Update on TRICARE Changes to ABA Therapy Services

The National Military Family Association met recently with TRICARE Management Activity (TMA) to discuss the new interim Applied Behavior Analysis (ABA) basic “medical” benefit. This change includes ABA as a covered TRICARE medical benefit for beneficiaries with certain diagnoses related to autism. Our Association asked for the meeting to learn how this benefit change would affect eligible military families.

Here’s what we learned from the meeting. 

  • Reimbursement for past ABA therapy services: Beneficiaries should submit claims to their TRICARE Managed Care Support Contractor (MCSC). They can submit claims for reimbursement for past services received; however, they should expect some review delays as TMA and the MCSCs work through the details. For the ABA services received overseas, beneficiaries can submit claims for reimbursement from February 16, 2008. For ABA services received in the United States, beneficiaries can submit claims for reimbursement from February 16, 2010. Of course, claims submissions must be in accordance with TRICARE filling deadlines and policy. Beneficiaries need to discuss with their TRICARE MCSC about filling claims for services received after the effective date of the new policy, July 27, 2012. 
  • What providers are eligible to provide ABA Therapy and how much will beneficiaries pay? According to TMA, the TRICARE MCSCs are building a network of Board Certified Behavior Analysis (BCBAs). BCBAs are the only authorized providers under the basic “medical” plan. Whether the provider is in the TRICARE network, whether the beneficiary is enrolled in TRICARE Prime or using Standard, and whether the beneficiary is an active duty or retiree family member will be factors in determining beneficiary costs. 
  • How will the basic “medical” benefit and ECHO (Extended Care Health Option) work together? Active duty beneficiaries with a diagnosis related to Autism Spectrum Disorder (ASD) will be able to receive ABA services under both the basic “medical” and the ECHO benefit. Tutors will continue to be an option for these beneficiaries who are part of the ECHO Autism Demonstration. Active duty beneficiaries will remain eligible for ECHO and the $36,000 benefit cap a year. Only “medically necessary” services will be authorized and covered under the TRICARE “basic” benefit. Active duty beneficiaries will work with their Primary Care Manager and case manager on benefit coordination between the basic “medical” and ECHO.

We also asked about the recent change by TMA to exclude beneficiaries with non-ASD diagnoses from receiving ABA therapy under the ECHO program. We were assured non-ASD diagnosed beneficiaries currently receiving ABA therapy under ECHO will be provided a “soft landing” during this transition. TRICARE MCSCs and case managers are working with impacted families on individualized “transition” plans. The MCSCs and case managers will offer families a re-evaluation of all “coverage” available to make sure they are fully participating in all available TRICARE benefits. Non-ASD diagnosed beneficiaries will have the opportunity to have their diagnosis re-assessed.

It is important to note that TMA is still developing its guidance for the interim benefit. Beneficiaries should expect more information and possible changes in how the benefit will be administered in the months ahead. You can keep up with the latest information by signing up for updates on the Applied Behavioral Analysis page of the TRICARE website.

Our Association has written in past Military Family Topics on this topic. Please read each of these articles for additional details and general information.

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 these changes will impact your family.

(Source: http://www.tricare.mil/abatherapy/)

 

 

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