TRICARE Reserve Select Handbook - Behavioral Health Care Services

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Behavioral Health Care Services

You may receive your first eight behavioral health outpatient visits per fiscal year (October 1–September 30) without prior authorization from Humana Military. After the first eight visits, prior authorization is required. Remember to obtain care only from TRICARE network providers or non-network, TRICARE-authorized 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

If you are unsure which type of provider would best meet your needs, contact Humana Military for assistance.

Figure 2.4 provides coverage details for covered behavioral health care services. Note: This chart is not intended to be all-inclusive. For additional information about covered and non-covered behavioral health care services and how to access care, contact Humana Military.

Figure 2.4 Behavioral Health Care Services: Coverage Details

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.* 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.
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.
Psychiatric 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. Psychiatric 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 by 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 (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 must 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* (may be waived if determined to be medically or psychologically necessary.) Note: No qualified RTCs were available in overseas locations at time of publishing.
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 are covered (waiver possible in accordance with policy criteria ). 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 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- 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

Last Update: March 15, 2010