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Research Questions

  1. How does the TRICARE coverage for Applied Behavior Analysis (ABA) as an early intervention for autism spectrum disorder compare with similar benefits in commercial and Medicaid programs?
  2. How do the TRICARE reimbursement rates for ABA services compare with commercial plans and Medicaid programs throughout the United States?
  3. Are there locations in the United States with potential provider shortages for TRICARE Applied Behavior Analysis users?
  4. How would providers respond to TRICARE's proposed $68 rate for one-to-one ABA therapy?

This study compared the Applied Behavior Analysis (ABA) benefit provided by TRICARE as an early intervention for autism spectrum disorder with similar benefits in Medicaid and commercial health insurance plans. The sponsor, the Office of the Under Secretary of Defense for Personnel and Readiness, was particularly interested in how a proposed TRICARE reimbursement rate decrease from $125 per hour to $68 per hour for ABA services performed by a Board Certified Behavior Analyst compared with reimbursement rates (defined as third-party payment to the service provider) in Medicaid and commercial health insurance plans. Information on ABA coverage in state Medicaid programs was collected from Medicaid state waiver databases; subsequently, Medicaid provider reimbursement data were collected from state Medicaid fee schedules. Applied Behavior Analysis provider reimbursement in the commercial health insurance system was estimated using Truven Health MarketScan® data. A weighted mean U.S. reimbursement rate was calculated for several services using cross-state information on the number of children diagnosed with autism spectrum disorder. Locations of potential provider shortages were also identified. Medicaid and commercial insurance reimbursement rates varied considerably across the United States. This project concluded that the proposed $68-per-hour reimbursement rate for services provided by a board certified analyst was more than 25 percent below the U.S. mean.

Key Findings

Treatment of autism spectrum disorder is a rapidly developing field

  • Applied Behavior Analysis (ABA) is widely accepted as an early intervention option. However, in the United States, insurance coverage, reimbursement rates, and coding for such treatments are still evolving.

Coverage and reimbursement rates for ABA vary widely in the United States

  • TRICARE's proposed rate of $68 per hour for one-to-one ABA therapy provided by a Board Certified Behavior Analyst, reduced from $125 per hour, is below the mean commercial insurance rate in ten of the 17 states where data figures were available and above the mean commercial insurance rate in seven of the 17 states.
  • The $68-per-hour rate is below the reimbursement rate in the 11 states that specify rates for master's- and doctoral-level ABA providers in Medicaid.
  • The U.S. weighted mean reimbursement rate for ABA services by a provider with a master's degree or doctorate is $94.72, based on local Medicaid and commercial insurance reimbursement rates, weighted by the number of children with ASD covered by each type of insurance in each location.
  • The weighted mean U.S. reimbursement rate for one-to-one therapy by paraprofessional is $65.16 per hour.
  • Adoption of the proposed $68 rate may prompt providers to either leave TRICARE's networks or prioritize ASD children from other health insurers over TRICARE–covered children.

Recommendations

  • TRICARE will need to re-evaluate reimbursement rates again before the Autism Care Demonstration ends on December 31, 2018, in order to calculate an updated national reimbursement rate based on 2018 data.
  • TRICARE should regularly evaluate ABA utilization and continuously monitor the adequacy of the ABA provider network.
  • TRICARE should remain engaged in discussions about policy and legislation changes affecting ABA coverage in other private and public health insurance plans.
  • The uptake of CPT codes for ABA will make it easier to evaluate utilization patterns of and reimbursement rates for ABA services.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Coverage of ABA–Comparison of TRICARE with Medicaid and Commercial Insurance

  • Chapter Three

    Reimbursement Rates for ABA, Medicaid, and Commercial Insurance

  • Chapter Four

    Potential Provider Shortage Areas

  • Chapter Five

    Discussion

  • Appendix

    Sensitivity Analysis Results

This research was sponsored by the Office of the Under Secretary of Defense for Personnel and Readiness (OUSD [P&R]) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the U.S. Navy, the U.S. Marine Corps, the defense agencies, and the Defense Intelligence Community.

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