Basic benefit covered services

  • Medical team conference with interdisciplinary team of healthcare professionals
  • Occupational Therapy (OT)
  • Pharmacotherapies
  • Physical Therapy (PT)
  • Psychotherapies
  • Psychological testing
  • Respite care
  • Speech Therapy (ST)

ACD covered services

  • Autism services coordination via the Autism Services Navigator (ASN) for beneficiaries enrolled on or after Oct. 1, 2021
  • Applied Behavior Analysis (ABA) services

TRICARE eligibility

To enroll in the ACD, beneficiaries must meet the following:

  • Must be enrolled in an eligible TRICARE plan
  • Active Duty Family Members (ADFM) must register for the Extended Care Health Option (ECHO)
  • Must also be diagnosed with ASD to receive services under the ACD program (diagnosis must be from a TRICARE-authorized Primary Care Manager (PCM) or specialist approved to diagnose ASD)

Approved Primary Care Managers (PCM):

  • Pediatricians
  • Pediatric family medicine physicians
  • Pediatric nurse practitioners

Approved specialists:

  • Board-certified developmental pediatrician
  • Board-certified neurodevelopmental pediatrician
  • Pediatric neurologist
  • Pediatric child psychologist
  • PhD clinical psychologist
  • Specific board-certified Doctors of Nursing Practice (DPN)

How the ACD works

Step 1: Receive Autism Spectrum Disorder (ASD) diagnosis

Diagnosis must come from an approved ASD-diagnosing Primary Care Manager (PCM) or specialist.

Approved PCM and specialists types:

  • PCM - pediatrician
  • PCM - pediatric family medicine physicians
  • PCM - pediatric nurse practitioner
  • Board-certified developmental pediatrician
  • Board-certified neurodevelopmental pediatrician
  • Pediatric neurologist
  • Pediatric child psychologist
  • PhD clinical psychologist
  • Specific board-certified Doctors of Nursing Practice (DPN)

Step 2: Get a referral and pre-authorization

Your child must get a referral to the ACD and a pre-authorization for all Applied Behavior Analysis (ABA) services. This is required for all TRICARE plans, including incidents where TRICARE is considered secondary (Other Health Insurance [OHI]).

  • The diagnosing provider will submit a referral for authorization
  • Your child will receive an authorization notice for six months of ABA services
  • A new referral from your ASD-diagnosing provider is required every two years
  • For beneficiaries enrolled on or after Oct. 1, 2021, Humana Military will assign an outreach coordinator who can assist with eligibility to the ACD

Are you requesting ABA services for the first time?

  • Humana Military will send an authorization notice which covers your child’s ABA assessment
  • Your child’s provider will complete the ABA assessment and then develop a treatment plan
  • Your child will receive an authorization notice for six months of ABA services (reauthorization is required every six months from your child’s provider)
  • ABA services are only available in locations with Board Certified Behavior Analysts (BCBA)

Step 3: Complete outcome measures

You and your child’s provider team must complete four baseline outcome measures before your child can get ABA services. This will help monitor your child’s progress.

Outcome measures

  • Vineland Adaptive Behavior Scales, 3rd Edition (Vineland-3)
  • Social Responsiveness Scale, Second Edition (SRS-2)
  • Pervasive Developmental Disorder Behavior Inventory (PDDBI)
  • Parenting Stress Index, Fourth Edition, Short Form (PSI-4) or Stress Index for Parents of Adolescents (SIPA)

You must complete the four outcome measures every six months or every 12 months (depending on the measure). If you need assistance in finding a provider to complete the outcome measures, please contact us at (866) 323-7155.

Step 4: Schedule an appointment

When you get your child’s authorization notice, schedule their ABA assessment with the provider listed in the authorization. If you would like to request a different provider, please call (866) 323-7155.

Your ABA supervisor’s role:

  • Plans, delivers and supervises your child’s ABA treatment program
  • Helps you to develop goals for your participation in your child’s ABA treatment plan
  • Updates your child’s treatment plan prior to your child’s next authorization period

Step 5: Work with your Autism Services Navigator (ASN)

TRICARE will assign your child an ASN if they are enrolled on or after Oct. 1 2021. Your child’s ASN acts as their primary clinical advocate.

The ASN will work with you to develop your child’s Comprehensive Care Plan (CCP).

Your child’s CCP will:

  • Set goals and track timelines for outcome measures and authorization dates
  • Connect you with clinical and non-clinical resources
  • Provide discharge, moving or transition support

Process for completing initial assessment

Humana Military follows a placement process to ensure beneficiaries have access to an Applied Behavior Analysis (ABA) provider within TRICARE’s access to care standards. 

Here’s how it works:

  • Humana Military will contact the ABA providers to inquire about availability for the initial assessment and treatment
  • Humana Military will assign a provider that meets the criteria for accepting a new referral (the provider placement process does not replace parent/caregiver choice)
  • The parent/caregiver should contact the assigned ABA provider to schedule the first visit with the beneficiary and complete the initial assessment

What to expect during an assessment

The initial assessment may involve multiple visits and includes a direct observation of the beneficiary needing care. Information will be collected to help develop an individualized treatment plan which will include treatment recommendations and goals.

The assessment includes:

  • Background information
  • A Functional Behavior Assessment (FBA)
  • Completion and review of the parent/caregiver interview and parent report rating scales
  • The development of a treatment plan including the Individual Education Plan (IEP) for children receiving ABA services in a public or private school setting
  • Completion and review of outcome measures
  • Parent/caregiver agreement on treatment plan

Getting a second opinion

The beneficiary can obtain a second opinion from a different ABA provider if requested. A new referral is not required as long as it is within the two-year timeline.
Two “ongoing” treatment authorizations of direct service are not permitted. It is important to communicate with Humana Military on which provider the beneficiary would like to use to avoid delays in authorization approval for treatment.

Outcome measures required under the ACD

TRICARE requires the following outcome measures for beneficiaries participating in the ACD:

  • Vineland Adaptive Behavior Scales, 3rd Edition (Vineland-3)
  • Social Responsiveness Scale, Second Edition (SRS-2)
  • Parenting Stress Index, Fourth Edition, Short Form (PSI-4)
  • Pervasive Developmental Disorder Behavior Inventory (PDDBI)
  • Stress Index for Parents of Adolescents (SIPA)

Autism Services Navigators (ASN)

What is an ASN?

An ASN is a licensed behavioral health professional or registered nurse who has experience in case management services.

The ASN role is to support the beneficiary and their family by:

  • Assisting families to develop and maintain Comprehensive Care Plans (CCP)
  • Coordinating and participating in the medical team conference meetings with the appropriate personnel
  • Assisting with beneficiary moves to/from outside regions
  • Providing support with outside resources

How do I get an ASN?

Beneficiaries who are new to the Autism Care Demonstration (ACD) on or after Oct. 1, 2021 are eligible for an ASN. If the beneficiary was previously enrolled in the ACD prior to Oct. 1, 2021 and has not received services for more than 12 months, the beneficiary would be considered “new” to the ACD and will need to be assigned an ASN.

  • Accepting enrollment to an ASN is a requirement to participate in the ACD and receive Applied Behavior Analysis (ABA) services
  • Beneficiaries who have been receiving continuous ABA services prior to Oct. 1, 2021 are not eligible for an ASN, but may request case management services

What can I expect?

Humana Military will assign the beneficiary an ASN once we verify the referral has all of the required documentation. The ASN will complete a welcome call once eligibility and referral requirements have been verified and will work with the parent/caregiver to complete a CCP. The CCP is a living document that the ASN and parent/caregiver will update throughout enrollment in the ACD.

Your care management dashboard

Humana Military will assign the beneficiary an ASN once we verify the referral has all of the required documentation. The ASN will complete a welcome call once eligibility and referral requirements have been verified and will work with the parent/caregiver to complete a CCP. The CCP is a living document that the ASN and parent/caregiver will update throughout enrollment in the ACD.

How do I get a referral?

The diagnosing provider will submit a referral to Humana Military for ABA services. Referrals must specify Applied Behavior Analysis (ABA) services and include proof of a definitive diagnosis using the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5 (or current edition)), including initial date of diagnosis, through either a referral reflecting a diagnosis of ASD or a diagnostic evaluation. DSM criteria must be documented in a DHA-approved checklist. 

 For beneficiaries enrolled to the ACD prior to Oct. 1, 2021, TRICARE-authorized ASD-referring and diagnosing providers have the option of submitting a definitive diagnosis referring provider attestation which fulfills both the DSM-5 diagnostic checklist and validated assessment tool eligibility requirements for the two year PCM referral requirements. 

Your provider should submit referral requests online for faster processing. The referral for ABA form and supporting documentation may be faxed when needed to (877) 378-2316. Please be aware that failure to provide necessary clinical information may result in delays, terminations of authorized care and denials for pended claims.

Referral cycle

Referrals for ABA services are valid for two years. The referral due date will be provided in writing to help track when a new request will be required.

The two-year referral cycle starts with the initial verified referral for ABA. Prior to the end of the current two-year cycle, a new referral must be submitted by your TRICARE-authorized ASD-diagnosing or referring provider.

Referrals remain valid within the two-year timeline, even if you:

  • Change providers
  • Get a second opinion
  • Move within the TRICARE East Region or outside of the TRICARE East Region

Treatment authorization process

Once the initial assessment has been completed, the Applied Behavior Analysis (ABA) provider will submit a request for treatment. Treatment authorizations are approved in six-month increments.

Humana Military must verify the following:

  • TRICARE eligibility
  • Autism Care Demonstration (ACD) eligibility
  • Treatment plan contains parent goals and engagement
  • Parent Pervasive Developmental Disorder Behavior (PDDBI) scores
  • Completion of outcome measures
  • Individualized Education Program (IEP), if applicable

The clinical review process will not be completed until all clinical documentation is provided. Beneficiaries can view authorization status by logging into their self-service account. Humana Military will not backdate and will deny reimbursement for services performed outside of the dates on the approved authorization.

Clinical review process

Humana Military’s licensed clinical reviewers (Board Certified Behavior Analysts (BCBA) and Board Certified Behavior Analysts-Doctoral (BCBA-D)) perform clinical necessity reviews on all treatment plans prior to authorizing treatment. Clinical necessity refers to services that are appropriate to address the diagnosed condition. For Applied Behavior Analysis (ABA) services this means addressing Autism Spectrum Disorder (ASD) symptoms.

Clinical reviews evaluate the following (although not inclusive):

  • A complete treatment plan
  • Progress with goals and scores of outcome measures
  • Level of clinical support
  • Duration of time in ABA services
  • Location of services
  • Specific goals addressing core symptoms of ASD
  • Recommended hours of ABA services requested

Once Humana Military has received a complete treatment authorization request from the ABA provider, the clinical review process will begin.

The clinical reviewer may request additional information needed to determine clinical necessity. If the additional information is not provided in a timely manner, this could potentially cause a gap in services.

Once the review is complete, the reviewer will authorize clinically necessary and appropriate treatment or request the provider submit an updated treatment plan for further review. In the event the provider is requested to submit an updated treatment plan, the clinical review process restarts when all information is received.

Service settings

TRICARE allows clinically-appropriate Applied Behavior Analysis (ABA) services to be rendered in various settings. ABA services must target the core symptoms of Autism Spectrum Disorder (ASD) and not be an excluded service under the Autism Care Demonstration (ACD). The clinical review process will be used to determine the appropriate location of ABA services.

Various service settings allowed:

Home

  • Considered the beneficiary’s residence
  • The ABA provider must render active delivery of ABA services that target the core symptoms of ASD

Clinic

  • The ABA clinic
  • The ABA provider must render active delivery of ABA services that target the core symptoms of ASD
  • Services may be conducted by all ABA provider types

Daycare

  • A daycare is a daycare center, child development center or after-school program (not pre-school)
  • The ABA provider must render active delivery of ABA services that target the core symptoms of ASD
  • ABA providers may not function as support aides or observers during care routines or activities (lunch, group activities, arts and crafts, etc)
  • Services may be conducted by all ABA provider types
  • Not affiliated with an educational setting

School setting

  • A school is a preschool, public school, private school or home school
  • Services may be administered by the ABA supervisor
  • The ABA provider must render active delivery of ABA services that target the core symptoms of ASD
  • ABA services performed by Behavior Technicians (BT) or assistant behavior analysts in a school setting are NOT allowed
  • The ABA supervisor may not function as a support aide or observer during care routines or activities
  • A current Individualized Education Program (IEP) or equivalent is required; ABA services may not duplicate IEP services
  • Academic or education goals are not covered under the ACD in any setting and should not be included within the Treatment Plan (TP)
  • ABA services must be rendered outside of home-schooling hours and cannot overlap with ABA services
  • A daycare center is not considered a school setting
  • Is affiliated with an educational setting

Community setting

  • Community settings include parks, restaurants, grocery stores, community events, doctor appointments, or any setting that is not part of a home, clinic or school setting
  • Services may be conducted by all ABA provider types
  • ABA services must be focused and time-limited
  • Only community settings that are clinically necessary and appropriate, as determined by clinical review, may be approved; specific exclusions apply to sporting events, camps and medical appointments
  • Approval of an appropriate community setting is dependent upon the goals identified in the Treatment Plan (TP); these goals must be clinically appropriate and target the core symptoms of ASD
  • Parent training is not allowed in community settings

Telemedicine

  • Only available for parent training after the first initial six months of treatment
Standards of care
What to expect from my Applied Behavior Analysis (ABA) provider

Good ABA practices:

  • Initial assessments and reassessments
  • Development of a treatment plan
  • One-on-one ABA services
  • Training of immediate family members on ABA
  • Modifications based on the progress of treatment plan goals, outcome measures and parent engagement

Red flags:

  • Using punishment (such as yelling at or hitting your child)
  • Offering general treatment recommendations without a personalized assessment
  • Lack of data showing progress
  • Lack of maintenance and generalization

If you are concerned that your Board Certified Behavior Analyst (BCBA) may have violated one or more of the Behavior Analyst Certification Board's (BACB) ethics requirements, you can report your issue of concern to the BACB's Ethics Department.

Planning for discharge

Discharge planning is an important part of treatment planning. This prepares beneficiaries for a successful transition once they have reached all treatment goals and Applied Behavior Analysis (ABA) services are no longer appropriate. The ABA provider will develop a discharge plan during the treatment planning process. Once the beneficiary is ready to be discharged from the ABA provider’s care, the ABA provider will submit a discharge plan to Humana Military.
The ABA provider should provide a minimum of a 45-day notice to both parents and Humana Military prior to discharge. As part of the transition, we will authorize parent training for a six month period.

Relocating while enrolled in the ACD:

  1. Notify us of the expected move date, we will request or transfer all documents currently on file.
  2. Find a new provider- if the move is within the East Region, we will assist you in finding a new provider. If the move is outside of the East Region, please contact the appropriate region for assistance with your transition to a new provider in your new location.
  3. Autism Services Navigator (ASN) coordination, if the beneficiary has an ASN and is relocating, they will remain eligible for an ASN. The assigned ASN will initiate contact with the appropriate region to transition coordination of care.

Exclusions

  • ABA services for any other diagnoses other than Autism Spectrum Disorder (ASD)
  • ABA services are not covered for symptoms and/or behaviors that are not part of the core symptoms of ASD (i.e., impulsivity due to Attention-Deficit/Hyperactivity Disorder (ADHD), reading difficulties due to learning disability, excessive worry due to anxiety disorder, etc.)
  • Educational/academic and vocational goals
  • ABA services are not authorized in the school setting as a shadow, aid or support to the beneficiary
  • ABA services in the school setting are limited to the role of the BCBA who is targeting a specific behavior excess or deficit and is for a limited duration
  • Any ABA services requested for the school setting must be specifically pre-authorized in the treatment plan for use in the school setting
  • Billing for school tuition
  • Rendering or billing for any two ABA providers at the same time
  • Rendering or billing for custodial care, personal care and/or child care
  • Billing for ABA services while the beneficiary is at another medical appointment to include another family member’s appointment
  • ABA goals targeting Activities of Daily Living (ADL) (principles of ABA such as chaining, schedules of reinforcement, task analysis may be taught during parent training sessions)
  • Billing of direct and indirect supervision of staff
  • Rendering or billing of any interventions considered psychotherapy to include cognitive behavior therapy, acceptance and commitment therapy, prolonged exposure, group psychotherapy

Contact our dedicated ACD team

Available Monday through Friday, 8 AM - 7PM (ET)

Send a secure message or email ACD-Compliant Officer

 

(866) 323-7155 (Phone)

(877) 378-2316 (Fax referrals)

(877) 200-0401 (Fax ECHO support)