Extended benefits for eligible dependents under subsection (d) may include comprehensive health care services (including services necessary to maintain, or minimize or prevent deterioration of, function of the patient) and case management services with respect to the qualifying condition of such a dependent, and include, to the extent such benefits are not provided under provisions of this chapter other than under this section, the following:

1. Diagnosis and screening.
2. Inpatient, outpatient, and comprehensive home health care supplies and services which may include cost-effective and medically appropriate services other than part-time or intermittent services (within the meaning of such terms as used in the second sentence of section 1861(m) of the Social Security Act (42 U.S.C. 1395x)).
3. Rehabilitation services and devices.
4. In accordance with paragraph (2), respite care for the primary caregiver of the eligible dependent.
5. In accordance with paragraph (3), service and modification of durable equipment and assistive technology devices.
6. Special education.
7. Vocational training, which may be furnished to an eligible dependent in the residence of the eligible dependent or at a facility in which such training is provided.
8. Such other services and supplies as determined appropriate by the Secretary.

Contracts for health benefits for certain members, former members, and their dependents

1. To assure that health benefits are available for the persons covered by subsection (c), the Secretary of Defense, after consulting

1. with the other administering Secretaries, shall contract under the authority of this section for health benefits for those persons under the same insurance, medical service, or health plans he contracts for under section 1079(a) of this title. However, eye examinations and (except as provided in subsection (i)) treatments for eating disorders may not be provided under such plans for persons covered by subsection (c).
2. For persons covered by this section the plans contracted for under section 1079(a) of this title shall contain the following provisions for payment by the patient:
   1. Except as provided in paragraph (2), the first $150 each calendar year of the charges for all types of care authorized by this section and received while in an outpatient status and 25 percent of all subsequent charges for such care during a calendar year.
   2. A family group of two or more persons covered by this section shall not be required to pay collectively more than the first $300 each calendar year of the charges for all types of care authorized by this section and received while in an outpatient status and 25 percent of the additional charges for such care during a calendar year.
   3. 25 percent of the charges for inpatient care, except that in no case may the charges for inpatient care for a patient exceed $535 per day during the period beginning on April 1, 2006, and ending on September 30, 2011. The Secretary of Defense may exempt a patient from paying such charges if the hospital to which the patient is admitted does not impose a legal obligation on any of its patients to pay for inpatient care.
   4. A member or former member of a uniformed service covered by this section by reason of section 1074(b) of this title, or an individual or family group of two or more persons covered by this section, may not be required to pay a total of more than $3,000 for health care received during any calendar year under a plan contracted for under section 1079(a) of this title.
3. Except as provided in subsection (d), the following persons are eligible for health benefits under this section:
   1. Those covered by sections 1074(b) and 1076(b) of this title, except those covered by section 1072(2)(E) of this title.
   2. A dependent (other than a dependent covered by section 1072(2)(E) of this title) of a member of a uniformed service—
      1. who died while on active duty for a period of more than 30 days; or

3. 2. 2. who died from an injury, illness, or disease incurred or aggravated—
         1. while on active duty under a call or order to active duty of 30 days or less, on active duty for training, or on inactive duty training; or
         2. while traveling to or from the place at which the member is to perform, or has performed, such active duty, active duty for training, or inactive duty training.
   3. A dependent covered by clause (F), (G), or (H) of section 1072(2) of this title who is not eligible under paragraph (1).
4.  
   1. A person who is entitled to hospital insurance benefits under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.) is not eligible for health benefits under this section.
   2. The prohibition contained in paragraph (1) shall not apply to a person referred to in subsection (c) who—
      1. is enrolled in the supplementary medical insurance program under part B of such title (42 U.S.C. 1395j et seq.); and
      2. in the case of a person under 65 years of age, is entitled to hospital insurance benefits under part A of title XVIII of the Social Security Act pursuant to subparagraph (A) or (C) of section 226(b)(2) of such Act (42 U.S.C. 426(b)(2)) or section 226A(a) of such Act (42 U.S.C. 426–1(a)).
   3.  
      1. Subject to subparagraph (B), if a person described in paragraph (2) receives medical or dental care for which payment may be made under Medicare and a plan contracted for under subsection (a), the amount payable for that care under the plan shall be the amount of the actual out-of-pocket costs incurred by the person for that care over the sum of—
         1. the amount paid for that care under Medicare; and
         2. the total of all amounts paid or payable by third party payers other than Medicare.
      2. The amount payable for care under a plan pursuant to subparagraph (A) may not exceed the total amount that would be paid under the plan if payment for that care were made solely under the plan.

4. 3. 3. In this paragraph:
         1. The term “Medicare” means title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
         2. The term “third party payer” has the meaning given such term in section 1095(h)(1) of this title.
   4.  
      1. If a person referred to in subsection (c) and described by paragraph (2)(B) is subject to a retroactive determination by the Social Security Administration of entitlement to hospital insurance benefits described in paragraph (1), the person shall, during the period described in subparagraph (B), be deemed for purposes of health benefits under this section—
         1. not to have been covered by paragraph (1); and
         2. not to have been subject to the requirements of section 1079(i)(1) of this title, whether through the operation of such section or subsection (g) of this section.
      2. The period described in this subparagraph with respect to a person covered by subparagraph (A) is the period that—
         1. begins on the date that eligibility of the person for hospital insurance benefits referred to in paragraph (1) is effective under the retroactive determination of eligibility with respect to the person as described in subparagraph (A); and
         2. ends on the date of the issuance of such retroactive determination of eligibility by the Social Security Administration.
   5. The administering Secretaries shall develop a mechanism by which persons described in subparagraph (B) of paragraph (2) who do not satisfy the condition specified in subparagraph (A) of such paragraph are promptly notified of their ineligibility for health benefits under this section. In developing the notification mechanism, the administering Secretaries shall consult with the Administrator of the Centers for Medicare & Medicaid Services.
5. A person covered by this section may elect to receive inpatient medical care either in (1) Government facilities, under the conditions prescribed in sections 1074 and 1076–1078 of this title, or (2) the facilities provided under a plan contracted for under this section. However, under joint regulations issued by the administering Secretaries, the right to make this election

5. may be limited for those persons residing in an area where adequate facilities of the uniformed service are available. In addition, subsections (b) and (c) of section 1080 of this title shall apply in making the determination whether to issue a nonavailability of health care statement for a person covered by this section.
6. The provisions of section 1079(h) of this title shall apply to payments for services by an individual health-care professional (or other noninstitutional health-care provider) under a plan contracted for under subsection (a).
7. Section 1079(i) of this title shall apply to a plan contracted for under this section, except that no person eligible for health benefits under this section may be denied benefits under this section with respect to care or treatment for any service-connected disability which is compensable under chapter 11 of title 38 solely on the basis that such person is entitled to care or treatment for such disability in facilities of the Department of Veterans Affairs.
8.  
   1. Subject to paragraph (2), the Secretary of Defense may, upon request, make payments under this section for a charge for services for which a claim is submitted under a plan contracted for under subsection (a) to a hospital that does not impose a legal obligation on any of its patients to pay for such services.
   2. A payment under paragraph (1) may not exceed the average amount paid for comparable services in the geographic area in which the hospital is located or, if no comparable services are available in that area, in an area similar to the area in which the hospital is located.
   3. The Secretary of Defense shall periodically review the billing practices of each hospital the Secretary approves for payment under this subsection to ensure that the hospital’s practices of not billing patients for payment are not resulting in increased costs to the Government.
   4. The Secretary of Defense may require each hospital the Secretary approves for payment under this subsection to provide evidence that it has sources of revenue to cover unbilled costs.
      1. If, prior to October 1, 2022, a category of persons covered by this section was eligible to receive a specific type of treatment for eating disorders under a

8. 4. 1. plan contracted for under subsection (a), the general prohibition on the provision of treatments for eating disorders specified in such subsection shall not apply with respect to the provision of the specific type of treatment to such category of persons.

Title 10, Chapter 55, Section 1092 of the United States Code covers studies and demonstration projects related to the delivery of health and medical care. The Secretary of Defense, in consultation with other administering Secretaries, conducts these projects to improve the quality, efficiency, convenience, and cost effectiveness of health care services. Section 1092 defines a demonstration as “a project of limited duration designed to test a different method for the finance, delivery or administration of health care activities for the uniformed services” (32 CFR 199.1(o)(3)). Demonstrations are authorized by statutory provisions. The DHA director has the authority to waive or alter any of the requirements of the TRICARE Basic Benefit in conducting the demonstration, except where alterations are prohibited by law.

1.  
   1. The Secretary of Defense, in consultation with the other administering Secretaries, shall conduct studies and demonstration projects on the health care delivery system of the uniformed services with a view to improving the quality, efficiency, convenience, and cost effectiveness of providing health care services (including dental care services) under this title to members and former members and their dependents. Such studies and demonstration projects may include the following:
      1. Alternative methods of payment for health and medical care services.
      2. Cost-sharing by eligible beneficiaries.
      3. Methods of encouraging efficient and economical delivery of health and medical care services.
      4. Innovative approaches to delivery and financing of health and medical care services.

1. 1. 5. Alternative approaches to reimbursement for the administrative charges of health care plans.
      6. Prepayment for medical care services provided to maintain the health of a defined population.
   2. The Secretary of Defense shall include in the studies conducted under paragraph (1) alternative programs for the provision of dental care to the spouses and dependents of members of the uniformed services who are on active duty, including a program under which dental care would be provided the spouses and dependents of such members under insurance or dental plan contracts. A demonstration project may not be conducted under this section that provides for the furnishing of dental care under an insurance or dental plan contract.
   3. The Secretary of Defense may include in the studies and demonstration projects conducted under paragraph (1) studies and demonstration projects to provide awards and incentives to members of the armed forces and covered beneficiaries who obtain health promotion and disease prevention health care services under the TRICARE program in accordance with terms and schedules prescribed by the Secretary. Such awards and incentives may include cash awards and, in the case of members of the armed forces, personnel incentives
   4.  
      1. The Secretary of Defense may, in consultation with the other administering Secretaries, include in the studies and demonstration projects conducted under paragraph (1) studies and demonstration projects to provide awards or incentives to individual health care professionals under the authority of such Secretaries, including members of the uniformed services, Federal civilian employees, and contractor personnel, to encourage and reward effective implementation of innovative health care programs designed to improve quality, cost-effectiveness, health promotion, medical readiness, and other priority objectives. Such awards and incentives may include cash awards and, in the case of members of the armed forces and Federal civilian employees, personnel incentives.
      2. Amounts available for the pay of members of the uniformed services shall be available for awards and incentives under this paragraph with respect to members of the uniformed services.

1. 5. The Secretary of Defense may include in the studies and demonstration projects conducted under paragraph (1) studies and demonstration projects to improve the medical and dental readiness of members of reserve components of the armed forces, including the provision of health care services to such members for which they are not otherwise entitled or eligible under this chapter.
   6. The Secretary of Defense may include in the studies and demonstration projects conducted under paragraph (1) studies and demonstration projects to improve the continuity of health care services for family members of mobilized members of the reserve components of the armed forces who are eligible for such services under this chapter, including payment of a stipend for continuation of employer-provided health coverage during extended periods of active duty.
2. Subject to the availability of appropriations for that purpose, the Secretary of Defense may enter into contracts or transactions (other than contracts, cooperative agreements, and grants) with public or private agencies, institutions, and organizations to conduct studies and demonstration projects under subsection (a).
3. The Secretary of Defense may obtain the advice and recommendations of such advisory committees as the Secretary considers appropriate. Each such committee consulted by the Secretary under this subsection shall evaluate the proposed study or demonstration project as to the soundness of the objectives of such study or demonstration project, the likelihood of obtaining productive results based on such study or demonstration project, the resources which were required to conduct such study or demonstration project, and the relationship of such study or demonstration project to other on-going or completed studies and demonstration projects.

(15) Unproven drugs, devices, and medical treatments or procedures. By law, CHAMPUS can only cost-share medically necessary supplies and

services. Any drug, device, or medical treatment or procedure, the safety and efficacy of which have not been established, as described in this paragraph (g)(15), is unproved and cannot be cost-shared by CHAMPUS except as authorized under paragraph 199.4(e)(26) of this part.

1. [a] drug, device, or medical treatment or procedure is unproven: [. . .]
   3. Unless reliable evidence shows that any medical treatment or procedure has been the subject of well-controlled studies of clinically meaningful endpoints, which have determined its maximum tolerated dose, its toxicity, its safety, and its efficacy as compared with standard means of treatment or diagnosis [. . .]
   4. If reliable evidence shows that the consensus among experts regarding the medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated doses, its toxicity, its safety, or its effectiveness as compared with the standard means of treatment or diagnosis [. . .]

B. Description of the Autism Care Demonstration

The Department’s continued evaluation of ABA for ASD must be accomplished while ensuring continuity of care for children currently receiving ABA and those who will be diagnosed with ASD and then seek treatment. Specific Autism Care Demonstration goals include:

1. Further analyzing and evaluating the appropriateness of the ABA tiered-delivery model under TRICARE generally in light of current and future Behavior Analyst Certification Board (BACB) Guidelines;
2. Determining the appropriate provider qualifications for the proper diagnosis of ASD and the provision of ABA, and assessing the added value of ABA Tutors, or Behavioral Technicians, beyond ABA provided by BCBAs;
3. Assessing, across the three TRICARE regions, the ASD beneficiary characteristics associated with full utilization of the ABA tiered-delivery model versus utilization of BCBA services only or non-utilization of any ABA services, and isolating factors contributing to significant variation across TRICARE regions in delivery of ABA;
4. Determining what beneficiary age groups utilize and benefit most from ABA interventions;
5. Assessing the relationship between receipt of ABA services and utilization of established medical interventions for children with ASD, such as speech and language pathology (SLP) therapy, occupational therapy (OT), physical therapy (PT), and pharmacotherapy; and
6. Assessing of the feasibility and advisability of establishing a beneficiary cost share for the treatment of ASD.

The Autism Care Demonstration will offer comprehensive ABA for all TRICARE eligible beneficiaries with an ASD when diagnosed by an appropriate provider. Under the Autism Care Demonstration, a Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst-Doctorate (BCBA-D) referred to as an “ABA Supervisor” will plan, deliver and/or supervise an ABA program. The BCBA or BCBA-D is supported by Board Certified Assistant Behavior Analysts (BCaBA) and/or paraprofessional Behavioral Technicians who work one-on-one with the beneficiary with ASD in the home and community setting to implement the ABA intervention protocol designed, monitored and supervised by the BCBA or the BCBA-D. A BCaBA and/or Behavioral Technician working within the scope of their training, practice, and competence may assist the BCBA or BCBA-D in various roles and responsibilities as determined appropriate by the BCBA or BCBA-D and delegated to the BCaBA and/or Behavioral Technician, and consistent with the BACB Guidelines (2012) and BACB certification requirements. As such, the Autism Care Demonstration will specifically require that BCaBAs and Behavioral Technicians work under the supervision of a BCBA or BCBA-D. ABA delivered solely by BCBAs or BCBA-Ds is also covered by the Autism Care Demonstration and will provide a comparative assessment of providing ABA services delivered solely by master’s level providers or under the ABA tiered delivery model in terms of access, quality, and cost. The Department will also compare naturally occurring utilization data of PT, OT, SLP and pharmacotherapy services without ABA to those also receiving ABA sole provider and tiered model services.

[. . .]

K. Evaluation of the Autism Care Demonstration

The Autism Care Demonstration will assist the Department in evaluating: The aspects of the ABA tiered-delivery model that are medical, educational, or other characterization; whether the provision of the ABA tiered-delivery model can effectively offset the difficulty parents have in using ABA interventions collaboratively, consistently, and intensely when interacting with their children who have an ASD; whether the use of BCaBAs and Behavioral Technicians creates more cost-effective access to ABA based on the limited number of BCBAs and BCBA-Ds, while maintaining the quality of ABA; the appropriateness of requirements for providers, referral, authorization, treatment planning, assessment, testing, reimbursement, cost-sharing, discharge planning, and oversight to increase access to ABA for TRICARE beneficiaries with an ASD, while ensuring appropriate progress and utilization.

To collect necessary data to achieve the goals outlined for the Autism Care Demonstration, two parental surveys will be administered: The first at the mid-period of the Autism Care Demonstration (2016) and a second upon its conclusion (2018). These parental surveys will contain questions regarding: The reasons why parents avail themselves of the ABA tiered-delivery model, BCBA-only ABA, or no ABA; the perceived impairment(s) of their child with ASD; their degree of difficulty in accessing ABA and other clinical services with ASD; and, their overall satisfaction and perceived benefit regarding the ABA services provided.

The Autism Care Demonstration will provide the Department the opportunity to continue evaluating the provision of ABA under TRICARE while avoiding disruption of potentially therapeutic ABA interventions that could greatly benefit TRICARE beneficiaries with ASD. This information will be essential for determining it and how ABA should be delivered under TRICARE if the clinical community and accumulated evidence clearly indicates that ABA is a reliably evidence-based medical intervention for the treatment of ASD.