[Federal Register Volume 82, Number 236 (Monday, December 11, 2017)]
[Notices]
[Pages 58186-58187]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-26567]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Extension of the Comprehensive Autism Care Demonstration for 
TRICARE Eligible Beneficiaries Diagnosed With Autism Spectrum Disorder

AGENCY: Department of Defense.

ACTION: Notice of an extension of a comprehensive demonstration project 
for all Applied Behavior Analysis (ABA) services, including the tiered-
model of ABA, for all TRICARE eligible beneficiaries diagnosed with 
Autism Spectrum Disorder (ASD).

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SUMMARY: This notice provides a five-year extension to the Military 
Health System's demonstration project entitled Comprehensive Autism 
Care Demonstration (``Autism Care
    Demonstration''). The initial purpose of the Autism Care 
Demonstration (ACD) was to further analyze and evaluate the 
appropriateness of the ABA services tiered delivery model under TRICARE 
(the medical benefit) in light of current and anticipated Behavior 
Analyst Certification Board guidelines. Based on the agency's 
experience in administering ABA services under the ACD, including 
engagement with beneficiaries, providers, advocates, associations, and 
other payers, much more analysis and experience is required in order to 
determine the appropriate characterization of ABA services as a medical 
treatment, or other modalities, under the TRICARE program coverage 
requirements--to include further research and evaluation of the 
results, whether Board Certified Behavior Analysts may appropriately be 
recognized and treated as independent TRICARE authorized providers of a 
proven medical benefit, and what authorities are required to add ABA 
services as a permanent benefit under the TRICARE program--whether as a 
proven medical benefit or otherwise.

DATES: The demonstration will continue through December 31, 2023.

ADDRESSES: Defense Health Agency, Health Plan Operations, 7700 
Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042.

FOR FURTHER INFORMATION CONTACT: For questions pertaining to this

[[Page 58187]]

demonstration project, please contact Mr. Richard Hart at (703) 681-
0047.

SUPPLEMENTARY INFORMATION: Under the demonstration, the Department 
implemented a provider model that allows reimbursement for ABA services 
rendered by providers who are not otherwise eligible for reimbursement. 
Additionally, since the implementation of the demonstration, Congress 
directed the agency to add outcome measures as a requirement to the 
program. Through revisions and accomodations to obtain achievable 
information, these outcome measures are aimed at assessing individual 
progress for each beneficiary, and provide limited utility to describe 
the population, and the program, as a whole. To acquire additional 
research results that are essential to evaluating the nature and 
efficacy of ABA services, the appropriate characterization of ABA 
providers, and the optimum means to administer coverage of ABA services 
under TRICARE, the agency is working with the Congressionally Directed 
Medical Research Program (CDMRP) to award a contract to a research 
group to analyze the TRICARE ACD participants' outcome measures, 
particularly assessing their responses to ABA service delivery as a 
total population. The CDMRP research study will be a descriptive 
analysis that has the potential to be the largest sample population of 
ABA services for the diagnosis of ASD in the entire body of research 
literature, therefore contributing significantly to the understanding 
of the efficacy of ABA service delivery. By extending the 
demonstration, the government will not only gain information about what 
TRICARE beneficiaries are receiving under the ACD and respective 
outcomes, the government will also gain greater insight and 
understanding of ASD in the TRICARE population, ABA services being 
delivered to TRICARE beneficiaries, and outcomes data.
    Additionally, as a next phase to improve the ABA services benefit, 
the Department will consult with stakeholders and utilize best 
practices identified in commercial and Medicaid plans as a guide to 
explore the potential for a single, nationwide contract to manage ABA 
service delivery under the ongoing authority of the ACD. This reflects 
a beneficiary-centric approach with many advantages that will provide 
improved coordination of benefits nationwide leading to improved 
consistency, quality, and beneficiary experience.
    A determination of the future of ABA under TRICARE and the efficacy 
of ABA services as a medical benefit would be premature at this point 
for the reasons stated above. It is therefore necessary for the 
Department to extend the ACD beyond its December 31, 2018, expiration 
in order to implement this multi-track approach. This approach will 
advance the comprehensive evaluation of ABA services for TRICARE 
coverage for the duration of the CDRMP research study under a single 
benefit contract. This extension will also ensure continuity of care 
for beneficiaries currently receiving ABA services, and for those 
beneficiaries who will be diagnosed with ASD in the future, for the 
duration of these ongoing initiatives and a reasonable time thereafter 
for analysis and appropriate TRICARE program changes, to include 
seeking any additional authorities that may be required.
    On June 16, 2014, the Department of Defense published a notice in 
the Federal Register (FR) (79 FR 34291), as amended by 80 FR 30664 (May 
29, 2015), of a TRICARE demonstration to further analyze and evaluate 
the appropriateness of the ABA tiered delivery model under TRICARE. The 
initial purpose of the demonstration was to determine the appropriate 
provider qualifications for the proper diagnosis of ASD and for the 
provision of ABA services, assess the feasibility and advisability of 
establishing a beneficiary cost share for ABA services for the 
treatment of ASD, and develop more efficient and appropriate means of 
increasing access to and delivering of ABA services under TRICARE while 
creating a viable economic model and maintaining administrative 
simplicity. The ACD was implemented on July 25, 2014, and expires 
December 31, 2018.
    ABA services are currently provided through the ACD and managed by 
the existing TRICARE regional managed care support contractors. This 
approach enabled TRICARE to quickly expand access to ABA services for 
over 14,000 children diagnosed with ASD and manage a comprehensive ABA 
benefit program. However, in efforts to manage ABA services similar to 
the TRICARE Basic medical benefit, many rules have been modified, or 
exceptions have been made, such as diagnosis and referral procedures, 
ABA provider qualifications and credentialing, safety and quality 
management reviews, and reimbursement rate methodology. Additionally, 
ABA services may involve a lengthy period of care and as families move 
or transfer across TRICARE regions, many experience inconsistencies in 
how the ABA services benefit is managed between TRICARE contracts. 
Based on lessons learned, DHA now seeks to improve ABA services 
delivery with a more unified approach to reduce variation and ensure 
ABA services are directed to beneficiaries in a manner that maximizes 
clinically necessary benefits to each child with minimal disruptions.
    The Department is committed to ensuring all TRICARE-eligible 
beneficiaries diagnosed with ASD reach their maximum potential, and 
that all treatment provided supports this goal. The need for effective 
treatment for the diagnosis of ASD is unquestioned, and while there is 
need for more scientific evidence, ABA remains the most widely accepted 
intervention. Therefore, the Department is pursuing a more effective 
method of delivering and validating the effectiveness of these 
services. The Department is exploring the potential for a single, 
nationwide contract, administered by a private sector health care 
company, with specialized experience and expertise in providing ABA 
services, will significantly improve the provision of ABA services to 
military beneficiaries diagnosed with ASD.
    Consequently, the Department has determined that extension of the 
demonstration is both in the best interest of TRICARE beneficiaries 
diagnosed with ASD, and necessary to fully evaluate the effectiveness 
of the delivery model employed by the demonstration while putting in-
place a nationwide contract. This extension will determine whether the 
ACD meets its stated purpose and provide the Department with consistent 
and reliable information necessary to make informed decisions regarding 
the provision of the ABA services benefit. This extension will allow 
the Department to make a formal decision regarding the use of that 
delivery model in the long-term. The demonstration continues to be 
authorized by Title 10, United States Code, Section 1092.

    Dated: December 5, 2017.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2017-26567 Filed 12-8-17; 8:45 am]
BILLING CODE 5001-06-P