Sunday, March 10, 2013

Military Family Battles TriCare For Effective Health Coverage For Their Disabled Teen

Kaitlyn Samuels, 16, of Keller, rides Uno in her physical therapy session at
Rocky Top Therapy Center in Keller.

Here is what Americans, especially those with pre-existing conditions, birth defects, the disabled and the elderly can expect under the Affordable Care Act, otherwise known as Obamacare: systematic flaws, legalities and a federal bureaucracy that will hold up treatment and deny health care to those who need it most.

This story is about a 16 year old from Texas named Kaitlyn, pictured, who was born with a brain abnormality preventing her brain from developing beyond a toddler. In addition, she is is unable to walk on her own due to severe scoliosis, which if left untreated could kill her. 

According to this report from The Dallas News, Kaitlyn will require physical therapy her entire life. However, her parents just learned that TriCare, the Department of Defense's military health care program, will not cover her physical therapy treatment, known as hippotherapy. TriCare will only cover traditional physical therapy because they say hippotherapy has not been proven to be effective and safe.

According to the report, “hippotherapy” is often interchangeable with “equine therapy” and “physical therapy on a horse.” It is also used to describe psychotherapy using a horse, as in the treatment of post-traumatic stress disorder. Tricare defines “hippotherapy” as “a form of exercise or therapeutic horseback riding,” according to Camacho, the TriCare spokesman. 

Jennifer and her husband, Mark, an active-duty Navy captain based at the Naval Air Station Joint Reserve Base Fort Worth, are advocating for Kaitlyn’s Law, a federal measure to require coverage of her treatment. They are seeking the support of key local lawmakers. They are fighting against what they view as deep systemic flaws in the military’s health care plan, including arbitrarily denied benefits and a murky appeals process. 
Kaitlyn’s therapy on a horse is no more expensive than it would be on a ball, and Tricare says it does not consider cost when determining benefits. But the insurance provider considers the treatment unproven and experimental. 
“There is a lack of reliable evidence establishing hippotherapy as safe and effective,” said Austin Camacho, a Tricare spokesman. 
The family’s case centers on whether a horse is a tool for physical therapy or a new form of therapy altogether. 
Tricare covers 9.6 million beneficiaries and is federally funded. Its policies cover traditional physical therapy, but that doesn’t seem to work for Kaitlyn. She caves into a deep, disengaged slouch while on a balance ball or barrel. When her therapist uses a horse, she sits up and engages. 
They make the rules, set the rules and are accountable to no one,” Jennifer said of Tricare. Fighting for her daughter’s benefits has been costly in both time and money, and has drawn the attention of national advocates. 
“The science changes, and I don’t think Tricare does a good enough job of analyzing whether it’s time to consider a new treatment,” said Jeremy Hilton, a Navy veteran and an advocate for military families facing illness and disability. Hilton’s wife is in the Air Force at Andrews Air Force Base in Maryland, and they have a 10-year-old daughter with cognitive disabilities. 
There’s no way to determine how many families have faced similar issues. “Most families would just do without,” he said. “They would just walk away.”
The Military Officers Association of America, which advocates on behalf of families for military benefits, is examining the Tricare appeals process and will testify before the House Armed Services Committee on its findings, said MOAA deputy director Karen Golden.
It appears Kaitlyn's family has been proactive in getting the support they need, however they are still actively working to get Kaitlyn's Law passed which would affirm a recent court decision that found in favor of providing the physical therapy Kaityln and others like her need, despite the type of tool used and regardless of what TriCare defines as "effective or safe" physical therapy.
Their lawyer, Dallas attorney Colby Vokey, argued that the horse is simply a tool in physical therapy, not an unproven treatment, as Tricare contends. Kaitlyn’s parents, pediatric neurologist and physical therapist all testified that her treatment is both necessary and effective.
Jennifer testified that Kaitlyn’s therapy would be covered by a Medicaid waiver, but that because of Mark’s military service, they never lived in a state long enough to get off the waiting list.
“If he was a deadbeat dad,” she said, “we would not be here right now.” 
Judge Calude R. Heiny, who heard the family’s case, wrote an opinion firmly in their favor.
“Physical therapy done in a pool is fine, but when done on a horse, it does not suddenly become some alternative, strange therapy,” he wrote. “The therapist is paid for the service she provides, not the tool she uses.” 
The catch: The judge’s opinion was nonbinding. His role was to recommend a decision to Tricare executives. Despite the judge’s recommendation for coverage, Tricare still refused. 
Tricare policy and operations deputy chief Michael O’Bar issued a final decision rejecting Heiny’s analysis, citing a “lack of reliable evidence establishing that hippotherapy is a proven treatment.”
While most private insurance companies don't always cover hippotherapy, The American Physical Therapy Association, disagrees with insurance policies such as TriCare which deny coverage for hippotherapy. 
The American Physical Therapy Association, based in Virginia, disagrees with the no-coverage policy.
“We do support the fact that hippotherapy is often used as a strategy” by a therapist, said Carmen Elliott, the director of payment and practice management. But, she said, people get lost in terminology. Just call it “physical therapy,” she said.
Tricare, though, is “barred by law” from covering therapy that lacks evidence of its safety and efficacy, said Camacho. That evidence includes clinical studies, medical literature, technology assessments and various reports, including those of expert organizations.
This was the basis of Tricare lawyer Michael Bibbo’s argument by teleconference from Colorado before the Department of Defense judge in February 2012.
“Congress can change the laws,” he said.
Tricare recouped $1,327.44 for Kaitlyn’s therapy after denying coverage that it initially provided. The amount in dispute was far less than the family’s legal fees, but for them, this was about future coverage.
Unfortunately, Kaitlyn's family aren't the first and likely won't be the last to deal with the federal TriCare bureaucracy of qualifying for necessary treatment for their daughter. But thanks to the support and help of others they have received donations to continue her treatment while their case is pending in the courts and awaiting legislative action. Since TriCare's final denial of service, they have sought the help of several well known Texas legislatures to help them get Kaitlyn's Law passed. 
Shortly before Christmas, Mark and Jennifer Samuels received an unanticipated gift. The nationwide powerhouse Akin Gump Strauss Hauer & Feld picked up their case pro bono. The time and money worries of pursuing further legal action evaporated. Jennifer counts her family as “extremely blessed.”
At around the same time, Jeffrey Gural, the chairman of a New York City real estate company, donated one year of physical therapy to Kaitlyn. Her family chose to share the treatment with other military children at Rocky Top.
The family and their Houston-based lawyer, Marcella Burke, started Kaitlyn’s Foundation at Rocky Top to provide treatment for Kaitlyn and others. The foundation has already received several sponsorships and donations.
With the support of Akin Gump, Mark and Jennifer are asking Texas Sens. John Cornyn and Ted Cruz and U.S. Rep. Michael Burgess, R-Lewisville, to sponsor a bill for Kaitlyn’s Law, which would guarantee coverage for Kaitlyn’s therapy and that of others like her.
Jennifer has been in closest contact with Burgess’ staff. His office confirmed they are aware of the Samuels case and are “happy to review and do our due diligence.”
While Kaitlyn’s Law is her parents’ priority, their strategy includes various approaches, Burke said. If legislative efforts fail, the next logical step would be filing a federal case.
 As the war wages on, Kaitlyn continues her weekly therapy sessions at Rocky Top. She doesn’t know that her parents are still in the throes of battle to maintain her care. She only knows that once a week, her mother walks her into the barn to meet her therapist, Suzanne Sessums. 


To support Kaitlyn’s Foundation, donations can be sent to:

Kaitlyn’s Foundation, c.o. Rocky Top Therapy Center, 660 Keller Smithfield Road, Keller, Texas 76248.
Make checks payable to Rocky Top with “Kaitlyn’s Foundation” in the memo line.
An online payment system will soon be available at
Spirit Night for Kaitlyn’s Foundation at Chick-fil-A at Alliance Town Center:
Kaitlyn’s Foundation will receive 20 percent of proceeds from 5 to 9 p.m. on April 1.
Urgent Care for Kids:
The organization will donate a dollar for every “like” and $2 for every “share” of the Kaitlyn’s Foundation photo posted on the Urgent Care for Kids Facebook page.
 mysignature-1.png©2008-2013 Patricia Garza

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