Behavioral Health Care Coverage Details
Figures 6.1 through 6.3 offer benefit summary details for covered behavioral health care services based on plan type.
Figure 6.1 Behavioral Health Care Outpatient Services: Coverage Details
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Behavioral Health Evaluation and Therapy
- Benefits are limited to two routine therapy sessions per week; more frequent visits require additional authorization.
- Each beneficiary is allowed up to eight routine therapy sessions per fiscal year without a medical necessity review or prior authorization; sessions beyond the initial unmanaged eight visits require a medical necessity review and prior authorization from ValueOptions. ADSMs must follow the protocol within their MTF for obtaining behavioral healthcare within the MTF. For care outside of the MTF, ADSMs must have a referral from their PCM or, if enrolled in TPR, from their service point of contact (SPOC).
Notes:
- The initial eight outpatient behavioral health care sessions do not require a PCM referral; beneficiaries may self-refer. (ADSMs must follow procedures as noted above.)
- Licensed or certified mental health counselors or pastoral counselors require a physician referral and ongoing physician supervision in order to be paid. The referral and supervision do not have to be from the beneficiary’s PCM. This information must be included on the CMS-1500 claim form in blocks #17 and #19. A copy of the referral should be kept in the patient’s chart.
- Providers are allowed one initial evaluation per beneficiary, per fiscal year without authorization. This initial evaluation does not count as a therapy session within the initial eight self-referred outpatient visits available to non-ADSMs.
- Crisis intervention always requires authorization; request as soon as possible after services are rendered.
Substance Use Disorders
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Benefit period begins with the first day of covered treatment and ends 365 days later.
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Benefits provide up to 60 individual or group outpatient therapy sessions and up to 15 family therapy sessions per benefit period when provided in a TRICARE-authorized facility.
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Services must be rendered by institutional providers and always require prior authorization.
Other Outpatient Services
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Psychological testing is generally approved up to six hours per year and requires a medical necessity review and prior authorization.
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Medication management checks do not require medical necessity review or authorization for up to two visits per month and do not count as a therapy session.
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Figure 6.2 Behavioral Health Care Inpatient Services: Coverage Details
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Behavioral Health Disorder
- Benefits provide up to 30 days per fiscal year or per admission for acute inpatient care for beneficiaries age 19 and older.
- Benefits provide up to 45 days per fiscal year or per admission for acute inpatient care for beneficiaries age 18 and younger.
- Benefits provide up to 150 days per fiscal year or per admission for care in TRICARE-approved RTCs for beneficiaries under age 21 (dependent upon facility age restrictions).
Substance Use Disorders: Acute Inpatient Care/Detoxification
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Covered for complications of alcohol and drug abuse or dependency and detoxification only when the patient’s condition is such that the personnel and facilities of a hospital are required.
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Covered for up to seven days per episode in a TRICARE-authorized facility.
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Days count toward the 30- or 45-day behavioral health care inpatient limits.
Substance Use Disorders: Rehabilitation
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Benefit period starts the first day of covered treatment and ends 365 days later.
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Benefits provide up to 21 days per benefit period (combined partial and/or inpatient).
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Up to seven days of detoxification are allowed per episode in addition to the 21 rehabilitative days.
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Days count toward the 30- or 45-day behavioral health care inpatient limits.
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Care must be provided in a TRICARE-authorized facility.
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Benefits provide up to one treatment episode in a one-year period and up to three treatment episodes during the beneficiary’s lifetime.
All Behavioral Health Care Inpatient Services
- All nonemergency admissions require prior authorization.
- Non-TRICARE Prime beneficiaries (e.g., TRICARE Standard, TRICARE Extra, TRS) living in designated catchment areas must obtain a nonavailability statement (NAS) before receiving nonemergency acute inpatient services.
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Figure 6.3 Behavioral Health Care Partial Hospitalization Programs: Coverage Details
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All Partial Hospitalization Services
- All services require medical necessity review and prior authorization.
- A minimum of three hours of therapeutic services are allowed up to five days per week and may include day, evening, night, and weekend programs.
Behavioral Health Disorder
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Benefits provide up to 60 treatment days per beneficiary, per fiscal year.
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The 60 treatment days are not offset by or counted toward the 30- or 45-day inpatient limit.
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Care must be provided in a TRICARE-authorized behavioral health PHP.
Substance Use Disorder
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Benefit period starts the first day of covered treatment and ends 365 days later.
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Benefits provide up to 21 treatment days (full day or partial day) per benefit period (combined partial and/or residential).
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Days count toward the 60-day psychiatric partial hospitalization limit.
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Care must be provided in a TRICARE-authorized substance use disorder treatment facility.
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