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TRICARE expands access to mental health care, substance use disorder treatment

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TRICARE is pleased to be implementing significant improvements to its mental health and substance use disorder (SUD) benefits to provide beneficiaries greater access to the full range of available mental health and SUD treatments.  

Army Maj. Gen. Jeffrey Clark, Director of Healthcare Operations at Defense Health Agency (DHA) said, “We are intently focused on ensuring the behavioral health of our service members and their families remains a top priority.  These sweeping changes reflect that commitment.”

TRICARE provides a generous and comprehensive mental health benefit to active duty service members, retirees, and their families, including psychiatric outpatient, inpatient, partial hospitalization, and residential treatment services.  

“But we are working to make the benefit even better,” said Dr. John Davison, Chief of the Condition-Based Specialty Care Section of DHA’s Clinical Support Division. “Major changes are underway that will improve access to mental health and substance use disorder treatment for TRICARE beneficiaries, revise beneficiary cost-shares to align with cost-shares for medical and surgical care, and reduce administrative barriers to care by streamlining the requirements for institutional providers to become TRICARE authorized providers.”

Dr. Patricia Moseley, senior policy analyst for military child and family behavioral health at DHA in Falls Church, Virginia, said being able to ensure TRICARE mental health benefits are offered on par with medical and surgical benefits was an important driving force for the changes.

“Being able to meet the principles of mental health parity in our benefit is very significant,” said Moseley.

Beginning Oct. 3, 2016, non-active duty dependent beneficiaries, retirees, their family members and survivors will generally pay lower co-payments and cost-shares for mental health care, such as $12 for outpatient mental health and SUD visits rather than the current rate of $25 per mental health visit.  Co-pays and cost-shares for inpatient mental health services will also be the same as for inpatient medical/surgical care. A full list of all mental health co-pay and cost-share changes will be posted on Oct. 3 on the TRICARE website.

Although the new copayment rules are effective Oct. 3, there is a chance that some providers may not be aware of these changes. Should beneficiaries be charged incorrect cost-shares or co-pays, TRICARE will correct claims retroactive to Oct. 3, 2016.

TRICARE already eliminated several restrictions relating to the lengths of stay allowed for inpatient mental health treatment and psychiatric Residential Treatment Center care for children and adolescents.  Additional day limits for services such as partial hospitalization, residential substance use disorder care, smoking cessation counseling, and other mental health treatment will also be removed effective Oct. 3, 2016. The removal of these limits altogether will further de-stigmatize mental health treatment and hopefully provide a greater incentive for beneficiaries to seek the care they need.   

“Now, the length of a course of treatment will be based solely on medical and psychological necessity,” said Davison.

For example, a person struggling with alcoholism has a limit of three outpatient treatments in his lifetime under TRICARE’s current benefits. However, substance use can be a lifelong struggle. The changes will allow people to seek help as many times as they need it. 

TRICARE will expand its coverage of treatment options for substance use disorders, including opioid use disorder, which can range from addiction to heroin to prescription drugs.  This change will provide more treatment options, such as outpatient counseling and intensive outpatient programs. Office visits with a qualified TRICARE authorized physician may include coverage of medication-assisted treatment (e.g., buprenorphine, or “suboxone”) for opioid addiction if the physician is certified to prescribe these medications.

Once additional changes are put into effect early next year, the process for facilities to become TRICARE-authorized will become easier and faster as TRICARE seeks to make its regulations consistent with industry standards. “These revisions will make mental health care and SUD treatment more community based,” said Moseley.

Gender dysphoria – a condition in which a person experiences distress over the fact that their gender identity conflicts with their sex assigned at birth – may be treated non-surgically by TRICARE-authorized providers effective Oct. 3.  Non-surgical treatment includes psychotherapy, pharmacotherapy and hormone treatment. Surgical care continues to be prohibited for all non-active duty beneficiaries.

“We are working as quickly as possible to implement these sweeping changes to the program over the next several months,” said Moseley. 

The reduction in cost-shares and co-pays will be effective Oct. 3, along with authorization of office-based substance use disorder treatment and non-surgical treatment of gender dysphoria.  Changes that require new or more detailed revision of TRICARE policy manuals, such as TRICARE authorization criteria for institutional mental health providers, will be rolled out early 2017. Updates will be posted as changes are implemented. For more information, please visit the TRICARE website.  

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