Legal & Planning

TRICARE Changes Policy on ABA Coverage: What You Need to Know

TRICARE is the health insurance program for the Department of Defense (DoD) which covers military personnel and their families.  According to Autism Speaks, there are approximately 23,000 military kids with autism.

In late June 2013, TRICARE revised its policies for coverage of Applied Behavior Analysis (ABA).  Below is a summary of the major changes set to take effect on July 25.  To understand how these changes might affect your child, please review your policy and contact your health insurance representative.

What Programs Are Covered?

Coverage for ABA is available through the following programs:

• TRICARE Basic (ABA is considered specialty care)
• Extended Care Health Option (“ECHO”)
• Autism Demonstration program
• ABA Pilot program for non-active duty family members.

To participate in the programs, the child must be at least 18 months old, and have been diagnosed with an ASD by a TRICARE authorized primary care physician.  Additionally, families must follow referral, authorization, initial assessment and treatment plan, and updated treatment plan requirements. The programs can cover up to 20 hours per week of ABA with an annual cap of $36,000.  The treatment under any program must be supervised by a Master’s or Ph.D. level Behavior Analyst (see www.bacb.com for information on certification and for a directory of who is certified). On July 18, 2013, the DoD announced that the changes outlined below would only affect those in the pilot program for non-active and retired military personnel and, despite earlier policy notices, would no longer impact those in TRICARE Basic or ECHO Demonstration progra.  However, as the policies evolve and as they are implemented, it is important to talk to your health care benefits representative regarding how the policies will affect your child’s services.

What are the Changes to the Programs?

Most notably, TRICARE has restructured the authorization and referral process, which must now go through the TRICARE Basic program.  Once treatment is authorized, families can receive hours under any of the programs, including the Autism Demonstration and the ABA Pilot programs. Under the referral and authorization system, parents must get a referral from their primary care physician or from a specialized autism provider.  The Managed Care Support Contractor (MCSC) will then refer the family for an ABA assessment, which must include the Autism Diagnostic Observation Scale (ADOS-2) and the Vineland Behavioral Scale (VBS-II). The ADOS is a play and interaction based assessment done by someone with specific training in its scoring and administration.  The VBS is a structured interview that covers many different behaviors and activities.  Based on the results, the provider can submit a request for authorization of ABA treatment.  Part of the referral for authorization of services requires the physician to submit a treatment plan.  As part of the treatment plan, the ADOS must be re-done every year and the VBS-II must be done every 180 days in order to reauthorize treatment.  The tests are done as a way to track progress on the person’s treatment plan. Some problems of note:

1. Not all providers are trained in administering the ADOS or VBS so finding providers and the probable waiting list to see those providers could delay access to treatment, especially for those in rural or underserved areas.  Add in the burden of frequent re-testing and the potential for delays increases dramatically.
2. These tests have not necessarily been validated as a repeated measure to show change over short periods of time.  While these measures have been used repeatedly in short time periods in clinical drug trials, using them as a means of tracking progress on a treatment plan has not been established.
3. Tests aren't necessarily appropriate for everyone and assessments should be determined by the treating provider and based on the child’s personal strengths and areas targeted for improvement.

The issue of re-testing becomes even more problematic if the results are used to discharge a child from ABA treatment.  Under the new policy guidelines, TRICARE can discharge a child from ABA if the child has met all treatment goals, the child is not making any measurable progress (based on the testing described above), the progress is determined not to be generalizable or durable over time, the progress is determined to not be transferrable to a community setting, the child, family or caregiver can no longer participate in ABA, or the child loses TRICARE eligibility.

Duration of ABA Treatment

Finally, TRICARE has limited the duration of ABA treatment to 2 years.  Anyone needing treatment longer than 2 years or any children over the age of 16 who need ABA must request a waiver to continue ABA treatment.  Advocates again are concerned about the restrictive nature of these changes. The changes are set to start on July 25, 2013 and will affect TRICARE beneficiaries in the non-active duty and retired personnel pilot program.  As of July 18, 2013, the changes will not affect TRICARE Basic or ECHO demonstration programs.  However, several questions remain regarding how care will be impacted for those currently receiving services or those in the process of receiving services prior to the changes taking place.  It is important to consult with your TRICARE case manager to see how your child might be affected. For more on this topic, visit www.autismspeaks.org and http://www.tricare.mil/