Editor’s Note: This article by Patricia Kime is part of MOAA’s 2020-21 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Mercer Consumer. A version of the guide appeared in the November 2020 issue of Military Officer magazine.
Health care coverage under TRICARE, the U.S. military’s health program, largely aligns with standards across the insurance industry — comprehensive coverage that adheres to federal statutes and aims to meet certain standards of care and best practices.
But while insurance companies must answer to patients, shareholders and their boards of directors, TRICARE must please beneficiaries, DoD, and the “largest board of directors” of all, Congress, which has the capability to change the program each year.
Change it nearly every year they do, creating a program that covers some services many insurers don’t and vice versa.
“Whatever Congress says, goes. If Congress says ‘You are going to cover this type of service; it may or may not be industry standard or something that the model health insurance or health delivery systems would do,’ DoD has to do it,” said Bryce Mendez, a defense health analyst at the Congressional Research Service.
For example, prior to 2005, TRICARE paid for a portion of therapy for dependents with autism, but military families were responsible for a hefty portion of the monthly bills, which can run more than a couple of thousand of dollars per month.
After Congress created the Extended Care Health Option program for special needs children of active duty personnel in 2001, more coverage was added for those with disabilities, including expanded treatments like applied behavioral analysis, added in 2005.
More than 15 years later, TRICARE covers the therapy, also known as ABA, for diagnosed beneficiaries regardless of sponsor status through a demonstration project currently slated to run through 2023.
Another unusual type of physical therapy for those with disabilities that is covered by TRICARE under the ECHO program is equine therapy or hippotherapy, which, until 2013 was not covered by TRICARE.
After a four-year battle fighting to get TRICARE to cover their daughter’s therapeutic riding sessions, now-retired Capt. Mark Samuels, USN, and his wife Jennifer settled with the Defense Health Agency (DHA) to cover the cost.
And DoD moved to cover hippotherapy as a medical treatment, even while many insurers don’t, although it is only available under ECHO for those diagnosed with multiple sclerosis or cerebral palsy.
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In addition to covering unique therapies (TRICARE also covers art and music therapy if it is part of an overall inpatient or intensive treatment program), it also carries some unusual benefits, like some over-the-counter drugs at lower or no cost.
Beneficiaries who get their medications at military pharmacies know they can pick up many common over-the-counter drugs at no cost if they are prescribed by their doctor, such as pseudoephedrine or ibuprofen.
But TRICARE’s pharmacy benefit also gives patients access to including Plan B One-Step emergency contraceptives for free and generic versions of antihistamines Zyrtec and Claritin, omeprazole – the generic of Prilosec heartburn medication – insulin and diabetes supplies and tobacco cessation products at lower costs.
TRICARE has a comprehensive program to pay for treatment for eating disorders, but eligibility differs across the beneficiary pool. For example, TRICARE covers the cost of stand-alone residential treatment center, but only for beneficiaries under age 21.
Provisions in the House and Senate fiscal 2021 defense policy bill seek to change the age restriction, requiring TRICARE to cover inpatient or residential services, partial hospitalization, and intensive outpatient or outpatient services at certified facilities regardless of age.
What TRICARE Doesn’t Cover
Several of the most requested treatments among military beneficiaries continue to not be covered by TRICARE: fertility services and chiropractic care.
While military personnel and family members have access to fertility treatments for a cost at a limited number of military treatment facilities, TRICARE covers some care – treatment for an illness or injury to a patient’s reproductive system, hormone and semen analysis and function tests – but it doesn’t cover advanced reproductive therapies like in vitro fertilization, artificial or intrauterine fertilization, or embryo, gamete, or zygote intrafallopian transfer.
Chiropractic and acupuncture services also are not covered for family members, although efforts may be in the works that could make such treatments available in 2021 or 2022 for “chiropractic care for certain types of pain or acupuncture for oncologic-related nausea,” according to a memo distributed to military support organizations last year.
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Nip and Tuck?
To the disappointment of many, TRICARE does not cover elective cosmetic surgery, which means beneficiaries aren’t able to get a nose job, face lift, breast augmentation, or liposuction without paying out of pocket.
These surgeries sometimes are offered at military treatment facilities to ensure that surgeons maintain the skills needed to support warfighters injured or disfigured in combat or training.
Eve Stoner, a former Marine, said she received a blepharoplasty – removal of the excess or drooping skin on her eyelids – from a Navy doctor at Naval Hospital Camp Lejeune, N.C., in 2007.
Having spent her enlistments working in the blazing sun on a flightline, she had “the face of an 80-year-old,” she said.
“After I got out, I went in to the ophthalmologist and made a comment about how bad my eyelids were … and he said ‘Oh, I can fix that,’” said Stoner, now a Marine spouse and TRICARE beneficiary.
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She also knows several military spouses who have received breast implants and other cosmetic work at military facilities, but while her surgery was a success, she doesn’t recommend it.
“I had no idea whether the doctor had any skills. I also didn’t know at the time there could be complications … and if they botch you, do you want them to try to fix it?” she said.
Now, Stoner saves her pennies to have any cosmetic work done.
“I know the [military] doctors need practice and that’s not a bad thing, but I’d rather do my research and pick and choose my own surgeon,” Stoner said.
Patricia Kime is a reporter who covers health care issues in the Washington, D.C., area.