Fort McCoy News August 23, 2013

Non-active-duty autism cases covered by TRICARE

Effective immediately, a new Applied Behavior Analysis (ABA) one-year pilot program for non-active duty Families with autistic members is in effect.

The ABA Pilot program applies only to non-active-duty Family members (ADFMs) (including Retiree Family members or TRICARE Reserve Select/TRICARE Retired Reserve/TRICARE Young Adult enrollees) diagnosed with Autism Spectrum Disorder (ASD), where ABA is deemed medically appropriate.

To qualify for ABA under the interim ABA policy, beneficiaries must be diagnosed with an Autism Spectrum Disorder by a TRICARE-authorized primary care provider or specialized ASD provider, which include:
• Any primary care manager if enrolled in TRICARE Prime, TRICARE Prime Remote, TRICARE Young Adult-Prime, or the US Family Health Plan.

• TRICARE-authorized Family practice, general medicine, internal medicine, and pediatric physicians if using TRICARE Standard and Extra, TRICARE Reserve Select or TRICARE Young Adult-Standard Physician board-certified or board-eligible in developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology or child psychiatry Ph.D. or Psy.D. clinical psychologist working primarily with children.

The ABA Pilot allows non-ADFMs to have a treatment option similar to the ADFM personnel enrolled to the extended care health option (ECHO) program.

Although the programs are not identical, it does allow ABA benefits to become more-widely available as the current best medical practice is to use tutors and Board Certified Assistant Behavioral Analysts (BCaBAs) more than the Board Certified Behavior Analysts (BCBAs).

No changes were made to the ABA reinforcement for ADFMs under the ECHO (outlined in TRICARE Operations Manual, Change 68, published Jan. 11, 2012). Beneficiaries with ASD will continue to receive basic TRICARE ABA coverage from BCBAs and BCBA-Doctorate(s).

TRICARE also continues to provide all necessary treatment for ASD, such as psychometric testing, physician services, psychological services, speech therapy, occupational therapy, physical therapy and pharmacy.

Under Section 705 of the National Defense Authorization Act (NDAA) for Fiscal Year 2013, the ABA Pilot was created.
The major change in ABA services created by Section 705 allows non-ADFMs participating in the ABA Pilot to receive ABA reinforcement from BCaBAs and minimally trained tutors being supervised by a BCBA or higher if they meet established ABA requirements (TRICARE Policy Manual, published June 25, 2013), to include diagnosis and testing criteria.

The ABA Pilot allows nonADFMs to obtain up to $36,000 per year of additional ABA reinforcement for services received from supervised BCaBAs and supervised tutors (not currently covered by the Basic TRICARE Programs).

Few, if any beneficiaries, are likely to exceed the $36,000 annual cap applicable to ABA reinforcement, according to TRICARE.

A 10 percent cost-share associated with these services is in effect. These services are in addition to ABA and supportive benefits currently available under TRICARE Policy.

For more information about these programs in the Fort McCoy community, visit the website or call the Health Benefits Adviser Office at 608-388-2246.

(Submitted by Fort McCoy Health Benefits Adviser Office based on information provided by TRICARE.)