TRICARE Prime Handbook

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Covered Services, Limitations, and Exclusions


Behavioral Health Care Services 


Active Duty Service Members
Active duty service members must have prior authorization before seeking behavioral health care. We do not want to discourage you from seeing a behavioral health specialist, but we want to make sure that your condition does not adversely affect your health and your ability to perform worldwide duty. Contact Humana Military before obtaining behavioral health care services.

All Others Enrolled in TRICARE Prime
You may receive the first eight behavioral health outpatient visits per fiscal year (October 1- September 30) from a network provider without a referral or prior authorization from your PCM. If you obtain these visits from a non-network provider without referral from your PCM and Humana Military, POS fees will apply. After the first eight visits (beginning on the 9th visit), you must obtain a referral from your PCM and receive prior authorization from Humana Military .

Authorized Behavioral Health Providers
The following types of behavioral health providers may be authorized providers under TRICARE:
  • Psychiatrists
  • Clinical psychologists
  • Certified psychiatric nurse specialists
  • Clinical social workers
  • Certified marriage and family therapists with a TRICARE participation agreement
  • Pastoral counselors—with physician referral and supervision
  • Mental health counselors—with physician referral and supervision
  • Licensed professional counselors—with physician referral and supervision
If you are unsure which type of provider would best meet your needs, contact Humana Military for assistance.

  

Figure 3.4 provides coverage details for covered behavioral health services. Note: This chart is not intended to be all-inclusive.
       
Behavioral Health Care Services : Coverage Details                                                          Figure 3.4   
Service Description 
Acute Inpatient Psychiatric Care

Acute inpatient psychiatric care may be covered on an emergency or nonemergency basis. Prior authorization from Humana Military is required for all
nonemergency inpatient admissions. In emergency situations, authorization is required for continued stay.

      Limitations
  • Patients age 19 and older are limited to 30 days per fiscal year.*
    Infectious diseases (Hepatitis B screening, human immunodeficiency virus [HIV] testing) and preventive therapy when at-risk (tetanus, animal bite, Rh immune globulin, and exposure to certain infectious diseases, including tuberculosis)
  • Patients age 18 and under are limited to 45 days per fiscal year.*
  • Inpatient admissions for substance use disorder detoxification and rehabilitation count toward the 30-or 45-day limit.

Note: Day limits may be waived if determined to be medically or psychologically necessary (See 10 USC 1079 (i)).


 
Medication 
Management 		 If you are taking prescription medications for a behavioral health care condition, you must be under the care of a provider who is authorized to prescribe those medications. Your provider will manage the dosage and duration of your prescription to ensure you are receiving the best care possible.
Partial Hospitalization

Psychiatric partial hospitalization provides interdisciplinary therapeutic services at least three hours per day, five days a week, in any combination of day, evening, night, and weekend treatment programs.

  • Prior authorization from Humana Military is required.
  • Facility must be TRICARE-authorized.
  • Partial hospitalization programs must agree to participate in TRICARE.

    Limitations      
  • Limited to 60 treatment days (whether a full-or partial-day treatment) in a fiscal year.* These 60 days are not offset or counted toward the 30 or 45 day inpatient limit.

 
Psychological Testing and Assessment  Covered when medically or psychologically necessary and provided in conjunction with otherwise-covered psychotherapy. Psychological tests are considered to be diagnostic services and are not counted against the limit of two psychotherapy visits per week.

Limitations
Testing and assessment is generally limited to six hours in a fiscal year.

Exclusions
Psychological testing is not covered for the following circumstances:
  • Academic Placement
  • Job Placement
  • Child custody disputes
  • General Screening in the absence of specific symptoms
  • Teacher or parental referrals
  • Diagnosed specific learning disorders or learning disabilities
Psychotherapy Prior authorization is required after the first eight behavioral health outpatient visits per beneficiary per fiscal year.* Covered psychotherapy includes:
  • Individual, conjoint, family, or group sessions
  • Collateral visits
  • Play therapy (This is a form of individual therapy used with children.)
  • Psychoanalysis (Prior authorization from Humana Military is required.)

    Limitations
  • Outpatient psychotherapy is limited to a maximum of two sessions per week in any combination of individual, family, collateral, or group sessions and is not covered when the patient is an inpatient in an institution.
  • Inpatient psychotherapy is limited to five sessions per week in any combination of individual, family, collateral, or group sessions. The duration and frequency of care is dependent upon medical necessity.
Residential Treatment Center (RTC) Care RTC care provides extended care for children and adolescents with psychological disorders that require continued treatment in a therapeutic environment.
  • Unless therapeutically contraindicated, the family and/or guardian should actively participate in the continuing care of the patient either through direct involvement at the facility or geographically distant family therapy.
  • Facility must be TRICARE-authorized.
  • Prior authorization from Humana Military is required.
  • RTC care is considered elective and will not be covered for emergencies.
  • Admission primarily for substance-use rehabilitation is not authorized.
  • Care must be recommended and directed by a psychiatrist or clinical psychologist.

    Limitations
  • Limited to 150 days per fiscal year* (limitation may be waived if determined to be medically or psychologically necessary).

    Note: No qualified RTCs were available in overseas locations at time of printing.
Treatment for Substance Use Disorders

A substance use disorder includes alcohol or drug abuse or dependence. TRICARE may cover services for the treatment of substance use disorders, including detoxification, rehabilitation, and outpatient group and family therapy. Emergency and inpatient hospital services are considered medically necessary only when the patient’s condition is such that the personnel and facilities of a hospital are required.

Note: All treatment for substance use disorders requires prior authorization from Humana Military.

Coverage and Limitations

  • Benefit Period—Only three substance use disorder treatment benefit periods in a lifetime (waiver possible in accordance with policy criteria) are covered. A benefit period begins with the first date of covered treatment and ends 365 days later, regardless of the total services actually used within the benefit period. Emergency and inpatient hospital services for detoxification, stabilization, and for treatment of medical complications of substance use disorders do not count for purposes of establishing the beginning of a benefit period.
  •  Detoxification—If chemical detoxification is needed, but does not require the personnel or facilities of a general hospital setting, detoxification services are covered in addition to rehabilitative care. In a diagnosisrelated group (DRG)-exempt facility, detoxification services are limited to seven days per year, unless the limit is waived.
  • Rehabilitation—Rehabilitation (residential or partial) is limited to 21 days per year or one inpatient stay in a facility subject to the DRG-based reimbursement system, per benefit period; you are limited to three benefit periods in your lifetime. All inpatient stays count toward the 30- or 45-day inpatient limit. Outpatient Care—Must be provided by an approved substance use disorder facility in a group setting. Coverage is limited up to 60 visits per fiscal year.* Individual outpatient care for substance use disorder is not covered.
  •  Family Therapy—Outpatient family therapy is covered beginning with the completion of rehabilitative care. You are covered for up to 15 visits in a benefit period.

* Fiscal year is October 1- September 30.
For additional information about covered and non-covered behavioral health care services and how to access care, contact Humana Military.

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Last Reviewed: July 11, 2008