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Autism Care Demonstration

TRICARE covers applied behavior analysis (ABA) for all beneficiaries through the TRICARE Autism Care Demonstration.

Autism Roundtable Documents

Download meeting minutes and questions/answers from the Autism Roundtable meetings.

Frequently Asked Questions

General Q&A

Q1:

Are current testing requirements for TRICARE ABA services being reviewed again?

A:

Yes. The Defense Health Agency has provided direction to the TRICARE regional contractors to no longer require the following tests for periodic review and reauthorization for continued ABA services.

  • Autism Diagnostic Observation Schedule (ADOS)
  • Cognitive testing (Wechsler Intelligence scale (WPPSI-IV, WISC-V, or WAIS-4)
  • Test of Nonverbal Intelligence (TONI) 

The removal of these outcome measures from TRICARE Autism Care Demonstration (ACD) requirements is effective May 17, 2017.  Requirements are unchanged for the Vineland Adaptive Behavior Scale and the Pervasive Developmental Disabilities Behavior Inventory (PDDBI).

Q2:

When will new testing requirements go into effect?

A:

The removal of the ADOS and cognitive testing from TRICARE Autism Care Demonstration requirements is effective May 17, 2017, the date of issuance of the Contracting Officer's Common Letter.  If additional future testing changes are made, we will ensure beneficiaries have sufficient time to schedule and complete any new requirements and we will work closely with beneficiaries who face challenges to ensure there is no disruption to care.

Q3:

I’m a beneficiary. I’m confused about TRICARE’s new Applied Behavior Analysis (ABA) coverage. It requires testing be done as part of a 2-year review process. My understanding is my child needs to get the testing done before TRICARE authorizes care for another 2 years. My child’s authorization ended in January 2017. Does he have to wait for the testing to be done before he can continue ABA services?

A:

TRICARE will continue to cover your ABA services as it moves to the new 2-year review requirement. The Defense Health Agency (DHA) knows it may be difficult in some areas to get appointments with specialized ASD diagnosing providers who can do the required resting. So:

  • If your child’s testing and 2-year review were approved before December 31, 2016, you now have 2 years to get the testing done before your authorization ends.
  • If your child’s 2-year review is due between January 1, 2017 and March 31, 2017, your ABA provider may ask your regional contractor to extend your child’s current ABA authorization. The provider needs to note that your child can’t get an appointment with a specialized ASD diagnosing provider before the current authorization ends.
  • If your child’s 2-year review is due after March 31, 2017 (beginning April 1, 2017), you have to complete and submit the results of the required testing as part of the 2-year review to get an authorization for 2 more years of ABA.
Q4:

The November 29, 2016 TRICARE Operations Manual (TOM) revision states that all beneficiaries diagnosed before October 1, 2014 must be re-diagnosed. Can you provide an explanation as to why beneficiaries diagnosed before October 20, 2014 now must receive a new diagnosis?

A:

Beneficiaries diagnosed before October 20, 2014 do not require a new diagnosis. The requirement is for all diagnoses to conform to the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5) classification. The TOM states, “…previously diagnosed beneficiaries (those diagnosed prior to October 20, 2014) receiving Applied Behavior Analysis (ABA) services for these disorders must conform to the DSM 5 criteria upon the next Periodic ABA Program Review per paragraph 8.5.” (TOM Chapter 18, Section 18, Paragraph 4.9). According to the DSM-5, “Individuals with a well-established DSM-IV (DSM - Fourth Edition) diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder.” No beneficiary is losing services based on the requirement to conform to the revision of the DSM-5 publication.

Q5:

Is there a timeline when the contractors will receive direction to pay at the rates put into law by the National Defense Authorization Act (NDAA) Fiscal Year (FY) 2017?

A:

DHA took immediate action to implement the revised Applied Behavior Analysis (ABA) reimbursement rates when the NDAA for FY 2017 was signed by the President on December 23, 2016. DHA in is in the process of coordinating contract guidance to the TRICARE regional contractors about implementing the revised rates. Revised rates will be retroactive to the effective date of the signing of the NDAA for FY 2017 on December 23, 2016. All claims submitted with a date of service of December 23, 2016 or later will be processed or re-processed at the revised rates. Due to the time required to reprogram payment systems, some claims may initially be paid at the previous (pre December 23, 2016) rates, but these will automatically be reprocessed and any difference between the rates will be paid to the provider. Once the revised rates are provided to the TRICARE regional contractors the rates will be posted on the publicly-available ABA Rates Page.

Q6:

Given that the requirement for the PDDBI (Pervasive Developmental Disorder Behavior Inventory) was published November 29, 2016, is there a grace period for when this requirement will be required? Also, there are two assessment forms. Which forms are required?

A:

The publication date of the change to the TOM which requires the PDDBI was November 29, 2016, and the effective date of this requirement was January 1, 2017. DHA recognizes that some ABA providers need to purchase the PDDBI and the tool may be on back order. Therefore, DHA will advise the contractors to allow a grace period until April 1, 2017 in order to permit time for BCBAs to purchase and become trained on this measure. There are two forms to the PDDBI: a parent form and a teacher form. Both forms are required. However, the teacher form can be completed by a Board Certified Behavior Analyst (BCBA), or assistant behavior analyst, who has significant knowledge of the beneficiary (interpreted from the PDDBI manual).

Q7:

While the PDDBI assessment is a validated tool for assessing areas of need for patients with autism, it has only been validated for patients between the ages 2 through 12.5 years old. The PDDBI has not been validated for younger and older patients. Can you please advise how ABA providers are to address patients outside the PDDBI age range?

A:

DHA is aware that the publisher of the PDDBI will be releasing a version of the tool that covers the ages of 13-18 years. With the anticipated release of the PDDBI for ages 13-18 years at the end of the first quarter of 2017 (per publisher), DHA will delay the requirement for the every 6-month testing for children under 2 or over 12.5 years until the second quarter 2017 when the PDDBI for ages 13-18 years is available. Children under 2 will not be subject to the PDDBI requirement until they reach the age of 2 years.

Q8:

One of the regions is requiring the use of the Gilliam Autism Rating Scale, Third Edition (GARS-3) for children outside the age limits of the PDDBI. This diagnostic tool is not appropriate for BCBAs to use as it violates our certification and state laws. Can you please provide guidance on how to address this issue with the contractor?

A:

Since the PDDBI is only valid for ages 2 – 12.5, DHA allows regional contractor discretion but suggested the use of the GARS-3 for the every 6 months tool for beneficiaries outside this age range. DHA has received multiple inquiries regarding the BCBA competency and ethical use of this tool. With the anticipated release of the PDDBI for ages 13-18 years at the end of the first quarter of 2017 (per publisher), DHA will delay the requirement for the every 6-month testing for children over 12.5 years until the second quarter 2017 when the PDDBI for ages 13-18 years is available, thus eliminating the need for the GARS-3.

Q9:

Would DHA consider making remote parent training, (Current Procedural Terminology code 0370T) via real time, acceptable?

A:

Telehealth into the home is inconsistent with the current TRICARE telehealth policy (See TRICARE Policy Manual Chapter 22, Section 19.1) and therefore, remote parent training into the home is currently not authorized. The current telehealth policy under the TRICARE Basic program is under revision and DHA will continue to monitor the development of the research literature on the use of telehealth for parent guidance for the diagnosis of Autism Spectrum Disorder.

Q10:

The November 29, 2016 change to the TOM states that no Qualified Autism Services Practitioner (QASP) will be able to provide supervision until the Qualified Applied Behavior Analysis (QABA) certification board develops a comparable course to that provided by the BACB. QABA has developed a supervisory course, effective January 1, 2017, for QASPs that meets the manual language of: "An equivalent eight-hour supervisory training course is required of QASPs certified by QABA” (TOM Chapter 18, Section 18, Paragraph 6.2.6.). Why are QASPs still receiving notification they are not permitted to supervise BTs?

A:

DHA has issued a clarification. QABA has met this TOM requirement by developing an equivalent eight-hour supervisory training course program for QASPs who are certified by QABA. QABA has designated the use of "S" (for supervisor) for those QASPs who complete this training. Beginning January 1, 2017 (the effective date of this manual change), QASPs certified by QABA with an active "S" designation status (QASP-S) may supervise BTs.

Q11:

The new requirement that one BT supervision be conducted in person every 30 days would significantly impact families receiving ABA services. Since its inception in 2008, the TRICARE autism demonstrations have supported distant supervision. Moreover, the Behavior Analyst Certification Board (BACB) guidelines and definitions of “face-to-face” supervision includes “real time video and audio” as acceptable and appropriate practices. Will DHA revisit this requirement for one in-person BT supervision per 30 day period?

A:

While DHA has permitted the remote supervision of BTs throughout the course of the ABA service demonstrations, remote supervision is not the preferred modality for delivering BT supervision. Conducting only remote supervision was not the intent of any iteration of the legacy ABA demonstrations. Per the BACB, “In-person, on-site observation is preferred.” DHA considered this BACB guidance when revising the previous supervision requirement of two supervision sessions per BT per beneficiary per 30-day period. BCBAs who are unable to supervise a beneficiary’s case on a monthly/in-person basis, (or delegate that monthly requirement to an assistant behavior analyst), should contact their TRICARE regional contractor for assistance in reassigning the case to a provider who can meet this supervision requirement.

Q12:

Will DHA reconsider the provisional status of BCBAs, assistant behavior analysts, and BTs?

A:

As stated in the Q&As from the October 19, 2016 Round Table, DHA will not permit a provisional status for BCBAs. DHA is treating this provider category like any other independent provider category that is required to be licensed, fully qualified, and authorized under TRICARE to be reimbursed for service.

Assistant behavior analysts have never been under consideration for a provisional status. As of the November 29, 2016 manual revision (effective January 1, 2017), BTs may be considered for a provisional status (up to 90 days) once they have completed their 40 hour training, passed the BT exam, and obtained Basic Life Support or Cardiopulmonary Resuscitation equivalent certification.

Q&A about the ABA Reimbursement Rates

View the ABA Maximum Allowed Amounts

Q1:

What is the current status on Applied Behavior Analysis (ABA) reimbursement rates?

A:

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.

Q2:

How did TRICARE determine these new ABA reimbursement rates?

A:

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.

Q3:

How do national and locality rates differ?

A:

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.

Q4:

Providers may express concern that these rates won't reflect the cost of providing ABA services?

A:

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.

Q5:

How does this affect the cost to the TRICARE beneficiary?

A:

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.

Q6:

When will the new rates take effect?

A:

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.

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