TRICARE Makes Changes to Autism Demo

TRICARE Makes Changes to Autism Demo: More Families Likely to Use ABA Benefit

For Non-Active Duty families (Retired, Reserve, and National Guard):

TRICARE has made major changes to the costs of the Autism Care Demonstration program, which covers Applied Behavior Analysis for eligible beneficiaries with a qualified family member:

  • Beginning October 1, 2015, Autism Care Demonstration cost-shares now match TRICARE Prime and Standard cost-shares for all ABA services provided by authorized ABA supervisors, assistant behavior analysts and behavior technicians (see below)
  • “Tiered” ABA services, those provided by assistant (supervised) ABA analysts and behavior technicians (ABA Tutors), no longer cost non-Active Duty members a 10% cost-share.
  • Any cost-shares that apply now count towards the family’s annual catastrophic cap, which is TRICARE’s term for annual out-of-pocket costs.

TRICARE’s definitions for types of ABA providers can be found on this TRICARE Fact Sheet  http://www.tricare.mil/~/media/Files/TRICARE/Publications/FactSheets/ACD_FS.pdf    (external link-download)

Provider Availability

 As a result of the reduction in TRICARE cost shares, demand for ABA services may increase. TRICARE has introduced additional provider requirements that may temporarily affect provider availability:

  • All ABA providers must now be trained in Basic Life Support (BLS) by December 31, 2015.
  • Behavior technicians (ABA Tutors) are now required to obtain their certification from a TRICARE-approved organization.

How Much Will ABA Cost Families?

TRICARE cost-shares depend on the service member’s status (Active-duty, Retired, Reserve / National Guard) and their TRICARE plan:

  • TRICARE Prime
    • Active duty family members: $0
    • Retired service members and families: $12
  • TRICARE Standard and Extra
    • Active duty family members:
      • 15% in network
      • 20% out of network
    • Retired family members:
      • 20% in network
      • 25% out of network
  • TRICARE Reserve Select
    • 15% in network
    • 20% out of network
  • TRICARE Retired Reserve
    • 20% in network
    • 25% out of network

There are no annual or lifetime caps on the amount of ABA TRICARE covers—this means the family member will not have to stop ABA services at any point in the year due to having reached a benefit maximum.

Respite Care for Active Duty Families Receiving ABA Services

Although ABA services have been “separated out” into the Autism Care Demonstration, the Demonstration project is still considered an Extended Care Health Option (ECHO) benefit for Active Duty families. Active Duty families must be enrolled in the Exceptional Family Member Program (EFMP) and registered for the Extended Care Health Option (ECHO) in order to participate in the Autism Care Demonstration.

These families are eligible for the 16-hour per month respite care benefit through ECHO. To receive respite care, a family must use at least one (1) other ECHO benefit during the month respite care is received. Because ABA services are considered an ECHO benefit for Active-Duty families, they can use ABA as their “other ECHO benefit” to get respite care.  There is no cost-share for Active Duty families using ABA services; however, if they choose to use another ECHO benefit such as respite care, the usual ECHO cost-share will apply for the month during which they use that service.

For more information about the changes to this benefit, visit the Autism Care Demonstration page on the TRICARE website. (external link)

For a PDF version of this document, please contact us at thebranch@wapave.org or by calling 253.565.2266, ext. 112