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3 The Military Health System T he Military Health System (MHS) provides care to specific military- connected beneficiaries in military health care facilities and certain civilian facilities where care is purchased. In reality, the MHS is not a single system and is fairly complex. Its beneficiaries are a diverse group, and include active duty service members (ADSMs), members of the National Guard and Reserves, retirees, and family members. The total beneficiary population is about 9.7 million. Operational oversight of the Defense Health Program, both the direct and purchased care systems, resides in the Office of the Under Secretary of Defense for Personnel and Readiness, through the Office of the Assistant Secretary of Defense for Health Affairs. The Army, Navy, and Air Force each have a designated surgeon general who has management responsibil- ity for the branch-specific services. Since the Marine Corps does not have a Medical Command, any physicians serving with the Marines are Navy officers, and as such, come under the authority of the Navy surgeon gen- eral. Increasingly, facilities are being managed jointly by more than one branch. In the National Capital Region, for example, the services provided by the former Army Walter Reed Hospital and the National Naval Medical Center have been integrated into the new Walter Reed National Medical Center on the grounds of the former National Naval Medical Center. This consolidated site is staffed by providers from both the Army and Navy and provides care for service members from different branches of the military. The general focus of the MHS is on ADSMs, fitness for duty, readi- ness, and care of the war fighter. In this context, substance use disorders (SUDs) generally are viewed as a condition that interferes with fitness for duty and service members’ ability to carry out their job duties, including 69

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70 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES deployments, particularly since positive identification of an SUD may lead to separation from uniformed service. Thus, SUDs are sometimes viewed as personnel issues and at other times as medical conditions. As a result, both the Personnel and Medical Commands are involved in the identification and management of SUDs. Although the focus of military treatment facili- ties is operational readiness, the Department of Defense (DoD) for many years has expressed a commitment to providing substance abuse treatment to eligible beneficiaries. This chapter provides an overview of the MHS. It describes the eligible beneficiaries, the direct care military treatment facilities, and the purchased care system. It also explains how service members and their dependents access SUD care and concludes with a summary. ELIGIBILITY FOR CARE To be eligible for health care services in the MHS, including those for substance abuse, one must be either a “sponsor” (generally the person who has served or is serving in the uniformed services) or the sponsor’s family member (spouse; dependent child under age 21 or under age 23 if a full- time student, or up to age 26 at additional cost1; or adult disabled child if disabled before age 21). Eligibility is determined by enrollment in the Defense Enrollment Eligibility Reporting System (DEERS), a computerized database of all beneficiaries eligible for health care and other uniformed services benefits (see Figure 3-1). Military treatment facilities and the MHS in general are designed to ensure the operational readiness of the members of the uniformed services. Readiness is the ability of the uniformed services to be prepared for opera- tional duties at all times. Readiness requires medical, dental, and mental health. DoD, in conjunction with the Department of Health and Human Services (for Public Health Service officers) and the National Oceanic and Atmospheric Administration (for NOAA officers), has a statutory responsi- bility to provide health care to identified beneficiaries. This care is provided through the direct care system at military treatment facilities and through the purchased care system by reimbursement to authorized providers via the TRICARE insurance plans (see Figure 3-2). Members of each of the seven uniformed services (see Figure 3-3) have the same overall health care benefits under the TRICARE plans, which include coverage of behavioral health benefits such as substance abuse ser- vices. Further, members of the same beneficiary category (i.e., active duty, Guard/Reserve, retiree, family member) also have similar benefits across the different branches of the military, with the same TRICARE plans from which to choose. 1 TRICARE Young Adult, a provision of the 2010 Patient Protection and Affordable Care Act.

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THE MILITARY HEALTH SYSTEM 71 Defense Enrollment Eligibility ReporƟng System (DEERS) Registry of eligible beneficiaries, including family members; requires enrollment by sponsor and substanƟaƟng informaƟon for family members Sponsors Usually the person who served in the uniformed service, whether currently acƟve duty, Guard or Reserve, or reƟred Dependents Family members of the sponsor who are eligible for TRICARE benefits; generally include spouse and children under age 21 (23 if full-Ɵme college student, or up to age 26 at addiƟonal cost); also includes adult disabled children if disabled before age 21 FIGURE 3-1  Defense Enrollment Eligibility Reporting System (DEERS). Although active duty readiness is a major focus of the MHS, ADSMs and their dependents are becoming an 3-1 Figure increasingly smaller percentage of the total beneficiary population. In 1999, ADSMs and their dependents R02254 represented 57 percent of the beneficiary population, and retirees and their vector editableduty population had shrunk dependents 43 percent. By 2010, the active to 43  percent, while the retiree population had grown to 57 percent. By 2015, estimates are that only 35  percent of beneficiaries will be ADSMs and their dependents, while 65 percent will be retirees and their dependents. Because older beneficiaries tend to utilize health care services more than do younger persons, this changing demographic is contributing to the ever- growing costs of military health care (Jansen, 2009). Figure 3-4 provides definitions of terms related to TRICARE and the uniformed services health care system. Active Duty Service Members and Their Dependents ADSMs generally receive medical care at military treatment facilities or field health stations. ADSMs are automatically enrolled in TRICARE Prime

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72 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES TRICARE Management Activity: OrganizaƟonal unit in DoD that manages TRICARE Direct Care System: Purchased Care System: Health care providers and faciliƟes Civilian providers and faciliƟes that are part of directly paid for by DoD in DoD contractor-established networks; care is “purchased” faciliƟes; most are on military by one of three contractors from the civilian sector installaƟons TRICARE Regions: Military Treatment Facilities: The United States is divided into three geographic Direct care faciliƟes that offer health areas—North, South, and West—each with a care services (e.g., a military hospital different TRICARE contractor that manages the on a military installaƟon) purchased civilian care in each region and coordinates the care in military treatment faciliƟes with DoD and the services TRICARE Regions Regional Contractor: The contractor that manages the purchased care system for a TRICARE region Authorized Providers: Providers who have been approved by TRICARE to see TRICARE beneficiaries; may be network or non- network Network Providers: Non-Network Providers: Providers who are in the managed care Authorized providers who are contractor network and agree to not part of a network; can accept TRICARE charges for charge their usual fees; can see reimbursement TRICARE Standard paƟents FIGURE 3-2  TRICARE organization of services. Military Services Nonmilitary Services • Air Force • U.S. Public Health Service • Army • NaƟonal Oceanic and Atmospheric • Navy AdministraƟon • Marine Corps Figure 3-2 R02254 FIGURE 3-3  The uniformed services. vector editable and are required to utilize military treatment facilities when those facilities are available. If ADSMs want to utilize a civilian provider outside of the TRICARE system, they must obtain specific permission to do so, even if they have private health insurance (such as from a working spouse) or are willing to pay the costs out of pocket. It is viewed as a readiness issue, and Figure 3-3 also relates to the Command’s “need to know.” R02254 vector editable

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THE MILITARY HEALTH SYSTEM 73 Military Health System • Military and civilian health care providers and faciliƟes that provide care to uniformed services–connected beneficiaries through Department of Defense funding TRICARE • The health care program serving uniformed service members and reƟrees and their families worldwide NaƟonal Guard and Reserve • Refers to members of the Army NaƟonal Guard, Army Reserve, Navy Reserve, Marine Corps Reserve, Air NaƟonal Guard, Air Force Reserve, and Coast Guard Reserve FIGURE 3-4  Terminology related to the uniformed services health care system. If readiness is to be maintained, the families of ADSMs also must receive the medical care they need. The stress of deployment would only be magnified if an ADSM were concerned about the health care available to his/her family members. Figure 3-4 R02254 Active Duty Retirees and Their Dependents vector editable Retirees and their dependents have earned their health care benefits through their years of active service. Until age 65, retirees and their family members have the option of participating in various TRICARE options, some with enrollment fees and copayments. When a retiree or family mem- ber reaches age 65 or is otherwise eligible for Medicare, TRICARE for Life becomes applicable. TRICARE for Life generally requires participation in Medicare Parts A and B and acts as a secondary payer. Beneficiaries usually bear no out-of-pocket costs for specific medical services received. TRICARE for Life also provides an enhanced benefit package over Medicare. Most TRICARE for Life benefits are provided by civilian TRICARE contractors; however, military treatment facilities provide care to these beneficiaries on a space-available basis as well. National Guard and Reserve Members and Their Dependents Members of the National Guard and Reserves and their dependents make up yet another beneficiary group. The specifics of coverage for this group are complex, depending on the particulars of the sponsor’s

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74 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES military duty. With the increased support provided by the Guard and Reserves for the wars in Iraq and Afghanistan, greater numbers of Guard members and Reservists have been called to extended active duty. Accord- ingly, their health care benefit options have increased somewhat over time. In general, if members of the National Guard or Reserves are on mili- tary duty for 30 days or less, such as for drilling, they qualify for care in the line of duty. Also, sponsors and family members are usually eligible for TRICARE Reserve Select, a premium-based program. When sponsors are activated or called to duty for more than 30 days, they and family members become eligible for essentially the same TRICARE benefits as other ADSMs. When Guard and Reserve members transition off active duty service, they are then eligible for the Continued Health Care Benefit Program (CHCBP), which the military offers to be in compliance with the Consolidated Omnibus Budget Reconciliation Act (COBRA). This program allows service members and their eligible dependents to maintain health insurance coverage for 18-36 months by paying the full premium. Addi- tional details are presented in Tables 3-1 and 3-2. Note that since many Guard and Reserve members have private health insurance as part of their civilian jobs, they and their families have a lower TRICARE participation rate than other ADSMs. Other Beneficiaries In addition to ADSMs, Guard members and Reservists, retirees, and their family members, the direct care system provides care for a fixed fee to certain government officials on occasion, including the President and mem- bers of Congress. However, these populations represent a small fraction of the care given and are not considered further in this report. DIRECT CARE: MILITARY TREATMENT FACILITIES The direct care system includes the providers and facilities that are directly managed by the military services. They are organized by service (i.e., Army, Navy, Air Force) and are managed by each service’s surgeon general. Thus, there is variation among the branches in the policies and the specific ways in which those policies are implemented to meet overall statu- tory mandates and DoD directives. However, greater uniformity is expected to develop over time for substance abuse treatment as well as other medical care as the different branches of the military increasingly share resources and facilities to treat service members regardless of their branch. DoD recently was tasked to conduct an evaluation of the proposed shift toward a Unified Medical Command that would oversee the medical services of all

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TABLE 3-1  Reserve Component Health Care Continuum Inactive Duty for Training/ Selected Reserve Active Duty Service Predeployment Deployment Postdeployment Transition Off Activity Duty Transitional TRICARE Assistance Reserve Select TRICARE for Active TRICARE for Active Management Continued Health Care (TRS) Duty Early Eligibility Duty Program (TAMP) Benefit Program (CHCBP) TRICARE Standard/ TRICARE Extra Prime/TRICARE TRICARE Standard/ TRICARE Standard/ TRICARE Standard/ TRICARE Standard/ Standard Prime Remote (TPR) Extra Prime/TPR Extra Prime/TPR Extra Prime Extra Prime Participating Inactive duty training Delayed effective Active duty orders Contingency orders •  Consolidated Omnibus Selected Reserve (IDT)/active duty date orders ≥31 days Budget Reconciliation Act training (ADT) orders Coverage begins: (COBRA)-like benefit Monthly Coverage begins: •  Member—day 1 Coverage begins: •  Must enroll within 60 Premiums Coverage begins: •  to 180 days Up • Family—day •  release from At days after separation •  Member—day 1 prior to 1 (any order active duty from active duty or loss (Not eligible • Family—day 1 (any deployment ≥31 days) •  Covered for 180 of eligibility for military if eligible order ≥31 days) •  Member and days health care for Federal family covered •  Must re-enroll in •  Quarterly premiums Employees Prime •  18-36 months of coverage Health Benefits •  TPR not available [FEHB] Program SOURCE: Powerpoint presentation by Brigadier General Margaret Wilmoth, Assistant for Mobilization and Reserve Affairs, U.S. Department of Defense, Office of Force Health Protection and Readiness, May 3, 2011, Washington, DC. 75

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76 TABLE 3-2  Continuum of Care When on Active Duty Military Duty Preactivation* (90 days Deactivation (upon (30 days or less) early eligibility) Activation leaving active duty) Continued Coverage Medical—Guard/ Treatment for line of Full TRICARE coverage Full TRICARE Transition Assistance TRS or Continued Reserve Member duty (LOD) conditions, as active duty service coverage as active Management Program Health Care Benefits TRICARE Reserve members duty service (TAMP) coverage* Program (CHCBP) Select (TRS) members Medical—Family TRS Full TRICARE coverage Full TRICARE TAMP TRS or CHCBP Members as active duty family coverage as active members duty family members Dental—Guard Treatment for LOD Full TRICARE coverage Full TRICARE TRICARE Dental TDP Reserve Member conditions only as active duty service coverage as active Program (TDP) members duty service memebrs Dental—Family TDP (Reserve TDP (active duty family TDP (active duty TDP (Reserve TDP (Reserve Members Component family member rates) family member Component family Component family member rates) rates) member rates) member rates) *If active duty is in support of a contingency operation. SOURCE: Powerpoint presentation by Brigadier General Margaret Wilmoth, Assistant for Mobilization and Reserve Affairs, U.S. Department of Defense, Office of Force Health Protection and Readiness, May 3, 2011, Washington, DC.

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THE MILITARY HEALTH SYSTEM 77 BOX 3-1 TRICARE Patient Priority System Priority 1 Active duty service members Priority 2 Active duty family members enrolled in TRICARE Prime Priority 3  Retirees, their family members, and survivors enrolled in ­TRICARE Prime Priority 4 Active duty family members not enrolled in TRICARE Prime Priority 5 All other eligible persons branches.2 It remains to be seen whether the military will move forward with such a large reorganization of its health services. DoD is required to provide care to ADSMs at military treatment facili- ties and also to their dependents on a space-available basis.3,4 While many categories of beneficiaries have some level of access to military treatment facilities, TRICARE Prime beneficiaries identify a facility where they will receive their primary care, and a specific primary care manager is then assigned. This provider manages their overall care and most referrals, including those for substance abuse treatment. Because of capacity limita- tions, military treatment facilities are unable to provide care to all eligible beneficiaries. TRICARE Prime beneficiaries generally receive care at their identified facility. Because of space limitations, however, a patient priority system has been developed for all beneficiaries (see Box 3-1). When military treatment facilities lack the capacity or capabilities needed by their primary beneficiaries, these beneficiaries generally can be seen by contracted civilian providers. The direct care system includes 59 inpatient hospitals and medical centers and 363 ambulatory care clinics, staffed by roughly 85,000 ADSMs and 53,000 civilians. Substance abuse services are provided in only a fraction of these facilities (TMA, 2011a). Table 3-3 details how the 108 (as of July 2012) military treatment facilities that provide specialty care for substance abuse are distributed by TRICARE region and by state or foreign country. 2 National Defense Authorization Act for Fiscal Year 2012, Public Law 112-81, 112th Cong. (December 31, 2011). 3 Scope and Duration of Federal Loan Insurance Program, 20 U.S.C. § 1074 (2012). 4 Medical and Dental Care for Dependents: General Rule, 10 U.S.C. § 1076 (2012).

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78 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES TABLE 3-3 Military Treatment Facilities That Provide Specialty Care for Substance Abuse, by TRICARE Region TRICARE Region State/Country Total U.S.-Based  91   North Region Connecticut (1), Delaware (1), District of Columbia (1),  23 Illinois (2), Kentucky (1), Maryland (6), New York (2), North Carolina (3), Ohio (1), Pennsylvania (1), Rhode Island (1), Virginia (3)   South Region Alabama (3), Florida (8), Georgia (5), Kentucky (2)  33 Louisiana (2), Mississippi (2), Oklahoma (3), South Carolina (2), Tennessee (1), Texas (5)   West Region Alaska (2), Arizona (3), California (5), Colorado (3),  35 Hawaii (4), Idaho (1), Kansas (3), Missouri (2), Montana (1), Nebraska (1), Nevada (2), New Mexico (2), North Dakota (1), Utah (1), Washington (4) Overseas  17   Overseas Pacific Japan (5), South Korea (2)   7  Eurasia-Africa Germany (5), Italy (2), Portugal (1), Turkey (1), United  10 Kingdom (1)   Latin America   0 TOTAL 108 SOURCE: http://www.tricare.mil/mtf. PURCHASED CARE: TRICARE As noted, to augment care provided by military treatment facilities, health care services are purchased from civilian providers. Overall, there are nearly 400,000 network individual providers for primary care, behav- ioral health, and specialty care. There are also more than 3,100 TRICARE ­ network acute hospitals nationwide (TMA, 2011a). Most of the care is purchased through one of three large TRICARE contractors, one per TRICARE region. Each of these contractors maintains a network of civilian providers that provide a full range of services, including substance abuse services (GAO, 2011). The specific providers vary over time. Table  3-4 shows the states that make up the various TRICARE regions and the con- tractor responsible for each region. Care through both the direct and purchased care systems is provided through a cluster of 12 TRICARE plans. The details of the specific plans affect the substance abuse treatment providers accessible to beneficiaries, as well as the co-payments. The 12 plans are based on four general models: (1) Prime, (2) Extra, (3) Standard, and (4) TRICARE for Life. (See Appendix E for a summary of these four models.) TRICARE Prime options are essentially health maintenance organiza- tions (HMOs). As noted earlier, beneficiaries have assigned primary care

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THE MILITARY HEALTH SYSTEM 79 TABLE 3-4 TRICARE Regions and Contractors TRICARE Region States Contractor U.S.-Based   North Region Connecticut, Delaware, District of Columbia, Health Net Illinois, Indiana, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Missouri (St. Louis), New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee (Ft. Campbell), Vermont, Virginia, West Virginia, Wisconsin   South Region Alabama, Arkansas, Florida, Georgia, Louisiana, Humana Mississippi, Oklahoma, South Carolina, Tennessee (excluding Ft. Campbell), Texas (excluding El Paso)   West Region Arizona, Arkansas, California, Hawaii, Idaho, TriWEST* Iowa (except Rock Island Arsenal), Kansas, Minnesota, Missouri (except St. Louis), Montana, Nebraska, New Mexico, North Dakota, Oregon, South Dakota, Texas (southwest corner), Utah, Washington, Wyoming Overseas International SOS   Overseas Pacific  Eurasia-Africa   Latin America *TriWEST lost the bid to renew its contract as the provider for the Western Region on March 16, 2012. It appealed this decision on May 3, 2012. The U.S. Government Account- ability Office denied the appeal on July 2, 2012. managers who make referrals for specialty care. The Prime options require pre-enrollment and use of network providers. ADSMs are automatically enrolled in TRICARE Prime. TRICARE Extra options utilize preferred provider organizations, which domestically are typically networks managed by one of the three national TRICARE contractors. Providers participating in Extra options are autho- rized providers who agree to accept TRICARE reimbursement, which in most cases is based on Medicare reimbursement schedules. The Extra plans do not require pre-enrollment and have no annual enrollment costs. Although refer- rals for specialty care are not necessary, preauthorization is required for many services, including substance abuse treatment (TMA, 2012c). TRICARE Standard is essentially a fee-for-service option utilizing autho- rized providers. Authorization involves a credential review and approval by TRICARE. Providers charge their usual rates, no pre-enrollment is required, and referrals are not necessary for specialty care. However, preauthoriza- tion is required for many services, including substance abuse treatment (TMA, 2012c).

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80 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES TRICARE for Life is the Medicare “wrap-around.” As discussed ear- lier, TRICARE beneficiaries aged 65 and older who participate in Parts A and B of Medicare are eligible for this plan. They must pay the Medicare enrollment fees but no additional annual TRICARE enrollment fees. Medi- care is the first payer; the TRICARE for Life plan generally pays all out-of- pocket Medicare costs and also provides some additional medical benefits (TMA, 2012a). TRICARE Prime now has a Point of Service option, which allows T­ ICARE Prime beneficiaries to participate as well in features of TRICARE R Standard and TRICARE Extra. Essentially, this option gives beneficiaries a greater choice of providers, although the providers must still be TRICARE authorized. Out-of-pocket expenses also increase. TRICARE Prime pro- vides the most comprehensive benefit, although the choice of providers is more limited than is the case under TRICARE Extra and TRICARE Stan- dard (TMA, 2011b). TRICARE also has a pharmacy benefit with four options, each of which is available to all TRICARE beneficiaries. Prescriptions can be filled at a pharmacy at a military treatment facility at no cost. Prescriptions can also be filled through a mail order pharmacy program that is managed by a single contracted worldwide pharmacy home delivery vendor. This service is used most often for routine prescriptions taken for chronic conditions. The third option is a retail pharmacy, which includes almost 64,000 contracted network retail pharmacies. The retail pharmacies can dispense a maximum 30-day medication supply. Finally, non-network pharmacies can be used if the other options are not available. The mail order and retail pharmacy programs have some co-payments, which vary with beneficiaries’ duty status and whether the prescription is for generic or brand name products. Waivers are possible for nonformulary pharmaceuticals (TMA, 2012b). CARE FOR SUBSTANCE USE DISORDERS FOR MILITARY SERVICE MEMBERS AND DEPENDENTS The preceding sections describe how ADSMs, members of the National Guard and Reserves, and their dependents access health care through the direct and purchased care systems. This section explains how each of these groups accesses SUD care in particular. SUD Care Provided Through the Direct Care System The SUD care available in the direct care system for service members and their dependents varies by service branch and location. The way each branch approaches prevention, screening, diagnosis, treatment, and man- agement for SUDs is guided by overarching policies laid out by DoD, as

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THE MILITARY HEALTH SYSTEM 81 well as by branch-specific policies. These policies set forth clear guidelines for zero tolerance of drug and alcohol abuse, as well as the legal and administrative consequences of such abuse (DoD, 1997). The requirement to provide education focused on preventing drug and alcohol abuse, to con- duct drug use testing, and to offer rehabilitation for substance use offenders also is laid out in DoD policies and instructions (DoD, 1985, 1994, 1997). Each branch is then responsible for developing its own branch-level policies to guide programs and activities that address SUDs. The branch policies set forth the specifics of how drug prevention, testing, and rehabilitation programs will operate. Some of the branch-level policies are more detailed than others and also address the responsibilities of personnel at different levels, as well as training and credentialing requirements for providers. Chapter 6 of this report provides a thorough review of all DoD and branch- level policies and programs addressing SUDs, while Chapter 8 details the requirements for credentialing and training for providers in these programs. The branches vary widely in how SUD care is delivered in the direct care system. In the Army, for instance, all SUD prevention activities and nearly all SUD treatment are provided under the authority of the Installa- tion Management Command, which is responsible for all personnel issues. In contrast, the Navy houses all of its SUD treatment services under the Navy Bureau of Medicine and Surgery, its Medical Command, while pre- vention activities and services are delivered under the Personnel Command. This “ownership” by either the Medical or Personnel Command has impli- cations for how care and services are delivered. Chapter 6 details the vari- ous types of SUD services and care that are provided within each branch of the military and the authority under which they operate. SUD Care Provided Through the TRICARE Network TRICARE is required to provide care for SUDs under the authority of 32 Code of Federal Regulations (CFR) 199.4.5 This care may include detoxification, rehabilitation, and outpatient group and family therapy. TRICARE provides a lifetime limit of three SUD treatment benefit periods (each benefit period is 365 days from the first visit), although this limit can be waived by the managed care support contractor that oversees the TRICARE plans for the region. Emergency and inpatient hospital services for detoxification and stabilization and for treatment of medical complica- tions from an SUD do not start a benefit period for treatment. Emergency and inpatient hospital services are deemed medically necessary when the personnel and facilities of a hospital are required to manage the patient’s 5 Basic Program Benefits, 32 CFR § 199.4 (2004).

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82 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES condition. All purchased treatment for SUDs requires prior authorization from the regional TRICARE contractor (TMA, 2008). Chemical detoxification is covered for up to 7 days, although more days can be covered if medically or psychologically necessary. These 7 days count toward the 30- or 45-day limit for acute inpatient psychiatric care per fiscal year. If an inpatient general hospital setting is not needed, however, up to 7 days of chemical detoxification is covered in addition to any further rehabilitative care. Rehabilitation for SUDs may occur in an inpatient or partial hospitalization setting. Coverage encompasses 21 days (or one inpatient stay per benefit period) in a TRICARE-authorized facility. These 21 days also count toward the 30- or 45-day limit for acute inpatient psychiatric care (TMA, 2008). Outpatient group therapy for SUDs must be provided by an approved Substance Use Disorder Rehabilitation Facility (SUDRF) (for more infor- mation on these facilities, refer to Chapter 7). The benefit includes 60 group therapy sessions in a benefit period. These sessions are in addition to the 15  sessions of outpatient family therapy covered by TRICARE. F ­ amily therapy is covered upon the completion of rehabilitative care (TMA, 2010). Note that individual outpatient therapy is not covered for SUDs unless it is provided through a SUDRF. As a TRICARE benefit, access to SUD services through contracted TRICARE providers requires preapproval through the contractor. Each of the contractors has a phone number that begins the preapproval process. SUD services can also be accessed through a ­ rovider-based toll-free number that is not limited to TRICARE benefi- p ciaries; TRICARE specialists return all calls to this number and assist with ­ referrals. Chapter 7 of this report describes the availability of and access to SUD care through the TRICARE benefit. Other Avenues for SUD Care In addition to the direct care and purchase care systems described above, members of the military and their families have several other avenues for SUD care. Like nearly all employers in the United States, the military has access to employee assistance programs; the specific contract provi- sions vary somewhat among the branches. An additional avenue is Military OneSource, which includes a website and nonclinical counseling that offer referral information on a wide range of topics, including substance abuse. Service members and their families may also receive care through Warrior Transition Units, the Soldier 360 Program, the Veterans Health Adminis- tration, and community programs such as Give an Hour. Some of these programs are reviewed in Chapter 6 and Appendix D of this report.

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THE MILITARY HEALTH SYSTEM 83 SUMMARY Through the direct care system and the TRICARE insurance benefit, the MHS provides comprehensive health care to military service members and their dependents. A multitude of insurance plans are available to eligible beneficiaries, along with a provider network that spans the globe. For the treatment of SUDs, service members and their dependents can access care both in military treatment facilities and through TRICARE network provid- ers. The TRICARE SUD benefit notably does not reimburse for office-based outpatient treatment. The implication of this benefit limitation is discussed further in Chapter 7. REFERENCES DoD (Department of Defense). 1985. Instruction 1010.6: Rehabilitation and referral services for alcohol and drug abusers. Washington, DC: DoD. DoD. 1994. Directive 1010.1: Drug abuse testing program. Washington, DC: DoD. DoD. 1997. Directive 1010.4: Drug and alcohol abuse by DoD personnel. Washington, DC: DoD. GAO (U.S. Government Accountability Office). 2011. Defense health care: Access to civilian providers under TRICARE standard and extra. Washington, DC: GAO. Jansen, D. 2009. Military medical care: Questions and answers. Washington, DC: Congres- sional Research Service. TMA (TRICARE Management Activity). 2008. TRICARE policy manual 6010.57-M. Falls Church, VA: TMA. TMA. 2010. Treatment for substance use disorders. http://tricare.mil/substanceusedisorders (accessed May 24, 2012). TMA. 2011a. Evaluation of the TRICARE program: FY 2011 report to Congress. http://www. tricare.mil/tma/downloads/TRICARE2011_02_28_11v8.pdf (accessed June 27, 2012). TMA. 2011b. TRICARE prime and TRICARE remote handbook. Falls Church, VA: TMA. TMA. 2012a. TRICARE for life. http://www.tricare.mil/mybenefit/home/overview/Learn AboutPlansAndCosts/TRICAREForLife (accessed June 14, 2012). TMA. 2012b. TRICARE pharmacy program. http://www.tricare.mil/mybenefit/home/­ Prescriptions/PharmacyProgram (accessed June 14, 2012). TMA. 2012c. TRICARE standard and extra. http://www.tricare.mil/standardextra (accessed June 14, 2012).

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