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Provider Handbook
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Outpatient Care for Alcoholism or Other Substance Use Disorders
Inpatient Detoxification
Substance Use Rehabilitation
Court-ordered Care |
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Alcoholism and Other Substance Use Disorders |
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Treatment for substance use disorders may include outpatient and/or inpatient services, as described below: |
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Outpatient Care for Alcoholism or Other Substance Use Disorders |
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TRICARE provides coverage for up to 60 facility-based, group therapy visits over the course of a “benefit year,” beginning the first day of the rehabilitation phase of treatment. Family therapy is covered for up to 15 visits per year, beginning the first day of therapy.
Outpatient individual therapy for substance use is not a TRICARE-covered benefit.
Waivers to the limits on care can be granted, in special circumstances, if the continued care meets certain requirements. This is true of both inpatient care and partial hospitalization.
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Inpatient Detoxification |
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Emergency and inpatient services are covered when medically necessary for the active medical treatment of the acute phases of substance use withdrawal (detoxification), for stabilization, and for the treatment of medical complications of substance use disorders. 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.
Coverage details include:
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- Covered for up to seven days in a TRICAREauthorized/certified facility, as medically necessary
- Counts toward the maximum of 30 or 45 days (depending on the patient’s age) of inpatient behavioral health care allowed per fiscal year
- Does not count toward the 21 days of rehabilitation mentioned in “Substance Use Rehabilitation.”
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Substance Use Rehabilitation |
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Rehabilitative care may occur in an inpatient or partial hospitalization setting. Care must be provided at TRICARE-authorized/certified facilities. The following details apply to substance use rehabilitation:
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- Prior authorization is required for rehabilitation stays.
- Care is covered for up to 21 days of rehabilitation per 365-day period in a TRICARE-authorized facility (includes inpatient and partial hospitalization days)
- Coverage during a single benefit period is limited to no more than one episode of care:
- Limited to one treatment episode in a one year period
- Limited to three treatment episodes during a person’s life.
- An inpatient rehabilitation stay counts toward the 30- or 45-day limit of inpatient behavioral health care allowed per fiscal year.
- TRICARE shares the cost of this partial hospitalization rehabilitation treatment for up to 21 days at a predetermined, all-inclusive per diem rate.
- A partial hospitalization rehabilitation counts toward the 60 day psychiatric partial hospitalization limit.
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Court-ordered Care |
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Court-ordered care is defined by TRICARE as medical services, including inpatient admissions, that a party in a legal proceeding is ordered or directed to obtain by a court of law. The fact that behavioral health services are ordered by a court for a TRICARE-eligible beneficiary does not determine the benefits available under TRICARE. TRICARE benefits are paid only if the services are medically or psychologically necessary to diagnose and/or treat a covered condition. The services must be at the appropriate level of care to treat the condition, and the beneficiary (or family) must have a legal obligation to pay for the services. |
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