TRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services, is the supplemental healthcare program for active and retired military service members and their families. TRICARE is a program of the United States Department of Defense Military Health System and includes coverage for individuals of the U.S. Air Force, Army, Navy, Marine Corps, Coast Guard, Commission Core, U.S. Public Health Service, and Commission Core of the National Oceanic and Atmospheric Association.
In 2017, TRICARE made massive changes to their mental health benefits, which now includes coverage for addiction treatment. The health insurance expansion included treatment for opioid addiction and other substance abuse issues. Drug and alcohol abuse has always been an ongoing problem for members of the United States Military, and these changes have continued to help active duty and retired service members who are struggling with addiction.
TRICARE may cover the following services:
- Inpatient services
- Intensive outpatient programs
- Intervention programs
- Medication-assisted treatment
- Family therapeutic services
- Partial hospitalization programs
- Residential treatment
Many different factors determine what treatment and rehab services are covered by TRICARE, including individual plan details, where the individual that is seeking treatment lives, legal requirements, and the type of treatment being sought.
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TRICARE Health Plans
Similar to other medical insurance plans, there are many options available to those that have TRICARE coverage. All of the plans available either meet or exceed the standards established by the Affordable Care Act (ACA) to ensure that people have the quality health insurance options for their specific needs.
While each plan has a comprehensive list of what it does and does not cover, there are eight different programs available:
- TRICARE Prime is a plan that provides coverage in specific geographical areas that are considered ‘prime’ locations in the United States.
- TRICARE Prime Remote is a plan that provides coverage in more remote locations of the U.S., as well as some areas overseas.
- TRICARE Standard and Extra is a plan that requires a paid fee but doesn’t require enrollment for members to receive service.
- TRICARE Standard Overseas is a plan that provides comprehensive coverage for people overseas.
- TRICARE for Life is a Medicare coverage option to provide additional help for people who have Medicare Part A and B.
- TRICARE Reserve Select is a premium-based plan that provides coverage for qualified reserve service members and family members.
- TRICARE Retired Reserve is a premium-based plan that provides coverage for retired service members under the age of 60 and their families.
- TRICARE Young Adult is a plan that provides coverage for young adult children who do not qualify for other TRICARE coverage.
Specific coverage will depend on the nature of an individual’s service and qualifications.
Do Treatment Centers Need to Be In-Network?
TRICARE typically only offers full coverage for select providers approved by the insurance company. Participating in-network providers have a pricing agreement with TRICARE for billing addiction treatment services. Patients of in-network addiction treatment facilities are only responsible for a small portion of the cost as an out-of-pocket expense.
Patients enrolled in the TRICARE Select, Reserve Select, Retired Reserve, Young Adult Select, Family Health, and Prime Remote plans are permitted to use the out-of-network provider of their choice. However, if patients choose out-of-network care, they may have to file individual claims and pay a higher percentage of the service cost. In fact, out-of-network providers can charge up to 15% more than the allowable charge. In some cases, TRICARE clients then must cover the full cost of out-of-network services and then seek reimbursement from the insurance company after treatment has been completed.
TRICARE Coverage for Inpatient Treatment
TRICARE covers residential treatment if a number of conditions are met, including: the patient has a formal substance use disorder diagnosis, the patient has withdrawal symptoms severe enough to require physician assistance, and the patient struggles to function in everyday life. If these requirements are met, TRICARE will cover both emergency and non-emergency inpatient addiction treatment. Emergency treatment is when a person has a medical or psychiatric crisis and requires immediate medical attention. TRICARE will cover the costs of detoxification, stabilization, and any medical complications. Non-emergency treatment is when someone decides to seek treatment for substance abuse on his or her own. This requires prior authorization from TRICARE before coverage will be provided. Coverage usually includes both detoxification and stabilization; depending on the plan, coverage may also include treatment for any additional co-occurring mental health conditions.
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TRICARE Coverage for Outpatient Treatment
TRICARE will also cover outpatient treatment if an individual’s plan meets the specific qualification requirements. A person must be active in addiction but not in need of hospitalization or around-the-clock care. There are several types of outpatient treatment covered by TRICARE, including: standard outpatient programs, intensive outpatient programs (IOP), and partial hospitalization programs (PHP).These programs offer the same therapy resources as residential treatment, such as group therapy and individualized counseling, but are administered through multiple weekly treatment sessions to help patients maintain their careers and families during the treatment process.
Standard outpatient treatment is the least intensive form of outpatient care and only requires people to attend therapy once or twice a week at an office-based TRICARE approved center. IOPs are more intensive and consist of therapy that must be attended several days per week. PHPs are the most intensive outpatient program and requires daily treatment that lasts approximately four to eight hours.
How Can I Pay the Costs Not Covered by TRICARE Insurance?
Knowing what services your insurance plan will or will not cover is an important step of exploring your treatment options. Fortunately, for those covered by TRICARE, there are many options available. If you’re unsure of your current plan’s benefits, contact a treatment provider to learn more about your recovery options.