HRSA TRAIN THE TRAINER program

2

• Brief overview of NAO contract• Version of trainingo Experience the training before

offering ito Questions about

implementation~ write down~ address tomorrow

Preview Day 1

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• Version of trainingo Scope of the problemo Military cultureo Behavioral health

issueso VA presentationo TRICARE presentationo Boots on the ground

Preview Day 1

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• Your CE evento Why train civilian providerso Description NAO

project/required formso Goals each content sectiono How to find speakers – each

sectiono CSSP toolkit and handouts

Preview Day 2

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• Your CE evento Resourceso CSSP provider database - demoo CE creditso Overview CE processo Have everything you’ll need

Preview Day 2

QUESTIONS?

Nao contract overview

• Each AHEC site required to offer CE events

• 75-100 people per site to educate• Prior to 30 September 2013• Audiences to target

o Primary careo Behavioral/mental health

Nao contract overview

• Required contento Military cultureo Identify service members – ask the

questiono Behavioral/mental health issues

• Keep content in mind while experiencing training today

QUESTIONS?

• Different kind of training

• Immerse in military culture

o Time format

o Date format

Introduction

Painting A Moving TrainPainting A Moving Train

Quote General Robert Mangus Assistant Commandant US Marine Corps

2007

“The most complex and dangerous conflicts, the most harrowing operations, and the most deadly wars, occur in the head.”

Introduction

(Anthony Swafford, Jarhead from PBS video Operation Homecoming)

“When we arrived home, it seemed surreal. I felt more out of place here than I had in Iraq. I isolated myself from friends and family and dwelled in my emptiness.”

Introduction

(Corporal Travis Williams, US Marine Corps testimony to US senators on a

fact-finding mission in Montana)

“For the first time in American history, 90% of wounded (service members) survive their injuries. “A greater percentage of men and women are coming home with …TBI and severe Posttraumatic Stress.”

Introduction

(Alive Day Memories: Home from Iraq HBO documentary

How many of you are…• Current Service

Members o Active duty?o Guard?o Reserve?

• Former Service Members?

Introduction

How many of you are…• Spouse of Current/Former

Service Members?• Sibling of Current/Former

Service Member?• Other family member?• Know a Current/Former Service

Member?

Introduction

How many of you are…• Physicians?• Nurses?• Mental health professional?• Allied health professional?• Public health professional?• Others?

Introduction

scope of the Problem

• Length of combat operationsoNovember 27, 2006 oWar in Iraq was longer than

WWII• All volunteer force = multiple

deployments

scope of the Problem

2.2 million Service Members Iraq and Afghanistan

“Over 75% of Soldiers and Marines [in Iraq] surveyed reported being in situations where they could be seriously injured or killed; 62-66% knew someone seriously injured or killed; more than one third described an event that caused them intense fear, helplessness or horror”

(Office of the Army Surgeon General Mental Health Advisory Team [MHAT] IV,

Final Report, Nov 06)

scope of the Problem

“The challenges are enormous and the consequences of non-performance are significant. Data…indicate that 38% of Soldiers and 31% of Marines report psychological symptoms. Among members of the National Guard, the figure rises to 49%. Further, psychological concerns are significantly higher among those with repeated deployments, a rapidly growing cohort.

(Report of the DoD Task Force on Mental Health June 2007)

scope of the Problem

Psychological concerns among family members • Area of concern• First Lady Joining Forces initiative to

support family members• Dr. Jill Biden – families serve – not in

uniform

scope of the Problem

Psychological concerns among family members • >1 million children in US under 11

y.o. experienced deployment of a parent – sometimes both – since 9/11

• Sesame Street videos• Available to service members through

Military One Source

scope of the Problem

• July – September 2010• Surveyed 911 Army soldiers and

Marines • All deployed OIF/OEF• Report released May 2011• Compared to surveys 2005,

2007, 2009 Office of the Army Surgeon General

Mental Health Advisory Team (MHAT) VII Report May

2011

scope of the Problem

• Rates of acute stress higher than any previous year except 2007o Acute stresso Depressiono Anxiety

• Ratings of individual morale significantly declined since 2005 and 2009

Office of the Army Surgeon General Mental Health

Advisory Team (MHAT) VII Report May 2011

scope of the Problem

• Suicide ideation rates the same• Higher exposure to concussive

events• Service members on 3rd-4th

deployment lower morale than those on 1st

Office of the Army Surgeon General Mental Health

Advisory Team (MHAT) VII Report May 2011

scope of the Problem

• Dramatic increase in combat exposure over previous surveys

• Behavioral health stigma unchanged

Office of the Army Surgeon General Mental Health

Advisory Team (MHAT) VII Report May 2011

scope of the Problem

Experience 20072010Death of unit member 48.6%73.4%Shooting at enemy 29.6%

78.5%IED exploded near them 32.8%

62.4%Responsible for death of 8.3%48.4% combatant

Office of the Army Surgeon General Mental Health

Advisory Team (MHAT) VII Report May 2011

scope of the Problem

• Where deployed service members live

• CSSP Data Maps - demo

Family Issues

• Military culture assumes that operational needs of the unit always take precedent over everything o Graduationso Weddingso Birth of service member’s own child

• Anything must be canceled at moment’s notice if operational need arises

(Jessica Meed, MPH)

Family Issues

• Spouses and children may think of themselves as serving when their loved one is deployed.

• Families make plans for big events that do not include the service member.

(Jessica Meed, MPH)

Public health model

• Most war fighters/veterans will NOT develop a mental illness but…

• All war fighters/veterans and their families face important readjustment issues

• This population-based approach is less about making diagnoses than about helping individuals and families retain a healthy balance despite the stress of deployment

(Jessica Meed, MPH)

Public health model

• Incorporates Recovery Model and other principles of the President’s New Freedom Commission on Mental Health

oThere is a difference between having a problem and being disabled

• The public health approach requires a progressively engaging, phase-appropriate integration of services

Public health model

This program must: • Be driven by the needs of the Service

Member/ veteran and his/her family rather than by DoD and VA traditions

• Meet prospective users where they live rather than wait for them to find their way to the right mix of our services

• Increase access and reduce stigma

Advantages of working at State & community levels

• National Guard programs are organized by state

• Each state has its own veterans outreach program

• Builds a system of interagency communication and coordination that may serve well at times of disaster

Take home point

There should be NO WRONG DOOR to which service members, veterans or their families can come for help

QUESTIONS?

Basic Training – Military Culture

Basic Training – Military Culture

Understanding the nature of the military culture, combat and the stresses of living and working in a war zone are critical to establishing credibility with your clients.

Basic Training – Military Culture

The military has its own laws, its own clothes and its own language. To serve them better and help ease their fears about treatment, we first need to understand what being a veteran is all about and be familiar with all things military. Scott Swain, 15-year Gulf War

veteran, Senior Director Veterans Services

Valley Cities Counseling and Consultation

Auburn, WA

Basic Training – Military Culture

• Armyo Army National Guard

• Navy• Marine Corps• Air Force

o Air National Guard• Coast Guard*

Basic Training – Military Culture

A word about lingo…some exampleso OEF = Operation Enduring Freedom

(Afghanistan)o OIF = Operation Iraqi Freedom (Iraq)o OND = Operation New Dawn (current

status of Iraq)

Basic Training – Military Culture

A word about lingo…some exampleso IED = Improvised Explosive Deviceo VBIED = Vehicle Born IED (car or suicide

bomb)o ROE = Rules of Engagemento The Wire = defines a relatively safe areaoIn Theatre/in Country = place of

deployment

Basic Training – Military Culture

A word about lingo…some exampleso FOB = Forward Operating Baseo MOS = Military Occupation Specialty –

job in the militaryo RPG = Rocket Propelled Grenadeo SAF = Small Arms Fire

Basic Training – Military Culture

A word about lingo…some exampleso DoD = Department of Defenseo VA = Department of Veterans’ Affairso TRICARE = military health insuranceo National Guard = state organization

deployed by Governoro Reserve = federal organization deployed

by President

Basic Training – Military Culture

A word about lingo…some exampleso Marine = Marineo Navy = Sailorso Army = Soldierso Air Force = Airmen/Airwomeno Coast Guard = Coast Guard - “Coasties”o National Guard = The Guardo Reserve = Reservist

Basic Training – Military Culture

• High standard of discipline helps organize and structure the armed forces

• Professional ethos of loyalty and self-sacrifice maintains order during battle

Basic Training – Military Culture

• Distinct set of ceremony and etiquette creates shared rituals and common identities

• Emphasis on group cohesion & esprit de corps connects service members to each other

Take home point

Know something about military culture

QUESTIONS?

Behavioral Health Issues

Assess BH Issues - PDhA

• The Post Deployment Health Assessment (PDHA)

• Self-administered global health survey when war fighters return from deploymento De-mobilization unito Chaotic environmento Screening tool not individual assessmento Lots of questionso Service members want to get home!

Assess BH Issues - PDHA

• Many service members not report symptoms at this timeo They do not recognize themo Do not want anything to interfere with

going home

• PDHA vs. PDHRA results on next few slides

Re-Assess BH Issues - PDhrA

• The Post Deployment Health Reassessment (PDHRA)

• Performed 6 months post deployment• After completing self report

instrument, Service Member private review with a health care provider

• VA and community reps onsite to help with transition

Post Deployment Concerns among Active and Reserve Component

service members

• Study followed 88,235 US service members o Returning from Iraq o Who completed Post Deployment

Health Assessment (PDHA)o And 6 months later a Post

Deployment Health Reassessment (PDHRA)

Post Deployment Concerns among Active and Reserve Component

service members

• Screening includes standard measures for o Posttraumatic Stress Disorder

(PTSD)o Major Depressiono Alcohol Abuseo Traumatic Brain Injuryo Other Mental Health problems

Changes among Active Duty (AD) and Reserve Component (RC) service members at

PDHRA

• Roughly ½ of those with PTSD symptoms on PDHA improved by PDHRA….yeto Were twice as many new cases of PTSD at

PDHRAo Depression rate doubled in Active Duty

(10%)o Tripled in Reserve Component (13%) at

PDHRA• Overall, 20.3% AD and 42.4% RC were

identified as needing MH treatment post deployment

Changes among Active Duty (AD) and Reserve Component (RC) service members at

PDHRA

• 4-fold Increase in concern about interpersonal conflict

• Alcohol abuse rate high (12%AD/15%RC) at PDHRA yet 0.2% referred for treatment

• If this is the progression among Service Members over the first 6 months, what about their family members?

Why Reserve Component at greater risk than Active Duty

members • AD - have on-going access to healthcare• RC - DoD health benefits (TRICARE) expire 6

months after deployment ends – pay for coverage

• RC - special VA benefits end 60 months after return (unless a service-connected condition is identified)

Why Reserve Component at greater risk than Active Duty members

• RC - may be geographically separated from military and VA facilities

• RC - > 1/2 service members beyond standard DoD benefit window by PDHRA

• RC - lack of day-to-day contact with Battle Buddies

• RC - added stress of transition back to civilian life

Mental Health Among OEF/OIF/OND Veterans

• Possible (provisional diagnosis) mental health problems reported among 50.2% of the eligible OEF/OIF/OND veterans who have presented to VAo PTSD (>24% all who presented to VA) o Depressive Disordero Affective Psychoseso Neurotic Disorders: o Nondependent Abuse of Drugs (+ tobacco use

disorder)o Alcohol Dependence:

Take home point

Post deployment mental health cannot just be about PTSD anymore

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Traumatic Events in oeF/OIF/OND

• Multi-casualty incidents (Suicide Bombers, VB/IEDs, ambushes)

• Seeing the aftermath of battle• Handling human remains • Friendly fire• Witnessed or committed atrocities

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Traumatic Events in oeF/OIF/OND

• Witnessing death/injury of close friend/favored leader

• Death/injury of women and children• Feeling/being helpless to defend or

counter-attack

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Traumatic Events in oeF/OIF/OND

• Being unable to protect/save a colleague or leader

• Killing at close range• Killing civilians/”avoidable”

casualties or deaths

PTSD, TBI and Combat

Stress

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Posttraumatic Stress Disorder (PTSD)• Characterized by a constellation of symptoms• Follow exposure to an extreme traumatic

event • Involves actual or threatened death or serious

injury• Response to the event must include

o Intense fearo Helplessness or horroro Symptoms that persist more one month and

include….

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Posttraumatic Stress Disorder (PTSD)• Re-experiencing the traumatic event

o Intrusive recollectionso Dreamso Nightmares

• Avoidance of trauma-associated stimulio Peopleo Situationso Noises

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Posttraumatic Stress Disorder (PTSD)• Persistent symptoms

o Increased arousal~ Sleep disturbance~ Hyper-vigilance~ Irritability~ Exaggerated startle response

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Posttraumatic Stress Disorder (PTSD)• PTSD diagnosis must be accompanied by

o Clinically significant distress oro Impairment in social, occupational or other

important areas of functiono Problems must persist at least one month after the

event

QUESTIONS?

• Proximity to explosions• Thrown from a vehicle• Lost consciousness (knocked out or

down) and for how long• Having symptoms of concussion after

the blasto Dizzinesso Headacheo irritability

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overview of Traumatic Brain Injury (TBI)

• Current symptomso Headacheso Dizzinesso Memory problemso Balance problemso Ringing in the earso Irritability

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overview of Traumatic Brain Injury (TBI)

• Current symptomso Sleep problems o Change in ability to smell or tasteo Sensitivity to sound or lighto Fatigueo trouble with concentration, attention,

thinking.

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Overview of Traumatic Brain Injury (TBI)

• May co-exist with PTSD• PTSD and TBI might be mistaken one for

the other• Screening

o 3-Question Screening Toolo Developed by the Defense and Veterans

Brain Injury Center (DVBIC) o In handouts section of CSSP Toolkit

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Overview of Traumatic Brain Injury (TBI)

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Triaging TBI

Consider consultation• Rehabilitative Medical

Specialist• Neurologist• Speech Pathologist• Audiologist• Vision Assessment

QUESTIONS?

TreatmentVA/DoD Clinical Practice

Guidelines

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Why Clinical Practice Guidelines important

• Assist clinicians in learningo Available treatmentso Reviewing their evidence based techniqueso Making practical, patient-specific choices

among them

Why Clinical Practice Guidelines important

• Provide clinical algorithms walk clinicians through the steps o Screeningo Initial assessment througho Treatment and o Re-assessment

• Most relevant - VA/DoD Clinical Practice Guidelines for the Management of Posttraumatic Stress

VA/DoD Clinical Practice Guidelines for the Management of Posttraumatic

Stress• Created by a working group VA and DoD

clinicians and researchers• Separate algorithms defined for primary

care providers and mental health professionals

• Evidence tables provided for each recommendation

VA/DoD Clinical Practice Guidelines for the Management of Posttraumatic

Stress• A substantial literature review included• In the public domain - FREE• Available at

www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm

Clinical Practice Guidelines• Other available clinical practice

guidelines o The American Psychiatric Association ando The International Society for Traumatic Stress

Studies• Both guidelines provide

o Introduction to available therapieso Significant background informationo Evidence-based treatment recommendations.

A Point of Caution

• Little evidence to support the use of Critical Incident Stress Debriefing/Management (CISD/M) in the prevention of PTSD among military personnel

• Debriefing in heterogeneous groups may actually increase the risk of PTSD by re-traumatizing survivors who are not prepared to be re-exposed to horrific memories

A Point of Caution

• CISD/M takes locus of control away from commanders/military leaders

• The military has an After Action Review (AAR)

process that is separate from CISD/M

Treatment Options

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Cognitive Therapy (CT)

• Identify and clarify patterns of thinking• Identify distressing trauma-related

thoughts• Convert these thought patterns into

more accurate thoughts• Address core beliefs about self,

others, larger world

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Exposure Therapy (eT)

• Reduce the fear associated with traumatic experience through repetitive, therapist-guided confrontation of feared places, situations, memories, thoughts, and feelings

• Exposure can be “imaginal” or “in vivo”• Reduced intensity of emotional and

physiological response is achieved through habituation.

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Stress Inoculation Training (Sit)• Anxiety management

o Among the most useful psychotherapeutic treatments for PTSD clients

o Determined by Expert Consensus Guideline Series

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Stress Inoculation Training (Sit)

• SIT can be thought of as a set of skills for managing stress and anxietyo Breathing controlo Deep Muscle Relaxationo Assertiveness Trainingo Role Playingo Covert Modelingo Thought Stoppingo Positive Thinkingo Self Talk

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Eye Movement Desensitization and Reprocessing (EMDR)• Accessing and processing traumatic

memories to bring these to resolution.

• The client focuses on emotionally disturbing material while at the same time focusing on an external stimulus (usually therapist directed bilateral eye movements, hand tapping, sounds)

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Pharmacotherapy

• Strongest evidenceo Specific serotonin reuptake inhibitors

(SSRI’s)o Venlafaxine

• Many drugs from a wide range of classes have been studied in PTSD

• Little evidence for their use except as adjunctive treatment

• Antipsychotics often prescribed in military settings

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Pharmacotherapy

• Research suggestso Prazosin reduces the frequency and intensity of

posttraumatic nightmareso May be effective in managing other symptoms of

PTSDo Cannot yet be recommended as stand-alone

treatment• Benzodiazepines NOT effective as first line

agents treatment of PTSDo Because potential for dependence and abuse, use

as single agents strongly discouraged

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Combat/OperationalStress

Reactions/Injuries

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Loss of people who are cared about both in Iraq and at home

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Combat Stress Injury• Happens to a person (not chosen)• Involves loss of normal integrity• Causes loss of function at least temporarily• Provokes predictable self-protective or

healing symptoms• Cannot be undone (though it usually heals)

--Capt. Bill Nash in Combat Stress Injury

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Combat Stress Injury - Trauma

• Participant in/witness to event(s) involving o Horroro Feelings that you or someone close to you will

dieo Helplesso Powerless

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Combat Stress Injury – Discomfort or Fatigue

• Accumulation of stress over time• Environmental hardships

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Beyond Diagnosis• Many problems of returning combat

veterans and their families are functional not so much clinical o Work Stress/Unemploymento Educational/Training Needso Housing Needs

~Financial and/or ~Legal Problems

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Beyond Diagnosis• Family Issues

oLack of Social SupportoEstrangementoFamily BreakupoKids in trouble

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Beyond PTSD and TBI• Psychological trauma may…

o Surface indirectly as an exacerbation of chronic physical ailments

~Shortness of breath in an asthmatic~Racing heart in a person with Congestive Failure) or;

o Be expressed in new somatic symptoms~Headaches~Abdominal pain

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Beyond PTSD and TBI• Psychological trauma may…

o Present as new or exacerbated substance abuse or

o Lie veiled behind vague complaints~Poor energy~Poor sleep~Malaise

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Common themes and Presenting Problems

• Marriage, relationship problems • Medical issues • Financial hardships • Endless questions from family/friends • Guilt, shame, anger • Lack of structure

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Common themes and Presenting Problems

• Feelings of isolation• Nightmares, sleeplessness• Lack of motivation • Forgetfulness • Feeling irritable, anxious “on edge”

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Take home point

Post deployment mental health problems are more FUNCTIONAL than CLINICAL

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Barriers to treatment

• Treatment beliefs not addressed• Fears of failure and fears of success• Labels and stereotypes• Avoidance• Realistic concerns

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Identifying and Treating Post Deployment MH Problems Among New Combat Veterans and their Families

• OEF/OIF/OND veterans often seek care outside DoD/VA

• Family members dealing with deployment-related stress and look for help in the community

• Is your practice prepared to identify or treat post deployment problems?

If you don’t take the temperature you can’t find the fever

• Know something about our nation’s military history and about our present military conflicts

• Know something about DoD and VA• Ask each patient if he/she is a Service

Member/veteran or a family member/ significant other of a service member or veteran?

• Know something about the different Service Branches and respect the difference!

Take home point

• Ask ALL your patients if they or someone close to them has served in the military

• If yes, ask about combat experience

Mental Health Problems: Now that You Found Them…

• Key - develop a supportive and collaborative therapeutic alliance with the patient and with his/her significant others

Review of take home points…

• No wrong door to enter to seek help

• Know something about military culture

• Post deployment MH not just PTSD• Issues service members & family

functional vs. clinical• Ask all patients about military

service

QUESTIONS?

Department of Veterans

Affairs

Who VA Serves

• 22.7 million veterans currently aliveoNearly three-quarters served during a

waro Served during official period of conflict

• Women account for 8% of all veterans (roughly 1.8 million women veterans)

http://www.va.gov/

Who VA Serves

• About ¼ nation's population is potentially eligible for VA benefits and services because they are veterans or family members

• VA currently provides health care to 5.5 million veterans (roughly 1 in 5 veterans)

• Roughly 10% of VA users are women veterans

http://www.va.gov/

Care Access Points

• 153 medical centersoat least one in each state, Puerto

Rico and the District of Columbia

• 909 ambulatory care and community-based outpatient clinics

Care Access Points

• 47 residential rehabilitation treatment programs

• 232 Vet Centers

• Community-based Vet Centers

Care Access Points

• 88 comprehensive home-care programs

• 4 DoD/VA Polytrauma Centers• My HealtheVet

http://www.myhealth.va.gov/• 21 Veterans Integrated Service

Networks (VISNs)

OEF/OIF/OND Veterans and VA

• End of Q2 FY 2011: oOver 1,318,510 OEF/OIF/OND

veterans eligible for VA services

o 56% (738,365) have already sought VA care

OEF/OIF/OND Veterans and VA

• Their three most common health issues:oMusculoskeletal oMental Healtho Symptoms, Signs and Ill-Defined

Conditions

Beyond DoD/VA Continuum

• Ideally such problems will be picked up somewhere within the DoD/VA continuum of care but:o If only 56% of All OEF/OIF/OND

Veterans eligible for VA care have come to VA

oWhere are the other 44%?

QUESTIONS?

And finally, just to prove that camouflage works …

TRICAREYour Military Health Plan

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Introduction to TRICARE

Presented by Health Net Federal Services

Greg Swanson TSC Administrator

Health Net Federal Services

Gregory.X.Swanson@healthnet.com

What is TRICARE?• Health care program for over 9 million military

beneficiaries – active duty, retired, families

• Integrated health care delivery system– Military treatment facilities (MTFs)– Civilian health care facilities

• TRICARE Prime

• TRICARE Standard and TRICARE Extra

• TRICARE Reserve Select (TRS)

• TRICARE For Life (TFL)

TRICARE Regions

North RegionHealth Net Federal Services,

Inc.1-877-TRICARE

www.healthnetfederalservices.com

South RegionHumana Military Healthcare

Services, Inc.1-800-444-5445

www.humana-military.com

West RegionTriWest Healthcare Alliance

1-888-TRIWESTwww.triwest.com

TRICARE Overseas1-888-777-8343

www.tricare.mil/overseas

TRICARE Prime• Cost-effective, managed care option available

in TRICARE Prime Service Areas

• Most care received from primary care manager (PCM) at a military treatment facility (MTF) or in the TRICARE civilian network

• PCMs refer for specialty care and regional contractor issues authorization (when necessary)

• Providers submit claims and prior authorization requests

• Pre-negotiated rates to providers

TRICARE Standard• Similar to civilian fee-for-service plans (no

monthly premiums, but with applicable deductibles and cost-shares)

• Receive care from TRICARE-authorized providers

• Providers “accept assignment” on claim-by-claim basis

• Providers who “accept assignment” file claims and accept TRICARE-allowable charge as payment in full

• Prior authorization required for specific services

TRICARE Extra• Preferred-provider option

• See TRICARE network providers and pay less

• Providers accept negotiated rate as payment in full

• Network providers submit claims for beneficiaries

TRICARE Reserve Select (TRS)• Premium-based health plan that

qualified National Guard and Reserve members may purchase for duration of service

• Similar coverage to TRICARE Standard and TRICARE Extra

• 2012 Monthly premium payment is $54.35 for individual member or $192.89 for family

• Coverage for survivors may continue 6 months after member’s death

TRICARE For Life (TFL)• For Medicare/TRICARE dual-eligible beneficiaries• Entitled to Medicare Part A and enrolled in Medicare Part

B• Medicare pays first, TRICARE pays second• Receive care from any Medicare-authorized provider*

(for acute care)• TFL claims administered by Wisconsin Physicians

Service (WPS)• Submit claims to Medicare first; Medicare forwards

claims to WPS• For Medicare eligibility, call 1-800-772-1213 • Confirm TFL eligibility by calling WPS at

1-866-773-0404• For more information on TRICARE For Life, visit

www.TRICARE4U.com.

*Additional rules apply for Skilled Nursing Facilities

TRICARE Pharmacy Program• Available to all eligible beneficiaries

• Large, uniform formulary

• Affordable costs to beneficiaries

• Local pharmacy providers (network and non-network), mail order, military treatment facility

• Dispense generic medications when available

• Prior authorization may be required for certain medications

• Certain medications have quantity or days’ supply limits

• Visit www.tricareformularysearch.org for medical necessity requirements and forms.

Visit www.tricare.mil/pharmacy for more information.

TRICARE • Myth – TRICARE involvement is a long, difficult process

for providers– Reality – TRICARE provider participation involves a

simple form and usually less than 1 month for acceptance (TRICARE Prime requires longer period of time and a signed contract.)

• Myth – TRICARE reimbursement is slow – Reality – TRICARE electronic reimbursement usually

occurs within 30 days or less of submission

• Myth – TRICARE pays less to providers than Medicare reimbursement– Reality – TRICARE reimbursement is tied to Medicare

rates – TRICARE Prime may pay slightly less than Medicare

TRICAREYour Military Health Plan

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TRICAREYour Military Health Plan

Behavioral Health Care Services

TRICARE Prime Beneficiaries(Except Active Duty)

• Entitled to eight (8) initial outpatient visits per fiscal year (Oct. 1–Sept. 30)

• No prior authorization required

• No primary care manager (PCM) referral is needed

• Must seek care from a TRICARE network provider

• Prior authorization is required after the eighth (8th) visit

TRICARE Standard andTRICARE Extra Beneficiaries

• No referrals required for any outpatient visits

• Entitled to eight (8) initial outpatient visits per fiscal year without authorization

• Prior authorization is required after the eighth (8th) visit

• Seeking care from a TRICARE network provider will reduce the patients out-of-pocket costs

Behavioral Health Care Providers

• Psychiatrists (M.D., D.O.)• Clinical Psychologists (Ph.D.)• Certified psychiatric nurse specialists (PNS)• Master’s-level clinical social workers (LCSW)• Certified marriage and family therapists (LMFT)• Licensed Professional Counselors (LPC’s) *

• Licensed Mental Health Counselors (LMHC’s) *

• Pastoral Counselors * *with physician referral and supervision

All providers require a Medicare # except LMFT’s & LPC’s

PA’s & NP’s are not recognized TRICARE Behavioral Provider’s and cannot bill codes 90801-90899

TRICARE Covered Outpatient BH Services

• Outpatient Services– Individual Therapy– Family Therapy– Collateral Visits– Play Therapy– Psychoanalysis*– Psychological Testing (max. 6 unit

benefit/yr)*

*Prior authorization required (Prior auth not required for Psych Testing, but providers need to verify yearly limit has not been exhausted.)

* IOP is NOT a TRICARE benefit

TRICARE Covered Inpatient BH Services

• Inpatient Services– Acute Inpatient Psychiatric Care

• Ages 19+ (30 day IP limit per fiscal year)• Ages 18 and below (45 day IP limit per fiscal year)

– Psychiatric Partial Hospitalization• Chemical Dependency (21 day limit per fiscal year)• Mental health (60 day limit per fiscal year)

– Residential Treatment Center (RTC) Care (150 day limit)– Substance Abuse*

• Detoxification (7 day limit per episode)• Rehabilitation (21 day limit with a max of one

rehab program per year and 3 per lifetime)

* Substance Abuse days count toward yearly IP limit

Overview of BH Costs and Fees

N/A$0$0TPR/TPRADFM

Cost-share after deductible is met25% of allowable charge

Cost-share after deductible is met20% of negotiated rate

N/AStandard

Cost-share after deductible is met20% of allowable charge

Cost-share after deductible is met 15% of negotiated rate

N/AExtra

No deductible$25 copayment

No deductibleNo copayment

$0Prime

Retirees and othersActive Duty Family Member

Active Duty Costs

Program

N/A$0$0TPR/TPRADFM

Cost-share after deductible is met25% of allowable charge

Cost-share after deductible is met20% of negotiated rate

N/AStandard

Cost-share after deductible is met20% of allowable charge

Cost-share after deductible is met 15% of negotiated rate

N/AExtra

No deductible$25 copayment

No deductibleNo copayment

$0Prime

Retirees and othersActive Duty Family Member

Active Duty Costs

Program

In Conclusion…• TRICARE is an insurance provider for a large

cadre of the patient population – the entire military community and families

• TRICARE may be the only health insurance for a whole population component, dependent on their military service status

• TRICARE is mandated to provide coverage to the military community and is dependent on civilian providers to do so

• www.tricare.mil

QUESTIONS?

(Boots on the Ground goes

here)