TRICARE’s behavioral health benefits may fall short of the Defense Health Agencies’ (DHA) goal of eliminating all unnecessary treatment limitations.
TRICARE is the health plan of the U.S. Department of Defense Military Health System, which covers military personnel, military retirees and their dependents.
In 2016, the DHA unveiled new program goals to expand TRICARE’s behavioral health coverage. These goals included eliminating certain coverage limits and making behavioral health coverage consistent with medical and surgical coverage.
A new report by the U.S. Government Accountability Office (GAO) examined the DHA’s efforts to achieve these goals and some of its limitations.
The report found there are still some barriers to care for beneficiaries. For example, TRICARE members are required to get authorization for inpatient behavioral health services but not for inpatient medical and surgical services. Additionally, TRICARE limits residential treatment to individuals under 21, with no coverage for the adult population.
“Through its issuance of a final rule in 2016, DHA voluntarily took important steps to improve TRICARE’s coverage of behavioral health services, including expanding the scope of available services and eliminating coverage limits,” the GAO report reads. “With these actions, DHA intended to align TRICARE’s coverage of behavioral health services with that for medical and surgical services to the extent feasible. However, in the intervening seven years, DHA has not comprehensively assessed the extent to which TRICARE behavioral health coverage meet the goals the agency outlined in the 2016 final rule.”
The GAO report also highlighted that the cost of behavioral health services varies widely among beneficiaries. TRICARE offers two types of plans, Prime, which is a managed care plan, and Select, a self-managed care plan. The report notes that typically, Prime members have lower cost-sharing requirements than Select members.
Another factor in cost-sharing is military status. Active military personnel can get access to health services, including behavioral health care, without any cost sharing. However, other beneficiaries, such as retired military members are required to cover some cost of services. Other factors, such as when a person enlisted also impact cost-sharing.
This variation in cost-sharing means that the cost of services to a patient can vary greatly. For example, a newly enlisted active duty service member with TRICARE Prime will pay $0 for an outpatient psychotherapy visit. Meanwhile, a military retiree with TRICARE Select will pay $49 for the same services.
Moving forward, the GAO recommends that DHA leadership should be regularly evaluating TRICARE’s coverage and how it is meeting its goals that were set out in 2016.
Our review brought to light examples where DHA may not be meeting its goals, including its goal to align behavioral health and medical and surgical benefits,” authors of the report wrote. “These results indicate that periodic assessments of TRICARE’s behavioral health coverage by DHA are warranted to ensure that the agency is aware of and can take steps to address any limits faced by beneficiaries that are inconsistent with DHA’s goals.”
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