Kutz: 
Director: 
Financial Management and Assurance:

Signed by: 

Robert J. Cramer: 
Managing Director: 
Office of Special Investigation:

[End of section]

Appendixes:

Appendix I: Objective, Scope, and Methodology:

We relied on a case study and selected the site visit approach for this 
work, principally because the many previously identified flaws in the 
existing pay processes had not yet been resolved and the Army did not 
maintain reliable, centralized data on the number, location, and 
disposition of mobilized reserve component soldiers who had requested 
to extend their active duty service because they had been injured or 
become ill in the line of duty. Therefore, it was not possible to 
statistically test controls or the impact control breakdowns had on 
soldiers and their families.

To obtain an understanding and assess the adequacy of the processes, 
personnel (human capital), and systems used to provide assurance that 
mobilized Army Guard and Army Reserve soldiers received entitled pays 
and associated medical benefits, we reviewed applicable policies, 
procedures, and program guidance; observed active duty medical 
extension processing operations; and interviewed cognizant agency 
officials. With respect to applicable policies and procedures, we 
obtained and reviewed procedural guidance for reserve component 
soldiers on active duty medical extension, the U.S. Army Medical 
Command field operating guide for reserve component soldiers on active 
duty medical extension, and other pertinent sections of Title 10 USC 
and DOD and Army regulations. We also used the internal controls 
standards provided in the Standards for Internal Control in Federal 
Government.[Footnote 21]

We applied the policies and procedures prescribed in these documents to 
the observed and documented procedures and practices followed by the 
key DOD components involved in providing active duty pays and medical 
benefits to reserve component soldiers. We also interviewed officials 
from the National Guard Bureau, Army Reserve, Army and DOD military pay 
offices, Army Manpower office, and regional medical commands, as well 
as installation and military treatment facility commanders to obtain an 
understanding of their experiences in applying these policies and 
procedures.

With respect to the Army's automated systems, we assessed whether they 
provided reasonable assurance that once an ADME order was issued, the 
appropriate pay, personnel, and medical eligibility systems are updated 
in an accurate and timely manner. To accomplish this, we interviewed 
and obtained available documentation from individuals responsible for 
entering ADME order transactions into the Army's order writing, pay, 
personnel, and medical eligibility systems. Although we requested the 
written policies and procedures used to update each of these systems, 
none had been established. We also relied on the extensive work 
recently performed on related GAO military pay engagements.[Footnote 
22] We did not test computer security or access controls or test 
individual transactions.

Because our preliminary assessment determined that the design of 
current operations used to route soldiers through the active duty 
medical extension process relied solely on error-prone manual documents 
and transactions and multiple, nonintegrated systems, we did not 
statistically test current processes or controls. We selected 
installations for review based on the reported populations of active 
duty medical extension and medical holdover soldiers, as well as other 
specialized traits, including presence of regional medical command. The 
installations we selected for review were: 6 of the top 7 installations 
with large active duty medical extension and medical holdover 
populations; the 4 installations with co-located Regional Medical 
Commands in the continental United States; 6 of the 15 Army Power 
Projection Platforms, which mobilize and deploy high priority reserve 
component in both of the continental armies in the United States (1st 
U.S. Army is east of the Mississippi River, 5th U.S. Army is west of 
the Mississippi River, excluding Minnesota); and a reserve training 
base that has the largest deployments of reserve component soldiers, 
and which also does not have a medical treatment facility. The 
installations we visited are listed in table 1.

Table 1: Audited Installations:

Installation: Fort Lewis, Washington; 
Characteristics: large active duty medical extension and medical 
holdover populations; Western Regional Medical Command; Power 
Projection Platform-5th U.S. Army.

Installation: Fort Knox, Tennessee; 
Characteristics: large active duty medical extension and medical 
holdover populations -1st U.S. Army.

Installation: Fort Benning, Georgia; 
Characteristics: large active duty medical extension and medical 
holdover populations; Power Projection Platform-1st U.S. Army.

Installation: Fort Campbell, Kentucky; 
Characteristics: large active duty medical extension and medical 
holdover populations; Power Projection Platform-1st U.S. Army.

Installation: Fort Dix, New Jersey; 
Characteristics: large active duty medical extension and medical 
holdover populations; Power Projection Platform-1st U.S. Army; 
reserve only.

Installation: Fort Bragg, North Carolina; 
Characteristics: large active duty medical extension and medical 
holdover populations; Power Projection Platform-1st U.S. Army.

Installation: Fort Carson, Colorado; 
Characteristics: Power Projection Platform-5th U.S. Army.

Installation: Fort Sam Houston, Texas; 
Characteristics: Great Plains Regional Medical Command.

Installation: Fort Gordon, Georgia; 
Characteristics: Southeast Regional Medical Command.

Installation: Walter Reed; 
Characteristics: North Atlantic Regional Medical Command.

Source: GAO.

[End of table]

At all the installations, we interviewed officials who were responsible 
for counseling soldiers on the active duty medical extension process, 
officials who prepared and submitted the medical extension application 
packets, case managers, primary care managers, medical hold unit 
commanders, and installation payroll personnel. We obtained 
documentation on and performed walkthroughs of the process to request 
an active duty medical extension for a reserve component soldier, the 
command and control structure of medical hold units, the case 
management function, installation medical extension tracking systems, 
and the medical-extension-to-pay system interface. We held interviews 
with officials from the Army National Guard Bureau, Army Reserve, Army 
Military Pay Operations, and Army Human Resource Command to augment our 
documentation and walkthroughs.

In addition, we interviewed officials who process and approve 
applications for active duty medical extensions at the Army Manpower 
Office in the Pentagon. We performed interviews and walkthroughs that 
depict how an application is processed once received by the office. 
Specifically, we gained an understanding of how an application is 
transmitted to the office, what standards were in use to review the 
approval for sufficiency of documentation, what standards were in use 
related to the timeliness of the documentation, and how the request is 
entered into the Army's Medical Operational Data System (MODS) for 
tracking. We obtained data from that office on the orders processed at 
the time our fieldwork began in February 2004 and updated data as of 
October 2004.

Further, we interviewed and discussed active duty medical extension 
issues with officials from the following offices or commands:

* National Guard Bureau (NGB), Arlington, Virginia:

* Army Reserve Affairs Office, Arlington, Virginia:

* U.S. Army Reserve Command (USARC), Fort McPherson, Georgia:

* 1ST U.S. First Army, Fort Gillem, Georgia:

* 5TH U.S. Army, Fort Sam Houston, Texas:

* U.S. Army Forces Command (FORSCOM), Fort McPherson, Georgia:

When the Army initiated the new medical retention order process during 
our fieldwork, we met with officials from the Army Human Resources 
Command in Alexandria, Virginia, who are responsible for processing 
those orders and obtained and analyzed copies of their implementing 
instructions. We discussed these instructions and the medical retention 
order request process with officials at each of the installations we 
reviewed. We also requested statistics, as of September 2004, from HRC- 
Alexandria regarding the number of soldiers currently on MRP orders, 
returned to active duty, and released from active duty before their 179-
day MRP orders expired.

After determining that the HRC-Alexandria data were incomplete, we also 
requested data from each of the installations we audited on soldiers 
who were released from active duty before their 179-day MRP orders 
expired to determine whether the Army continued to pay them after they 
were released from active duty. For the 132 soldiers identified by the 
Army, as of the date of this report, as released from active duty, we 
determined their pay status in DJMS-RC and obtained pay and personnel 
records for those soldiers who inappropriately remained in pay status. 
As of the date of this report, we are continuing to investigate 
soldiers who were overpaid by the Army. Due to the timing of this 
report and the fact that the first wave of 179-day MRP orders did not 
expire until October 27, 2004, we were unable to assess how effectively 
the Army identified soldiers who required an additional 179 days of MRP 
and whether those soldiers will experience pay problems or difficulty 
obtaining new MRP orders. In addition, because the Army does not 
maintain reliable data on the current status and disposition of injured 
soldiers we could not test or determine whether all soldiers who should 
be on MRP orders are actually applying and getting into the system.

During the course of our investigation we identified sources at various 
forts and facilities, who were familiar with the ADME process. These 
individuals provided us with the names and contact information of 
soldiers who were having trouble with the ADME process. To obtain a 
more detailed understanding of the ADME process challenges associated 
with it, and problems soldiers faced, we visited four forts and 
interviewed 38 soldiers at the forts. Based on the information that we 
obtained at the forts, we further developed 10 case studies. To 
corroborate the information provided by our 10 case study solders, we 
obtained and reviewed soldiers' official military pay records, 
mobilization and ADME orders, bank statements, and credit records. 
Although the information obtained is limited to the 10 soldiers, the 
soldiers that were chosen highlight a variety of problems that soldiers 
experienced with the ADME process. As for soldiers' statements 
regarding non-pay issues, when possible, we corroborated soldiers' 
statements with Army officials familiar with the soldiers. When we 
could not readily corroborate their statements by other evidence, we 
have taken great care to attribute the information to the soldiers we 
interviewed.

We briefed DOD, Army, and National Guard Bureau officials from the 
selected sites on the details of our audit, including our findings and 
their implications. We conducted our fieldwork from February 2004 
through October 2004 in accordance with U.S. generally accepted 
government auditing standards. We requested and received written 
comments on a draft of this report from the Department of the Army. 
These comments are presented and evaluated in the "Agency Comments and 
Our Evaluation" section of this report and are reprinted in appendix II.

[End of section]

Appendix II: Comments From the Department of the Army:

OFFICE OF THE UNDER SECRETARY OF DEFENSE: 
PERSONNEL AND READINESS:
4000 DEFENSE PENTAGON: 
WASHINGTON, D.C. 20301-4000:

JAN 24 2005:

Mr. Gregory D. Kutz:
Director, Financial Management and Assurance: 
U.S. Government Accountability Office: 
Washington, D.C. 20548:

Dear Mr. Kutz:

This is the Department of Defense response to the GAO draft report, 
"MILITARY PAY: Gaps in Pay and Benefits Create Financial Hardships for 
Injured Army National Guard and Reserve Soldiers," dated November 5, 
2004 (GAO Code 192115/GAO-05-125). The response is provided in two 
sections: 1) Responses to the GAO's 22 recommendations for executive 
action and 2) Other relevant comments on portions of the report.

My point of contact is Norma St. Claire, who can be reached at 703-696- 
8710 or via email at norma.stclaire@osd.pentagon.mil.

Sincerely,

Signed by: 

Charles S. Abell: 
Principal Deputy:

Enclosure As stated:

GAO DRAFT REPORT DATED NOVEMBER 5, 2004 GAO-05-125 (GAO CODE 192115)

"MILITARY PAY: GAPS IN PAY AND BENEFITS CREATE FINANCIAL HARDSHIPS FOR 
INJURED ARMY NATIONAL GUARD AND RESERVE SOLDIERS"

DEPARTMENT OF DEFENSE COMMENTS TO THE GAO RECOMMENDATIONS:

RECOMMENDATION 1: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff (DCS), Army G-1 to develop and 
promulgate comprehensive, integrated policies and procedures for 
managing and treating reserve component soldiers with service-connected 
injuries or illnesses that address specific organizational 
responsibilities for managing programs that deal with injured or ill 
reserve component soldiers, including which officials have the ultimate 
responsibility for the success of these programs. (p. 31/GAO Draft 
Report)

DoD RESPONSE: The Department has initiated corrective action. 
Currently, the G-1 is working with the U.S. Army Forces Command in 
developing an Army Regulation on all Medical holdovers.

RECOMMENDATION 2: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address where orders that extend a soldier's active duty 
status are to be cut, how they are to be distributed, and to whom they 
are to be distributed - for both command and control purposes and to 
update the Army's pay, personnel, and medical eligibility systems. (p. 
31 /GAO Draft Report)

DoD RESPONSE: Headquarters, Department of the Army (HQDA), G-1 will 
work with the Human Resources Command (HRC), the Office of the Chief 
Army Reserve, the National Guard Bureau, the Defense Finance and 
Accounting System (DFAS), the Office of the Assistant Secretary of 
Defense for Reserve Affairs (OASD/RA), and the Defense Manpower Data 
Center to develop an integrated policy, which will be incorporated into 
the guidance and implementation of the Army regulation.

RECOMMENDATION 3: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address standards for being retained on active duty 
orders, including timeframes and criteria for extension or retention 
beyond one year. (p. 31/GAO Draft Report)

DoD RESPONSE: The Department has initiated corrective action. The G-1 
is working with the Office of the Surgeon General of the Army and the 
Physical Disability Agency to develop an integrated policy.

RECOMMENDATION 4: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address criteria that clearly establishes priorities for 
where a soldier may be attached for medical care (i.e. medical facility 
has the specialties and the capacity needed to treat the soldier, 
proximity to soldiers residence). (p. 32/GAO Draft Report)

DoD RESPONSE: HQDA G-1 will work with the Office of the Surgeon General 
(OTSG)/Medical Command (MEDCOM) on policy and procedural development 
for medical issues.

RECOMMENDATION 5: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address minimum eligibility criteria for soldiers 
applying for such programs as Active Duty Medical Extensions (ADME) and 
Medical Retention Processing (MRP). (p. 32/GAO Draft Report)

DoD RESPONSE: HQDA, G-1, in conjunction with the OTSG, has already 
established minimum eligibility. The ADME is in the Procedural Guidance 
on the HQDA, G-1 Website. MRP has been established by the OTSG.

RECOMMENDATION 6: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address avenues through which soldiers may apply for 
programs such as ADME or MRP. (p. 32/GAO Draft Report)

DoD RESPONSE: This action is almost complete. The ADME process has been 
posted on the Website since inception July 2000. The MRP is for 
mobilized RC Soldiers who no longer can meet the deployable standards 
within the 60 days allowed. MRP is now posted on the HRC website.

RECOMMENDATION 7: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address specific documentation required to be retained 
or extended on active duty orders for medical treatment or evaluation. 
(p. 32/GAO Draft Report)

DoD RESPONSE: The Army has completed this action. The ADME program has 
established specific documentation. The MRP implementation guidance 
lists specific documents required to be retained or extended on active 
duty for medical treatment or evaluation.

RECOMMENDATION 8: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address entitlements of each program for both the 
soldier and his/her dependents. (p. 32/GAO Draft Report)

DoD RESPONSE: HQDA, G-1 will take the necessary action to develop 
methods to inform Service members of their entitlements.

RECOMMENDATION 9: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to develop and promulgate 
comprehensive, integrated policies and procedures for managing and 
treating reserve component soldiers with service-connected injuries or 
illnesses that address correctly linking of the cost of programs such 
as ADME and MRP to the mission or operation in which the soldier was 
involved. (p. 32/GAO Draft Report)

DoD RESPONSE: Establishing the MRP will link all Soldiers to the Global 
War on Terrorism (GWOT) mission. The HQDA G-1 will work with the 
Assistant Secretary of the Army, Manpower and Reserve Affairs (Force 
Management, Manpower and Resources) (ASA(M&RA)FM) and the DFAS to 
follow through on this recommendation.

RECOMMENDATION 10: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to require that officials 
designated with the responsibility for managing these programs develop 
performance measures to evaluate the efficiency and effectiveness of 
the programs - including timeliness of application processing, soldier 
satisfaction, and the length of time soldiers are in the program. (p. 
32/Draft Report)

DoD RESPONSE: First, concerning the timeliness of the application - the 
ADME has a tracking system where the Army can track all applications. 
The MRP is in the process of establishing a tracking system. Secondly, 
concerning soldier satisfaction - the ASA (M&RA) and Forces Command 
(FORSCOM) are conducting periodic site visits and performing sensing 
sessions with the soldiers. Finally, concerning the length of time 
soldiers are in the program - this data is tracked through the Medical 
Operational Data System (MODS) Medical holdover (MHO) Module and the 
Army will enforce utilization of this feature.

RECOMMENDATION 11: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to require that officials 
designated with the responsibility for managing these programs develop 
performance measures to evaluate the program's success and enable the 
Army to take any corrective actions needed to address documented 
shortcomings in program performance. (p. 32/Draft Report)

DoD RESPONSE: The ASA (M&RA) and FORSCOM are addressing this 
recommendation for the MRP. The HQDA, G-1 is addressing this for the 
ADME with an internal tracking tool designed to assist in developing 
program performance measures.

RECOMMENDATION 12: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to provide the 
infrastructure and resources needed to support these programs and make 
needed process improvements to provide reasonable assurance that 
officials responsible for managing and treating injured and ill reserve 
component soldiers are adequately trained on program requirements, 
benefits and their processes. (p. 32/Draft Report)

DoD RESPONSE: The Army is already engaged in process improvements and 
will continue to refine the programs and processes.

RECOMMENDATION 13: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to provide the 
infrastructure and resources needed to support these programs and make 
needed process improvements to provide reasonable assurance that 
reserve component soldiers and unit commanders will be educated on 
these programs, their requirements, and their benefits. (p. 32/Draft 
Report)

DoD RESPONSE: The HQDA, G-1 will work with the Office of the Chief Army 
Reserve and the National Guard Bureau to accomplish this task.

RECOMMENDATION 14: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to provide the 
infrastructure and resources needed to support these programs and make 
needed process improvements to provide reasonable assurance that the 
administrative burden on the soldier is alleviated through coordinated, 
customer-friendly processes and easy access to staff responsible for 
both administrative and medical treatment aspects of the programs. (p. 
32/Draft Report)

DoD RESPONSE: The HQDA, G-1 will work with the appropriate 
organizations accordingly to accomplish this tasking.

RECOMMENDATION 15: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to provide the 
infrastructure and resources needed to support these programs and make 
needed process improvements to provide reasonable assurance that paper-
intensive application processes are replaced with user-friendly 
automated processes, to the extent possible, in which soldiers are 
notified or have easy access to the current status of their 
application. (p. 32/Draft Report)

DoD RESPONSE: The HQDA, G-1 will work with the appropriate 
organizations to provide easy access to the soldiers on the current 
status of their medical extension or retention processing requests.

RECOMMENDATION 16: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to provide the 
infrastructure and resources needed to support these programs and make 
needed process improvements to provide reasonable assurance that the 
practice of garnishing soldiers' wages to resolve accounting problems 
created by the use of retroactive rescissions of soldiers' orders is 
ended. (p. 32/Draft Report)

DoD RESPONSE: The Army will work with the DFAS to implement necessary 
process improvements.

RECOMMENDATION 17: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to require that the gaining 
MTF be notified and receive a copy of the soldier's orders when a 
soldier is transferred from one MTF to another for treatment. (p. 32/ 
Draft Report)

DoD RESPONSE: The HQDA, G-1 will work with the OTSG to implement this 
recommendation.

RECOMMENDATION 18: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to require that the 
information in MODS is routinely updated and utilized to the maximum 
extent possible to provide visibility over and manage injured and ill 
reserve component soldiers. (p. 32/Draft Report)

DoD RESPONSE: This recommendation has already been implemented.

RECOMMENDATION 19: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to require that new orders 
extending active duty for injured or ill soldiers are sent directly to 
the staff responsible for updating the appropriate pay, personnel, and 
medical eligibility systems. (p. 33/Draft Report)

DoD RESPONSE: For the ADME, the current distribution includes both the 
Army Reserve and NGB, and a DFAS representative. A Command and Control 
element will be added to the distribution. The MRP distributes to the 
Medical Retention Processing Unit's (MRPU's), the Installations, and to 
the DFAS. The servicing demobilization installation is providing 
support to the soldier will also be added to the distribution.

RECOMMENDATION 20: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to require that controls are 
put in place to provide assurance that the order end date in the pay 
system is changed to reflect the actual date the soldier was released 
from active duty when soldiers are released from active duty before 
their orders expire. (p. 33/Draft Report)

DoD RESPONSE: The HQDA, G-1 will work with the appropriate 
organizations to implement this recommendation.

RECOMMENDATION 21: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to design and implement 
integrated order writing, pay, personnel, and medical eligibility 
systems that provide visibility over injured and ill reserve component 
soldiers. (p. 33/Draft Report)

DoD RESPONSE: The Department's long-term solution is the implementation 
of the Defense Integrated Military Human Resource System (DIMHRS). Many 
of the current administrative problems the Army faces today, whether it 
is with financial records, personnel accountability, medical records, 
or orders production, directly or indirectly stem from incompatible 
data systems. To be effective, data must be able to accurately flow 
among all Army components, and between the Services. This is one of 
DIMHRS major intents.

RECOMMENDATION 22: The GAO recommended that the Secretary of the Army 
direct the Deputy Chief of Staff, Army G-1 to design and implement 
integrated order writing, pay, personnel, and medical eligibility 
systems that ensure the order writing system automatically updates the 
pay, personnel, and medical eligibility systems. (p. 33/Draft Report)

DoD RESPONSE: The Department's long-term solution is the implementation 
of the DIMHRS.

GAO DRAFT REPORT DATED NOVEMBER 5, 2004:

GAO-05-125 (GAO CODE 192115)

"MILITARY PAY: GAPS IN PAY AND BENEFITS CREATE FINANCIAL HARDSHIPS FOR 
INJURED ARMY NATIONAL GUARD AND RESERVE SOLDIERS"

DEPARTMENT OF DEFENSE COMMENTS OTHER:

GAO document (pages 3,11,13, and 24) The report contains incorrect 
information regarding pay and benefits, specifically in regards to Post 
Exchange (PX) and Defense Commissary Agency commissary access.

DoD comment: The report repeatedly refers to Soldiers and/or family 
members losing their PX and/or commissary benefits if the Soldier was 
dropped from an active duty status. This information is incorrect. All 
Soldiers and/or family members in possession of a valid identification 
card (regardless of active, reserve, or guard status) are entitled to 
unlimited use of PX facilities at any time. Access to the PX is not 
limited only to Soldiers on active duty status. In the matter of 
commissary benefits, prior to November 2003, non-active status Army 
Reserve and National Guard soldiers assigned to units were authorized 
24 visits per year to the commissary. Beginning in November 2003, the 
Defense Commissary Agency implemented the provisions of the 2004 
National Defense Authorization Act, which eliminated restrictions 
previously in place for Army Reserve and National Guard Soldiers and 
their families. Recommend revision of the report to remove these 
incorrect and misleading statements.

GAO document (page 7 - V bullet) Defines medical holdover (MHO).

DoD comment: The definition of "medical holdover" is incorrect. MHO is 
a generic, broad-based term used to describe mobilized Reserve 
Component (RC) soldiers in support of the GWOT who were unable to 
deploy due to pre-existing or new medical conditions, or who developed 
new medical conditions or aggravated pre-existing medical conditions 
during deployment. These soldiers are currently non-deployable. 
Mobilized GWOT soldiers, who were extended under ADME or are now 
extended under MRP programs, are also MHO soldiers. RC soldiers on ADME 
from weekend drill, annual training, etc., are not MHO soldiers.

GAO document (page 7 - 2nd paragraph) States that mobilized RC soldiers 
who are in MHO are attached to a medical hold unit and would typically 
apply for ADME orders through that unit.

DoD comment: MHO soldiers are not assigned nor attached to medical 
treatment facility (MTF) medical holding units (MHU). It is true some 
MHO soldiers are assigned to MTF MHUs, but these are normally active 
compo soldiers who are unable to perform their military operational 
skill even within the confines of a limited duty profile. Although a 
few installations, such as Ft. Bragg, did assign their MHO soldiers to 
the MTF MHU, the Army policy is that MHO soldiers belong to the 
garrison commander and are assigned to some type of garrison holding 
unit. Most "holding units" were created out of the Garrison Support 
Units (GSU) or other garrison units. The implementation of the MRP 
program created specific derivative unit identification codes (DUIC) 
for medical retention processing units (MRPU) to which MRP/MHO soldiers 
are now assigned. The MRPUs, which fall under garrison commander and 
IMAs, are staffed by mobilized soldiers requested by the IMAs to 
provide command and control to MHOS on the garrison. Non-mobilized ADME 
soldiers (who are not MHOS) are assigned or attached to the MTF MHUs 
for medical management.

GAO document (page 10 - 3 rd paragraph) States MRP is for soldiers who 
become injured or ill while on mobilization orders in support of the 
Global War on Terrorism.

DoD comment: MHO/MRP also includes soldiers with pre-existing 
conditions that were not identified within 25 days of mobilization or 
that were aggravated after mobilization. Soldiers with identified pre- 
existing conditions during the first 25 days are released from active 
duty. Soldiers who incur new injuries during the first 25 days may 
remain on active duty as a MHO.

GAO document (page 22) The report contains contradictory and misleading 
statements regarding issues with billeting conditions.

DoD comment: The report refers to medical hold Soldiers at Fort Lewis 
having to make three separate moves to make room for demobilizing 
units. While one move has been made recently to free up barracks for 
returning units, these barracks were only occupied on a temporary 
basis. Initial medical holdover billets at Fort Lewis were located in 
World War II era billets located on North Fort Lewis, primarily in the 
7C block of buildings. As part of an effort to improve living 
conditions for medical holdover soldiers, they were relocated to newly 
renovated permanent barracks on the main post in late CY 2003. These 
barracks had been made available by the deployment of the 3rd Brigade, 
2nd Infantry Division (Stryker Brigade Combat Team) to Iraq, and were 
expected to be vacated upon the Brigade's return. This move was 
accomplished in the Fall of 2004 to barracks vacated by the 1st 
Brigade, 
25th Infantry Division (Stryker Brigade Combat Team). Due to re- 
stationing actions, a final move to new, modular barracks facilities is 
planned for the March 2005 timeframe. These new facilities will provide 
a permanent home for those medical holdover soldiers retained at Fort 
Lewis for their medical care and treatment. Also, the unqualified 
anecdote contained in the case study on page 23 alleges that handicap 
accessible facilities were not emplaced until built by soldiers in the 
Holding company in October 2003. This statement is incorrect. As early 
as June 2003, barracks utilized by the Garrison medical holdover 
company were modified by the installation Directorate of Public Works 
with external ramps to first floor doorways, adaptive equipment in 
bathrooms (floor mats, grab rails, and flexible shower heads), and 
wider step platforms. These modifications have been made in all 
subsequently occupied barracks for soldiers with mobility issues.

GAO document (case studies) The report contains two case studies that 
appear to not have been validated with Fort Lewis.

DoD comment: While the report is clear regarding validation of pay 
issues presented by soldiers, there appears to have been no validation 
of the soldier comments regarding accessibility of the barracks at the 
time of their stay. The presentation of such unqualified statements in 
a report implies that they are true and correct statements of fact, 
which in this case is both untrue and misleading. While not 
specifically identified in the case studies, an initial review 
indicates additional information is appropriate with regard to certain 
aspects of the case studies.

In the example of the Sergeant from G Company, 140TH Aviation Regiment, 
the implication is that the soldier was ordered to return to Fort Lewis 
simply because he was receiving care through an Air Force hospital. In 
this case, the soldier was identified as an individual who had not 
properly been recovered into the Army's accountability system and 
assigned/attached to a unit for management of required personnel and 
medical actions. While delays in returning the soldier to California to 
complete his treatment were unfortunate, the soldier was placed on a 
remote medical treatment program, which both established proper 
accountability and allowed him to reside at his home of record while 
his treatment was completed.

In the other two case studies, additional research would be required to 
properly identify and document their case histories.

GAO document (page 30 - 2nd paragraph) States that the Army does not 
know how many soldiers have been released from active duty before their 
179-day MRP order had expired.

DoD comment: Content is incorrect. The Army MRP guidance specifies the 
use of MODS as the primary data source for MHO/MRP information. The 
guidance further specifies that case managers are responsible for the 
accuracy, timeliness and comprehensive entry of data into MODS. 
[Guidance: Annex Q (MEDICAL HOLDOVER OPERATIONS) to HQDA OPORD 04-01 
and FORSCOM Implementing Instructions].

GAO document (page 32 - 2nd, 3rd and 4th bullets at the top of the 
page) 
States that the minimum eligibility criteria for soldiers applying for 
such programs as ADME and MRP, avenues through which soldiers may apply 
for such programs, and specific documentation required to be retained 
or extended on active duty orders for medical treatment or evaluation.

DoD comment: These statements are not consistent with DoD policy (DoD  
1241.2, "Reserve Component Incapacitation System Management," sections 
6.6.3, 6.6.3.2, and 6.6.3.3) concerning retention on active duty until 
found fit or processed through the DES. It is not the soldier's 
responsibility to ensure he or she is retained on active duty when 
injured or ill. It is the service responsibility to ensure the injured 
or ill RC member is retained on active duty (unless the member requests 
otherwise) until he or she is either medically cleared or processed 
through the DES. A more appropriate description of the process is as 
follows:

- The service should establish criteria to determine at what point the 
member should continue treatment or proceed through the DES.

- If the member is approaching the expiration of his or her orders and 
has not been found fit for duty or is still being processed through the 
DES, then the service shall initiate action to retain the member on 
active duty unless the member requests to be released from active duty.

GAO document (page 32 - 4th bullet of paragraph 2) States that paper- 
intensive application processes are replaced with user-friendly 
automated processes, to the extent possible, in which soldiers are 
notified or have easy access to the current status of their application.

DoD comment: Content is incorrect. There is not an application process, 
or at least one submitted by the member. Recommend removing reference 
to an application. A more appropriate approach would be:

- User-friendly systems will be in place that would allow the soldier 
to review the status of their extension on active duty. 

GAO Comments:

1. See the "Agency Comments and Our Evaluation" section of this report.

2. DOD correctly points out that reserve component soldiers and their 
families--regardless of their active duty status--are entitled to Post 
Exchange and commissary benefits, however, the reality is that these 
soldiers could no longer gain access to the Post Exchange and 
commissary because they no longer had valid military identification. 
When a reserve component soldier's active duty orders expire before new 
orders are approved, the soldier's active duty military identification 
is no longer valid. Similarly, the soldier no longer has a valid 
reserve duty military identification card because this card was 
replaced with an active duty identification card upon mobilization. 
Therefore, when reserve component soldiers are dropped from active duty 
status before they are officially released from active duty, they have 
no means of producing valid military identification and gaining access 
to these facilities.

3. The written comments provided by DOD attempt to clarify the 
definition of MHO soldiers and the Medical Hold Unit as well as which 
soldiers are included in MRP. However, DOD's definition does not differ 
from our understanding or what we have described in our report. As 
discussed previously in our report, soldiers who sustained injuries 
during annual training, weekend drills, or other activities associated 
with their Army National Guard or Army Reserve duties are eligible for 
ADME but are not MHO soldiers. Further, these soldiers fall outside the 
scope of our audit because our report specifically focused on soldiers 
who were activated for operations in support of the Global War on 
Terrorism.

4. We agree that Medical Hold units are not typically part of the MTF 
organization but are extensions of a Garrison Support Unit and that the 
Installation Management Command has command and control over Medical 
Hold units. However, we note in a footnote in the draft report on which 
DOD commented that these units may sometimes be found at Army military 
medical treatment facilities.

5. We do not believe our report is in conflict with DOD's comment that 
MRP units include soldiers with preexisting conditions that were not 
identified within 25 days of mobilization or who had injuries that were 
aggravated after mobilization.

6. DOD commented that our reference to medical hold soldiers at Fort 
Lewis having to make three separate moves to make room for demobilizing 
units is contradictory and misleading. According to DOD, not all of the 
moves were made to make room for demobilizing units. Some of the moves 
were made to improve the quality of the housing provided. We did not 
attempt to determine the validity or the necessity of any of the moves, 
however, the inconvenience to the injured soldiers of moving from 
location to location is the same regardless of the reason.

7. We corroborated the information provided by our 10 case study 
soldiers with the soldiers' official military pay records, mobilization 
and ADME orders, bank statements, and credit records. In no case did 
the statements made by a soldier about gaps in pay differ significantly 
from the evidence we obtained. As for statements made about 
infrastructure, accommodations, and other qualitative factors, we 
attempted to and when possible, we did corroborate soldiers' statements 
with Army officials familiar with the soldiers. When we could not 
readily corroborate their statements by other evidence, we have taken 
great care to attribute the information to the soldiers we interviewed. 
Testimonial information that we could not corroborate by other evidence 
was not used as the basis for our conclusions and recommendations.

8. We reaffirm our conclusion that the Army does not know how many 
soldiers have been released from active duty before their 179-day MRP 
orders had expired. According to DOD, the Army MRP guidance specifies 
the use of MODS as the primary data source for MHO/MRP information. The 
guidance further specifies that case managers are responsible for the 
accuracy, timeliness and comprehensive entry of data into MODS. The MRP 
implementing instructions are not sufficiently explicit to 
satisfactorily deal with the issue of MODS or tracking the status of 
injured or ill reserve component soldiers. We believe that implementing 
instructions should contain clear, complete, and comprehensive 
information needed to carry out Army polices and regulations--instead 
of providing references to other policies, procedures, and 
instructions, which can create confusion. More importantly, the Army 
does not track soldiers that are released from MRP orders before their 
179-day orders expire. As discussed in the report previously, HRC- 
Alexandria officials asserted that, as of October 2004, a total of 51 
soldiers had been released from active duty before their 179-day MRP 
orders expired. At the same time, Fort Knox, one of the few 
installations that tracked these data, reported it had released 81 
soldiers from active duty who were previously on MRP orders--none of 
whom were included in the list of 51 soldiers provided by HRC- 
Alexandria. Thus it is clear that the Army does not know how many 
soldiers have been released from MRP orders. Further, as stated in the 
report, the soldiers that were released early from their orders were 
improperly paid over $ 62,000, which the Army and DFAS were unaware of 
until we notified them.

9. As discussed previously in this report, we found that the soldier 
carries a large part of the burden when trying to understand and 
successfully navigate the Army's poorly defined requirements and 
processes for obtaining extended active duty orders. Therefore, we 
continue to believe that the Army needs (1) policies and procedures 
that establish minimum eligibility criteria for programs such as ADME 
and MRP and avenues through which soldiers may apply with Army 
assistance for such programs and (2) user-friendly processes in which 
soldiers are notified or have easy access to the status of their active 
duty extension.

[End of section]

Appendix III: GAO Contact and Staff Acknowledgments:

GAO Contact:

Diane Handley (404) 679-1986; 
John Ryan (202) 512-9587:

Acknowledgments:

Staff members who made key contributions to this report were Gary 
Bianchi, Francine DelVecchio, Carmen Harris, Jamie Haynes, Kristen 
Plungas, Maria Storts, and Truc Vo.

(192115):

FOOTNOTES

[1] For the purpose of this report, the term mobilized includes all 
Army reserve component soldiers called to perform active service.

[2] GAO, Military Pay: Army National Guard Personnel Mobilized to 
Active Duty Experienced Significant Pay Problems, GAO-04-89 
(Washington, D.C.: Nov. 13, 2003); GAO, Military Pay: Army Reserve 
Soldiers Mobilized to Active Duty Experienced Significant Pay Problems, 
GAO-04-911 (Washington, D.C.: Aug. 20, 2004). 

[3] DOD includes Operations Enduring Freedom, Operation Nobel Eagle, 
and Operation Iraqi Freedom as part of the Global War on Terrorism. 

[4] ADME will still exist for soldiers who are not mobilized as part of 
the Global War on Terrorism--such as soldiers injured in Bosnia or 
Kosovo or during annual training exercises.

[5] Army Manpower is an organization within the Army Deputy Chief of 
Staff, G-1, formerly the Army Deputy Chief of Staff for Personnel. The 
G-1 is the Army's human resource provider, handling human resource 
programs, policies, and systems. The Army Human Resources Command is a 
field operating activity that reports directly to the G-1. 

[6] The Army maintained data on soldiers who were currently on ADME 
orders but did not track soldiers who were applying for ADME or who had 
been dropped from their active duty orders.

[7] Some soldiers also elect to be released from duty and choose to 
seek care through their private insurers or utilize government-provided 
transitional assistance. Eligible soldiers may also seek care through 
the Veterans Administration. 

[8] Under the transitional assistance management program, prior to 
October 2004, service members with fewer than 6 years of active service 
are eligible for health care benefits for 60 days. With 6 years or more 
of active service, eligibility increases to 120 days. In November 2003, 
the Congress increased this time period to 180 days through the end of 
September 2004. Emergency Supplemental Appropriations Act for Defense 
and for the Reconstruction of Iraq and Afghanistan, 2004, Pub. L. No. 
108-106, § 1117, 117 Stat. 1209, 1218 (Nov. 3, 2003). In October 2004, 
Congress permanently extended the period of eligibility to 180 days for 
all categories of service members.

[9] While soldiers in medical holdover status may not have had service- 
connected injuries or illnesses, they would be eligible to apply for an 
active duty medical extension by virtue of the fact that they have a 
medical condition that necessitates treatment for more than 30 days 
beyond the end of their existing active duty orders.

[10] Medical hold units handle command and control for active duty and 
mobilized reserve component soldiers who are not medically fit for 
duty. These units may sometimes be found at Army military medical 
treatment facilities, including Army hospitals.

[11] According to Procedural Guidance for Reserve Component Soldiers on 
Active Duty Medical Extension, Section 8b, the soldier's ADME request 
is required to be submitted through "whoever has command and control 
over the soldier at the time of request". Some installations chose to 
have the garrison support unit (GSU) remain as the soldiers command and 
control authority until their original mobilization orders expired. 
Therefore, the initial ADME request would be submitted through the GSU 
instead of the medical hold unit.

[12] Department of the Army Form 4187, Personnel Action.

[13] According to the procedural guidance, this is to be a formal 
memorandum (on letterhead) from the attending physician, which states 
the current diagnosis; current treatment plan; prognosis; date the 
soldier is expected to be returned to full duty; and full name, grade, 
and office telephone number of physician. If available, a physical 
profile should accompany this statement. 

[14] Department of the Army Form 3349, Physical Profile.

[15] Soldiers who do not meet medical military retention standards may 
be placed on the temporary disability retired list, the permanent 
disabled retired list, may be separated from service with severance, 
or, in rare cases, be retained with a disability if the soldier is 
still needed by the military. Department of Defense Directive 1332.18, 
Separation or Retirement for Physical Disability (Nov. 4, 1996); 
Department of Defense Instruction 1332.38, Physical Disability 
Evaluation; (Nov. 14, 1996), See Army Regulation 635-40, Physical 
Evaluation for Retention, Retirement, or Separation (Aug. 15,1990).

[16] Army Regulation 40-400, Patient Administration, paragraph 3-2, 
(Mar. 12, 2001) and Army Regulation 135-381, Incapacitation of Reserve 
Component Soldiers, paragraph 2-1 (June 1, 1990).

[17] Army Regulation 135-381, Incapacitation of Reserve Component 
Soldiers, paragraph 7-2 (June 1, 1990).

[18] We did not audit these costs for the purpose of determining if the 
Army properly recorded them against available funding sources. Instead, 
we applied DOD's criteria for contingency operations cost accounting in 
DOD's Financial Management Regulation, Vol. 12, Chapter 23 (February 
2001).

[19] GAO, Military Personnel: DOD Actions Needed to Improve the 
Efficiency of Mobilizations for Reserve Forces, GAO-03-921 (Washington, 
D.C.: Aug. 21, 2003)

[20] There are over 800 DOD card issuance facilities located in the 
U.S. on Army installations and with Army National Guard and Reserve 
units.

[21] GAO, Standards for Internal Control in Federal Government, GAO/ 
AIMD-00-21.3.1 (Washington D.C.: November 1999). These standards 
provide the overall framework for establishing and maintaining 
effective internal control and for identifying and addressing areas of 
greatest risk of fraud, waste, abuse, and mismanagement.

[22] GAO, Military Pay: Army Reserve Soldiers Mobilized to Active Duty 
Experienced Significant Pay Problems, GAO-04-911 (Washington, D.C.: 
Aug. 20, 2004).

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