Does TRICARE Pay for Rehab? Explaining Your Coverage

TRICARE is the healthcare program for uniformed service members, retirees, and their families worldwide. It provides comprehensive healthcare benefits, supporting the health and well-being of those who serve and have served the nation.

TRICARE-Covered Rehabilitation Services

TRICARE covers medically necessary rehabilitation services. These services aim to restore function, improve capability, or reduce disability from illness, injury, or other health conditions. Coverage encompasses various therapies, each targeting specific aspects of a patient’s recovery and functional improvement.

Physical Therapy (PT) focuses on restoring physical function, improving mobility, and increasing strength. It is used for recovery after surgeries, managing chronic pain, or rehabilitating musculoskeletal injuries. Occupational Therapy (OT) helps individuals regain the ability to perform daily activities, such as dressing, eating, or managing household tasks, improving independence.

Speech Therapy and Language Pathology (ST/SLP) addresses disorders related to communication, swallowing, and cognitive function. Patients recovering from strokes, those with developmental delays, or individuals experiencing voice disorders benefit from these services. Mental Health Rehabilitation services are also covered, including individual therapy, group therapy, and intensive outpatient programs (IOP) and partial hospitalization programs (PHP). These services support beneficiaries managing various mental health conditions.

Substance Use Disorder (SUD) Rehabilitation coverage includes a spectrum of care levels, from detoxification services to inpatient, residential, and outpatient treatment programs. All covered rehabilitation services must be prescribed and provided by a TRICARE-authorized provider.

TRICARE Plans and Eligibility for Rehabilitation

Eligibility for TRICARE benefits extends to active duty service members, retired service members, their family members, and certain survivors. The specific TRICARE plan a beneficiary is enrolled in influences access and coverage for rehabilitation services. Each plan offers different structures regarding provider choice, referral requirements, and out-of-pocket costs.

TRICARE Prime operates as a managed care option, requiring beneficiaries to enroll with a primary care manager (PCM). This PCM coordinates all healthcare, including referrals for specialized services like rehabilitation. While Prime has lower out-of-pocket costs, it limits beneficiaries to a network of providers, ensuring coordinated care within a defined system.

TRICARE Select is a fee-for-service plan offering greater flexibility in choosing healthcare providers. Beneficiaries can seek care from any TRICARE-authorized provider, whether network or non-network, without a PCM referral for most services. This flexibility comes with higher out-of-pocket costs, as beneficiaries may pay a portion of the service cost.

TRICARE For Life is for Medicare-eligible uniformed service retirees and their family members. Under this plan, TRICARE acts as a secondary payer to Medicare, covering services after Medicare has paid its portion. The US Family Health Plan (USFHP) is an option where beneficiaries receive care through a network of civilian healthcare providers. The choice of plan depends on the sponsor’s status, location, and individual healthcare needs.

Requirements for TRICARE Rehabilitation Coverage

Many rehabilitation services, particularly for those enrolled in TRICARE Prime or for specific types of intensive care, require both referrals and prior authorization. These requirements help manage care and confirm medical necessity.

For TRICARE Prime beneficiaries, obtaining a referral from their primary care manager (PCM) is essential. The PCM assesses the patient’s condition and determines the necessity of rehabilitation, then issues a formal referral to a specialist or facility. This referral includes the diagnosis, recommended therapy type, and anticipated treatment duration. It serves as an official endorsement for specialized care.

Prior authorization means obtaining approval from TRICARE or its regional contractor before services begin. This is required for services like residential treatment, extended courses of therapy, or high-cost interventions. The rehabilitation provider submits a request for prior authorization, including detailed medical necessity documentation and a comprehensive treatment plan. This documentation outlines the patient’s condition, proposed therapy goals, and why the specific rehabilitation service is the most appropriate course of action.

Verifying the provider’s network status is a preparatory step that impacts coverage. Using a TRICARE-authorized provider, especially one within the network for Prime beneficiaries, helps avoid unexpected costs and ensures services align with TRICARE’s reimbursement policies.

Finding Providers and Beginning Rehabilitation

Once referrals and prior authorizations are secured, the next step involves locating a TRICARE-authorized provider and scheduling initial appointments. TRICARE offers resources to assist beneficiaries in this search. The official TRICARE website’s provider directory helps find in-network or TRICARE-authorized providers in a specific geographic area.

The provider directory allows beneficiaries to search by specialty (physical therapy, occupational therapy, or mental health services) and filter results by location. It is important to confirm that a chosen provider is TRICARE-authorized to ensure coverage. While network providers have direct agreements with TRICARE and result in lower out-of-pocket costs, non-network providers may also be TRICARE-authorized, though they might require higher cost-shares or balance billing.

After identifying a suitable provider, beneficiaries can schedule an initial consultation. During this first appointment, the rehabilitation specialist assesses the patient’s condition and needs. This assessment forms the basis for developing a personalized treatment plan, outlining specific goals, therapy type and frequency, and expected duration.

Maintaining open communication with the rehabilitation provider is important for ongoing care. Beneficiaries should monitor authorization expiration dates and discuss extension needs with their provider. The provider can then submit updated documentation to TRICARE for continued coverage.

Costs Associated with TRICARE Rehabilitation

While TRICARE covers a significant portion of costs, beneficiaries are responsible for certain out-of-pocket expenses. These costs vary based on the specific TRICARE plan, service type, and whether the provider is in-network or out-of-network.

Deductibles are amounts beneficiaries must pay for covered services before TRICARE begins to pay. For example, under TRICARE Select, beneficiaries have an annual deductible that must be met before cost-sharing applies to rehabilitation services. The deductible amount varies by sponsor status and family type.

Copayments or cost-shares represent a fixed amount or a percentage of the service cost that the beneficiary pays for each visit or service. TRICARE Prime beneficiaries have lower or no copayments for in-network rehabilitation services. In contrast, TRICARE Select beneficiaries incur higher cost-shares, especially when utilizing non-network providers, where they may pay a higher percentage of the TRICARE-allowable charge.

A catastrophic cap is the annual limit a beneficiary pays out-of-pocket for TRICARE-covered services, including rehabilitation. Once this cap is reached within a fiscal year, TRICARE pays 100% of all additional covered services for the remainder of that year. This cap provides financial protection against very high medical expenses. Services not medically necessary or those from non-network providers who do not accept the TRICARE-approved amount may result in additional costs, leading to balance billing.