TRICARE: Mental Health and Substance Use Disorder Treatment for Child and Adolescent Beneficiaries
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1 TRICARE: Mental Health and Substance Use Disorder Treatment for Child and Adolescent Beneficiaries Clinical Support Division Condition-Based Specialty Care Section June 24, 2015 Medically Ready Force Ready Medical Force 1
2 While the requirements of the Mental Health Parity Act of 1996 and the Mental Health Parity Addiction Equity Act (MHPAEA) of 2008, as well as the plan benefit provisions contained in the Patient Protection and Affordable Care Act, do not apply to the TRICARE program, which is governed by separate set of statutes, DoD fully supports the principle of mental health parity. The Department is taking action to ensure TRICARE s mental health and substance use disorder benefit meets the intent of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Recent statutory amendments Agency rulemaking Medically Ready Force Ready Medical Force 2
3 Recent statutory changes to the Benefit In 2014 the Department sought legislative relief as an important first step in advancing mental health parity The National Defense Authorization Act Fiscal Year 2015, Section 703 Elimination of Inpatient Day Limits And Other Limits In Provision of Mental Health Services Amended section 1079 of Title 10 United States Code to remove TRICARE day limits on inpatient mental health services Medical necessity of care will still be reviewed Currently revising the TRICARE Program Manuals to meet requirements Reduces perceived administrative barriers to ongoing care and enhances continued access to care Medically Ready Force Ready Medical Force 3
4 The Department is in the process of drafting proposed regulatory changes to implement the removal of quantitative day limits, as well as other revisions to the TRICARE mental health and SUD treatment benefit, consistent with earlier DoD and IOM recommendations, current standards of practice in mental health and addiction medicine, and our governing laws. The last comprehensive rulemaking occurred in 1995 (Final Rule: Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Mental Health Services; Federal Register, Vol. 60, No. 44, March 7, 1995). At that time: Great concern for fraud, waste, and abuse Day limits and cost-sharing for MH were adopted in an effort to control spiraling costs Certification standards were adopted before robust national accreditation bodies existed in order to ensure quality A Proposed Rule will be submitted for public comment as part of DHA s required rulemaking process Medically Ready Force Ready Medical Force 4
5 Substance Use Disorder (SUD) Treatment Institutional providers Detoxification and SUD rehabilitation facilities (SUDRF) Approved SUDRFs are hospital based or freestanding, Contractor certified Partial Hospital Programs (PHP); Half-Day PHP/Intensive Outpatient Programs - SUD Treatment Hospital based or freestanding, Contractor certified Full-day or half-day programs Outpatient and Family Therapy Provided in approved SUDRF and PHPs; freestanding or hospital based **Presumptive limits may be waived on medical necessity Medically Ready Force Ready Medical Force 5
6 Residential Treatment Centers Non-emergency, residential psychiatric care Children and adolescents, ages 5-21 Coverage based on medical and psychological necessity Waivers available for all presumptive day limits RTCs in all TRICARE regions (58) North (20); South (20); and West (18) Access to other Step-up and Step-down care Acute inpatient psychiatric care; PHP; Half-Day PHP/Intensive Outpatient Programs; and Eating Disorder Programs (that meet provisions of an authorized provider category) Individual professional providers Medically Ready Force Ready Medical Force 6
7 Challenges to accessing RTCs and SUD-PHPs Facilities must be willing to undergo TRICARE Quality Monitoring Contractor certification and health care accreditation Community shortfalls: SUD-PHPs and for RTC provider staffing Child psychiatrists and psychologists, and advanced practice nurses RTC geographic locations mirror CMS, Psych under 21 programs Lowest RTC numbers: west and northeast coasts and northern tier Few civilian health insurance programs reimburse RTC care Lowers demand for care Increases use of geographically accessible acute inpatient care Medically Ready Force Ready Medical Force 7
8 North Region Health Net Federal Services South Region Humana Military West Region United Healthcare Military and Veterans TRICARE Overseas Program Medically Ready Force Ready Medical Force 8
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