TRICARE and the Autism Care Demonstration (Military Families)

What it is

Military families do not use state autism mandates. ABA for TRICARE-covered children runs through the Autism Care Demonstration (ACD), a TRICARE-wide program that covers ABA to target the core symptoms of autism spectrum disorder.

Important structural point: ABA under the ACD is separate from the regular TRICARE medical benefit. Occupational therapy, physical therapy, speech therapy, psychological services, testing, and prescription drugs are covered under the standard TRICARE medical benefit when clinically necessary. ABA specifically sits in the ACD.

• The ACD began July 25, 2014.
• It is currently authorized to run through December 31, 2028 (as stated on

the TRICARE ACD page; the demonstration has been extended before, so verify the current end date).

Who qualifies

ABA under the ACD is available to qualifying family members of active duty service members, retirees, and certain National Guard and Reserve members. To qualify, the child must be:

• Enrolled in a TRICARE health plan, and
• Diagnosed with ASD by an approved provider.

(Active duty families also have ECHO, the Extended Care Health Option, which provides supplemental services for qualifying disabilities. ECHO is separate from the ACD.)

How to get ABA under the ACD (the steps)

Step 1: Get diagnosed by an approved provider

The ASD diagnosis must come from an approved diagnosing provider. That means either a primary care provider in family practice, pediatrics, or pediatric/ family nurse practitioner; or a board-certified/board-eligible specialist in clinical psychology (doctoral), a qualifying Doctor of Nursing Practice, developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, or adult/child psychiatry.

Step 2: Referral and pre-authorization

• **All TRICARE plans require a referral to the ACD and pre-authorization for

all ABA services.**

• Your diagnosing provider submits the referral to your regional contractor or

US Family Health Plan (USFHP) provider.

• You get an authorization letter covering six months of ABA services.
• A new referral from the ASD diagnosing provider is required **every two

years**.

• First-time requests: you first get an authorization for the ABA assessment;

the provider completes the assessment and builds the treatment plan; then you get the six-month ABA authorization. The provider requests reauthorization every six months.

Step 3: Complete outcome measures

Before ABA can start, you and the provider team complete four baseline outcome measures, then repeat them every six or twelve months (depends on the measure):

1. Pervasive Developmental Disorder Behavior Inventory (PDDBI)
2. Vineland Adaptive Behavior Scales
3. Social Responsiveness Scale (SRS)
4. Parenting Stress Index (PSI) or Stress Index for Parents of Adolescents (SIPA)

These drive reauthorization decisions, so keep copies.

Step 4: Schedule with your ABA supervisor

Your authorized ABA supervisor oversees the treatment program, sets goals for your participation, and updates the treatment plan before the next authorization period.

Step 5: Work with your Autism Services Navigator (ASN)

TRICARE assigns an ASN as the primary care coordinator. Families with an ASN must complete a comprehensive care plan (CCP) within 90 days. The CCP sets goals, tracks outcome-measure and authorization timelines, connects you to clinical and non-clinical resources, and provides transition support (moving, discharge). Note: you will not have an ASN if you are in the USFHP or live overseas.

Overseas

The ACD is available overseas in only a few locations. Overseas, generally only the ABA sole-provider model delivered by board certified behavior analysts is authorized and reimbursed. Tiered ABA is not authorized overseas except in U.S. territories. Contact your regional call center for the process.

Practical tips

• The re-authorization cycle is every six months with updated outcome

measures. Track authorization end dates and start renewals early to avoid service gaps (same discipline as any commercial plan; see aba-prior-authorization).

• Keep a master file of the diagnosis, referral, treatment plan, outcome

measures, and authorization letters.

• The official source is the TRICARE ACD page and the TRICARE Operations Manual

Chapter 18 (linked above). ACD rules change with policy revisions, so confirm current requirements there.