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Tricare is one of the largest health insurance providers in the United States and its Tricare West branch covers most of the western United States. Tricare is also one of the most transparent insurance providers out there, offering simple percentage rates for out of network providers. In addition, it covers some 9+ million people across the United States. If you have Tricare for yourself or for your family, you’re probably wondering what your options for addiction treatment are with Tricare West.
Tricare West has a lot to offer for anyone looking for addiction treatment. However, the plan has a significant number of limitations, which means you’ll likely be unable to seek out inpatient care unless you have a reference from a doctor and an emergency situation. Understanding the offerings and what you can get will help you to make the best choices for your health and for your budget as you move into treatment.
Yes, all health insurance providers are required by law to offer coverage for substance use disorder treatment (SUD). This is required under the Affordable Care Act also known as Obamacare. However, the amount and the extent to which coverage is offered is not regulated, meaning that many providers like Tricare offer specific stipulations on what they do and do not cover.
For example, Tricare West focuses on offering coverage for outpatient care. Individuals who want to attend an inpatient program require prior authorization. In addition, you may require notifications of when you’re admitted and a notice that this is on an emergency basis.
In addition, Tricare West does not offer coverage for hospital treatment of drug and alcohol abuse or detoxification unless you can show that a hospital setting is medically required.
Therefore, you may have more trouble getting the treatment you want than you would with another provider.
In theory, Tricare West covers all types of substance use disorder treatment, including all 5 of the diagnosis related group categories. This means you can get treatment for alcohol or drug abuse with rehabilitation therapy, comorbid or dual diagnosis and complications of substance abuse, and rehab for those without complications.
You can get medical treatment for detox providing you can prove it’s medically necessary.
Tricare West prioritizes outpatient treatment and offers full coverage for this.
You can get full coverage for your in-hospital or in-clinic stay providing you can prove it is medically necessary. This typically means you’ll need a doctor’s referral and preauthorization.
Patients with comorbidities, complications, and dual diagnosis can seek out care with a doctor’s referral and pre-authorization. You can also be admitted to emergency care without pre-authorization, providing you notify Carelon within 1 business day.
Essentially, you can generally get the treatment you need with Tricare. However, you will have to ensure you go through the proper channels to get approval and referrals.
Tricare West has a simple deductible system. In fact, for its premium-based plans, you can expect to pay:
That makes it very straightforward to see what your costs will be – although these costs will still vary depending on the cost of your substance use disorder treatment.
All Tricare West plans allow you to seek out an out of network provider. However, you will, on average, pay about 15% more for an out of network provider. In some cases, especially for inpatient services, you could pay significantly more. For example, the rate for an out of network inpatient treatment with Tricare Select Group B can be as high as $1,112 per day plus the 25% copayment. That same treatment with an in-network provider can be as little as $250 per day plus 20% copayment for Group B. Essentially, it’s significantly cheaper to choose an in-network provider so you probably want to opt for that.
Going to treatment with Tricare West is relatively simple. In fact, you typically only have to talk to your doctor, get a referral, and you’re good to go. Your doctor will handle all of the preauthorization requirements for you.
In addition, if you’re traveling to out of state treatment, Tricare may reimburse that as well, providing you are not on active duty.
It’s also always a good idea to verify that your treatment provider is in the Tricare network, as that will save you a lot on total costs.
That’s it, otherwise, Tricare and your healthcare providers will do the rest.
If you or a loved one is struggling with substance abuse, Tricare West will cover your treatment. However, the amount it covers will depend on your group, your plan, and whether you’re going to an in network provider or not. The best place to start is always your primary care provider, as Tricare West actually charges extra for not having a referral from your primary doctor.
Good luck getting treatment.