‘Kaitlyn’s Law’ to Authorize TRICARE Reimbursement of Horse and Other Physical Therapies Introduced in CongressPosted by Jason Van Steenwyk
A law requiring TRICARE to fund or reimbursed certain therapies for individuals with disabilities and the severely wounded or injured was introduced this week in the House of Representatives. The Rehabilitative Therapy Parity for Military Beneficiaries Act, dubbed “Kaitlyn’s Law” by supporters, seeks to amend Title 10 with the following language:
(g) Rehabilitative therapy provided pursuant to subsection (a)(17) may include additional therapeutic exercises or therapeutic activities if such exercises or activities are included in the authorized individual plan of care of the individual receiving such therapy. Such exercises or activities may include, in addition to other therapeutic exercises or therapeutic activities, therapies provided on a horse, balance board, ball, bolster, and bench.
The law has received bipartisan sponsorship from Representative Michael Burgess (R-Texas), its primary sponsor, and from cosponsors Tom Cotton (R-Arkansas) and Marc A. Veasey (D-Texas).
The bill has come to pass largely because of the efforts of the parents of a child named Kaitlyn Samuels, the 17-year-old daughter of a Navy officer.
Kaitlyn has severe scoliosis, epilepsy, cerebral palsy and some cognitive disabilities that render her unable to speak. She requires regular physical therapy sessions to help her develop and strengthen her back and abdominal muscles to help support the weight of her spine and upper body. If she does not regularly exercise these muscles, it is possible that she could slowly suffocate herself.
Her physical therapists had trouble finding a therapy that she would tolerate. She has limited insight into her condition and had not been cooperative with standard modes of therapy, such as benches and balance balls. But when therapists tried the same exercises on horseback, Kaitlin responded very well. According to the family, since she does not tolerate the other forms of therapy, her horseback therapy is the only thing preventing her scoliosis from curving her spine to the point where her internal organs are crushed.
Unfortunately, TRICARE officials didn’t care. At least for long. They covered the horseback therapy for a while, and then changed their minds about it, demanding over $1,300 in reimbursements from the family for payments already made.
While the standard therapies were readily approved under existing TRICARE guidelines, the same therapies done on horseback were deemed non-reimbursable. Horse therapy, or hippotherapy, as it’s called in the medical profession, was considered “unproven” by TRICARE, even though it was already proven in Kaitlyn’s particular case. The family appealed the decision through several reviews, but TRICARE ultimately ruled against them.
As we reported here last year, TRICARE officials overruled the recommendation of the hearing officer and denied the benefit – putting the government in the absurd position of approving therapies that are proven not to work while specifically denying the one therapy that was effective.
The Samuels family fought back – contacting their Congressional representatives, networking with the tight-knit community of parents of special needs children (who have some PR skills of their own!), starting a Facebook page and leveraging social media to get the word out about their private foundation.
Kaitlyn has been able to continue her therapy, thanks to generous private donations.
Meanwhile, the bill now goes to the House Ways and Means Committee.
TRICARE beneficiaries may have noticed new kinds of “Emergency Centers” popping up in their area. It may seem like a tempting health care option but, free-standing emergency rooms (ER) that are not affiliated with a hospital may not be TRICARE-authorized. If a provider, such as a free-standing ER, is not authorized then TRICARE is prohibited from paying it “facility fees.” That can leave a beneficiary stuck with a big bill.
Beneficiaries need to “know before you go.” Check a free-standing ER’s TRICARE status – before emergency care is needed. Beneficiaries can check if a provider is TRICARE-authorized by calling their regional contractor. Contact information for regional contractors is available at www.tricare.mil/contactus. All TRICARE network providers are also searchable at www.tricare.mil/findaprovider.
TRICARE defines an emergency department as an organized, hospital-based facility available 24 hours a day providing emergency services to patients who need immediate medical attention. Emergency departments affiliated with a hospital are most likely TRICARE-authorized providers. Beneficiaries who seek care at a free-standing ER need to ask if the facility is affiliated with a hospital-based emergency department. If it isn’t, the beneficiary will need to make a decision about getting care elsewhere or being responsible for the facility charges.
Learn more about emergency care under TRICARE at www.tricare.mil/emergency.
Source material here.
More than six in ten private mental health care providers won’t take TRICARE patients, according to a newly-released study from the United States Government Accountability Office.
While the access problems for TRICARE members was most acute for mental health care, the survey found that more than one non-enrolled TRICARE beneficiary in three had trouble finding a care provider in TRICARE Prime service areas, which have civilian provider networks. Additionally, TRICARE Prime members rated their satisfaction level with their health care provided via TRICARE even lower than Medicare Fee-for-Service beneficiaries.
The term “non-enrolled beneficiaries” refers to beneficiaries who are not enrolled in TRICARE Prime and who use the TRICARE Standard or Extra options, or TRICARE Reserve Select (TRS).
Among the GAO’s findings:
- 25 percent of non-enrolled beneficiaries experienced problems finding a civilian primary care provider;
- 25 percent of non-enrolled beneficiaries experienced problems finding a civilian specialty care provider.
- 28 percent experienced problems accessing a civilian mental health care provider.
The top reasons that non-enrolled beneficiaries got turned away or had difficulty accessing care include:
- Doctors not taking TRICARE payments
- Doctors not taking new TRICARE patients
- Travel distance was too great
- Doctors not taking any new patients
- The wait for an appointment was too long
21 percent of respondents answered “other.”
According to the GAO, mental health providers were much more likely than other kinds of care providers to report that they had never heard of TRICARE or didn’t understand what it was. Specifically, 30 percent of mental health professionals report never having heard of TRICARE, compared with between 6 percent of primary care providers and 9 percent of specialists.
Nationwide, the study found that even though 82 percent of civilian health care providers are aware of TRICARE, only 58 percent of them are taking on new TRICARE patients. In contrast, 86 percent of care providers take new Medicare patients, and 72 percent take on new Medicaid patients.
14 percent of health care providers who don’t take TRICARE cited problems with reimbursement as the reason. Another 10 percent of respondents cited insurance image problems or issues with TRICARE in the past. 8 percent report that TRICARE does not cover their specialty. Specialists were more likely to report that they weren’t taking TRICARE because of reimbursement issues than primary care providers. Primary care providers were more likely to report that they weren’t taking on any new patients – which could point to a larger problem with a shortage of primary care physicians.
Overall TRICARE acceptance levels have declined from 76 percent in 2005-2007, the last time the GAO conducted this survey, to the end of 2008-2011, which is the period covered in the study.
“If you like your health care plan, you can keep it.” That was the promise Barack Obama made in 2009, selling his health reform plan that became the Affordable Care Act.
It turns out that’s not even true for federal TRICARE beneficiaries.
If you live more than 40 miles from a military installation, chances are you are no longer welcome with TRICARE Prime. Pentagon officials have announced that most of these retired and surviving widow(ers) will be booted from TRICARE Prime as of October 1.
Most of those affected will have to enroll in TRICARE Standard.
The change will not affect those enrolled in Medicare and using TRICARE for Life, nor will those on active duty. However, the change will affect any adults under age 26 enrolled in the TRICARE Young Adult program, if they are over 40 miles from a military installation.
This is actually a six-month reprieve – officials were originally considering forcing enrollees off of TRICARE Prime as of April 1.
TRICARE officials are looking at making an exception for those within 100 miles of primary care managers if they sign a drive-time access waiver.
What does this mean? According to the Reserve Officers Association of America, you may have to find a new doctor.
Also, your costs will change: You will no longer pay flat co-payments per visit and an annual enrollment fee. Instead, you will have to pay a deductible of $150 per year (for singles) or $300 per year (for families), as well as a 25 percent co-insurance – up to $3,000 per fiscal year.
There is the potential for an exception for retired servicemembers, military families, and young adults to remain in Prime if they reside within 100 miles of an available primary care manager and sign a drive-time access waiver.
The Pentagon estimates that limiting TRICARE Prime coverage to those outside of 40 miles of military installations will save taxpayers some $56 million per year.
TRICARE Standard, incidentally, has higher customer satisfaction ratings than TRICARE Prime, according to the Military Officers Association of America.
Ironically, even as the U.S. government kicks 170,000 of its own retirees, survivors and adult children of servicemembers off of their preferred health insurance plan, the White House still maintains on its website that rumors of people being forced to change doctors or forced off their health care plans is a “myth.”
Here’s a little post-holiday gift for you! Your check is no longer welcome at two TRICARE programs.
If you are enrolled in TRICARE Reserve Select (TRS) or TRICARE Retired Reserve (TRR) and you have been mailing in your premiums, you must switch to an electronic form of payment as of January 1st, 2013.
Starting this New Years Day, TRICARE will no longer take your check. You can only pay your premiums via automatically recurring payments by credit card or debit card, or via electronic funds transfer. TRICARE recommends that you check with your bank to ensure that they send EFT payments electronically.
If you don’t pay the premium by the due date, or you send in a check, rather than convert to an electronic form of payment, you will lose your coverage.
To enroll in an electronic payment program, contact your regional TRICARE administrator. You can get their contact information at this web page.
Kaitlyn N. Samuels, the 16-year-old daughter of a Navy officer, was born with a variety of congenital disabilities, including cerebral palsy, severe life-threatening progressive scoliosis, and developmental retardation – her brain functions at the toddler level.
Kaitlyn needs ongoing physical therapy to help her exercise the muscles that allow her to sit upright and stabilize herself. Otherwise the curvature of her spine will eventually cause bones to leave their sockets and crush her lungs. She doesn’t respond to physical therapy in a hospital or clinic setting, though. So her therapists hit on the idea – get her on the back of a horse.
The response was positive. While Kaitlyn would shut down and not cooperate with her therapy sessions in a clinical setting, she loves riding the horse. And it accomplishes many of the physical therapy treatment objectives – she has to concentrate on sitting upright and using her thigh, back and abdominal muscles to stabilize herself and compensate for the movement of the horse.
And what American girl doesn’t love horses?
Naturally, TRICARE, being a government bureaucracy, can’t figure that out. They issued a final decision denying coverage for her physical therapy.
While TRICARE does normally provide coverage for physical therapy in general, it won’t cover Kaitlyn’s, because Kaitlyn doesn’t do her therapy in a clinical setting with a ball and bench and other traditional clinical tools.
Hippotherapy – that is, doing physical therapy on horseback, rather than with the usual set of balls, benches and weights in a clinical setting – does not qualify for TRICARE funding, the government asserted – and so when they realized that the therapist was using a horse to get positive results rather than a ball to get no results, they stopped funding the treatment.
They even sent Kaitlyn’s father a bill – $1,324 – to reimburse them for treatment they had already funded.
The Samuels family went to appeal TRICARE’s decision. And won, initially. The hearing officer sided with Kaitlyn’s family. He held that physical therapy was physical therapy, regardless of whether it took place on horseback or in a clinic with benches, weights and braces. If physical therapy was a covered benefit, and hippotherapy was an effective form of it, it didn’t matter whether the tool was a horse or a large plastic ball.
“It cannot be forgotten that even though [Kaitlyn] is 15 years old, she has the mental capacity of a toddler-preschool child,” he wrote in his recommendation. “It would be a waste of the Government’s money to pay for therapy in a traditional setting for it would provide no benefit.”
TRICARE’s Deputy Chief of Policy and Operations, Michael O’Bar, even went against the recommendations of his own hearing officer in the case, stating that he believed the hearing officer misapplied the statutes that govern the nature of medical documentation and peer-reviewed studies required to prove the efficacy of hippotherapy for the medical condition. As of this writing, Kaitlyn’s hippotherapy is not covered under TRICARE, period. They would fund it if she were not cooperating with her therapy in a hospital and getting no results. But TRICARE refuses to fund a treatment that has actually proven to be effective, in Kaitlyn’s case.
TRICARE officials, for their part, argue that they cannot responsibly fund experimental therapies, nor can they fund therapies that do not have a body of peer-reviewed work demonstrating effectiveness.
Kaitlyn’s family, her therapist and their lawyers, meanwhile, argue that the treatment is the same – the fact that hippotherapy takes place on a horse instead of on a ball is incidental. And given that the treatment modality, other than the context and the specific tool used, is identical, it doesn’t make sense for the government to fund one but not the other.
The government lawyer assigned to argue the case, however, argued that if one treatment that they didn’t fund worked, and the treatment that they were willing to cover was useless, then they couldn’t be the same treatment.
The government still maintains that they will fund the useless therapy in the hospital or clinic setting – but they will not fund the therapy that actually works.
O’Bar’s finding is the final authority within the TRICARE appeals process. The next step, should the Samuels family decide to pursue it, is a lawsuit in federal court – an expensive and time-consuming process.
Medicaid Doesn’t Work for Military Families
Most families with severely disabled children can apply for Medicaid benefits in the states in which they live. But for military families, Medicaid isn’t so simple: While Medicaid dollars are largely federal, each state runs its own Medicaid program – and waiting lists for Medicaid benefits are routine. In some cases, families can be on the waiting list for years before becoming eligible for benefits. But military families move every three years – usually out of state – and have to start at the bottom of the waiting list each time. That’s what’s happening here, according to Kaitlyn’s mother. Her daughter does qualify for Medicaid, but the family doesn’t stay in one state long enough for that to matter, because of the waiting list requirements. If Kaitlyn’s daughter were a deadbeat dad, she says, “We wouldn’t be here right now.”
Hippotherapy and the Romney Family
Hippotherapy came to public attention earlier this year, when it became public that Ann Romney, wife of former Republican presidential candidate Mitt Romney, credited horseback therapy with saving her life. Ann Romney was diagnosed with multiple sclerosis in 1998. The Romneys – being a family of substantial means – own a partnership in a competitive horse breeding operation, and have ready access to horses.
Ann Romney’s use of horse therapy actually became a campaign issue, briefly, and MSNBC television personality Lawrence O’Donnell actually mocked for her use of hippotherapy to treat her MS symptoms.
A number of studies have, indeed, supported the clinical benefits of hippotherapy for a variety of conditions. TRICARE, however, continues to deny treatment for the Kaitlyn Samuels.
Congress has struck a tentative deal on the 2013 Defense Authorization Bill, at least at the committee level, and lobbyists for veterans and servicemembers groups seem to have one some important victories, sources say.
According to the Military Officers Association of America – one of the key lobbying organizations in Washington for career military and retirees – the deal contains the following provisions:
A 1.7 percent increase in base pay
The defeat of a drastic increase in TRICARE pharmacy copays proposed by the Obama Administration: Copays are capped at $17 per brand-name medication for 2013, and future increases are pegged to retirement pay increases. The Administration wanted to raise the current copay from $12 to $26, and then to $34 per medication over the next four years.
The Obama Administration also wanted to eliminate access to medications not on the current TRICARE formulary altogether. The Defense deal Congress reached this week ensures they will continue to be available, though for a $44 copay. That is substantially more expensive than the current $25 per medication, but “better than not having them available at all,” say MOAA sources.
The co-pay for mail-order generic medications remains at zero. The Administration wanted to reinstate a $9 copay for generics by 2017, but was unsuccessful in getting this included.
The bill does impose new obligations among TRICARE for Life beneficiaries: They must try using cheaper military pharmacies or mail-order for refills for at least a year, beginning, most likely, in March in 2013. After one year, beneficiaries can opt to revert back to the retail pharmacy system. Congress hopes the savings from this arrangement will offset the cost of the lower copays to the taxpayer.
The law also makes it easier for wounded medically-retired veterans to collect Combat-Related Special Compensation for those with combat-related disabilities. Those affected will see an increase in CRSC payments effective 1 January 2013.
Additionally, active duty service members will be getting a 3.8 percent increase in their housing allowance next year, on average, though allowances at some locations will actually decline.
Active duty servicemembers are also receiving an increase in basic allowance for subsistence. The new rates:
Enlisted: $352.27 per month
Officers: $242.60 per month
In other developments, the new Defense Authorization Bill makes same-sex marriages legal on military bases if they are legal in their respective states. However, military chaplains cannot be required to participate in marrying same-sex couples.
The bill also authorizes TRICARE to pay for abortions, if the patient is a victim of rape or incest.
Furthermore, the law also requires the military to discharge convicted sex offenders, and requires military officials to retain closed reports of sexual assaults for up to 50 years, in order to support disability claims against the government and possible prosecution of perpetrators, subject to the statute of limitations.
For years, Congress has granted the Secretary of Defense broad authority to unilaterally set TRICARE premiums and fees itself, rather than seek Congressional approval.
This worked fine for a long time, because previous Administrations did not seek to make major changes and blindside Congress with sudden fee hikes.
The Obama Administration has repeatedly moved to hike TRICARE premiums – by substantial amounts. For example, last year, TRICARE Pharmacy co-pays increased $2 to $3 dollars. The Obama Administration turned around and attempted to double or triple pharmacy co-pays – to the tune of $21 to $31 per medication.
This is a big deal to those who rely on these medications – particularly TRICARE-For-Life beneficiaries.
Naturally, the prospect of major, sudden TRICARE fee hikes causes angry phone calls and letters to Congressional representatives from veterans, military families, and their powerful lobbying organizations.
This year, Congress said ‘enough,’ and finally tied the Administration’s hands. According to Steve Strobridge, a retired Air Force colonel and Director of Government Relations for the Military Officers Association of America, the Administration had crossed a line and abused its discretional authority.
“In effect, Congress told the Pentagon, “You’ve repeatedly abused the adjustment authority we gave you and show no signs of changing that behavior, so we’re taking your authority away,” explains Strobridge. “Instead, we’re putting a formula in law that will ensure future adjustments are more appropriate and predictable.”
Government Exec magazine describes the proposals, counterproposals, and legislative sponsors in more detail here.
Provisions in the new Defense Authorization Act now tie increases in pharmacy co-payment to increases in retirement pay. Since Congress controls this expense, rather than the Secretary of Defense, Congress therefore took substantial control of the TRICARE fee structure back from the Secretary and put it back with electoral representatives, accountable to the public.
In another cost-cutting effort, those who are on TRICARE Prime will see another big change on April 1st, 2013, starting in parts of the Western Region. Retirees and their dependents who live more than 40 miles from a military medical treatment facility will be forced off TRICARE Prime and moved to TRICARE Standard. It’s estimated that approximately 30,000 veterans and their families will be affected in Iowa; Minnesota; Oregon; Reno, Nevada; and Springfield, MO. (Patients within 100 miles of a primary care provider may stay on it providing they sign an access waiver and there is network capability.)
Three problems are at the heart of the manner: an increase of out-of-pocket cost for our veterans; the distance that many veterans will have to drive in predominately rural areas to access medical services; and the lack and timing of public announcements made to inform beneficiaries of the changes.
TRICARE Prime is based on a health maintenance organization (HMO) model. Beneficiaries pay an enrollment fee but have a set (low) cost out-of-pocket per medical service (doctor visit, prescription, x-rays, etc.). TRICARE Standard is an indemnity, or straight fee-for-services, program. While there is no enrollment fee, beneficiaries pay a percentage of their doctor’s charges. (TRICARE Prime Remote is not available to retirees.) The concern comes from retirees living on a fixed income who will end paying a higher percentage (and higher dollar amount) of their overall income for their medical needs on Standard than they would on Prime.
Retiree living in largely rural states with few active-duty military bases will take the brunt of the change. Those beneficiaries who cannot find doctors who take Standard or pay the higher fees associated with this change or may find themselves driving longer distances to find health care. This could mean several hours in many instances; not appealing in a wellness check scenario, and definitely not when one is ill.
Communication from the Pentagon regarding this issue has been rather sparse. Although plans for revamping TRICARE Prime have been in the works since 2007, no formal announcements have been made. Neither will the Pentagon confirm the number of retirees affected, answer letters from Congressional members asking the Department of Defense to detail the new plans as well as projected outcomes, or respond to inquiries from the press regarding this matter.
The five areas of the Western region will not be alone for long. TRICARE’s Northern and Southern Regions (and is guessed, the rest of the Western region) will switch its Prime members to Standard as of October 1st, 2013. This brings the grand total to 171,000 beneficiaries affected in the United States.
Greg Walden (D-OR), Mark Amondei (R-NV), and Suzanne Bonamici (D-OR) have sponsored H.R. 6635, also known as the TRICARE Protection Act. This bipartisan bill seeks to allow affected beneficiaries to switch to TRICARE Prime Remote for two years giving them access to the same benefits and additional time to prepare for the switch to Standard, to have the military spearhead the efforts to help find retirees new doctors, and to study and report the economic and service affects on the beneficiaries. It went to the House Armed Service Committee December 5th, 2012. Unfortunately, it is not expected to pass. In this time of “going off the fiscal cliff,” finding additional savings to offset the bill for a program that seemingly has already been “fixed” does not hold much sway in Washington.
TRICARE officials recently announced an enhanced mobile phone application. The new additions allow beneficiaries to manage their TRICARE pharmacy benefits via a secure cell phone connection. New features include medication reminders, which allows beneficiaries to set up daily alerts to make sure they take their medications as prescribed and don’t skip a dose.
The new app also includes an account registration feature, which lets beneficiaries create their ESI account right on their smart phone.
“The Express Rx mobile app gives beneficiaries access to their prescription information anytime, anywhere,” said Rear Adm. Thomas J. McGinnis, chief of TRICARE Pharmacy Operations.
Currently, the Express Rx app and mobile-optimized website allow beneficiaries to register for TRICARE Pharmacy Home Delivery and change current prescriptions over to home delivery. They can also order home delivery refills and check order status. Another feature lets beneficiaries look up information on their current prescriptions. For GPS-enabled smart phones, the app can direct beneficiaries to the nearest network retail pharmacy.
Smartphone users can download the app for free by going to www.express-scripts.com/mobile or using services like the Apple App Store or Android Marketplace. The mobile-optimized pharmacy website is accessible at http://m.esrx.com
Other available free apps to download through the Apple App Store or Android Marketplace are the TriWest mobile app and the Defense Manpower Data Center’s milConnect mobile app. Beneficiaries in the South Region can make use of the mobile Humana Military website, https://m.humana-military.com/ while beneficiaries in the North Region can use the mobile Health Net mobile site, https://m.healthnet.com.
For more information about TRICARE pharmacy program, visit www.tricare.mil/pharmacy. Learn how to switch to TRICARE pharmacy home delivery at www.tricare.mil/homedelivery.