Autism Care Demonstration

The TRICARE Comprehensive Autism Care Demonstration covers applied behavior analysis services. Under the ACD, ABA services are authorized to target the core symptoms of autism spectrum disorder.

ASD affects essential human behaviors such as social interaction, the ability to communicate ideas and feelings, imagination, and relationship formation. TRICARE covered services must be clinically necessary and appropriate. These include occupational therapy, physical therapy, speech therapy, psychological services, psychological testing, and prescription drugs. The TRICARE medical benefit covers these services.

ABA services are a benefit covered under the ACD. This is separate from the TRICARE medical benefit. ABA services are a set of techniques based on behavior modification principles, like positive reinforcement, to increase or decrease targeted behaviors. ABA services can help develop skills like language and social interaction. These services can also help to decrease maladaptive behaviors. TRICARE covers clinically necessary and appropriate ABA services that target the core symptoms of ASD.

The ACD began on July 25, 2014. It’s currently authorized to run through Dec. 31, 2028.

Does your child qualify for the ACD?

ABA services are covered under the ACD for all qualifying family members of active duty service members, retirees, and certain National Guard and Reserve members.

To qualify for the ACD, your child must be:

• Enrolled in a TRICARE health plan
• Diagnosed with ASD by an approved provider

Are you an active duty service member?

ADSMs with a child diagnosed with ASD must enroll in your service branch’s Exceptional Family Member Program. Your child must also enroll in the Extended Care Health Option.

• EFMP works to help military families with special needs during the duty assignment process and after families have arrived at their new installation. Each service branch has its own EFMP and enrollment process. Contact your service branch or visit Military OneSource for more information
• ECHO provides supplemental services to active duty family members with qualifying psychological or physical disabilities.

Is ACD available overseas?

Yes. However, it’s only available in very few locations overseas. Generally, the ABA sole provider model provided by board certified behavior analysts is the only model that’s authorized and reimbursed overseas. Tiered ABA services aren’t authorized overseas, except in U.S. territories. Contact your regional call center when seeking ABA services. They’ll walk you through the process.

How the ACD Works

Follow the steps below to get started.

Step 1: Get diagnosed

Your child must be diagnosed by an approved diagnosing provider, which includes either:

• Family practice physicians
• Pediatricians
• Pediatric or family nurse practitioners

Board-certified or board-eligible physicians in the following disciplines:

• Licensed clinical psychology, doctoral level
• Doctors of Nursing Practice, meeting certain criteria
• Developmental behavioral pediatrics
• Neurodevelopmental pediatrics
• Pediatric neurology
• Adult or child psychiatry
  

Step 2: Get a referral and pre-authorization

• Your child must get a referral to the ACD and a pre-authorization for all ABA services. All TRICARE plans require this.
• Your child’s diagnosing provider will submit a referral to your regional contractor* or US Family Health Plan provider for authorization.
• Your child will get an authorization letter for six months of ABA services.
  • A new referral from your ASD diagnosing provider is required every two years.

*ABA services are only available in locations with board-certified behavior analysts.

Are you requesting ABA services for the first time?

• You’ll get an authorization letter for your child from your regional contractor or USFHP provider. This authorization covers your child’s ABA assessment.
• Your provider will complete your child’s ABA assessment. Then, your provider will develop your child’s treatment plan.
• You’ll get an authorization letter for six months of ABA services. Your child’s provider will request reauthorization every six months.

Step 3: Complete outcome measures

• You and your child’s provider team must complete four baseline outcome measures before your child can get ABA services. This will help monitor your child’s progress. The four measures are the:
  • Pervasive Developmental Disorder Behavior Inventory
  • Vineland Adaptive Behavior Scales
  • Social Responsiveness Scale
  • Parent Stress Index or Stress Index for Parents of Adolescents
• You must complete the four outcome measures every six months or every 12 months. The frequency depends on the measure.

Step 4: Schedule an appointment

When you get your child’s authorization letter:

• Schedule your child’s ABA assessment appointment. Your child’s authorization letter gives you the provider’s contact information. Check your authorization status.
• If you’d like to see a different provider, or if you aren’t offered care within the 28-day specialty careSpecialized medical/surgical diagnosis, treatment, or services a primary care provider isn’t qualified to provide. access standard, contact your:
  • Regional contractor
  • USFHP designated provider

Your authorized ABA supervisor:

• Oversees your child’s ABA treatment program
• Helps you to develop goals. These goals are for your participation in your child’s ABA treatment plan.
• Updates your child’s treatment plan. This will be done before your child’s next authorization period.

Step 5: Work with your autism services navigator

TRICARE will assign your child an ASN. Your child’s ASN acts as the primary care coordinator. Beneficiaries who are assigned an ASN must complete a comprehensive care plan within 90 days.

You and your child’s ASN will develop your child’s comprehensive care plan. Your child’s CCP will:

• Set goals
• Track timelines. These timelines include for both outcome measures and authorization dates.
• Connect you with:
  • Clinical resources
  • Non-clinical resources
• Provide discharge, moving, or transition support

Note: You won’t have an ASN if you’re enrolled in the USFHP or if you live overseas.

Paying for ABA Under the Autism Care Demonstration 

You pay the copayment or cost-share for your TRICARE plan for all ABA services. All ABA services rendered on one day will be subject to one copaymentA fixed dollar amount you may pay for a covered health care service or drug.. 

Note: These amounts apply to your calendar year (Jan. 1–Dec. 31) catastrophic cap. There aren’t yearly or lifetime caps on the amount of ABA services TRICARE covers. This means your child won’t reach a benefit maximum and have to stop receiving clinically necessary and appropriate ABA services.