TRICARE, formerly called the Civilian Health and Medical Program of the Uniformed Services, is the healthcare program for uniformed military service members and their families, including retired members of the US Air Force, Army, Navy, Marine Corps, Coast Guard, the Commission Core, the US Public Health Service, and the Commission Core of the National Oceanic and Atmospheric Association. All beneficiaries are offered coverage that can include:
- Health plans
- Special programs
- Dental plans
TRICARE advertises that the majority of its programs meet the requirements for minimum essential coverage as established by the Affordable Care Act. TRICARE is managed by the Defense Health Agency under the Assistant Secretary of Defense. TRICARE is managed within three regions (North, South, and West), and each region has its own regional contractor. Information on providers for each of the regions can be found at this link.
Plans of Coverage
TRICARE offers numerous healthcare plans. All of these plans meet or exceed the minimum standards of care as defined by the Affordable Care Act. The availability of each plan depends on the state in which one lives and certain demographic factors of the potential enrollee.
A list of complete health plans, their benefits, who qualifies for them, etc., that are offered by TRICARE can be found here. Refer to the link for specific information about any one of the following healthcare plans that TRICARE offers:
- TRICARE Prime is available in prime geographical areas. Some individuals may have to pay annual enrollment fees. Coverage availability is based on an individual’s zip code. In addition, TRICARE Prime Remote is available in remote areas in the US; TRICARE Prime Overseas is available at locations near hospitals overseas; and TRICARE Prime Remote Overseas is available in specific locations overseas.
- TRICARE Standard and Extra is a fee-for-service plan available in the US that does not require enrollment if an individual meets certain specifications.
- TRICARE Standard Overseas is a comprehensive coverage package available at all overseas locations, but the Extra option is not available.
- TRICARE for Life consists of Medicare wraparound coverage for individuals who have Medicare Part A and Part B.
- TRICARE Reserve Select is a plan for qualified reserve service members and their families.
- TRICARE Retired Reserve is a premium plan for retired reserve members, reserve members’ families, and survivors of reserve members.
- TRICARE Young Adult is a plan that adult children who qualify can purchase after their eligibility for other TRICARE coverage ends (typically at age 21 or age 23 if the person is enrolled in college).
- The US Family Health Plan is an additional TRICARE prime option available in six areas of the US.
Coverage for Substance Abuse
The Affordable Care Act mandated that insurance providers must provide some coverage for mental health services, including coverage for substance use disorders. TRICARE offers coverage for various aspects of substance use disorder treatment.
According to the company website, coverage is outlined below.
- Emergency hospital inpatient services associated with detoxification, stabilization, or for emergency medical complications arising from a substance use disorder are covered. Certain limitations may apply depending on the policy.
- Withdrawal management treatment (medical detox) through residential treatment or partial hospitalization treatment is generally covered.
- For individuals with an opiate use disorder diagnosis, certain medication-assisted treatments are covered (e.g., buprenorphine from qualified and DEA-registered physicians).
- Treatments and assessments are covered, including psychological assessments (for recognized psychiatric disorders but not for academic purposes), collateral visits (for information on test results, psychoeducation, instructions, etc.), substance use disorder therapy (group and individual), psychoanalysis (from certified providers), psychotropic drug treatment, electroconvulsive treatment (for certain mental health disorders), and adjunctive treatments (e.g., music or art therapy) if these are part of specific programs, such as residential treatment or partial hospitalization programs.
- Residential (inpatient) services may be covered if:
- The person has a formal diagnosis of a substance use disorder according to the DSM-5.
- The person has withdrawal symptoms that are severe enough to require inpatient treatment, require 24-hour monitoring, or cause severe distress in several major areas. Only medically necessary services are covered; individuals should check with their insurance agent regarding the definition of these services as it applies to their situation.
- Partial hospitalization services may be covered if:
- The substance use disorder interferes with the person’s normal functioning.
- The treatment requires medical detox with access to medical services.
- The person cannot be treated as an outpatient but does not require 24-hour supervision.
- The person needs stabilization from acute symptoms of substance abuse or is transitioning from an inpatient unit to a higher level of care.
It is important to note most of these services are provided and covered if they are deemed a medical necessity. The formal definition of a medical necessity states that the treatment and supplies are provided by healthcare entities, appropriate for the evaluation and treatment of the condition, and consistent with the applicable standards of care. TRICARE states that it does not cover aversion therapy (e.g., Antabuse treatment) and domiciliary facilities (e.g., halfway houses or sober living homes) as these do not meet the standards of medical necessity. Other services, like laundry services and housekeeping services in residential substance use disorder treatment facilities, will most likely be disputed.
In some cases, physicians may be able to formally state that certain treatments that might not normally get approval are medically necessary, but this is rare. For example, acupuncture treatment for mental health disorders (including substance use disorders) is not covered under most insurance policies, even if physicians order it. A list of treatments not covered by TRICARE for substance use disorders that might be offered at some facilities include:
- Behavioral health care services and supplies for weight reduction
- Certain counseling services, such as stress management, marital therapy, or lifestyle modifications
- Certain educational programs
- Custodial services
- Guided imagery
- Primal therapy
- Sexual dysfunction therapy
- Treatment for developmental disorders (e.g., developmental reading disorders [dyslexia], developmental mathematics disorders, developmental expressive and receptive language disorders, and developmental articulation disorders)
- Transcendental meditation and most other forms of meditation
- Yoga treatment for substance use disorders
Treatments that are experimental in nature or that do not have sufficient empirical evidence to justify their use in the treatment of the substance use disorder in question will not be covered. A more complete list of treatments not covered and any specifying conditions regarding these treatments can be found here.
Individuals who require coverage for substance use disorder treatment, including residential treatment and rehabilitation services, should always check regarding coverage for specific services with the appropriate customer service department or their agent before enrolling in any type of residential care program.
The process of getting approval for specific services is facilitated if a physician can make a formal referral for drug rehab treatment; in many cases, standards for medical necessity are automatically considered to be met if a physician makes the formal referral. A referral for drug rehab from a counselor or therapist may result in issues with getting the specific services approved. In the case where an individual does not get a referral for rehab from a physician, one can request that a physician take part in the formal intake evaluation, and recommendations made by the physician as part of the intake process can facilitate the approval of services. However, it should be recognized that many services may not be covered under one’s policy.
Click below to learn about some of the major insurance providers with policies that may cover drug treatment or ancillary services.