Tricare home health care: The Tricare Standard benefit offers home health care services.
It covers a maximum of 28 hours per week of part-time or 35 hours per week of intermittent home health aide services and physical, speech or occupational therapy. All care must be provided by a participating home health care agency and be authorized in advance by the regional contractor. It is important to understand this type of care and the Tricare coverage details. Home health care covers part-time or intermittent skilled nursing services and home health care services for those confined to the home.
To qualify for home health care, Tricare beneficiaries must:
• Be homebound.
• Have a physician-certified plan of care.
• Have a case manager who periodically assesses needs and required services.
• Need skilled nursing care on an intermittent basis or physical therapy or speech-language pathology services or have continued need for occupational therapy
In general, beneficiaries are considered homebound if their conditions prevent them from leaving their homes without considerable and taxing effort. If beneficiaries regularly leave their homes for therapeutic, psychosocial or medical treatment or to attend an accredited, certified adult day-care program, they will not be disqualified from home health care.
The patient’s primary care provider or attending physician will determine if the patient is eligible for home health care services and will develop a plan of care, which will be reviewed by the physician, case manager and/or regional contractor every 90 days, or when there is a change in the patient’s condition. Home health care services require prior authorization.
For beneficiaries who are registered in the Extended Care Health Option (ECHO) and who require more than 35 hours per week of home care health services, Tricare offers ECHO Home Health Care. ECHO is available to active duty family members who qualify based on specific mental or physical disabilities. For more information about home health care and other services, visit www.tricare.mil/coveredservices. (Source: Tricare Standard Health Matters Newsletter 2013)
Tricare behavioral health care update: Tricare behavioral health care services are available to you and your family during times of need that can be caused by stress, depression, grief, anxiety or other reasons. Under Tricare regulations, Tricare beneficiaries (except for active duty service members) may see an authorized provider for the first eight outpatient behavioral health visits per fiscal year (Oct. 1-Sept. 30) for a medically diagnosed and covered condition to a provider authorized under Tricare regulations to see patients independently.
Before the ninth visit, your behavioral health care provider must obtain prior authorization from your regional contractor. It is important to understand Tricare’s requirements for accessing behavioral health care, including seeing authorized providers and seeking prior authorizations when required.
Authorized Behavioral Health Care Providers. You may seek outpatient behavioral health care from Tricare-authorized providers. The following types of behavioral health providers may be authorized providers under Tricare:
• Certified psychiatric nurse specialists
• Certified marriage and family therapists
• Licensed clinical social workers
• Clinical psychologists
• Licensed mental health counselors
Note: A physician referral and supervision may be required to see mental health counselors and is always required to see pastoral counselors. Contact your regional contractor to find out if a mental health counselor requires physician referral and supervision before getting services.
Inpatient hospital behavioral health care services are considered medically necessary only when the patient’s condition requires the care provided by hospital personnel and facilities. All treatment for substance use disorders requires prior authorization from your regional contractor.
Prior Authorization. Prior authorization from the regional contractor is required for all non-emergency inpatient behavioral health care services. Prior authorization is also always required for psychiatric partial hospitalization and psychiatric adolescent residential treatment center care. Psychiatric emergencies do not require prior authorization for admission to an inpatient unit, but authorization is required for continued stay. Admissions resulting from psychiatric emergencies should be reported to your regional contractor within 24 hours of admission or the next business day, and must be reported within 72 hours of an admission. Authorization for continued stay is coordinated between the inpatient unit and the regional contractor.
Substance use Disorder Services. Substance use disorders include alcohol or drug abuse or dependence. Services are only covered when provided by Tricare-authorized institutional providers. Tricare covers three substance use disorder rehabilitation treatment periods in a lifetime and one per benefit period. A benefit period begins with the first date of the covered treatment and ends 365 days later.
All treatment for substance use disorders requires prior authorization from your regional contractor. For more information on behavioral health care services, refer to www.tricare.mil/mentalhealth.
(Source: Tricare Standard Health Matters Newsletter 2013)