Does TRICARE Cover ABA Therapy?

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Does TRICARE Cover ABA Therapy?

Yes, TRICARE insurance covers Applied Behavior Analysis (ABA) therapy for autism under the TRICARE comprehensive Autism Care Demonstration(ACD) when services are deemed clinically necessary and appropriate.¹ However, depending on the details of your particular TRICARE plan, costs may vary.

ABA therapy is founded on the science of learning and behavior. Typically, it is used as part of autism therapy and treatment and other developmental disabilities. It teaches actions that will make patients’ lives safer and more satisfying.² ABA therapy is one of several evidence based therapies that focus on a behavioral approach.

Licensed behavioral therapists help autistic individuals develop abilities such as:

• Language and communication skills
• Social skills
• Hygiene and self-care practices
• Leisure and play abilities
• Motor skills

How to Verify TRICARE ABA Therapy Insurance Coverage

The most reliable way to determine your TRICARE ABA therapy coverage is to contact your insurance carrier directly. While Athena Care does not offer ABA therapy, we do provide comprehensive mental and behavioral health services in Tennessee, including autism assessment, psychotherapy and counseling, medication management, TMS, Spravato and more. We’re also in-network with most major insurance companies. Contact us below, and one of our care coordinators will help you navigate your insurance coverage and get the care you need.

Requirements, Eligibility & Process for TRICARE ABA Coverage

According to Tennessee state law, contracts and plans that offer benefits for neurological illnesses must also provide autism benefits for treating children under the age of 12.³

The uniformed forces health insurance program known as TRICARE covers active duty service members, active duty family members, members of the National Guard and Reserve and their families, retirees and their family members, survivors, and some former spouses worldwide.⁴

For your child to qualify for TRICARE ABA therapy coverage, the following must be true:⁵

• Your child is registered in a TRICARE health plan.
• An authorized medical professional has determined that your child has Autism Spectrum Disorder (ASD).

The following steps are how to obtain ABA therapy TRICARE coverage:

1. Get Diagnosed: A primary care physician in a specific specialty or a board certified behavior analyst within a particular discipline must diagnose your child with autism.
2. Get a Referral and Pre-Authorization: All ABA services for your child must be pre-authorized and referred to the ACD. Your child’s diagnosing professional will request authorization from your local contractor or US Family Health Plan (USFHP) provider. An authorization document for six months of ABA services will be given to your child.
3. Complete Outcome Measures: You and your child’s provider team must complete four baseline outcome measurements before your child can start ABA services. This will support tracking your child’s development. The four measures are as follows:
   1. Pervasive Developmental Disorder Behavior Inventory
   2. Vineland Adaptive Behavior Scales
   3. Social Responsiveness Scale
   4. Parent Stress Index or Stress Index for Parents of Adolescents
4. Schedule an Appointment: When you receive your child’s authorization letter, make an appointment for your child’s ABA assessment. You can get in touch with the provider using the information on the authorization letter. If you’d like to go with a different provider, contact your regional provider or USFHP-designated provider.
5. Work with your Autism Services Navigator (ASN): Your child will receive an ASN from TRICARE. Only if you are new to the TRICARE Autism Care Demonstration will your child receive an ASN, which acts as a primary care coordinator.
   1. Note: if you participate in the USFHP or reside abroad, you won’t have an ASN.

A TRICARE ABA therapist will regularly complete assessments to check your child’s progress throughout treatment. Then, every six months, they will formulate a revised treatment plan evaluation to update the plan. Following that, they will propose a transition/discharge plan or ask for the continuation of ABA services and insurance coverage.

Every two years, a new referral from the person diagnosing your child’s ASD will be required. After that, a new authorization is needed for the next six months of ABA services.

The services of a behavior analyst providing ABA in a school setting are not covered.

How Much Does ABA Therapy Cost Without Insurance?

The average cost of ABA is $120 per hour. Some children require up to 40 hours of ABA therapy each week to reach their full potential, which costs $4,800 per week or $249,600 annually.⁶

Forbes estimates that the annual cost of ABA therapy without insurance is about $17,000. However, it might range from $45,000 to $100,000 annually for some children.⁷ The CDC estimates that average yearly medical costs for a child with ASD are $4,110 to $6,200 higher than for children without the condition.⁸