Tricare is consolidating its disparate autism therapy programs into one Autism Care Demonstration Project for children of active-duty, retired and reserve component personnel starting July 25.
The new program will draw in Applied Behavior Analysis services now provided under the Tricare Basic plan, the Extended Care Health Option Autism Demonstration and an ABA pilot program. The ABA pilot was created last year to expand coverage for retiree families, according to a Defense Department announcement in the June 16 Federal Register.
The program will address several issues that have surfaced from the current “patchwork” of ABA coverage, Pentagon officials said.
For example, it will solve eligibility issues and problems related to continuity of care when active-duty sponsors retire.
It will also eliminate a requirement for a diagnostic observation scale test after two years of therapy to ensure continued coverage; remove the annual or lifetime caps on the amount of ABA Tricare will cover; and simplify guidelines on diagnosis, testing and reviews.
Still, the new program raises some concerns, said Karen Driscoll, associate director for federal government affairs and military relations at the advocacy group Autism Speaks.
First, she said, it does not extend coverage to special-needs children who benefit from ABA therapy but don’t have an autism diagnosis, such as those with Down and Fragile X syndromes.
Driscoll said ABA therapy “helps many children with other development disabilities. We strongly believe that all children should have access to quality care.”
Another concern is cost. Driscoll said the 10-percent cost share for retiree families has no limit and is not applied toward the family’s annual Tricare catastrophic cap.
An intensive treatment program could run “several thousand dollars a year in cost shares alone.” She suggested the cost shares be applied to a family’s annual out-of-pocket Tricare maximum.
The program addresses what was seen as a sticking point with earlier versions of Tricare’s ABA coverage.
By law, Tricare can only pay for services provided by a master’s degree-level instructor. The ECHO program and ABA pilot allowed board certified assistant behavioral analysts and tutors supervised by a certified instructor to provide the therapy; these changes were incorporated into the new demonstration project.
About 3,300 Tricare beneficiaries receive ABA therapy under the basic program while 5,131 are enrolled in the extended therapy under the ECHO program.
Under the pilot program that covers children of retirees, nearly 300 beneficiaries have been approved for or are receiving ABA therapy.
Tricare will begin enrolling new beneficiaries in the demo program starting July 25; all beneficiaries will be covered by Dec. 31.