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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.*
• 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.

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 30/45-day inpatient limit.

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
• Specific diagnosed learning disorders or learning disabilities

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 your regional contractor 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.

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.

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 diagnosis-related 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-/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.