HM NWAE TRICARE Programs 2025 Study Guide

TRICARE Prime
- Defined as a managed care option that offers the most affordable and comprehensive coverage.
- Mandatory enrollment for Active Duty Service Members (ADSMs).
- Patient care is primarily received at military hospitals and clinics.
- Specialty care provided by civilians necessitates a referral.
TRICARE Select
- A fee-for-service plan structure.
- Beneficiaries are permitted to visit any TRICARE-authorized provider without requiring a referral.
- Despite the lack of referral requirements for most services, specific care types, such as inpatient mental health, still demand prior authorization.
TRICARE For Life (TFL)
- Functions as Medicare-wraparound coverage.
- Available to military retirees and eligible family members.
- Requires the beneficiary to have both Medicare Part A and Medicare Part B.
- Medicare serves as the primary payer, while TRICARE operates as the secondary payer.

Administration
- The TRICARE Dental Program is administered by United Concordia Companies, Inc.
Orthodontic Coverage Eligibility
- Eligible spouses: Covered up to the age of $23$ .
- Eligible children: Covered up to the age of $21$ .
- Full-time students: Children enrolled as full-time students remain eligible for orthodontic coverage up to the age of $23$ .
Dental Care for Active Duty Service Members (ADSMs)
- ADSMs obtain the majority of their dental care from military dental clinics.
- In instances where civilian care is necessary, it is managed through the Active Duty Dental Program (ADDP).
National Guard and Reserve Provisions
- Upon being called to active duty, a member's individual TDP coverage is automatically placed on hold, and they transition to active duty dental benefits.
- During this period, the member's family retains TDP coverage, benefiting from lower monthly premiums.

Standard Covered Services
- Obstetric visits.
- Ultrasounds.
- Management of high-risk pregnancies.
- Hospital care.
- Anesthesia.
- Caesarean sections.
- Breastfeeding support and breast pumps.
Expanded Coverage and Specialized Programs
- Prenatal and postpartum physical therapy.
- Pelvic floor therapy.
- Childbirth and Breastfeeding Support Demonstration: This program includes support services from designated doulas and lactation specialists.
Home Births
- Planned deliveries at home are covered only when they occur within the United States.
- Home births are explicitly not covered in overseas locations.
Cost and Referrals
- Active Duty Service Members (ADSMs) and Active Duty Family Members (ADFMs) enrolled in TRICARE Prime incur zero out-of-pocket costs for covered maternity services.
- For TRICARE Prime beneficiaries, the Primary Care Manager (PCM) is responsible for coordinating maternity care.
- Beneficiaries enrolled in TRICARE Select may see any TRICARE-approved provider for maternity care without a referral.

Psychotherapy Session Limits
- Individual sessions: Covered for a duration of up to $60\,\text{minutes}$ .
- Individual crisis sessions: Covered for a duration of up to $120\,\text{minutes}$ .
- Family or conjoint sessions: Covered for a duration of up to $90\,\text{minutes}$ .
- Family or conjoint crisis sessions: Covered for a duration of up to $180\,\text{minutes}$ .
- Group sessions: Covered for a duration of up to $90\,\text{minutes}$ .
Marriage Counseling Coverage
- Coverage for marriage counseling is restricted to cases where it is medically necessary for the treatment of a diagnosed mental disorder.
Psychological Testing and Assessment
- Covered: Testing intended to assist in the diagnosis of a mental disorder and the development of a treatment plan.
- Not Covered: Testing conducted for academic placement, job placement, or child custody disputes.
Substance Use Disorder (SUD) Treatments
- Covered treatments include detoxification, Intensive Outpatient Programs (IOP), Partial Hospitalization Programs (PHP), and Medication-Assisted Treatment (MAT).
- Explicitly excluded treatments: Aversion therapy and any unproven treatments.
Prior Authorization Requirements
- Mandatory for all inpatient mental health services.
- Includes acute mental health care, SUD treatment, rehabilitation, and admissions to residential treatment facilities.

Q1. Under the TRICARE Dental Program (TDP), up to what age are eligible children covered for orthodontic treatment if they are NOT full-time students?
- The answer is $21$ .
Q2. Which of the following is explicitly NOT covered under TRICARE's Psychological Testing and Assessment benefits?
- The answer is testing for child custody disputes. Covered items include testing to diagnose a mental health disorder, testing to develop a treatment plan, and testing ordered by TRICARE-authorized providers for clinical evaluation.
Q3. Active duty family members (ADFMs) enrolled in which TRICARE plan have no out-of-pocket costs for covered maternity services?
- The answer is TRICARE Prime.
Q4. TRICARE covers deliveries planned at home under which of the following conditions?
- The answer is only in the United States (Stateside).
Q5. How long is a standard individual psychotherapy session covered under TRICARE?
- The answer is up to $60\,\text{minutes}$ .
Q6. TRICARE will cover marriage counseling ONLY when:
- The answer is when it is necessary for the treatment of a diagnosed mental disorder.
Q7. Which TRICARE program acts as a Medicare-wraparound coverage for military retirees who have both Medicare Part A and Part B?
- The answer is TRICARE For Life.