Tricare Therapy Copay

Health Care Committee Goals

Mosfet 300a. Family therapy is considered outpatient psychotherapy and is a covered benefit when determined to be medically or psychologically necessary for treatment of a diagnosed mental health disorder. Family therapy may involve all or a portion of the family. Tricare Cost Co-Pay Schedule. Military.com By Jim Absher. The following tables provide examples of cost-shares or copayments and annual deductibles for families who use civilian. With an average copay/cost-share of $24 across networks and TRICARE programs, this rule will conservatively save beneficiaries up to $230,000 per year in cost-sharing and will conservatively save TRICARE $1.1 million per year as a result of reduced visits to referring providers. DoD considered several alternatives to this. Telemedicine copayment waiver: TRICARE is waiving copayments and cost-shares for covered audio-only or audio/video telemedicine rendered by network providers on or after May 12, 2020. This waiver applies to covered in-network telehealth services, not just services related to COVID-19. The TRICARE Autism Care Demonstration (ACD) covers ABA services for all eligible TRICARE beneficiaries diagnosed with Autism Spectrum Disorder (ASD). The demonstration began July 25, 2014, and will continue through December 31, 2023. ABA services require prior authorization.

Top 2021 Legislative Goals

• Protect the value of the TRICARE health benefit by opposing any legislation or policy change that would disproportionately increase enrollment fees, deductibles, copays/cost shares or the catastrophic cap. Seek roll back of copay increases for mental health and Physical/Speech/ Occupational Therapy visits.

• Ensure TRICARE policy is updated to cover new technology and evolving treatment protocols as well as benchmarks established by commercial plans and other government payers, including:

• Non-pharmaceutical pain management treatments including chiropractic care and acupuncture.
• FeNO testing for airway issues/asthma
• Lab developed tests, including diagnostic genetic testing
• Expanded eating disorder treatment coverage
• ECHO enhancements to address coverage gaps identified in 2015 MCRMC report
• Premium free TRICARE coverage for young adult dependents up to age 26 to align TRICARE with commercial plans

• Leverage DoD Inspector General report Evaluation of Access to Mental Health Care in the Department of Defense to seek improvements in mental health care access for service members and military families including a pilot of MHS schedulers for behavioral health appointments, targeted improvements to TRICARE provider directories, and increased provider reimbursement to bolster the TRICARE network of mental health providers.

Top 2021 Policy and Oversight Goals

• Ensure proposed military medical billet cuts, any other uniformed/civilian/contracted medical personnel reductions and/or military treatment facility downsizing or closures are not implemented until DoD presents to Congress a thorough analysis of civilian care availability and plan to mitigate impacts on readiness and beneficiary care. As MTFs restructure, demand transparency on access to care metrics to evaluate impact of changes on beneficiaries.
• Ensure the T-5 contract includes access to high quality network providers and effective customer service support for all beneficiaries. Support DoD's phased approach for testing regional/market level health plan options and alternative payment models such as value-based care using demonstration authority vs. changing TRICARE construct completely without testing.
• Monitor transition of MTF administration to DHA and secure a transparent analysis and report on access to care at the MTF level as well as beneficiary problem tracking and resolution.

Legislative, Policy & Oversight Principles, Positions and Goals
The healthcare benefit is a commitment a grateful nation makes to service members, their families, retirees and survivors for their extraordinary service and sacrifice. The military health care benefit must reflect that decades of arduous service and sacrifice in uniform constitute a very large, pre-paid, in-kind premium that warrants a top-tier, low cost health benefit. Significant out-of-pocket cost increases reduce the value of the benefit after the service member has fulfilled their commitment and are unacceptable.
TMC will not support any out-of-pocket cost increases used to fund readiness. While the Coalition understands the importance of military readiness and force lethality, the currently serving and retirees should not be tapped to fund it.
Specific goals include:
Keep the cost to beneficiaries in check

• Reverse TRICARE Prime copay increases and reduce TRICARE Select copays for Grandfathered/Group A retirees. With these copay hikes, DHA has defied Congressional intent to protect current beneficiaries from excessive fee increases.
• Encourage DoD to implement a tiered specialty care copayment structure that reduces TRICARE copays for mental health and physical/speech/occupational therapy visits.
• Oppose any plan to increase TRICARE fixed dollar cost shares (including enrollment fees, deductibles, copays and the catastrophic cap) for military retirees more than the annual COLA.
• Seek to cap further increases in the TRICARE Select inpatient copay.
• Expand beneficiary copay waivers and other incentive programs for various preventive services and related medical treatments.

Ensure TRICARE beneficiaries have access to high quality care

• Ensure proposed military medical billet cuts or any other uniformed/civilian/contracted medical personnel reductions are not implemented until DoD presents to Congress a thorough analysis of civilian care availability and plan to mitigate impacts on readiness and beneficiary care.
• Monitor and provide input on TRICARE T-5 contract process to ensure access to high quality network providers and effective customer service support for all beneficiaries.
• Monitor transition of MTF administration to DHA and seek legislation requiring a transparent analysis and report on access to care at the MTF level as well as beneficiary problem tracking and resolution.
• Ensure TRICARE reimbursement policies are updated to cover new technology and evolving treatment protocols including:

1. Non-pharmaceutical pain management treatments including chiropractic care and acupuncture.
2. FeNO testing for airway issues/asthma
3. Lab developed tests, including diagnostic genetic testing
4. Expanded eating disorder treatment coverage
5. ECHO enhancements to address coverage gaps identified in 2015 MCRMC report
6. Premium free TRICARE coverage of young adult dependents up to age 26 to align TRICARE with commercial plans

• Extend coverage for eligible children of veterans' families until age 26 under CHAMPVA.
• Consistent with the Federal Employee Health Benefit Plan (FEHBP) and CHAMPVA, allow surviving spouses to retain TRICARE with remarriage at age 55.
• Seek legislation to reinstate TRICARE benefits for remarried survivors when the second marriage ends.
• Expand definition of Qualifying Life Events to include dissatisfaction with MTF access or quality to allow those who are dissatisfied with their care to switch to TRICARE Select.
• Ensure health care benefits pertain equally to all seven federal uniformed services, including the USPHS Commissioned Corps and NOAA Commissioned Corps.
• Leverage DoD Inspector General report Evaluation of Access to Mental Health Care in the Department of Defense to seek improvements in mental health care access for service members and military families including a pilot of MHS schedulers for behavioral health appointments, targeted improvements to TRICARE provider directories, and increased provider reimbursement to bolster the TRICARE network of mental health providers.

• Ensure access to care for those service members and their families stationed in isolated, remote and rural locations either through a robust provider network or by maintaining an MTF presence.
• Ensure the move into alternative payment models, including value-based provider payments, does not adversely affect access, cost or quality of care for TRICARE beneficiaries.
• Encourage DoD and VA to adopt advanced and innovative technologies and practices to improve beneficiary health and engagement. Leverage the features of the DoD's new electronic health record (EHR) and telehealth capabilities to increase efficiency, improve operations, and to increase access to care, including behavioral health care.
• Seek system-wide (DoD and VA) changes related to environmental hazards and toxic wounds, including: 1) improvements to the pre- and post-deployment health monitoring/assessment programs; 2) increased research on the impact of exposures to environmental toxins or hazardous substances including studies on the descendants of those exposed. 3) improved clinical evaluation and treatment; 4) advocate for appropriate legislation (e.g. registries for toxic exposure, establishing a center of excellence for diagnosis, treatment and research) 5) congressional oversight of these efforts and 6) maintain DoD and VA attention on these issues.
• Advocate for increased DoD efforts to ensure consistency between the MTFs and purchased care sectors in meeting Prime access standards and focusing on beneficiary and provider needs in administering authorizations and referrals for specialty care.
• Advocate for improvement and standardization of case management services and for the seamless integration of care between and within all Services, MTFs, the TRICARE Regions and the VA.
• Expand training of all providers (with emphasis on those practicing in primary care and mental health), especially those in the purchased care network, in military cultural sensitivity and treatment of traumatic injuries (e.g., PTSD, TBI, and MST).
• Seek legislative or policy action to address problems with pediatric care identified by the Defense Health Board's Pediatric Health Care Services Report including:

• Urge TRICARE to adopt a pediatric definition of 'medical necessity' to ensure military children are not disadvantaged relative to those covered by Medicaid or commercial plans.
• Align pediatric care with evidence-based practices whether delivered within MTFs or in the community.
• Establish a system-wide program to track and measure outcomes and other metrics related to quality, cost, and the patient experience for military kids and their families.

​Protect the value of the TFL benefit

• Oppose TFL enrollment fees that would discourage Medicare-eligible beneficiaries from accessing their earned health care benefit
• Oppose initiatives that would reduce TFL coverage (e.g., some studies have proposed a $500 deductible and coverage limits to 50% of the next $5,000).
• Encourage the inclusion of TFL beneficiaries in DoD preventive programs and ensure parity between Medicare and TRICARE programs.

TRICARE Pharmacy Program

• Oppose any reduction of current pharmacy benefits, to include any future copay increases or access limitations to MTF pharmacies for all beneficiaries particularly at MTFs that are downsized or descoped to active duty only clinics.
• Oppose any effort to charge fees or copayments for use of MTF pharmacies.
• Oppose pharmacy copayments based on the percentage of drug cost to the government.
• Require DoD to track beneficiary satisfaction and prescription drug availability with the TRICARE mail order pharmacy program.
• Advocate for copay flexibility when a full supply cannot be filled or when a beneficiary cannot use TMOP due to out-of-stocks.
• Urge DoD to create an appeals process for TRICARE Tier 4 drugs.

Military and Veteran Women's Health and Fertility Treatments
Women comprise the fastest growing demographic in both the active military and veteran populations. Since the lifting of the ban on ground combat, the roles of military women have also been evolving. To ensure continued operational readiness, military and veteran's medical research and services must reflect these trends.

Infertility: DoD and VHA should gather Baseline Data on patient infertility. Senate Report 116-48 (page 211) accompanying NDAA 2020 directed the Secretary of Defense to conduct a study on the incidence of infertility among both male and female members of the armed forces. This Study was due to Congress no later than 01 Jun 2020. When available, the report should provide better infertility data for the active force than is currently available. VHA should also be required to establish base-line data on infertility among the veterans' population.
DOD and the VHA provide limited infertility treatment.
A. TRICARE covers the cost of a number of types of infertility treatments; however, the cost of IVF treatments is covered only under limited circumstances: the infertility must be service-connected, the patient must be legally married and both the patient and his/her spouse must be capable of providing their own gametes.
B. VHA Medical facilities. Few VHA medical facilities offer a wide range of infertility treatments and even at those hospitals that do offer some treatment there are long waiting lists and co-pays are usually required. No IVF treatment is offered at any VHA Medical Center. However, some veterans with service-connected infertility can received cost-covered IVF treatment at civilian facilities.
Recommendations:
1. Coverage of ART: Both TRICARE and VHA should be tasked to establish and maintain data bases on infertility among their patients. Both DoD and VHA coverage of assisted reproductive technology (ART) should be reexamined addressing the following issues: Should the definition of service-connected infertility be expanded? Should the marriage requirement be eliminated? Should IVF be provided for those who can't produce their own gametes? Should ART coverage be extended beyond service-connected infertility?
2. Toxic Exposures: Both the Department of Defense and the Department of Veterans Affairs should be tasked with studying the nexus of service-connected toxic exposures to both male and female infertility.
PTSD Treatment, Research and Development

• The incidence of and repercussions from PTSD and TBI are a source of genuine concern affecting the mental health of individual service members, their families, and the resiliency of the force overall. For too long, the DoD has been risk averse in confronting the reality of this problem and its effects. This is especially concerning because there has been a lack of private sector investment because of the limited commercial market for military PTSD and TBI. Lack of private sector interest makes it more important for DHA to take the lead in fostering the introduction of new therapies.

1. Priority should be given to fostering the further development of Phase III FDA designated breakthrough drugs.
2. The DOD should support Phase III clinical trials especially for new therapies that have been designated as 'breakthrough' by the FDA.

• Increase capacity to provide mental health care to wounded warriors suffering from traumatic brain injury and post-traumatic stress disorder by expanding the use of USPHS mental health experts and behavioral scientists.

Dental Program

• Address network adequacy problems with TRICARE Dental Program

National Guard and Reserve Health Care

Infertility: DoD and VHA should gather Baseline Data on patient infertility. Senate Report 116-48 (page 211) accompanying NDAA 2020 directed the Secretary of Defense to conduct a study on the incidence of infertility among both male and female members of the armed forces. This Study was due to Congress no later than 01 Jun 2020. When available, the report should provide better infertility data for the active force than is currently available. VHA should also be required to establish base-line data on infertility among the veterans' population.
DOD and the VHA provide limited infertility treatment.
A. TRICARE covers the cost of a number of types of infertility treatments; however, the cost of IVF treatments is covered only under limited circumstances: the infertility must be service-connected, the patient must be legally married and both the patient and his/her spouse must be capable of providing their own gametes.
B. VHA Medical facilities. Few VHA medical facilities offer a wide range of infertility treatments and even at those hospitals that do offer some treatment there are long waiting lists and co-pays are usually required. No IVF treatment is offered at any VHA Medical Center. However, some veterans with service-connected infertility can received cost-covered IVF treatment at civilian facilities.
Recommendations:
1. Coverage of ART: Both TRICARE and VHA should be tasked to establish and maintain data bases on infertility among their patients. Both DoD and VHA coverage of assisted reproductive technology (ART) should be reexamined addressing the following issues: Should the definition of service-connected infertility be expanded? Should the marriage requirement be eliminated? Should IVF be provided for those who can't produce their own gametes? Should ART coverage be extended beyond service-connected infertility?
2. Toxic Exposures: Both the Department of Defense and the Department of Veterans Affairs should be tasked with studying the nexus of service-connected toxic exposures to both male and female infertility.
PTSD Treatment, Research and Development

• The incidence of and repercussions from PTSD and TBI are a source of genuine concern affecting the mental health of individual service members, their families, and the resiliency of the force overall. For too long, the DoD has been risk averse in confronting the reality of this problem and its effects. This is especially concerning because there has been a lack of private sector investment because of the limited commercial market for military PTSD and TBI. Lack of private sector interest makes it more important for DHA to take the lead in fostering the introduction of new therapies.

1. Priority should be given to fostering the further development of Phase III FDA designated breakthrough drugs.
2. The DOD should support Phase III clinical trials especially for new therapies that have been designated as 'breakthrough' by the FDA.

• Increase capacity to provide mental health care to wounded warriors suffering from traumatic brain injury and post-traumatic stress disorder by expanding the use of USPHS mental health experts and behavioral scientists.

Dental Program

• Address network adequacy problems with TRICARE Dental Program

National Guard and Reserve Health Care

• Simplify TRICARE for retirement eligible National Guard and Reserve service members:
  • Eliminate TRICARE Retired Reserve
  • Provide TRICARE Reserve Select (TRS) for early retirement age (50 to 60) servicemembers at the same subsidized premium rate as other Retired Reserve members waiting for receipt of retirement pay at age 60.
  • Provide TRICARE for early retirement age (50 to 60) servicemembers concurrently with receipt of their retirement pay as other age 60 Retired Reserve members.
• Expand TRICARE Prime enrollment to National Guard and Reserve members at no cost, regardless of duty status, because medical readiness is a requirement for service -- not a benefit.
• Expand TRS for USPHS Ready Reserve regardless of duty status by replacing the term 'Selected Reserve' with 'Uniformed Services'. (10 USC 1076d(a))
• Fund TRS for federal employees who are Ready Reservists earlier than fiscal year 2030 (10 USC 1076d).
• Authorize Individual Ready Reservists the option to enroll in TRS as an opportunity to maintain medical readiness for recall/activation. (10 USC 1076d).
• Provide an option for RC servicemembers and families to retain private health coverage under active duty orders in lieu of switching to TRICARE (i.e. with a DoD allowance for full premium costs of the private policy).
• Authorize National Guard members separating from full-time duty (32 USC 502(f)) Transitional Assistance Management Program coverage (10 USC 1145).
• Amend title 10 United States Code, to authorize the Secretaries of the military departments to provide annual medical exams, behavioral health and annual dental exams to members of the reserve components periodically needed to meet readiness and fitness standards pre- and post-deployment.
• Seek improvements to the pre- and post-activation health assessment and corrective programs
• Secure funds for government treatment of RC members to correct any medical, dental or behavioral health readiness deficiencies during periodic health assessment screenings.
• Expand funded dental care to cover 180 days post-activation.
• Fund and provide care and services for RC members, including mental/behavioral health issues such as substance abuse and suicide.

​Health and Safety on Military Installations

• Seek ways to improve oversight of private contractors' identification and abatement of health and safety hazards in privatized military facilities.
• TMC will work with DoD and Congress to reevaluate long term abatement plans for health and safety hazards in installation housing and facilities.

Readiness

• Support funding for the Uniformed Services University of Health Sciences as the prime educator of military health providers, which is essential to the uniformed provider pipeline and increases the number of culturally competent providers for military beneficiaries.

Tricare Prime Therapy Copay

Public Health Service

How Much Is Copay For Tricare

• Approval of the MOU between VHA and USPHS to create and fund ten slots per year at USUHS for medical students who agree to join USPHS and then serve in VHA clinics and hospitals to repay the government for their medical education.

What Is The Copay For Tricare

Other Issues

Tricare Prime Copay For Physical Therapy

• Electronic Health Record. The DoD and VA's modernization approach for the EHR are both estimated to take a decade and cost billions for full implementation throughout both health systems. Vigilant oversight of the implementation process is a must for Congress and a priority of the TMC.
• The Services must implement a robust set of policies and procedures for accessing and evaluating military dependent (minor) medical records when a former military dependent enters military service to ensure their medical records are interpreted and used appropriately.