Autism, or Autism Spectrum Disorder (ASD), is a condition with a wide range of challenges as well as strengths, which commonly begin manifesting themselves in young children. Autism can affect a person’s ability to communicate, socialize, move or reason, all to varying degrees. Some might struggle with certain abilities, but excel in others.
In a word, autism is complex.
For a complex condition, in which no two individuals are alike, a complex system of care is required. TRICARE provides coverage for autism, but families might be required to pay a cost share depending on their plan.
Sometimes it helps just to get a nuts-and-bolts picture, before you start peeling back the layers. Here’s that picture:
In a Nutshell, What Does TRICARE Cover?
TRICARE’s Comprehensive Autism Care Demonstration is the process through which beneficiaries are diagnosed, referred to treatment and gain access to appropriate care.
TRICARE covers the following services, as needed, for beneficiaries diagnosed with ASD:
- Occupational therapy
- Physical therapy
- Physician services
- Psychological testing and services
- Prescription medications
- Speech therapy
- Applied Behavior Analysis (ABA)
Applied Behavior Analysis (ABA) is a practice based on the principles of learning, which aims to promote positive behaviors and reduce harmful behaviors. ABA techniques can be used to help autistic children practice behaviors like basic communication skills or complex reasoning skills. TRICARE covers ABA services that are provided by PhD or Master’s-level professionals. For that reason, ABA services are available only at a limited number of locations overseas.
To qualify for ABA services, active duty service members must be enrolled in the Exceptional Family Member Program (EFMP) and the Extended Care Health Option (ECHO). Learn more about ECHO benefits here.
What Is the Process of Getting Care?
If you suspect that your child needs treatment for autism, consult with your child’s doctor. TRICARE provides coverage for a wide range of services, and they provide a step-by-step plan to access the right combination of care.
- Get a diagnosis either from your child’s primary care manager or from a specialized ASD diagnosing provider.
- Get a referral and authorization. You will be referred to a provider for six months of ABA services. You will receive an authorization letter for this. Every six months, your authorized ABA provider will need to request to continue services. Your PCM or specialized ASD diagnosing provider must submit a new referral for ABA services every two years.
- Make an Appointment. After you get your authorization letter, you are free to make an appointment with the listed ABA provider. Your provider will assess the needs of your child, develop a treatment plan, work with your child, support caregivers throughout the process and reassess your child when it’s appropriate. You may request a different ABA provider if you wish.
- Complete Special Testing. Every six months, your child’s ABA provider must complete outcomes measures at baseline, and every two years a specialized ASD diagnosing provider must do the same thing. Be sure to schedule appointments for these assessments.
Learn more about the process for getting care here.
How Much Does It Cost Me?
That depends on your plan and your sponsor’s military status. Some plans require no co-pays or cost shares, while others do. If your plan does require out-of-pocket expenses, your payments are applied toward your catastrophic cap, which is the most you can pay every year for TRICARE-related services.
It’s important to note that the services that TRICARE will cover will not change from plan to plan, but the out-of-pocket costs associated with them will. If you anticipate retiring or changing your TRICARE plan for another reason, call TRICARE or visit their web page to learn more about how your costs could be affected.
