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Autism Care Demonstration Update: Key changes heading into May 2021

Friday, April 23, 2021

In late March, TRICARE announced sweeping changes to its Autism Care Demonstration (ACD), which provides applied behavior analysis (ABA) benefits to TRICARE-eligible beneficiaries diagnosed with autism spectrum disorder. Due to the extensive changes, TRICARE is implementing the revised ACD in phases, with all updates to be in place by Jan. 1, 2022. In addition to these notices, we offer a detailed timeline on our website to help you track dates. 

What you need to know for May:

1. Referral requirements and timeline. We are realigning existing ACD participants to a new chronological two-year referral cycle timeline based on the date we received the current referral cycle. We will notify affected beneficiaries of the new dates by July 1 and again at the next reauthorization period, as additional requirements will need to be met for referrals expiring on or after Oct. 1. 

2. New outcome measure timeline. As of May 1, beneficiaries new to the ACD will start on a one-year cycle for the Vineland and SRS-2. We are transitioning existing ACD beneficiaries to this new one-year Vineland and SRS-2 cycle, and will notify beneficiaries of the new dates. 

3. Referral for outcome measures no longer required. As of May 1, primary care managers and ASD-diagnosing providers no longer need to submit a referral request to HNFS for beneficiaries who need outcome measures. HNFS will authorize directly to specific ABA provider groups that we have identified as being able to perform all four outcome measures (two existing, two being introduced in August) for any beneficiary regardless of the treating ABA provider. This means increased access to ABA providers who can complete these required assessments.  

4. Authorizations for CPT® 97153. Beginning May 1, HNFS will no longer authorize behavior technicians and assistant behavior analysts for CPT® 97153 services performed in a preschool or school setting (public or private). For authorizations approved by HNFS on or after May 1, ABA in a school setting must be rendered by an authorized ABA supervisor. Beneficiaries should seek academic/educational support for the school setting through the IEP process when applicable. 

5. Confirming diagnosis. As of May 1, primary care managers who make an initial ASD diagnosis no longer need to refer the beneficiary to a specialized ASD-diagnosing provider to confirm that diagnosis. While not required, beneficiaries are encouraged to see an ASD-diagnosing provider to assist in managing their complex care.

6. ABA rates. The Defense Health Agency recently posted updated ABA rates at www.health.mil/rates. Please note there are two new sets of rates. The May 1 rates reflect DHA’s annual ABA rate update. The August 1 rates reflect upcoming changes to the ACD.

Did you miss DHA’s April webinar series? You can review past presentations and sign up for ACD-specific email alerts at www.health.mil/autism. We encourage you to visit www.health.mil/autism and www.tricare-west.com often as updates will be made throughout the year.