TRICARE Responds to ABA Court Ruling

TRICARE Management Activity (TMA) released an interim TRICARE Manual Change C-163 in response to the recent U.S. District Court ruling, which ordered TMA to cover Applied Behavioral Analysis (ABA) therapy under the TRICARE Basic Program. C-163 allows coverage for ABA services for any TRICARE beneficiary with a diagnosis of Autism Spectrum Disorder (ASD), including retirees and their dependent family members. Although this is great news, keep in mind that this benefit could only be in effect until litigation is complete. The Association recommends that families proceed with caution and be sure to keep all receipts when receiving ABA services under this new interim benefit. This is especially important for retired beneficiaries.

Military families with questions about this policy change are encouraged to contact their TRICARE Managed Care Support Contractor directly.

Our Association remains committed to supporting all military families with special needs. If you are a military family with a special needs family member, share how the new interim ABA benefit will impact your family on our Facebook page.

Here is a synopsis of important information embedded in the TRICARE Policy Manual for C-163.

  1. Effective date of the benefit is retroactive. For ABA services received within the United States, the effective date is March 5, 2010. For ABA services received overseas, the effective date is March 5, 2008. 
  2. Coverage is only for beneficiaries diagnosed with ASD rendered by a TRICARE authorized Primary Care Provider or by a specialized ASD provider.
  3. Payable services include: an initial beneficiary assessment; development of a treatment plan; one-on-one ABA interventions with an eligible beneficiary, training of immediate family members to provide services; and mentoring of the beneficiary’s progress toward the treatment goal.
  4. Reimbursement will be the lesser of: the CHAMPUS Maximum Allowable Charge; $125 per hour for services provided by an authorized provider; the negotiated rate; or the billed charge. The reimbursement is for providers that provide services in conjunction with ABA under the TRICARE Basic benefit.
  5. TRICARE authorized providers when referred by and working under the supervision of those identified by TRICARE are those who:
  • Have a current State license to provide ABA services; or
  • Are currently State-certified as an Applied Behavioral Analyst; or
  • Are certified by the Behavioral Analyst Certification Board (BACB) as a Board Certified Behavioral Analyst (BCBA) in cases when state license or certification is not available; and
  • Otherwise meet all applicable requirements of TRICARE-authorized providers.
  • Providers certified by the BACB as a Board Certified Assistant Behavior Analyst (BCaBA) are NOT TRICARE authorized ABA providers under the TRICARE Basic Program.
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