Questions & Answers

• All applied behavior analysis (ABA) services must be clinically necessary and appropriate. The goals must target the core symptoms of autism spectrum disorder (ASD).
• There are no age limits.
• There are no time limits.
• ABA services are authorized for six months at a time.
• Weekly hours are based on the individual, clinically necessary needs of the patient.

• Regularly. Your child’s ABA supervisor will complete assessments throughout the authorization to check on the progress.
• Every six months. Your child’s ABA supervisor will complete an updated treatment plan assessment to update the treatment plan. Then they’ll request continuation of ABA services or identify a transition/discharge plan.
• Every two years. You’ll need a new referral from your child’s ASD diagnosing provider. After this, you’ll need a new authorization for the next six months of ABA services.

• Sole provider model. Authorized ABA supervisors with a master’s degree or higher provide all applied behavior analysis services.
• Tiered provider model. This includes the use of supervised assistant behavior analysts and/or behavior technicians, in addition to the authorized ABA supervisor. They’ll implement a treatment plan the authorized ABA supervisor developed.
• You don’t have to choose between the sole provider or tiered provider models. That decision is based on clinical necessity.
• The person with ASD can get ABA services from either. This is excluded outside of the U.S. and U.S. territories.
• ABA services depends on individual needs and provider availability.

Yes. But only one ABA supervisor is responsible for your child’s treatment. You may seek guidance from another ABA supervisor.

• Example: your treating ABA supervisor lacks the sub-specialty expertise to treat a specific behavior.

When consulting with another ABA supervisor, your child’s primary ABA supervisor remains:

• Responsible for the treatment plan.
• The main provider authorized to bill for ABA services.

You can also request your referral from your primary care physician for a second opinion.

ABA services may be delivered as a team approach. So another ABA supervisor may provide ABA services as a team participant. However, the designated ABA supervisor remains responsible. They’re the only one who TRICARE authorizes to bill for ABA services.

• Yes. You can file a written complaint or grievance with your regional contractor.
• Do you want to change your provider? Contact your regional contractor.

Parents should work with the provider to make decisions together.

• You must follow referral and authorization guidelines.
• ABA providers can adjust treatment plans.
• Failure to follow the ACD requirements could result in claims denial.
• TRICARE prohibits ABA providers from terminating services without any transition plan.

We care about what is best for each patient. The contractors will work with families and providers if continued coverage becomes an issue.

Your child’s coverage and testing requirements are the same. This is true with all TRICARE plans. Only your costs vary by plan.

Yes. However, it’s only available in very few locations overseas. ABA services overseas are only authorized for the sole provider model. Tiered ABA services aren’t authorized overseas, except in U.S. territories. Please contact your regional call center when seeking ABA services. They’ll walk you through the process.

Your annual catastrophic cap is the most your family pays out of pocket each year for TRICARE-covered services. You’ll pay one copayment for all ABA services you get that day. Other services are subject to their regular copayments. The amount will vary depending on your TRICARE plan. It’ll also vary if you have other health insurance.

There are a wide range of services available. Contact your diagnosing provider or your contractor. They can help you find resources and services in your local area. Remember, every child is different and may need other resources.

The treating provider and the ASN, when assigned, should engage the family with the resources available to them. There is no penalty if a family declines a recommendation. However, the recommendations made will likely help the family progress and meet goals.

To be clinically necessary, a service must be:

• Clinically indicated,
• Appropriate to address the diagnosed condition,
• Doesn’t exceed the beneficiary’s needs,
• Individualized,
• Specific, and
• Consistent with the confirmed diagnosis.

ABA services rendered by a behavior technician in the school setting is not covered. If there is a clinically necessary and appropriate goal, we may authorize a Board Certified Behavior Analyst (BCBA), depending on the clinical necessity review. We encourage families to work with their county school board regarding appropriate school services. You must have pre-authorization for any BCBA ABA services. Your contractor must approve any goals. The goals must be focused and time-limited.

Generally, the parents are expected to generalize mastered skills on their own. A BCBA may be authorized for certain community settings, but contact your contractor for details.

Your child’s eligibility and enrollment requirements won’t change. Your child must enroll in ECHO. You’ll have up to 90 days to enroll your child in ECHO.

You and your family can access clinical and non-clinical resources, including:

• Contractor-identified local resources
• Parent-mediated programs
• Applied behavior analysis (ABA) services for parents, such as:
  • Telehealth
  • ABA group sessions

If you enrolled your child in the Autism Care Demonstration (ACD) before Oct. 1, 2021 you don’t have to get a new authorization until your next two-year referral appointment. An approved ACD diagnosing provider must make your child’s next referral.

You must get documentation for your next referral at your two-year review date. If your child’s first (ASD) diagnosis comes on or after age 8, the diagnosis must come from a specialized ASD diagnosing provider.

• Children diagnosed more than two years before you requested applied behavior analysis services, must get an updated diagnostic assessment.