Applied Behavior Analysis Pilot
The Applied Behavior Analysis (ABA) Pilot is available in the United States and District of Columbia to non-active duty family membersBeneficiaries whose sponsors are not serving on active duty in a uniformed service, including sponsors who are: retired; survivors of deceased service members; Medal of Honor recipients no longer serving on active duty; and National Guard and Reserve members who are not currently serving on active duty for more than 30 consecutive days. diagnosed with an Autism Spectrum Disorder. Through the ABA Pilot, ABA reinforcement, usually provided by the parents/caregivers, can be provided by non-certified “surrogate parental intervention assistantsUsually Board-Certified Assistant Behavior Analysts and paraprofessional “ABA Tutors” working under the supervision of Board-Certified Behavior Analysts at the masters-level or doctoral-level.."
Benefits under the ABA Pilot are available to non-active duty family membersBeneficiaries whose sponsors are not serving on active duty in a uniformed service, including sponsors who are: retired; survivors of deceased service members; Medal of Honor recipients no longer serving on active duty; and National Guard and Reserve members who are not currently serving on active duty for more than 30 consecutive days. , age 18 months and older who meet the following qualifications.
1. Autism Spectrum Disorder Diagnosis from a Physician
The diagnosing provider must be an authorized physician primary care manager (PCM) or a specialized Autism Spectrum Disorder diagnosing provider.
|PCMs who are authorized to diagnose and refer for ABA
||If using TRICARE Prime, TRICARE Young Adult-Prime or the US Family Health Plan, an authorized PCM must be a physician. PCMs who are nurse practitioners, physician assistants or other types of providers can’t diagnose an Autism Spectrum Disorder for TRICARE coverage purposes.
If using TRICARE Standard and Extra, TRICARE Retired Reserve or TRICARE Young Adult-Standard, if you don’t have a PCM, the authorized primary care provider can be any TRICARE-authorized family practice, internal medicine, or pediatric physician.
|Specialized Autism Spectrum Disorder diagnosing providers
||Physicians who are board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology or child psychiatry, or a PhD or PsyD. clinical psychologist working primarily with children.
2. Referral to a Board-Certified Behavior Analyst
The diagnosing provider (described above) must refer you to a Board-Certified Behavior Analyst with a Master’s degree or higher:
- must be qualified to perform an ABA assessment.
- you may be referred to a military hospital or clinic for the initial ABA assessment
- referring provider will provide ongoing oversight of all approved ABA.
3. Prior Authorization from your Regional Contractor
The request for prior authorization must include a description of why ABA is appropriate.
- If enrolled in a Prime Option, your physician PCM will coordinate the prior authorization.
- For all other plans, you may need to work with your regional contractor for prior authorization:
The initial referral and prior authorization to the Board Certified Behavior Analyst is for the ABA assessment only.
- A second referral and prior authorization for ABA is required once the initial ABA assessment is complete.
- Once the ABA assessment is complete, each ABA referral and prior authorization shall be for one year of ABA at a time.
- A new referral is required for each period of authorized care.
4. Initial ABA Assessment
ABA assessment is a process used for developing an individual ABA treatment plan. For TRICARE coverage purposes, the ABA assessment must be completed by a Board-Certified Behavior Analyst with a Master’s degree or higher. The assessment includes data from:
- Direct observation, measurement and recording of behavior
- A functional assessment that may include a functional analysis to address problematic behaviors
- Data gathered from parent/caregiver interview and parent report rating scales
- Baseline psychometric testing using:
- Autism Diagnostic Observation Schedule (ADOS-II) for diagnosis, and
- Vineland Adaptive Behavioral Scale (Vineland-II) to assess functioning
The initial ABA treatment plan must specify the number of hours per week recommended for ABA reinforcement services under the ABA Pilot.
- ABA reinforcement is authorized for one year at a time. A new referral requesting authorization for one year will be required prior to expiration of the initial one year authorization
- The ABA treatment plan is updated by the Board Certified Behavior Analyst and will be based on periodic reassessment of progress toward objectives and goals
- The Vineland-II, a test which takes about 30 minutes to take and assesses ability to function, must be repeated every 180 days as one measure of treatment progress Individual reviews for continued treatment will consider all facts and circumstances, including referring provider input, parent/caregiver involvement and concerns, and any factors contributing to impediments to demonstrated progress
- Testing alone can't determine TRICARE authorization for ABA.
- TRICARE cost shares up to $36,000 annually.
- 10% cost share applies—doesn’t count toward the annual deductible or catastrophic cap.
- Few, if any beneficiaries, will likely exceed the $36,000 annual cap applicable to ABA reinforcement.