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Substance Use Disorders in the U.S. Armed Forces (2013)

Chapter: Appendix G: Access Standards for TRICARE Prime Enrollees

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Suggested Citation:"Appendix G: Access Standards for TRICARE Prime Enrollees." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
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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 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.

Suggested Citation:"Appendix G: Access Standards for TRICARE Prime Enrollees." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
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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 additional 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.

Suggested Citation:"Appendix G: Access Standards for TRICARE Prime Enrollees." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Page 369
Suggested Citation:"Appendix G: Access Standards for TRICARE Prime Enrollees." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
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Problems stemming from the misuse and abuse of alcohol and other drugs are by no means a new phenomenon, although the face of the issues has changed in recent years. National trends indicate substantial increases in the abuse of prescription medications. These increases are particularly prominent within the military, a population that also continues to experience long-standing issues with alcohol abuse. The problem of substance abuse within the military has come under new scrutiny in the context of the two concurrent wars in which the United States has been engaged during the past decade--in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom and Operation New Dawn). Increasing rates of alcohol and other drug misuse adversely affect military readiness, family readiness, and safety, thereby posing a significant public health problem for the Department of Defense (DoD).

To better understand this problem, DoD requested that the Institute of Medicine (IOM) assess the adequacy of current protocols in place across DoD and the different branches of the military pertaining to the prevention, screening, diagnosis, and treatment of substance use disorders (SUDs). Substance Use Disorders in the U.S. Armed Forces reviews the IOM's task of assessing access to SUD care for service members, members of the National Guard and Reserves, and military dependents, as well as the education and credentialing of SUD care providers, and offers specific recommendations to DoD on where and how improvements in these areas could be made.

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