The Uniformed Services Family Health Plan is a TRICARE Prime option administered by participating nonprofit health systems in six service areas. Johns Hopkins runs the Mid-Atlantic one. For intake this matters more than it sounds: a USFHP member holds a TRICARE Prime benefit, but the plan — not Humana Military — is the entity that receives the ABA referral, issues the authorization and pays the claim. USFHP members cannot use TRICARE network providers and cannot get care at military hospitals and clinics.
The clinical rules are still the Autism Care Demonstration’s. DHA directs the ABA referral to "your regional contractor or US Family Health Plan provider," and the ACD requirements — the approved diagnosing-provider list, the DSM-5 checklist, the four outcome measures, the six-month authorization cycle and the two-year referral renewal — apply the same way. Johns Hopkins requires its ABA providers to attest that they have completed its ACD-ABA training and understand the ACD requirements, billing, authorizations, exclusions and documentation standards.
DHA describes USFHP as "a TRICARE Prime option administered by participating nonprofit plans in six service areas in the U.S." Members get most care through a primary care provider in the plan’s own network, and out-of-pocket costs are the same as TRICARE Prime. Two hard limits shape referrals: USFHP members cannot get care at military hospitals and clinics except for emergency care, and cannot use TRICARE network providers. Being TRICARE-certified is not enough to see a Hopkins USFHP member — the ABA provider has to be in the Hopkins USFHP network.[1][2]
Eligibility runs to active duty family members, retired service members and their families, families of activated Guard and Reserve members, non-activated Guard and Reserve members and families qualifying under TAMP, retired Guard and Reserve members aged 60 and older and their families, survivors, Medal of Honor recipients and their families, and qualified former spouses — all living in a USFHP service area. USFHP can also be chosen as a TRICARE Young Adult option.[1][2]
On the service area, there is a small discrepancy worth knowing about. Johns Hopkins’ own site describes coverage across "MD, DE, DC, and parts of PA, VA, and WV," while TRICARE’s USFHP listing gives it as Maryland, Washington DC, and parts of Pennsylvania, Delaware, Virginia and West Virginia — putting Delaware among the partial states. Either way, the plan settles it by ZIP code through its own service-area tool, and that is what intake should use.[1][2]
DHA’s own description of the path names USFHP explicitly: the child’s diagnosing provider "will submit a referral to your regional contractor or US Family Health Plan provider for authorization," and the family then receives an authorization letter for six months of ABA services. The first authorization covers the ABA assessment; the provider completes the assessment and treatment plan; a six-month treatment authorization follows; and reauthorization is requested every six months. A new referral from the ASD diagnosing provider is required every two years.[5][4][6]
The eligibility and diagnosis gates are the ACD’s. The diagnosis must come from an approved diagnosing provider — family practice physicians, pediatricians and pediatric or family nurse practitioners on the primary-care side; developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry, doctoral-level licensed clinical psychologists and qualifying DNPs on the specialist side. A first diagnosis at age 8 or later must come from a specialized ASD diagnosing provider, and a diagnosis more than two years old requires an updated diagnostic assessment. Active duty family members must register in ECHO.[5][4][6]
Johns Hopkins layers its own provider-side requirement on top: ABA providers must attest that they have completed the required ACD-ABA training course and that they understand the ACD provider requirements, "correct billing practices/claims filing, authorizations, exclusions, and medical records documentation for the ACD-ABA program." If your clinic is onboarding with Hopkins USFHP, that attestation is a prerequisite, not a formality.[5][4][6]
Four baseline outcome measures must be completed by the family and the provider team before ABA services can begin: the PDDBI, the Vineland Adaptive Behavior Scales, the Social Responsiveness Scale, and either the Parent Stress Index or the Stress Index for Parents of Adolescents. After baseline, the cadence is mixed — DHA states the four measures must be completed "every six months or every 12 months," with the PDDBI and the PSI-4-SF or SIPA on the six-month cycle, and the Vineland-3 and SRS-2 annually. The ABA provider completes the PDDBI teacher form, and the SRS-2 interview or teacher form annually.[5][7]
This is the operational core of the ACD and it does not soften because a nonprofit health system rather than a defense contractor is holding the file. Build the measure calendar at intake: baseline before the first treatment authorization, the six-month package before each reauthorization, the annual additions on schedule, and the two-year referral renewal booked with the diagnosing provider well in advance.[5][7]
One USFHP-specific difference to set expectations on: DHA states that families enrolled in USFHP do not get an Autism Services Navigator. In the regional contractor model the ASN is the family’s coordinator and the person who chases a stuck outcome measure. Under USFHP that coordination falls to the plan and to the ABA provider, which in practice means your team owns the deadlines.[5][7]
No. The Autism Care Demonstration chapter of the TRICARE Operations Manual (Revision C-57, June 24, 2026) never mentions electronic visit verification. Its proof-of-service rule is the progress note. Each session note needs the beneficiary’s full name, “The date and time of session to include start and end time,” the location, the length of the session, the rendering provider’s legible name, type and dated signature, the authorized ABA supervisor’s name and the names of everyone present. Paid claims must also show the rendering provider and NPI “per unique claim line (i.e., every session must be identified as its own unique line on any claim submitted).”[9]
The TRICARE Operations Manual (Ch. 18 Sec. 3, Revision C-57, June 24, 2026) makes graphs one of two accepted formats, not a requirement. Each reassessment and treatment plan (TP) update must describe “progress toward short and long-term treatment goals for the identified targets in each domain utilizing either graphic representation of ABA TP progress or an objective measurement tool consistent with the baseline assessment.” The update is due every six months and must include: the date and time it was completed; the ABA provider who did it; an “Evaluation of progress on each treatment target (i.e., Met, Not Met, Discontinued)”; the interventions that did not work and how the TP changed; and new targets, objectives and goals, with changes based on “the cumulative six month assessment of the PDDBI and other outcome measures.” Parent/caregiver engagement is a required goal, reassessed every six months. The authorized ABA supervisor and the parent/caregiver both sign. The reassessment, PDDBI included, must be “conducted, completed, and submitted no later than 30 calendar days prior to the end of the current authorization.”[9]
The manual names USFHP Designated Providers among the contractors it binds (it excludes them only from the Autism Services Navigator and a few education provisions). So this TP-update standard applies to the plan’s ABA reviews too. Ask the plan whether it adds a form or template of its own.[9]
The DHA-level setting rules apply: ABA rendered by a behavior technician in a school setting is not covered, while a BCBA may be authorized for a clinically necessary, focused and time-limited goal after clinical necessity review and with the contractor approving the goals. Community settings require checking with the plan first, and families are generally expected to generalize mastered skills themselves. Because USFHP plans administer the ACD under their own designated-provider arrangement, get the plan’s answer on school and community delivery in writing before you schedule the session — not after.[6][1][8]
Costs are TRICARE Prime costs: USFHP "has the same out-of-pocket costs as TRICARE Prime," ABA is billed as outpatient specialty care, and one copayment covers all ABA services received on a single day. As currently published, active duty family members pay $0 for network specialty care under Prime, and retirees and all others pay $39. There are no annual or lifetime dollar caps on ABA, and what the family pays counts toward the TRICARE catastrophic cap.[6][1][8]
Where this guide stops: Johns Hopkins publishes an ACD-ABA provider presentation and a USFHP provider manual, but both are served behind bot protection and could not be retrieved for this review, so the plan-specific supervision, unit-limit, concurrent-billing and documentation rules are not restated here. Ask Johns Hopkins USFHP provider relations for the current ACD-ABA training deck and provider manual, and confirm anything operational against those rather than against another region’s contractor guidance.[6][1][8]
Johns Hopkins’ own ABA provider material could not be retrieved for this review (its PDFs sit behind bot protection), so the answer here is the DHA rule. The TRICARE Operations Manual chapter that runs the Autism Care Demonstration names USFHP designated providers in its scope and excludes them only from specific paragraphs, such as the autism services coordination rules in paragraphs 6.0 to 6.9. Its licensing, telehealth and referral rules therefore apply to the plan.[9][10]
The DHA manuals answer both visitor questions. On licensure, the ACD chapter requires ABA providers to meet the licensing or certification requirements “extant in the State, county, municipality, or other political jurisdiction in which ABA services are provided under the ACD.” The TRICARE Policy Manual’s telehealth section pays only when the service is “within a provider’s scope of practice under all applicable state(s) law(s) in which services are provided and or received.” On telehealth, 97151, 97153, 97155, 97157 and 97158 “may not be conducted via TH,” and 97156 parent/caregiver sessions may be done by telehealth only after the first six-month authorization period per authorized provider. So an out-of-state BCBA cannot assess or deliver direct ABA remotely, and can deliver remote parent training only after six months and only if licensed or otherwise authorized where the child is. On back-dating, the ACD referral rule is that “A retroactive referral shall not be accepted.”[9][10]
This page is not legal advice. TRICARE Operations Manual Ch. 18 Sec. 3 ¶ 8.8 (Revision C-57, June 24, 2026) sets the ACD discharge rules. ABA ends on loss of TRICARE eligibility, or when the ABA supervisor, the contractor or the family determines that the child met the treatment-plan goals, made “no measurable progress” after successive review periods and repeated plan changes, has gains that do not generalize, or “can no longer participate in ABA services (due to medical problems, family problems, or other factors that prohibit participation).” It also ends if the diagnosing provider or PCM changes the diagnosis or no longer believes ABA is clinically necessary.[9]
How it must end: “Termination of ABA services under any circumstance must not occur abruptly by the authorized ABA supervisor. All termination plans must be submitted at least 45 calendar days prior to the termination of services.” The contractor “shall work with the ABA provider to ensure a smooth transition,” and if a supervisor ends services abruptly the contractor must “report the authorized ABA supervisor to the appropriate credentialing/licensure board.” Discharge planning belongs in every treatment plan, a discharge summary with the reason is required (it is not billable), and when direct ABA is no longer clinically necessary the contractor uses parent training to fade services over one six-month authorization. For a child whose aggression a setting cannot manage, the manual’s answer is a planned transition with 45 days’ notice, not an abrupt stop.[9]
TRICARE Operations Manual Ch. 18 Sec. 3 (Revision C-57) assigns each ACD code to a provider level. 97151 (assessment and treatment-plan updates): the authorized ABA supervisor “or as delegated to an assistant behavior analyst”; not by telehealth. 97153: the BT, the assistant behavior analyst or the supervisor, paid no lower than $12.50, $18.75 and $31.25 per 15 minutes respectively; capped at 32 units a day and 160 a week; not by telehealth. 97155: the supervisor or a delegated assistant, at least once a month by the supervisor personally; not by telehealth. 97156: the supervisor may delegate caregiver teaching to an assistant, “but only the authorized ABA supervisor may bill for this service using this code”; up to 8 units a day, home or clinic only. 97157 and 97158: the supervisor. In school, only 97153 “rendered by the authorized ABA supervisor (not delegated to the assistant)” is authorized.[9]
No credential modifier (HM, HN, HO, HP) is set in the chapter. Instead, every claim line must carry “the NPI of the rendering provider per unique claim line,” and remote parent sessions carry modifier GT or 95. When 97153 and 97155 are billed for the same time the contractor “shall pay the higher rate and deny the other.” For a family changing agencies, a second-opinion assessment authorization may overlap an approved one, but “Two ‘ongoing’ treatment authorizations of direct services (CPT codes 97153, 97155, 97156, 97157, and 97158) are not permitted.”[9]
The AMA CPT Editorial Panel accepted six new adaptive behavior codes, revised 97151–97158 and deleted 0362T and 0373T, effective January 2027. The AMA's CPT 2027 HCPAC vote document lists the new codes as 97148 and 97149 (supporting assessment of harmful behavior, two technicians), 97159 and 97160 (treatment of harmful behavior, two technicians), 97173 (treatment with analysis delivered by the physician or QHP) and 97180 (non-face-to-face services by the physician or QHP). The codes are national; what each payer decides is which ones it authorizes and pays, and how.[14][15][16]
The TRICARE Operations Manual's Autism Care Demonstration chapter (Chapter 18, Section 3, Revision C-57, June 24, 2026) still describes only the Category I codes 97151–97158, and no revision addressing the 2027 code changes had been posted as of November 1, 2026. Watch for a TOM revision before January 1, 2027, and confirm with the regional contractor which codes an authorization spanning January 1 should carry.[14][15][16]
The Autism Care Demonstration is audited every year. The TRICARE Operations Manual tells the regional contractor to audit, "on an annual basis," at least 30 records for each ABA provider group, combining administrative-record and medical-documentation reviews with one medical team conference session note. For the TRICARE Overseas Program and USFHP the audit "must include a minimum of 10% of records" for each group.[16]
Findings lead first to outreach and education, then to "progressively more severe administration action, commensurate with the seriousness of the identified problems." The contractor "shall recoup all claims determined to be insufficient per supporting documentation for claims payment," and recoups claims for session notes "that describe the rendering of non-ABA services" and for a supervisor whose BACB, BICC or QABA certification or state license carries a restriction. One penalty is automatic: 97155 "must be completed at least one time per month by the authorized ABA supervisor," and a provider who misses it faces "a 10% penalty on all ABA claims for that beneficiary for the entire six-month authorization."[16]
The questions that decide whether a family can start with Johns Hopkins US Family Health Plan, and what they have to bring. Each maps onto something intake should ask on the first call.
None under the ACD: no age limit, no time limit and no annual or lifetime dollar cap on ABA, and the demonstration applies to USFHP members the same way it applies to regional TRICARE members. Age changes the diagnosing pathway rather than the benefit — a first diagnosis at age 8 or later must come from a specialized ASD diagnosing provider. Eligibility itself runs to active duty family members, retired service members and their families, activated and non-activated Guard and Reserve families, TAMP qualifiers, retired Guard and Reserve aged 60 and older, survivors, Medal of Honor recipients and qualified former spouses — plus TRICARE Young Adult, for which USFHP can be chosen.[5][1]
The ACD clocks apply unchanged: a diagnosis more than two years old requires an updated diagnostic assessment, and a new referral from the ASD diagnosing provider is required every two years along with an updated DSM-5 checklist. Because USFHP families do not get an Autism Services Navigator — DHA states beneficiaries enrolled in USFHP and those living overseas do not have one — nobody outside your team is chasing those dates. Build the renewal calendar at intake.[5][6][1]
The ACD’s closed list, and the plan does not widen it. Approved primary care providers are family practice physicians, pediatricians, and pediatric or family nurse practitioners. Approved specialists are board-certified or board-eligible physicians in developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, or adult or child psychiatry, plus doctoral-level licensed clinical psychologists and qualifying Doctors of Nursing Practice. A first diagnosis at age 8 or later must come from a specialized ASD diagnosing provider. LCSW: no. TRICARE Operations Manual Ch. 18 Sec. 3 ¶ 11.13.1 (Revision C-57) lists every authorized ASD diagnosing and referring provider, and licensed clinical social workers are not on it. The manual names LCSWs only as possible Autism Services Navigators and as providers of parent-mediated programs, not as diagnosers.[9][5][6]
A DSM-5 checklist and a validated assessment tool at the door, then the ACD’s four outcome measures for the life of the case: the PDDBI, the Vineland Adaptive Behavior Scales, the Social Responsiveness Scale, and either the Parent Stress Index or the Stress Index for Parents of Adolescents. All four must be completed by the family and provider team before ABA services can begin. After baseline the cadence is mixed — the PDDBI and the PSI-4-SF or SIPA every six months, the Vineland-3 and SRS-2 annually — with the ABA provider completing the PDDBI teacher form and the SRS-2 interview or teacher form annually. With no Autism Services Navigator to chase a stuck measure, these deadlines belong to your team.[5][7][1]
Required, and the routing is the whole point of this guide. DHA directs the diagnosing provider to submit the ABA referral “to your regional contractor or US Family Health Plan provider for authorization” — for a USFHP member that is Johns Hopkins, not Humana Military. The first authorization covers the ABA assessment; the provider completes the assessment and treatment plan; a six-month treatment authorization follows; reauthorization is requested every six months; and a new referral from the ASD diagnosing provider is required every two years. Active duty family members must register in ECHO, with EFMP enrollment the prerequisite. Two network facts gate the same door: USFHP members cannot use TRICARE network providers or military hospitals and clinics except for emergencies, and Johns Hopkins requires its ABA providers to hold an ACD-ABA training attestation.[5][1][4]
One code, after six months. Johns Hopkins’ own ABA provider material could not be retrieved for this review, so the answer is the DHA rule. The DHA rule applies to USFHP: TRICARE Operations Manual Ch. 18, Sec. 3 names USFHP designated providers among the contractors it binds and carves them out only of specific paragraphs (such as the navigator rules in 6.0–6.9). It says 97151, 97153, 97155, 97157 and 97158 “may not be conducted via TH,” that 97156 parent/caregiver sessions “may be conducted via TH only after the first six-month authorization period per authorized provider,” that remote sessions “must include the GT or 95 modifier on claims,” and that “all services provided via TH must adhere to State laws governing TH services.” Asynchronous telehealth is excluded. Plan the first six months fully in person.[9][4]
Johns Hopkins USFHP states: “TRICARE requires authorization notification within two working days but not to exceed five working days following receipt of the request and all required information” — consistent with the DHA ACD rule that compliant ABA treatment plans be reviewed “within the five business days.” The required outcome measures must accompany “the initial and concurrent requests for authorization,” or authorizations may be delayed or denied. The manual sets no reauth lead time of its own; the DHA rule it cites (TRICARE Operations Manual 6010.59-M, Ch. 18) says a reauthorization “should be requested” as early as 60 calendar days and no later than 30 calendar days before the six-month authorization ends, and late submissions are not backdated.[11][12]
“If other health insurance coverage exists, plan coverage is available only as a secondary payor (except in cases involving Medicaid, Indian Health Services, and Veteran’s Administration) and only after a claim has been filed with the double coverage plan and a payment determination issued.” So bill the commercial plan first; COB claims are due “90 days from the date the primary insurance adjudicated the original claim.” The plan will not pay “amounts denied by the other health insurer because the claim was not filed in a timely manner or because the member failed to satisfy some other requirement,” and families may not waive the other coverage. Under the DHA ACD rule, “For Other Health Insurance (OHI), beneficiaries receiving ABA services must obtain a referral and prior authorization” — get the USFHP ABA authorization even when the other plan is primary.[11][12][13]
Coverage decides whether Johns Hopkins US Family Health Plan pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Excluded, with one exception, under the DHA rule. Johns Hopkins’ own ABA provider material could not be retrieved for this review, but TRICARE Operations Manual Ch. 18, Sec. 3 names USFHP designated providers among the contractors it binds. Concurrent billing is excluded for all ACD Category I codes “except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session,” with documentation of two separate rendering providers and locations. If 97153 and 97155 are billed concurrently, the contractor “shall pay the higher rate and deny the other.” The manual’s pairing table allows 97151 with 97153, 97156, 97157 or 97158, and 97156 with 97153, 97155 or 97158; it bars 97155 with 97151 or 97153.[9][4]
Set by the DHA rule. Johns Hopkins’ own ABA provider material could not be retrieved for this review. The DHA rule applies to USFHP: TRICARE Operations Manual Ch. 18, Sec. 3 names USFHP designated providers among the contractors it binds and carves them out only of specific paragraphs (such as the navigator rules in 6.0–6.9). Ceilings: 97151 up to 32 units for the initial assessment and up to 24 units per later authorization, used within 14 calendar days of the first 97151 date of service; 97153 denied above “32 units (eight hours) per day or 160 units (40 hours) per week”; 97155 not authorized above eight units (two hours) a day; 97156 denied above eight units a day; 97157 and 97158 authorized at four to six units a day, with groups of no more than eight.[9][4]
DHA’s ACD rule applies to all TRICARE plans: ABA delivered by a behavior technician in a school setting is not covered. A BCBA may be authorized where the goal is clinically necessary, focused and time-limited, with pre-authorization and the contractor approving the goals. For community settings, families are generally expected to generalize mastered skills on their own; a BCBA may be authorized for certain community settings only after checking with the plan.[6]
The rendering provider goes on every line, under the DHA rule. TRICARE Operations Manual Ch. 18, Sec. 3, which names USFHP designated providers among the contractors it binds, requires every ACD provider to have an NPI (“all claims must have the rendering provider’s name and NPI for processing”), requires paid claims to carry “the NPI of the rendering provider per unique claim line,” and requires the HIPAA taxonomy of each provider type: 103K00000X behavior analyst, 106E00000X assistant behavior analyst, 106S00000X behavior technician. Claims must be electronic. The network fact comes first: USFHP members cannot use TRICARE network providers, so the ABA provider must be in the Hopkins USFHP network, and Johns Hopkins requires an ACD-ABA training attestation covering “correct billing practices/claims filing.”[9][4][1]
Johns Hopkins USFHP administers the ACD and requires its ABA providers to attest to completing its ACD-ABA training, but its plan-specific supervision requirements are published in provider material that could not be retrieved for this review. Do not apply another region’s contractor guidance in their place.[4]
Blocked on: Johns Hopkins USFHP provider relations — request the current ACD-ABA training deck and the USFHP provider manual; plan line 800-808-7347
Johns Hopkins’ ACD-ABA attestation covers medical-records documentation for the program, but the plan’s specific session-note and signature standard is not published where it could be verified for this review.[4]
Blocked on: Johns Hopkins USFHP ACD-ABA training deck and provider manual, via provider relations
Within limits set by the TRICARE Operations Manual. BTs deliver 97153. Assistant behavior analysts may deliver 97153, and 97151, 97155 and 97156 when the supervisor delegates them, but 97156 is billed only by the authorized ABA supervisor. Every claim line carries the rendering provider’s NPI; no HM/HN/HO/HP modifier is required by the chapter.
At least 45 calendar days. The TRICARE Operations Manual says termination “must not occur abruptly” and that “All termination plans must be submitted at least 45 calendar days prior to the termination of services.” A supervisor who stops abruptly is reported to the credentialing or licensure board. This is the payer rule, not legal advice.
No. The TRICARE Operations Manual’s ACD chapter (¶ 11.13.1) limits ASD diagnosing and referring providers to pediatricians, family medicine physicians, pediatric or family nurse practitioners, and specialists: board-certified or board-eligible developmental-behavioral or neurodevelopmental pediatricians, child neurologists and child psychiatrists, doctoral-level licensed clinical psychologists and qualifying board-certified DNPs. LCSWs are not on the list.
No. The TRICARE Operations Manual’s Autism Care Demonstration chapter has no electronic visit verification requirement. Proof of service is the session progress note, with start and end times, location, length, the rendering provider’s signature and the supervisor’s name, plus one claim line per session carrying the rendering provider’s NPI.
Graphs are one of two accepted formats, not a requirement. The TRICARE Operations Manual asks each six-month reassessment and treatment plan update to show progress on every target “utilizing either graphic representation of ABA TP progress or an objective measurement tool consistent with the baseline assessment.” It must also mark each target Met, Not Met or Discontinued, name the interventions that changed, and carry the PDDBI and the other outcome measures due that period. The supervisor and the parent sign it, and it goes in at least 30 days before the authorization ends. The manual binds USFHP Designated Providers, so the same standard applies here.
It is a TRICARE Prime option — one of six Uniformed Services Family Health Plans administered by nonprofit health systems. Members get TRICARE Prime benefits and Prime cost-sharing, but through the plan’s own network, and cannot use TRICARE network providers or military hospitals and clinics except for emergency care.
The plan. DHA directs the ASD diagnosing provider to submit the ABA referral to the regional contractor or the US Family Health Plan provider — for a USFHP member that is Johns Hopkins, not Humana Military.
Yes. ABA for TRICARE beneficiaries is covered under the ACD regardless of plan, and the referral, six-month authorization cycle, two-year referral renewal and four outcome measures all apply. Johns Hopkins requires its ABA providers to attest to completing its ACD-ABA training.
Maryland and Washington DC plus parts of Pennsylvania, Delaware, Virginia and West Virginia. The plan’s own site lists Delaware alongside Maryland and DC, while TRICARE’s listing puts it among the partial states — check the ZIP against the plan’s service-area tool.
No. DHA states that beneficiaries enrolled in USFHP, and those living overseas, do not have an ASN. The coordination the navigator normally provides falls to the plan and the ABA provider.
Only parent training (97156), only after the first six-month authorization, and only where the BCBA is licensed or otherwise authorized for the child’s location. The DHA manuals the plan administers require compliance with licensing law where services are provided and received, and bar telehealth for the assessment and direct ABA codes. Authorizations are not back-dated: the ACD does not accept retroactive referrals.
TRICARE Prime rates, since USFHP has the same out-of-pocket costs as Prime. ABA is outpatient specialty care and one copay covers all ABA services on a single day: currently $0 for active duty family members and $39 for retirees and others on network specialty care. There is no annual or lifetime cap on ABA.
Not under the DHA rule the plan administers. TRICARE Operations Manual Ch. 18, Sec. 3 says 97156 “may be used only in a home or clinic/office-based setting” (97157 only in a clinic or office). A daycare can be authorized for direct ABA when clinically necessary, but hold parent training at home, in the clinic, or by telehealth after the first six-month authorization. Confirm any daycare plan with the USFHP plan in writing.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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