Military Special Needs Network
Proudly Supporting all Military Families with a Special Needs Dependent
TRICARE Policy Interpretation for ABA Therapy
July 4, 2013
Dear Military Families,
On June 25th, TRICARE issued new policy guidance addressing how Applied Behavioral Analysis (ABA) will be provided to the military children of our active duty and retiree families. Advocates across the military family arena are shocked and dismayed at the language this new policy contains as much of it is arbitrary and capricious. Our expectation is that many military families and their children will have their therapy either curtailed significantly or lose this much needed therapy entirely.
The following is our assessment of this new policy and our initial areas of concern. Simply put, because of TRICARE’s failure to work with military families and the organizations that represent them, our assessment at this time is preliminary….there are simply too many unanswered questions. We think it is critical to ensure you know about this new policy now and have an opportunity to understand how this policy change might impact your family. We have tried to keep these points as easy to understand and communicate to others as possible. We expect a more thorough analysis from Autism Speaks and other groups in the near future and will continue to keep you informed as we know more.
- ALL military families (both active duty and retirees) must be referred via a TRICARE-authorized provider for ABA services. All authorization will go thru TRICARE BASIC (medical side) first, which covers the assessment for eligibility for services, plus then treatment program design, supervision of the ABA program and parent training, if approved.
- In order to qualify for ABA services, child MUST have an Autism Spectrum Disorder as defined by the DSM-IV. This includes Autism, PDD-NOS, Aspergers and the other disorders under the Autism Spectrum. The diagnosis can be made by a child’s primary care physician, pediatrician or a specialist provider such as a developmental pediatrician. There is a note that the policy will be updated at a later date to reflect the DSM-5, which was recently released.
- The initial ABA assessment must include Autism Diagnosis Observations Scale (ADOS-2) and Vineland Behavioral Scale II (VBS-II) test batteries. (Policy does not state if TRICARE will cover the costs of these tests however). Results of these tests must be included in assessment.
- The psychometric testing referenced above must be repeated EVERY SIX MONTHS to assess the progress of your child. You can lose your ABA services if your child does not show measurable progress. For some of our children, simply ‘not regressing’ is considered progress, but will that count when it comes to reauthorizations? Also, not considered is the effect of PCSing, which often results in regression. Additionally, we have questions regarding children that have extreme behaviors (i.e. SIBs, destructiveness, aggression) or other co-morbid conditions or special needs that make testing difficult or impossible.
- These tests can be administered by your ABA provider (some have licensed psychologists or other qualified persons on staff), or if they are not qualified to administer them, by another authorized Tricare provider. There is no mention of what provision there is if there are problems finding qualified providers or for long wait lists for a qualified provider. We are extremely concerned that this alone could delay therapy authorizations for many families.
- If you’re stationed overseas, ABA can only be provided by either a BCBA or BCBA-D, regardless of what program you use. If you live in a location where your host nation has no BCBAs or BCBA-Ds, there is NO benefit available for your family.
- The policy limits the usage of ABA therapy to no more than two years, but is authorized a year at a time. If your child still shows the need for ABA therapy after two years, you can request an exception to policy waiver, but there is no guidance provided as to criteria for waiver approval.
- Skills gained via therapy must be generalizable between settings and durable over time for continuation of ABA therapy.
- ABA is available for beneficiaries aged 18 months to 16 years. We are unsure as to why Tricare has chosen these age limits.
- Family members/caregivers must participate during ABA sessions. Your ABA providers will be training you to implement and reinforce skills and behaviors. In fact, the parents/caregivers will be “graded” as the ABA provider must submit an annual report of how well you are consistently able to implement the interventions at home. If cannot do this, you can lose your ABA services, is this qualifies for discharge criteria.
- If your current ABA Supervisor is a BCaBA, they can no longer supervise ABA tutors. All ABA therapy must be supervised by a Master’s Degree level BCBA or Doctorate level BCBA-D. But, BCaBA-level supervisors can be tutors now. At a reduced rate, of course.
We do not know whether this policy will affect all children immediately from July 25th or whether in place authorizations will be honored. We just want to keep you informed and educated about TRICARE decisions and are available for any of your questions and comments.
Sincerely,
American Military Families Autism Support & Military Special Needs Network
4 comments on “TRICARE Policy Interpretation for ABA Therapy”
Comments, discussion and insight always welcome!
Military Special Needs Network 
I am not familiar with ABA therapy, but having two kids who receive occupational, physical, and speech therapies, I will say that the provisions for ABA seem very similar to the guidelines used to approve and continue OT, PT, and Speech. As for the repeated screenings to show improvement, we as parents, should already have a team of doctors that would be qualified to persorm such tests in a timely manner.
Unfortunately, it’s not as simple as you make it sound and God knows that I wish it were. Autism affects behavior, communication and social skills. It is a spectrum disorder meaning there are kids who are very severe and can’t speak (but that doesn’t mean they don’t understand) to those who are less severe and have difficulty with behavior and social skills on the other end of the spectrum. No two people with autism are alike. The rates of autism are at epidemic proportions with 1 in 88 children being diagnosed with autism and it’s even higher among children from military families. Applied behavior analysis (ABA) gives our kids the best chance of leading productive lives by teaching them the appropriate behavior and other skills to be productive members of society. The professionals who provide ABA therapy are not located in every town. I drive 1 hour for my son to receive therapy. Most recommendations are for 40 hours per week of ABA not the 1 hour or 30 minutes usually approved for speech, OT, and PT, which are other therapies that kids with ASD also need. ABA is usually not provided in public schools. The ADOS and Vineland are not the best tests to determine if a child is making progress. Most kids with autism regress before making progress. The waiting list to see a doctor who can diagnose a child with autism and perform the tests can be 6 months or longer. Where I live, the waiting list to see a developmental pediatrician is 2 years! ABA therapy needs to continue for years and just because a child reaches the age of 16 doesn’t mean that he/she no longer has autism. Autism is a lifelong disability. Hopefully, this helps you understand why these Tricare changes are causing so many issues for military families who have children with ASD.
Well I’d like to begin with expressing my lack of excitement over the sudden unnecessary changes. I mean come on! It’s enough to cut jobs to save a buck or two, but to have to intervene in the mental health services of our children? This is an area that should not be touched unless there have been no signs of improvements in the services, but at this point its not about that. It is especially appalling that Tricare will have to appoint specific ABA services as opposed to actually listening to the families as what works for them.
I really don’t understand about the age limit! What are the families to do with the children who have a 17 year old? They are obviously too young to even be considered for social security and even if social security is not an option. Would out of pocket cost have to become an option?
As parents, we want to do everything possible to ensure our children not “fit in” but are able to function successfully in society like everyone else. This will be difficult if services are taken away or dramatically changed-especially services that have been successful.
Mental health services should be the last type of services to touch or even consider to change. These services are important and giving our children a chance at a normal life.
I think some parents would be shocked by services they are not receiving from their providers currently. Right now providers are supposed to complete an FBA, even if skills based assessments are used, to help develop the treatment plan. Parent training is a CURRENT requirement as well as quarterly reviews. Value options does a poor job for Tricare of enforcing these rules. While I don’t agree with all of the new terms, I do see a need to hold these therapists more accountable. As a parent, I had one company develop a treatment plan with no assessment at all. Another had the tutor service my son for months before she completed the treatment plan. I have to stay on them for things the insurance company should be requiring they do.