TRICARE Announces Changes to Policy Regarding ABA Coverage

On July 18, TRICARE announced that there will be no change in policy for active duty family members who need Applied Behavior Analysis (ABA) therapy. Active duty family members may still receive ABA therapy by enrolling in the Extended Health Care Option (ECHO) Autism Demonstration. This is contrary to policies that were announced last month that would have imposed new requirements on active duty families seeking authorization for ABA treatment.

Also on July 18, TRICARE confirmed plans to launch an ABA Pilot to provide coverage for non-active duty family members (NADFMs) needing ABA therapy. The Pilot is set to launch on July 25 and will run for one year.

To receive ABA therapy through the ABA Pilot, beneficiaries must first receive an Autism Spectrum Disorder (ASD) diagnosis from a TRICARE-authorized physician Primary Care Manager (PCM) or specialized ASD provider. The diagnosing physician will then provide a referral for an ABA assessment. The ABA assessment must be performed by a Board-Certified Behavior Analyst (BCBA) and must include two standardized baseline tests, the ADOS-II and the Vineland Behavioral Scale. Once the initial assessment is completed and a treatment plan is developed, the diagnosing physician can submit a referral for ABA treatment.  All ABA therapy, including the initial assessment, requires prior authorization from a TRICARE regional contractor.

Under the ABA Pilot, the Vineland-II standardized test must be administered every 180 days to assess progress and determine the need for continued treatment. Authorizations for ABA treatment will be valid for one year. To receive additional therapy beyond one year, TRICARE states that families will need to obtain a new referral requesting authorization for an additional year.

TRICARE will cost share up to $36,000 annually. 10% cost-share applies, which doesn’t count toward the TRICARE Standard deductible or the family’s catastrophic cap.

We are gratified that TRICARE has reversed course and decided not to impose new requirements on active duty families needing ABA therapy. We are also pleased that the ABA Pilot will make this treatment available to non-active duty family members. However, we still have concerns about how these changes will be implemented.  We believe families may have difficulty accessing TRICARE-authorized providers to administer the required standardized tests. We are concerned about what will happen to families at the end of the one year pilot program. Most urgently, we are alarmed by the lack of communication to the beneficiary community, health care providers, and regional contractors regarding implementation of this new program. We will continue to monitor this situation and inform military families as developments occur.  In the meantime, you can link to TRICARE for information or to sign up for email alerts on ABA coverage.  

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