TRICARE Provides New Coverage for Low Back Pain Physical Therapy

1/14/2021

Do you have acute or chronic low back pain? If the answer is yes, you aren’t alone. According to the Centers for Disease Control and Prevention, low back pain is the most common type of pain reported by patients. You can take preventive steps and manage low back pain safely and effectively. As of Jan. 1, 2021, if you need physical therapy for your low back pain, the Defense Health Agency established a demonstration. With the demonstration, TRICARE will waive cost-shares for qualified beneficiaries for up to three physical therapy sessions in 10 states.

Low back pain responds well to self-care as well as physical therapy. Self-care should be the first treatment for low back pain. This includes stretching, hot or cold therapy, strengthening exercises, and anti-inflammatory drugs that you can get over the counter. If these methods aren’t effective, then your provider may recommend that you get physical therapy for your low back pain.

“We want you to seek appropriate and quality care when you need to for your back pain,” said Erica Ferron, a health care policy analyst with the Defense Health Agency. “We hope this trial demonstration encourages those who need physical therapy to treat and manage their low back pain.”

What is the demonstration and who qualifies?

Under the Low Back Pain and Physical Therapy Demonstration, TRICARE will waive cost-shares for up to three physical therapy sessions for those with low back pain. This is only available in 10 states: Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee, and Virginia. If you’re an active duty service member (ADSM), you aren’t eligible for the demonstration. As an ADSM, you already have no cost-shareA percentage of the total cost of a covered health care service that you pay. for physical therapy. However, medically necessary physical therapy is a covered service for all TRICARE beneficiaries. This is regardless of your eligibility for the demonstration.

To qualify to have your cost-share waived, you need a new primary diagnosis of low back pain. You must both live in and get care in one of the 10 above named states. And you must have a referral from a TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. DS. Your referral must be to a network TRICARE-authorized provider, unless you’re using TRICARE For Life.

If you’re already getting physical therapy for your low back pain, you won’t get the three waived cost-shares. Only your new physical therapy treatment is eligible for waived cost-sharing. After the three sessions, you must pay your regular cost-shares and copayments for your future sessions.

What is a TRICARE demonstration?

A demonstration is a special provision that lets TRICARE try new methods of delivering health care. It also gives financial relief to a certain population. After the demonstration, the service may or may not become a TRICARE covered service. The low back pain demonstration runs from Jan. 1, 2021 to Dec. 31, 2023. TRICARE may extend the demonstration or end it.

To learn more, check out Low Back Pain and Physical Therapy Demonstration. You can also reach out to your TRICARE regional contractor if you have questions or need assistance. Take command of your health this year. 

At the time of posting, this information is current. For the most recent information, contact your TRICARE contractor or local military hospital or clinic.

Last Updated 10/14/2021