Appendix G

Access Standards for TRICARE Prime Enrollees

In the military’s purchased care system, access to substance use disorder (SUD) care by family members and retirees1 differs somewhat by TRICARE program. This appendix describes policies of TRICARE Prime, the largest program used by Active and Reserve Component family members when their military sponsor is called to active duty, as well as by retirees. Access standards for TRICARE Prime that apply to all health care needs of beneficiaries also apply to their behavioral health needs with few exceptions.

INITIAL ASSESSMENT

TRICARE Prime policy states that the initial visit to evaluate a new or recurring behavioral health problem is considered primary care, and the beneficiary should be evaluated by a provider who is professionally capable or specifically privileged to perform behavioral health assessments. Family members and retirees may choose whether to receive the initial assessment from their primary care provider, an integrated mental health provider within their primary care clinic, or a behavioral health care provider.

ROUTINE APPOINTMENT: NEW CONDITION

Policy states that beneficiaries requesting an appointment for a new or recurring behavioral health condition must be seen by an appropriately

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1 If retirees obtain Medicare Parts A and B they are no longer eligible for TRICARE Prime, but would instead be eligible for TRICARE for Life secondary coverage to Medicare.



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Appendix G Access Standards for TRICARE Prime Enrollees In the military’s purchased care system, access to substance use disorder (SUD) care by family members and retirees1 differs somewhat by TRICARE program. This appendix describes policies of TRICARE Prime, the largest program used by Active and Reserve Component family members when their military sponsor is called to active duty, as well as by retirees. Access standards for TRICARE Prime that apply to all health care needs of ben- eficiaries also apply to their behavioral health needs with few exceptions. INITIAL ASSESSMENT TRICARE Prime policy states that the initial visit to evaluate a new or recurring behavioral health problem is considered primary care, and the beneficiary should be evaluated by a provider who is professionally capable or specifically privileged to perform behavioral health assessments. Family members and retirees may choose whether to receive the initial assessment from their primary care provider, an integrated mental health provider within their primary care clinic, or a behavioral health care provider. ROUTINE APPOINTMENT: NEW CONDITION Policy states that beneficiaries requesting an appointment for a new or recurring behavioral health condition must be seen by an appropriately 1 Ifretirees obtain Medicare Parts A and B they are no longer eligible for TRICARE Prime, but would instead be eligible for TRICARE for Life secondary coverage to Medicare. 369

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370 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES trained provider within 7 calendar days and within 30 minutes’ travel time of the beneficiary’s residence. All TRICARE Prime beneficiaries have access to a primary care provider representative by telephone around the clock. SPECIALTY APPOINTMENTS Following an initial behavioral health assessment, referrals for addi- tional care are to be provided within the access standard for specialty care, which is 4 weeks (28 days), unless the referring provider determines that care is needed more urgently. Beneficiaries must be offered an appointment with an appropriately trained provider within 1 hour’s travel time from the beneficiary’s residence. Military treatment facilities have first priority for providing referred specialty care or inpatient care for behavioral health conditions for all TRICARE Prime beneficiaries. PRIOR APPROVAL Referral by a primary care provider is not required for family members and retirees for the first eight outpatient behavioral health visits.