ABA Therapy/Autism Benefit Comparison Chart

The following chart offers a side-by-side comparison of the Applied Behavior Analysis Therapy benefit under the TRICARE Basic Program and the Extended Care Health Option (ECHO) Autism Demonstration Project regarding eligibility criteria, referrals and authorizations, provider requirements, benefit maximums, claims and reimbursement, case management, and document requirements for provider certification. Applied Behavior Analysis (ABA) Therapy Under TRICARE Basic Program Eligibility Criteria Applied Behavior Analysis (ABA) therapy under the TRICARE Basic Program is available for any TRICARE beneficiary, including retirees and their dependent family members, with a diagnosis of Autism Spectrum Disorder (ASD) as diagnosed by a Primary Care Provider (PCP) or specialized autism spectrum disorder (ASD) Provider with one of the following: Pervasive Developmental Disorders (PDD) and their associated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes: o Autistic Disorder (299.00) o Rhetts Disorder (299.80) o Childhood Disintegrative Disorder (CDD) (299.10) o Aspergers Disorder (299.80) o Pervasive Development Disorder Not Otherwise Specified (PDDNOS), including Atypical Autism (299.80) Referrals/Authorizations Referrals for TRICARE Prime enrollees are required for ABA services. Prior Authorization is not required. Covered Services require that the beneficiary be diagnosed by a ECHO Autism Demonstration Project Eligibility Criteria Benefits under the demonstration project are available to children of active duty Service members (ADSMs) who are: At least 18 months of age; and Registered in ECHO; and Diagnosed with Autism Spectrum Disorder (ASD) by a Primary Care Provider (PCP) or ASD provider with one of the following: PDD and their associated ICD-9-CM diagnostic codes: o Autistic Disorder (299.00) o Rhetts Disorder (299.80) o Childhood Disintegrative Disorder (CDD) (299.10) o Aspergers Disorder (299.80) o PDDNOS, including Atypical Autism (299.80)

Referrals/Authorizations Referrals and Prior Authorization are required. To request additional services, submit the prior authorization request a minimum of 15 business days prior to the current authorization expiration date. Attach a copy of the updated

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. TriWest Healthcare Alliance provides access to quality health care for 2.9 million members of America's military family in the 21-state TRICARE West Region. HO2372012-02052013

Applied Behavior Analysis (ABA) Therapy Under TRICARE Basic Program TRICARE-authorized primary care provider or by a specialized ASD provider defined as one of the following: A physician board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology, or child psychiatry A Ph.D. clinical psychologist working primarily with children

ECHO Autism Demonstration Project behavior plan and progress report. Services will be authorized only for those beneficiaries diagnosed by a TRICARE-authorized primary care provider or by a specialized ASD provider defined as one of the following: A physician board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology, or child psychiatry A Ph.D. clinical psychologist working primarily with children Provider Requirements TRICARE currently authorizes only board-certified ABA therapists for ASD-related services. The Autism Demonstration allows tutors supervised by an ABA therapist to deliver Educational Interventions for Autism Spectrum Disorder (EIA) services to eligible beneficiaries. For services provided in conjunction with ABA under the Autism Demonstration Project, the following are TRICARE-authorized provider requirements for EIA Supervisors. Have a current, state-issued license to provide ABA services; or Have a current State-issued certificate as a provider of ABA services; Or Have a current certification from the BACB (www.bacb.com) as either a BCBA or a BCaBA where such state-issued license or certification is not available; and Otherwise meet all applicable requirements as outlined in the TRICARE Operations Manual, Chapter 20, Section 9,

Provider Requirements For services provided in conjunction with ABA under the TRICARE Basic benefit, the following are TRICARE-authorized provider requirements when referred by and working under the supervision of those identified in the TRICARE Policy Manual, Chapter 7, Section 3.18: Have a current state license to provide ABA services; or Are currently state-certified as an Applied Behavioral Analyst; or Where such state license or certification is not available, are certified by the Behavioral Analyst Certification Board (BACB) (www.bacb.com) as a Board Certified Behavior Analyst (BCBA); and Otherwise meet all applicable requirements of TRICAREauthorized providers. Note: Individuals certified by the BACB as a Board Certified Assistant Behavior Analyst (BCaBA) are not TRICARE-authorized ABA providers under the TRICARE Basic Program.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. TriWest Healthcare Alliance provides access to quality health care for 2.9 million members of America's military family in the 21-state TRICARE West Region. HO2372012-02052013

Applied Behavior Analysis (ABA) Therapy Under TRICARE Basic Program Services of Tutors are not covered under the TRICARE Basic program benefit.

ECHO Autism Demonstration Project paragraphs 5.2, 5.3 and 5.4. Authorized supervisors will be required to direct and oversee tutors who will provide hands-on services to children with autism. Tutors must be qualified and specially trained to work with children with special needs as outlined in the TRICARE Operations Manual, Chapter 20, Section 9, paragraph 5.3. Qualified tutors who are not otherwise available under the ECHO program will be available to deliver EIA services to eligible beneficiaries under the demonstration project while under a supervisory agreement with an ABA therapist. Benefit Maximum There is a $36,000 fiscal year (Oct-Sep) ECHO benefit cap that applies to all ECHO benefits, except ECHO Home HealthCare (EHHC). The benefit cap applies for each ECHO beneficiary in a family. Claims and Reimbursement Claims for ABA services will be submitted electronically by a TRICARE-authorized provider on a Centers for Medicare and Medicaid Services (CMS)-1500 form. ECHO claims are reimbursed for the amount authorized to the fiscal year benefit limit: 90887 - Conducting the required quarterly progress meetings with the TRICARE beneficiarys caregivers will be reimbursed at the lesser of providers billed charge or CMAC. 99080 - Development of the required EIA progress report (EPR) and updated behavior plan. This will be completed

Benefit Maximum No fiscal year caps apply to ABA services under TRICARE Basic. All applicable deductibles, copayments and cost-shares apply.

Claims and Reimbursement Claims for ABA services will be submitted electronically by a TRICARE-authorized provider on a Centers for Medicare and Medicaid Services (CMS)-1500 form. 90887 - Conducting progress meetings, Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible person, or advising them how to assist patient will be reimbursed at the lesser of providers billed charges or CHAMPUS Maximum Allowable Charge (CMAC). 99080 - Development of an updated treatment plan will be reimbursed at the lesser of providers billed charges or

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. TriWest Healthcare Alliance provides access to quality health care for 2.9 million members of America's military family in the 21-state TRICARE West Region. HO2372012-02052013

Applied Behavior Analysis (ABA) Therapy Under TRICARE Basic Program CMAC. S5108 is used for the following services with reimbursement at the lesser of providers billed charges or $31.25 per 15 minute unit: o Functional Behavioral Assessment and Analysis and initial treatment plan o One-on-one ABA interventions with an eligible beneficiary, training of immediate family members to provide services in accordance with the treatment plan; and monitoring of the beneficiarys progress toward treatment goal NOTE: CPT Code 99199 and HCPCS Code H2019 are not allowed for ABA Therapy under the TRICARE Basic Program benefit.

ECHO Autism Demonstration Project and billed in the 5th month of the 6-month authorization period. The reimbursement rate will be at the lesser of providers billed charge or CMAC. H2019 - EIA services provided directly by an EIA Tutor will be reimbursed at the lesser of providers billed charge or $12.50 per 15-minute unit. S5108 is used for the following services with reimbursement at the lesser of providers billed charges or $31.25 per 15 minute unit: o Functional Behavioral Assessment and Analysis and initial treatment plan o Supervision of tutors implementing ABA interventions with an eligible beneficiary, training of immediate family members in accordance with the treatment plan; and monitoring of the beneficiarys progress toward treatment goal Case Management A team of ECHO nurses is available as a point of contact for all ECHO beneficiaries, sponsors and providers. ECHO nurses are responsible for all ECHO care authorization requests. Documentation Requirements Provider Certification The application process for the Autism Demonstration Project begins with the completion of the Autism Services Demonstration certification application for each BCBA or BCaBA. You can download this application from TriWest.com/Provider>Find a Form>Certification>Autism Services Demonstration Certification. Include each supervisors BCBA or BCaBA certification application and resume. Include a copy of the Declaration of Professional Liability Insurance page under the autism groups name with a minimum

Case Management For complex cases, a case manager may be assigned upon request. Documentation Requirements Provider Certification The application process for direct Applied Behavior Analysis (ABA) therapy begins with the completion of the Applied Behavioral Analyst Certification application, which can be downloaded from TriWest.com/Provider>Find a Form>Certification>Applied Behavioral Analyst Certification Form. If you are certified as a BCBA, please submit a copy of your BCBA certification, a copy of state licensure in ABA Therapy, if applicable and a copy of your resume with your application. Include a copy of the Declaration of Professional Liability

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. TriWest Healthcare Alliance provides access to quality health care for 2.9 million members of America's military family in the 21-state TRICARE West Region. HO2372012-02052013

Applied Behavior Analysis (ABA) Therapy Under TRICARE Basic Program Insurance page under the autism groups name with a minimum coverage of $1 million/$3 million and IRS form W-9. All BCBAs interested in providing services under the TRICARE basic program must be certified by TriWest. Application and further information can be found on TriWest.com. NOTE: Providers for the TRICARE Basic Program benefit will only be certified on an as-needed basis for geographically-based shortages or continuity of care.

ECHO Autism Demonstration Project coverage of $1 million/$3 million and IRS form W-9. A resume must also be attached for each Tutor, and the Tutors names should be listed on page five of the application. If any of these items are missing or expired, the certification process will be delayed. NOTE: Providers for the ECHO Autism Demonstration Project benefit will only be certified on an as-needed basis for geographically-based shortages or continuity of care.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. TriWest Healthcare Alliance provides access to quality health care for 2.9 million members of America's military family in the 21-state TRICARE West Region. HO2372012-02052013