Health & Safety

December 18, 2015
 

Ask the Doc

99th Medical Group

doctor
Q: Does TRICARE cover applied behavior analysis?
 
A: TRICARE may cover Applied Behavior Analysis (ABA) or other therapeutic services for beneficiaries with Autism Spectrum Disorder. Visit the TRICARE Comprehensive Autism Care Demonstration page for information on how to get ABA care.
How long has TRICARE covered applied behavior analysis (ABA)?
• We’ve covered ABA for active duty family members since 2005 through the Extended Care Health Option (ECHO), and before that, through the Program for Persons with Disabilities.
• The ECHO Autism Demonstration began in March 2008. This demo increased access to supervised services from Assistant Behavior Analysts and ABA tutors (now called Certified Behavior Technicians).
• In August 2012, we expanded coverage to non-active duty family members through the basic program and the ABA Pilot.
• On Dec. 31, 2014, all beneficiaries using the ECHO Autism Demonstration or the ABA Pilot were fully transitioned into the Autism Care Demo.
What’s the difference between the sole provider model and the tiered model, and do I have to choose one option?
• You don’t have to choose between the sole provider model and the tiered model.
• Your child can get ABA services from either or both.
• Whichever model you choose depends on the patient’s individual needs and provider availability.
In a sole provider model, your child gets all applied behavior analysis services from just one provider (Authorized ABA with a Master’s degree or higher).
In a tiered model, your child gets ABA services from a team of providers lead by an Authorized ABA Supervisor. Here’s an example of the tiered model:
• Your child can see both types of providers for different services: Authorized ABA Supervisor for applied behavior analysis assessments, treatment plans and help for parents. Assistant Behavior Analyst or Certified Behavior Technician for direct one-on-one ABA. In this scenario, the Authorized ABA Supervisor submits the bill.
Can we see more than one Authorized ABA Supervisor?
• Yes, but only one Authorized ABA Supervisor is authorized to provide ABA services for each beneficiary at a time. You may seek consultation from another Authorized ABA Supervisor if your treating Authorized ABA Supervisor lacks sub-specialty expertise to treat a specific behavior. When your primary Authorized ABA Supervisor consults with another Authorized ABA Supervisor, your primary Authorized ABA Supervisor remains responsible for the Treatment Plan and is the sole provider authorized to bill for ABA services. You can also request a referral from your primary care physician for a second opinion. Also, ABA may be delivered as a team approach and therefore another Authorized ABA Supervisor may provide ABA services as a team participant. However, the designated Authorized ABA Supervisor remains responsible and is the only one who is authorized to bill for ABA services.
Can I file a complaint about an Authorized ABA, Assistant Behavior Analyst or Certified Behavior Technician?
• Yes, you can file a written complaint or grievance with your regional contractor. If you want to change your provider, please contact your regional contractor and they will assist you.
Can ABA end against parents’ wishes?
• Parents should work with the provider to make decisions together.
• You must follow authorization guidelines and get your care reauthorized every six months.
• Adjustments may be made to the treatment plan.
• Failure to follow the Autism Care Demo requirements could result in denial of claims.
We care about what is best for each child. We will work closely with families and providers in situations where continued coverage becomes an issue.
What happens if my sponsor transitions from Prime to Standard, or vice-versa?
• Your coverage and testing requirements are the same no matter what TRICARE plan you use. Only your costs vary by plan.
What if my sponsor retires from active duty?
• Your Autism Care Demo coverage is the same. Only your costs will change.
Is the Autism Care Demo available overseas?
• Yes, however, the demo is only available in very limited locations overseas. We only cover ABA services overseas when provided by doctoral (PhD) or masters level providers (Authorized ABA Supervisors). We don’t cover ABA services overseas from supervised Assistant Behavior Analysts or Certified Behavior Technicians. Please contact your Regional Call Center when seeking ABA services. We will walk you through the process.
How do our out-or-pocket costs (cost shares and copayments) for applied behavior analysis apply towards our catastrophic cap?
• Cost shares and copayments are required by law. They vary depending on your TRICARE plan and if you have other health insurance. The catastrophic cap is the most your family pays out-of-pocket each year for TRICARE-covered services. All out-of-pocket expenses for ABA services apply to your annual catastrophic cap: $1,000 for active duty families and TRICARE Reserve Select families; $3,000 for retiree families

Send your questions to askthedoc@us.af.mil




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