Individuals with autism spectrum disorder typically need lifelong services to help them live their best lives. This typically starts in childhood, and there are many health plans and public health institutions that can help with the cost of providing critical services. Though in some cases the family and/or the child need to meet certain criteria.
One of the most important options is known as the TRICARE Comprehensive Autism Care Demonstration (ACD). It specifically covers applied behavior analysis (ABA) services, which are considered the gold standard in psychological services for individuals with autism spectrum disorder. It’s worth noting that under the ACD, applied behavior analysis services are authorized to strategically address the core symptoms of autism spectrum disorder (ASD).
The ACD started on July 25, of 2014, and is still authorized to run through Dec. 31, 2023. Whether it will be renewed before January 1st, 2024 remains to be seen. Though its current success is emboldening.
How Does A Child Qualify for the ACD?
There are several important criteria a child needs to meet in order to fully qualify for the ACD. This starts with being enrolled in a TRICARE health plan. The child also needs to be diagnosed with autism spectrum disorder by an approved provider. Though there are some changes in qualification criteria for children from a family with an active-duty service member (ADSM).
An active-duty service member who has a child diagnosed with autism spectrum disorder needs to be enrolled in their service branch’s Exceptional Family Member Program. It’s important to note that children themselves must also be enrolled in the Extended Care Health Option (ECHO).
How Does the ACD Work?
There are several important steps in the qualification process necessary to be actively enrolled in the ACD. This starts with the child being officially diagnosed by an approved diagnosing provider. This also needs to include either the consent of the primary care physician, like the child’s pediatrician and/or a specialist in family practice, pediatrics, or a board-certified specialist. Qualifying disciplines include:
- A pediatrics nurse practitioner
- A board-certified or board-eligible physician
- A Licensed clinical psychologist at the doctoral level
A Doctor’s of Nursing Practitioner can also provide diagnosis, so long as their area of specialization comes from one of the following:
- Developmental behavioral pediatrics
- Neurodevelopmental pediatrics
- Pediatric neurology
- Adult or child psychiatry
Once the child has been officially diagnosed with autism spectrum disorder, they will need to get a referral and pre-authorization. This also means that the child must get a referral to the ACD and a pre-authorization for all ABA services. Every TRICARE plan requires these criteria.
This also means that the child’s diagnosing provider needs to submit a referral to the regional contractor, or the United States Family Health Plan (USFHP) provider for authorization.
Most children will get an authorization letter for six months of ABA services to start with. It is then relatively easy to expand the duration of services from there, depending on the outcome of this first initial period. At that point, a new referral from the child’s ASD diagnosing provider is required every two years.
Important Tips When Requesting ABA Services for the First Time?
There is admittedly a lot of important paperwork and processes that need to be followed the first time you apply for ABA services for a child with autism spectrum disorder. This starts with getting an authorization letter for your child from your regional contractor or USFHP provider. This documentation helps to cover the child’s initial ABA assessment.
At that point, the child’s provider will complete the child’s ABA assessment. They will also provide a customized treatment plan for the child’s ASD symptoms, needs, and required services. This comes with an authorization letter for six months of ABA services. Your child’s provider will request reauthorization every six months, up to the first two years. After which, the child will need diagnostic approval every six months.
Keeping all of this documentation together in both a physical and digital form can help streamline the recertification process later.
It’s also important to note that under the TRICARE comprehensive ACD that ABA services are only available in locations with board-certified behavior analysts.
Completing Outcome Measures for an Approved Child
The family and the child’s provider team need to complete four baseline outcome measures before the child can receive ABA services. This is intended to help monitor the child’s progress and may factor into the future reapplication process. The four measures that need to be addressed are:
- Pervasive Developmental Disorder Behavior Inventory
- Vineland Adaptive Behavior Scales
- Social Responsiveness Scale
- Parent Stress Index or Stress Index for Parents of Adolescents
These four outcome measures need to be evaluated by a qualifying provider every six months or every 12 months. The required frequency depends on the measure as well as the child’s customized treatment plan.
Scheduling an Appointment for an ABA Assessment
Once you receive the child’s authorization letter, you can schedule the child’s ABA assessment appointment. This authorization letter gives you the provider’s contact information, as well as all of your authorization status information.
It might also include:
- The contact information for the closest regional contractor
- The contact information for a USFHP designated provider
- The authorized ABA supervisor for the child’s case
This information can also be used in different facets to help oversee the child’s ABA treatment program, as well as to develop short and long-term goals. Any necessary updates to the child’s treatment plan will be done before your child’s next authorization period. This is a standard procedure and helps to streamline reapproval in the TRICARE Comprehensive ACD.
Working with your Autism Services Navigator
An Autism Services Navigator (ASN) is assigned to each child in the ACD. They essentially act as the primary care coordinator, which helps reduce the logistics and medical billing burden on the family, to let them focus on helping the child with ASD to meet their active milestones.
You and your child’s ASN will develop your child’s comprehensive care plan (CCP). This will include:
- Setting short & long-term goals
- Tracking important timelines
- Using timelines for outcome measures
- Applying timeline information for key authorization dates
- Connecting with critical clinical resources
- Non-clinical resources
- Provide moving, transition, or discharge support
