Over the last month, military families and service providers went through great lengths to contact their TRICARE officials, legislators, support organizations and the media regarding TRICARE’s new policy on Applied Behavioral Analysis therapy.
Their actions, caused by a lack of timely official information on impacts of implementing the new Comprehensive Autism Care Demonstration coverage and concerns of limited access to appropriate care for military children with autism, made Defense Health Agency officials take note.
As a short-term measure, Defense Department officials announced postponement of provider rate changes until April 20, 2015, while RAND Corp. completes an independent analysis of prevailing rates for the service.
On Oct. 15, senior leadership of DHA and DoD met for a roundtable discussion with stakeholders. The meeting included military autism parents, military healthcare providers and representatives of autism, military and professional organizations.
A summary of the main outcomes of that meeting follows. You can download the handouts from the meeting here. Please note that while this feedback was provided by DoD officials, it is advisable to wait for the official notification.
- The new policy, which was announced in the Federal Registry in June, went into effect on July 25, 2014. The reason for the July 25 date is due to the statutory end date of the Pilot program to avoid that those beneficiaries would be dropped from coverage.
- The new contracts that some providers have recently received do not have to be signed until Dec. 31, 2014 as is explained in the policy. DHA will send additional clarification to the contractors concerning this. Also note that the policy includes that exceptions can be made to extend a current authorization by the TRO Director to ensure that there is no lapse in coverage for a beneficiary.
- Beneficiaries can but do not have to choose between the Sole Provider Model (BCBA only) and the Tiered Delivery Model (tutor model). They can choose to combine these models as is in accordance with the BACB Guidelines. The key is that everything should be part of one comprehensive treatment plan for that child supervised by 1 BCBA so that that BCBA can decide who needs to be on the team for that child, whether that’s a BT, a BCaBA or another BCBA. So collaboration with another BCBA is allowed as long as the supervising BCBA for that treatment plan remains the same. In addition the billing has to be done by 1 BCBA or by 1 ACSP.
- The Registered Behavior Technician Certification regulation taken under consideration to ensure consistency between the TRICARE requirement regarding and the BACB Guidelines and the RBT Requirements.
- The current rate reduction delay includes the BCaBA rates.
- The BCaBA is allowed to supervise if so determined by the BCBA in charge of the treatment plan. The BCaBA has to be supervised at a min rate of one hour of supervision per month in line with BACB Guidelines. To bill for supervision by a BCaBA that can be done under the BCBA code for supervision as is done by other services.
- The 5 percent supervision requirement of BTs in the TRICARE manual is derived from following the BACB recommended minimum of one hour of supervision for every 20 hours of direct services per child, which comes out to 5 percent.
- Regarding the discharge criteria, treatment should be provided until the patient shows improvement or until the patient is dissatisfied with the treatment. It is meant to be case specific and therefor therapeutic determination will be made by the therapists. But there has to be the ability to evaluate, discharge or change the program when that is appropriate so there is a solid treatment. This is to ensure good quality of ABA therapy which has been a concern that previous focus groups brought to the table.
- There is no two-year limit to therapy. That decision is left up to the clinicians. In addition, even if all parties involved including the beneficiary, the PCM and the therapist want to stop treatment this does not mean that the beneficiary can never go back into treatment if needed.
- Financial constraints are never used as a crosscheck. How much something is going to cost does not drive what is best for patients. Being fiscally responsible however is different.
- There has not been a change in cost shares. The specific cost share for NAD families for tutor services is unchanged from the previous Pilot Program. The intent of Demonstration Programs such as the Pilot Program and the new Autism Care Demonstration is to closely examine its data as well as the concerns of its stakeholders in order to make course corrections. Given that currently not much data is available from the Pilot Program and many concerns from stakeholders have been expressed regarding the math of the cost shares this will be taken under consideration.*
- The specified domains of behavior, communication and social skills in the policy are meant only to map treatment and do not limit the skills ABA therapy can address but rather are as determined by the ABA therapist.
In addition the following concerns and comments were heard.
- There was a concern regarding the required minimum age of 18 months for beneficiaries with reason that currently children can be diagnosed as early as 9 months.
- The discharge criteria in the TRICARE manuals are not consistent with the BACB Guidelines.
- There was a discussion regarding providing the treatment plan to the PCM in order for the PCM to better support their patients and families, especially those not familiar with ABA therapy, and to consult to see whether treatment is going as they expect and as is intended. One attendee expressed that such a system was already in place, in such that providers are already required to submit their treatment plan and updates to TRICARE every 6 months.
- It was suggested to continue to have access to the data collected on the ABA benefit programs. However the concern was that any new data will not be comparable as TRICARE has already and will again change the marketplace by continuing to change regulations.
- A suggestion was made to create the standard for ABA insurance coverage using the 6 years’ worth of data and the great ideas already available and with the help of these working groups instead of continuing further studies and data tracking.
- A concern was brought up to look into that only a majority of military children with autism access ABA therapy.
- It was expressed to reconsider the reimbursement cuts that are currently delayed as the outcomes of this would be devastating to families and providers.
While there are still questions remaining, this meeting was a great step in the right direction and further follow-up has already been provided by Autism Speaks to DHA.
The senior leadership at this meeting expressed a great deal of concern and care for their patients, our children with autism. Their intent of the TRICARE regulations for ABA was and is to ensure that appropriate care is given to our kids.
In cases where this did not get translated in policy, it was acknowledged and was promised to be considered for revision. DoD officials expressed a desire to reach out more broadly to its stakeholders and to improve its communication.
They plan to try to set up another roundtable meeting with providers within the next few weeks. In the mean time they intent to process the feedback, work on clarifications and improvements and send out updates as applicable.
Katja Kox-Fishe provided this report. For more information on changes to ABA, please visit the AMFAS ABA Ops Center at http://amfas.org/aba2014.