TRICARE Waives Copays for Low Back Pain PT

By Western Berks Physical Therapy on February 8th, 2021

Treating Pain with Physical Therapy

TRICARE Waives Copays for Physical Therapy for Low Back Pain

TRICARE, one of the nation’s largest insurers wants their members to get physical therapy for back pain. They think that treating back pain with physical therapy is so important that they’re willing to waive copays for their members.

The Defense Health Agency (DHA) has authorized a “Low Back Pain Physical Therapy Demonstration” through TRICARE that will waive copays for up to three physical therapy visits for patients with low back pain. The aim of this demonstration is to evaluate whether waiving the costs for beneficiaries increases participation, decreases low-value care, and/or decreases the overall cost of care for treating patients with low back pain. The demo runs from Jan. 1, 2021 through Dec. 31, 2023.

This a huge deal. When’s the last time you remember an insurance company covering the entire cost of anything? Now that you know about TRICARE’s low back pain program, let’s dive into back pain treatments and see why TRICARE is such a big fan of physical therapy.

You probably already know that back pain is a common problem. What you might not know is that the medical system isn’t very good at treating it. “Non-drug treatments like physical therapy” are the first treatment recommended for back pain. Unfortunately, many providers don’t follow this guideline and treatments are often recommended based on opinion rather than research. This means insurance companies and patients often end up spending a lot of money for outcomes that are less than stellar.

Here’s how it usually goes: You go see your doctor with back pain. They might give you medication, recommend rest, some stretches, send you for x-rays or an MRI. Next will likely be a referral to a specialist like an orthopedic surgeon. Chances are you won’t be having surgery right away, so the specialist will either refer you to physical therapy, or back to your doctor where you’ll end up with a physical therapy referral. The path will look different for each person, but the end result is usually the same: multiple failed treatments, imaging you probably didn’t need and a delay of weeks or months to get to a physical therapist.

Multiple large studies have looked at the effects of early physical therapy on low back pain with impressive results. One of them was done in 2006 in Seattle by Virginia Mason Health Center. They teamed up with Aetna and Starbucks to send workers with back pain to see both a physical therapist and physician for their first treatment. The study showed that with physical therapy, people got better faster, missed less work and were more satisfied with their care. The cost savings were also so great that Aetna ended up paying Virginia Mason more for physical therapy treatments because Aetna was saving so much money.

Intel ran a similar program with their employees, getting people with back pain to a physical therapist within 48 hours. Previously it took about 19 days for people to get to a physical therapist. With the earlier access to physical therapy, patients completed their care in 21 days, compared with 52 days previously and costs dropped up to 30%. Intel also found more satisfaction with care and a faster return to work.

Data proves that physical therapy is the cheapest and most effective treatment for low back pain. It’s clear that people with back pain should start treatment with their physical therapist, but the reality is that most don’t. TRICARE’s pilot program that waives copays for up to three physical therapy visits aims to change that. If successful it will lead to lower costs for both TRICARE and their members while delivering better outcomes in less time.

For more information on TRICARE’s Low Back Pain and Physical Therapy Demonstration, click here or read below.

TRICARE Low Back Pain and Physical Therapy Demonstration

The Low Back Pain and Physical Therapy Demonstration waives cost-shares for up to three covered physical therapy sessions for eligible beneficiaries. After the third covered physical therapy session, you’ll pay regular cost-shares and copayments.

  • The demo runs from Jan. 1, 2021 through Dec. 31, 2023. TRICARE may terminate or extend the demo.
  • The waived cost-shares don’t apply towards your annual deductible.
  • If you’re enrolled in TRICARE Prime, your Point of Service fees won’t be waived.

Who’s Eligible?

You must reside in and receive care in one of the following states.

  • Arizona
  • California
  • Colorado
  • Florida
  • Georgia
  • Kentucky
  • North Carolina
  • Ohio
  • Tennessee
  • Virginia

You aren’t eligible for this demonstration if you’re:

How it Works

You must have:

  • A new primary diagnosis of low back pain. Your diagnosis must be made after the demo starts. If your diagnosis is from before Jan. 1, 2021, you aren’t eligible for this demo.
  • A referral from a TRICARE-authorized provider. There are two types of TRICARE-authorized providers: Network and Non-Network. Your referral must be to an in-network TRICARE-authorized provider.
    • If you’re using TRICARE For Life, you’ll only need to see a TRICARE-authorized provider.