Comprehensive Autism Care Demonstration, 34291-34296 [2014-14023]

Agencies

• DEPARTMENT OF DEFENSE
• Office of the Secretary

[Federal Register Volume 79, Number 115 (Monday, June 16, 2014)]
[Notices]
[Pages 34291-34296]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-14023]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF DEFENSE

Office of the Secretary


Comprehensive Autism Care Demonstration

AGENCY: Department of Defense.

ACTION: Notice of a comprehensive demonstration project for all Applied 
Behavior Analysis (ABA), including the tiered-model of ABA, for all 
TRICARE beneficiaries with Autism Spectrum Disorder (ASD).

-----------------------------------------------------------------------

SUMMARY: This notice is to advise interested parties of a Military 
Health System (MHS) demonstration project entitled Comprehensive Autism 
Care Demonstration (``Autism Care Demonstration''). The purpose of the 
Autism Care Demonstration is to further analyze and evaluate the 
appropriateness of the ABA tiered-delivery model under TRICARE in light 
of current and anticipated Behavior Analyst Certification Board (BCBA) 
Guidelines. Currently, there are no established uniform ABA coverage 
standards in the United States. Therefore, the demonstration seeks to 
determine the appropriate provider qualifications for the proper 
diagnosis of ASD and the provision of ABA, assess the feasibility and 
advisability of establishing a beneficiary cost share for the treatment 
of ASD, and develop more efficient and appropriate means of increasing 
access and delivering ABA services under TRICARE while creating a 
viable economic model and maintaining administrative simplicity.
    Faced with various temporary authorities and the resulting 
complexity of the current interim TRICARE policies concerning coverage 
of ABA for ASD, the Department will create a new comprehensive Autism 
Care Demonstration providing all TRICARE-covered ABA under one new 
demonstration. This will encompass ABA services that recently have been 
provided under a patchwork of the TRICARE Basic Program (i.e., the 
medical benefits authorized under

[[Page 34292]]

Section 199.4 of title 32, Code of Federal Regulations), the Extended 
Care Health Option (ECHO) Autism Demonstration (i.e., the supplemental 
ABA benefits authorized for certain active duty family members under 
Section 199.5 of title 32, Code of Federal Regulations), and the ABA 
Pilot (i.e., the supplemental ABA benefits authorized for certain non-
active duty family members--including retiree dependents and others--
under Section 705 of the National Defense Authorization Act (NDAA) for 
Fiscal Year (FY) 2013). It will preserve most of the terms and 
conditions of coverage under that patchwork, incorporating some lessons 
learned. Coverage of ABA and related services under this new 
demonstration will apply comprehensively to all TRICARE eligible 
beneficiaries with a diagnosis of ASD. Eligible beneficiaries'' include 
dependents of active duty, retired, TRICARE-eligible Reserve Component, 
and certain other non-active duty members. Because there has been 
insufficient time to accomplish the congressional intent behind Section 
705 of the FY13 NDAA, reconcile the various temporary authorities, and 
address the resulting complexity of the current interim TRICARE 
policies concerning coverage of ABA for ASD, this demonstration will 
consolidate TRICARE coverage of ABA based on the Department's 
demonstration authority in section 1092 of title 10, U.S. Code. The 
overarching goal is to analyze, evaluate, and compare the quality, 
efficiency, convenience and cost effectiveness of those autism-related 
services that do not constitute the proven medical care provided under 
the medical benefit coverage requirements that govern the TRICARE Basic 
Program.

DATES: Effective Date: July 25, 2014. This demonstration authority will 
remain in effect until December 31, 2018.

ADDRESSES: Defense Health Agency, Health Plan Execution and Operations, 
7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042.

FOR FURTHER INFORMATION CONTACT: For questions pertaining to this 
demonstration, please contact Mr. Richard Hart at (703) 681-0047.

SUPPLEMENTARY INFORMATION: 

A. Background Regarding the Autism Care Demonstration

    Autism Spectrum Disorder (ASD) affects essential human behaviors 
such as social interaction, the ability to communicate ideas and 
feelings, imagination, and the establishment of relationships with 
others. The TRICARE Basic Program offers a comprehensive health benefit 
offering a full array of medically necessary services to address the 
needs of all TRICARE beneficiaries with an ASD diagnosis. TRICARE's 
Basic Program provides occupational therapy (OT) to treat deficits and 
promote the development of self-care skills; physical therapy (PT) to 
treat motor skill deficiencies and promote coordination; speech and 
language pathology therapy (SLP) to treat deficits in speech and 
language development and promote communication skills; psychiatry, 
psychology and therapists to address psychopharmacological needs, 
psychotherapy, and psychological testing. Additionally, the full range 
of medical specialties to address the medical conditions common to this 
population are covered.
    Applied Behavior Analysis (ABA) is the design, implementation, and 
evaluation of environmental modifications to produce socially 
significant modification in human behavior. ABA is based on the 
principle that an individual's behavior is determined by past and 
current environmental events in conjunction with organic variables such 
as the individual's genetic endowment and ongoing physiological 
variables. ABA, by certified behavior analysts, focuses on treating 
behavioral difficulties by changing an individual's environment (i.e., 
shaping behavior patterns through reinforcement and consequences). ABA 
is delivered optimally when family members/caregivers participate by 
consistently reinforcing the ABA interventions in the home setting in 
accordance with the prescribed treatment plan developed by the behavior 
analyst.
    To date, the Department has not considered ABA to be medical in 
nature. As such, coverage of ABA as a medical treatment for ASD had 
been excluded from the TRICARE Basic Program and covered only for 
Active Duty Family Members (ADFMs) enrolled in the Extended Care Health 
Option (ECHO) until recent litigation and legislation provided 
temporary extension of some ABA under the Basic Program and expansion 
of additional services to other beneficiaries. However, ABA services 
are perceived as helpful by parents and some providers for the 
developmental trajectory of children with ASD. Although there is still 
a paucity of conclusive clinical evidence in that regard, there is 
growing support in the field of developmental pediatric medicine for 
the view that ABA will at some point emerge as a medically necessary 
treatment for ASD. However further assessment is needed to determine 
the appropriate characterization of ABA as an educational service or 
medical treatment, and the parameters for how ABA should be provided.
    The provision of ABA as an intervention is still in its infancy. 
Although the Behavior Analyst Certification Board (BACB) has 
established national guidelines for behavior analysts, they have yet to 
issue national certification standards for the ABA ``Tutors'' or 
``Behavioral Technicians'' who interact with ASD-diagnosed 
beneficiaries for multiple hours per day. Furthermore, only nine states 
currently license the behavior analysts who evaluate, develop treatment 
plans, and supervise delivery of ABA interventions for ASD-diagnosed 
beneficiaries, and their national certification standards are in the 
process of evolving. Additionally, the American Medical Association 
(AMA) has just recently developed Category III Current Procedure 
Terminology (CPT) codes (i.e., a temporary set of codes for emerging 
technologies, services, and procedures) for ABA, which are not yet 
implemented and that will influence how ABA encounters are classified 
and reimbursed in the future.
    Over the course of the ABA Pilot, TRICARE has been engaging with 
various stakeholders regarding TRICARE's coverage of ABA for ASD. 
Included in these groups have been participants from various national 
provider organizations, families of children with ASD, military 
providers who treat ASD, military beneficiary-related associations, and 
ASD advocacy groups. Feedback received regarding the ABA Pilot 
addressed issues including: The autonomy of BCBAs in formulating and 
implementing ABA treatment plans; the appropriate use of standardized 
testing to assess progress; appropriate procedures to ensure valid 
diagnosis of ASD; how to best transition care from the ECHO Autism 
Demonstration to the ABA Pilot when a beneficiary's sponsor retires 
from active duty; and the nature of discharge criteria that should be 
applied to ABA interventions. Based on the extensive and helpful 
feedback, the Department adjusted the ABA Pilot to implement lessons 
learned to date. For example, administration of the Autism Diagnostic 
Observation Scale, second edition (ADOS-2), was changed to being 
required only at the beginning of enrollment in the ABA Pilot, and the 
requirement for a repeat ADOS-2 was dropped for waiver requests for 
continued ABA beyond two years. To ensure continuity of care during 
transition periods, ADFMs enrolled in the ECHO Autism Demonstration who

[[Page 34293]]

transition to retiree dependent status were allowed direct entry into 
the ABA Pilot, and a one-year grace period was granted to allow 
sufficient time to meet the ABA Pilot's diagnosis, referral and 
assessment requirements. However, additional evaluation is needed 
beyond the one-year ABA Pilot period to: (a) Evaluate the adequacy of 
procedure changes made to date concerning coverage provided to non-
ADFMs as well as implement additional planned adjustments, and (b) test 
the acceptance and applicability of the ABA coverage requirements and 
procedures developed for the ABA Pilot for the larger ADFM beneficiary 
population currently receiving ABA services under the ECHO Autism 
Demonstration, and (c) compare options for treating ASD under the 
TRICARE Basic Program generally. Under the new comprehensive Autism 
Care Demonstration, the Department will further evaluate the delivery 
of ABA services and integrate feedback from groups on the ABA tiered-
delivery model to include the provision of ABA core services such as 
the initial ABA assessment, the initial ABA Treatment Plan (TP), the 
delivery of ABA specialized interventions, repeat ABA assessments, and 
ABA TP updates. The Department now seeks to transition that temporary 
patchwork structure into a more comprehensive program that will better 
support analysis and comparisons of the most appropriate standards, 
procedures and protocols for the delivery and financing of ABA services 
under TRICARE.
    This transition includes moving ABA temporarily added in 2012 to 
the TRICARE Basic Progam into the Autism Care Demonstration, but 
without substantively changing the coverage. This is supported by the 
Department's interim coverage determination of June 28, 2013, which 
reaffirmed that available evidence does not support coverage under the 
TRICARE Basic Program, but deferred any change during the term of the 
NDAA-2013 ABA Pilot, which has a statutory end date of one year from 
the implementation date: July 24, 2014. In connection with the National 
Defense Authorization Act for Fiscal Year 2014, Congress considered but 
did not enact any changes in TRICARE ASD or ABA coverage and did not 
extend the ABA Pilot. Based on the Department's ongoing need to further 
analyze, compare and evaluate the nature and options for treating ASD, 
the Department will transition of all current ABA to the new Autism 
Care Demonstration to allow the Department to further analyze, compare, 
evaluate, and refine the procedures and protocols concerning the 
provision of ABA services and the ABA tiered delivery model.
    The end result of this transition is that with very minimal change, 
all ABA currently provided under the patchwork combination of ECHO, the 
ECHO Demonstration, and the NDAA-2013 ABA Pilot will now be provided 
under the comprehensive Autism Care Demonstration through 2018. At that 
time, the interim coverage determination will be reassessed based on 
accumulated TRICARE experience and any other pertinent new information.

B. Description of the Autism Care Demonstration

    The Department's continued evaluation of ABA for ASD must be 
accomplished while ensuring continuity of care for children currently 
receiving ABA and those who will be diagnosed with ASD and then seek 
treatment. Specific Autism Care Demonstration goals include:
    1. Further analyzing and evaluating the appropriateness of the ABA 
tiered-delivery model under TRICARE generally in light of current and 
future Behavior Analyst Certification Board (BACB) Guidelines;
    2. Determining the appropriate provider qualifications for the 
proper diagnosis of ASD and the provision of ABA, and assessing the 
added value of ABA Tutors, or Behavioral Technicians, beyond ABA 
provided by BCBAs;
    3. Assessing, across the three TRICARE regions, the ASD beneficiary 
characteristics associated with full utilization of the ABA tiered-
delivery model versus utilization of BCBA services only or non-
utilization of any ABA services, and isolating factors contributing to 
significant variation across TRICARE regions in delivery of ABA;
    4. Determining what beneficiary age groups utilize and benefit most 
from ABA interventions;
    5. Assessing the relationship between receipt of ABA services and 
utilization of established medical interventions for children with ASD, 
such as speech and language pathology (SLP) therapy, occupational 
therapy (OT), physical therapy (PT), and pharmacotherapy; and
    6. Assessing of the feasibility and advisability of establishing a 
beneficiary cost share for the treatment of ASD.
    The Autism Care Demonstration will offer comprehensive ABA for all 
TRICARE eligible beneficiaries with an ASD when diagnosed by an 
appropriate provider. Under the Autism Care Demonstration, a Board 
Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst-
Doctorate (BCBA-D) referred to as an ``ABA Supervisor'' will plan, 
deliver and/or supervise an ABA program. The BCBA or BCBA-D is 
supported by Board Certified Assistant Behavior Analysts (BCaBA) and/or 
paraprofessional Behavioral Technicians who work one-on-one with the 
beneficiary with ASD in the home and community setting to implement the 
ABA intervention protocol designed, monitored and supervised by the 
BCBA or the BCBA-D. A BCaBA and/or Behavioral Technician working within 
the scope of their training, practice, and competence may assist the 
BCBA or BCBA-D in various roles and responsibilities as determined 
appropriate by the BCBA or BCBA-D and delegated to the BCaBA and/or 
Behavioral Technician, and consistent with the BACB Guidelines (2012) 
and BACB certification requirements. As such, the Autism Care 
Demonstration will specifically require that BCaBAs and Behavioral 
Technicians work under the supervision of a BCBA or BCBA-D. ABA 
delivered solely by BCBAs or BCBA-Ds is also covered by the Autism Care 
Demonstration and will provide a comparative assessment of providing 
ABA services delivered solely by master's level providers or under the 
ABA tiered delivery model in terms of access, quality, and cost. The 
Department will also compare naturally occurring utilization data of 
PT, OT, SLP and pharmacotherapy services without ABA to those also 
receiving ABA sole provider and tiered model services.
    To ensure continuity of ABA care for all beneficiaries, the Autism 
Care Demonstration will be implemented in a phased approach to 
transition from those coverage rules that currently exist under the 
patchwork of programs to the new consolidated Autism Care Demonstration 
as all actions necessary to start services under the Autism Care 
Demonstration are completed (i.e., development of proposed policy 
language, funding, publication of policy manuals, and contract 
modifications). The Department will commence ABA coverage under the 
Autism Care Demonstration model by July 25, 2014, the statutory end 
date of the current ABA Pilot, with all beneficiaries transitioned from 
their current ABA coverage model to the new consolidated Autism Care 
Demonstration not later than December 31, 2014. Only ABA will be 
transitioned to the new consolidated Autism Care Demonstration. All 
medically necessary services that address the needs of TRICARE

[[Page 34294]]

beneficiaries with an ASD diagnosis (e.g., SLP, OT, PT, 
pharmacotherapy, etc.) will otherwise continue under the TRICARE Basic 
Program. Additionally, the full range of medical specialties to 
diagnose and treat medical conditions covered in accordance with the 
regulations governing TRICARE Basic Program benefits.
    Likewise, the ECHO program as currently outlined in Section 199.5 
of title 32, Code of Federal Regulations remains otherwise unaffected. 
ECHO-registered active duty family members will continue to receive all 
services and supplies determined by the Department to assist in 
reducing the disabling effects of an ECHO-eligible dependent's 
qualifying conditions, except for the changes concerning coverage of 
ABA that will be implemented in the new comprehensive Autism Care 
Demonstration noted above. Participation in the Autism Care 
Demonstration by ADFMs requires registration in ECHO and shall 
constitute participation in ECHO for purposes of ECHO registered 
beneficiary eligibility for other ECHO services (e.g., respite care). 
By linking registration in ECHO, the Department can ensure these 
beneficiaries continue to receive all services and supplies determined 
by the Department to assist in reducing the disabling effects of an 
ECHO-eligible dependent's qualifying conditions such as respite care, 
durable equipment, and additional PT, OT and SLP services available 
under ECHO.
    Supplemental ABA benefits authorized for certain non-ADFMs--
including retiree dependents and others--under Section 705 of NDAA-2013 
shall be likewise transitioned from the one-year ABA Pilot to the new 
Autism Care Demonstration. During the transition period of the 
remainder of 2014, the regional contractors will work with 
beneficiaries with ASD to ensure smooth transitions to avoid 
disruptions in ABA.
    The Autism Care Demonstration will authorize TRICARE reimbursement 
of the following ABA to TRICARE eligible beneficiaries with an ASD 
diagnosed by an appropriate provider: An initial beneficiary ABA 
assessment, to include administration of appropriate diagnostic tests, 
and a functional behavioral assessment and analysis; development of an 
ABA Treatment Plan (TP) with goals and objectives of behavior 
modification and specific-evidenced based interventions; one-on-one ABA 
interventions and assessments in accordance with the treatment plan 
goals and objectives; and periodic ABA TP updates that reflect re-
assessment of the beneficiary's progress toward meeting treatment goals 
and objectives specified in the ABA TP.

C. Providers Under the Autism Care Demonstration

    TRICARE coverage of ABA under the Autism Care Demonstration will 
require a diagnosis of ASD rendered by an appropriate provider. For 
purposes of the Autism Care Demonstration, ASD shall only be diagnosed 
by certain TRICARE-authorized physician Primary Care Managers (P-PCMs) 
or by a specialized ASD provider. TRICARE authorized P-PCMs for the 
purposes of the diagnosis of ASD for coverage under the Autism Care 
Demonstration include: TRICARE authorized family practice, internal 
medicine and pediatric physicians, whether they work in the purchased 
care or direct care system. TRICARE authorized specialty ASD providers 
include: TRICARE authorized physicians board-certified or board-
eligible in behavioral developmental pediatrics, neurodevelopmental 
pediatrics, and pediatric neurology or adult or child psychiatry; or 
doctoral-level licensed clinical psychologists. Other PCMs, including 
Nurse Practitioners (NPs) and Physician Assistants (PAs), or other 
providers not having the qualifications described above, are not ASD 
diagnosing providers for Autism Care Demonstration purposes. In cases 
where a beneficiary does not have a P-PCM (such as when assigned to a 
NP or PA), the ASD diagnosis may be rendered by a TRICARE authorized 
physician in any of the disciplines described above under P-PCM, or by 
a TRICARE authorized specialty ASD provider.
    The minimal educational level required for an ABA Supervisor under 
the Autism Care Demonstration's tiered model, and consistent with the 
BACB Guidelines (2012), is the master's degree. Both BCBAs and BCBA-Ds 
have a scope of practice at the full clinical level, which enables them 
to perform full ASD assessments, develop treatment plans, reassessments 
and updates, and supervise the BCaBAs and paraprofessional Behavioral 
Technician staff working under them. Although TRICARE previously 
authorized BCaBAs to practice independently under ECHO and the ECHO 
Autism Demonstration, those provisions pre-dated the more recent BACB 
Guidelines (2012). Therefore, BCaBAs must be supervised by BCBAs or 
BCBA-Ds under the Autism Care Demonstration. BCaBAs have a scope of 
practice that allows them to assist the BCBA or BCBA-D in clinical 
support and case management activities, to include assisting in the 
supervision of the Behavioral Technicians and the training of TRICARE 
eligible family members to implement ABA interventions in accordance 
with the ABA TP. However, under the BACB Guidelines, BCaBAs may not 
practice independently of the supervision of a BCBA or BCBA-D, and 
TRICARE may not cost-share on claims for services provided to TRICARE 
beneficiaries submitted for unsupervised services of a BCaBA.
    Behavioral Technicians are paraprofessionals who meet the 
educational requirements established by the Department, which follow 
current BACB Guidelines for Behavioral Technician certification (2014). 
Under the Autism Care Demonstration, Behavioral Technicians will 
require one hour of direct supervision for every ten hours of ABA 
therapy interventions provided. A Behavioral Technician may not conduct 
the ABA assessment, or establish a child's ABA TP. TRICARE may not 
cost-share on claims for services provided to TRICARE beneficiaries 
submitted for unsupervised services of Behavioral Technicians.

D. Referral and Authorization

    After a TRICARE eligible beneficiary is diagnosed with an ASD by an 
appropriate diagnosing provider (as discussed above), a referral with 
the supporting diagnosis must be submitted by the TRICARE-authorized 
physician Primary Care Manager (P-PCM) or specialized ASD provider who 
rendered the diagnosis to the regional contractor. Other PCMs, 
including NPs and PAs, or other providers not having the qualifications 
of an appropriate provider described above, may not refer beneficiaries 
for ABA. Upon receipt, the regional contractor shall issue a timely 
authorization for ABA under the Autism Care Demonstration for one year 
from a TRICARE authorized BCBA or BCBA-D including a referral for 
diagnostic testing as needed. That authorization will enable each 
beneficiary with ASD to seek developmentally appropriate ABA from any 
TRICARE authorized BCBA or BCBA-D. The provision of ABA by a BCBA or 
BCBA-D under the Autism Care Demonstration shall include the elements 
of a full ASD assessment discussed in paragraph B above. Prior to the 
expiration of each one-year authorization period for ABA under the 
Autism Care Demonstration, the BCBA or BCBA-D shall request re-
authorization from the regional contractor based on documented 
appropriateness of continued ABA, which shall include an updated ABA 
TP. Discharge criteria to guide regional medical directors in 
determining if/

[[Page 34295]]

when ABA is no longer appropriate for a particular beneficiary shall 
include the following factors: No measurable progress made toward 
meeting goals identified on the ABA TP after successive progress review 
periods and repeated modifications to the treatment plan; ABA TP gains 
are not generalizable or durable over time and do not transfer to the 
larger community setting (to include school) after successive progress 
review periods and repeated modifications to the treatment plan; the 
patient can no longer participate in ABA (due to medical problems, 
family problems or other factors that prohibit participation); the 
patient has met ABA TP goals and is no longer in need of ABA; and loss 
of eligibility for TRICARE benefits as defined in 32 C.F.R. 199.3.

E. Testing and Assessment

    For any beneficiary whose ASD diagnosis was not made by an 
authorized specialty ASD provider as defined above, diagnostic 
assessment using the Autism Diagnostic Observation Schedule, Second 
Edition (ADOS-2) is required within the first year of ABA to confirm 
the diagnosis of ASD. For assessment of clinical progress, BCBAs 
supervising provision of ABA for beneficiaries must ensure that 
appropriate, individualized assessment of progress toward behavioral 
targets and goals is documented weekly and reviewed by the BCBA or 
BCBA-D on at least a monthly basis. Progress can be presented either in 
graphic form, and/or using standardized assessment measures (e.g., the 
Assessment of Basic Language and Learning Skills-Revised [ABLLS-R] or 
the Verbal Behavior Milestones Assessment and Placement Program [VB-
MAPP], administered every 6 months). The assessment method selected 
should be consistent (i.e., administered at baseline and follow-up) for 
the entire episode of care. Annual standardized assessment of adaptive 
functioning using the Vineland Adaptive Behavior Scales, Second Edition 
(Vineland-II) is covered, but not required. Documentation of clinical 
progress must be submitted with the treatment plan annually to the 
referring provider and the regional contractor for continued 
authorization of ABA.

F. ABA Provided Under the TRICARE Overseas Program (TOP)

    ABA shall only be authorized under the TOP for ABA provided 
directly by either a BCBA or BCBA-D in countries that have BCBA and 
BCBA-Ds certified by the BACB. The TOP contractor will verify 
compliance with all requirements outlined in the Autism Care 
Demonstration. European and other international providers certified by 
the BACB as a BCBA or BCBA-D are TRICARE authorized providers of direct 
ABA for the overseas program. BCaBAs are not not independent TRICARE 
authorized providers of ABA for the overseas program, regardless of 
their status in their host nation, nor are their services as part of 
the tiered model authorized overseas. Likewise, Behavioral Technicians 
are not authorized to provide ABA overseas. In situations where there 
are no BCBAs or BCBA-Ds certified by the BACB within the TRICARE 
specialty care access standards in the host nation, TRICARE may not 
cost-share ABA under the Autism Care Demonstration, or otherwise.

G. Cost-Sharing

    Under the Autism Care Demonstration, the Department will implement 
beneficiary cost-sharing requirements that will not be subject to an 
annual cap. For ABA provided by a BCBA or BCBA-D, beneficiary cost 
sharing will be equal to the cost sharing applicable to services under 
the TRICARE Basic Program. TRICARE Standard program deductible and 
cost-share amounts are defined in 32 C.F.R. 199.4. TRICARE Extra 
program deductible and cost-share amounts are defined in 32 C.F.R. 
199.17. TRICARE Prime program enrollment fees and copayments are 
defined under the Uniform Health Maintenance Organization (HMO) Benefit 
Schedule of Charges in 32 C.F.R. 199.18. For information on fees for 
Prime enrollees choosing to receive care under the Point of Service 
(POS) option, refer to 32 CFR 199.17.
    For ABA provided by a BCaBA and/or Behavioral Technicians under the 
supervision of a BCBA or BCBA-D, the sponsor/beneficiary cost-share for 
active duty family members every month in which ABA benefits are 
received shall be equal to the monthly ECHO fee as required 32 CFR 
199.5 and set forth in TRICARE Policy Manual, Chapter 9, Section 16.1. 
Registration in ECHO for active duty family members and payment of the 
monthly ECHO cost-share satisfies the monthly Autism Care Demonstration 
cost share for ABA provided by a BCaBA and/or Behavioral Technicians. 
Non-active duty cost sharing for ABA provided by a BCaBA and/or 
Behavioral Technicians will be 10%, as it has been under the ABA Pilot. 
These cost sharing requirements will continue to be outside the TRICARE 
Basic Program catastrophic cap.

H. ABA Provider Reimbursement

    Revised reimbursement rates and claims processes will be developed 
and implemented as appropriate for TRICARE cost-sharing of ABA under 
the Autism Care Demonstration. These revised billing codes and 
procedures will be disseminated with publication of the TRICARE policy 
manual changes regarding provision of ABA. Only BCBAs and BCBA-Ds may 
submit claims and receive TRICARE reimbursement for ABA under the 
Autism Care Demonstration.

I. Program Integrity and Oversight

    A utilization review process will be established for the Autism 
Care Demonstration to provide quality oversight of ABA cost-shared by 
TRICARE and to ensure developmentally appropriate ABA is provided to 
all eligible TRICARE beneficiaries with ASD. A component of Autism Care 
Demonstration oversight will address methods to identify ABA 
overutilization or other forms of misuse. Clinical requirements are 
specified for documentation on the initial ABA TP and ABA TP updates. 
The TRICARE Quality Monitoring Contractor (TQMC) shall perform random 
record review for coding compliance and quality monitoring of the ABA 
TP every 180 days. TQMC findings of improper coding compliance shall be 
reported to the regional contractor in accordance with the TRICARE 
Operations Manual, Chapter 13. This is essential to maximizing access 
to the limited number of behavior analysts available to assist those 
beneficiaries with ASD.

J. Communications

    The DHA will educate beneficiaries, providers, and other 
stakeholders about this change through multiple communications 
channels, including: Traditional media; social media; internet content; 
provider education; outreach to beneficiary organizations, advocacy 
groups, and other stakeholders; printed materials; customer service 
updates; and subscriber emails.

K. Evaluation of the Autism Care Demonstration

    The Autism Care Demonstration will assist the Department in 
evaluating: The aspects of the ABA tiered-delivery model that are 
medical, educational, or other characterization; whether the provision 
of the ABA tiered-delivery model can effectively offset the difficulty 
parents have in using ABA interventions collaboratively, consistently, 
and intensely when interacting with their children who have

[[Page 34296]]

an ASD; whether the use of BCaBAs and Behavioral Technicians creates 
more cost-effective access to ABA based on the limited number of BCBAs 
and BCBA-Ds, while maintaining the quality of ABA; the appropriateness 
of requirements for providers, referral, authorization, treatment 
planning, assessment, testing, reimbursement, cost-sharing, discharge 
planning, and oversight to increase access to ABA for TRICARE 
beneficiaries with an ASD, while ensuring appropriate progress and 
utilization.
    To collect necessary data to achieve the goals outlined for the 
Autism Care Demonstration, two parental surveys will be administered: 
The first at the mid-period of the Autism Care Demonstration (2016) and 
a second upon its conclusion (2018). These parental surveys will 
contain questions regarding: The reasons why parents avail themselves 
of the ABA tiered-delivery model, BCBA-only ABA, or no ABA; the 
perceived impairment(s) of their child with ASD; their degree of 
difficulty in accessing ABA and other clinical services with ASD; and, 
their overall satisfaction and perceived benefit regarding the ABA 
services provided.
    The Autism Care Demonstration will provide the Department the 
opportunity to continue evaluating the provision of ABA under TRICARE 
while avoiding disruption of potentially therapeutic ABA interventions 
that could greatly benefit TRICARE beneficiaries with ASD. This 
information will be essential for determining it and how ABA should be 
delivered under TRICARE if the clinical community and accumulated 
evidence clearly indicates that ABA is a reliably evidence-based 
medical intervention for the treatment of ASD.

    Dated: June 11, 2014.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2014-14023 Filed 6-13-14; 8:45 am]
BILLING CODE 5001-06-P