Senators Ask DoD to Delay Tricare Autism Therapy Rate Changes

Tricare should postpone plans to cut payment rates for providers of autism therapy until they can conduct a "careful re-evaluation" on research of what the rates should be, four senators wrote in a letter sent Tuesday to the Defense Department.

"We are writing to express our great concern about the Defense Health Agency's (DHA) proposal to reduce Tricare reimbursement rates in 2016 for Applied Behavior Analysis (ABA) therapy to beneficiaries diagnosed with Autism Spectrum Disorder (ASD)," the letter states. "We, therefore, ask that you postpone these reimbursement rate cuts until valid reimbursement rates for ABA providers have been established."

The bi-partisan letter was sent to Defense Secretary Ashton Carter and is signed by Sen. Thom Tillis, R-North Carolina; Sen. Kirsten Gillibrand, D-New York; Sen. Amy Klobuchar, D-Minnesota; and Sen. Jerry Moran, R-Kansas.

Currently, ABA providers are paid a fixed rate based on education and certification level, regardless of location. That rate has not been altered in seven years, Tricare officials said.

Under the new plan, the national hourly rate will be set at $114.23 for providers with a doctorate -- more than $10 less than the current rate -- and then further adjusted either up or down based on a geographic rate calculation used by Medicare. Under the plan, each education level will receive a different rate based on location. The base rates were chosen based on a pair of studies commissioned by Tricare last year, Tricare officials said.

But those studies came to different rate conclusions, the senators said in the letter. And the rate reductions that Tricare chose after examining the studies, which are available on Health.mil, put beneficiaries at risk of being dropped by providers.

"With the announced cuts, some ABA providers have already announced plans to leave certain service areas and we expect more providers will follow suit upon implementation of the cuts," they wrote. "Over time, given the disparity between the national average reimbursement rate and Tricare proposed rates, we expect the imbalance between supply and demand to further reduce military family access to these ABA services."

Tricare officials told Military.com that they know of no ABA providers who have stopped accepting Tricare because of the rate proposal, although some have said they might pending the final rate announcements, expected this week, while others have stopped accepting new patients, they said.

Tricare officials said that they are confident the new rates are competitive with private insurers, although information about what those companies pay for services is proprietary. The ABA providers' complaints about the cuts are not the result of the new rates being too low, but instead a reaction to a rate change after seven years of unchanged payment levels, said Douglas McBroom, who oversees Tricare's autism program.

"Part of it is that we paid these fixed rates for seven years and that set a bar where they just thought that was rate," McBroom told Military.com. "I feel in my heart that the rates are competitive. ... Tricare is never the highest and never the lowest."

McBroom said while some providers may drop Tricare as a result of the rate change, users will still be able to access ABA therapy through an out-of-network provider if necessary until an in-network one is available.

"If there are no network providers, we ... use the out-of-network providers," he said. "I know that some of them are a little concerned. The bottom line is no Tricare Prime patient is going to be left without a provider."

Beneficiaries who need a new provider can call their regional Tricare contractor for help, he said.

One benefit to the new rate structure, McBroom said, is that unlike under the past system, payment amounts will be adjusted annually. That means if the Medicare calculation on which the rates are based increases or decreases for any given area, the Tricare ABA payment rate will change accordingly.

"I'm trying, as we talk to the providers, to remind them 'hey, you're not going to be frozen seven more years, you're going to get an adjustment,'" he said.

Tricare currently has 10,500 beneficiaries authorized for ABA care, McBroom said, and 23,000 providers, including 400 added since January when the rate changes were announced.

-- Amy Bushatz can be reached at amy.bushatz@military.com.