ABA Maximum Allowed Amounts (rates effective Spring 2016, with 15% Max Reduction applied), updated 4/25/16
These rates were calculated by updating the National Rates presented at the ABA Roundtable (Dec 3, 2015) based on a re-survey of the states' Medicaid rates in January and February 2016. The updated National Rates were then adjusted using the Medicare geographic locality factors, exactly as used to adjust all other TRICARE rates. The rates depicted are either the actual rate calculated or the current rate less 15%, whichever is higher. The rates have also been adjusted to ensure that they are no less than the Medicaid rates in those states which have adopted statewide Medicaid rates for these services. The rates are effective April 1, 2016, for the localities below numbered 301-389. The rates without a locality number at the bottom are effective May 1, 2016. The rates, like all other TRICARE rates, will be reviewed and appropriately adjusted annually and published at the same time as the CHAMPUS Maximum Allowable Charge rates (usually in March or April). If Medicare establishes rates for ABA services, those rates will be adopted by TRICARE as required by law.
NOTES: (1) Rates are for 60 minute sessions with exception of non-hourly rates. (2) This version corrects a calculation error regarding the 14 new localities listed at the bottom.
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Reports on ABA Reimbursement Rates
The two reports on ABA reimbursement rates are attached as announced at the Autism Roundtable on Dec. 3, 2015. The first report was completed by the RAND Corporation and the second by Kennell and Associates, Inc. In general, TRICARE professional rates are based on the Medicare reimbursement rates, but since Medicare does not cover ABA services, the studies were requested to determine the commercial and Medicaid reimbursements for the specific ABA services covered by the TRICARE Autism Care Demonstration. DHA reviewed the reports and decided to adopt the "National Rates" proposed as Option 3 in the Kennell and Associates report. These National Rates were calculated using the statewide Medicaid rates (from the 29 States with established statewide rates) after increasing those rates to adjust for differences in reimbursement rates between Medicaid and Medicare. The National Rates (calculated annually) are then adjusted using the Medicare Geographic Practice Cost Index (GPCI) to create rates for each of the 89 localities recognized by Medicare. Adopting this rate calculation process ensures the ABA rates are not frozen for another seven year period as they will now be reviewed and appropriately adjusted each year like all other TRICARE rates. TRICARE leadership is confident that the careful analysis of rates resulted in fair and competitive reimbursement rates. If Medicare establishes rates for the eight CPT codes TRICARE recognizes, those rates will immediately be adopted as required by law.
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Description |
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| Kennell Report: Options for 2016 TRICARE ABA Reimbursement Rates |
This report, prepared by Kennell and Associates, Inc. provides alternative methods that the Defense Health Agency could use to calculate the 2016 TRICARE national maximum allowed amounts for Applied Behavior Analysis services. |
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| RAND Report: TRICARE Applied Behavior Analysis Benefit |
This report, prepared by the RAND Corporation, provides a comparison of TRICARE's current applied behavior analysis benefit with Medicaid and commercial benefits. The comparison includes reimbursement rates, copayments and annual caps. |
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4/25/2016
NOTE: These rates were calculated by updating the National Rates presented at the ABA Roundtable (Dec 3, 2015) based on a re-survey of the states' Medicaid rates in January and February 2016. The updated National Rates were then adjusted using the Medicare geographic locality factors, exactly as used to adjust all other TRICARE rates. The rates depicted are either the actual rate calculated or the current rate less 15%, whichever is higher. The rates have also been adjusted to ensure that they are no less than the Medicaid rates in those states which have adopted statewide Medicaid rates for these services. The rates are effective April 1, 2016, for the localities below numbered 301-389. The rates without a locality number at the bottom are effective May 1, 2016. The rates, like all other TRICARE rates, will be reviewed and appropriately adjusted annually and published at the same time as the CHAMPUS Maximum Allowable Charge rates (usually in March or April). If Medicare establishes rates for ABA services, those rates will be adopted by TRICARE as required by law.NOTES: (1) Rates are for 60 minute sessions with exception of non-hourly rates. (2) This version corrects a calculation error regarding the 14 new localities listed at the bottom.
Recommended Content:
Autism Care Demonstration, Applied Behavior Analysis Maximum Allowed Amounts
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