FAQ Series: Affordable Care Act and TRICARE – Dental, Vision, Breast Pumps

tricare-patientWith the roll-out of the Affordable Care Act (ACA), many TRICARE beneficiaries have questions about specific ACA provisions and whether those provisions will impact TRICARE. Specifically, military families have contacted us with questions about dental, pediatric vision coverage, and breast pumps for new moms.

General Information
The ACA defines “10 essential health benefits.” All insurance plans sold to individuals and small businesses (e.g., those sold on the exchanges) will have to cover items and services in the “10 essential health benefits” categories. Self-insured employers (large employers such as Apple, Home Depot, Yahoo, etc. who choose to pay claims from their own money vs. purchase a typical insurance policy for their employees) are exempt from the essential benefit requirement. More than half of Americans who have health insurance provided by their employers are in self-insured health benefit plans. Additionally, most large employer plans already cover most of the 10 broad essential benefits categories.

The ACA also requires most health plans to cover preventative services at no cost to the patient.

The ACA requires dental coverage for children. How does this compare to TRICARE?
Pediatric dental coverage is one of the ACA’s “10 essential health benefits.” The ACA gives states wide latitude to decide what specific “essential benefits” insurers must offer in their policies. According to the American Dental Association, most states will require plans to provide an adequate array of dental services (Utah is the only state to offer only preventative services).

TRICARE offers three dental programs for service members and military families: the TRICARE Dental Program, the TRICARE Retiree Dental Program, and the TRICARE Active Duty Dental Program. The dental programs offer coverage to active duty service members and their families, Guard and Reserve members (activated or not) and their families, retirees and their families, and surviving spouses and their children. TRICARE’s dental programs already cover children and the services included in the ACA mandated pediatric dental plans.

The ACA requires pediatric vision coverage. How does this compare to TRICARE?
Pediatric vision coverage is one of the “10 essential health benefits” the ACA requires. However, there is limited information on the healthcare.gov website regarding vision benefit specifics. According to the American Academy of Ophthalmology, individual and small group health insurance plans (such as those sold on the exchanges) will be required to include full coverage of childhood comprehensive eye exams and glasses or contact lenses for vision correction.

TRICARE offers coverage for routine eye exams for both children and adults. They will also cover treatment for medical conditions of the eye. TRICARE does not, however, cover contact lenses or eyeglasses for vision correction except under very limited circumstances. Visit the TRICARE website to read their Vision Benefits Fact Sheet (located on the right side of the page under “Related Downloads”) for details.

The ACA requires insurance plans to cover breast pump rental or provide breast pumps for new moms. How does this compare to TRICARE?
The ACA requires most health plans to cover preventative health services specifically for women, including breastfeeding comprehensive support and counseling. As part of breastfeeding support, the ACA requires insurers to cover breast pumps. However, plans that are grandfathered are exempt from this requirement.

TRICARE will only cover a breast pump if the baby is premature and meets certain criteria.

Will TRICARE’s coverage change to include these additional benefits the ACA requires?
TRICARE operates completely independently of the ACA which is concerned only with commercial insurers. Since TRICARE is not a health insurance policy or company, but a federal health benefits program, it is not subject to the laws that govern the insurance industry either at the federal or state level. As such, TRICARE is not required to adhere to the provisions in the ACA.

This does not mean that TRICARE will never change policy to enhance coverage. For example, to bring TRICARE in line with the ACA provision extending parents’ health insurance to their children up to age 26, the FY11 National Defense Authorization Act gave the Defense Department the authority to extend TRICARE coverage to young adults. Something similar would be required to provide pediatric vision and breast pump coverage to TRICARE beneficiaries, but no legislation or policy changes regarding these benefits have been introduced to date.

Do you have additional questions about how the ACA provisions impact TRICARE? Post a comment or send us an email at info@militaryfamily.org.

Posted by Karen Ruedisueli and Katie Savant, Government Relations Department

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