2.0 Description
2.1 Under TRICARE,
hippotherapy is an exercise program; thus, it is excluded from coverage
under the TRICARE Basic Program. Hippotherapy is proposed to offer
a person with a disability a means of physical activity that aids
in improving balance, posture, coordination, the development of
a positive attitude, and a sense of accomplishment.
2.2 Hippotherapy
is a unique type of exercise or event that must be performed in
unique settings such as indoor or outdoor arenas or ranches. Hippotherapy
requires not only a horse and a therapist, but also additional staff,
including a horse handler and side-walkers to ensure safety. In
addition, the horse and rider require special equipment (helmets,
pads, surcingle, bridle, etc.).
3.0 Policy
3.1 Hippotherapy
is covered under the ECHO program only for those beneficiaries with
a primary or secondary diagnosis of Multiple Sclerosis (MS) or Cerebral
Palsy (CP).
3.2 Hippotherapy services must be prescribed by
a physician based on a determination that the patient will benefit
from the provision of these non-medical services above and beyond
what is provided under the TRICARE Basic Program’s medical benefit.
3.3 Hippotherapy
prescribed by a physician is covered as a non-medical ECHO benefit
under the “other services” category of the ECHO program. Hippotherapy
is not a substitute for otherwise covered physical therapy provided
under the TRICARE Basic Program.
3.4 Hippotherapy services must
be authorized in accordance with
Sections 4.1.
Additionally, providers of hippotherapy must establish a plan with
outcome goals. They must document in the medical record of the beneficiary
evidence of ongoing improvement in the beneficiary receiving the hippotherapy
intervention to continue authorization of hippotherapy. If ongoing
improvement is not noted, authorization for continued sessions should
be denied.
3.5
Providers
of Hippotherapy
3.5.1 Only TRICARE authorized physical therapists
and occupational therapists who have obtained additional credentialing
from the American Hippotherapy Certification Board (AHCB), or other
similar credentialing organization approved by the Director, Defense
Health Agency (DHA), or designee, shall be considered as an authorized
provider to render hippotherapy services under ECHO.
3.5.2 Services
must be provided at a Professional Association of Therapeutic Horsemanship International
(PATH Intl.) accredited facility, or similar accrediting organization
as approved by the Director, DHA, or designee.
3.6 Reimbursement
3.6.1 Reimbursement
is allowed for only the professional services provided by a TRICARE authorized
physical therapist or occupational therapist who has obtained the
credentialing outlined in
paragraph 3.5 of this policy.
3.6.2 Reimbursement
is made using the allowable charge rate (i.e., the lowest of the
actual billed charge, the prevailing charge, or the maximum allowable
charge). See the TRICARE Reimbursement Manual (TRM),
Chapter 5, Section 1.
3.6.3 The amount
of the Government’s cost for hippotherapy received in any month
accrues to the maximum fiscal year ECHO benefit of $36,000.
4.0 TRICARE
Encounter Data (TED) Record
TED records submitted
for covered hippotherapy services must include Special Processing Code
“PF ECHO”.
5.0 Exclusions
5.1 No reimbursement
shall be made for the facility fee (e.g., stable fee, ranch fee),
or for a fee related to the care, feeding, maintenance, equipment,
or any other item related to the care of the horse. Also excluded
from reimbursement: any special equipment (helmets, pads, surcingle,
bridle, etc.).
5.2 Hippotherapy as a substitute for authorized
physical therapy under the TRICARE Basic Program is excluded.
5.3 Hippotherapy
services provided by a person or in a setting other than those outlined
in
paragraph 3.5 of
this policy are excluded from coverage.
5.4 Equine assisted psychotherapy,
which is different from hippotherapy, is excluded.