TRICARE Program benefits include an all-inclusive, economical health care coverage option that has numerous pharmaceutical benefits, health program options, dental care options and other specific programs. This section will provide detailed information on the many services covered by TRICARE.
TRICARE provides coverage for one all-inclusive ophthalmologic optical exam every two years under the TRICARE Prime program. These eye exams can be performed at any TRICARE approved ophthalmologist or optometrist. You will not need your primary care provider’s referral for you to visit a TRICARE network provider. However, a referral will be needed if you decide to visit a non-TRICARE network provider. If you do not submit the referral, the visit could otherwise be declined to be covered by TRICARE.
TRICARE CHILD OPTICAL BENEFITS
TRICARE’s well-child benefit provides coverage to all children, regardless of their health plan, for one vision and optical screening at birth and when they are 6 months old. This screening includes tests for visual acuity, red reflex and ocular alignment. Also, two all-inclusive optical exams are also provided when the child is ages 3 to 6 years old. This screening includes tests for strabismus and amblyopic issues. After the age of 6, an all-inclusive optical exam can be completed every two years.
BEHAVIORAL AND MENTAL HEALTH COVERAGE
TRICARE offers coverage for behavioral and mental health care that is psychologically or medically necessary in order to treat any underlying behavioral health problem.
Some specific outpatient services will require authorizations and referrals. This however is not applicable to active duty service members being attended to at military treatment facility. Access to care and the facility’s standards will also vary depending on location, the TRICARE program option, and the type of beneficiary.
Psychotherapy is a behavioral health care plan that is normally conducted under discussion with the patient. Both inpatient and outpatient psychotherapy treatments are covered in cases where it is necessary to offer a patient medical or psychological treatment for a behavioral health disorder.
A maximum of two sessions per week for a combination of family, individual, collateral, or group sessions is covered under the outpatient psychotherapy program. A maximum of five sessions per week is covered in inpatient psychological care for any combination of session types. The frequency and duration of additional care will be determined by the medical necessity. Below are the covered therapy sessions:
- Individual Psychotherapy: The therapy is available to children and adults to help ease their emotional issues, encourage personality development and growth, and regress or change troubling behavior. Sessions of up to 1 hour in length are covered. Emergency sessions can be extended for up to a 2-hour session. Individual psychotherapy coverage does not insure patients diagnosed with substance abuse unless it is determined that the individual also suffers from a mental disorder.
- Play Therapy: This is a form of the individual psychotherapy that is used to treat and diagnose children.
- Conjoint or Family Psychotherapy: This therapy is designed to offer treatment for the whole family. Regular sessions of a maximum of 90 minutes are covered, and emergency sessions may be extended to a maximum 3 hours as needed.
- Group Psychotherapy: A maximum of 90-minute sessions are covered.
- Collateral Visits: This is not a therapy session, but a means to gather information and execute treatment aims. Collateral visits are termed as individual psychotherapy sessions lasting for up to a 1-hour session.
Beneficiaries can choose to combine a collateral visit with any other psychotherapy visits.
This service is different from psychological therapy because it requires authorization prior to treatment of the patient. Once the authorization is granted, the service is then administered by the necessary health care professionals and therapists.
The psychological assessment and testing service is only covered when it is provided in conjunction with psychotherapy and is utilized to help diagnose or plan treatment for patients. The tests are limited to a maximum of 6 hours during the fiscal year from the dates of October 1 till until September 30 of the following year. Any tests which require more than 6 hours are subject to medical assessments.
The beneficiary’s location, TRICARE plan option, as well as his or her beneficiary type will determine the access, care, authorization requirements, referrals, and availability of inpatient services. All non-emergency behavioral health services require prior authorization. Emergency inpatient services will require authorization for continued stay.
PSYCHIATRIC INPATIENT INTENSIVE CARE
Patients may be sent to the intensive care psychiatric treatment if the patient is at high risk that their physical wellness is threatened by a behavioral health disorder. This could be for the extent of the need if 24-hour psychiatric and medical care is warranted.
LIMITS APPLIED TO THE BENEFITS
- Patients ages 19 years old and above are restricted to 30 days per fiscal year or per single admission.
- Patients ages 18 years old and under are restricted to 45 days per fiscal year or per single admission.
PSYCHIATRIC PARTIAL HOSPITALIZATION PROGRAM (PHP)
This program is prescribed for stabilization of a critical behavioral health problem or for switching of a patient from an inpatient program to an outpatient program. The psychiatric PHP treatment provides medical therapeutic services for at least 3 hours per day and 5 days per week. The treatment may include weekend, evening, day or night programs.
Up to 60 days of coverage per full or half-day programs are provided by TRICARE under authorized TRICARE programs for behavioral health disorders. Psychiatric PHP treatment for a subtance abuse diagnosis is restricted to the maximum rehabilitation treatment. The 30-45 day restriction for psychiatric inpatient intensive care does not apply to the psychiatric PHP treatment.
SUBSTANCE USE DISORDERS
These disorders are inclusive of chemical dependence, drug, or alcohol abuse. The treatment and other services provided are covered only by institutional providers that are authorized by TRICARE. The institutions include authorized hospitals or independent substance use disorder correctional facilities providing organized treatment plans that are based in hospitals (substance use disorder rehabilitation facilities). Detoxification and rehabilitation treatments are offered along with outpatient group, individual, or family therapy.
TRICARE provides coverage for a maximum of three substance abuse rehabilitation treatments per benefit period or in a lifetime. A benefit period is counted from the first date of treatment coverage to the end of 365 days.
EMERGENCY INPATIENT DETOXIFICATION
TRICARE offers coverage for inpatient chemical detoxification treatments in emergency cases where hospital staff and facilities (or even substace use rehabilitation facilities) are needed. TRICARE authorized institutions offer a maximum of 7 days of coverage for every episode. If the episodes after evaluation require additional medical and psychological attention, the extra days required for treatment may be covered by TRICARE.
The 30-45 day restriction for psychiatric inpatient intensive care applies to inpatient detoxification treatment but not to the point where rehabilitation is required.
The rehabilitation of substance use disorders may take place in a PHP center or an inpatient center. A 21-day period of rehabilitation is covered for every benefit period in facilities authorized by TRICARE, regardless if they are PHP, inpatient, or a combination of the two types of rehab. The 30-45 day restriction for psychiatric inpatient intensive care applies, as well as the 60-day PHP restrictions, for treatments.
Outpatient services must be provided in a group or individual setting by any subtance use disorder rehabilitation facility that is authorized by TRICARE. The benefits available are:
- A maximum of 60 visits for every benefit period for group and individual therapy
- A maximum of 15 visits for every benefit period for family therapy; limits can be lifted if additional visits are required to be psychologically evaluated or are medically necessary and have been approved
TRICARE YOUNG ADULT
This is a health care plan that is based on premiums which eligible dependents may buy. The TRICARE Young Adult plan provides pharmacy and medical benefits while dental care coverage is excluded from the plan.
The TRICARE Young Adult plan is available to dependent children whose eligibility for the normal TRICARE coverage expires when they are at the age 21 or 23 ( depending on if they are enrolled to study full-time at approved higher learning institutions). The care an individual may receive is determined on whether or not you are enrolled in the TRICARE Prime or Standard options. You are eligible to buy TRICARE Young Adult Plan if you are an adult whose sponsor is eligible.
The following people are considered eligible sponsors:
- Military Force members
- Servicemembers who have retired
- Reserve and National Guard active members
- Reserve or National Guard members who are yet to be activated, but are using the TRICARE Reserve Select program
- Reserve or National Guard members who are retired, but are utilizing the TRICARE Retired Reserve program
Other eligibility requirements include:
- You are not married
- You are at least 21 years of age but under the age of 26
- You are not qualified for health plans sponsored by employers under your employment status
- You are otherwise not qualified for TRICARE program coverage
Note: If you are enrolled to study full-time at approved higher learning institutions and your sponsor gives you financial support of up to 50%, you may not be eligible until you reach the age of 23 years old or if you graduate, whichever of the two comes first.
HOW TRICARE YOUNG ADULT PROGRAM WORKS
Monthly premiums must be paid for you to take part in TRICARE Young Adult Program. The premium rates are set annually on the basis of a calendar year. The premium amounts currently charged as of 2016 are as follows:
- Standard Health Plan Option: $228 per month
- Prime Health Plan Option: $306 per month
The health care costs that are paid by you will then depend on the above options. The costs will also be different when using the Standard Option, depending on your sponsor’s active duty status , and the type of health care provider you visit. Visit the TRICARE Young Adult Website for more information.
SPECIAL TRICARE PROGRAMS
Special programs are offered to cover specific beneficiary health conditions and concerns. The programs are mostly based on specific criteria for qualification that are dependent on a beneficiary’s plan, category, or status. Health promotion programs on topics ranging from alcohol education, weight management, and smoking cessation are included in the program.
Some programs cater for specific beneficiary groups such as pre-activation benefits for Reserve and National Guard members and the foreign force member health care plan. Others are for certain health conditions, e.g. Cancer Clinical Trials. Restrictions on the number of participants or on certain geographic locations are placed on programs, e.g. chiropractic care. Visit www.tricare.mil for more information on special health TRICARE programs.