[Federal Register Volume 80, Number 103 (Friday, May 29, 2015)]
[Notices]
[Pages 30664-30665]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-13001]
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DEPARTMENT OF DEFENSE
Office of the Secretary
Comprehensive Autism Care Demonstration Amendment
AGENCY: Department of Defense.
ACTION: Notice of amendments to the comprehensive demonstration project
for all Applied Behavior Analysis (ABA), including the tiered-model of
ABA, for all TRICARE beneficiaries with Autism Spectrum Disorder (ASD).
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SUMMARY: This notice is to advise interested parties of amendments to a
Military Health System (MHS) demonstration project entitled
Comprehensive Autism Care Demonstration (ACD). The purpose of the ACD
is to further analyze and evaluate the appropriateness of the ABA
delivery model under TRICARE in light of current and anticipated
guidelines and best practices from the Behavior Analyst Certification
Board (BACB) and other resources. The demonstration seeks to determine
the appropriate provider qualifications for the proper diagnosis of ASD
and the provision of ABA, refine the beneficiary cost-sharing
requirements and provider reimbursement rates for the treatment of ASD,
determine the appropriate patient safety and fraud prevention measures
to implement regarding coverage of ABA for ASD, and develop more
efficient and appropriate means of increasing access and delivering ABA
services under TRICARE while creating a viable economic model and
maintaining administrative simplicity.
First, the Department will align all ACD cost-shares with existing
TRICARE Basic Program cost-share requirements under Standard/Extra and
Prime to include allowing all ABA services under the ACD to accrue to
the annual catastrophic cap. In addition, under the ACD the removal of
the $36,000 annual limit on the amount the government may cost-share
will continue. This will establish cost-share parity for the ACD by
aligning it with existing TRICARE Basic program requirements generally,
while remaining consistent with the requirement set forth in 32 CFR
199.4(f) that Active Duty benefits must be greater than benefits for
non-Active Duty beneficiaries. As a result of this adjustment, all
TRICARE beneficiaries receiving ABA for ASD under the ACD will now be
protected from excessive out of pocket costs by the applicable
catastrophic cap based on their sponsor's status and TRICARE plan under
which covered. Second, the Department will also adjust all ABA
reimbursement rates under the ACD by implementing adjustments based on
Geographic Practice Cost Indices (GPCI). This will align the ACD
reimbursement rates with the method used to determine many current
CHAMPUS Maximum Allowable Charge (CMAC) rates (which are adjusted by
local wage indices or geographic regions), and with the rates of other
payers (which vary by location nationwide).
DATES: These changes will be effective October 1, 2015. The
demonstration will continue through December 31, 2018.
ADDRESSES: Defense Health Agency, Health Plan Operations, 7700
Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042.
FOR FURTHER INFORMATION CONTACT: For questions or comments pertaining
to this demonstration project, please contact Mr. Richard Hart at (703)
681-0047.
SUPPLEMENTARY INFORMATION:
A. Background Regarding the ACD Amendments
In June 2014, the Department published the ACD Notice in the
Federal Register (FR) (79 FR 34291-34296, June 16, 2014) upon Office of
Management and Budget (OMB) approval and in compliance with 32 Code of
Federal Regulations (CFR) 199.1(o) and Department of Defense (DoD)
Administrative Instruction -102 that govern TRICARE demonstrations. The
ACD incorporates the previous temporary ABA policies into a single
program based on limited demonstration authority to ensure continued
ABA coverage for all TRICARE beneficiaries--including Active Duty
Family Members (ADFMs) and non-Active Duty Family Members (non-ADFMs)--
diagnosed with ASD.
The Department conducted two ACD round table events for parents,
advocacy groups, and other stakeholders on October 15, 2014 and
December 3, 2014. The round tables were well attended and senior
Department officials listened to concerns, answered questions, and took
matters for further analysis and action. The Department received
constructive feedback from these round tables and directly from
interested stakeholders. The Department greatly appreciates the
participation of all interested parties, and through this process has
gained additional insights about how to design and implement an optimum
care delivery and reimbursement system for beneficiaries diagnosed with
ASD. Among a number of issues raised by stakeholders, two fundamental
concerns emerged from the round table meetings that require immediate
adjustments under the ACD. The first was that the beneficiary cost-
sharing provisions under the ACD may have an adverse financial impact
on beneficiaries as the one-on-one ABA therapy does not accrue to the
catastrophic cap and thus may put ABA ``out of reach'' for some
families. The second concern was that TRICARE reduced the reimbursement
rate of $125/hour for ABA one-on-one therapy for Board Certified
Behavior Analysts (BCBA) to $68/hour and this reportedly would cause
providers to disengage TRICARE beneficiaries leading to decreased
access. The Department will amend the ACD as outlined below in order to
address these critical concerns.
[[Page 30665]]
B. Cost-Sharing Amendment
Under the TRICARE program, cost-sharing by beneficiaries is
required by law. It serves a number of purposes, including the means
for obtaining a beneficiary's individual investment and commitment to
the care sought, discouraging unnecessary use and overutilization of
limited health care resources, and controlling overall TRICARE program
costs to ensure sustainability of the benefits.
TRICARE has kept the various cost-shares related to ABA under the
ACD the same as cost-shares and co-payments previously established
under the Extended Care Health Option (ECHO) Autism Demonstration for
ADFMs, the ABA Pilot for non-ADFMs, and ABA under the Basic Program.
Under the ACD, all ABA services provided by a master's level or above
Board Certified Behavior Analyst (BCBA/BCBA-doctoral) (initial ABA
assessment and treatment plan, ABA reassessments and treatment plan
updates, direct one-on-one ABA, and parent/caregiver guidance in ABA)
count toward the medical benefit catastrophic cap under the TRICARE
Basic benefit. TRICARE covers 100% of charges for BCBA/BCBA-D services
after a family's out-of-pocket costs reach an annual cap of $1,000.00
for Active Duty and TRICARE Reserve Select families, and $3,000.00 for
retirees and their families.
However, tiered model ABA services provided by supervised Board
Certified Assistant Behavior Analysts (BCaBAs) and Behavior Technicians
(BTs) were based on tiered model ABA services previously provided under
ECHO and the ABA Pilot. Many families receive a bulk of their care
under the tiered service delivery model. These ABA services include
supervision and intensive one-on-one ABA which may take place for many
hours over an extended period of time, and do not currently apply
towards the benefit catastrophic cap. For ABA provided by supervised
BCaBAs and BTs, ADFMs pay the same monthly fee amount based on the
sponsor's pay grade. Non-ADFMs pay the same out of pocket costs under
the ACD (as they did under the ABA Pilot)--10% of the allowed charge
for these services. Because these tiered model ABA services do not
accrue to the annual catastrophic cap and out of pocket costs are not
limited, there have been concerns expressed by beneficiaries and
advocates that this policy may have an adverse financial impact on some
families and put tiered model ABA services ``out of reach'' for those
families.
To address this concern, the Department will apply all beneficiary
cost-shares for ABA services under the ACD, including tiered model
services (ABA provided by supervised BCaBAs and BTs), toward the
catastrophic cap in the same manner as TRICARE Basic program benefits
generally. The Department will implement this amendment to the
beneficiary cost-share requirements by aligning cost-shares for all ABA
services under the ACD with existing TRICARE program cost-sharing
requirements. TRICARE Standard program deductible and cost share
amounts are defined in 32 CFR 199.4. TRICARE Extra program deductible
and cost-share amounts are defined in 32 CFR 199.17. TRICARE Prime
program enrollment fees and copayments are defined under the Uniform
Health Maintenance Organization (HMO) Benefit Schedule of Charges in 32
CFR 199.18. For information on fees for Prime enrollees choosing to
receive care under the Point of Service (POS) option, refer to 32 CFR
199.17.
C. ABA Provider Reimbursement Amendment
The ACD, as a demonstration, has flexibility in creating
reimbursement methodologies, rather than being constrained by otherwise
existing TRICARE program provider reimbursement requirements. The
Defense Health Agency has broad discretion to evaluate alternative
methods of payment and the appropriate reimbursement rates for ABA
under the TRICARE demonstration authority. Although care available
under the TRICARE program must generally be reimbursed using the
reimbursement requirements of 10 U.S.C. 1079(h) and 32 CFR 199.14(j) to
``to the extent practicable'', or (in the absence of a practicable
Medicare rate) to use the prevailing rate, the ACD has no obligation to
comply with this provision. As a result, the ABA reimbursement rates
under the ACD may be established through different mechanisms.
When TRICARE reimburses individual professional providers, they are
reimbursed at the rate known as the CHAMPUS Maximum Allowable Charge
(CMAC). In general, the CMAC rates mirror the Medicare rates. The CMAC
rates are adjusted by geographic locality by using the Medicare
Geographic Price Cost Index (GPCI). The geographic locality adjustments
are in place for approximately 70 areas in the United States.
With the publication of the ACD policy in September, 2014, the
Department came under intense criticism from providers that the rate
reduction for one-on-one ABA by BCBAs from $125 to $68 was too drastic
and out of line with existing market rates. Some providers indicated
that they would disengage TRICARE beneficiaries as a result of the
proposed rate reduction. The Department responded by placing the rate
reduction in abeyance pending a complete analysis of the ACD
reimbursement rates by the RAND Corporation and further evaluation and
a determination of appropriate rates by the Department.
Extensive analysis of ABA reimbursement rates in effect for both
commercial insurers and Medicaid, including data collected by RAND,
indicate that the reimbursement rate of $125/hour for one-on-one ABA
for BCBAs that TRICARE is currently paying is above the prevailing rate
in most locations. In many instances, TRICARE is either the highest or
one of the highest payers. As a result of this extensive analysis, the
Department will adjust ABA reimbursement rates under the ACD to be more
consistent with other payers and implement geographic adjustments based
on GPCI. Once national rates for all of the ABA CPT codes are
determined, then adjustments for local wage indices or geographic
localities will be applied on an annual basis. In addition to alignment
with geographic rates, adjustments will be made for provider type
(Ph.D. level, master's level, bachelor's level, and technician).
National rates will be established via an independent Government
analysis using all available data, including but not limited to the
results of the independent RAND ABA study. Although the general 15%
limitation on reduction of TRICARE reimbursement rates set forth in 10
U.S.C. 1079(h)(2) does not apply to rate determinations for
demonstrations established under the authority of 10 U.S.C. 1092, the
Department will nonetheless gradually reduce rates (if needed based on
the results of the independent analysis) by no more than 15% per year
until alignment with the prevailing geographic rate based on provider
type is reached.
Dated: May 26, 2015.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2015-13001 Filed 5-28-15; 8:45 am]
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