Comprehensive Autism Care Demonstration Amendment, 30664-30665 [2015-13001]

Agencies

• DEPARTMENT OF DEFENSE
• Office of the Secretary

[Federal Register Volume 80, Number 103 (Friday, May 29, 2015)]
[Notices]
[Pages 30664-30665]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-13001]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Comprehensive Autism Care Demonstration Amendment

AGENCY: Department of Defense.

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

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SUMMARY: This notice is to advise interested parties of amendments to a 
Military Health System (MHS) demonstration project entitled 
Comprehensive Autism Care Demonstration (ACD). The purpose of the ACD 
is to further analyze and evaluate the appropriateness of the ABA 
delivery model under TRICARE in light of current and anticipated 
guidelines and best practices from the Behavior Analyst Certification 
Board (BACB) and other resources. The demonstration seeks to determine 
the appropriate provider qualifications for the proper diagnosis of ASD 
and the provision of ABA, refine the beneficiary cost-sharing 
requirements and provider reimbursement rates for the treatment of ASD, 
determine the appropriate patient safety and fraud prevention measures 
to implement regarding coverage of ABA for 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.
    First, the Department will align all ACD cost-shares with existing 
TRICARE Basic Program cost-share requirements under Standard/Extra and 
Prime to include allowing all ABA services under the ACD to accrue to 
the annual catastrophic cap. In addition, under the ACD the removal of 
the $36,000 annual limit on the amount the government may cost-share 
will continue. This will establish cost-share parity for the ACD by 
aligning it with existing TRICARE Basic program requirements generally, 
while remaining consistent with the requirement set forth in 32 CFR 
199.4(f) that Active Duty benefits must be greater than benefits for 
non-Active Duty beneficiaries. As a result of this adjustment, all 
TRICARE beneficiaries receiving ABA for ASD under the ACD will now be 
protected from excessive out of pocket costs by the applicable 
catastrophic cap based on their sponsor's status and TRICARE plan under 
which covered. Second, the Department will also adjust all ABA 
reimbursement rates under the ACD by implementing adjustments based on 
Geographic Practice Cost Indices (GPCI). This will align the ACD 
reimbursement rates with the method used to determine many current 
CHAMPUS Maximum Allowable Charge (CMAC) rates (which are adjusted by 
local wage indices or geographic regions), and with the rates of other 
payers (which vary by location nationwide).

DATES: These changes will be effective October 1, 2015. The 
demonstration will continue through December 31, 2018.

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

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

SUPPLEMENTARY INFORMATION:

A. Background Regarding the ACD Amendments

    In June 2014, the Department published the ACD Notice in the 
Federal Register (FR) (79 FR 34291-34296, June 16, 2014) upon Office of 
Management and Budget (OMB) approval and in compliance with 32 Code of 
Federal Regulations (CFR) 199.1(o) and Department of Defense (DoD) 
Administrative Instruction -102 that govern TRICARE demonstrations. The 
ACD incorporates the previous temporary ABA policies into a single 
program based on limited demonstration authority to ensure continued 
ABA coverage for all TRICARE beneficiaries--including Active Duty 
Family Members (ADFMs) and non-Active Duty Family Members (non-ADFMs)--
diagnosed with ASD.
    The Department conducted two ACD round table events for parents, 
advocacy groups, and other stakeholders on October 15, 2014 and 
December 3, 2014. The round tables were well attended and senior 
Department officials listened to concerns, answered questions, and took 
matters for further analysis and action. The Department received 
constructive feedback from these round tables and directly from 
interested stakeholders. The Department greatly appreciates the 
participation of all interested parties, and through this process has 
gained additional insights about how to design and implement an optimum 
care delivery and reimbursement system for beneficiaries diagnosed with 
ASD. Among a number of issues raised by stakeholders, two fundamental 
concerns emerged from the round table meetings that require immediate 
adjustments under the ACD. The first was that the beneficiary cost-
sharing provisions under the ACD may have an adverse financial impact 
on beneficiaries as the one-on-one ABA therapy does not accrue to the 
catastrophic cap and thus may put ABA ``out of reach'' for some 
families. The second concern was that TRICARE reduced the reimbursement 
rate of $125/hour for ABA one-on-one therapy for Board Certified 
Behavior Analysts (BCBA) to $68/hour and this reportedly would cause 
providers to disengage TRICARE beneficiaries leading to decreased 
access. The Department will amend the ACD as outlined below in order to 
address these critical concerns.

[[Page 30665]]

B. Cost-Sharing Amendment

    Under the TRICARE program, cost-sharing by beneficiaries is 
required by law. It serves a number of purposes, including the means 
for obtaining a beneficiary's individual investment and commitment to 
the care sought, discouraging unnecessary use and overutilization of 
limited health care resources, and controlling overall TRICARE program 
costs to ensure sustainability of the benefits.
    TRICARE has kept the various cost-shares related to ABA under the 
ACD the same as cost-shares and co-payments previously established 
under the Extended Care Health Option (ECHO) Autism Demonstration for 
ADFMs, the ABA Pilot for non-ADFMs, and ABA under the Basic Program. 
Under the ACD, all ABA services provided by a master's level or above 
Board Certified Behavior Analyst (BCBA/BCBA-doctoral) (initial ABA 
assessment and treatment plan, ABA reassessments and treatment plan 
updates, direct one-on-one ABA, and parent/caregiver guidance in ABA) 
count toward the medical benefit catastrophic cap under the TRICARE 
Basic benefit. TRICARE covers 100% of charges for BCBA/BCBA-D services 
after a family's out-of-pocket costs reach an annual cap of $1,000.00 
for Active Duty and TRICARE Reserve Select families, and $3,000.00 for 
retirees and their families.
    However, tiered model ABA services provided by supervised Board 
Certified Assistant Behavior Analysts (BCaBAs) and Behavior Technicians 
(BTs) were based on tiered model ABA services previously provided under 
ECHO and the ABA Pilot. Many families receive a bulk of their care 
under the tiered service delivery model. These ABA services include 
supervision and intensive one-on-one ABA which may take place for many 
hours over an extended period of time, and do not currently apply 
towards the benefit catastrophic cap. For ABA provided by supervised 
BCaBAs and BTs, ADFMs pay the same monthly fee amount based on the 
sponsor's pay grade. Non-ADFMs pay the same out of pocket costs under 
the ACD (as they did under the ABA Pilot)--10% of the allowed charge 
for these services. Because these tiered model ABA services do not 
accrue to the annual catastrophic cap and out of pocket costs are not 
limited, there have been concerns expressed by beneficiaries and 
advocates that this policy may have an adverse financial impact on some 
families and put tiered model ABA services ``out of reach'' for those 
families.
    To address this concern, the Department will apply all beneficiary 
cost-shares for ABA services under the ACD, including tiered model 
services (ABA provided by supervised BCaBAs and BTs), toward the 
catastrophic cap in the same manner as TRICARE Basic program benefits 
generally. The Department will implement this amendment to the 
beneficiary cost-share requirements by aligning cost-shares for all ABA 
services under the ACD with existing TRICARE program cost-sharing 
requirements. TRICARE Standard program deductible and cost share 
amounts are defined in 32 CFR 199.4. TRICARE Extra program deductible 
and cost-share amounts are defined in 32 CFR 199.17. TRICARE Prime 
program enrollment fees and copayments are defined under the Uniform 
Health Maintenance Organization (HMO) Benefit Schedule of Charges in 32 
CFR 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.

 C. ABA Provider Reimbursement Amendment

    The ACD, as a demonstration, has flexibility in creating 
reimbursement methodologies, rather than being constrained by otherwise 
existing TRICARE program provider reimbursement requirements. The 
Defense Health Agency has broad discretion to evaluate alternative 
methods of payment and the appropriate reimbursement rates for ABA 
under the TRICARE demonstration authority. Although care available 
under the TRICARE program must generally be reimbursed using the 
reimbursement requirements of 10 U.S.C. 1079(h) and 32 CFR 199.14(j) to 
``to the extent practicable'', or (in the absence of a practicable 
Medicare rate) to use the prevailing rate, the ACD has no obligation to 
comply with this provision. As a result, the ABA reimbursement rates 
under the ACD may be established through different mechanisms.
    When TRICARE reimburses individual professional providers, they are 
reimbursed at the rate known as the CHAMPUS Maximum Allowable Charge 
(CMAC). In general, the CMAC rates mirror the Medicare rates. The CMAC 
rates are adjusted by geographic locality by using the Medicare 
Geographic Price Cost Index (GPCI). The geographic locality adjustments 
are in place for approximately 70 areas in the United States.
    With the publication of the ACD policy in September, 2014, the 
Department came under intense criticism from providers that the rate 
reduction for one-on-one ABA by BCBAs from $125 to $68 was too drastic 
and out of line with existing market rates. Some providers indicated 
that they would disengage TRICARE beneficiaries as a result of the 
proposed rate reduction. The Department responded by placing the rate 
reduction in abeyance pending a complete analysis of the ACD 
reimbursement rates by the RAND Corporation and further evaluation and 
a determination of appropriate rates by the Department.
    Extensive analysis of ABA reimbursement rates in effect for both 
commercial insurers and Medicaid, including data collected by RAND, 
indicate that the reimbursement rate of $125/hour for one-on-one ABA 
for BCBAs that TRICARE is currently paying is above the prevailing rate 
in most locations. In many instances, TRICARE is either the highest or 
one of the highest payers. As a result of this extensive analysis, the 
Department will adjust ABA reimbursement rates under the ACD to be more 
consistent with other payers and implement geographic adjustments based 
on GPCI. Once national rates for all of the ABA CPT codes are 
determined, then adjustments for local wage indices or geographic 
localities will be applied on an annual basis. In addition to alignment 
with geographic rates, adjustments will be made for provider type 
(Ph.D. level, master's level, bachelor's level, and technician). 
National rates will be established via an independent Government 
analysis using all available data, including but not limited to the 
results of the independent RAND ABA study. Although the general 15% 
limitation on reduction of TRICARE reimbursement rates set forth in 10 
U.S.C. 1079(h)(2) does not apply to rate determinations for 
demonstrations established under the authority of 10 U.S.C. 1092, the 
Department will nonetheless gradually reduce rates (if needed based on 
the results of the independent analysis) by no more than 15% per year 
until alignment with the prevailing geographic rate based on provider 
type is reached.

    Dated: May 26, 2015.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2015-13001 Filed 5-28-15; 8:45 am]
 BILLING CODE 5001-06-P