Detailed Steps on Becoming a TRICARE Benefit
What does TRICARE cover?
TRICARE covers treatments, procedures, drugs, or devices (benefits) that are medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. and considered proven. >>See What TRICARE Covers
What does “medically necessary and considered proven” mean?
It means the benefit is:
- Proven—it isn’t experimental
- Safe—it won’t hurt you and it’s approved by regulatory agencies
- Effective—it works
TRICARE doesn’t cover benefits that are:
- Unproven or experimental
- Specifically excluded by statutes, regulations, or policy
How does a benefit become a benefit?
A TRICARE covered benefit must be:
- Allowed by law or the Code of Federal Regulations (and not specifically excluded)
- Proven, safe, and effective
- Representative of the standard for good health care in the United States
- Funded, and
- Officially added to the TRICARE program with a policy change
Adding or Revising a Benefit
The Defense Health Agency collaborates with experts and stakeholders to:
- Review new benefits to add
- Revise current benefits
Step 1: Identify a new benefit
We identify the need for a new or revised benefit by:
- Reviewing changes to federal law
- Monitoring changes in national health care coverage and reimbursement
- Monitoring advances in medical science
- Reviewing provider and beneficiary denials brought to our attention through the appeals process
- Input from other sources, for example, military leadership, providers, or beneficiaries
Step 2: See if it’s allowed by law and regulations
We determine if current laws and regulations allow coverage for the new or revised benefit. If the law specifically excludes the benefit, only Congress can revise it.
Does the new or revised benefit conflict with the Code of Federal Regulations?
- If so, it requires a change to regulation—this is called rulemaking
- Rulemaking is a lengthy process. It usually requires months to years to complete
Step 3: Research to make sure it’s proven safe and effective
We research and review the benefit to decide if it’s proven safe and effective.
- We request scientific reviews, such as technology assessments.
- This sometimes requires a rule. If so, this happens at the same time the rule is developed.
- Sometimes, we may offer a demonstration or pilot program to study the benefit and collect data.
While we respect the opinion of your personal physician, the law requires us to consider:
- Research studies with clinically meaningful endpoints published in the refereed (peer-reviewed) medical literature
- Published formal technology assessments
- Published reports of national professional medical associations
- Published positions of national medical policy organizations
- Published reports of national expert opinion organizations
If the benefit is proven safe and effective, we move to the next step.
It is important to understand that just because a provider, or group of providers, have elected to use a procedure in their practice, doesn’t mean TRICARE will consider it proven safe and effective.
Step 4: TRICARE evaluates all clinical data and decides whether to create a new benefit
TRICARE reviews and evaluates all clinical data.
Step 5: Develop policy for how we will cover it
We develop new policy or update existing policy.
Step 6: Get Funding
We identify resources to fund the new or revised benefit.
- Funding for new benefits competes with existing and planned benefits.
- Unlike private insurance companies, we can’t increase premiums to pay for new services.
Step 7: Publish revisions to the TRICARE Manuals
We update the TRICARE Manuals to include the new or revised benefit.
Step 8: Change the regional health service support contracts
We change the regional health care support contracts so you can start getting the care.
- We modify the regional contracts.
- Regional contractors educate providers on the new or revised benefit.
Step 9: You can start using the new benefit
Your regional contractor can help you with your questions.
There are certain rare conditions where it may be hard to know if treatment is proven safe and effective. In these cases, the process for becoming a benefit may be different. If you have questions, please call your regional contractor.