1. TRICARE® Comprehensive Autism Care Demonstration: An Overview of TRICARE-Covered Services for Autism Spectrum Disorder
ATTENTION PRESENTER: To ensure that those using TRICARE get the most up-to-date information about their health benefit, you must go to for the latest version of this briefing before each presentation. Briefings are continuously updated as benefit changes occur.
Presenter Tips:
Review the briefing with notes prior to your presentation.
Remove any slides that don’t apply to your audience.
Review the Other Important Information briefing slides and the Costs briefing slides at to identify any additional slides to add to your presentation.
Launch the briefing in “slide show” setting for your presentation.
TRICARE Resources: Go to to view, download and print copies of TRICARE educational materials. Suggested resources include: Autism Care Demonstration fact sheet, A Conversation About Autism and Your TRICARE Health Care Benefit brochure, Resources for Service overview and Costs and Fees sheet.
Estimated Briefing Time: 30 minutes
Target Audience: Those using TRICARE with a child diagnosed with autism spectrum disorder
Briefing Objectives: Increase awareness and understanding of the Autism Care Demonstration and inform beneficiaries of services covered by TRICARE for those diagnosed with autism spectrum disorder.
Optional Presenter Comments: Welcome to the TRICARE Comprehensive Autism Care Demonstration briefing. The goal of today’s presentation is to give you a general understanding of the services TRICARE covers for beneficiaries diagnosed with autism spectrum disorder, as well as other important information about your TRICARE benefit. Contact information will be included at the end of this presentation.

2. Today’s Agenda: TRICARE Comprehensive Autism Care Demonstration
During today’s briefing, we will discuss autism spectrum disorder, or ASD, TRICARE-covered services available to beneficiaries diagnosed with ASD and the Autism Care Demonstration.
We will also cover other important information about the Affordable Care Act.
Finally, we will provide resources for getting assistance and finding answers to any additional questions.
To learn more about TRICARE options, go to
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To sign up for benefit correspondence by , go to

3. Today’s Agenda: Autism Spectrum Disorder (ASD) Overview
Optional Presenter Comment: First I will provide an overview of autism spectrum disorder, or ASD.

4. Autism Spectrum Disorder (ASD) Overview: What Is ASD?
ASD affects essential human behaviors such as social interaction, the ability to communicate ideas and feelings, imagination and the establishment of relationships with others.
It also includes restricted repetitive behaviors, interests and activities, such as doing the same action over and over again, insisting on a certain routine or ritual or obsessing on a topic.

5. Today’s Agenda: TRICARE-Covered Services
Optional Presenter Comment: We will now discuss TRICARE-covered services.

6. TRICARE-Covered Services: Covered-Services for ASD
TRICARE covers occupational therapy, physical therapy, health care provider services, psychological services, psychological testing, prescription drugs and speech therapy under your TRICARE program option (for example, TRICARE Prime or TRICARE Standard). These medical services are covered under the TRICARE medical benefit.
TRICARE also covers applied behavior analysis, or ABA, under the Autism Care Demonstration, which is a separate program that runs through December 31, This is separate from the TRICARE medical benefit that provides coverage of the other services listed on this slide.
For more information, go to
Note: Overseas, coverage of ABA services is limited. This will be discussed in more detail later in this presentation.

7. TRICARE-Covered Services: Applied Behavior Analysis
ABA is a covered benefit that applies a set of techniques based on behavior modification principles, such as positive reinforcement, to increase or decrease targeted behaviors.
ABA may help develop skills, such as speech, self-help and social interactions. It may also help to decrease certain behaviors, such as aggression or self-injury.

8. Today’s Agenda: Autism Care Demonstration
Optional Presenter Comment: We will now discuss the Autism Care Demonstration.

9. Autism Care Demonstration: Eligibility
ABA services are covered under the Autism Care Demonstration for all qualifying dependents of active duty service members, or ADSMs, retired service members and certain National Guard and Reserve members.
This includes beneficiaries covered under TRICARE Prime options, TRICARE Standard and TRICARE Extra, TRICARE Reserve Select (member-and-family coverage), TRICARE Retired Reserve (member-and-family coverage), TRICARE For Life, TRICARE Young Adult, the Transitional Assistance Management Program and the Continued Health Care Benefit Program (for those no longer eligible for TRICARE).
There are no age limits under the Autism Care Demonstration.
If you have questions about eligibility for ABA services, call your regional contractor. Contact information will be provided at the end of this presentation.

10. Autism Care Demonstration: Active Duty Service Member Sponsors
ADSMs who are seeking ABA services for family members with ASD must sign up for their service’s Exceptional Family Member Program, or EFMP, and register their family members in the Extended Care Health Option, or ECHO, (unless waived in specific situations) within 90 days so they may get the other supplemental services offered under ECHO.
EFMP helps military families with special needs during the duty-assignment process and after families arrive at their new installation.
Each service branch has its own EFMP and enrollment process. For more information about EFMP, contact your service branch’s EFMP representative or visit To find an EFMP representative, visit the Military Installations website at
If overseas, contact the TRICARE Area Office, or TAO, director for your area at and select the option for your overseas area.
ECHO provides supplemental services to active duty family members, or ADFMs, with qualifying mental or physical disabilities, including ASD. It offers integrated services and supplies beyond those offered under your TRICARE program option (for example, TRICARE Prime or TRICARE Standard). These services and supplies may include assistive services, durable equipment, rehabilitative services, respite care, training and transportation. For more information, go to
The government’s coverage limit for all ECHO benefits combined, excluding ECHO Home Health Care, is $36,000 per beneficiary, per fiscal year, or FY, which is Oct. 1 through Sept. 30. ABA does not count against this yearly cap for ECHO benefits. ABA is provided under the Autism Care Demonstration, which places no cap on ABA coverage.

11. Autism Care Demonstration: Costs
There are no yearly or lifetime caps on the amount of ABA TRICARE covers. Your child won’t have to stop ABA services at any point in the year due to having reached a benefit maximum.
As of October 1, 2015, you pay the copayment or cost-share for your TRICARE program option (for example, TRICARE Prime or TRICARE Standard) for all ABA services, and that expense will apply to your yearly TRICARE catastrophic cap.
ADFMs with TRICARE Prime pay $0.
ADFMs with TRICARE Standard and TRICARE Extra, as well as TRICARE Reserve Select members pay:
15 percent of the TRICARE-allowable amount with a network provider (after the yearly deductible is met)
20 percent of the TRICARE-allowable amount with a non-network provider (after the yearly deductible is met)
Retired family members with TRICARE Prime pay $12.
Retired family members with TRICARE Standard and TRICARE Extra, as well as TRICARE Retired Reserve members pay:
20 percent of the TRICARE-allowable amount with a network provider (after the yearly deductible is met)
25 percent of the TRICARE-allowable amount with a non-network provider (after the yearly deductible is met)
The yearly TRICARE catastrophic cap is $1,000 per family, per FY for ADFMs and TRICARE Reserve Select members. The yearly TRICARE catastrophic cap is $3,000 per family, per FY for retirees, their family members, TRICARE Retired Reserve members and all others.
For more information about costs, go to or

12. Autism Care Demonstration: Steps to Getting Care
To qualify for covered ABA services under the Autism Care Demonstration, your child must first be diagnosed with ASD by an approved ASD-diagnosing provider. This provider can either be:
A primary care physician with a specialty in family practice, internal medicine or pediatrics; or
A specialized ASD-diagnosing provider who is board-certified or board-eligible in developmental- behavioral pediatrics, neurodevelopmental pediatrics, child neurology, adult or child psychiatry or licensed clinical psychology (doctoral level).
Note: Either testing or an appointment with a specialized ASD-diagnosing provider is required within one year to confirm an ASD diagnosis made by a primary care physician. Primary care managers, or PCMs, who are not physicians don’t qualify to make an ASD diagnosis.
Your approved ASD-diagnosing provider must send a referral to your regional contractor with the ASD diagnosis and supporting documentation.
Your regional contractor will give prior authorization for six months of ABA under the Autism Care Demonstration. The prior authorization will include the name of an authorized ABA supervisor who is accepting new patients. Make an appointment with that provider or follow the instructions on the next slide for selecting a different provider.

13. Autism Care Demonstration: Getting an ABA Provider
Your regional contractor will send you the name of an ABA provider who is accepting new patients with your prior authorization.
If you are not offered care within the 28-day specialty care access standard, call your regional contractor.
To choose a provider other than the one listed on your prior authorization, call your regional contractor at:
Health Net, LLC (North): (ask to speak with ASD specialists)
Humana Military/ValueOptions (South):
UnitedHealthcare Military & Veterans (West):

14. Autism Care Demonstration: Types of Providers
TRICARE-authorized providers meet TRICARE licensing and certification requirements and are certified by TRICARE to provide care to TRICARE beneficiaries. There are two types of TRICARE-authorized providers: network and non-network.
Network providers accept TRICARE’s payment as the full payment for any covered health care services you get. You can save money by seeing network providers. They also file claims for you.
Non-network providers do not have an agreement with TRICARE and you may have to file your own claims. There are two types of non-network providers: participating and nonparticipating.
Participating: Accept TRICARE's payment as the full payment for any covered health care services you get and file claims for you on a case-by-case basis.
Nonparticipating: Do not accept TRICARE's payment as the full payment for covered health care services or file claims for you. They may charge up to 15 percent above the TRICARE- allowable charge. You are responsible for that amount in addition to any deductible or cost- share.
Note: Outside the U.S. and U.S. territories, which include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands, there may be no limit to the amount that nonparticipating non-network providers may charge.
If you see a provider without prior authorization from your regional contractor, you may be responsible for the full cost of care.
Go to to find a list of TRICARE-authorized network or non-network providers.

15. Autism Care Demonstration: Types of ABA Providers
There are several types of TRICARE-authorized ABA providers who may provide services under the Autism Care Demonstration. They include authorized ABA supervisors, assistant behavior analysts working under the supervision of an authorized ABA supervisor and behavior technicians working under the supervision of an authorized ABA supervisor.
An authorized ABA supervisor is a master’s degree level or higher certified behavior analyst or other TRICARE-authorized ABA provider practicing within the scope of his or her state licensure or state certification. The Autism Care Demonstration covers all ABA services given by an authorized ABA supervisor, such as ABA assessment, treatment plan development and updates and direct one-on-one ABA services.
An assistant behavior analyst is a supervised bachelor’s degree level behavior specialist who provides ABA services under the supervision of an authorized ABA supervisor. The Autism Care Demonstration covers certain services provided by an assistant behavior analyst, such as duties delegated by an authorized ABA supervisor. Assistant behavior analysts can’t practice independently.
A behavior technician is a supervised ABA team member who meets specified training requirements and can provide one-on-one ABA services under the supervision of an authorized ABA supervisor. Behavior technicians were previously called ABA tutors.
Behavior technicians can be supervised by an assistant behavior analyst, but the assistant behavior analyst must be under the supervision of an authorized ABA supervisor and must be certified by Dec. 31, 2016.
Note: Overseas, only master’s level and above board-certified behavior analysts who have been certified by the Behavior Analyst Certification Board can provide ABA services. TRICARE does not cover ABA services overseas from assistant behavior analysts or behavior technicians.

16. Autism Care Demonstration: Types of ABA Services
As part of the care you get under the Autism Care Demonstration, your child’s authorized ABA supervisor will:
Complete an initial ABA assessment of your child
Develop an individual treatment plan under which all ABA services are provided
Work one-on-one with your child or supervise an assistant behavior analyst or behavior technician to provide the ABA services one-on-one to your child
Help you, other parents and other caregivers of your child learn ABA techniques and practice ABA independently with your child
Reevaluate your child every six months to determine progress and update the individual treatment plan
The individual treatment plan developed by your child’s authorized ABA supervisor should include:
Personalized ABA objectives and goals
A description of skills and behaviors that can help address problems, including the areas of social interaction, communication and behavior
Objectives and goals for parents and/or caregivers to help with day-to-day ABA interventions
A recommendation of how many hours per week of ABA services your child should get
The treatment plan dictates the types of services and the number of hours of ABA needed each week. The hours may change during the reevaluation of your child.
The treatment plan is updated as progress toward objectives and goals are reviewed.

17. Autism Care Demonstration: Ongoing ABA Requirements
There are ongoing ABA requirements under the Autism Care Demonstration.
Every six months, your child must get a reassessment and a treatment plan update. Your child’s authorized ABA supervisor will submit this documentation to your regional contractor. Your regional contractor must get the required documentation to give reauthorization.
A new referral from an approved ASD-diagnosing provider is required for ABA services every six months.
Before the end of the six-month authorization period, your child’s authorized ABA supervisor will need to request reauthorization of ABA services from your regional contractor. This needs to occur every six months.
Every two years, there must be a periodic ABA program review to see if ABA is helping your child and, if not, to determine how to best help your child before your regional contractor can reauthorize ABA for another six months.

18. Autism Care Demonstration: Overseas
Overseas, in very limited locations and circumstances, your child may be able to get ABA services from behavior analysts who are certified by the Behavior Analyst Certification Board.
This means that ABA services are only authorized in countries that have providers with these certifications. The ABA benefit is not available in overseas countries where there are no board- certified behavior analysts within the TRICARE specialty care access standards.
Tiered model services (for example, assistant behavior analysts and behavior technicians) are not covered overseas.
For more information on getting ABA services overseas, contact the TOP contractor. Contact information will be provided at the end of this presentation.

19. Today’s Agenda: Other Important Information
Optional Presenter Comment: We will now discuss other important information.

20. Other Important Information: The Affordable Care Act
The Affordable Care Act, or ACA, requires most Americans to maintain basic health care coverage, called minimum essential coverage. The TRICARE program meets the minimum essential coverage requirement under the ACA.
If you do not have minimum essential coverage, you may have to pay a penalty for each month you are not covered. The penalty will be collected each year with federal tax returns.
Each tax year, you will get an IRS Form 1095 from your pay center. It will list your TRICARE coverage status for each month.
If your military pay is administered by the Defense Finance and Accounting Service, or DFAS, you can opt in to get your tax forms electronically through your DFAS myPay account. For more information, visit
For more information about the IRS tax forms, visit
Note: The IRS will use information from DEERS to verify your coverage. It is important for sponsors to keep their information and their family members’ information up to date in DEERS, including Social Security numbers. It is also important to update DEERS when personal eligibility information changes, including military career status and family status (for example, marriage, divorce, birth or adoption).
If you are losing TRICARE or are not TRICARE-eligible, you can find other health care coverage options through the Health Insurance Marketplace at
Premium assistance or state Medicaid coverage may be available based on income, family size and the state you live in.
For more information, visit

21. Today’s Agenda: For Information and Assistance
Optional Presenter Comment: The next slide provides contact information that may be useful to you while using the Autism Care Demonstration.

22. For Information and Assistance: Looking For More Information?
This slide shows contact information for stateside and overseas regional contractors, as well as other important information sources.
Remember, your regional contractor is based on where you live.
Only call Medical Assistance numbers to coordinate overseas emergency care.