TRICARE and Applied Behavioral Analysis (ABA)

 

Families have asked us many times, “What is ABA?” and, “Is it something that may be effective in addressing my child’s needs?” The following is provided to give a brief description of what Applied Behavioral Analysis (ABA) is and how you might offset the costs of the program.

Applied Behavioral Analysis (ABA) programs use intensive behavioral interventions that directly address a child’s behavioral deficits and excesses. Target skills are broken down into finite discrete tasks. The behavioral therapist works one-on-one with a child using repetition, feedback, and positive reinforcement to help the child master small tasks. Once mastered, basic skills are used as building blocks to develop more complex abilities.  Behavioral excesses such as tantrumming, aggression, and repetitive behaviors, are also addressed so that a child may learn how to socially interact more effectively and appropriately.

ABA programs are used most commonly with children with autism and are scientifically supported by peer reviewed research and by the Surgeon General’s Report. [see: www.surgeongeneral.gov/library/mentalhealth/chapter3/sec3.html]

Characteristics of a typical intensive behavior program are:

  • 20 to 40 hours per week of one-on-one behavioral intervention
  • 1:1 teaching by trained therapists of cognitive, language, social, and self-help skills
  • The use of positive reinforcement to motivate the child
  • Functional assessment of what drives the child’s interactions with the environment
  • Use of concrete statistical data to track progress and modifications to program based on the data

Early intensive behavioral intervention can make a significant difference in the life of a child. Rooted in basic behavioral principles, its fundamental goal is not only to teach a child specific skills, but to ultimately develop a child’s ability to learn how to learn.

The educational modality known as Applied Behavioral Analysis (ABA) is included as a benefit under this issuance when provided by a TRICARE-authorized provider. Payable services include periodic evaluation of the beneficiary, development of a treatment plan, and training of individuals to provide services in accordance with the treatment plan.

TRICARE can also pay for the “hands-on” ABA services when provided by a TRICARE-authorized provider. However, TRICARE cannot pay for such services when provided by family members, trainers, or other individuals who are not TRICARE-authorized providers as per Chapter 9, Section 17.1.

Services cost-shared through the ECHO may be provided by an authorized institutional or individual professional provider on an inpatient or outpatient basis and rendered in the beneficiary’s natural environment. This includes at home, school, or other location that is suitable for the type of services being rendered.

To be reimbursed for ABA services, the ABA provider must be

  • Certified by the Behavior Analyst Certification Board (BACB) as a Board Certified Associate Behavior Analyst (BCABA) bachelor’s degree level, or
  • Certified by the Behavior Analyst Certification Board (BACB) as a Board Certified Behavior Analyst (BCBA) master’s degree level, or
  • A TRICARE certified provider with requisite credentials.

TRICARE will not pay for ABA services provided by trainers or other paraprofessionals. This means that ABA services rendered in tiered service models, in which a BACB-certified provider supervises some number of non-certified trainees who provide the actual “hands-on” services, do not qualify for reimbursement. Pre-authorization of ABA services is required.

The TRICARE Management Activity (TMA) has determined that Applied Behavioral Analysis is an educational benefit. It is available through and subject to the requirements of Enhanced Care Health Option (ECHO),  but it is not a benefit of the Basic Program. Although ABA has not been officially added to the policy manual and specified as a covered benefit, beneficiaries are now seeking coverage for this type of program through the TRICARE Policy Manual, 6010.47-M, Chapter 8, Section 1.11 Special Education Benefit and are billing for these services through HCPCS Level III Code 98290.

To be eligible for the ABA benefit the TRICARE beneficiary must meet the following:

  • Be registered in the ECHO program; and
  • Have a qualifying condition requiring ABA services; and
  • Utilize a TRICARE-authorized provider of ABA services

Be aware that TRICARE may reimburse for claims only from TRICARE-authorized providers and that the total of all ECHO  benefits reimbursed by TRICARE in any month is not more than $ 2,500. Except in very limited situations, families will be responsible for all ECHO  costs over the $ 2,500  per month cap. Families can contact STOMP and request an  ECHO fact sheet for eligibility requirements.

Although most commonly utilized with children with Autism, TMA has not limited funding to this specific disability category.  No specified instruction has been provided to the Regions regarding the details of provision of the services although the Managed Care Support Contractors have been informed of the above determination regarding ABA. Interested beneficiaries are encouraged to contact their Case manager or Lead Agent for their region to work through these issues. Contact information is listed on the TRICARE website at www.tricare.osd.mil under Regions.  Click on your region to find the information you need.

Note: Special education services available under the TRICARE Basic Program are not eligible to be cost-shared under the ECHO.

STOMP and PAVE do not endorse any individual therapy or program. This information is provided to allow families to investigate for themselves the potential for such programs benefiting their child. We recommend that when considering any program for which you are seeking TRICARE funding that you talk with your special needs coordinator or TRICARE Health Benefits Advisor for further assistance. Families working with TRICARE to implement ABA programs for their children are welcome to contact STOMP for guidance or to share successes!

Contact us:

stomp@washingtonpave.com or call 1-800-5PARENT

Other references:

  • Families for Effective Autism Treatment (FEAT) at www.feat.org
  • TRICARE www.tricare.osd.mil
  • The TRICARE  Funding Autism Treatment list exists to enable families attempting to obtain funding through TRICARE for a variety of autism treatments including but not limited to Applied Behavior Analysis, supplements, AIT etc.) to connect with each other, sharing information and support. – subscribe_TRI-FAT@topica.com

DISCLAIMER:

The above general summary has been reviewed by appropriate TMA staff and found to be substantively accurate. However, the information neither constitutes an endorsement of any treatment option nor does it represent a factual determination of TRICARE coverage of Applied Behavioral Analysis in any particular case or circumstance.

 

“Working Together with Military Families of Individuals with DisAbilities!”

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