TRICARE: PTAs and OTAs As Authorized Providers

TRICARE: PTAs and OTAs

TRICARE to update its coverage for physical and occupational therapy assistants

The TRICARE Health program serves active duty and retired service members as well as their families world-wide. Tricare pays for the healthcare services of authorized providers under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). Only providers listed as authorized CHAMPUS providers can receive reimbursement from Tricare, and while occupational and physical therapists are listed as authorized CHAMPUS providers, occupational therapist assistants (OTAs) and physical therapist assistants (PTAs) are not. Thus, Tricare does not currently reimburse for OTA and PTA services, even if the services are supervised by a licensed occupational or physical therapist.

Effective April 16, 2020 the Department of Defense issued a final rule that establishes PTAs and OTAs as authorized providers in ways similar to Medicare provisions.

Taken from TRICARE final rule document:

“This final rule implements section 721 of the National Defense Authorization Act for Fiscal Year 2018 (NDAA-18), and advances two of the components of the Military Health System’s quadruple aim of improved readiness and better health. The TRICARE Basic benefit currently includes physical therapy (PT) and occupational therapy (OT) services rendered by TRICARE-authorized providers within the scope of their license when prescribed and monitored by a physician, certified physician assistant, or certified nurse practitioner. Allowing licensed registered physical therapists and occupational therapists to include those services of qualified assistants performing under their supervision as covered services may increase access to PT and OT services, and increase beneficiary choice in provider selection. Adding coverage of services by authorized therapy assistants may increase access at the same time the Agency anticipates that an active and aging beneficiary population will increasingly use these services.”

Also Notable in the Final Rule (from the APTA) Regarding TRICARE for PTAs and OTAs

  • Qualification and supervision requirements for the most part mirror Medicare provisions for PTAs and OTAs.
  • Direct supervision will be required in the private practice setting, with the supervising PT required to be in the office suite where the PTA is working and immediately available to provide assistance and direction — but not required to be in the room with the PTA while the procedure is being performed.
  • Outside of private practice, the rule calls for “general supervision” that does not require the PT’s presence during the PTA’s performance of the procedure. The supervising PT will have continuing responsibility for training the PTA.
  • Where state or local supervision laws are more stringent, PTs and PTAs will be required to follow those laws.
  • Physical therapy aides will not be covered, even if working under the supervision of a TRICARE authorized PTA or PT.
  • DoD adopted APTA’s recommendation to change its terminology and is now using the term “physical therapist assistants” in reference to the PTA, abandoning its use of “physical therapy assistants.”

“Although we’ve known that this change would be happening since 2017, we’re pleased that DoD issued the final rule slightly ahead of schedule, and with virtually all of the suggestions provided by APTA,” said Kara Gainer, APTA’s director or regulatory affairs. “PTAs are crucial members of the service delivery team, and their inclusion in TRICARE will significantly improve patient access to effective, needed care.”

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