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Autism Care Demonstration, TRICARE Health Program, Applied Behavior Analysis Maximum Allowed Amounts
Many TRICARE beneficiaries diagnosed with Autism Spectrum Disorder (ASD) receive Applied Behavior Analysis (ABA) care under the Autism Care Demonstration. Beginning spring 2016, TRICARE reimbursement rates for ABA providers under the Demonstration will change to become more consistent with national prevailing rates. The current ABA reimbursement rates will be replaced with rates for each geographic location, similar to how all other TRICARE rates are established.
TRICARE currently pays a single reimbursement rate to all ABA providers, adjusted to their level of education, in the U.S., regardless of location. TRICARE established these rates more than eight years ago when there was no data to determine what actual rates should be. “Adjusting reimbursement rates by location and educational level is standard practice for TRICARE and other health plans,” said Ms. Mary Kaye Justis, Director, TRICARE Health Plan at the Defense Health Agency. “Our highest priority was to establish rates that ensure our beneficiaries have access to ABA therapy while being conscious of prevailing market indexes across the nation.”
TRICARE took several steps to ensure access to care with new reimbursement rates. Efforts to monitor the existing ABA provider networks and add additional providers where needed are ongoing. TRICARE commissioned two external studies to examine ABA costs on a national level. This information allowed TRICARE to establish rates based on how other health plans, including state Medicaid plans, pay ABA providers.
“TRICARE continues to offer one of the most generous ABA benefits in the nation,” said Justis. “Families have been passionate in their advocacy for children diagnosed with ASD and we want you to know that we’ve heard your voices, and TRICARE will continue to listen.”
TRICARE also recently changed ABA cost shares to be consistent with other cost shares under TRICARE PrimeA managed care option available in Prime Service Areas in the United States; you have an assigned primary care manager who provides most of your care.TRICARE Prime and Standard. These changes resulted in a significant benefit improvement by applying the beneficiary’s cost-share for ABA services towards the annual TRICARE catastrophic cap, which limits the maximum out-of-pocket expenses a family will pay per year for their medical care.
For more information about the Autism Care Demonstration, visit the TRICARE website.