TriCare is the healthcare entitlement for Active Duty, Active Duty Family Members, and Retired Military and their eligible family members in the United States. Currently, Managed Health Network (MHN) manages TriCare benefits in the North Region and Arbour Health System (AHS) has developed a new agreement with MHN effective March 1, 2010.
All AHS hospitals are included in the network and some new services were added concurrent with the new contract and changes in TriCare benefits. Arbour Health System will be one of the few systems in Massachusetts with a TriCare contract covering all levels of care with a broad geographic focus.
In addition to the hospitals’ inpatient mental health and detoxification services being contracted with TriCare, Arbour-Fuller’s DDART/EATS program was added as a Substance Use Disorder Rehabilitation Facility (SUDRF). The SUDRF provides medically monitored, interdisciplinary addiction-focused treatment to patients who have psychoactive substance abuse disorders. The program is appropriate for patients whose addiction-related symptoms or concomitant and emotional/behavioral problems reflect persistent dysfunction in several major life areas. There are specific certification and accreditation requirements which have been met by Arbour-Fuller.
Also, TriCare previously covered only partial hospitalization programs for primary substance abuse diagnoses but have expanded benefits to cover primary psychiatric (and/or co-occurring substance) diagnoses. TriCare only includes hospital-based PHPs in their network and therefore excludes Arbour Counseling Services PHP programs.
An agreement for outpatient services is currently being pursued on behalf of Arbour Counseling Services and this should be in place following implementation and approval of delegated clinician credentialing policies and procedures. TriCare has significant need for mental health and substance abuse outpatient services in Massachusetts. TriCare is structured as a triple option plan which includes Prime (Managed Care option), Extra (Preferred Provider Network), and Standard (the CHAMPUS fee-for-service) plans. Eligible beneficiaries choose whether to be enrolled in the managed care option, Prime, which decreases out-of-pocket responsibility but requires adherence to managed care rules, or remain in the Standard fee-for-service plan with deductibles, cost-shares and fewer administrative requirements.
Beneficiaries who remain in Standard and receive their care through contracted network providers are considered to be using the Extra option and have lower cost-shares. TMA developed and implemented TriCare to replace CHAMPUS in the early 1990’s, awarding regional contracts slowly across the United States and Puerto Rico. During the first generation of contracts there were 15 regions. The TriCare Managed Care Service Contractors (MCSCs), including MHN, administer the TriCare entitlement, adjudicate claims, and provide all UR/UM and Quality services per the contract requirements. TRICARE rules, benefit coverage, claims reimbursement and processes are determined by TMA and legislatively authorized by Congress.