United States Government Accountability Office Report to Congressional Committees DEFENSE HEALTH December 2023 CARE DOD Assessment Needed to Ensure TRICARE Behavioral Health Coverage Goals Are Being Met GAO-24-106597 December 2023 DEFENSE HEALTH CARE DOD Assessment Needed to Ensure TRICARE Behavioral Health Coverage Goals Are Being Met Highlights of GAO-24-106597, a report to congressional committees Why GAO Did This Study What GAO Found Behavioral health conditions, which The Department of Defense's (DOD) TRICARE program offers comprehensive include mental health and substance health coverage, including behavioral health services, to beneficiaries, including use disorders, affect millions of people active duty service members, retirees, and their eligible family members. and can have harmful consequences Managed by DOD's Defense Health Agency (DHA), TRICARE offers several plan on the military and its service options. Most beneficiaries are covered under TRICARE Prime, a managed care members, including decreasing option, or TRICARE Select, a self-managed, preferred provider organization readiness. Concerns about the option. TRICARE requires certain beneficiaries to share in the cost of covered accessibility of behavioral health services based on a number of factors set in law. Collectively, these factors can services have been longstanding. DHA result in varying cost-sharing amounts for TRICARE beneficiaries who receive has taken steps to enhance behavioral health services. For example TRICARE's coverage of these services through a 2016 final rule that expanded • Beneficiary category. TRICARE allows active duty service members to behavioral health coverage. obtain covered behavioral health services without cost sharing. Retirees are Congress included a provision in required to share in the costs of their services. statute for GAO to report on TRICARE's coverage of behavioral • Plan option. TRICARE Prime beneficiaries generally face lower cost sharing health services. This report (1) than TRICARE Select beneficiaries. describes requirements that apply to TRICARE's coverage of behavioral TRICARE also requires the two regional contractors who help administer the health services, and (2) examines DHA delivery of care from civilian providers to authorize the medical necessity of efforts to achieve its goals to improve certain behavioral health services for both Prime and Select beneficiaries. TRICARE's behavioral health coverage. 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 GAO reviewed DHA documentation, coverage for new services and eliminated certain coverage limits, such as the including the 2016 final rule and maximum number of treatment sessions, to help make TRICARE's coverage of TRICARE benefit descriptions for 2023 behavioral health services consistent with its coverage for medical and surgical Prime and Select plans, which cover services. In the intervening 7 years, however, DHA has not comprehensively most beneficiaries. GAO also assessed TRICARE coverage of behavioral health services to determine compared requirements for four types whether, or to what extent, its program goals are being met. In conducting its of health services, selected based on their similar setting and intensity, and review, GAO identified TRICARE authorization requirements and coverage limits interviewed DHA and contractor that may not be consistent with DHA's program goals. For example: officials. • Authorization requirements. TRICARE beneficiaries must obtain What GAO Recommends authorization for inpatient behavioral health services but not for inpatient medical and surgical services, with limited exceptions. GAO is making a recommendation to DHA that the agency periodically assess progress toward meeting • Coverage limits. TRICARE limits residential treatment to individuals under DHA's behavioral health coverage age 21. One contractor noted that current standards of medical practice for goals and address any inconsistencies. the treatment of those with eating disorders and post-traumatic stress DOD concurred with GAO's disorder include such coverage for adults. recommendation. 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. View GAO-24-106597. For more information, contact Alyssa M. Hundrup at (202) 512-7114 or HundrupA@gao.gov. United States Government Accountability Office Contents Letter 1 Background 4 TRICARE Beneficiary Cost Sharing and Authorization Requirements for Behavioral Health Services 6 DHA Expanded TRICARE Behavioral Health Coverage but Lacks Information on Whether Program Goals Are Being Met 11 Conclusions 14 Recommendation for Executive Action 14 Agency Comments 15 Appendix I Comments from the Department of Defense 18 Appendix II GAO Contact and Staff Acknowledgments 20 Tables Table 1: TRICARE Covered Behavioral Health Services and Settings, 2023 6 Table 2: Examples of TRICARE Cost-Sharing Requirements for a Retired Service Member's Behavioral Health Treatment, by Plan Option, 2023 7 Table 3: Examples of TRICARE Select Cost-Sharing Requirements for Active Duty Family Members' Selected Behavioral Health Services, by Sponsor's Military Enlistment or Commissioning Date, 2023 8 Table 4: TRICARE Authorization Requirements for Select Behavioral Health Services, 2023 10 Table 5: DHA Program Goals and Changes to Improve TRICARE Behavioral Health Coverage, 2016 Final Rule 12 Table 6: DHA Authorization Requirements for TRICARE Nonemergent Inpatient Behavioral Health and Medical and Surgical Admissions 13 Figure Figure 1: Example of TRICARE Beneficiary Cost-Sharing Amounts, 2023 9 Page i GAO-24-106597 TRICARE Behavioral Health Abbreviations DHA Defense Health Agency DOD Department of Defense This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-24-106597 TRICARE Behavioral Health Letter 441 G St. N.W. Washington, DC 20548 December 20, 2023 Congressional Committees Behavioral health conditions, which include mental health and substance use disorders, affect millions of people. 1 These conditions can have a variety of harmful consequences on the military and its service members, including decreasing readiness. To support military deployments and provide peacetime health care, the Department of Defense (DOD) offers a full range of medical care and services, including services to treat behavioral health conditions, to about 9.6 million active duty service members, retirees, and their eligible family members. 2 DOD's Defense Health Agency (DHA) manages the TRICARE program, which provides comprehensive health care coverage that beneficiaries can obtain in military hospitals and clinics or through TRICARE's network of civilian providers. There have been longstanding questions about the accessibility of behavioral health services, even for those with coverage for these services. For example, in 2022, we reported on multiple challenges that individuals face in accessing behavioral health care, including navigating coverage limitations and preauthorization requirements that can affect their ability to access services. 3 Since 1996, several laws have been enacted to help align private health insurance plans' coverage of behavioral health services with their 1We define behavioral health conditions as all mental, emotional, and substance use disorders that are included in the Diagnostic and Statistical Manual of Mental Disorders. Mental health conditions include anxiety disorders; mood disorders, such as depression; post-traumatic stress disorder; and schizophrenia. Substance use disorders include alcohol use disorder and opioid use disorder. 2TRICARE is also available to National Guard and Reserve members, retirees, and their eligible family members. Eligible family members include spouses and dependent children. 3See GAO, Mental Health Care: Access Challenges for Covered Consumers and Relevant Federal Efforts, GAO-22-104597 (Washington, D.C.: Mar. 29, 2022). Preauthorization requirements, which require a health plan enrollee to receive prior approval for care, are a common feature of private health insurance plans. Page 1 GAO-24-106597 TRICARE Behavioral Health coverage for medical and surgical services. 4 Generally, this means that the financial requirements and treatment limitations that certain private health insurance plans impose on behavioral health services-such as copayment amounts, number of annual visits allowed, or authorization requirements-must not be more restrictive than those imposed on medical or surgical services. Although these laws do not apply to TRICARE, DHA took steps through a 2016 final rule to improve TRICARE's coverage of behavioral health services. 5 These steps included expanding the scope of covered services and eliminating certain treatment limitations. The James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 includes a provision for GAO to report on TRICARE's coverage of behavioral health services. 6 In this report, we 1. describe cost-sharing and authorization requirements that apply to TRICARE's coverage of behavioral health services. 2. examine steps DHA has taken to achieve its goals to improve TRICARE behavioral health coverage. To describe cost-sharing and authorization requirements that apply to TRICARE's coverage of behavioral health services, we reviewed relevant laws, regulations, the TRICARE policy manual, and DHA documentation, including summary coverage descriptions for the treatment of behavioral health conditions in 2023. 7 We also reviewed coverage descriptions and documentation created by TRICARE's two managed care support contractors (contractors) who administer TRICARE for DHA within the United States in two regions (East and West). 8 We focused our review on coverage requirements for TRICARE Prime and TRICARE Select-two options that covered about 70 percent of all enrolled TRICARE 4For example, The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires large group health plan sponsors, including employers, that choose to offer mental health and substance use disorder services to ensure that coverage of these services is no more restrictive than coverage for medical and surgical services. The Patient Protection and Affordable Care Act extended these parity requirements to most small group and individual health insurance plans. 581 Fed. Reg. 61,068 (Sept. 2, 2016). 6Pub. L. No. 117-263, § 709, 136 Stat. 2395, 2655 (2022). 7The TRICARE Policy Manual provides instructions to DHA's contractors about how to implement the TRICARE benefit. 8In2023, the two TRICARE contractors were Humana Government Business and Health Net Federal Services. Page 2 GAO-24-106597 TRICARE Behavioral Health beneficiaries at the end of fiscal year 2022 (the most recently available information at the time of our analysis). 9 To clarify and confirm our understanding of these requirements, we interviewed officials from DHA and the two contractors. To examine steps DHA has taken to achieve its goals to improve TRICARE behavioral health coverage, we reviewed federal laws and regulations, including the 2016 final rule that outlined DHA's goals to improve TRICARE's behavioral health coverage. In addition, we assessed DHA's communication of these goals to the contractors, including through the TRICARE Policy Manual. We also examined the alignment of cost-sharing and authorization requirements between two behavioral health and two medical and surgical services, which we selected based on their similar setting and intensity. 10 Our review was limited to the 2023 TRICARE Prime and Select plan options. We also interviewed DHA officials, the two contractors, and representatives from four beneficiary stakeholder groups who had been active in examining TRICARE behavioral health coverage. 11 We examined whether DHA's steps to improve TRICARE behavioral health coverage were aligned with control activities and monitoring components of federal standards for internal control. Using these standards, we assessed whether DHA had assurance that it was meeting the goals it established in the 2016 final rule. 12 We conducted this performance audit from January 2023 through December 2023 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. 9Department of Defense, Defense Health Agency, Evaluation of the TRICARE Program: Fiscal Year 2023 Report to Congress (February 28, 2023). 10The behavioral health services we examined were outpatient psychotherapy and inpatient admissions; the medical and surgical services we examined were outpatient physical therapy and inpatient admissions. 11The four groups were the Eating Disorders Coalition, Military Officers Association of America, National Military Family Association, and the TRICARE for Kids Coalition. 12GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C: Sept. 10, 2014). Internal control is a process effected by an entity's oversight body, management, and other personnel that provides reasonable assurance that the objectives of an entity will be achieved. Page 3 GAO-24-106597 TRICARE Behavioral Health DHA operates its own large, complex health system that provides health Background care at military medical treatment facilities-including hospitals and clinics located on or near military installations-and through networks of civilian providers. Within the United States, TRICARE is organized into two regions, East and West. DHA contracts with two private companies-one per region-to administer the program. The contractors have a variety of responsibilities, including developing and maintaining networks of civilian providers and performing a variety of customer service functions, including enrolling beneficiaries, authorizing treatment, and processing claims. They must also comply with provisions outlined in their contracts, such as reimbursing providers for covered services in accordance with law and TRICARE policy. DHA oversees the contractors' administration of TRICARE, including whether they are ensuring that coverage decisions are consistent with federal law and agency policy. TRICARE offers a variety of plan options, and most beneficiaries are enrolled in either TRICARE Prime or TRICARE Select. 13 While active duty service members are automatically enrolled in TRICARE Prime, others may select a plan option during an annual open enrollment period. 14 • TRICARE Prime is a health maintenance organization-style option in which beneficiaries typically receive most of their care through a primary care manager. 15 If the local military hospital or clinic is unable to provide a necessary service, the primary care manager refers the beneficiary to obtain this care from TRICARE's network of civilian providers. • TRICARE Select is a self-managed, preferred provider organization option that allows beneficiaries flexibility in managing their own health care. Beneficiaries with Select may obtain covered services from any TRICARE-authorized provider. Select beneficiaries are not required to 13Department of Defense, Defense Health Agency, Evaluation of the TRICARE Program: Fiscal Year 2023 Report to Congress (February 28, 2023). 14TRICARE includes two types of beneficiaries: (1) sponsors, which include active duty service members, eligible National Guard and Reserve members, and retirees, and (2) their eligible family members. 15Primary care managers are responsible for providing routine, non-emergency, and urgent health care. All TRICARE Prime beneficiaries select or are assigned a primary care manager. TRICARE Prime beneficiaries may obtain preventive services and outpatient mental health care from any TRICARE network provider without a referral. However, they must obtain a referral from the primary care manager for all other care, or will otherwise face higher costs. Page 4 GAO-24-106597 TRICARE Behavioral Health have a primary care manager and generally do not require referrals for specialty care. TRICARE Prime and Select also have financial features, such as annual enrollment fees, deductibles, and catastrophic caps, which can vary by a number of factors. For example, TRICARE allows active duty service members to obtain health care services at a military hospital or clinic without facing enrollment fees or deductibles. 16 In contrast, retirees are required to pay an annual fee at the time of their enrollment and may be required to pay for their covered services until reaching an annual deductible amount. After that point, TRICARE and the beneficiary share in the cost of covered services, requiring the beneficiary to pay either a fixed amount per service or a percentage of the cost, up to the catastrophic cap. While the characteristics of TRICARE plan options vary, Prime and Select generally cover the same services for all beneficiaries. For behavioral health, covered services include diagnostic and therapeutic services in a range of outpatient, emergency, and inpatient settings. Some outpatient services, such as psychotherapy, are also available via telemedicine. TRICARE beneficiaries may obtain covered behavioral health services from a variety of provider types, including psychiatrists, clinical psychologists, certified clinical social workers, and others. (See Table 1.) 16Active duty service members are entitled to medical and dental care in any facility of any uniformed service without cost sharing. Active duty service members and certain others may also purchase supplemental insurance; these programs reimburse TRICARE beneficiaries for out of pocket medical expenses paid to civilian providers Page 5 GAO-24-106597 TRICARE Behavioral Health Table 1: TRICARE Covered Behavioral Health Services and Settings, 2023 Services Settings • Psychotherapy (including individual, family, and group • Office-based outpatient psychotherapy) • Intensive outpatient program • Psychoanalysis • Partial hospitalization program • Psychological testing and assessment • Opioid treatment program • Pharmaceuticals • Residential substance use disorder rehabilitation • Medication management facility • Electroconvulsive treatment • Residential treatment centerb • Collateral visitsa • Inpatient hospital • Medication assisted treatment • Emergency department • Transcranial magnetic stimulation Source: Defense Health Agency information. | GAO-24-106597 Notes: Behavioral health services include services to treat mental health conditions and substance use disorders. Covered services may be available in multiple settings; some covered services are available via telemedicine. TRICARE beneficiaries may obtain behavioral health services from a range of provider types, including psychiatrists, clinical psychologists, certified clinical social workers, and others. aCollateral visits include the interpretation or explanation of results of psychiatric or other medical examinations to family or other responsible persons, and the provision of advice on how to assist the patient. bCoverage for residential treatment centers is restricted to children and adolescents up to age 21. TRICARE requires some beneficiaries to share in the cost of the TRICARE Beneficiary behavioral health services they obtain. It also requires its contractors to Cost Sharing and authorize certain behavioral health services to ensure that such treatment is medically necessary, appropriate, and reasonable. Authorization Requirements for Behavioral Health Services Cost-sharing TRICARE cost-sharing requirements are established in law and vary Requirements based on multiple factors, including beneficiary category, plan option, and provider network status. • Beneficiary category. TRICARE cost-sharing requirements vary based on the beneficiary's relationship to the military-e.g., active- duty, retired, reservist, or family member. For example, TRICARE allows active duty service members to obtain covered services, including behavioral health services, without any cost sharing. In contrast, TRICARE requires other beneficiaries, such as retirees, to share the cost of their covered services. Page 6 GAO-24-106597 TRICARE Behavioral Health • Plan option. TRICARE cost sharing varies by plan option. For behavioral health services, TRICARE Prime beneficiaries generally face lower cost sharing than beneficiaries with TRICARE Select. 17 For example, compared with retirees with TRICARE Prime, retirees with TRICARE Select pay one-third more for outpatient psychotherapy and nearly twice as much as for emergency room visits. 18 (See table 2.) Table 2: Examples of TRICARE Cost-Sharing Requirements for a Retired Service Member's Behavioral Health Treatment, by Plan Option, 2023 Prime Select Outpatient psychotherapy $36/visit $49/visit Emergency room visit $73/visit $138/visit Source: Defense Health Agency. | GAO-24-106597 Note: Cost-sharing requirements are applicable to TRICARE beneficiaries with military enlistment or commissioning dates prior to January 1, 2018, for services obtained from an in-network provider. • Provider network status. TRICARE Prime and Select beneficiaries face lower cost sharing when obtaining services from a provider who is part of the TRICARE network, compared to an out-of-network provider. 19 TRICARE Select cost-sharing requirements also differ based on when one's sponsor joined the miliary, either through military enlistment or commissioning. Those who joined the military prior to January 1, 2018, face different cost sharing than those who did so after that date. 20 For example, for an outpatient psychotherapy visit, an active duty family member whose sponsor joined prior to January 1, 2018, must pay $37. This is compared to the $30 that an active duty family member whose sponsor joined after that date is required to pay. (See Table 3.) 17Similar to TRICARE, health maintenance organization plans generally require lower cost sharing than preferred provider organization plans in the private health insurance market. 18These amounts are applicable to retirees with military enlistment or commissioning dates prior to January 1, 2018, for services obtained from an in-network provider. 19TRICARE beneficiaries may seek care from a provider who is not part of the TRICARE network by choice or by necessity, such as when there are no network providers available in a beneficiary's location. If unable to locate a network provider for a medically necessary service, a contractor may authorize a Prime beneficiary to obtain care from a TRICARE- authorized out-of-network provider and waive additional fees associated with this care. 20The National Defense Authorization Act for Fiscal Year 2017 established TRICARE cost-sharing requirements based on when a sponsor joined the military. Pub. L. No. 114- 328, § 701, 130 Stat. 2000, 2180 (2016). In some cases, cost sharing amounts for those who joined after January 1, 2018, are more than amounts for those who joined prior to that date; in other cases, they are less. Page 7 GAO-24-106597 TRICARE Behavioral Health Table 3: Examples of TRICARE Select Cost-Sharing Requirements for Active Duty Family Members' Selected Behavioral Health Services, by Sponsor's Military Enlistment or Commissioning Date, 2023 Military enlistment or commissioning date Prior to January 1, 2018 January 1, 2018, or later Outpatient psychotherapy visit $37/visit $30/visit Inpatient behavioral health admission $21.30/day or $25/admission (whichever is $73/admission more) Source: Defense Health Agency. | GAO-24-106597 Note: Cost-sharing amounts apply to services rendered by an in-network provider. The National Defense Authorization Act for Fiscal Year 2017 established TRICARE cost-sharing requirements based on when a sponsor joined the military. Pub. L. No. 114-328, § 701, 130 Stat. 2000, 2180 (2016). In some cases, cost sharing amounts for those who joined after January 1, 2018, are more than amounts for those who joined prior to that date; in other cases, they are less. Collectively, these factors result in TRICARE beneficiaries facing various cost-sharing amounts for behavioral health services. For example, as Figure 1 illustrates, the cost-sharing amounts associated with obtaining two services-outpatient psychotherapy and inpatient care-vary based on multiple factors. Page 8 GAO-24-106597 TRICARE Behavioral Health Figure 1: Example of TRICARE Beneficiary Cost-Sharing Amounts, 2023 Note: The cost-sharing requirements listed are applicable to services obtained from a provider within the TRICARE network. TRICARE Prime active duty service members who joined the military prior to 2018 also face $0 cost sharing for these behavioral health services. Page 9 GAO-24-106597 TRICARE Behavioral Health Authorization TRICARE also requires its contractors to verify that certain services, Requirements including certain behavioral health services, are medically necessary, appropriate, and reasonable before beneficiaries can access them. 21 Authorization may be required before services are rendered (preauthorization); as a condition of ongoing treatment (continuing stay authorization); or at both junctures. 22 TRICARE's authorization requirements for behavioral health services are the same across TRICARE Prime and Select plan options and do not vary by beneficiary characteristics. However, these requirements vary by the type of service a beneficiary is seeking. For example, for care at a residential treatment center, DHA requires its contractors to authorize treatment prior to admission and at least every 30 days thereafter. By contrast, DHA does not require preauthorization for emergency care or certain outpatient behavioral health services, such as psychotherapy. Table 4 lists TRICARE's authorization requirements for select behavioral health services. Table 4: TRICARE Authorization Requirements for Select Behavioral Health Services, 2023 Services available without Services requiring preauthorization Services requiring preauthorization and preauthorization continuing stay authorization • Outpatient office-based • Psychoanalysis • Nonemergency inpatient services, including • Electroconvulsive treatment care, including admissions individual and group to hospitals or residential psychotherapy visits treatment centers • Intensive outpatient program • Partial hospitalization program • Opioid treatment program, including medication- assisted treatment • Emergency care Source: GAO analysis of Defense Health Agency information. | GAO-24-106597 Note: Authorization requirements apply to TRICARE Prime and Select. 21TRICARE also requires preauthorization for certain medical and surgical services such as organ transplants and skilled nursing facility admissions. TRICARE contractors may also retroactively review the medical and surgical services provided to beneficiaries to ensure their medical necessity. 22To meet relevant authorization requirements, health care providers, such as primary care physicians or hospitals, send information to support the need for a specific treatment to the relevant contractor for review and approval. Without such authorization, a beneficiary could be responsible for paying a larger portion of the cost of the service. Page 10 GAO-24-106597 TRICARE Behavioral Health DHA also allows its contractors to establish additional authorization requirements to ensure medical necessity, appropriateness, and reasonableness of care. 23 However, our review of contractors' documentation of authorization requirements showed, and officials from both contractors confirmed, that the contractors had not implemented any additional authorization requirements for behavioral health services. In its final rule issued in September 2016, DHA took steps to improve DHA Expanded TRICARE's coverage of behavioral health services. 24 Specifically, the TRICARE Behavioral final rule established several program goals, such as expanding the scope of behavioral health services (see table 5). DHA broadened Health Coverage but TRICARE's coverage to include new behavioral health services, such as Lacks Information on intensive outpatient programs and opioid treatment programs. DHA also eliminated certain limits on coverage, such as a maximum number of Whether Program outpatient psychotherapy and substance use disorder treatment Goals Are Being Met sessions. 25 In addition, DHA sought to align cost-sharing and other requirements for behavioral health and medical and surgical services to the extent feasible. 26 According to agency officials, these changes represent the last major update to TRICARE's coverage of behavioral health services. With these changes, officials said DHA achieved the program goals outlined in the final rule. 23TRICARE Policy Manual, Chapter 1, Sec. 6.1. 2481 Fed. Reg. 61,068 (Sept. 2, 2016). 25To implement these changes, DHA revised the TRICARE Policy Manual and sent these updates to the contractors for implementation. DHA officials and contractors confirmed that they implemented related changes by January 2018, retroactive to October 2016. 26To assess feasibility, DHA officials said they considered whether potential changes met statutory requirements, improved beneficiary outcomes and access, and constrained costs, among other considerations. DHA officials were unable to provide documentation describing their feasibility assessment because the agency did not formally document its work. Further, citing significant staff turnover, DHA officials noted that they have limited institutional knowledge regarding this assessment. Page 11 GAO-24-106597 TRICARE Behavioral Health Table 5: DHA Program Goals and Changes to Improve TRICARE Behavioral Health Coverage, 2016 Final Rule Program goals Summary of changes Eliminate unnecessary treatment • Eliminated limits on the number of covered psychotherapy treatment sessions, limitations on TRICARE's coverage of substance use disorder treatment sessions, inpatient hospitalization days, behavioral health services, to align with psychological testing sessions, smoking cessation quit attempts and related coverage for medical and surgical counseling sessions. services • Identified substance use disorder treatment as a covered benefit. • Eliminated annual and lifetime limits for substance use disorder treatment. • Eliminated exclusions on the non-surgical treatment of gender dysphoria. • Aligned beneficiary cost sharing for behavioral health services with that for TRICARE's medical/surgical benefits. Expand the scope of covered behavioral • Defined and authorized TRICARE coverage for intensive outpatient programs, health services opioid treatment programs, and certain other outpatient treatments including office based opioid treatment. Establish payment methodologies for • Set payment rates for intensive outpatient programs and opioid treatment newly covered behavioral health programs. services Streamline requirements for providers to • Streamlined the process for institutional behavioral health providers to become treat TRICARE beneficiaries authorized to receive payment for the treatment of TRICARE beneficiaries. Source: GAO analysis of 81 Fed. Reg. 61,068 (Sept. 2, 2016) and Defense Health Agency (DHA) information. | GAO-24-106597 We did not comprehensively assess TRICARE behavioral health coverage relative to DHA's program goals. However, our analysis of the four health services we focused on identified areas where TRICARE's coverage may not be consistent with DHA's goal to eliminate all unnecessary treatment limitations. For example, DHA requires preauthorization and continuing stay authorizations for all nonemergent inpatient behavioral health services provided to TRICARE beneficiaries. However, with limited exceptions, it does not require such authorizations for nonemergent inpatient medical and surgical services. 27 (See Table 6.) 27DHA requires preauthorization for certain inpatient medical and surgical services, including adjunctive dental care requiring inpatient stays and skilled nursing facility stays for TRICARE beneficiaries who are also eligible for Medicare. TRICARE also allows the contractors to implement additional authorization requirements as needed. We found that one contractor implemented preauthorization requirements for nonemergency inpatient medical and surgical care. We did not identify inconsistencies when examining cost-sharing requirements for the behavioral health and medical surgical services we reviewed. For example, a retired service member with TRICARE Select was required to pay the same co-payment amount ($49 per visit) regardless of whether he or she was obtaining psychotherapy or physical therapy from an in-network provider. Page 12 GAO-24-106597 TRICARE Behavioral Health Table 6: DHA Authorization Requirements for TRICARE Nonemergent Inpatient Behavioral Health and Medical and Surgical Admissions Behavioral health admission Medical and surgical admission Preauthorization Required Not required Continuing stay authorization Required at least every 30 days Not required Source: GAO analysis of Defense Health Agency (DHA) information. | GAO-24-106597 Note: DHA requires preauthorization for certain inpatient medical services, such as skilled nursing facility stays for TRICARE beneficiaries who are also eligible for Medicare.. In addition, one contractor and three stakeholders we interviewed identified another limitation in TRICARE's coverage of behavioral health Eating Disorders in the Military services that may be inconsistent with the agency's goal of eliminating Eating disorders are complex conditions that can involve dangerous eating behaviors, such unnecessary treatment limitations. Specifically, TRICARE limits coverage as the restriction of food intake or binge of residential treatment center services to children and adolescents under eating. These conditions raise the risk of mortality and are associated with serious age 21. One contractor noted that current standards of medical practice physical and mental health problems, include services provided in residential treatment center for adults, including anxiety, depression, substance use, including for treatment of eating disorders and post-traumatic stress or post-traumatic stress disorder. According to the Defense Health Agency, 72 percent of all disorder. Three stakeholders also noted concerns with limiting access to TRICARE beneficiaries with diagnosed eating residential treatment center services in this manner. DHA officials said disorders were aged 21 or older in fiscal year 2019. Additionally, the annual incidence rate that TRICARE does not cover residential treatment center care for adults of eating disorders among active duty service ages 21 and older because this setting was not proven to be safe and members increased 79 percent between 2017 effective when the agency issued its related guidance in 2021. 28 and 2021. The potential effects that eating disorders can have on the health and combat readiness of service members and their DHA officials said that if they were to make changes to TRICARE's dependents underscores the importance of behavioral health coverage, they would consider the effect of any such screening and treating this population. changes with respect to their alignment goals. However, since issuing the Source: Defense Health Agency and GAO. | GAO-24-106597 2016 final rule, DHA has not comprehensively assessed the TRICARE behavioral health benefit to ensure that coverage meets its goals. Without 28In February 2023, the American Psychiatric Association updated its practice guideline for treating eating disorders to include residential treatment centers as a potential treatment setting. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Eating Disorders, Fourth Edition (February 2023). DHA officials said they were aware of these guidelines and could consider them as one source in any future medical benefit determination. Regarding post-traumatic stress disorder, the American Psychiatric Association's guideline does not discuss residential treatment care. However, the Department of Veterans Affairs has offered residential treatment for veterans with post-traumatic stress disorder for over 10 years. DHA officials noted that they do not consider other federal programs' coverage of benefits when determining TRICARE coverage. Page 13 GAO-24-106597 TRICARE Behavioral Health Post-Traumatic Stress Disorder in the periodic efforts to assess the extent to which TRICARE coverage Military continues to meet DHA goals, the agency may be unaware of and Post-traumatic stress disorder can occur therefore unable to address any potential inconsistencies, which could after experiencing or witnessing a life- adversely affect beneficiaries' access to covered services. The lack of threatening event, such as getting wounded in combat, and is a prevalent mental health such an assessment by DHA is also inconsistent with federal internal disorder among service members. According to the Department of Veterans' control standards for control activities and monitoring, which specify that Affairs, 7 percent of military veterans will be management should take steps to achieve their goals and establish diagnosed with post-traumatic stress disorder at some point in their lives. monitoring systems to evaluate progress. Symptoms can be debilitating and include insomnia; intense anxiety; and difficulty coping with work, social, and family relationships. Left untreated, post-traumatic stress disorder can lead to substance abuse, severe depression, and suicide. Treatment may lessen the severity of symptoms and improve the overall quality of life for individuals with this disorder. Source: Defense Health Agency and Department of Veterans Affairs. | GAO-24-106597 Behavioral health conditions can have harmful consequences on the Conclusions military and its service members, including decreasing military readiness. Through its issuance of a final rule in 2016, DHA voluntarily took important steps to improve TRICARE's coverage of behavioral health services, including expanding the scope of available services and eliminating coverage limits. With these actions, DHA intended to align TRICARE's coverage of behavioral health services with that for medical and surgical services to the extent feasible. However, in the intervening 7 years, DHA has not comprehensively assessed the extent to which TRICARE behavioral health coverage meet the goals the agency outlined in the 2016 final rule. 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. These results indicate that periodic assessments of TRICARE's behavioral health coverage by DHA are warranted to ensure that the agency is aware of and can take steps to address any limits faced by beneficiaries that are inconsistent with DHA's goals. We are making the following recommendation to DHA: Recommendation for Executive Action The Director of DHA should take steps to periodically assess, and document its assessments of, TRICARE's behavioral health coverage to determine the extent to which the coverage meets its program goals, Page 14 GAO-24-106597 TRICARE Behavioral Health including those outlined in the 2016 final rule, and take steps to address any inconsistencies. (Recommendation 1) We provided a draft of this report to DOD for review and comment. In its Agency Comments comments, which are reprinted in appendix I, DOD concurred with our recommendation, noting that DHA would periodically review coverage and benefits to ensure that program goals are met. DOD also provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of Defense, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or HundrupA@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. Alyssa M. Hundrup Director, Health Care Page 15 GAO-24-106597 TRICARE Behavioral Health List of Committees The Honorable Jack Reed Chairman The Honorable Roger Wicker Ranking Member Committee on Armed Services United States Senate The Honorable Maria Cantwell Chair The Honorable Ted Cruz Ranking Member Committee on Commerce, Science, and Transportation United States Senate The Honorable Jon Tester Chair The Honorable Susan Collins Ranking Member Subcommittee on Defense Committee on Appropriations United States Senate The Honorable Chris Murphy Chair The Honorable Katie Britt Ranking Member Subcommittee on Homeland Security Committee on Appropriations United States Senate The Honorable Mike Rogers Chairman The Honorable Adam Smith Ranking Member Committee on Armed Services House of Representatives Page 16 GAO-24-106597 TRICARE Behavioral Health The Honorable Sam Graves Chairman The Honorable Rick Larsen Ranking Member Committee on Transportation and Infrastructure House of Representatives The Honorable Ken Calvert Chairman The Honorable Betty McCollum Ranking Member Subcommittee on Defense Committee on Appropriations House of Representatives The Honorable Dave Joyce Chairman The Honorable Henry Cuellar Ranking Member Subcommittee on Homeland Security Committee on Appropriations House of Representatives Page 17 GAO-24-106597 TRICARE Behavioral Health Appendix I: Comments from the Department Appendix I: Comments from the Department of Defense of Defense Page 18 GAO-24-106597 TRICARE Behavioral Health Appendix I: Comments from the Department of Defense Page 19 GAO-24-106597 TRICARE Behavioral Health Appendix II: GAO Contact and Staff Appendix II: GAO Contact and Staff Acknowledgments Acknowledgments Alyssa M. Hundrup, (202) 512-7114 or HundrupA@gao.gov GAO Contact In addition to the contact named above, Susan Anthony (Assistant Staff Director), Patricia Roy (Analyst-in-Charge), and Andres De La Torre Acknowledgments Perez made key contributions to this report. Also contributing were Sam Amrhein, Ethiene Salgado-Rodriguez, and Emily Wilson Schwark. Page 20 GAO-24-106597 TRICARE Behavioral Health The Government Accountability Office, the audit, evaluation, and investigative GAO's Mission arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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