Autism Care Demonstration: Service Settings

TRICARE allows applied behavior analysis (ABA) services to be rendered in various settings, as clinically appropriate. Regardless of the setting, authorized ABA services must:

• Target core autism spectrum disorder (ASD) symptoms. 
• Not be an excluded service under the Autism Care Demonstration (ACD).

Part of the clinical necessity review process includes determining the appropriateness of the location where ABA services may be rendered for the beneficiary. 
 

Home

• The home is the beneficiary's residence.  
• Services may be provided by all ABA provider types (as authorized per the treatment plan).
• The ABA provider must render active delivery of ABA services that target core ASD symptoms.  
• Refer to "School Settings" for home-schooling information.
   

Clinics/Centers

• A clinic (center) is an outpatient ABA clinic or center.
• Services may be provided by all ABA provider types (as authorized per the treatment plan).
• The ABA provider must render active delivery of ABA services that target core ASD symptoms.
• Parent/caregiver training minimum requirements apply. 
   

Daycare (non-preschool)

• A daycare is a daycare center, child development center or after-school program, or adult care setting.
• Services may be provided by all ABA provider types (as authorized per the treatment plan).
• The ABA provider must render active delivery of ABA services that target core ASD symptoms.  
• ABA providers may not function as support aides or observers during care routines or activities (such as, lunch, group activities, arts and crafts, etc.). 
   

School Settings

• A school is defined as a preschool, public school, or private school, or home-school.
• Services only may be administered by ABA supervisors (as authorized per the treatment plan) and all criteria must be met:
  • The ABA supervisor must render active delivery of ABA services that target core ASD symptoms.   
  • The services must be focused and time-limited. 
  • ABA services performed by behavior technicians (BTs) or assistant behavior analysts in a school setting are not allowed. 
  • The ABA supervisor may not function as a support aide or observer during school routines or activities (such as, lunch, group activities, arts and crafts, etc.). 
  • A current Individualized Education Program (IEP) is required. ABA services may not duplicate IEP services or goals.
  • Academic or educational goals are not covered under the ACD in any setting, including the school setting. 
  • If your child is home-schooled, authorized ABA services must be rendered outside of home-schooling instruction. Home-schooling instruction cannot overlap ABA services. 
  • Daycare centers/child development centers/after-school programs are not considered school settings under the ACD. (Refer to the “Daycare” section.)
     

Community settings

Community settings are any location not part of a home, clinic/center or school setting. Community settings include grocery stores, parks, restaurants, medical offices, or events such as youth sports or local community events. 

• Services may be provided by all ABA provider types (as authorized per the treatment plan).
• The ABA provider must render active delivery of ABA services that target core ASD symptoms.  
• The services must be focused and time-limited.
• Specific exclusions apply to sporting events and camps.
• Exclusions also apply to ABA services rendered during medical appointments (doctor visits, physical therapy, etc.), to include another family member's appointments.
• Because community settings often do not allow for frequent/repeated treatment opportunities and often target areas not specific to an ASD diagnosis, Health Net Federal Services, LLC (HNFS) will use the clinical necessity review process to determine whether a community setting, provider types and goal/unit recommendations are clinically appropriate.
   

Telemedicine

Telemedicine is the use of secure video conferencing to provide active delivery of ABA services to beneficiaries at home.

• Audio-only services are not allowed. 
• Only the following services are allowed via telehealth when authorized:
  • Parent/caregiver guidance by the ABA supervisor or assistant behavior analyst
  • Medical team conferences by the ABA supervisor
• The ABA supervisor or assistant behavior analyst must render active delivery of ABA services that target core ASD symptoms.  
• BTs may not provide services via telehealth.  
• Outcome measures are not allowed via telehealth but may be rendered via indirect methods. (Refer to the “Indirect” section.) 
   

Indirect

• Indirect refers to email and U.S. postal mail (report writing, reviewing records, etc.).
• Outcome measures may be performed by TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA supervisors via indirect methods.

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