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.