By Cheryl Pellerin
DoD News, Defense Media Activity
WASHINGTON, Oct. 10, 2014 - TRICARE has delayed until April a 46-percent reduction in the reimbursement level for some autism services while it awaits the results of an independent assessment of the prevailing rate for the services, defense officials said today.
The reduced reimbursement rate -- for one-on-one therapy with a board-certified behavior analyst for those with autism spectrum disorder -- was one of several program changes scheduled to go into effect Oct. 20 as TRICARE implements its new Comprehensive Autism Care Demonstration, or Autism Care Demo.
On Sept. 19, after the Defense Department published related changes to the TRICARE Operations Manual, providers and beneficiaries raised issues.
Rand Corp. independent analysis
On Oct. 8, Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson directed that the rate change be postponeduntil April 20, 2015, while RAND Corp. completes an independent analysis of prevailing rates for the service.
TRICARE will continue to pay the previous rate of $125 an hour for one-on-one therapy with a board-certified behavior analyst rather than the new $68-per-hour rate. Defense officials say the new Autism Care Demo does not cut applied behavior analysis benefits.
The new TRICARE Autism Care Demo began July 25 and replaces current applied behavior analysis benefits with one simple program, according to the TRICARE website.
TRICARE-covered services
TRICARE covers the following services under the basic applied behavior analysis benefit, and a TRICARE-authorized board-certified behavior analyst must provide the services:
-- An initial applied behavior analysis assessment and treatment plan;
-- Direct one-on-one applied behavior analysis services;
-- Supervision of subordinate applied behavior analysis providers;
-- An updated applied behavior analysis treatment plan and updates; and
-- Training of family members or caregivers.
According to TRICARE, those who already have been diagnosed with autism spectrum disorder and now receive applied behavior analysis will not lose coverage and will automatically move to the new program by Dec. 31.
Those who are diagnosed with autism spectrum disorder after July 25 will receive current benefits under the Autism Care Demo byDec. 31. Beneficiaries should contact their regional or plan contractor for information about how to get started.
What's new?
What's new about the Autism Care Demo is that there is one benefit -- everyone gets the same applied behavior analysis benefits. The demo also expands the time period allowed for testing. Beneficiaries have a year to get the Autism Diagnostic Observation Schedule-2 assessment, if it is needed.
The new demo has no maximums, also called caps. There is no $36,000 annual cap, no lifetime cap and no maximum age for benefits.
The demo also has simplified diagnostic criteria. For example, specialized autism spectrum disorder diagnosing providers can waive the Autism Diagnostic Observation Schedule-2 requirement.
These specialized providers are board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry, or licensed clinical psychology at the doctoral level.
Expanded assessment options
The new demo also offers expanded progress assessment options. Board-certified behavior analysts can choose the assessment tool or other metric to measure progress.
Under the new Autism Care Demo, beneficiary costs for applied behavior analysis will not increase, the TRICARE website says. A beneficiary's plan and type of provider used determine how much such services cost.
To see a board-certified behavior analyst who has a master's degree or higher, active-duty family members with TRICARE Prime would pay nothing. Active-duty family members with TRICARE Standard or Extra and TRICARE Reserve Select would pay 15 percent of the cost for an in-network provider and 20 percent for an out-of-network provider.
To see a board-certified behavior analyst who has a master's degree or higher, retired family members with TRICARE Prime would pay a $12 copay. Retired family members with TRICARE Standard or Extra and TRICARE Retired Reserve would pay 20 percent for an in-network provider and 25 percent for an out-of-network provider.
Non-active-duty family members who see a board-certified assistant behavior analyst or a behavior technician will continue to pay a 10-percent cost share for supervised applied behavior analysis. Active-duty family members will continue to pay their extended health care option enrollment fee for the same services.
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