TRICARE Manuals - Display Chap 18 Sect 9 (Change 104, Dec 23, 2021)

1.0 PURPOSE

The purpose of the Demonstration is to evaluate if waiving cost-sharing for up to three PT visits increases TRICARE beneficiary uptake of PT; decreases low-value care; and/or decreases the overall cost of care for treating patients with LBP.

2.0 BACKGROUND

2.1 On June 30, 2020, a notice was published in the Federal Register (FR) (85 FR 39179) announcing the start of this demonstration. Throughout and at the end of this demonstration, the Defense Health Agency (DHA) will conduct an evaluation to determine the overall benefit of the demonstration to beneficiaries and to the TRICARE Program. Based upon the evaluation results, DHA will determine if changes will be made to cost-sharing for PT or other types of care for patients with LBP.

2.2 Most of the TRICARE population will experience LBP at some point in their lives, with a majority of LBP lasting a few weeks or less. Acute LBP is the period up to 4 weeks from onset of symptoms and typically resolves with rest and self-care. Subacute LBP lasts from 4 to 12 weeks, while chronic LBP persists beyond 12 weeks. LBP results in massive costs to DHA and to society, both in the form of direct medical costs and indirect costs such as decreased productivity.

2.3 PT is one recommended treatment for LBP that does not resolve with time or analgesics. Once patients start PT, they tend to continue PT visits; however, there are several factors that limit access to PT, such as limited appointment availability and opportunity costs (e.g., taking time off of work, paying for public transportation, or finding child care). These barriers move beneficiaries towards lower-value services such as inappropriate or excessive use of opioids, imaging in the absence of red flags, and surgery. This demonstration seeks to incentivize the uptake of PT by waiving cost-sharing for up to three visits.

3.0 DEMONSTRATION GOALS AND EVALUATION

3.1 The demonstration will test the following research questions and hypotheses. DHA may add, delete, or change hypotheses throughout the demonstration.

3.1.1 Does waiving cost-sharing for up to three PT visits increase the initial uptake of PT visits among patients with LBP?

3.1.2 Does waiving cost-sharing for up to three PT visits increase the overall number of PT visits among patients with LBP?

3.1.3 Does incentivizing the use of PT services reduce the number of opioids prescribed to patients with LBP?

3.1.4 Does incentivizing the use of PT services reduce the amount of imaging services provided to patients with LBP?

3.1.5 Does incentivizing the use of PT services reduce the number of back surgeries for patients with LBP?

3.1.6 Does incentivizing the use of PT services reduce the total cost of care for a LBP episode?

3.1.7 Does improved access to PT services prevent chronic LBP (i.e., do fewer patients transition from acute and subacute pain to chronic pain)?

3.1.8 Does incentivizing the use of PT services reduce the number of other low-value services or other LBP treatments?

3.2 This demonstration evaluation may include an optional survey to determine for which reasons a patient begins and ceases PT visits, as well as assess access to care, quality of care, and overall health status. This survey, if approved, will be administered by DHA. It will be sent electronically to TRICARE beneficiaries with a primary diagnosis of LBP who receive PT services in the demonstration states.

4.0 POLICY AND BENEFICIARY ELIGIBILITY

4.1 Under the demonstration, beneficiary cost-sharing for up to three PT visits shall be waived for TRICARE beneficiaries with LBP who meet criteria established in paragraph 4.0.

4.2 TRICARE Prime, TRICARE Select, and TRICARE For Life (TFL) beneficiaries in selected states (see paragraph 4.5) who have a cost-share for PT services are eligible to participate. This includes Dual Eligible beneficiaries and beneficiaries with Other Health Insurance (OHI) with TRICARE as a second payer, as long as the beneficiary has a cost-share for the associated visit(s).

4.3 Only new PT treatment episodes of care are eligible for waived cost-sharing under this demonstration. In order to be eligible for waiving of cost-shares under the demonstration, the first appointment in the episode of care shall meet all requirements for the demonstration. If the first appointment does not meet any requirement of the demonstration, the beneficiary is not eligible for cost-share waiving for that episode of care.

4.4 PT services shall be provided by an in-network TRICARE-authorized provider.

• TFL beneficiaries are exempt from the requirement to receive care from an in-network provider. TFL beneficiaries shall still receive services from a TRICARE-authorized provider for those services to be eligible under this demonstration.

4.5 This demonstration is limited to beneficiaries residing in, and receiving care in, the following states: Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee, and Virginia.

4.6 Participants shall be prescribed or referred to PT services by a TRICARE-authorized provider as required by applicable policy and regulation.

4.7 This demonstration applies to TRICARE beneficiaries with any of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes listed in Figure 18.9-1 as a primary diagnosis. There is no limitation on the number of weeks from onset of symptoms to receiving PT services under this demonstration (i.e., PT visits for acute, subacute, or chronic LBP may be eligible for waived cost-sharing):

Figure 18.9-1 LBP Diagnosis Codes
ICD-10-CM Diagnosis Code	ICD-10-CM Diagnosis Short Description
M47.26	Other spondylosis with radiculopathy, lumbar region
M47.27	Other spondylosis with radiculopathy, lumbosacral region
M47.28	Oth spondylosis w radiculopathy, sacr/sacrocygl region
M47.816	Spondylosis w/o myelopathy or radiculopathy, lumbar region
M47.817	Spondyls w/o myelopathy or radiculopathy, lumbosacr region
M47.818	Spondyls w/o myelpath or radiculopathy, sacr/sacrocygl rgn
M47.896	Other spondylosis, lumbar region
M47.897	Other spondylosis, lumbosacral region
M47.898	Other spondylosis, sacral and sacrococcygeal region
M48.06	Spinal stenosis, lumbar region
M48.061	Spinal stenosis, lumbar region without neurogenic claud
M48.062	Spinal stenosis, lumbar region with neurogenic claudication
M48.07	Spinal stenosis, lumbosacral region
M48.08	Spinal stenosis, sacral and sacrococcygeal region
M51.16	Intervertebral disc disorders w radiculopathy, lumbar region
M51.17	Intvrt disc disorders w radiculopathy, lumbosacral region
M51.26	Other intervertebral disc displacement, lumbar region
M51.27	Other intervertebral disc displacement, lumbosacral region
M51.36	Other intervertebral disc degeneration, lumbar region
M51.37	Other intervertebral disc degeneration, lumbosacral region
M51.86	Other intervertebral disc disorders, lumbar region
M51.87	Other intervertebral disc disorders, lumbosacral region
M53.2X6	Spinal instabilities, lumbar region
M53.2X7	Spinal instabilities, lumbosacral region
M53.2X8	Spinal instabilities, sacral and sacrococcygeal region
M53.3	Sacrococcygeal disorders, not elsewhere classified
M53.86	Other specified dorsopathies, lumbar region
M53.87	Other specified dorsopathies, lumbosacral region
M53.88	Oth dorsopathies, sacral and sacrococcygeal region
M54.16	Radiculopathy, lumbar region
M54.17	Radiculopathy, lumbosacral region
M54.18	Radiculopathy, sacral and sacrococcygeal region
M54.30	Sciatica, unspecified side
M54.31	Sciatica, right side
M54.32	Sciatica, left side
M54.40	Lumbago with sciatica, unspecified side
M54.41	Lumbago with sciatica, right side
M54.42	Lumbago with sciatica, left side
M54.5	Low back pain
M54.89	Other dorsalgia
M54.9	Dorsalgia, unspecified
M99.03	Segmental and somatic dysfunction of lumbar region
M99.04	Segmental and somatic dysfunction of sacral region
M99.23	Subluxation stenosis of neural canal of lumbar region
M99.33	Osseous stenosis of neural canal of lumbar region
M99.43	Connective tissue stenosis of neural canal of lumbar region
M99.53	Intvrt disc stenosis of neural canal of lumbar region
M99.63	Osseous and sublux stenos of intvrt foramin of lumbar region
M99.73	Conn tiss and disc stenos of intvrt foramin of lumbar region
M99.83	Other biomechanical lesions of lumbar region
M99.84	Other biomechanical lesions of sacral region
S33.100A	Subluxation of unspecified lumbar vertebra, init encntr
S33.100D	Subluxation of unspecified lumbar vertebra, subs encntr
S33.100S	Subluxation of unspecified lumbar vertebra, sequela
S33.110A	Subluxation of L1/L2 lumbar vertebra, initial encounter
S33.110D	Subluxation of L1/L2 lumbar vertebra, subsequent encounter
S33.110S	Subluxation of L1/L2 lumbar vertebra, sequela
S33.120A	Subluxation of L2/L3 lumbar vertebra, initial encounter
S33.120D	Subluxation of L2/L3 lumbar vertebra, subsequent encounter
S33.120S	Subluxation of L2/L3 lumbar vertebra, sequela
S33.130A	Subluxation of L3/L4 lumbar vertebra, initial encounter
S33.130D	Subluxation of L3/L4 lumbar vertebra, subsequent encounter
S33.130S	Subluxation of L3/L4 lumbar vertebra, sequela
S33.140A	Subluxation of L4/L5 lumbar vertebra, initial encounter
S33.140D	Subluxation of L4/L5 lumbar vertebra, subsequent encounter
S33.140S	Subluxation of L4/L5 lumbar vertebra, sequela
S33.5XXA	Sprain of ligaments of lumbar spine, initial encounter
S33.6XXA	Sprain of sacroiliac joint, initial encounter
S33.8XXA	Sprain of oth parts of lumbar spine and pelvis, init encntr
S33.9XXA	Sprain of unsp parts of lumbar spine and pelvis, init encntr
S39.002A	Unsp injury of muscle, fascia and tendon of lower back, init
S39.002D	Unsp injury of muscle, fascia and tendon of lower back, subs
S39.002S	Unsp injury of musc/fasc/tend lower back, sequela
S39.012A	Strain of muscle, fascia and tendon of lower back, init
S39.012D	Strain of muscle, fascia and tendon of lower back, subs
S39.012S	Strain of muscle, fascia and tendon of lower back, sequela
S39.092A	Inj muscle, fascia and tendon of lower back, init encntr
S39.092D	Inj muscle, fascia and tendon of lower back, subs encntr
S39.092S	Inj muscle, fascia and tendon of lower back, sequela
S39.82XA	Other specified injuries of lower back, initial encounter
S39.82XD	Other specified injuries of lower back, subsequent encounter
S39.82XS	Other specified injuries of lower back, sequela
S39.92XA	Unspecified injury of lower back, initial encounter
S39.92XD	Unspecified injury of lower back, subsequent encounter
S39.92XS	Unspecified injury of lower back, sequela

4.8 Exclusions

4.8.1 Services provided to a beneficiary not residing in a demonstration state.

4.8.1.1 Beneficiaries who move from a demonstration state to a non-demonstration state are no longer eligible for the demonstration, even if they had already received one or two visits with cost-share waivers under the demonstration prior to relocation. These beneficiaries may still receive and submit the survey described in paragraph 3.2.

4.8.1.2 Beneficiaries who move from a non-demonstration state to a demonstration state become eligible for the demonstration, provided they are beginning a new PT treatment (i.e., beneficiaries may not begin PT treatment in a non-demonstration state, then receive three PT visits without cost-sharing as part of the same treatment plan after moving to a demonstration state).

4.8.2 Cost-share/copayment waivers in excess of three visits. TRICARE beneficiaries shall only receive up to a total of three PT visits with waived cost-sharing for LBP for the duration of the demonstration (i.e., the beneficiary shall not receive waived cost-shares beyond three visits, even if beginning a new episode of care). Beneficiaries may receive PT (with cost-sharing) for other conditions and then receive up to three PT visits with waived cost-sharing for LBP (see paragraph 4.3).

4.8.3 Services provided to a beneficiary by a provider not located in a demonstration state.

4.8.4 Cost-share/copayment waivers for services provided by out-of-network providers (with the exception of services provided to TFL beneficiaries).

4.8.5 Beneficiaries enrolled in the TRICARE Overseas Program (TOP), Continued Health Care Benefit Program (CHCBP), and Uniformed Services Family Health Plan (USFHP) are excluded from this demonstration.

4.8.6 Beneficiaries receiving care from a Medicare-certified home health agency (HHA) under the TRICARE Reimbursement Manual (TRM), Chapter 12, are also excluded.

5.0 CONTRACTOR RESPONSIBILITIES

The contractor shall:

5.1 Verify the beneficiary’s eligibility.

5.2 Determine whether a PT treatment constitutes an existing or new episode of care.

5.3 Provide information on beneficiary eligibility to beneficiaries and providers requesting such information under the demonstration, either prior to or following a PT appointment.

5.4 Provide full payment for the eligible PT visit (i.e., TRICARE’s allowed amount and the amount for the copayment or other cost-share) for claims processed as part of the demonstration for eligible beneficiaries. See paragraph 7.0 for reimbursement details.

5.5 Assign all claims processed under the demonstration with a Special Processing Code (SPC) of LB. The TRICARE Encounter Data (TED) SPC for the demonstration is “LB Low Back Pain Demonstration.” Only those claims for which cost-shares are waived shall include the SPC. See TRICARE Systems Manual (TSM), Chapter 2.

5.6 Provide a quarterly report as described in the Contract Data Requirements List (CDRL). Details for reporting are identified in DD Form 1423, CDRL, located in Section J of the applicable contract. This requirement only applies to the Managed Care Support Contractors (MCSCs).

5.6.1 Provide contact information for participants to DHA, for administration of the participant survey. Failure of a beneficiary to provide an email address does not impact beneficiary eligibility for the demonstration.

5.6.2 If DHA opts to not conduct the survey described in paragraph 3.2, DHA will notify the contractor that the contact information described in paragraph 5.6.1 is no longer required.

5.7

5.7 Provide education to beneficiaries and providers on the demonstration.

5.7.1 The contractor shall inform the beneficiary that the beneficiary is participating in the demonstration after at least one cost-share has been waived. MCSCs shall include in such a notification that the beneficiary may be given the opportunity to participate in a survey about their demonstration participation, and request the beneficiary provide a valid email address to be eligible to receive the survey. The contractor shall notify the beneficiary in the method of their choosing (a statement on the explanation of benefits, an email, etc.).

5.7.2 MCSCs shall include in educational material that a correct email address is required in order for the beneficiary to be eligible to participate in the survey. This requirement need not be met in every piece of educational material, but shall be included in the education campaign where appropriate.

5.7.3 The MCSCs shall request or confirm the beneficiary’s email address during any beneficiary-initiated encounter related to the demonstration. The beneficiary shall be told that providing the email address is optional and does not impact eligibility for the demonstration, but that providing an email will make them eligible to complete the survey (not every eligible beneficiary will receive a survey). The MCSCs are not required under the demonstration to actively pursue an email address beyond the requirements in paragraph 5.6.2. Requirements regarding obtaining email addresses listed in this section apply only to the MCSCs’ obligations related to the demonstration, and do not eliminate or otherwise alter the MCSCs’ obligations to maintain correct beneficiary contact information elsewhere in the manuals or contract.

5.8 Manage and resolve all inquiries related to the demonstration.

6.0 DHA RESPONSIBILITIES

DHA will perform periodic reviews and evaluations of the demonstration.

7.0 REIMBURSEMENT AND COST-SHARING

7.1 Reimbursement for the demonstration shall follow current TRICARE reimbursement procedures for PT, except that TRICARE will now be responsible for the beneficiary cost-share amount.

7.2 Cost-sharing for up to three PT visits shall be waived for eligible beneficiaries who meet requirements under paragraph 4.0.

• The waived cost-sharing for up to three PT visits includes waiving the beneficiary’s deductible, if applicable, for those visits. The waived deductible amount under this demonstration shall not count towards the beneficiary’s satisfaction of the deductible.

7.3 After the third PT visit, cost-sharing shall follow normal cost-sharing amounts (including deductible) established in TRM, Chapter 2, Section 1 for TFL beneficiaries and in TRM, Chapter 2, Section 2 for all other beneficiaries.

7.4 Missed or canceled appointments are not eligible for waived cost-shares under the demonstration.

7.5 For TRICARE Prime beneficiaries, Point of Service (POS) fees are not waived under this demonstration.

7.6 Normal double coverage provisions apply to services provided under the Demonstration. Acceptable evidence of processing by the double coverage plan is outlined in TRM, Chapter 4.

8.0 EFFECTIVE DATE AND DURATION

The demonstration is effective as of January 1, 2021, and will terminate December 31, 2023; however, the Director, DHA, or designee may terminate this demonstration at any time.