[Federal Register Volume 72, Number 232 (Tuesday, December 4, 2007)]
[Notices]
[Pages 68130-68132]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E7-23477]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Autism Services Demonstration Project for TRICARE Beneficiaries 
Under the Extended Care Health Option Program

AGENCY: Department of Defense.

ACTION: Notice of an autism services demonstration project for TRICARE 
beneficiaries under the Extended Care Health Option program.

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SUMMARY: This notice is to advise interested parties of a Military 
Health System (MHS) demonstration project entitled Enhanced Access to 
Autism Services Demonstration Project.
    The Department proposes a demonstration program under the 
Department's demonstration authority under 10 United States Code 
(U.S.C.) 1092 to expand the availability of Intensive Behavioral 
Intervention (IBI) services (defined as an intensive application of 
certain behavior modification interventions) to Extended Care Health 
Option (ECHO) program beneficiaries with autism. The demonstration 
program will permit TRICARE cost sharing of services by IBI tutors 
under a modified corporate services model. This demonstration will 
determine whether military families are able to make more effective use 
of the special education benefit in the ECHO program. Additionally, the 
demonstration will help determine the effectiveness of expanding the 
provider base in improving the access to services for TRICARE and 
attendant improvement in functional outcome for those military 
dependent children receiving services.
    For purposes of this demonstration, provider qualifications will be 
established by the Department pending development of national standards 
by a nationally recognized certifying body for ABA providers, which 
standards the Department determines appropriate for acceptance in the 
delivery of quality care under the program. The Department intends to 
retain the ECHO benefit as currently outlined in 32 Code of Federal 
Regulations (CFR) 199.5, except for the changes that will be 
implemented in the demonstration program noted above.

DATES: Effective Date: 60 days after publication in the Federal 
Register. This demonstration will remain in effect for two years from 
the start date of the demonstration.

ADDRESSES: TRICARE Management Activity, Office of the Chief Medical 
Officer, 5111 Leesburg Pike, Suite 810, Falls Church, VA 22041-3206.

FOR FURTHER INFORMATION CONTACT: Captain Robert DeMartino, Office of 
the Chief Medical Officer, TRICARE Management Activity, telephone (703) 
681-0064.

SUPPLEMENTARY INFORMATION:

A. Background

    The Military Health System (MHS) is a $33 billion dollar 
enterprise, consisting of 76 military hospitals, over 500 military 
health clinics, and an extensive network of private sector health care 
partners, which provides medical care for over 9 million beneficiaries 
and Active Duty Service Members. While an accurate count of the number 
of military-dependent children with autism is not available, estimates 
based on prevalence rates in the general population suggest that among 
the more than 1.2 million children of Active Duty Military personnel, 
between 7,000-9,000 would carry one of the autism spectrum disorder 
diagnoses.
    Autistic spectrum disorders affect essential human behaviors such 
as social interaction, the ability to communicate ideas and feelings, 
imagination, and the establishment of relationships with others. A 
number of treatments, therapies and interventions have been introduced 
to ameliorate the negative impact of autism on these areas of concern. 
Intensive Behavioral Intervention (IBI) services (defined as an 
intensive application of certain behavior modification interventions) 
have been shown to reduce or eliminate specific problem behaviors and 
teach new skills to individuals with autism. Applied behavior analysis 
(ABA), a systematized educational process of collecting data on a 
child's behaviors and using a variety of behavioral conditioning 
techniques to teach and reinforce desired behaviors while extinguishing 
harmful or undesired behaviors, is one of the best studied IBI 
interventions. Time-limited, focused ABA methods have been shown to 
reduce or eliminate specific problem behaviors and teach new skills to 
individuals with autism.

B. The Extended Care Health Option (ECHO) Program

    ECHO replaced the Program for Persons with Disabilities (PFPWD) on 
September 1, 2005, as authorized by section 701(b) of the National 
Defense Authorization Act for Fiscal Year 2002, Public Law 107-107, 
which revised subsections (d), (e), and (f) of section 1079 of Title 
10, United States Code, and is implemented under 32 CFR 199.5. Under 
ECHO, qualifying Active Duty family members may receive benefits not 
available under the basic program. For example, special education 
services are specifically excluded from the TRICARE basic program under 
10 U.S.C. 1079(a)(9). Qualifying conditions under ECHO include moderate 
or severe mental retardation, a serious physical disability, or an 
extraordinary physical or psychological condition. Under 10 U.S.C. 
1079(e), ``* * * Extended benefits for eligible dependents * * * may 
include * * * training, rehabilitation, special education, and 
assistive devices.'' IBI, as a behavioral intervention that shapes 
behaviors and teaches skills, is a special education service that can 
be cost-shared under ECHO. The government cost-share for these extended 
benefits is limited under 10 U.S.C. 1079(f)(2)(A) to a maximum of 
$2,500 per month.
    While participation in ECHO is voluntary, registration is required, 
by law, for a TRICARE beneficiary to receive the ECHO benefit. The 
registration process includes providing the managed care support 
contractor (MCSC) with evidence that the beneficiary is enrolled in the 
Exceptional Family Member Program provided by the sponsor's branch of 
Service.

C. The ECHO Program and Providers of ABA

    An authorized outpatient provider under the ECHO program must, 
under 32 CFR 199.6(e), be a provider otherwise authorized under the 
TRICARE basic program. Alternatively, if not recognized as such, if 
they provide services that are only authorized under the TRICARE ECHO 
program, such as special education services, the provider must meet all 
the applicable licensing and other regulatory requirements in that 
state, county, municipality or other governmental jurisdiction in which 
the ECHO service is rendered. In the absence of such licensing or 
regulatory requirements, the Director, TRICARE Management Activity, or 
designee determines the applicable requirements necessary to be an 
authorized provider.

[[Page 68131]]

At the present time, no state is known to license or have explicit 
regulatory oversight over providers of ABA services.
    As a health plan, TRICARE is obligated to take reasonable steps to 
assure the safety, efficacy, and quality of care it provides. One of 
the most common ways that health plans can assure high quality care is 
to require that the providers they reimburse meet widely recognized and 
accepted minimum standards for knowledge, training and experience. The 
only available nationally recognized credential for IBI services is for 
ABA providers through the Behavior Analyst Certification Board (BACB) 
which certifies providers at the bachelor's degree level (Board 
Certified Associate Behavior Analyst--BCABA) and at the master's degree 
level (Board Certified Behavior Analyst--BCBA).
    Absent state licensing or regulation of ABA providers, the 
Director, TRICARE Management Activity, established a requirement that 
ABA providers be certified by the BACB. It was expected that high 
demand for ABA services would provide incentive for large numbers of 
ABA providers to become certified BCBAs and BCABAs. The current TRICARE 
benefit allows cost sharing of BACB-certified ABA therapists when 
providing consultation to the beneficiary in the home or at school, 
designing and maintaining a behavioral treatment plan, providing hands-
on IBI services, and training and supervising family members in 
delivery of IBI. TRICARE currently does not authorize the reimbursement 
of the ``hands-on'' provider of IBI services unless the provider is an 
authorized TRICARE provider as described above.
    Though the number of BCBAs and BCABAs continues to increase, it is 
widely recognized that there is a relative paucity of board certified 
analysts. As a result, it is difficult in most areas, especially rural 
areas, for beneficiaries to find TRICARE authorized ABA providers.
    The impact of the scarcity of certified providers is ameliorated by 
the commonly practiced business model in which a supervising or lead 
therapist develops the behavioral treatment plan for a child and then 
provides indirect supervision of the hands-on ABA tutors (also referred 
to as technicians or instructors) who engage in the one-on-one 
treatment with the child. In the best scenario, several tutors then 
provide each client with the recommended intensity of behavioral 
services (in the range of 8-40 hours a week). Unfortunately, such a 
provider type is not currently regulated by the states or within the 
industry, nor is this provider type officially recognized by the BACB. 
In addition, there is no state or industry oversight of IBI or ABA 
business entities, no standardized education or training of tutors, and 
no verification of basic protections such as criminal background checks 
as a condition of employment. Therefore, none of the criteria exist for 
tutors that were applied by the Director, TRICARE Management Activity, 
when authorizing BCABAs and BCBAs as individual providers under the 
ECHO program.

D. Congressional Directives to the Department of Defense on Autism 
Services

    The John Warner National Defense Authorization Act for Fiscal Year 
2007, section 717, required the Department to develop a plan to provide 
services to military-dependent children with autism within the 
authority of the ECHO program. Part of the plan was to develop a 
demonstration project to expand the availability of IBI services. This 
demonstration implements the plan outlined in the July 2007 report to 
Congress that met the section 717 requirement.

E. Description of Demonstration Project

    The proposed demonstration project will modify the corporate 
services provider requirements of 32 CFR 199.6(f) as they apply to 
hands-on IBI tutors who engage in the one-on-one treatment with the 
child, while employed and supervised by an authorized IBI supervisor 
(requirements for TRICARE authorized IBI Tutors and IBI Supervisors 
will be detailed prior to the start of the demonstration project in the 
TRICARE Operations Manual, available at (http://manuals.tricare.osd.mil). Under 32 CFR 199.6(e)(2)(ii)(B), an ECHO 
outpatient care provider includes an individual, corporation, 
foundation, or public entity that predominantly renders services of a 
type uniquely allowable as an ECHO benefit. The TRICARE corporate 
service provider class under 32 CFR 199.6(f) is established to 
accommodate individuals who would meet the criteria for status as a 
TRICARE authorized individual professional provider as established by 
paragraph (c) of section 199.6, but for the fact that they are employed 
directly or contractually by a corporation or foundation that provides 
principally professional services which are within the scope of the 
TRICARE basic program benefit.
    Currently, TRICARE authorizes IBI services only by ABA trained 
outpatient care providers who are generally individual practitioners, 
and many practices are not incorporated. As a result, they do not meet 
most of the requirements under 32 CFR 199.6(f) to qualify as a 
corporate service provider. This demonstration project will expand who 
is eligible to provide IBI supervisory services and require IBI 
Supervisors to meet the following criteria to qualify as a ``corporate 
service'' provider under this demonstration, and receive reimbursement 
for services provided by tutors implementing their treatment plan.
    (1) IBI Tutors must be individuals who are employed directly or 
contractually by a TRICARE authorized IBI Supervisor.
    (2) Payment for otherwise allowable services by tutors under this 
demonstration project may be made to a TRICARE-authorized IBI 
Supervisor subject to the applicable requirements, exclusions and 
limitations of this demonstration.
    (3) The Director, TRICARE, Management Activity, or designee, may 
create discrete types within the allowable tutor category of provider 
established by this demonstration to improve the efficiency of TRICARE 
management.
    (4) The Director, TRICARE Management Activity, or designee, may 
require, as a condition of authorization, that the IBI Supervisor, or 
the IBI Tutor established by this demonstration project:
    (A) Maintain all applicable business license requirements of state 
or local jurisdictions.
    (B) Cooperate fully with a designated utilization and clinical 
quality management organization which has a contract with the 
Department of Defense for the geographic area in which the provider 
does business;
    (C) Render services for which direct or indirect payment is 
expected to be made by TRICARE only after obtaining TRICARE written 
authorization.
    (5) Otherwise allowable services may be rendered at the authorized 
supervising IBI provider's place of business, or in the beneficiary's 
home under such circumstances as the Director, TRICARE Management 
Activity, or designee, determines to be necessary for the efficient 
delivery of such services.
    (6) The Director, TRICARE Management Activity, or designee, may 
limit the term of a participation agreement for any category or type of 
provider established by this demonstration project.
    (7) The Director, TRICARE Management Activity, or designee, shall 
determine whether the appropriate

[[Page 68132]]

employment or contractual relationship exists between the IBI 
Supervisor and IBI Tutor. Such determination is conclusive and may not 
be appealed.
    (8) Conditions of authorization.
    An applicant must also meet the following conditions to be eligible 
for authorization as a TRICARE corporate services provider under this 
demonstration project:
    (A) Meet the qualifications and requirements for IBI Supervisors 
established by the Director, TRICARE Management Activity or designee; 
and
    (B) Ensure that IBI Tutors meet the requirements for TRICARE 
authorization specified by The Director, TRICARE Management Activity or 
designee; and
    (C) Comply with all applicable organizational and individual 
licensing or certification requirements that are extant in the state, 
county, municipality, or other political jurisdiction in which the 
provider renders services; and
    (D) Has entered into a participation agreement approved by the 
Director, TRICARE Management Activity, or designee, which complies with 
the participation agreement requirements established by the Director; 
and
    (E) Pricing and payment methodology: The pricing and payment of 
procedures rendered by a provider authorized under this demonstration 
project shall be limited to those methods for pricing and payment 
allowed by 32 CFR part 199 which the Director, TRICARE Management 
Activity, or designee, determines contribute to the efficient 
management of this demonstration project.
    (F) Termination of participation agreement. A provider may 
terminate a participation agreement upon 45 days written notice to the 
Director, TRICARE Management Activity.
    This demonstration will test the advisability and feasibility of 
permitting TRICARE reimbursement for IBI services delivered by non-
professional providers, under a modified corporate services model, in 
the absence of state or industry oversight. Neither the TRICARE Basic 
Program nor the ECHO program currently authorizes reimbursement for 
providers working within this type of unregulated corporate structure. 
Should the demonstration result in a determination to make a permanent 
change to the TRICARE benefit to permit reimbursement of services 
provided by IBI tutors under a corporate services model, such decision 
would require a change to the Code of Federal Regulations.
    In addition to provider qualifications, the demonstration project 
may outline criteria and requirements for covered services, limitations 
to the benefit, beneficiary eligibility, data gathering and use 
requirements and documentation of treatment effectiveness that are 
specific to services delivered under the demonstration project.

F. Evaluation

    An evaluation of the demonstration will be conducted. The 
evaluation will be designed to use a combination of administrative and 
survey measures of health care outcomes (clinical, utilization, 
financial, and humanistic measures) to provide analyses and comment on 
the effectiveness of the demonstration in meeting its goal of providing 
increased access to safe, efficacious, and quality behavioral services 
for military children with autism.

    Dated: November 28, 2007.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
 [FR Doc. E7-23477 Filed 12-3-07; 8:45 am]
BILLING CODE 5001-06-P