Tricare is changing its autism therapy reimbursement rates to better align them with commercial insurance rates and Medicaid, Defense Department officials said Tuesday.
The move will increase reimbursements for some therapists while trimming rates for others, but DoD officials said the changes should not affect the nearly 10,000 Tricare beneficiaries who receive Applied Behavior Analysis therapy for autism symptoms.
Tricare consolidated its various ABA therapy benefit programs in 2014 to ensure that active-duty and retiree dependents with autism had access to treatment.
But the new Autism Care Demonstration Project also proposed slashing reimbursement rates to some providers by nearly half, prompting some to say they would no longer accept Tricare.
DoD postponed implementation of the severe cuts, contracting instead with the Rand Corp. and a health policy research firm to help determine whether the level of coverage for ABA in the military health system was appropriate.
The new reimbursement rates — 20 percent higher than Medicaid's rates for ABA — are a result of those reviews.
"Our benefit is extremely rich ... when I've been in meetings on ABA with commercial providers, Tricare was held out as having the most comprehensive benefit and the most generous benefit," said Tricare Health Plan Director Mary Kaye Justis.
DoD now pays doctorate- and master's-level therapists $125 an hour, bachelor's degree-level providers $75 an hour, and technicians $50 an hour.
The new basic national hourly rates will change to $114.23 for doctorate-level therapists, $107.14 for master's therapists, $67.39 for therapists with bachelor's degrees and $40.12 for technicians.
These rates also will be adjusted by geographic location.
As a result of the reviews, Tricare turned out to be the highest payer in many markets, "significantly above both Medicaid and as well as commercial rates," Justis said. "At that point, we started saying, 'What is the best way to adjust our rates so we are more consistent with the market and can continue to assure access?' "
To ease the impact of reductions on therapists' budgets, Tricare will reduce locality rates by no more than 15 percent per year until the calculated locality rate is reached, officials said.
ABA therapy is one-on-one instruction for autism patients that focuses on promoting appropriate behavior, social skills, communication and emotional expression. Costs per patient can run $30,000 to $60,000 a year.
Tricare officials said DoD needed to tweak its reimbursement rates because they have been largely unchanged since they were first instituted in 2008, and little cost data was available.
The new rates are designed to ensure beneficiaries can access treatment while ensuring the government is not overpaying, Justis said.
She added that despite the rate trims for some, Tricare's ABA budget, which has totaled $80 million in 2014, is likely to increase.
"The population for folks receiving ABA services continues to grow. We haven't done cost estimates on what the rate change impact would be because we continue to see growth," she said.