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
Section 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 Defense Health Agency (DHA)-approved credentialing organization,
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 DHA-approved accrediting
organization.
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.
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 are excluded
from coverage.
5.4 Equine assisted psychotherapy,
which is different from hippotherapy, is excluded.
6.0 Effective Date
June 11, 2013.