Rand Health Q. 2017 Jan; 6(2): 10.
Published online 2017 Jan 13.
Comparison with Medicaid and Commercial Benefits
Margaret Maglione, Srikanth Kadiyala, Amii Kress, Jaime L. Hastings, and Claire E. O'Hanlon
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This study compared the Applied Behavior Analysis benefit provided by TRICARE as an early intervention for autism spectrum disorder with similar benefits in Medicaid and commercial health insurance plans.
Keywords: Autism Spectrum Disorders, Defense Health Agency, Health Insurance Cost Sharing, Medicaid, Military Families
This study compared the Applied Behavior Analysis (ABA) benefit provided by TRICARE as an early intervention for autism spectrum disorder with similar benefits in Medicaid and commercial health insurance plans. The sponsor, the Office of the Under Secretary of Defense for Personnel and Readiness, was particularly interested in how a proposed TRICARE reimbursement rate decrease from $125 per hour to $68 per hour for ABA services performed by a Board Certified Behavior Analyst compared with reimbursement rates (defined as third-party payment to the service provider) in Medicaid and commercial health insurance plans. Information on ABA coverage in state Medicaid programs was collected from Medicaid state waiver databases; subsequently, Medicaid provider reimbursement data were collected from state Medicaid fee schedules. Applied Behavior Analysis provider reimbursement in the commercial health insurance system was estimated using Truven Health MarketScan® data. A weighted mean U.S. reimbursement rate was calculated for several services using cross-state information on the number of children diagnosed with autism spectrum disorder. Locations of potential provider shortages were also identified. Medicaid and commercial insurance reimbursement rates varied considerably across the United States. This project concluded that the proposed $68-per-hour reimbursement rate for services provided by a board certified analyst was more than 25 percent below the U.S. mean.
Applied Behavioral Analysis (ABA) is an intervention based on learning theory principles aimed at improving the functional, communication, and social skills of children diagnosed with autism spectrum disorder (ASD). The Office of the Under Secretary of Defense for Personnel and Readiness (OUSD [P&R]) asked the RAND National Defense Research Institute (NDRI) to compare TRICARE's ABA benefit, provided through a new Comprehensive Autism Care Demonstration (ACD), with ABA benefits from other publicly funded programs and commercial insurance plans. OUSD [P&R] was particularly interested in how the proposed TRICARE reimbursement rate of $68 per hour for ABA services performed by a Board Certified Behavior Analyst (BCBA) compares with reimbursement rates in Medicaid and commercial health insurance plans.
This study compared TRICARE's ACD, including reimbursement rates, patient copayments, and annual caps, with ABA benefits offered by Medicaid and commercial health plans. This study provides data on ABA benefits, reimbursement rates in the public and commercial U.S. health insurance markets, and availability of ABA providers by location.
Our initial review of the existing policy and academic literatures did not identify any sources that comprehensively contained this information. We undertook two strategies to ascertain the majority of this information.
In late 2014, the majority of state Medicaid programs that provided ABA services did so through waivers. We identified state Medicaid programs that covered ABA using a comprehensive database on existing state Medicaid Section 1915(c) Home and Community-Based Services waiver-covered services (found at Medicaid.gov) and searches of state websites that reported covering ASD via the waiver system. After identifying state Medicaid programs that covered ABA via the waiver system, we searched state Medicaid fee schedules for ABA provider reimbursement rates. We note here that this search strategy misses information on any state ABA reimbursement rates in the Medicaid programs that covered ABA via their main (nonwaiver) Medicaid program.
We identified a large data source (Truven Health MarketScan® Research Databases) that contains figures on commercial insurance payments for a wide variety of services. Although not a random sample, the MarketScan data in 2013 contained comprehensive outpatient service utilization information on approximately one in four children enrolled in the U.S. commercial health insurance system. We are not aware of any larger existing data source for identifying provider reimbursement rates for ABA services in the commercial insurance market.
In addition to identifying reimbursement rates in the Medicaid and commercial insurance markets in the above manner, we also searched through the Medicaid waiver databases, the academic and policy literatures for information on cost-sharing for ABA services in the private and public health insurance systems. Information on out-of-pocket spending in the private health insurance markets was also derived from analyses of MarketScan data.
We did not identify any cost-sharing requirements within the Medicaid waivers filed by states to cover ABA. In the commercial health insurance data that we evaluated, there was a standard (fixed percentage or fixed copay depending on the type of health insurance plan) cost-share for ABA services. We calculated the mean patient out- of-pocket amount for each U.S. state. Mean out-of-pocket spending, as a percentage of the total (insurer and patient) payment, for treatment provided by master's- or doctoral-level providers, known as BCBAs, with the Current Procedural Terminology (CPT) code of H2012 for invoicing, varied across states from 0.4 percent in Michigan to 14.0 percent in Utah. Mean out-of-pocket spending, as a percentage of the total (insurer and patient) payment for therapeutic behavioral health services provided by a bachelor's-level Board Certified Assistant Behavior Analyst (BCaBA), Behavior Technician, or unspecified education-level provider (CPT code H2019), ranged from about 1 percent in Kansas to 12 percent in Ohio.
ABA Reimbursement Rates
We found substantial state variation in provider reimbursement rates for ABA services within the Medicaid and commercial health insurance systems. Herein, the reported commercial insurance rates represent third-party payment to the service provider and do not include patient cost-share amounts.
In fall 2014, state Medicaid reimbursement rates for a BCaBA or behavior technician ranged from $25 to $75 per hour. For providers with a master's degree (required for BCBA certification) or doctorate (required for certification as a BCBA-D), Medicaid reimbursement rates varied from $55.50 to $125 per hour. According to 2013 commercial health insurance claims data, mean state reimbursement rates in the commercial insurance sector varied from $24.64 to $160 per hour for a provider with a bachelor's degree or an unspecified education level (BCaBA or Behavioral Technician). For providers with a master's degree or doctorate, reimbursement rates in the commercial health insurance system varied from $36.90 to $196.50 per hour.
The mean national reimbursement rate, derived from this commercial data and Medicaid information, weighting the state-level results by the number of children diagnosed with ASD in each state, was $65.16 per hour for therapeutic behavioral services (H2019) from a BCaBA, Behavioral Technician or unspecified-level provider, or $94.72 per hour for master's- or doctoral-level providers. Sensitivity analyses using information on state-level utilization rates resulted in weighted average calculations that were very similar. In sum, the $68-per-hour reimbursement rate proposed by TRICARE for services provided by a BCBA (which requires a master's degree) is more than 25 percent below the U.S. mean.
The state variation in Medicaid and commercial reimbursement rates identified in this study implies that a single U.S. rate for TRICARE as a whole may not be sustainable in areas where the TRICARE rate is substantially below the prevailing local rate. For example, if TRICARE adopted the $68-per-hour rate for one-to-one ABA provided by a BCBA or BCBA-D proposed in September 2014, the TRICARE rate would be below the mean commercial insurance rate in the first ten states where data were available and above the mean commercial insurance rate in the other seven states. Providers in those ten states might be disincentivized to accept TRICARE patients compared with enrollees from other private health insurance plans.
ABA Provider Locations
To identify locations of potential ABA provider shortages, we obtained data from the Behavior Analyst Certification Board (BACB) on the location of all board certified ABA providers in the United States as of May 2015, and then calculated the number of children (younger than 18) with ASD in TRICARE per each provider in larger ZIP code--based geographic areas throughout the United States.
Fifteen areas with potential TRICARE ABA users (children with ASD) had no board certified ABA providers. The number of children with ASD in TRICARE in those ZIP code--based locations ranged from 12 in southern Missouri to 288 in western Idaho. Locations with a high number of potential TRICARE ABA users per certified provider include several sites in the Southwest (San Diego, southern Arizona, and west Texas) and in the Southeast (Virginia, South Carolina, Georgia, and Alabama). These locations have more than 100 potential TRICARE users for each BCBA.
There are currently no best practice standards as to the number of board certified providers per number of children with ASD. According to 2012 BACB guidelines, the average caseload for a BCBA supervising focused treatment without support from a BCaBA is ten to 15 children; with a supporting BCaBA, the average caseload is 16 to 24 children (BACB, 2012). As our analysis included only potential users in TRICARE, we were unable to calculate potential overall caseloads; this would require estimates of the entire number of children with ASD in each ZIP code location. Unfortunately, such data are not available.
Coverage and reimbursement rates for ABA vary widely in both commercial plans and Medicaid programs throughout the United States. We were asked to compare TRICARE's proposed rate of $68 per hour for one-to-one ABA therapy provided by a BCBA or BCBA-D, reduced from $125 per hour, with the current U.S. market. The proposed $68-per-hour rate is below the mean commercial insurance rate in ten of the 17 states where data figures were available and above the mean commercial insurance rate in the other seven states. Compared with 14 states that specify rates for master's- and doctoral-level ABA providers in Medicaid, the $68-per-hour rate is below the reimbursement rate in 11 states. Based on local Medicaid and commercial insurance reimbursement rates, weighted by the number of children with ASD covered by each type of insurance in each location, the weighted mean U.S. reimbursement rate for ABA services performed by a BCBA or BCBA-D is $94.72.
This research was sponsored by the Office of the Under Secretary of Defense for Personnel and Readiness (OUSD [P&R]) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the U.S. Navy, the U.S. Marine Corps, the defense agencies, and the Defense Intelligence Community.
- BACB ---See Behavior Analyst Certification Board.
- Behavior Analyst Certification Board. Guidelines: Health Plan Coverage of Applied Behavior Analysis Treatment for Autism Spectrum Disorder. 2012. Tallahassee, Fla.