TRICARE is a health insurance program available to uniformed military service members as well as their families. This provider offers comprehensive health plans for all beneficiaries which include dental plans, health plans, prescriptions, and special programs.
Those who serve our country undergo an enormous amount of stress both while they are serving and when they return. This stress can lead to a number of health issues, one of them being the potential for addiction. That’s why TRICARE offers comprehensive coverage for drug and alcohol addiction treatment services.
Using TRICARE Insurance For Addiction Treatment
For those seeking help with a substance use disorder, TRICARE provides a number of different covered options for drug and alcohol addiction treatment. Services covered may include detox programs and inpatient rehab programs. The goal is to make recovery from addiction as affordable and accessible as possible.
As with other insurance carriers, the amount of coverage an individual will receive will be based on his or her plan and eligibility restrictions. Understanding the type of TRICARE plan you have and what it covers is the first step toward recovery from addiction.
The 2008 Mental Health Parity and Addiction Equity Act ensures that mental health and substance abuse services are covered to the same extent that other medical services are covered under insurance plans. As a result, if your insurance plan will cover other medical expenses, such as a stay at the hospital, then it will also cover at least some of the expenses for addiction treatment.
How Much Will TRICARE Insurance Cover For Addiction Treatment?
There are three basic insurance terms you will need to know in order to understand what kind of insurance coverage you can receive for addiction treatment. These terms include:
- Copay/coinsurance — A copay is a flat fee that you will need to pay each time you visit a doctor’s office, each day of stay at a treatment center, or for each treatment you receive. For example, a single day at an inpatient drug and alcohol addiction treatment may have a copay of $150 and TRICARE will pay the rest.
- Deductible — Your deductible is how much you must pay out-of-pocket each year before TRICARE will pay for medical treatments or services. For example, if your deductible is $500, you must spend $500 on medical services or treatment before TRICARE will begin paying.
- Maximum Out-Of-Pocket — Many TRICARE insurance plans have a maximum out-of-pocket that ensures that once you’ve reached this limit, the insurance company will cover 100 percent of additional medical services or treatment.
It’s important to keep in mind that while TRICARE will provide a certain amount of coverage for you to receive addiction treatment, the amount you personally pay will depend on the particular rehab facility you choose to attend.
For example, if TRICARE will cover 75 percent of drug and alcohol addiction inpatient treatment, and you go to a rehab center that costs $8,000, you will be responsible for paying $2,000. However, if you go to a treatment facility that costs $35,000, you will still have to pay 25 percent, which will be $8,750.
Prior Authorization Requirements For TRICARE Insurance Plans
You do not need prior approval to receive emergency services, but you do need prior authorization for ongoing treatment as well as non-emergency inpatient drug and alcohol treatment with TRICARE insurance.
Approval for inpatient drug and alcohol addiction treatment will be given to the individual if one or more of the following conditions are met:
- poses a threat to himself/herself or others
- needs specialized medication
- needs psychological treatment
- experiencing serious impairment to functioning
- unable to maintain self-care despite being in outpatient treatment
- needs to be in a hospital full time
Do Rehab Centers Need To Be In-Network For TRICARE Insurance Coverage?
In order to receive the most coverage offered by TRICARE, it’s important that patients select providers that have been approved by TRICARE. In-network providers work with TRICARE to offer high-quality services and treatment for a portion of the cost to patients.
Those who have TRICARE Select, Reserve Select, Retired Reserve, Young Adult Select, or Prime Remote insurance plans can seek out-of-network care. However, choosing out-of-network providers will require the individual to pay higher out-of-pocket costs.
Seeking out-of-network services or treatment may mean that you have to pay up to 15 percent more than if you were to choose an in-network provider. You may also be required to pay the full cost of services out-of-pocket and then file a claim with TRICARE to be reimbursed.
To determine which drug and alcohol addiction treatment program offers the best rates through TRICARE, it’s important to call ahead to get a verification of your benefits. Sometimes, an out-of-network rehab facility will offer a more affordable rate than an in-network facility, but it’s important to get the information before arriving to avoid confusion or excess out-of-pocket fees.
Addiction Treatment Services Covered With TRICARE Insurance
TRICARE offers comprehensive coverage for drug and alcohol addiction treatment services that typically includes a complete continuum of care. Becoming familiar with your plan is important to ensure you understand what all is covered.
Outpatient Treatment Services Covered By TRICARE
TRICARE covers most aspects of addiction treatment, starting from the initial diagnosis. Here is a list of the outpatient treatment services typically covered by TRICARE:
- Diagnosis — Some patients choose to first see their primary care physician before deciding on which type of treatment to seek. The PCP will help the individual select the most appropriate treatment option for his or her condition.
- Outpatient and Intensive Outpatient Programs — TRICARE will cover outpatient or intensive outpatient programs (IOP) with no prior authorization. They will also cover these treatment services for those transitioning from an inpatient program who need further treatment.
- Opioid Treatment Programs — For those with an opioid addiction, TRICARE will cover opioid treatment programs and office-based opioid treatment. Both forms of treatment involve Medication Assisted Treatment (MAT) as well as other forms of therapy to help the individual recover from an opioid addiction.
Inpatient Treatment Services Covered By TRICARE
In addition to outpatient drug and alcohol addiction services, TRICARE also offers coverage for many inpatient treatment services depending on your plan and in some cases prior approval. These inpatient services include:
- Medically Monitored Detox Programs — Medical detox programs are inpatient drug and alcohol addiction services that help an individual safely and comfortably withdraw from substances. This may include the use of medication to help manage symptoms and reduce cravings.
- Partial Hospitalization Programs — Partial hospitalization programs (PHP) are for individuals who need medical monitoring but not on a 24/7 basis. TRICARE only covers PHP in the U.S. and U.S. territories.
- Emergency Inpatient Hospitalization – TRICARE will cover emergency inpatient hospital stays and treatment if you need help with the management of withdrawal symptoms, need to be stabilized, or have medical complications as a result of your substance use disorder.
- Non-Emergency Inpatient Hospitalization – TRICARE will also cover non-emergency inpatient hospitalization if prior authorization is received and certain conditions are met.
- Residential Treatment Programs – Residential, or inpatient, drug and alcohol addiction treatment programs require patients live at the treatment facility for an extended period of time. This is often considered the best form of treatment for substance use disorders, especially for those with a more severe addiction. TRICARE will cover residential treatment programs but requires prior authorization.
Identifying Your TRICARE Insurance Coverage
To understand your TRICARE insurance coverage and what treatment options are covered under your plan, you will first need to know which plan you have with TRICARE and the insurance carrier’s network. TRICARE offers several different health plans, and each will vary on the exact amount of coverage you will receive for drug and alcohol addiction treatment.
To ensure you make the most cost-effective decision, it’s important to stay within the network of TRICARE providers. However, if you decide that out-of-network treatment will be more beneficial, be sure that you fully understand the amount you are expected to pay out-of-pocket to avoid any surprise fees.
Contact us to learn more about using TRICARE for drug and alcohol addiction treatment.
Disclaimer: This site is not affiliated with, nor endorsed by, TRICARE Insurance. The information about TRICARE’s benefits are meant for informational purposes only, and the details of your plan’s coverage may be different.
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