Read Next: Tricare to Offer Free Physical Therapy for Back Pain in Some Locations Copayments for prescriptions available through Tricare's home delivery program also will remain the same, a 90-day. Does TRICARE For Life cover physical therapy? A: Once Medicare reaches the maximum they will pay for the year TRICARE For Life will consider as the primary payer. MD orders, progress notes, etc. May be requested to determine medical necessity. Copayments will be waived retroactively to March 18 for certain testing and office visits related to the testing. The test must be one approved, cleared, or authorized by the Food and Drug Administration to detect SARS-CoV-2 or diagnose COVID-19. A percentage of the TRICARE deductible, cost-shares, applicable excess charges and co-pays left behind by TRICARE. Many times, this option is less expensive than the employer-sponsored health plan. Please refer to the certificate of.

How Much Does Tricare Pay For Physical Therapy

• Copayments and cost-shares are subject to change at the beginning of each calendar year.
  • Copayments are per occurrence or per visit.
  • Cost-shares are a percentage of the contracted rate for network providers and the maximum TRICARE allowable for non-network providers on certain types of services.
• Beneficiaries have an out-of-pocket maximum for covered medical expenses; this is known as the catastrophic cap.
• Point of Service cost-shares and deductibles may apply to TRICARE Prime and TRICARE Prime Remote beneficiaries (excluding active duty service members).

Important Note: Active duty service members do not have any out-of-pocket costs for care.

2021 Costs

Tricare Prime Retiree Physical Therapy Copay

2021 Cost Information by Benefit

Detailed information on copayments and cost-shares is listed below by benefit. You can also view this information using the cost links in our Benefits A-Z list.

Physical therapy is covered to aid in the recovery from disease or injury to help the patient in attaining greater self-sufficiency, mobility and productivity by improving muscle strength, joint motion, coordination, and endurance. Physical therapy is covered when rendered and billed by a licensed, registered physical therapist or other authorized professional provider acting within the scope of his or her license. Professional services performed by a supervised licensed physical therapy assistant (PTA) must be billed under the licensed physical therapist’s National Provider Identification (NPI) number using the CQ modifier. PTAs may not provide an initial examination, evaluation, assessment, or establish a diagnosis or plan of care.

Outpatient therapy is authorized based on one visit per day. All active duty service members (ADSMs), TRICARE Prime and TRICARE Prime Remote beneficiaries who have an assigned primary care manager (PCM) require an approval from Health Net Federal Services, LLC (HNFS) for physical therapy services. TRICARE Prime Remote beneficiaries (excluding ADSMs) without an assigned PCM and TRICARE Select beneficiaries do not require an approval from HNFS prior to services being rendered; however, a physician’s order is required for claims processing.

Coverage is based on the beneficiary's medical needs. The number of visits authorized indicates the actual number of visits, not the individual units per CPT® code. The following baselines will be used as a guide for the number of visits and duration of approval:

• Acute injuries (for example, musculoskeletal conditions such as ankle sprain, shoulder sprain, low back pain or torn hamstring) = 12 visits with a duration of 120 days
• Post-operative care (for example, hip and knee replacement) = 24 visits with a duration of 150 days
• Long term conditions (for example, neurological conditions such as stroke, traumatic brain or spinal cord injury, pediatric neurodevelopmental conditions, swallow testing or feeding therapy) = 72 visits with a duration of 180 days

Individualized Education Program Requirements

Physical therapy to treat a physical or occupational deficiency due to a cognitive or developmental disorder for beneficiaries age three to 21 requires a physician letter of attestation whenever there is evidence presented to TRICARE that there is an individualized education program in place for special education services. TRICARE may cover additional physical therapy when a physician attests in writing the intensity and/or timeliness of any physical therapy services being offered by the educational agency does not meet the medical needs of the beneficiary.

Excluded Services

Does Tricare Pay For Physical Therapy

• diathermy, ultrasound and heat treatments for pulmonary conditions
• general exercise programs
• electrical nerve stimulation used in the treatment of upper motor neuron disorders such as multiple sclerosis
• separate charges for instruction of the patient and family in therapy procedures
• repetitive exercise to improve gait, maintain strength and endurance, and assistive walking such as that provided in support of feeble or unstable patients
• range of motion and passive exercises, which are not related to restoration of a specific loss of function
• maintenance therapy that does not require a skilled level of assistance
• vocational assessment and training or assessments to determine status of disability
• athletic training evaluation (CPT 97005 and 97006)
• CPT 97532 or 97533 when used to improve cognitive function as a result of neuronal growth through the repetitive exercise of neuronal circuits
• CPT 97532 or 97533 for sensory integration training
• services provided to address disorders or conditions resulting from occupational deficits