Military Expands Access to MH Care Through TRICARE

The Department of Defense issued a final rule on October 3 that broadly expands access to mental health and substance abuse treatment for military service members.

The rule affects services for 9.4 million individuals covered by TRICARE, the military health insurance program whose beneficiaries include active duty, National Guard, and Reserve members; their family members; and service retirees and their families.

Parity legislation like the Mental Health Parity Act (MHPA) of 1996, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, and the Patient Protection and Affordable Care Act (PPACA) did not cover the TRICARE program.

APA President Maria A. Oquendo, M.D., commended the Department of Defense for expanding access to mental health and substance use disorder treatment for military members. “The men and women who serve our country and their families deserve this treatment, and I hope that the rule is fully implemented so that their mental health needs are addressed the same way as any other health issue.”

The rule puts the TRICARE system more in sync with broader health care industry standards, according to former U.S. Army psychiatrist Charles Engel, M.D., a senior scientist at the RAND Corporation in Boston, in an interview.

For a start, the new rule eliminates quantitative and nonquantitative limitations on mental health and substance use treatment. All inpatient and outpatient mental health day limits were eliminated, as were annual and lifetime limitations on outpatient services and substance use disorder treatment.

Copayments for mental health visits were cut from the current $25 to $12, the existing standard for general medical and surgical care under TRICARE.

Substance use treatment had been previously provided only through specialized substance use disorder rehabilitation facilities. Now, such treatment will include and encourage outpatient medication-assisted treatment, enabling qualified TRICARE contract providers to use buprenorphine and other medications.

The rule also now permits “coverage of all nonsurgical medically necessary and appropriate care in the treatment of gender dysphoria.”

This latter might seem to be a narrowly focused category, but there is a reason behind it, said Engel.

“A recent change in regulations permits transgendered persons to serve openly in the Armed Forces, so there is a need to provide appropriate medical and mental health services for them,” said Engel.

A RAND study determined that costs for the added services would be relatively low—$8.4 million per year—since only a small number of service members would need them, and such services would be provided only to uniformed beneficiaries.

TRICARE is trying to expand its cohort of providers as well. Previously, provider certification requirements “proved overly restrictive and at times inconsistent with current industry-based institutional provider standards and organization,” according to the document. So TRICARE regulations for credentialing providers “have been rewritten in their entirety” to bring them more in line with civilian standards to allow additional qualified providers to enter the system, presumably contributing to expanded access to care.

The changes will increase the Defense Health Agency’s costs by $58 million, a modest difference in light of the Pentagon’s overall $582 billion annual budget.

The added costs will largely be due to the shift to lower copays but will be held down because many of the planned changes were already being used under a system of waivers.

Overall, the new rule represents a step forward for service members and their families, but their effects need to be documented better, said Engel.

“There are lots of complex pieces in these changes, but there has been little large, independent health care services analysis of the system,” he said. “What works for those in uniform may be in tension with what is best for nonuniformed military health system beneficiaries. However, the rule highlights the complexity of the system’s mission—to care equitably and effectively for both.” ■