Alcoholism and Other Substance Use Disorders
Treatment for substance use disorders may include outpatient and/or inpatient services, as described below.
Outpatient Care for Alcoholism or Other Substance Use Disorders
TRICARE provides coverage for up to 60 outpatient therapy visits (individual or group) at an approved facility over the course of a benefit period, beginning the first day of the rehabilitation phase of treatment. Family therapy is covered for up to 15 visits per benefit period, beginning the first day of therapy. Non-facility-based outpatient services are not a covered benefit for a beneficiary with a primary diagnosis of substance use disorder/dependence in an office-based setting.
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.
Detoxification
Detoxification 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:
-
Covered for up to seven days per episode in a TRICARE-authorized facility, if 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 the following section, “Substance Use Rehabilitation”
Substance Use Rehabilitation
Rehabilitative care may occur in an inpatient or partial hospitalization setting. Care must be provided at TRICARE-authorized facilities.
The following details apply to substance use rehabilitation:
-
Prior authorization is required for rehabilitation stays.
-
Care is covered for up to 21 days of rehabilitation per benefit period in a TRICARE-authorized facility (includes inpatient and partial hospitalization days or a combination of both).
-
Coverage is subject to the following limits:
-
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 stay counts toward the 60-day psychiatric partial hospitalization limit.
|
