Autism Care Demonstration

Autism Care Demonstration

Once you are enrolled in EFMP and registered in ECHO, you may be eligible for services under the Autism Care Demonstration (ACD) benefit—a program under TRICARE that allows families to access ABA services for their children diagnosed with autism. As of 2019, to qualify, children need to have an autism diagnosis given by a diagnosing specialist (consult your insurer for a full, updated list of accepted specialists). If a general physician or PCM gave the initial autism diagnosis, the child can still start ABA services, but will need a diagnosis from a qualified specialist within a year.

TRICARE requires the administration of three outcome measures in order to receive prior authorization for ABA services. These measures are the Vineland Adaptive Behavior Scale, Third Edition (Vineland 3), the Social Responsiveness Scale, Second Edition (SRS-2), and the Pervasive Developmental Disability Behavior Inventory (PDDBI). ABA services may start after the initial assessment and submission of the PDDBI. To continue ABA services and receive reauthorization, the PDDBI and two additional outcome measures must be submitted in regular intervals. The PDDBI is required every six months. The Vineland 3 and SRS-2 are required within the first year of the initial autism diagnosis and every two years in conjunction with the two year referral for continued services.

These measures are not diagnostic and are meant to measure progress or lack thereof, in addition to scoring the severity level of focused skills. The Vineland 3 and SRS-2 may be administered by either the specialized autism diagnosing provider or in some cases by the ABA provider. See TRICARE’s website for a full list of qualified professionals able to administer these measures. These measures are used as one component of several to determine if the current/proposed treatment plan is appropriate for the child or needs to be modified. Families may contact the regional contractors if they are experiencing TRICARE issues that are keeping them from receiving ABA services for their children diagnosed with autism.

To find an ABA provider, ask the child’s PCM for a referral for ABA services. The regional contractor will issue an authorization with a local ABA provider. Families can also search for ABA providers using the Provider Directories on the Health Net Federal Services (HNFS) or Humana Military websites. Note: The ACD is available overseas in limited locations; contact your regional call center for more information.

The ACD has been extended through 2023. It is expected to undergo significant changes in the coming years in order to make the program more comprehensive and centered around the family. These pending changes include case management, integration of speech and occupational therapies as part of comprehensive treatment plans, increased access to respite care, and a stronger focus on outcomes.

Families can also email this contact if they are experiencing other TRICARE issues that are keeping them from receiving ABA services for their children on the spectrum.

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