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The United States Armed Forces are currently in the midst of their Autism Care Demonstration (ACD). This is a plan aimed at providing ABA services under the TRICARE insurance to the families of active-duty, retiree, and Reserve and Guard members, and to gather data for future programs geared toward treating patients with autism spectrum disorder.

As with any specialized services, one of the main questions we encounter at Amvik Solutions is what the cost will be to the families who qualify to receive treatment for their children and those providing therapy.

The following guidelines can help to clarify some of the basic points concerning the cost of coverage.

1.The TRICARE Plan a family falls under is critical in determining costs.

Every family receiving ABA services under TRICARE will be responsible to pay the copay or cost-share designated under their respective coverage plan. They are as follows:

  • Active Duty Family Members (ADFMs) covered under TRICARE Prime will not be responsible for any cost ($0).
  • ADFMs who have the TRICARE Standard and Extra plans are responsible for 15% of costs with a network provider and 20% with a non-network provider. The same applies to TRICARE Reserve Select members.
  • Retired Family Members under TRICARE Prime will pay a $12 copayment for ABA services.
  • Retired family that are covered by TRICARE Standard and Extra, as well as Retired Reserve members will pay 20% with a network ABA therapy provider and 25% to one that is non-network.

While many families will be aware of their specific benefits, there is always the need for professional involved in the field of ABA therapy to be informed on current TRICARE coverage in order to assist these families in the treatment process.

2. Families also need to be aware of their yearly deductible and catastrophic cap

The catastrophic cap is simply the maximum amount that a TRICARE member will pay in any given fiscal year. The status of a family determines what that cap will be for them each year.

For active duty families and those using TRICARE Reserve Select, the cap will be $1, 000 for the family each fiscal year. All other families will have a cap set at $3,000. This amount applies to all covered services, including pharmacy copayments and annual deductibles.

The annual deductible varies depending on the plan, rank of sponsor, and the number of people being covered in each family.

The cost can go as low as $50 for an individual ranked E4 and below, with the cost rising to $150 for all members with a higher rank. Retired individuals will always pay the $150 amount.

For active duty and guard/reserve members, the maximum family amount will be $100/$300, depending again on rank. The same is true for families of retired members.

3. The ABA reimbursement rates under TRICARE were cut in 2016 and there are more planned cuts.

On April 1 of last year, TRICARE implemented cuts that affected reimbursement for ABA therapy by as much as 15% in certain cases. The reason for this was an effort by TRICARE to line up their costs with Medicare standards for health service rates, which they are required to do so by law.

The main problem with this thinking is that Medicare doesn’t reimburse for ABA therapy. The trickle-down effect is something that has caught the attention of several interested parties.

For providers, the primary change that has come about because of the cuts is that many have been forced to make cuts in staff and pay, while not accepting new patients. For agencies that have a large percentage of patients who are covered by TRICARE, this trend is something that could continue for at least the next few years.

There are over 10,500 families currently covered by TRICARE’s ABA therapy services and many offer high praise for the results. But there are another 16,000 families that are eligible for care and these cuts have left many unsure whether they can find providers able to take on new patients amidst the cuts.

The ACD is definitely a step in the right direction when it comes to Autism care and ABA therapy.

TRICARE programs are something that all ABA providers should be informed on, as they will likely come into contact with families covered under this insurance.

Let Amvik Solution help keep you informed on TRICARE and all other ABA-related news.

At Amvik Solutions, we know that there is always a great deal of information related to ABA therapy to understand, as well constant changes in legislation that affect the care patients receive.

Contact us today 805.227.3392 to find out more about our WebABA software, billing services, and additional support.