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One of the most rewarding benefits of being an ABA therapy provider is the care and assistance your practice is able to offer to the families of the United States Armed Forces members.

In order to meet the  insurance and healthcare needs of uniformed services members and their families around the world, the health care program known as TRICARE  provides comprehensive coverage to military personnel and their dependents with benefits that include health plans, special program, prescriptions, and more.

One of special programs delivered through TRICARE is the TRICARE Comprehensive Autism Care Demonstration which can help military families  cover the expenses associated with ABA therapy and services.

What is the Autism Care Demonstration?

The current demonstration is being used to evaluate and determine qualifications for providers offering ABA therapy, as well as assessing the reimbursement rates for ABA providers, services, evaluations, and supervision that allow for effectiveness and economic viability.

The rates established for the Autism Care Demo were implemented in 2014 and will remain effective until December 31, 2018.

To determine current ABA TRICARE rates several initiatives were taken including four roundtable discussions which involved a consortium of ABA providers, pediatric physicians, ABA certification organizations, Defense Health Agency (DHA) personnel, and autism advocacy groups.    

Alongside these discussions  were two commissioned reports  developed by the RAND Corporation and Kennel and Associates, Inc. to help establish TRICARE professional rates that would be comparable to current commercial and Medicaid reimbursement rates. The DHA endorsed the “National Rates” as established within the Kennel and Associates report.

These National Rates were calculated using the statewide Medicaid rates of 29 states with established rates and increased to adjust those rates for differences in reimbursement rates between Medicaid and Medicare. They were then adjusted once again using the Medicare Geographic Practice Cost Index (GPCI) to create rates for each of the 88 localities recognized by Medicare.  This will ensure that ABA rates are not inappropriately fixed for years and will allow them to be readjusted on annual basis like other TRICARE rates.

What are the CPT codes TRICARE recognizes for ABA services?

The codes recognized by TRICARE do not appear in the current Medicare Physician Fee Schedule (MPFS) but were developed as to create a baseline within the program because of the current variations in ABA provider reimbursement rates from Medicaid and commercial health insurers.

The CPT codes recognized by TRICARE are:

TRICARE has established that if Medicare recognizes these eight CPT codes and develops a rate for them, those rates will be followed as required by law.

TRICARE Rates

TRICARE took into account the variation of national rates for ABA services, as well as cost of living and network capacity to provide those services in the 88 localities across the country using the Medicare GPCI.

TRICARE utilized this method to ensure that rates are competitive with commercial rates and Medicare standards.

ABA Maximum Allowed Amounts for each locality (rates effective December 23, 2016) were brought about through the National Defense Authorization Act (NDAA) for FY 2017.

Assisting a TRICARE family.

TRICARE beneficiaries may not fully understand the scope of their benefits and may need some assistance or guidance in order to obtain the ABA therapy services needed.

The TRICARE website has developed a set guideline to help families get the care they need.

The steps include:

Getting the beneficiary diagnosed through an approved diagnosing provider which may include a Primary Care Physician in the following specialities:

  1. Family practice
  2. Internal medicine
  3. Pediatrics
  4. Specialized ASD Diagnosing Provider

Patients must obtain a referral and authorization prior to services beginning.

  1. Diagnosing provider will submit the referral and authorization will occur for six month increments.
  2. Authorized ABA supervisor will request continuation of ABA services every six months.

After obtaining an authorization, families will schedule an appointment  with a ABA provider to:

  1. Complete an ABA evaluation
  2. Develop a treatment plan
  3. Work with the child one-on-one
  4. Assist parents and caregivers
  5. Re-evaluate child as needed

Scheduling appointments for outcome measures special testing.

  1. Within two years of beginning the program and in subsequent two year intervals.

Additional guidance and support for families can be found here at the Autism Care Demonstration Fact Sheet.

If you have any additional questions regarding providing ABA therapy care services to families who are able to obtain ABA therapy services through TRICARE contact Amvik Solutions today.

Let Amvik Solutions support you in your role as an ABA provider to America’s military families today.

Our understanding of insurance credentialing, medical billing, practice management software, and more can provide you the help you need to run a successful ABA practice.

We also offer a number of services to increase your patient-load and receive payment for claims so you can continue to provide meaningful and quality ABA services.

Contact us today at (805) 277-3392 to find out more about our services or to find out more about TRICARE.