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Autism Care Demonstration: Benefits and Costs

Overview

TRICARE’s Autism Care Demonstration (ACD) allows for clinically necessary and appropriate applied behavior analysis (ABA) services to be rendered to TRICARE-eligible beneficiaries diagnosed with autism spectrum disorder (ASD). 

The demonstration, which began in July of 2014, is currently scheduled to continue through Dec. 31, 2023. The overarching goal of the ACD is to “analyze, evaluate, and compare the quality, efficiency, convenience, and cost effectiveness of ABA services that do not constitute proven medical care provided under the medical benefit coverage requirements that govern the TRICARE Program.” (TRICARE Operations Manual, Chapter 18, Section 4) 

ABA providers are authorized to render only ABA services targeting the core symptoms of ASD under the ACD.

Services Covered

  • initial assessments and reassessments
  • development of a treatment plan to include specific goals and discharge planning
  • one-on-one intensive applied behavior analysis (ABA) services
  • training of immediate family members on ABA principles and generalization of skills
  • program modifications based on progress within the treatment plan goals, outcome measures and parent engagement 
     

Benefit Limitations

  • No minimum or maximum age limit or duration limit; services are based on clinical necessity
  • ABA assessments authorized for 45 days
  • ABA services authorized for six months at a time 
     

Autism Services Navigators

On Oct. 1, 2021, TRICARE introduced the Autism Services Navigator (ASN) role to the ACD. Contractors, such as Health Net Federal Services, LLC, are responsible for assigning ASNs to new beneficiaries. As an ABA provider, you may be contacted by the ASN as part of the care coordination process.

Learn more on our Autism Services Navigator page.
 

Cost Information

Deductibles, cost-shares and copayments are based on the beneficiary’s TRICARE plan type (TRICARE Prime, TRICARE Select, etc.).

  • Costs are based on specialty outpatient services under office visit rates.
  • No maximum payment or annual cap for ABA services.
  • One copayment for all ABA services rendered on the same day. Non-ABA services rendered on the same day will follow normal rules.
  • One copayment for the initial assessment 14-calendar day period for CPT® code 97151.
  • All services under the Autism Care Demonstration (ACD) require prior authorization, even for beneficiaries who have other health insurance. 

Rates

Reimbursement rates are based on independent analyses of commercial and Centers for Medicare and Medicaid Services (CMS) ABA rates, and vary by geographic locality. Visit https://www.health.mil/rates to view current rates. 

Balance billing

ABA providers may not bill TRICARE beneficiaries more than 100% of the rates posted at https://www.health.mil/rates. The balance billing guidelines defined in the TRICARE Reimbursement Manual (Chapter 3, Section 1, paragraph 4.0) do not apply.

For more details on reimbursement rate and claims requirements, visit our Billing page.

Hold harmless

Network providers cannot bill TRICARE beneficiaries for non-covered care unless the beneficiary was informed in advance the care was not covered by TRICARE, and agreed in advance and in writing to pay for the specific non-covered care.

 

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