Humana Military Beneficiary

Autism

Autism Spectrum Disorder (ASD) is a collective term indicating Autistic Disorder (AD), childhood disintegrative disorder (CDD), Aperger’s Syndrome (AS), and Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS). ASD can often be reliably detected by the age of 3 years, and in some cases as early as 18 months. Children with ASD often demonstrate deficits in social interaction, verbal and nonverbal communication, and repetitive behaviors or interests. Symptoms range from mild to severe and present differently in each child. There is no single best treatment for all children with ASD. However, most professionals agree that early intervention is important. Most also agree that children with ASD respond well to highly structured, specialized programs.

Applied behavior analysis (TRICARE basic benefit)

Under the basic program, TRICARE covers Applied Behavior Analysis (ABA) services for all eligible beneficiaries with a diagnosis of ASD. ABA reinforcement services are covered separately for Active Duty Family Members (ADFMs) under the DoD enhanced access to autism services demonstration and for Non-Active Duty Family Members (NADFMs) under the DoD Applied Behavior Analysis (ABA) Pilot for non-active duty family members. All ABA Services require prior authorization from ValueOptions.

ABA payable services include:
  • An initial beneficiary assessment
  • Development of a treatment plan
  • One-on-one ABA interventions with an eligible beneficiary, training of immediate family members to provider services in accordance with the treatment plan
  • Monitoring of the beneficiary’s progress toward treatment goals
ABA Basic services will be provided only for those eligible beneficiaries with an ASD diagnosis rendered by a TRICARE-authorized primary care physician or by a specialized ASD provider defined as:
  • Physician board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology or child psychiatry; or
  • Ph.D. or Psy.D. clinical psychologist working primarily with children
Find more information about the TRICARE ABA basic benefit on the TRICARE website, or call ValueOptions at 1-866-323-7155.

Autism demonstration overview

The enhanced access to autism services demonstration provides TRICARE reimbursement for ABA for active duty family members with autism spectrum disorders. Beneficiaries must register for the Extended Care Health Option (ECHO) to participate in the enhanced access to autism services demonstration.
This demonstration will enable the DoD to determine whether:
  • There is increased access to these services
  • The services are reaching those most likely to benefit from them
  • The quality of those services is meeting a standard of care currently accepted by the professional community of providers, including the Behavior Analyst Certification Board (BACB); and
  • Requirements are met for state licensure and certification where such exists
Find more information about the Enhanced Access to Autism Services Demonstration on the TRICARE website, or call ValueOptions at 1-866-323-7155.

Autism pilot overview

The ABA Pilot offers a supplemental benefit for NADFMs with an autism spectrum disorder by allowing bachelors-level Board-Certified Assistant Behavior Analysts (BCaBAs) and paraprofessional ABA Tutors working under the supervision of masters-level Board-Certified Behavior Analysts (BCBAs) or Board-Certified Behavior Analysts-Doctoral (BCBA-Ds) to conduct ABA reinforcement that is often provided by parents. This Pilot is effective for services provided on July 25, 2013 for a one year period (July 25, 2014). All ABA pilot services require prior authorization from ValueOptions.

Specific outcomes to be assessed as part of this pilot will include:
  • Utilization of basic program ABA and enhanced access ABA reinforcement for ADFMs and NADFMs
  • Access to care as measured by wait times and reported availability of ABA providers and ABA tutors (as parent/caregiver “extenders” of ABA reinforcement techniques)
  • Cost of providing appropriate ABA under the basic program, and ABA reinforcement under the ECHO autism demonstration (for ADFMs), and the ABA pilot (for NADFMs)
  • Feasibility of assessing treatment progress as measured by improvement in communication, social and behavioral functioning from baseline for beneficiaries with ASD receiving ABA, plus ABA reinforcement under TRICARE
Find more information about the Applied Behavior Analysis pilot for NADFMs on the TRICARE website, or call ValueOptions at 1-866-323-7155.