Applied Behavior Analysis Maximum Allowed Amounts

The current ABA reimbursement rates were established more than eight years ago when no analytical data was available to determine such rates.  Today, there is data available through Medicaid and commercial insurance rates to equably determine fair and balanced reimbursement rates for the multiple levels of ABA providers, services, evaluations, and supervision that are consistent with the procedures used by TRICARE to determine the CHAMPUS Maximum Allowable Charge for other medical treatments and procedures. These new rates were announced December 1, 2015 and will go into effect in March or April 2016 to coincide with annual CMAC rate changes.

The implementation and evaluation of the Autism Care Demonstration is very important to TRICARE with a priority on providing the highest quality, effective treatment for TRICARE beneficiaries.  Over the past year, we have conducted four Roundtable discussions chaired by the Assistant Undersecretary of Defense for Personnel and Readiness that were widely attended by ABA providers, military pediatric physicians, ABA certification organizations, DHA personnel, and autism advocacy groups.  Together we gained a greater understanding of the field of ABA services. We then commissioned two independent research groups to thoroughly evaluate amounts paid by commercial and government payers for ABA services.  They delivered reports based on both Medicaid and commercial insurers’ ABA reimbursement rates.  TRICARE rates are primarily based on Medicare reimbursement rates.  Since Medicare does not cover ABA services, a further analysis was conducted to determine the average difference between Medicaid and Medicare reimbursements for a number of high-volume TRICARE mental health service codes.  The Medicaid rates were then adjusted so that the resulting rates approximate what Medicare would have paid for ABA services.  TRICARE leadership is confident that our careful analysis of rates resulted in fair and equitable reimbursement rates that remain among the highest across the industry.

We have established a national rate for all categories of ABA care which is consistent with every other medical need TRICARE covers.  In addition, TRICARE implements a universally established procedure to adjusting the national rate to reflect the capacity of the provider network and the cost of living in 88 localities across the country using the Medicare Geographic Practice Cost Index (GPCI).  The reimbursement rates of virtually all TRICARE covered benefits apply this method.  Having the GPCI applied to ABA is a step towards transitioning ABA from an educational resource to a medical service which is stated as an objective of this demonstration project.  Locality rates have also now been calculated and released on December 1, 2015.

This process ensures the ABA rates will be adjusted annually based on the established or newly created statewide Medicaid rates and published at the same time as the CHAMPUS Maximum Allowable Charge rates, which is normally in March or April of each year.

The establishment of a national rate based on the CHAMPUS Maximum Allowable Charge and locality rates through Medicare Geographic Practice Cost Index is standard procedure for the administration of medical benefits under the TRICARE Basic Program. There are 88 local geographic areas under TRICARE.  Each area is evaluated for both cost of living, and network capacity to provide services.  This approach is consistent with our goal to develop efficient and appropriate means for delivering ABA services, create a viable economic model, and maintain administrative simplicity while ensuring access to the best possible care. Access to appropriate and effective health care is our first priority.  Integrating ABA services under the standard administration of medical benefits is a necessary step in the evolution of ABA services from an educational discipline to a medical discipline.  Our rates continue to be very competitive and well above Medicare and most commercial rates.

Recent changes to the ACD now align cost shares and catastrophic cap protections with each beneficiary’s TRICARE option (Prime or Standard), reducing the cost share burden for many of the families.  Further, for those beneficiaries who pay a percentage cost-share whose providers are reimbursed at a lower rate than the legacy rate, the beneficiaries’ cost-share will also decrease.  This combination of changes will reduce the “out-of-pocket” cost for many beneficiaries and their families.

The rates will be released and effective the same date as the CMAC annual rate adjustment for all medical care, typically in the spring of each year. We expect the 2016 CMAC to be released in March or April 2016.