All military insurance contract management companies (e.g., TriWest for the western states, including Colorado) offer some coverage for services provided by Board Certified Behavior Analysts (BCBAs) and Board Certified assistant Behavior Analysts (BCaBAs) through the TRICARE ECHO program. The TRICARE Extended Care Health Option (ECHO) provides funding for services to eligible beneficiaries who qualify based on specific mental or physical disabilities:
- “Diagnosis of a neuromuscular developmental condition or other condition in an infant or toddler expected to precede a diagnosis of moderate or severe mental retardation or serious physical disability
- Extraordinary physical or psychological condition causing the beneficiary to be homebound
- Moderate or severe mental retardation
- Multiple disabilities (may qualify if there are two or more disabilities affecting separate body systems)
- Serious physical disabilities” (http://www.triwest.com/document_library/pdf_docs/echo_flyer.pdf),
which often include Autism, Aspergers, Developmental delays, and certain physical disabilities. ECHO offers an integrated set of services (i.e., special education) and supplies not available through the basic TRICARE program. ECHO benefits are only available to qualified active duty family members (family members of activated National Guard or Reserve members). Active duty family members must qualify for ECHO through Case Managers in each TRICARE region. Many families qualify for up to $36,000 per October 1 benefit year.
To learn more about this benefit, go to https://www.triwest.com/ and click on the “Beneficiary” text or picture. On the next page, you will see a search box. Just enter the word “ECHO” and you will see a list of resources. By selecting the item in “TriWest Suggests” marked “ECHO: Extended Care Health Option”, you will find a wealth of information. We suggest you click on the link “TRICARE ECHO Benefit Flyer” (http://www.triwest.com/document_library/pdf_docs/echo_flyer.pdf) for easy to understand information on the program, including monthly cost-share by rank and contact information for services. A new FAQ may be found at http://www.triwest.com/provider/newslist.aspx?aud=1&xf=112210_echoservices, which even more detailed information on the program.
Note, It has been our experience that you will need your base physician to write a prescription/order for ABA therapy, using the CPT of 99199 to assist with authorizing your dependent’s access to these services. Lacking this document usually delays your enrollment.
Department of Defense Autism Demonstration Project
While you are on the main ECHO page, you will see information on the Autism Demonstration Project to the right side of the page, a related benefit administered by the ECHO staff. This benefit is exclusively for persons qualified with diagnoses of Autism, Aspergers and Pervasive Developmental Disorder, Not Otherwise Specified (PDD, NOS). If you click on “Autism Demo” you will find more information on this topic. In essence, by allowing Tutors to provide the services directly, you are often able to access increased hours of service. Unfortunately, this benefit caps the allowable BCBA hours to facilitate this end. However for some families, this benefit may truly hit the mark. You should talk with your ECHO Case Manager to learn more about the two programs, then talk with your identified BCBA or BCaBA to learn how the choices may effect treatment for your child.
We are providers in both systems.
Health Insurance Mandated Autism Treatment (HIMAT) for Colorado Insurance Plans
On July 1, 2010, certain private, Colorado-based group health insurance policies will begin to cover certain treatments for ASD. The new law is called HIMAT (Health Insurance Mandated Autism Treatment; previously referred to as Senate Bill 09-244). Check with your Human Resources Department and your insurer to see if you qualify for this benefit. If your insurance card has “CoDoI” printed in the lower left corner, you may be entitled to this benefit.
The law is comprised of three parts, one dealing with OT, ST, PT services, one dealing with ABA, and one dealing with general safeguards of treatment and coverage, including an elimination of Autism as a pre-existing condition for which some insurers have refused to provide diagnosed individuals coverage of any type. In short, it is a good law. To learn more, we suggest http://www.autismcolorado.org/index.php/himat, and click on “Overview Document”, just below the word “HIMAT”.
Many families are reporting difficulty accessing these benefits, while most providers are reporting that they are not being afforded the opportunity to become credentialed by any insurers. If they are not credentialed, they are unlikely to be allowed to provide services. Providers are not being given the basic information on how to help families. They are being told that the families must call their plans and request the services needed. It is important for you to participate in this process if you believe you are entitled to HIMAT benefits or they may be denied to you by your insurer. In cased like that, The Division of Insurance may be able to help. You can contact them at (800) 930-3745 - Toll Free Outside Denver or http://www.dora.state.co.us/insurance/.
We are attempting to become credentialed (paneled) with most insurers; the majority of them are yet to email or return any of our calls. We will keep trying, especially since we are the largest group of Board Certified providers in the state (BCBA and BCaBA employees, combined).