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Formerly known as Civilian Health, TRICARE is a health care program for military service members, veterans and their dependents. Insurance coverage is available for all branches of the military including the Navy, Army, Air Force, Coast Guard, Marine Corps, and the United States Public Health Service. TRICARE is managed by the Defense Health Agency and all plans meet coverage minimums according to and established by the Affordable Care Act (ACA). Members and beneficiaries are provided coverage for the following:
- Health Plans: TRICARE offers several different health plans with availability dependent on who you are and where you live.
- Dental Plans: TRICARE covers dental care needed to treat a covered medical condition, injury or disease.
- Prescriptions: Most prescription drugs approved by the U.S. Food and Drug Administration (FDA) are covered by TRICARE.
- Special Programs: Certain supplemental programs are offered based on individual beneficiary health concerns or conditions.
TRICARE is divided into three separate regions, East, West and Overseas, each having its own regional contractor. The East and West regions are broken up geographically within the United States. Anywhere outside of the United States is considered Overseas. Together, TRICARE has approximately 9.4 million total members. You can find your region and your administrator here: Read more about the different TRICARE regions and which organization manages your Tricare plan.
- TRICARE East: Managed by Humana Military
- TRICARE West: Managed by Health Net
- TRICARE Overseas Program (TOP): Managed by International SOS
TRICARE Health Plans
TRICARE offers several health plan options to uniformed service members, national guard/reserve members, survivors, former spouses, medal of honor recipients and family members. In addition, others registered in the Defense Enrollment Eligibility Reporting System (DEERS) may also qualify for coverage. The types of beneficiaries include Sponsors (active duty, retired and guard/reserve members) and their family members (spouses and children).
Plan availability depends on your beneficiary category and your geographic location. TRICARE health plan options include:
- TRICARE Prime: available to eligible members and their families who reside in Prime Service Areas (areas which ensure medical readiness of active duty). Members participating in this plan are assigned a primary care manager (PCM) who coordinates care for the patient. Certain beneficiaries may be required to pay annual enrollment fees. This plan offers the most affordable and comprehensive coverage.
- TRICARE Prime Remote: available to eligible members and their families who reside in “remote” areas of the United States. If a member’s home and work address are both located more than 50 miles from a military hospital or clinic then they would be eligible for this plan. This plan offers the most affordable and comprehensive coverage for those located in remote U.S. locations.
- TRICARE Prime Overseas: available to active duty service members, activated national guard/reserve members and command-sponsored family members who reside in overseas areas near military hospitals and clinics. There are no enrollment fees for this plan. This plan offers the most affordable and comprehensive coverage for those living outside of the U.S.
- TRICARE Prime Remote Overseas: available to active duty service members, activated national guard/reserve members and command-sponsored family members who reside in the following regions: Eurasia-Africa, Latin America, Canada, and Pacific. There are no enrollment fees for this plan. This plan offers the most affordable and comprehensive coverage for those living in remote overseas locations.
- TRICARE Select: available to all non-active duty beneficiaries. Referrals are not required with this plan, but you may need prior authorization for some services. This plan offers the most freedom of choice. Members do not receive a TRICARE card with this plan as a military ID is used for proof of coverage.
- TRICARE Select Overseas: available to active duty and activated guard/reserve family members, retired service members, and their families. This plan offers a fee-for-service option, which allows the most flexibility in getting care, but costs more out-of-pocket than the TRICARE Prime Overseas option.
- TRICARE For Life: available worldwide where Medicare does not provide coverage. This plan offers Medicare-wraparound coverage for beneficiaries who have Medicare Part A and B. Enrollment is not required but Medicare Part B premiums must be paid. There are minimal out-of-pocket costs with this plan and there is no annual deductible for services covered by Medicare and TRICARE.
- TRICARE Reserve Select: available worldwide for qualified Select Reserve members and their families. There are no referrals required for this premium based plan, however prior authorization may be necessary.
- TRICARE Retired Reserve: available worldwide for qualified Select Retired Reserve members and their families. There are no referrals required for this premium based plan, however prior authorization may be necessary.
- TRICARE Young Adult: available to qualified adult children after “regular” TRICARE coverage ends at age 21, or 23 for college students, but under the age of 26. TRICARE Young Adult Plan options include Select, Prime, Prime Overseas, Prime Remote or Prime U.S. Family Health Plan (USFHP).
- S. Family Health Plan (USFHP): available to eligible members through networks of community-based, not-for-profit health care systems. Participating providers include Johns Hopkins Medicine, Martin’s Point Health Care, Brighton Marine Health Center, St. Vincent Catholic Medical Centers, CHRISTUS Health and Pacific Medical Centers.
TRICARE Coverage for Substance Abuse
It is important to remember that regardless of insurance coverage, reaching out for help is the first step towards getting better. Fortunately for those covered by TRICARE, there are many options available depending on your individual needs. With the passage of the Affordable Care Act (ACA), insurance companies, including TRICARE, are required to provide coverage for mental health and substance use disorder services.
If emergency mental health care is needed you do not need prior authorization. You should call 9-1-1 or go to your nearest emergency room. For non-emergency mental health care, you may need to get a referral or prior authorization before going to a treatment facility, based on your particular plan. TRICARE covers both medically and psychologically necessary substance abuse care for both inpatient and outpatient treatment. Some common covered treatments include:
- Detoxification: The management of withdrawal symptoms, or detoxification, may be appropriate for those experiencing acute phases of substance use withdrawal. This level of care requires the personnel and facilities of a hospital or a Substance Use Disorder Rehabilitation Facility (SUDRF). You may need prior authorization for non-emergency inpatient detoxification.
- Residential Treatment: TRICARE covers residential treatment for substance abuse when members have a significant impairment that interferes with normal functioning and are unable to function in the community with only outpatient services. Individuals in this level of care do not require the services of a hospital full-time, however residential treatment centers do provide a highly structured therapeutic environment with 24-hour services. Prior authorization is usually required for residential treatment.
- Partial Hospitalization Program (PHP): This level of care is appropriate when members have significant impairment from substance abuse that interferes with normal functioning. Individuals often transition to PHP after detoxification or residential treatment or if they are unable to maintain a healthy lifestyle in a lower level of outpatient care. Services may be provided during the day, evening, night or weekend and individuals usually reside in a recovery residence for added support. Prior authorization may be required for PHP.
- Intensive Outpatient Program (IOP): TRICARE will cover IOP for a member with a substance abuse disorder who needs stabilization, symptom reduction or prevention of relapse. Individuals can transition to IOP after completing a higher level of care, like PHP, or if regular outpatient care is not appropriate. Services may be provided during the day, evening, night or weekend and individuals may reside in a recovery residence for added support or live at home. Prior authorization is usually not required for IOP.
- Outpatient (OP): Outpatient psychotherapy may be covered by TRICARE when it is medically or psychologically necessary to treat a substance use disorder. Outpatient treatment includes individual, family or group psychotherapy. Individuals can transition to OP after completing a higher level of care, like PHP or IOP. Prior authorization may be required for certain outpatient services.
TRICARE does not cover certain treatments that are not considered “medically necessary.” The standards for such programs are not readily available to advocate for optimal treatment, as opposed to a rehabilitation center or hospital. In some instances, physicians may be able to overrule situations that aren’t typically thought of as medically necessary, however these occasions are uncommon. Some examples of treatments related to substance abuse that TRICARE typically will not cover include:
- Aversion, bioenergetic, carbon dioxide, filial, marathon, megavitamin, orthomolecular, primal, sedative action electrostimulation or sexual dysfunction therapy
- Certain counseling services including nutritional counseling, stress management, marital therapy, or lifestyle modifications
- Experimental procedures
- Services that are not medically or psychologically necessary for the diagnosis and treatment of substance abuse
- Therapy for developmental disorders including dyslexia, developmental mathematics disorders, developmental language disorders, and developmental articulation disorders
Substance Abuse Treatment with TRICARE
According to Kevin Dwyer, spokesman for the Defense Health Agency which manages TRICARE, “New TRICARE mental health benefits, including expanded treatment for opioid and other substance-use issues, went live July 13.” These updates became necessary with the opioid epidemic on the rise and over 115 people in the United States dying due to an overdose each day.
The misuse of an addiction to opioids, including prescription pain pills, heroin, and fentanyl, is a serious national crisis that affects public health as well as social and economic welfare. The Centers for Disease Control and Prevention estimates that the total economic burden of prescription opioid misuse alone in the United States is $78.5 billion a year.
In addition to expanded treatment for substance abuse, TRICARE has also for the first time ever instituted an open enrollment period. “This provides greater options for beneficiaries, with the ability to really shape their plan, the ability to own their health and really be in control of that directly,” said Chief of TRICARE Patrick Grady. Members are able to make changes to their coverage during open season windows from the second full week in November to the second full week in December.
TRICARE Resources for Substance Abuse Treatment
Individuals in need of substance use disorder treatment are encouraged to check their policy for covered services with a TRICARE representative (or their insurance broker/agent) prior to entering into a residential care program. The approval and referral process for TRICARE varies by policy so it’s important to be aware of what requirements need to be met beforehand. Most substance abuse treatment centers who are approved TRICARE providers can assist those in need of help and walk them through the necessary steps.
TRICARE insurance coverage is complicated and can be a confusing process, especially when dealing with issues surrounding substance abuse. Drug and alcohol addiction affects the entire family and getting help for a loved one can be a difficult task. Fortunately, there are many qualified and experienced people who are willing to help. If you are concerned about a friend or family member’s addiction or are struggling yourself, contact us now at 1-888-797-2559 to speak to one of our treatment experts.