TRICARE Coverage for Autism Spectrum Disorder (ASD)
Overview
TRICARE provides substantial coverage for Autism Spectrum Disorder including diagnostic evaluations, Applied Behavior Analysis (ABA) therapy, speech therapy, occupational therapy, and developmental pediatrics. The Extended Care Health Option (ECHO) program provides additional benefits beyond standard TRICARE for eligible dependents.
Treatment Options Covered by TRICARE
- Comprehensive diagnostic evaluation
- Applied Behavior Analysis (ABA) therapy
- Speech-language therapy
- Occupational therapy
- Developmental pediatrics
- Behavioral health counseling
- Social skills training
- Parent training and education
- Assistive technology devices
- ECHO Home Health Care (for qualified dependents)
- Respite care (through ECHO)
How TRICARE Covers Autism Spectrum Disorder (ASD)
TRICARE covers all medically necessary autism services. ABA therapy is covered under the Comprehensive Autism Care Demonstration, which provides ABA services through TRICARE-authorized ABA providers. ECHO provides an additional $36,000 per fiscal year for qualifying services beyond basic TRICARE coverage.
Coverage by Plan
TRICARE Prime
Covered with $0 copay for most services when referred by PCM. ABA therapy covered under the Autism Care Demonstration. ECHO benefits available for active duty dependents.
TRICARE Select
Covered with standard cost shares. ABA therapy: network cost shares apply. ECHO benefits available for active duty dependents.
TRICARE For Life
Standard Medicare + TFL coverage for therapy services. ECHO not available for retirees.
Estimated Costs
| Scenario | Estimated Cost |
|---|---|
| Diagnostic evaluation (Prime) | $0 with referral |
| ABA therapy session (Prime ADFM) | $0 |
| ABA therapy session (Select ADFM, network) | Standard outpatient cost share |
| Speech therapy session (Prime ADFM) | $0 with referral |
| ECHO annual benefit | Up to $36,000/fiscal year beyond TRICARE |
Authorization Requirements
ABA therapy requires authorization through the Comprehensive Autism Care Demonstration. An initial diagnostic evaluation and treatment plan are required. Ongoing authorization reviews occur periodically. ECHO benefits require separate registration and authorization.
Network & Provider Notes
Finding ABA providers in the TRICARE network can be challenging in some areas. TRICARE is working to expand ABA provider availability. Contact your regional contractor for assistance locating authorized ABA providers.