The nature of an individual’s service and credentials will determine specific coverage.
Inpatient Treatment Coverage
TRICARE will pay for residential treatment if the following requirements are met: the patient has an official drug use disorder diagnosis, the patient experiences withdrawal symptoms severe enough to require physician help, and the patient struggles to function in daily life. TRICARE will fund both emergency and non-emergency inpatient addiction treatment if these conditions are satisfied. When a person is in a medical or psychological crisis and requires rapid medical assistance, they are said to be in need of emergency treatment. The costs of detoxification, stabilization, and any other medical problems will be covered by TRICARE. When an individual decides to seek treatment for substance misuse on his or her own, this is referred to as non-emergency treatment. Prior permission from TRICARE is required before coverage may be granted.
Outpatient Treatment Coverage
If an individual’s plan fulfills the particular qualification standards, TRICARE will also fund outpatient therapy. A person must be addicted yet not require hospitalization or round-the-clock care. TRICARE covers several forms of outpatient care, including conventional outpatient programs, partial hospitalization programs (PHP), and intensive outpatient programs (IOP). These programs include the same therapeutic tools as residential treatment, such as group therapy and specialized counseling, but are delivered through numerous weekly treatment sessions to allow patients to keep their jobs and families while in treatment.
Standard outpatient treatment is the least intense kind of outpatient care, requiring patients to attend therapy once or twice a week at a TRICARE-approved location. IOPs are more rigorous and include therapy that must be completed multiple days per week. PHPs are the most intensive outpatient programs, requiring daily therapy lasting four to eight hours.
Do Treatment Centers Need to Be In-Network?
TRICARE generally only provides full coverage for providers that have been pre-approved by the insurance carrier. For billing addiction treatment services, participating in-network providers have a pricing agreement with TRICARE. As an out-of-pocket payment, patients at in-network addiction treatment clinics are only liable for a tiny fraction of the cost.
Patients participating in the TRICARE Select, Retired Reserve, Reserve Select, Family Health, Young Adult Select, and Prime Remote plans can see any out-of-network physician they want. Patients who choose out-of-network treatment, on the other hand, maybe required to file individual claims and pay a greater proportion of the service cost. Out-of-network providers, in fact, can charge up to 15% more than the permitted price. In some circumstances, TRICARE members must pay the entire cost of out-of-network treatments and then request reimbursement from the insurance carrier when treatment is finished.
Verifying Your Insurance
Fortunately, if you use TRICARE network providers, you are only liable for the expenditures that remain after TRICARE pays the provider the agreed amount. You will have a greater out-of-pocket expense if you choose a non-network provider. To settle the remaining charges, you may normally work out a payment plan with the provider. However, speaking with a TRICARE representative and discussing which alternatives give the most value for your case will be the simplest approach to evaluate your coverage, perks, and expenses.