TRICARE, the health plan offered by the U.S. Department of Defense (DoD), serves the military community, including active-duty personnel, retirees, and their dependents. This health plan is crucial for ensuring that military families have access to necessary medical services. In 2016, the Defense Health Agency (DHA) set ambitious goals to improve TRICARE behavioral health coverage, aiming to align it more closely with medical and surgical benefits and eliminate unnecessary treatment limitations. This move was part of a broader effort to ensure that military personnel and their families could receive the behavioral health care they need without facing restrictive coverage caps. However, despite these efforts, a recent report by the U.S. Government Accountability Office (GAO) indicates that TRICARE behavioral health coverage still falls short of achieving the DHA’s goals.
DHA’s 2016 Goals: The Intent to Expand and Improve
In 2016, the DHA unveiled a set of program goals intended to enhance TRICARE behavioral health coverage. These goals were designed to reduce barriers to care and ensure that behavioral health services were more consistent with medical and surgical benefits. This included eliminating certain coverage limits and extending the scope of services available under the plan. The overarching aim was to make TRICARE behavioral health coverage as accessible and equitable as any other medical service, removing arbitrary restrictions and ensuring that service members, retirees, and their families could get the care they needed without unnecessary delays or denials.
The DHA took a significant step in this direction by issuing a final rule in 2016 that expanded coverage and eliminated some of the most restrictive treatment limitations. The rule’s intention was clear: to provide broader access to behavioral health services and better align them with other health care benefits. Despite these positive changes, a 2023 GAO report highlighted several areas where TRICARE behavioral health coverage is still lacking, particularly in its ability to fully meet the goals set out by the DHA.
Gaps in Behavioral Health Coverage: What’s Still Missing?
The GAO report sheds light on several key areas where TRICARE behavioral health coverage continues to fall short of the DHA’s 2016 objectives. One of the primary issues highlighted in the report is the disparity in how behavioral health services are treated compared to medical and surgical care. Specifically, the report reveals that TRICARE members are still required to obtain prior authorization for inpatient behavioral health services, whereas no such authorization is necessary for inpatient medical and surgical services. This creates an imbalance in the treatment of mental health versus physical health care, leading to additional barriers for individuals seeking timely behavioral health treatment.
Furthermore, the report notes that TRICARE behavioral health coverage for residential treatment remains severely limited. Currently, residential treatment is only covered for beneficiaries under the age of 21, meaning that adults—who often require intensive, long-term care for conditions like substance use disorders or severe mental health issues—are excluded from these vital services. This restriction means that many individuals who could benefit from residential treatment find themselves without options under TRICARE behavioral health coverage. In a field where long-term care is frequently essential to recovery, this gap in coverage is a significant concern for those who need it the most.
The GAO report underscores that while the DHA took important steps in 2016 to improve TRICARE behavioral health coverage, there has been no comprehensive assessment of the progress made toward meeting these goals. As a result, the report urges DHA to evaluate its behavioral health coverage more regularly to ensure that it is meeting its objectives and providing comprehensive, accessible care to beneficiaries.
Cost-Sharing Discrepancies: An Additional Barrier
Another critical issue identified by the GAO is the variation in cost-sharing requirements among TRICARE beneficiaries, which adds another layer of complexity to accessing care. TRICARE offers two types of plans—Prime and Select—with different cost-sharing structures. Generally, Prime members face lower out-of-pocket costs than Select members, but this varies based on several factors, including military status and length of service.
For example, active-duty service members are eligible to receive health care, including behavioral health services, at no cost-sharing requirements. This is an important benefit for those on active duty, who are often under significant stress due to their service commitments. However, for retirees and other beneficiaries, the costs can vary widely depending on their specific TRICARE plan. A newly enlisted active-duty member enrolled in TRICARE Prime will not pay anything for an outpatient psychotherapy visit, but a retiree with TRICARE Select could face a $49 copayment for the same service.
This disparity in cost-sharing makes TRICARE behavioral health coverage less predictable and can create financial strain for retirees or family members of military personnel who may not be covered by the same benefits. Moreover, the differences in cost-sharing based on military status and other factors like when a person enlisted can result in inconsistent access to necessary care, potentially causing financial hardship for those who need behavioral health services the most.
The Need for Ongoing Assessment and Reform
The GAO’s findings suggest that despite the steps taken by the DHA in 2016, more work is needed to ensure that TRICARE behavioral health coverage is fully aligned with its medical and surgical coverage. The report urges the DHA to conduct regular and comprehensive evaluations of its behavioral health benefits to identify and address any gaps that continue to exist. Without ongoing oversight and reform, the system may continue to fall short of meeting the needs of military families who depend on TRICARE for comprehensive health care.
As noted by the authors of the GAO report, “Our review brought to light examples where DHA may not be meeting its goals, including its goal to align behavioral health and medical and surgical benefits.” The need for periodic assessments of TRICARE behavioral health coverage is evident. These evaluations would help DHA identify and address any barriers to care that are inconsistent with the agency’s stated goals, ensuring that beneficiaries have access to the care they deserve.
Recommendations for Improvement: What Needs to Be Done?
Moving forward, the GAO recommends that the DHA take several steps to improve TRICARE behavioral health coverage. The most urgent recommendation is for the DHA to implement regular reviews of its behavioral health benefits to ensure they are meeting the original goals set out in the 2016 rule. These reviews should assess whether behavioral health services are accessible, affordable, and equitable for all TRICARE beneficiaries.
Additionally, the DHA should explore ways to eliminate unnecessary barriers to care, such as prior authorization requirements for inpatient behavioral health services and the age limit for residential treatment. These changes would help to ensure that TRICARE behavioral health coverage remains equitable and comprehensive, providing access to care when it is most needed.
Conclusion: The Path Toward Comprehensive Behavioral Health Coverage
While the DHA has made significant strides in expanding and improving TRICARE behavioral health coverage, the recent GAO report reveals that there is still work to be done. For military families who depend on TRICARE, having access to comprehensive, affordable, and timely behavioral health services is vital. To meet its 2016 goals and provide the best possible care for its beneficiaries, the DHA must continue to evaluate and refine its policies, ensuring that there are no unnecessary barriers to care. By taking these steps, the DHA can fulfill its commitment to providing high-quality, equitable health care to the military community.
