Defense Health Care: DOD Assessment Needed to Ensure TRICARE Behavioral Health Coverage Goals Are Being Met

What GAO Found

The Department of Defense's (DOD) TRICARE program offers comprehensive health coverage, including behavioral health services, to beneficiaries, including active duty service members, retirees, and their eligible family members. Managed by DOD's Defense Health Agency (DHA), TRICARE offers several plan options. Most beneficiaries are covered under TRICARE Prime, a managed care option, or TRICARE Select, a self-managed, preferred provider organization option. TRICARE requires certain beneficiaries to share in the cost of covered services based on a number of factors set in law. Collectively, these factors can result in varying cost-sharing amounts for TRICARE beneficiaries who receive behavioral health services. For example

• Beneficiary category. TRICARE allows active duty service members to obtain covered behavioral health services without cost sharing. Retirees are required to share in the costs of their services.
• Plan option. TRICARE Prime beneficiaries generally face lower cost sharing than TRICARE Select beneficiaries.

TRICARE also requires the two regional contractors who help administer the delivery of care from civilian providers to authorize the medical necessity of certain behavioral health services for both Prime and Select beneficiaries.

In a 2016 final rule, DHA set program goals for improving TRICARE's behavioral health coverage and took steps to help achieve these goals. DHA added coverage for new services and eliminated certain coverage limits, such as the maximum number of treatment sessions, to help make TRICARE's coverage of behavioral health services consistent with its coverage for medical and surgical services. In the intervening 7 years, however, DHA has not comprehensively assessed TRICARE coverage of behavioral health services to determine whether, or to what extent, its program goals are being met. In conducting its review, GAO identified TRICARE authorization requirements and coverage limits that may not be consistent with DHA's program goals. For example:

• Authorization requirements. TRICARE beneficiaries must obtain authorization for inpatient behavioral health services but not for inpatient medical and surgical services, with limited exceptions.
• Coverage limits. TRICARE limits residential treatment to individuals under age 21. One contractor noted that current standards of medical practice for the treatment of those with eating disorders and post-traumatic stress disorder include such coverage for adults.

By periodically assessing TRICARE's behavioral health coverage, DHA can identify any areas where changes may be needed and better ensure that beneficiaries do not face limits that are inconsistent with DHA's program goals.

Why GAO Did This Study

Behavioral health conditions, which include mental health and substance use disorders, affect millions of people and can have harmful consequences on the military and its service members, including decreasing readiness. Concerns about the accessibility of behavioral health services have been longstanding. DHA has taken steps to enhance TRICARE's coverage of these services through a 2016 final rule that expanded behavioral health coverage.

Congress included a provision in statute for GAO to report on TRICARE's coverage of behavioral health services. This report (1) describes requirements that apply to TRICARE's coverage of behavioral health services, and (2) examines DHA efforts to achieve its goals to improve TRICARE's behavioral health coverage.

GAO reviewed DHA documentation, including the 2016 final rule and TRICARE benefit descriptions for 2023 Prime and Select plans, which cover most beneficiaries. GAO also compared requirements for four types of health services, selected based on their similar setting and intensity, and interviewed DHA and contractor officials.