Autism Care Demonstration: General

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).

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.

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 testing. 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.

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.

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 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.

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).

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.

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.

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.

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.

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.

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.