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New TRICARE Regulations to Improve Access to Addiction Treatment

by ASAM Staff | September 27, 2016

The Department of Defense released a final rule that expands coverage for substance use disorder treatment for active-duty military members, families and retirees covered by TRICARE or Champus health plans. Access to medication assisted treatment, including office-based opioid addiction treatment (OBOT), elimination of year or lifetime limits on treatment days, and reduced cost-sharing are some of the improvements to addiction treatment coverage. Additionally, more providers should be eligible to treat patients covered by TRICARE and Champus, as certification requirements have been changed. While the Mental Health Parity and Addiction Equity Act and the Affordable Care Act rules do not apply to TRICARE, many of the recent changes are in the spirit of those two laws.

Previous TRICARE regulations restricted access to substance use disorder (SUD) care by imposing quantity limits on partial hospitalization, outpatient therapy, family therapy and smoking cessation counseling. They also restricted benefits for intensive outpatient programs for mental health and SUD, office-based opioid treatment and opioid treatment programs (OTPs). Cost-sharing for mental health and SUD treatments were higher than those for equivalent physical health treatments as well.

The new rules, effective October 3, 2016, will remove TRICARE coverage limits on:

  • inpatient mental health days for adults and children,
  • residential treatment centers (RTC) for beneficiaries younger than 21,
  • partial hospitalization and Substance Use Disorder Rehabilitation Facilities (SUDRF) treatment,
  • annual and lifetime limits on treatment episodes for SUD,
  • outpatient psychological testing,
  • weekly limits on outpatient therapy,
  • family therapy and outpatient therapy provided by free-standing or hospital based SUDRFs, and
  • smoking cessation quit attempts.

Outpatient coverage for medically necessary treatment by TRICARE-authorized providers will also not be subject to quantitative limits.

Previous regulations imposed a high barrier on providers who wished to provide care to patients with TRICARE or Champus health coverage. Under the new rule, institutional providers will be allowed to become TRICARE-authorized providers if they are accredited by an accrediting organization approved by the Director of the Defense Health Agency and agree to execute a participation agreement with TRICARE. Previous rules around staffing levels and other requirements will no longer apply. In addition, OTPs are now allowed to become TRICARE-authorized providers.

The updated regulations explicitly authorize intensive outpatient (IOP) care for substance use disorders and psychiatric disorders as a covered benefit. IOP providers will need to be accredited by an accrediting body approved by the Director of the Defense Health Agency to provide services to TRICARE members. OBOT and OTP services are also now explicitly covered.

For TRICARE beneficiaries who are subject to cost-sharing, co-pays are reduced to match charges for medical/surgical benefits. Additionally, partial hospitalization programs will be charged on an outpatient basis, not inpatient as previously required.

For information about provider payment rates or to read the full regulation, click here.

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