July 5, Dear Parents:

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1 Dear Parents: July 5, 2013 We were recently made aware of some changes regarding autism benefits for retirees under your insurance through TRICARE-Prime. Please see the excerpt below that was released through the National Military Family Association: Last year Judge Walton s ruling mandated that retiree families would be able to receive [ABA] treatment as well through their TRICARE benefit. However, following an appeal by TRICARE, Judge Walton last week issued a new ruling reversing his decision. In his ruling, Judge Walton said that he erred in his 2012 decision by mandating that TRICARE provide coverage and said that the proper course of action was to remand the case back to the TRICARE Management Activity (TMA). Under the new ruling, TMA will have an opportunity to reconsider its policy or explain to the court why ABA should not be fully covered under TRICARE. Our Association contacted TMA to find out how families will be affected by this ruling. We were told that for the immediate future TRICARE will continue to provide coverage to families receiving ABA therapy under the basic benefit as mandated by the 2012 court order In addition, in response to a provision in the National Defense Authorization Act for 2013 TRICARE has announced that this summer they will launch a pilot program similar to the Autism Demonstration that will benefit retiree families. TRICARE has not yet provided further details, but we will continue to monitor the situation and provide updates as we receive them. The following changes will be effective at the end of July: ABA services for non-active duty family members (NADFM) will be accessed through TRICARE-Basic Services will be provided by an ABA Tutor or Board Certified Assistant Behavior Analyst (BCaBA), no longer the current Board Certified Behavior Analyst (BCBA) Supervision will be provided by the BCBA Cost-share will be 10% instead of $25 daily There will be a $36,000 annual cap for services The pilot program is currently projected to run from July 22, 2013 through July 21, 2014 at which point it will be reassessed. Currently, this is the only information we have in regards to the changes in your autism benefits. Please reference the attached Question and Answer document released by TRICARE that covers questions regarding both ABA Pilot (for NADFM) and ABA DEMO (for ADFM). Be assured that you will receive updates from your clinic as new information surfaces. Sincerely, Reaching Milestones Clinical Directors

2 Q. How do I access ABA services? A. The TRICARE Basic Program is the single entry point for all TRICARE-eligible beneficiaries referred for Applied Behavioral Analysis (ABA) covered under the TRICARE Basic Program, and for any additional ABA reinforcement covered separately under the Autism Demonstration (for ADFMs) or ABA Pilot (for NADFMs). The ABA assessment, ABA under the TRICARE Basic Program, and any ABA reinforcement otherwise authorized under the Autism Demonstration for ADFMs or the ABA Pilot for NADFMs require: (a) a referral by a provider who is authorized to diagnose an Autism Spectrum Disorder (ASD) and refer to specialty care, and (b) authorization by the appropriate Managed Care Support Contractor (MCSC) prior to either initiation of the ABA assessment or beginning ABA. Referral for ABA assessment shall precede referral for ABA, which is contingent upon the results of the ABA assessment. Each authorization period for ABA shall be for one year. A new referral is required for each period of authorized care. Q. How is current ABA under ECHO, the Autism Demonstration, and the TRICARE Basic Benefit going to be addressed once these changes are in effect? Are beneficiaries grandfathered in, or do they need to meet new referral, assessment/testing, medical necessity review, and documentation requirements of the revised TRICARE Basic Benefit policy? A. Beneficiaries currently receiving ABA under the TRICARE Basic Program or the Autism Demonstration may continue to receive those services until their current authorization expires. Upon expiration, reauthorization will be based on a new referral, assessment/testing, medical necessity review, and documentation requirements of the revised TRICARE Basic Program ABA coverage policy. Q. What is the difference between ABA under the TRICARE Basic Program and ABA reinforcement under the Autism Demonstration and the ABA Pilot? A. ABA under the TRICARE Basic Program includes: an initial ABA assessment, the initial ABA treatment plan, the delivery of ABA specialized interventions delivered by the Board Certified Behavior Analysts (BCBA) or BCBA-D (doctorate-level), TRICARE eligible parent/caregiver ABA training, repeat ABA assessments, and ABA treatment plan updates. ABA reinforcement under the Autism Demonstration and the ABA Pilot by supervised Board Certified Assistant Behavior Analysts (BCaBAs) and ABA tutors acting as surrogate parental interventionists are meant to effectively offset the difficulty parents have in using ABA reinforcement techniques collaboratively, consistently, and intensely when interacting with their children who have ASD. Q. Is there a cost-share? A. ABA is a specialty service under the TRICARE Basic Program requiring a specialty referral; the specialty care cost-share applies based on a beneficiary/sponsor s status (i.e., ADFM, Retiree dependent, TRICARE Reserve Select dependent, TRICARE Retired Reserve dependent, TRICARE Young Adult participant, CHCBP participant) and TRICARE option (i.e., Prime, Standard, Extra). ABA reinforcement under the Autism Demonstration requires the standard ECHO cost sharing according to the sponsor s pay grade. ABA reinforcement under the ABA Pilot requires a 10 percent sponsor/nadfm cost share, regardless of whether they are using Standard/Extra or Prime.

3 Q. Why is TRICARE using three programs the TRICARE Basic Program, the Autism Demonstration, and the ABA Pilot to provide ABA? A. TRICARE may provide only services that are authorized by law and regulations. The ABA Pilot for NADFMs it is a separate program from the services provided to ADFMs under the ECHO Autism Demonstration, although it is modeled after the ECHO Autism Demonstration in many respects. It is also separate from the TRICARE Basic Program that provides ABA delivered by BCBAs or above to all TRICARE beneficiaries with an ASD diagnosis. Each program is authorized by separate legal authorities. Q. Why is TRICARE limiting providers of ABA under the TRICARE Basic Program to only masterslevel BCBAs or above, when the number of BCBAs in the United States is limited and beneficiaries with ASD need access to ABA? A. TRICARE authorized behavioral health providers in the TRICARE Basic Program have to meet required minimum standards, including a master s degree, state license/certification, or (in lieu of state licensure/certification) a nationally recognized certification. Only a master s-prepared BCBA or doctoral-level BCBA-D meets these requirements; therefore, only BCBA and BCBA-D services are covered under the TRICARE Basic Program. Lesser qualifications (i.e., bachelor s level BCaBA or lay-level ABA Tutors) do not meet TRICARE Basic Program criteria for individual providers of behavioral health services. However, under the ECHO Autism Demonstration, and now under the one-year ABA Pilot, all eligible TRICARE beneficiaries with an ASD diagnosis will be eligible for the ABA reinforcement provided by BCaBAs and ABA tutors when supervised by TRICARE-authorized BCBAs or above. Q. Why is TRICARE no longer covering direct BCBA or BCaBA services under ECHO, and why can t BCaBAs supervise ABA Tutors under the revised Autism Demonstration or ABA Pilot. A. The revised Autism Demonstration (providing ABA reinforcement for ADFMs) and new ABA Pilot (providing ABA reinforcement for NADFMs) will allow cost-sharing for ABA reinforcement provided by BCaBA and ABA tutors working under the supervision of a master s level Board Certified Behavior Analyst (BCBA). This is consistent with the ABA tiered services delivery model advanced by the Behavior Analyst Certification Board (BACB). Although TRICARE initially allowed BCaBAs to provide direct ABA services as ECHO-only providers, and to supervise ABA tutors under the Autism Demonstration, further review of the status of BCaBAs and their role in behavior analysis indicates that they are not generally considered independent ABA providers, but are still in training and should work under the supervision of a masters-level BCBA or above. Q. Why are there $36,000 annual caps on what TRICARE pays under the Autism Demonstration and ABA Pilot? A. TRICARE has an obligation by law to pay only for appropriate services under the Autism Demonstration and ABA Pilot. By law, the amount TRICARE can pay annually for autism reinforcement provided to ADFMs in ECHO is capped at $36,000. The $36,000 cap on payment for such services provided in the ABA Pilot for NADFMs mirrors the ECHO payment limit. Since many ABA services are now provided as a benefit under the TRICARE Basic Program with no annual cap, we anticipate the number of families impacted by the $36,000 cap will decrease when only the costs of ABA reinforcement is applied to the ECHO Autism Demonstration and ABA Pilot caps.

4 Q. Are the TRICARE Program changes concerning ABA coverage temporary or permanent? A. ABA reinforcement for ADFMs under the Autism Demonstration is currently authorized through March 14, 2014, which may be extended by DoD under TRICARE s Demonstration Authority. ABA reinforcement for non-adfms under the ABA Pilot is currently authorized for one year from implementation, and is currently projected to run from July 22, 2013, through July 21, Any extension of the ABA Pilot requires additional legislative authority. As required by section 705 of the FY2013 NDAA, DoD will submit a preliminary report to Congress in December 2013, with a follow-on report upon completion of the one-year ABA Pilot. The report will include an evaluation of beneficiary cost shares; a comparison of providing various ABA under the TRICARE Basic Program, ECHO (including the ECHO Autism Demonstration), and the ABA Pilot; recommended changes in legislation; and additional appropriate information. Q. When will families be notified about the start of these TRICARE program changes, and how they will be notified? A. Beneficiaries will be notified about the nature of the ABA Pilot and its start date, as well as related changes to ABA provided under the TRICARE Basic Program and the current ECHO Autism Demonstration, starting in June 2013 in accordance with the detailed TRICARE Communications Plan. Methods of notification will include press releases, notices on the TMA s website, and briefings to beneficiary advocacy groups.

5 Q. Is ABA available overseas? A. ABA may be authorized under the TRICARE Overseas Program (TOP) only for ABA provided by either a BCBA or BCBA-D in countries that have BCBAs and BCBA-Ds certified by the BACB. ABA reinforcement under both the Autism Demonstration and the ABA Pilot is limited to the 50 United States and the District of Columbia.