Military Families: Insurance Reference
- Enroll your child in the Exceptional Family Member Program (EFMP) at one of the local offices.
- Enroll your child in the Extended Health Care Option (ECHO) program. It used to be called the Program for Persons with Disabilities (PFPWD). Note that certain sections of the form must be completed by your physician and by a public official in your county. This program is not available to families of retirees.
Congress created the ECHO program to make services accessible to active duty service members in one state that are not accessible in another state because they are required to move frequently and are normally not in one area long enough to wait to become eligible for services through Medicaid waivers in most states. Some services are only accessible through Tricare’s ECHO program and not through regular Tricare. Most notably is Applied Behavior Analysis (ABA) therapy. However, most services (such as OT, PT and S&L) are only available through the regular, basic program. There is a monthly co-pay depending on the sponsor’s rank. The program provides up to $2500 of services per month for each family member enrolled in ECHO. You may sign up for the Tricare ECHO email newsletters subscription.
Tricare’s ABA Policy
Applied Behavior Analysis (ABA) therapy is a structured one-on-one program to identify and address problem areas unique to each individual autistic child and is currently approved through ECHO. When this program changed from the PFPWD to ECHO, the criteria to get ABA changed. They are currently listed in sections 2.2 through 2.4 of chapter 9 of the Tricare Policy Manual 6010.54-M, dated 1 AUG 02. Most autistic children qualify for services under the “Significant Physical Disabilities” at section 2.3 by having problems with “unaided performance” with the major life activities of cognition and age appropriate abilities. A number of potential qualifying conditions are listed in this section. Some Tricare personnel may insist that the child must also have a mental retardation (MR) diagnosis too, but that is absolutely not correct. Tricare will not approve ABA therapy for what is viewed as only educational issues, but only for behavioral or medical problems, which is why you also have to have your school system or county health agency complete the Public Use Certification Form, which should be provided by your case manager. Again, a home ABA program is possible, if the local school system states that they “only provide ABA for educational purposes”, if they do that at all. The CPT code to be used for ABA therapy is 99199 for Tricare. A list of certified providers is on the certificant registry.
When in doubt, submit a claim to Tricare for anything that you think might qualify. If denied, appeal right away using the info from their denial letter and the justification from the Tricare policy manual.
Once enrolled in ECHO for any service, then you are also eligible for 16 hours a month of respite care by a Tricare-authorized Home Health Care provider. However, this is only for your disabled child, and they may not also watch any of your other children, unless you can work out something with the actual respite care provider on the side. You will need to have a new request from a MD for this “non-skilled nursing” entitlement. The respite care provider must be a Tricare-authorized “home health care agency” provider, so you cannot use a neighbor, family member, or anyone like that. Under “specialty” go to “home health care agency” on your Tricare web site. Hit search and go to the provider tab to see who is a Tricare-authorized “home health care agency” provider in your area. Then, call whoever comes up to verify that they do accept and bill Tricare and have non-skilled nursing providers (certified nursing assistants usually) before determining which provider would be the best fit for your family. The request should state something like “non-skilled respite care by “provider’s name and address” for up to 16 hours/ month X 12 months.” The request can and should be for 12 months at a time, even though Tricare can only do the authorizations for 6 months at a time. You can only use this benefit if you have money left from your $2500. If you use your full $2500 on ABA, you cannot also receive respite hours.
Seeing a evidence-based medical approach (DAN!) Doctor
Under Tricare Prime
Referrals may be requested through your military pediatrician to see a evidence-based medical approach doctor. You may request an “autism specialist to medically evaluate and treat autism” under section 3.10 on treatment of mental disorders, chapter 7 of the Tricare Policy Manual 6010.54-M, dated 1 AUG 02. You can try to find a evidence-based medical approach doctor in your area by checking the evidence-based medical approach Clinicians List. Tricare will only pay for an MD. It is good to have the specific evidence-based medical approach doctor listed on the referral, since that makes the authorization process go a lot faster. Yearly laboratory tests and heavy metal chelation (authorized under Tricare section 2.7 of chapter 7) are covered.
Under Tricare Standard
Under Tricare Standard you do not need a referral to see a evidence-based medical approach doctor. With Standard you are responsible for the first $350 then Standard pays 80% of the allowable amount up to $1000. After the $1000 they pay the full allowable amount. evidence-based medical approach doctors are not likely to be contracted through Tricare and their rates will be much higher than the Tricare allowable amount. For example, if your doctor charges $400/hour and Tricare allows $150, Tricare will pay 80% of $150 ($120), you will be responsible for the remaining $280 until you have paid out of pocket $1000.
Using Tricare Supplements with Tricare Standard
Purchasing a Tricare supplement when using Standard can be a wise investment. Do a Google search for “Tricare supplement” and check out the plans available. They are often listed in the back of the Military “Times” newspapers.
MOAA Example: The Military Officers Association offers a plan for active duty officers. There is a 6 month pre-existing condition clause. This means that for the first 6 months they will not pay for something you have already been receiving. For example, if your child has been attending speech therapy, you will have to pay the co-pays for the first 6 months. After 6 months the supplement will pay the difference between the Tricare allowable amount and the doctor’s billed amount. In the example above of the Defeat autism Now! doctor fees the supplement would pay $260 and you would pay $20. After you have reached your cap you won’t even have to pay the $20.
Nutritional supplements are only covered by Tricare if they are fed only by tube, are ordered by an MD, can be gotten only from a pharmacy and are the child’s primary source of nutrition
Any military pediatrician can order tests for kids with autism for outside labs, but the military lab will probably insist that they can do tests like them for free and just as well. This is not quite true. Great Plains Lab (GPL), Doctors Data (DD), Great Smokies Lab, Genova Diagnostics, Quest and Lab Corp are Tricare-authorized.
You can get these tests done without any payment from you at all. Or, you can prepay at a lower rate.
- Verify with Tricare claims that they will pay for these tests before you take the samples and send it to the lab, just to be sure.
- You or your doctor order the appropriate test kits from the lab using their web site or by phone.
- Have a doctor sign off on the test request form, and then send the sample to the lab using the express package service that they provide. The doctor will need to put the lab request into Tricare through the military referral system (for Prime only) electronically and list the specific test (and non-network lab to be used if it is for Quest or Lab Corp). A military lab will take and process a blood sample if it is necessary and you have a valid test request form.
- Then, complete the form for an insurance payment, which will have to be backed up by your credit card number in case Tricare does not pay. Be sure to note that you want a copy of the test results sent directly to you when you send back in the test kit and form, as well as to the doctor.
Source Autism Research Institute