Since the Tricare Comprehensive Autism Care Demonstration is a different program then the normal Tricare benefit, there are certain procedures beneficiaries must follow to get covered treatment. These include separate diagnosis and approval. There is also a separate payment schedule for treatment.
Step 1: Get Diagnosed
Your child must by diagnosed by an approved diagnosing provider, which includes either:
1. A Primary Care Physician with the Following Specialties:
- Family practice
- Internal medicine
- Pediatrics
Tricare requires either testing or evaluation by a specialized Autism Spectrum Disorder (ASD) diagnosing provider within one year to confirm the diagnosis.
2. A Specialized ASD Diagnosing Provider who is Board Certified or Board Eligible in:
- Developmental Behavioral Pediatrics
- Neurodevelopmental Pediatrics
- Pediatric Neurology
- Adult or Child Psychiatry
- Licensed Clinical Psychology, doctoral level
Step 2: Get a Referral and Authorization
- This is required for everyone in all Tricare plans
- Your diagnosing provider will submit a referral to your regional contractor or US Family Health Plan provider for authorization
- You'll get an authorization letter for Applied Behavior Analysis (ABA) for six months.
- A new referral and authorization is required every six months.
Step 3: Schedule an Appointment
When you get your authorization letter:
- Schedule your appointment the provider listed in the letter.
- If you'd like to see a different provider, contact your regional contractor.
Your authorized ABA supervisor will:
- Complete an ABA evaluation
- Develop an individual treatment plan
- Work one-on-one with your child
- Help parents and caregivers
- Supervise services provided by assistant behavior analysts and behavior technicians
- Re-evaluate your child as needed
Questions and Answers About The Tricare Comprehensive Autism Care Demonstration
How much ABA my child can get?
- No age limits
- No duration limits
- Care is authorized for six months at a time
What to expect during the course of treatment?
- Periodically: Re-evaluation and changes to the treatment plan
- Every Six Months: New referral and authorization
- Every Two Years: Clinical necessity review to see if treatment is working
How much will Tricare pay for treatment under the Comprehensive Autism Care Program?
Your Tricare plan determines how much you'll pay for all ABA services:
- Tricare Prime
- Active duty family members: $0
- Retired service members and families: $12
- Tricare Select
- Active duty family members:
- $21 in network
- 20% out of network
- Retired family members:
- $28 in network
- 25% out of network
- Active duty family members:
- Tricare Reserve Select
- $15 in network
- 20% out of network
- Tricare Retired Reserve
- $25 in network
- 25% out of network
These amounts will apply to your annual catastrophic cap. There's no annual or lifetime dollar limit to the amount of ABA services Tricare may cover.
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