Autism Care Demonstration Eligibility
TRICARE beneficiaries who meet the following qualifications are eligible to receive ABA services under TRICARE's Autism Care Demonstration:
The beneficiary is:
- a dependent of an active duty service member enrolled in TRICARE Prime or TRICARE Select (Active duty family members must register for the Extended Care Health Option [ECHO] to participate in the Autism Care Demonstration. ECHO registration deadlines apply. Learn more on our registering for ECHO page.),
- a retiree/retiree family member enrolled in TRICARE Prime or TRICARE Select,
- a National Guard and Reserve member or family member covered under TRICARE Reserve Select or TRICARE Retired Reserve,
- covered under the Transitional Assistance Management Program,
- covered under TRICARE For Life,
- a participant in TRICARE Young Adult,
- a participant in the North Atlantic Treaty Organization or Partnership for Peace, or
- no longer TRICARE-eligible, but participates in the Continued Health Care Benefits Program
Diagnosis (Autism Spectrum Disorder)
Eligible beneficiaries must have an autism spectrum disorder (ASD) (F84.0) diagnosed by a TRICARE-authorized physician primary care manager (P-PCM) or by a specialized ASD-diagnosing provider:
- P-PCM specializing in family practice or pediatrics or internal medicine, or
- Specialized ASD provider who is a physician board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology, or child psychiatry; PhD clinical psychologist working primarily with children; or board-certified doctor of nursing practice (DNP).*
Note: Diagnoses and referrals from nurse practitioners, physician assistants and residents/students in organized health care, or other providers not having the above qualifications, will not be accepted unless the referral is co-signed by a P-PCM or ASD diagnosing provider in one of the approved specialties.
*For DNPs credentialed as developmental pediatric providers, dual American Nurses Credentialing Center (ANCC) board certifications are required as either a pediatric nurse practitioner or a family nurse practitioner, and either a child psychiatric mental health nurse practitioner, or a child psychiatric and mental health clinical nurse specialist. Eligible DNPs must also be trained and certified in the ADOS-2.
Beneficiaries diagnosed with ASD, Asperger’s Disorder, Rett Syndrome, Childhood Disintegrative Disorder (CDD) or Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) prior to October 20, 2014, may continue to be eligible for ABA services, as long as they meet current TRICARE policy criteria upon the next ABA benefit review. At which time, the diagnosis must indicate ASD (F84.0).