Comprehensive Autism Care Demonstration Amendment

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).