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TRICARE mental health benefit and cost changes

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. These changes will make TRICARE’s mental health care and SUD treatment benefits on par with other public and commercial health care programs.

The first change includes a better alignment of mental health co-pays and cost-shares with medical and surgical costs. See chart below for specific information.

Active duty family members

Plan

Fiscal year 2016 co-pays/cost-shares

Co-pays/cost-shares effective October 3, 2016

TRICARE Prime/Remote

$0 for any type of care

No change

TRICARE Standard and Extra

Outpatient:

  • Network: 15% of negotiated rate
  • Non-network: 20% of allowable charge
Inpatient: $20 per day ($25 minimum charge)

Partial Hospital Programs (PHPs): $20/day

Outpatient: No change

Inpatient: regular hospitalization per diem charge ($18.20 per day) ($25 minimum charge)

PHPs: will be cost-shared on an outpatient basis, subject to the applicable outpatient deductible and cost-sharing of 20% (Standard) and 15% (Extra) of the PHP per diem rate.


Retired service members, their families and all others

Plan

Co-pays/cost-shares as of fiscal year 2016

Co-pays/cost-shares effective October 3, 2016

TRICARE Prime

Outpatient:

  • Individual: $25
  • Group: $17
Inpatient: $40 per day

PHPs: $40/day

Outpatient: $12 per visit

Inpatient: $11 per day ($25 minimum charge)

PHPs: will be cost shared on an outpatient basis ($12 per visit)

TRICARE Standard and Extra

Outpatient:

  • Network: 20% of negotiated rate
  • Non-network: 25% of allowable charge
Inpatient: Network: 20% of the total charge, plus 20% for separately billed professional services

Non-network:
  • High-volume hospitals: 25% hospital specific per diem, plus 25% for separately billed services
  • Low-volume hospitals: $229 per day or 25% of the billed charges, whichever is less, plus 25% for separately billed services
  • Residential treatment center: 25% of the allowed amount
PHPs: 25% (Standard) and 20% (Extra) of the allowed amount, plus 25% (Standard) and 20% (Extra) of the allowable charge for separately billed professional services

Outpatient: No change

Inpatient: No change 

Non-network:

  • High-volume hospitals: No change
  • Low-volume hospitals: $235 per day (updated to FY17 rate) or 25% of the billed charges, whichever is less, plus 25% for separately billed services
  • Residential treatment center: No change
PHPs: will be cost-shared on an outpatient basis, subject to the applicable outpatient deductible and cost-sharing of 25% (Standard) and 20% (Extra) of the PHP per diem rate

The second change involves the removal of treatment limitations for mental health care. See chart below for specific information.

Service

Treatment limits as of fiscal year 2016

Change effective October 3, 2016

Hospitalization

30 days for adults*
45 days for children per year*

Coverage is based upon a determination of medical or psychological necessity and the use of appropriate utilization management tools which are used for all other medical and surgical benefits.

Psychological testing
 6 hours per year
Outpatient therapy
 2 sessions per week
Psychiatric partial hospitalization and substance use disorder rehabilitation facility partial hospitalization services
 60 days per year
Family therapy
15 inpatient and 60 outpatient visits in a free-standing or hospital-based substance use disorder rehabilitation facility
Psychiatric residential treatment centers
150 days per year*
Substance use disorder – lifetime treatment episodes

lifetime 3 treatment episodes for substance use disorder
Substance use disorder – detoxification
7 days per episode
Substance use disorder – residential treatment
21 days per episode
Smoking cessation  2 quit attempts in a 12-month period, and 18 face-to-face counseling sessions per attempt
*Psychiatric hospitalization and psychiatric residential treatment center day limits removed in TRICARE policy manual change 155 on February 8, 2016.

Gender dysphoria

TRICARE is also expanding the benefit for treatment of gender dysphoria. Coverage that is now included are non-surgical, medically and psychologically necessary treatment such as psychotherapy, pharmacotherapy and hormone replacement therapy.

Learn more

These changes will be implemented immediately. Should beneficiaries be charged incorrect cost-shares or co- pays, TRICARE will correct claims retroactive to October 3, 2016.