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This rule proposes revisions to the TRICARE regulation to reduce administrative barriers to access to mental health benefit coverage and to improve access to substance use disorder (SUD) treatment for TRICARE beneficiaries, consistent with earlier Department of Defense and Institute of Medicine recommendations, current standards of practice in mental health and addition medicine, and governing laws. This proposed rule has four main objectives: (1) To eliminate of quantitative and qualitative treatment limitations on SUD and mental health benefit coverage and align beneficiary cost-sharing for mental health and SUD benefits with those applicable to medical/surgical benefits; (2) to expand covered mental health and SUD treatment under TRICARE, to include coverage of intensive outpatient programs and treatment of opioid dependence; (3) to streamline the requirements for institutional providers to become TRICARE authorized providers; and (4) to develop TRICARE reimbursement methodologies for newly recognized mental health and SUD intensive outpatient programs and opioid treatment programs.

Statement of Need:

This rule is necessary to comply with the statutory provisions in section 703 of the National Defense Authorization Act for FY 2015 which removed TRICARE statutory day limitations on inpatient mental health services. It is also necessary to adopt the four main objectives listed above. In general, the DoD, pursuant to chapter 55 of title 10 U.S.C., covers health care, including mental health care, services and supplies, which are medically or psychologically necessary to prevent, diagnose, and/or treat a mental or physical illness, injury, or bodily malfunction. In 1996, Congress enacted the Mental Health Parity Act of 1996 (MHPA 1996) which required employment-related health insurance coverage offered in connection with group health plans to provide parity in aggregate lifetime and annual dollar limits for mental health benefits and medical and surgical benefits. In October 2008, the Mental Health Parity and Addictions Equity Act (MHPAEA) was signed into law as part of the Emergency Economic Stabilization Act of 2008. The changes made by MHPAEA consists of new standards, including parity for substance use disorder benefits, as well as amendments to the existing mental health parity provisions exacted in MHPA. This law requires group health insurance plans that provide both medical/surgical and mental health benefits to provide those benefits at parity. Specifically, financial requirements (e.g., deductibles, co-payments, or coinsurance) and treatment limitations (e.g., days of coverage and number of visits) cannot be more restrictive for mental health benefits than they are for medical/surgical benefits. The MHPAEA was amended by the Patient Protection and Affordable Care Act, as amended by the Health Care and Reconciliation Act of 2010, to also apply to individual health insurance coverage. TRICARE is not a group health plan subject to the MHPA 1996, the MHPAEA of 2008, or the Health Care and Reconciliation Act. However, the provisions of these acts serve as a model for TRICARE in proposing changes to existing benefit coverage so as to reduce administrative barriers to treatment and increase access to medically or psychologically necessary mental health care consistent with TRICARE statutory authority.

Summary of the Legal Basis:

This regulation is proposed under the authorities of 10 U.S.C., section 1073, which authorizes the Secretary of Defense to administer the medical and dental benefits provided in chapter 55 of title 10 U.S.C. The Department is authorized to provide medically necessary and appropriate medical care for mental and physical illnesses, injuries and bodily malfunctions, including hospitalization, outpatient care, drugs, and treatment of mental conditions under 10 U.S.C. section 1077(a)(1)-(3) and (5). Although section 1077 identifies the types of health care to be provided in military treatment facilities, these types of health care are incorporated by reference as the types of health care benefits authorized for coverage within the civilian health care sector for active duty family members and retirees and their dependents through sections 1079 and 1086, respectively. In general, the scope of TRICARE benefits covered within the civilian health care sector and the TRICARE authorized providers of those benefits are found at 32 CFR part 199.4 and 199.6, respectively. Reimbursement is addressed in 32 CFR 199.14.

Alternatives:

To the extent this rule implements statutorily required provisions, no alternatives are applicable. Further, any alternative that fails to address administrative barriers to mental health and SUD treatment and increasing access to medically or psychologically necessary mental health care consistent with TRICARE statutory authority is inconsistent with principles of mental health parity and ignores well-validated evidence and current standards of practice in mental health and SUD treatment.

Anticipated Costs and Benefits:

This rule is not anticipated to have an annual effect on the economy of $100 million or more. Thus, economically, it is not a substantive, significant rule under the Executive Order and the Congressional Review Act. All services and supplies authorized under the TRICARE Basic Program must be determined to be medically necessary in the treatment of an illness, injury or bodily malfunction before the care can be cost shared by TRICARE. For this reason, DoD anticipates that TRICARE will have a marginal increase in cost associated with increased access to authorized mental health and SUD treatment within the TRICARE Basic Program. Failure to prevent or treat these conditions results in severe and widespread consequences, including increased risk of suicide and exacerbation of mental and physical health disorders. Short-term treatments usually are followed by relapses. These proposed revisions will increase access to mental health and SUD treatment, including long-term outpatient care and other systemic supports, resulting in more comprehensive care and hopefully a greater incentive for beneficiaries to seek the care they need.

Risks:

This proposed rule implements statutorily required provisions for adoption and implementation. No risk to the public is applicable as this proposed rule expands access to care, and streamlines requirements for TRICARE authorized provider approval.