What is the Department of Defense Enhanced Access to Autism Services Demonstration?

The Enhanced Access to Autism Services Demonstration will permit TRICARE reimbursement for Educational Interventions for Autism Spectrum Disorders (EIA) delivered by supervised Tutors in the absence of state or industry oversight.

I am a sponsor residing in Puerto Rico and have a child who needs these services.  Would he/she be eligible for the Department of Defense Enhanced Access to Autism Services Demonstration?

No.  The Demonstration is currently only being offered in the 50 United States and the District of Columbia.
       
What is Educational Interventions for Autism Spectrum Disorder (EIA), as defined in the Department of Defense Enhanced Access to Autism Services Demonstration?
          
EIA has been shown to reduce or eliminate specific behavior problems and teach new skills to individuals with autism.  EIA consists of one-on-one teaching which may help increase daily behavior skills of an autistic child.
            
Why is the Enhanced Access to Autism Services Demonstration being initiated? 
                
The Enhanced Access to Autism Services Demonstration is being initiated to allow for greater availability of Autism Spectrum Disorder providers.

Who is eligible for the Department of Defense Enhanced Access to Autism Services Demonstration?
       
The benefit is available to Active Duty Family Members who: 

My child has already been diagnosed with Autism Spectrum Disorder (ASD) by a TRICARE authorized provider.  Does he/she need to be evaluated again to be eligible for the Department of Defense Enhanced Access to Autism Services?
         
No.  If a diagnosis of ASD has already been made, the child is NOT required to be re-diagnosed with ASD or to complete diagnostic testing to participate in the Demonstration.
           
What Educational Intervention (EIA) services will TRICARE cost-share under the Department of Defense Enhanced Access to Autism Services Demonstration?

EIA claims may be cost-shared when services rendered meet the established criteria within the Demonstration policy.

What providers can deliver Educational Intervention (EIA) services under the Department of Defense Enhanced Access to Autism Services Demonstration?

EIA Tutors and EIA Supervisors who are an extension of a Corporate Service Provider, and meet the established policy requirements.

Can any Educational Intervention (EIA) Tutor render services whenever they choose under the Department of Defense Enhanced Access to Autism Services Demonstration? 

No.  All EIA Tutors must:

Are these Tutors permitted to render Educational Intervention (EIA) services without supervision under the Department of Defense Enhanced Access to Autism Services Demonstration?

No.  A provider of EIA services qualified by meeting TRICARE requirements, and who delivers services to TRICARE beneficiaries, will do so only under the supervision of an authorized EIA Supervisor.

Does my child need to wait for services under the Department of Defense Enhanced Access to Autism Services Demonstration while I’m completing the eligibility process?

No. To avoid delaying receipt of services under this Demonstration,  the regional Managed Care Support Contractor (MCSC) may grant otherwise eligible-apparent beneficiaries a provisional eligibility status for a period of not more than 120 days during which ECHO and Demonstration benefits will be authorized and payable.

What eligibility process must my child complete to receive services under the Department of Defense Enhanced Access to Autism Services Demonstration?

To receive services under the Demonstration, your child must have a qualifying diagnosis, be enrolled in your Services Exceptional Family Member Program (EFMP) if applicable, and registered in the Extended Care Health Option (ECHO).   (This provisional status is portable across the 50 United States and the District of Columbia).

How would I know if my child may be eligible for services offered under the Department of Defense Enhanced Access to Autism Services Demonstration?

If your child has been diagnosed with any condition specified in the Demonstration policy, or identified in the ECHO policy, the determination for services will be decided by your regional Managed Care Support Contractor after all supportive documentation has been submitted for review.

My child is not in the public school system.  Can he/she still qualify for services under the Department of Defense Enhanced Access to Autism Services Demonstration?

If the child is home schooled or in a private school and not required by state law to have an Individual Education Plan (IEP) or an Individual Family Service Plan (IFSP), the child’s Primary Care Provider (PCP) or Specialized Autism Spectrum Disorder (ASD) Provider must certify that the child’s disability related to ASD results in dysfunction severe enough to require special education and other supportive services. 

Does a parent who chooses not to participate in the Department of Defense Enhanced Access to Autism Services Demonstration retain the ability to use current ECHO services (to include ABA)?

Yes.  Authorized services being received under the ECHO and the TRICARE Basic Program may still be utilized. 

My child was not eligible for Educational Intervention (EIA) services under the Department of Defense Enhanced Access to Autism Services Demonstration.  Can he/she still use their ECHO benefits?

Yes.   Absence of eligibility for Educational Intervention (EIA) services under the Demonstration does not keep ECHO beneficiaries from receiving otherwise authorized allowable services. 

I have been informed by my Managed Care Support Contractor (MCSC) that my child is not eligible for Educational Intervention (EIA) services under the Department of Defense Enhanced Access to Autism Services Demonstration.  Can I appeal this?

No.  A determination that your child is not eligible for benefits under the Demonstration is considered a factual determination based on a requirement of the law or regulation, and as such is not appealable.

Is there training required for the parent or caregiver under the Department of Defense Enhanced Access to Autism Services Demonstration?

Yes.  Parental training is included in the Behavioral Plan (BP).  The EIA Supervisor will determine the extent of parent/caregiver involvement expected.

How much is the Government cost-share for the services provided under the Department of Defense Enhanced Access to Autism Services Demonstration?

The Government cost-share is a maximum of $2,500 per month per qualified beneficiary.

How do I find a provider that meets the requirements in the Department of Defense Enhanced Access to Autism Demonstration?

The best way to locate a provider of these services is to work directly with your regional Managed Care Support Contractor.  If you have already been assigned a Case Manager, he/she will be your first point of contact.

If you find a provider on your own that you feel can provide these services, be sure to check with your Case Manager, or regional Managed Care Support Contractor to verify that the provider meets the requirements of the Demonstration.