Beneficiary Online Handbook

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Outpatient Mental Health
Hospitalization for Mental Illness
Substance Use Treatment
Partial Hospitalization
Getting Behavioral Health Care

Behavioral Health Care Services
ADFM represents the active duty family member responsibility. 
Services Covered  TRICARE Prime 

TRICARE EXTRA 

TRICARE Standard 

Outpatient Mental Health(1)(2)(5)
Maximum one-hour of therapy up to two times each week (when medically necessary)
Crisis intervention and sessions greater than 50 minutes require separate authorization.

 ADFM: No copayment


Retirees, their Family Members and Survivors: $25 copayment for individual visits $17 copayment for group visits 		 ADFM: 15% of the negotiated fee


Retirees, their Family Members and Survivors: 20% of the negotiated fee

ADFM: 20% of the allowable charge

Retirees, their Family Members and Survivors: 25% of the allowable charge 

Hospitalization for Mental Illness(1)(2)(3)(4)
Up to 30 days per fiscal year for adults age 19 and over; up to 45 days per fiscal year for age eighteen and under

Residential treatment centers: Up to 150 days in a TRICARE-certified residential treatment center for children and adolescents 

ADFM: No copayment

 

Retirees, their Family Members and Survivors: Per diem charge of $40.
No separate copayment/ cost-share for separately billed professional charges

 ADFM: Per diem charge of $20 ($25 minimum charge per admission)

Retirees, their Family Members and Survivors: 20% of the total charges for institutional services based on the negotiated rate, plus 20% cost-share of separately billed professional charges  		ADFM: Per diem charge of $20 ($25 minimum charge per, admission)

Retirees, their Family Members and Survivors: Lesser of $175 per day or 25% of both facility and professional allowable charges. (Charge may vary depending on the type of facility and reimbursement.) 

Substance Use Treatment(1)(2)(3)
(Inpatient, partial)

Up to seven days for detoxification per episode

Up to 21 days for rehabilitation per 365 days. Maximum of one rehabilitation program per year and three per lifetime
Detoxification and rehabilitation days count toward the benefit limit for mental health benefits. 

 Same as above  Same as above  Same as above
Partial Hospitalization(1)(2)(3)
Up to 60 days per fiscal year. (Minimum of three hours a day, five days a week of therapeutic services.) Program must be TRICARE-certified as a mental health partial hospitalization program		 Same as above Same as above ADFM: Per diem charge of $20 ($25 minimum charge per admission)
Retirees and others: 25% of TRICARE allowable amount, plus 25% cost-share of separately billed professional charges 
1. Requires pre-authorization.
2. TRICARE Standard beneficiaries may have to pay up to 15 percent over the maximum allowable charge when the provider does not accept assignment (balance billing). Treatment must be provided by a TRICARE authorized provider.
3. Cost-share and daily inpatient charges are subject to change at the beginning of each fiscal year (October 1–September 30).
4. NAS Note: A nonavailability statement (NAS) is required for all nonemergency inpatient admissions with TRICARE Extra and TRICARE Standard. This does not apply to admissions to RTC, PHP, and SUDRF facilities.
5. All services provided by Licensed Mental Health Counselors (LMHCs) and Licensed Professional Counselors (LPCs) must be referred and supervised by a physician (M.D. or D.O.).


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Getting Behavioral Health Care
Outpatient behavioral health services must be pre-authorized by calling ValueOptions at
1-800-700-8646.

Note: It is important to inform your behavioral health provider if you are seeing other providers for psychotherapy to ensure coordination of treatment. Generally, the TRICARE benefit is limited to up to two psychotherapy sessions in a calendar week (Sunday-Saturday). This will alert the provider to contact ValueOptions for preauthorization for services beyond the allowed TRICARE benefit.

If the provider is a Licensed Mental Health Counselor (LMHC) or a Licensed Professional Counselor (LPC), a physician referral is required prior to the initial evaluation and oversight must continue through the course of the therapy to be continued by TRICARE.

In addition, the following behavioral health care services require pre-authorization:
 
  • Psychoanalysis
  • Psychological/neuropsychological testing
  • Electroconvulsive therapy
  • Therapy sessions in excess of 1 hour (crisis intervention). 
Sessions with a psychiatrist for medication only do not require authorization unless the psychiatrist also provides therapy during the visit. 

All inpatient behavioral health and substance abuse treatment must be authorized in advance by calling ValueOptions at 1-800-700-8646, including residential treatment centers (RTCs), psychiatric partial hospitalization programs (PHPs), and substance use disorder partial hospitalization programs. 

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Last Reviewed: September 4, 2007