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Autism Speaks Reports On Efforts To Improve New TRICARE Plan

October 24, 2014

WASHINGTON, DC (October 24, 2014) -- Autism Speaks, military families and other service and advocacy organizations met last week with TRICARE and Department of Defense (DoD) representatives to address questions and concerns regarding coverage of Applied Behavior Analysis (ABA) under TRICARE’s new Autism Care Demonstration (ACD). A copy of TRICARE meeting handouts is included HERE.

The following summary of the TRICARE meeting is to help inform the community of issues discussed. Confirmation with your regional contractor is strongly recommended before making any decisions affecting your operations or a beneficiary’s treatment plan. If you are not receiving a timely or complete response to your policy questions from the regional contractor, please email us at

  1. Reimbursement rate cuts to services delivered by a Board Certified Behavior Analyst (BCBA) and Board Certified Assistant Behavior Analysts (BCaBA) have been put on hold for 180 days. The DoD has contracted with the RAND Corporation to conduct an independent study to assess ABA reimbursement rates. The Contractor shall continue to process claims at the prior reimbursement rates of $125 for services delivered by a BCBA and $75 for one-on-one ABA delivered by a BCaBA. A copy of TRICARE’s letter to the regional contractors can be found HERE.
  2. TRICARE confirmed that BCBA delivered services can be combined with the tiered service delivery model provided one BCBA is designated for treatment plan oversight.  We requested this be clarified in policy to ensure consistent implementation across the three regions.
  3. The issue of one BCBA per case was raised, and TRICARE representatives confirmed that this meant that one BCBA must be responsible for care coordination and oversight of the patient’s treatment plan. TRICARE further explained that this was “a billing issue” and “the ACD does not limit a team approach to ABA or preclude consultation with or assistance by other BCBAs.” We requested this be clarified in policy to ensure consistent implementation across the three regions.
  4. BCaBAs may perform supervision duties, but must also work under the supervision of a BCBA. When asked how BCaBA supervision services were to be billed, TRICARE explained that the BCaBA supervision must be billed by the BCBA. We requested this be clarified in policy to ensure consistent implementation across the three regions.
  5. Concern was raised that the new Registered Behavior Technician (RBT) certification requirement may result in treatment delays. A one-year delay of this requirement was proposed by attendees. TRICARE agreed to re-examine its RBT timeline and the additional requirements it places on technicians over and above the RBT requirements.
  6. There was discussion regarding the discharge criteria and the two-year clinical review included in the ACD policies; concerns were raised that other outpatient services do not have discharge criteria mandated in policy. The disparity between TRICARE’s discharge criteria and the BACB guidelines was also discussed. TRICARE assured attendees that this language was not intended to discharge patients from care and that such decisions should be made at the clinician level with patients and parents. TRICARE agreed to reconsider the discharge language and the necessity of a two-year clinical review.
  7. Concerns about the minimum age eligibility of 18 months were raised. TRICARE agreed to re-examine this requirement.
  8. TRICARE confirmed that the monthly five percent supervision rule applied to time the behavior technician spends with each ABA recipient.
  9. There was discussion emphasizing the importance of ensuring referring physicians receive a copy of the ABA treatment plan and progress report each six months.
  10. There was discussion about expanding the pool of ABA providers to include licensed clinical psychologists as long as ABA was in the scope of their practice. TRICARE agreed to reconsider including licensed clinical psychologists as authorized ABA providers.
  11. Concerns were raised that not all cost shares under the ACD accrue to the family catastrophic cap, resulting in significant out-of-pocket costs for non-active duty family members and effectively barring access to recommended treatment services. TRICARE and DoD personnel agreed to re-examine the ACD cost shares and catastrophic cap concerns, but it was unclear what the timetable for that would be.
  12. Because of time, the group was not able to discuss concerns regarding limitations on treatment domains, but the handouts TRICARE provided for the meeting include assurances that, "The ACD interprets the medically identified ASD treatment domains as behavior, communication, and social skills broadly to include the array of targets identified by the BCBA during the development of the ABA treatment plan. The ACD does not limit ABA treatment plan targets developed by the BCBA but rather leaves treatment plan targets to the professional judgment of the BCBAThe change in terminology is intended to map care and treatment to medically defined requirements – not to limit the scope of care that can be provided.”

Autism Speaks will continue to work for positive policy improvements to ensure all beneficiaries with autism have access to affordable and timely services in a manner consistent with best practices.  As policy develops, we will work to keep the community informed.