80 FR 30664 - Comprehensive Autism Care Demonstration Amendment
DEPARTMENT OF DEFENSE
Office of the Secretary Federal Register Volume 80, Issue 103 (May 29, 2015)
Office of the Secretary
Federal Register Volume 80, Issue 103 (May 29, 2015)
| Page Range | 30664-30665 | |
| FR Document | 2015-13001 |
[Federal Register Volume 80, Number 103 (Friday, May 29, 2015)] [Notices] [Pages 30664-30665] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2015-13001] ----------------------------------------------------------------------- DEPARTMENT OF DEFENSE Office of the Secretary Comprehensive Autism Care Demonstration Amendment AGENCY: Department of Defense. ACTION: Notice of amendments to the comprehensive demonstration project for all Applied Behavior Analysis (ABA), including the tiered-model of ABA, for all TRICARE beneficiaries with Autism Spectrum Disorder (ASD). ----------------------------------------------------------------------- SUMMARY: This notice is to advise interested parties of amendments to a Military Health System (MHS) demonstration project entitled Comprehensive Autism Care Demonstration (ACD). The purpose of the ACD is to further analyze and evaluate the appropriateness of the ABA delivery model under TRICARE in light of current and anticipated guidelines and best practices from the Behavior Analyst Certification Board (BACB) and other resources. The demonstration seeks to determine the appropriate provider qualifications for the proper diagnosis of ASD and the provision of ABA, refine the beneficiary cost-sharing requirements and provider reimbursement rates for the treatment of ASD, determine the appropriate patient safety and fraud prevention measures to implement regarding coverage of ABA for ASD, and develop more efficient and appropriate means of increasing access and delivering ABA services under TRICARE while creating a viable economic model and maintaining administrative simplicity. First, the Department will align all ACD cost-shares with existing TRICARE Basic Program cost-share requirements under Standard/Extra and Prime to include allowing all ABA services under the ACD to accrue to the annual catastrophic cap. In addition, under the ACD the removal of the $36,000 annual limit on the amount the government may cost-share will continue. This will establish cost-share parity for the ACD by aligning it with existing TRICARE Basic program requirements generally, while remaining consistent with the requirement set forth in 32 CFR 199.4(f) that Active Duty benefits must be greater than benefits for non-Active Duty beneficiaries. As a result of this adjustment, all TRICARE beneficiaries receiving ABA for ASD under the ACD will now be protected from excessive out of pocket costs by the applicable catastrophic cap based on their sponsor's status and TRICARE plan under which covered. Second, the Department will also adjust all ABA reimbursement rates under the ACD by implementing adjustments based on Geographic Practice Cost Indices (GPCI). This will align the ACD reimbursement rates with the method used to determine many current CHAMPUS Maximum Allowable Charge (CMAC) rates (which are adjusted by local wage indices or geographic regions), and with the rates of other payers (which vary by location nationwide). DATES: These changes will be effective October 1, 2015. The demonstration will continue through December 31, 2018. ADDRESSES: Defense Health Agency, Health Plan Operations, 7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042. FOR FURTHER INFORMATION CONTACT: For questions or comments pertaining to this demonstration project, please contact Mr. Richard Hart at (703) 681-0047. SUPPLEMENTARY INFORMATION: A. Background Regarding the ACD Amendments In June 2014, the Department published the ACD Notice in the Federal Register (FR) (79 FR 34291-34296, June 16, 2014) upon Office of Management and Budget (OMB) approval and in compliance with 32 Code of Federal Regulations (CFR) 199.1(o) and Department of Defense (DoD) Administrative Instruction -102 that govern TRICARE demonstrations. The ACD incorporates the previous temporary ABA policies into a single program based on limited demonstration authority to ensure continued ABA coverage for all TRICARE beneficiaries--including Active Duty Family Members (ADFMs) and non-Active Duty Family Members (non-ADFMs)-- diagnosed with ASD. The Department conducted two ACD round table events for parents, advocacy groups, and other stakeholders on October 15, 2014 and December 3, 2014. The round tables were well attended and senior Department officials listened to concerns, answered questions, and took matters for further analysis and action. The Department received constructive feedback from these round tables and directly from interested stakeholders. The Department greatly appreciates the participation of all interested parties, and through this process has gained additional insights about how to design and implement an optimum care delivery and reimbursement system for beneficiaries diagnosed with ASD. Among a number of issues raised by stakeholders, two fundamental concerns emerged from the round table meetings that require immediate adjustments under the ACD. The first was that the beneficiary cost- sharing provisions under the ACD may have an adverse financial impact on beneficiaries as the one-on-one ABA therapy does not accrue to the catastrophic cap and thus may put ABA ``out of reach'' for some families. The second concern was that TRICARE reduced the reimbursement rate of $125/hour for ABA one-on-one therapy for Board Certified Behavior Analysts (BCBA) to $68/hour and this reportedly would cause providers to disengage TRICARE beneficiaries leading to decreased access. The Department will amend the ACD as outlined below in order to address these critical concerns. [[Page 30665]] B. Cost-Sharing Amendment Under the TRICARE program, cost-sharing by beneficiaries is required by law. It serves a number of purposes, including the means for obtaining a beneficiary's individual investment and commitment to the care sought, discouraging unnecessary use and overutilization of limited health care resources, and controlling overall TRICARE program costs to ensure sustainability of the benefits. TRICARE has kept the various cost-shares related to ABA under the ACD the same as cost-shares and co-payments previously established under the Extended Care Health Option (ECHO) Autism Demonstration for ADFMs, the ABA Pilot for non-ADFMs, and ABA under the Basic Program. Under the ACD, all ABA services provided by a master's level or above Board Certified Behavior Analyst (BCBA/BCBA-doctoral) (initial ABA assessment and treatment plan, ABA reassessments and treatment plan updates, direct one-on-one ABA, and parent/caregiver guidance in ABA) count toward the medical benefit catastrophic cap under the TRICARE Basic benefit. TRICARE covers 100% of charges for BCBA/BCBA-D services after a family's out-of-pocket costs reach an annual cap of $1,000.00 for Active Duty and TRICARE Reserve Select families, and $3,000.00 for retirees and their families. However, tiered model ABA services provided by supervised Board Certified Assistant Behavior Analysts (BCaBAs) and Behavior Technicians (BTs) were based on tiered model ABA services previously provided under ECHO and the ABA Pilot. Many families receive a bulk of their care under the tiered service delivery model. These ABA services include supervision and intensive one-on-one ABA which may take place for many hours over an extended period of time, and do not currently apply towards the benefit catastrophic cap. For ABA provided by supervised BCaBAs and BTs, ADFMs pay the same monthly fee amount based on the sponsor's pay grade. Non-ADFMs pay the same out of pocket costs under the ACD (as they did under the ABA Pilot)--10% of the allowed charge for these services. Because these tiered model ABA services do not accrue to the annual catastrophic cap and out of pocket costs are not limited, there have been concerns expressed by beneficiaries and advocates that this policy may have an adverse financial impact on some families and put tiered model ABA services ``out of reach'' for those families. To address this concern, the Department will apply all beneficiary cost-shares for ABA services under the ACD, including tiered model services (ABA provided by supervised BCaBAs and BTs), toward the catastrophic cap in the same manner as TRICARE Basic program benefits generally. The Department will implement this amendment to the beneficiary cost-share requirements by aligning cost-shares for all ABA services under the ACD with existing TRICARE program cost-sharing requirements. TRICARE Standard program deductible and cost share amounts are defined in 32 CFR 199.4. TRICARE Extra program deductible and cost-share amounts are defined in 32 CFR 199.17. TRICARE Prime program enrollment fees and copayments are defined under the Uniform Health Maintenance Organization (HMO) Benefit Schedule of Charges in 32 CFR 199.18. For information on fees for Prime enrollees choosing to receive care under the Point of Service (POS) option, refer to 32 CFR 199.17. C. ABA Provider Reimbursement Amendment The ACD, as a demonstration, has flexibility in creating reimbursement methodologies, rather than being constrained by otherwise existing TRICARE program provider reimbursement requirements. The Defense Health Agency has broad discretion to evaluate alternative methods of payment and the appropriate reimbursement rates for ABA under the TRICARE demonstration authority. Although care available under the TRICARE program must generally be reimbursed using the reimbursement requirements of 10 U.S.C. 1079(h) and 32 CFR 199.14(j) to ``to the extent practicable'', or (in the absence of a practicable Medicare rate) to use the prevailing rate, the ACD has no obligation to comply with this provision. As a result, the ABA reimbursement rates under the ACD may be established through different mechanisms. When TRICARE reimburses individual professional providers, they are reimbursed at the rate known as the CHAMPUS Maximum Allowable Charge (CMAC). In general, the CMAC rates mirror the Medicare rates. The CMAC rates are adjusted by geographic locality by using the Medicare Geographic Price Cost Index (GPCI). The geographic locality adjustments are in place for approximately 70 areas in the United States. With the publication of the ACD policy in September, 2014, the Department came under intense criticism from providers that the rate reduction for one-on-one ABA by BCBAs from $125 to $68 was too drastic and out of line with existing market rates. Some providers indicated that they would disengage TRICARE beneficiaries as a result of the proposed rate reduction. The Department responded by placing the rate reduction in abeyance pending a complete analysis of the ACD reimbursement rates by the RAND Corporation and further evaluation and a determination of appropriate rates by the Department. Extensive analysis of ABA reimbursement rates in effect for both commercial insurers and Medicaid, including data collected by RAND, indicate that the reimbursement rate of $125/hour for one-on-one ABA for BCBAs that TRICARE is currently paying is above the prevailing rate in most locations. In many instances, TRICARE is either the highest or one of the highest payers. As a result of this extensive analysis, the Department will adjust ABA reimbursement rates under the ACD to be more consistent with other payers and implement geographic adjustments based on GPCI. Once national rates for all of the ABA CPT codes are determined, then adjustments for local wage indices or geographic localities will be applied on an annual basis. In addition to alignment with geographic rates, adjustments will be made for provider type (Ph.D. level, master's level, bachelor's level, and technician). National rates will be established via an independent Government analysis using all available data, including but not limited to the results of the independent RAND ABA study. Although the general 15% limitation on reduction of TRICARE reimbursement rates set forth in 10 U.S.C. 1079(h)(2) does not apply to rate determinations for demonstrations established under the authority of 10 U.S.C. 1092, the Department will nonetheless gradually reduce rates (if needed based on the results of the independent analysis) by no more than 15% per year until alignment with the prevailing geographic rate based on provider type is reached. Dated: May 26, 2015. Aaron Siegel, Alternate OSD Federal Register Liaison Officer, Department of Defense. [FR Doc. 2015-13001 Filed 5-28-15; 8:45 am] BILLING CODE 5001-06-P
![30664 Federal Register / Vol. 80, No. 103 / Friday, May 29, 2015 / Notices
OMB Desk Officer: Ms. Jasmeet Comprehensive Autism Care FOR FURTHER INFORMATION CONTACT: For
Seehra. Demonstration (ACD). The purpose of questions or comments pertaining to
Written comments and the ACD is to further analyze and this demonstration project, please
recommendations on the proposed evaluate the appropriateness of the ABA contact Mr. Richard Hart at (703) 681–
information collection should be sent to delivery model under TRICARE in light 0047.
Ms. Seehra at the Office of Management of current and anticipated guidelines SUPPLEMENTARY INFORMATION:
and Budget, Desk Officer for DoD, Room and best practices from the Behavior
10236, New Executive Office Building, Analyst Certification Board (BACB) and A. Background Regarding the ACD
Washington, DC 20503. other resources. The demonstration Amendments
You may also submit comments, seeks to determine the appropriate In June 2014, the Department
identified by docket number and title, provider qualifications for the proper published the ACD Notice in the
by the following method: diagnosis of ASD and the provision of Federal Register (FR) (79 FR 34291–
Federal eRulemaking Portal: http:// ABA, refine the beneficiary cost-sharing 34296, June 16, 2014) upon Office of
www.regulations.gov. Follow the requirements and provider Management and Budget (OMB)
instructions for submitting comments. reimbursement rates for the treatment of approval and in compliance with 32
Instructions: All submissions received ASD, determine the appropriate patient Code of Federal Regulations (CFR)
must include the agency name, docket safety and fraud prevention measures to 199.1(o) and Department of Defense
number, and title for the Federal implement regarding coverage of ABA (DoD) Administrative Instruction -102
Register document. The general policy for ASD, and develop more efficient and that govern TRICARE demonstrations.
for comments and other public appropriate means of increasing access The ACD incorporates the previous
submissions from members of the public and delivering ABA services under temporary ABA policies into a single
is to make these submissions available TRICARE while creating a viable program based on limited
for public viewing on the Internet at economic model and maintaining demonstration authority to ensure
http://www.regulations.gov as they are administrative simplicity. continued ABA coverage for all
received without change, including any First, the Department will align all TRICARE beneficiaries—including
personal identifiers or contact ACD cost-shares with existing TRICARE Active Duty Family Members (ADFMs)
information provided. To confirm Basic Program cost-share requirements and non-Active Duty Family Members
receipt of your comment(s), please under Standard/Extra and Prime to (non-ADFMs)—diagnosed with ASD.
check http://www.regulations.gov include allowing all ABA services under The Department conducted two ACD
approximately two to three days after the ACD to accrue to the annual round table events for parents, advocacy
submission to verify posting (except catastrophic cap. In addition, under the groups, and other stakeholders on
allow 30 days for posting of comments ACD the removal of the $36,000 annual October 15, 2014 and December 3, 2014.
submitted by mail). limit on the amount the government The round tables were well attended
DoD Public Collections Clearance may cost-share will continue. This will and senior Department officials listened
Officer: Mr. Frederick C. Licari. establish cost-share parity for the ACD to concerns, answered questions, and
Written requests for copies of the by aligning it with existing TRICARE took matters for further analysis and
information collection proposal should Basic program requirements generally, action. The Department received
be sent to Mr. Licari at: Publication while remaining consistent with the constructive feedback from these round
Collections Program, WHS/ESD requirement set forth in 32 CFR 199.4(f) tables and directly from interested
Information Management Division, 4800 that Active Duty benefits must be stakeholders. The Department greatly
Mark Center Drive, 2nd Floor, East greater than benefits for non-Active appreciates the participation of all
Tower, Suite 02G09, Alexandria, VA Duty beneficiaries. As a result of this interested parties, and through this
22350–3100. adjustment, all TRICARE beneficiaries process has gained additional insights
Amy G. Williams, receiving ABA for ASD under the ACD about how to design and implement an
Editor, Defense Acquisition Regulations will now be protected from excessive optimum care delivery and
System. out of pocket costs by the applicable reimbursement system for beneficiaries
[FR Doc. 2015–12897 Filed 5–28–15; 8:45 am]
catastrophic cap based on their diagnosed with ASD. Among a number
sponsor’s status and TRICARE plan of issues raised by stakeholders, two
BILLING CODE 5001–06–P
under which covered. Second, the fundamental concerns emerged from the
Department will also adjust all ABA round table meetings that require
DEPARTMENT OF DEFENSE reimbursement rates under the ACD by immediate adjustments under the ACD.
implementing adjustments based on The first was that the beneficiary cost-
Office of the Secretary Geographic Practice Cost Indices (GPCI). sharing provisions under the ACD may
This will align the ACD reimbursement have an adverse financial impact on
Comprehensive Autism Care rates with the method used to determine beneficiaries as the one-on-one ABA
Demonstration Amendment many current CHAMPUS Maximum therapy does not accrue to the
AGENCY: Department of Defense. Allowable Charge (CMAC) rates (which catastrophic cap and thus may put ABA
are adjusted by local wage indices or ‘‘out of reach’’ for some families. The
ACTION: Notice of amendments to the geographic regions), and with the rates
comprehensive demonstration project second concern was that TRICARE
of other payers (which vary by location reduced the reimbursement rate of
for all Applied Behavior Analysis nationwide).
(ABA), including the tiered-model of $125/hour for ABA one-on-one therapy
Lhorne on DSK2VPTVN1PROD with NOTICES
DATES: These changes will be effective for Board Certified Behavior Analysts
ABA, for all TRICARE beneficiaries with
October 1, 2015. The demonstration will (BCBA) to $68/hour and this reportedly
Autism Spectrum Disorder (ASD).
continue through December 31, 2018. would cause providers to disengage
SUMMARY: This notice is to advise ADDRESSES: Defense Health Agency, TRICARE beneficiaries leading to
interested parties of amendments to a Health Plan Operations, 7700 Arlington decreased access. The Department will
Military Health System (MHS) Boulevard, Suite 5101, Falls Church, amend the ACD as outlined below in
demonstration project entitled Virginia 22042. order to address these critical concerns.
VerDate Sep<11>2014 15:17 May 28, 2015 Jkt 235001 PO 00000 Frm 00014 Fmt 4703 Sfmt 4703 E:\FR\FM\29MYN1.SGM 29MYN1](https://thefederalregister.org/doc/80_FR_30767/page/1.svg)
![Federal Register / Vol. 80, No. 103 / Friday, May 29, 2015 / Notices 30665
B. Cost-Sharing Amendment To address this concern, the criticism from providers that the rate
Under the TRICARE program, cost- Department will apply all beneficiary reduction for one-on-one ABA by
sharing by beneficiaries is required by cost-shares for ABA services under the BCBAs from $125 to $68 was too drastic
law. It serves a number of purposes, ACD, including tiered model services and out of line with existing market
including the means for obtaining a (ABA provided by supervised BCaBAs rates. Some providers indicated that
beneficiary’s individual investment and and BTs), toward the catastrophic cap in they would disengage TRICARE
commitment to the care sought, the same manner as TRICARE Basic beneficiaries as a result of the proposed
discouraging unnecessary use and program benefits generally. The rate reduction. The Department
overutilization of limited health care Department will implement this responded by placing the rate reduction
resources, and controlling overall amendment to the beneficiary cost-share
in abeyance pending a complete
TRICARE program costs to ensure requirements by aligning cost-shares for
analysis of the ACD reimbursement
sustainability of the benefits. all ABA services under the ACD with
existing TRICARE program cost-sharing rates by the RAND Corporation and
TRICARE has kept the various cost- further evaluation and a determination
shares related to ABA under the ACD requirements. TRICARE Standard
program deductible and cost share of appropriate rates by the Department.
the same as cost-shares and co-
payments previously established under amounts are defined in 32 CFR 199.4. Extensive analysis of ABA
the Extended Care Health Option TRICARE Extra program deductible and reimbursement rates in effect for both
(ECHO) Autism Demonstration for cost-share amounts are defined in 32 commercial insurers and Medicaid,
ADFMs, the ABA Pilot for non-ADFMs, CFR 199.17. TRICARE Prime program including data collected by RAND,
enrollment fees and copayments are indicate that the reimbursement rate of
and ABA under the Basic Program.
defined under the Uniform Health $125/hour for one-on-one ABA for
Under the ACD, all ABA services
Maintenance Organization (HMO) BCBAs that TRICARE is currently
provided by a master’s level or above
Benefit Schedule of Charges in 32 CFR paying is above the prevailing rate in
Board Certified Behavior Analyst
199.18. For information on fees for most locations. In many instances,
(BCBA/BCBA-doctoral) (initial ABA
Prime enrollees choosing to receive care TRICARE is either the highest or one of
assessment and treatment plan, ABA
under the Point of Service (POS) option,
reassessments and treatment plan the highest payers. As a result of this
refer to 32 CFR 199.17.
updates, direct one-on-one ABA, and extensive analysis, the Department will
parent/caregiver guidance in ABA) C. ABA Provider Reimbursement adjust ABA reimbursement rates under
count toward the medical benefit Amendment the ACD to be more consistent with
catastrophic cap under the TRICARE The ACD, as a demonstration, has other payers and implement geographic
Basic benefit. TRICARE covers 100% of flexibility in creating reimbursement adjustments based on GPCI. Once
charges for BCBA/BCBA–D services methodologies, rather than being national rates for all of the ABA CPT
after a family’s out-of-pocket costs reach constrained by otherwise existing codes are determined, then adjustments
an annual cap of $1,000.00 for Active TRICARE program provider for local wage indices or geographic
Duty and TRICARE Reserve Select reimbursement requirements. The localities will be applied on an annual
families, and $3,000.00 for retirees and Defense Health Agency has broad basis. In addition to alignment with
their families. discretion to evaluate alternative geographic rates, adjustments will be
However, tiered model ABA services methods of payment and the made for provider type (Ph.D. level,
provided by supervised Board Certified appropriate reimbursement rates for
Assistant Behavior Analysts (BCaBAs) master’s level, bachelor’s level, and
ABA under the TRICARE demonstration technician). National rates will be
and Behavior Technicians (BTs) were authority. Although care available under
based on tiered model ABA services established via an independent
the TRICARE program must generally be
previously provided under ECHO and Government analysis using all available
reimbursed using the reimbursement
the ABA Pilot. Many families receive a data, including but not limited to the
requirements of 10 U.S.C. 1079(h) and
bulk of their care under the tiered 32 CFR 199.14(j) to ‘‘to the extent results of the independent RAND ABA
service delivery model. These ABA practicable’’, or (in the absence of a study. Although the general 15%
services include supervision and practicable Medicare rate) to use the limitation on reduction of TRICARE
intensive one-on-one ABA which may prevailing rate, the ACD has no reimbursement rates set forth in 10
take place for many hours over an obligation to comply with this U.S.C. 1079(h)(2) does not apply to rate
extended period of time, and do not provision. As a result, the ABA determinations for demonstrations
currently apply towards the benefit reimbursement rates under the ACD established under the authority of 10
catastrophic cap. For ABA provided by may be established through different U.S.C. 1092, the Department will
supervised BCaBAs and BTs, ADFMs mechanisms. nonetheless gradually reduce rates (if
pay the same monthly fee amount based When TRICARE reimburses needed based on the results of the
on the sponsor’s pay grade. Non-ADFMs individual professional providers, they independent analysis) by no more than
pay the same out of pocket costs under are reimbursed at the rate known as the 15% per year until alignment with the
the ACD (as they did under the ABA CHAMPUS Maximum Allowable Charge prevailing geographic rate based on
Pilot)—10% of the allowed charge for (CMAC). In general, the CMAC rates provider type is reached.
these services. Because these tiered mirror the Medicare rates. The CMAC
model ABA services do not accrue to Dated: May 26, 2015.
rates are adjusted by geographic locality
the annual catastrophic cap and out of by using the Medicare Geographic Price Aaron Siegel,
Lhorne on DSK2VPTVN1PROD with NOTICES
pocket costs are not limited, there have Cost Index (GPCI). The geographic Alternate OSD Federal Register Liaison
been concerns expressed by locality adjustments are in place for Officer, Department of Defense.
beneficiaries and advocates that this approximately 70 areas in the United [FR Doc. 2015–13001 Filed 5–28–15; 8:45 am]
policy may have an adverse financial States. BILLING CODE 5001–06–P
impact on some families and put tiered With the publication of the ACD
model ABA services ‘‘out of reach’’ for policy in September, 2014, the
those families. Department came under intense
VerDate Sep<11>2014 15:17 May 28, 2015 Jkt 235001 PO 00000 Frm 00015 Fmt 4703 Sfmt 9990 E:\FR\FM\29MYN1.SGM 29MYN1](https://thefederalregister.org/doc/80_FR_30767/page/2.svg)
Document Created: 2015-12-15 15:31:51
Document Modified: 2015-12-15 15:31:51
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Notices | |
| Action | Notice of amendments to the comprehensive demonstration project for all Applied Behavior Analysis (ABA), including the tiered-model of ABA, for all TRICARE beneficiaries with Autism Spectrum Disorder (ASD). | |
| Dates | These changes will be effective October 1, 2015. The demonstration will continue through December 31, 2018. | |
| Contact | For questions or comments pertaining to this demonstration project, please contact Mr. Richard Hart at (703) 681-0047. | |
| FR Citation | 80 FR 30664 |
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