2017-26567. Extension of the Comprehensive Autism Care Demonstration for TRICARE Eligible Beneficiaries Diagnosed With Autism Spectrum Disorder

AGENCY:

Department of Defense.

ACTION:

Notice of an extension of a comprehensive demonstration project for all Applied Behavior Analysis (ABA) services, including the tiered-model of ABA, for all TRICARE eligible beneficiaries diagnosed with Autism Spectrum Disorder (ASD).

SUMMARY:

This notice provides a five-year extension to the Military Health System's demonstration project entitled Comprehensive Autism Care Demonstration (“Autism Care

Demonstration”). The initial purpose of the Autism Care Demonstration (ACD) was to further analyze and evaluate the appropriateness of the ABA services tiered delivery model under TRICARE (the medical benefit) in light of current and anticipated Behavior Analyst Certification Board guidelines. Based on the agency's experience in administering ABA services under the ACD, including engagement with beneficiaries, providers, advocates, associations, and other payers, much more analysis and experience is required in order to determine the appropriate characterization of ABA services as a medical treatment, or other modalities, under the TRICARE program coverage requirements—to include further research and evaluation of the results, whether Board Certified Behavior Analysts may appropriately be recognized and treated as independent TRICARE authorized providers of a proven medical benefit, and what authorities are required to add ABA services as a permanent benefit under the TRICARE program—whether as a proven medical benefit or otherwise.

DATES:

The demonstration will continue through December 31, 2023.

ADDRESSES:

Defense Health Agency, Health Plan Operations, 7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042.

FOR FURTHER INFORMATION CONTACT:

For questions pertaining to this demonstration project, please contact Mr. Richard Hart at [phone].

SUPPLEMENTARY INFORMATION:

Under the demonstration, the Department implemented a provider model that allows reimbursement for ABA services rendered by providers who are not otherwise eligible for reimbursement. Additionally, since the implementation of the demonstration, Congress directed the agency to add outcome measures as a requirement to the program. Through revisions and accomodations to obtain achievable information, these outcome measures are aimed at assessing individual progress for each beneficiary, and provide limited utility to describe the population, and the program, as a whole. To acquire additional research results that are essential to evaluating the nature and efficacy of ABA services, the appropriate characterization of ABA providers, and the optimum means to administer coverage of ABA services under TRICARE, the agency is working with the Congressionally Directed Medical Research Program (CDMRP) to award a contract to a research group to analyze the TRICARE ACD participants' outcome measures, particularly assessing their responses to ABA service delivery as a total population. The CDMRP research study will be a descriptive analysis that has the potential to be the largest sample population of ABA services for the diagnosis of ASD in the entire body of research literature, therefore contributing significantly to the understanding of the efficacy of ABA service delivery. By extending the demonstration, the government will not only gain information about what TRICARE beneficiaries are receiving under the ACD and respective outcomes, the government will also gain greater insight and understanding of ASD in the TRICARE population, ABA services being delivered to TRICARE beneficiaries, and outcomes data.

Additionally, as a next phase to improve the ABA services benefit, the Department will consult with stakeholders and utilize best practices identified in commercial and Medicaid plans as a guide to explore the potential for a single, nationwide contract to manage ABA service delivery under the ongoing authority of the ACD. This reflects a beneficiary-centric approach with many advantages that will provide improved coordination of benefits nationwide leading to improved consistency, quality, and beneficiary experience.

A determination of the future of ABA under TRICARE and the efficacy of ABA services as a medical benefit would be premature at this point for the reasons stated above. It is therefore necessary for the Department to extend the ACD beyond its December 31, 2018, expiration in order to implement this multi-track approach. This approach will advance the comprehensive evaluation of ABA services for TRICARE coverage for the duration of the CDRMP research study under a single benefit contract. This extension will also ensure continuity of care for beneficiaries currently receiving ABA services, and for those beneficiaries who will be diagnosed with ASD in the future, for the duration of these ongoing initiatives and a reasonable time thereafter for analysis and appropriate TRICARE program changes, to include seeking any additional authorities that may be required.

On June 16, 2014, the Department of Defense published a notice in the Federal Register (FR) (79 FR 34291), as amended by 80 FR 30664 (May 29, 2015), of a TRICARE demonstration to further analyze and evaluate the appropriateness of the ABA tiered delivery model under TRICARE. The initial purpose of the demonstration was to determine the appropriate provider qualifications for the proper diagnosis of ASD and for the provision of ABA services, assess the feasibility and advisability of establishing a beneficiary cost share for ABA services for the treatment of ASD, and develop more efficient and appropriate means of increasing access to and delivering of ABA services under TRICARE while creating a viable economic model and maintaining administrative simplicity. The ACD was implemented on July 25, 2014, and expires December 31, 2018.

ABA services are currently provided through the ACD and managed by the existing TRICARE regional managed care support contractors. This approach enabled TRICARE to quickly expand access to ABA services for over 14,000 children diagnosed with ASD and manage a comprehensive ABA benefit program. However, in efforts to manage ABA services similar to the TRICARE Basic medical benefit, many rules have been modified, or exceptions have been made, such as diagnosis and referral procedures, ABA provider qualifications and credentialing, safety and quality management reviews, and reimbursement rate methodology. Additionally, ABA services may involve a lengthy period of care and as families move or transfer across TRICARE regions, many experience inconsistencies in how the ABA services benefit is managed between TRICARE contracts. Based on lessons learned, DHA now seeks to improve ABA services delivery with a more unified approach to reduce variation and ensure ABA services are directed to beneficiaries in a manner that maximizes clinically necessary benefits to each child with minimal disruptions.

The Department is committed to ensuring all TRICARE-eligible beneficiaries diagnosed with ASD reach their maximum potential, and that all treatment provided supports this goal. The need for effective treatment for the diagnosis of ASD is unquestioned, and while there is need for more scientific evidence, ABA remains the most widely accepted intervention. Therefore, the Department is pursuing a more effective method of delivering and validating the effectiveness of these services. The Department is exploring the potential for a single, nationwide contract, administered by a private sector health care company, with specialized experience and expertise in providing ABA services, will significantly improve the provision of ABA services to military beneficiaries diagnosed with ASD.

Consequently, the Department has determined that extension of the demonstration is both in the best interest of TRICARE beneficiaries diagnosed with ASD, and necessary to fully evaluate the effectiveness of the delivery model employed by the demonstration while putting in-place a nationwide contract. This extension will determine whether the ACD meets its stated purpose and provide the Department with consistent and reliable information necessary to make informed decisions regarding the provision of the ABA services benefit. This extension will allow the Department to make a formal decision regarding the use of that delivery model in the long-term. The demonstration continues to be authorized by Title 10, United States Code, Section 1092.

Dated: December 5, 2017.

Aaron Siegel,

Alternate OSD Federal Register Liaison Officer, Department of Defense.