BACB Certification

BACB requirements for certification include specifications for the levels of education, training, experience, examination, adherence to an ethics code, and in some cases ongoing supervision. The BACB currently certifies professional practitioners of ABA at two levels:

• BCBA—an independent practitioner who can provide ABA services and supervise delivery of those services by others. Requires at least a master’s degree, university coursework in specified topics, supervised experiential training, and passage of the BCBA professional examination in behavior analysis. BCBAs with doctoral degrees can apply for the Board Certified Behavior Analyst-Doctoral (BCBA-D) designation.¹
• Board Certified Assistant Behavior Analyst (BCaBA)—a practitioner who can provide ABA services under the supervision of a BCBA or BCBA-D. Requires a bachelor’s degree, university coursework in specified topics in behavior analysis, supervised experiential training, and passage of the BCaBA professional examination in behavior analysis.²

Both of these certification programs have been accredited since 2007 by the National Commission for Certifying Agencies (NCCA) of the Institute for Credentialing Excellence (Carr & Nosik, 2017; Johnston, Carr, & Mellichamp, 2017). To maintain their certifications, BCBAs and BCaBAs need to complete continuing education requirements and adhere to an ethics code (BACB, 2020, 2025).

The BACB currently certifies paraprofessional practitioners of ABA at one level:

• RBT—a paraprofessional practitioner required to work under the direction and close supervision of professional behavior analysts who have met BACB requirements for serving as supervisors. Current requirements are at least a high school education or equivalent, passage of a criminal background check, completion of a BACB-approved 40-hour training program, passage of an initial competency assessment, and passage of the RBT examination in behavior analysis.

The RBT program was developed in 2017 by the BACB. It is also accredited by the NCCA. To maintain their credential, RBTs are asked to adhere to an ethics code (BACB, 2021) and their supervisors document that they have fulfilled the supervision requirements.

As of the end of 2023, certifications totaled more than 66,000 BCBAs, more than 5,600 BCaBAs, and more than 163,000 RBTs, with the vast majority located in the United States (Luke, 2024). There has been tremendous growth in certificants across the three areas in the past decade (see Figure 4-1). Growth in the field was likely spurred by availability of funding, which led to industry development and university-level training. Notably, more than 70% of certified professionals purport to working with autistic individuals.

FIGURE 4-1

Certificant growth. NOTE: BCaBA = Board Certified Assistant Behavior Analyst; BCBA = Board Certified Behavior Analyst; RBT = Registered Behavior Technician. SOURCE: Luke, 2024.

State Licensure

Starting in 2009, U.S. states began adopting laws that require individuals to hold a state-issued license in order to use a specified title (e.g., Licensed Behavior Analyst) and, in all but two states, to practice ABA professionally (the Oregon and Wisconsin laws are title acts only). At this writing, 39 states have adopted behavior analyst licensure laws (BACB, n.d.). All of these states license behavior analysts with graduate degrees to practice ABA independently. Several states also license assistant behavior analysts with bachelor’s degrees to practice under the supervision of licensed behavior analysts. Most states exempt behavior technicians and other paraprofessionals from direct regulation by the state as long as they are supervised properly by a licensed behavior analyst or assistant behavior analyst. At present, five states require ABA paraprofessionals to be registered or certified by the state licensing entity in addition to being supervised by a licensed professional behavior analyst.

Behavior analyst licensure programs are administered by governmental entities that vary across states (e.g., stand-alone behavior analyst licensing boards, omnibus licensing boards, licensing boards of other professions, state agencies with no licensing board). In all states, however, behavior analysts are licensed in their own right, not as members of other professions. Because the requirements for the BACB’s professional certifications parallel requirements for licenses in many professions—degree(s), university coursework, experiential training, professional exam in the subject matter—most of the licensure laws and/or the associated rules make current BACB certification a qualification for obtaining the state-issued license. In the remaining states, BACB certifications are written into various laws and rules as qualifications for designing, overseeing, and/or delivering ABA services (e.g., health insurance laws or rules, Medicaid policies, developmental disability services laws or rules, education laws or rules).³

Health Care Provider Taxonomy Codes

Adoption of the public policies described above made it possible for many ABA providers to have their services funded by health insurance and placed them squarely within the category of behavioral healthcare providers. Several additional actions were required, however, to enable health insurance reimbursement for ABA services. One was the establishment of Health Care Provider Taxonomy codes, which are unique 10-digit numbers used to classify a set of healthcare providers by their areas of specialization. Healthcare providers use these codes to apply for the National Provider Identification (NPI) numbers that are required to bill health plans, including Medicare. These taxonomy codes are issued and owned by the American Medical Association (AMA) National Uniform Claim Committee. Codes for behavioral analysts and technicians were issued in 2016 pursuant to an application submitted by the BACB and Association of Professional Behavior Analysts.⁴

Current Procedural Terminology Codes

To be reimbursed by public and commercial health plans in the United States, healthcare providers use billing codes linking to procedures and services. When the first state laws requiring health plans to cover ABA services for autistic beneficiaries were adopted, there were no billing codes that were specific to those services. Health plans and providers used existing codes, selected mainly from the Healthcare Common Procedure Coding System maintained by the Centers for Medicare & Medicaid Services, that came reasonably close to describing ABA services (e.g., H2019, “therapeutic behavioral services”). To enable ABA providers to bill health plans appropriately, it was necessary to obtain Current Procedural Terminology (CPT) codes for ABA services.⁵

In 2014, the AMA CPT Editorial Panel issued 16 Category III (temporary) CPT codes for adaptive behavior/ABA services pursuant to a process initiated by the ABAI. In 2019, the Panel issued eight revised codes as Category I with two revised codes remaining Category III, replacing the original Category III code set. Of these 10 revised codes, three are for adaptive behavior/ABA assessment services and seven are for treatment services; and of the seven treatment services codes, there are three for services delivered to a single individual, two for services delivered in small groups, and two for guidance to families. See Box 4-2 for descriptions of these codes. Some codes are for services administered by behavior technicians under the direction of qualified health professionals. Qualified health professionals are considered licensed behavioral analysts, BCBAs, or licensed psychologists who have competence in behavior analysis (American Medical Association, 2018). None of the code descriptors for ABA are restricted to any specific diagnoses or patient populations.⁶

BOX 4-2

ABA Billing Codes.

Commercial and Public Insurance Coverage for ABA Services

Since 2019, all 50 states have adopted laws or issued regulatory guidance requiring certain commercial health insurance plans to cover ABA services for individuals with autism (Autism Speaks, 2020b). These state mandates typically apply to fully insured plans, including those sold through the individual and small group markets, and state employee health benefit plans. In addition, private health insurance plans purchased through the Health Insurance Marketplace in 33 states and the District of Columbia include coverage for ABA services (Autism Speaks, 2022a).

Self-funded employer-sponsored health plans, which are regulated under ERISA and not subject to state insurance mandates, vary in their ABA coverage (Autism Speaks, 2022c). As of 2018, approximately 45% of companies with 500 or more employees included coverage for ABA or similar behavioral health services for individuals with autism (Autism Speaks, 2022c).

At the federal level, all plans within the Federal Employees Health Benefits Program have been required to cover ABA services for individuals with autism since 2017 (U.S. Office of Personnel Management, 2017). Similarly, the Civilian Health and Medical Program of the Department of Veterans Affairs has included ABA as a covered benefit since December 2020 (Autism Speaks, 2020a; U.S. Department of Veterans Affairs, 2023). Coverage through the Children’s Health Insurance Program (CHIP) varies by state when not part of state Medicaid programs (Autism Speaks, n.d.a). Under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate, state Medicaid programs are required to provide all medically necessary services for beneficiaries under age 21. From 2014 to 2022, state agencies sought to clarify ABA as a covered benefit under EPSDT in Medicaid plans or regulations (Autism Speaks, 2022b).

During these developments in health benefit coverage, policies, benefit designs, and ultimately administration of and access to ABA services have varied across states and plans. Some of this variation has included differences in financial caps, age eligibility, limits on hours of ABA per week, and qualifications of diagnosing providers and those administering ABA services (Autism Speaks, 2020b; DoD, 2024b). More recently, since amendments to MHPAEA in 2021, the Department of Labor Employee Benefits Security Administration has conducted outreach and enforcement efforts to address common deficiencies in health benefit plans related to mental health parity, including those that exclude or limit ABA for treatment of autism (Employee Benefits Security Administration, 2023, 2025).

Determination of Medical Necessity

Medical necessity is a term that payors use to describe the process for determining whether they will cover a specific service or treatment. While specific criteria for determining medical necessity vary between payors, determinations generally adhere to common principles described by American Medical Association (2023) and American Academy of Pediatrics (AAP) (Giardino et al., 2022) to ensure treatment is

• in accordance with generally accepted standards of medical practice;
• clinically appropriate for the individual in terms of type, frequency, extent, site, and duration;
• not primarily for the economic benefit of the health plans and purchasers or for the convenience of the individual, treating physician, or other healthcare provider;
• based on the best scientific evidence, considering the available hierarchy of medical evidence; and
• likely to produce incremental (and/or future) health benefits relative to the next best alternative that justify any added cost.

Additionally, all 50 states’ Medicaid programs have definitions of medical necessity that are used in determining coverage for EPSDT benefits that states are required to cover under federal law.⁸ In general, states define medically necessary services as those that improve health or lessen the impact of a condition, prevent a condition, or restore health (National Academy for State Health Policy, 2021).

When determining medical necessity for ABA treatment, payors typically followed principles set out by the AMA, AAP, and state Medicaid programs. However, payors tend to have medical necessity guidelines that are specific to ABA coverage, as is the case with other specialty treatments.

The following list of medical necessity criteria is summarized from publicly available health plan guidelines from Cigna Healthcare,⁹ Anthem Blue Cross Blue Shield,¹⁰ UnitedHealthcare,¹¹ Molina Healthcare,¹² Magellan Health,¹³ and Kaiser Permanente¹⁴:

• Diagnosis—a diagnosis needs to be based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013) by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice
• Clinical appropriateness—treatment is in accordance with generally accepted medical standards of care for the diagnosed condition and has been determined effective for that condition including intensity and duration guidelines
• Convenience—treatment is required and not undertaken primarily for the convenience of either the individual or provider
• Level of service—appropriate level of service is identified for the individual including functional improvement requirements
• Comprehensive assessment of functional impairments in communication, behavior, and social skills completed by a professional trained to administer the assessment tool and interpret the result
• ABA planning that includes baseline assessments and individualized goals based on identified functional deficits
• Periodic review for the continuation of service including identification of new or continuing treatment goals and treatment planning

These criteria as well as standard care practices (discussed below) recognize three important and separate “assessment” stages related to the delivery of ABA: (1) assessment related to diagnosing autism in an individual; (2) initial assessment before starting ABA to identify goals, needs, target behaviors, etc. and develop treatment plan; and (3) ongoing assessment to track progress, revisit goals and plan, and determine continued need for ABA. Available standardized assessment tools might be appropriate at any of these stages.

Diagnosis assessment is conducted by board-certified and qualified healthcare providers (e.g., pediatric physicians, nurse practitioners, and specialty providers). As discussed in Chapter 2, diagnosing autism is a complex clinical process based solely on assessments of behavior using observations or historical reports of behavior. The DSM-5 criteria help ensure consistency and reliability in the diagnosis of autism across healthcare providers. In addition, several objective measures and standardized diagnostic tools have been developed to help clarify observations and information on individuals’ behaviors. However, while meaningful, these tools are not uniformly available and a valid diagnosis need not be contingent on their use.

At other stages of assessment in planning and monitoring ABA services, professional behavior analysts assess clients’ strengths and weaknesses in multiple skill domains (cognitive, communication, social, self-help, maladaptive behaviors, etc.), as well as the preferences and circumstances of the clients and their families. Skills that need to be developed can be broken down into small components. Behavior analysts develop written protocols for technicians or paraprofessionals (see tiered delivery model below) as well as caregivers (see caregiver engagement and training below) to follow to help individuals develop skills. Behavior analysts monitor the implementation of protocols, review data on clients’ progress frequently, and adjust treatment protocols as needed (NASEM, 2024a). See further discussion on evaluating progress below.

Treatment Plans and Delivery of ABA Services

For delivery of ABA, a treatment plan is put together by the behavior analyst, who documents initial and ongoing assessments, individual goals and objectives, and proposed approach to ABA for the client as well as training and support for the caregiver. Section 4.2 of the CASP guidelines (CASP, 2024) covers many aspects of developing and delivering ABA treatments plans. Coordination with other healthcare professionals will be useful for planning treatment as well as assessing progress with ABA. Other professionals can provide assessments of an individual’s general cognitive functioning, speech and language skills, specific learning disabilities, dental health, and medical status (including co-occurring conditions). It is important to develop an understanding of a client’s strengths and challenges and to be aware of other interventions and medical services. Some aspects of treatment plans and ABA delivery are summarized in the following sections: scope and goal development, amount of ABA, settings and modality, safety measures and crisis management, and tiered delivery and staffing.

Scope and Goal Development

As discussed further in Chapter 5, the scope of intervention may be comprehensive (targeting multiple behaviors in multiple domains such as self-care, language and communication, and reduction of challenging behavior) or focused (targeting a limited number of behaviors). Comprehensive ABA treatment typically seeks to enable the client to develop and/or maintain many adaptive behaviors and may also address any maladaptive behaviors that jeopardize the client’s health or safety. Focused ABA treatment may address only a small number of adaptive behaviors from one or two domains, such as specific self-care skills. If one or more maladaptive behaviors are targeted, the professional ethical standards guide ABA providers to also target one or more adaptive behaviors that compete with or are alternatives to the maladaptive behavior(s) (CASP, 2024).

Goals refer to the aim(s) of treatment—that is, the behaviors that are targeted for treatment and the nature and amount of improvement that is sought. Individual goals or targets are determined by ABA providers drawing on information about a client’s and family’s needs, strengths, and life circumstances. Treatment plans often include short-term and long-term goals. Protocols or written procedures in the treatment plans can guide ABA providers in implementing assessment and treatment of each goal (CASP, 2024).

Many healthcare professionals recognize activities of daily living (ADLs) are valid targets for ABA. While ADLs can refer to a range of functional tasks individuals complete regularly and independently (Matson, Hattier, & Belva, 2012), for healthcare contexts and medical decision making, ADLs often refer to critical health and safety tasks. These fundamental self-care tasks have been codified in 26 U.S.C. § 7702B(c)(2) under the Health Insurance Portability and Accountability Act as activities related to eating, toileting, transferring, bathing, dressing, and continence. In some circumstances, these fundamental tasks are known as basic ADLs in contrast to instrumental ADLs that are less crucial to daily functioning but useful for independent living (e.g., meal preparation and money management). Medical conditions, such as autism, can affect one’s ability to perform ADLs.

The ACD currently limits goals of ABA services to those targeting the core symptoms of autism and specifically excludes ADLs. Commercial payors generally cover a broader set of goals that meet individual health needs, including ADLs or adaptive living skills. The committee heard quite a bit from ABA providers and military-connected families on the importance of targeting goals around basic ADLs. See Box 4-3.

BOX 4-3

Perspectives on Activities of Daily Living.

Settings and Modality

Research shows that for most autistic individuals, ABA treatment needs to be delivered in multiple settings to enable behavior changes to generalize (carry over) from the primary treatment conditions to other places, times, people, and stimuli (Arnold-Saritepe et al., 2023; CASP, 2024; Falligant et al., 2021; Green, 2025; Rincover & Koegel, 1975; Waters et al., 2020). If ABA interventions are delivered outside of an autistic individual’s natural setting, provision of the services should plan for the generalized use of the skill being taught in other places, with other people, and/or in the presence of other stimuli. It may not be obvious to an individual with autism how to use new skills in other settings. As such, the delivery of ABA has developed in ways to be administered more often in real-world settings for best progress. Like other aspects of ABA services, the location (e.g., clinic, house, school, community setting) in which services are delivered are individualized to the client’s circumstances and can vary by session over the treatment duration. Some military families utilizing the ACD reported how limitations on settings have impacted their child’s treatment goals and ability to thrive outside the home. (These family perspectives appear in Box 4-4.)

BOX 4-4

Perspectives on Treatment Settings.

Although ABA services are typically delivered in person, certain conditions may make telehealth delivery necessary or advantageous (e.g., for individuals residing in areas with no qualified providers nearby, during infectious disease outbreaks or natural disasters, for military families who need to retain services while transitioning to a new duty station).

The CASP standards specify that decisions about telehealth treatment need to be driven by clinical usefulness for the individual, treatment targets, the availability of resources and assistance necessary for safe and effective telehealth delivery of ABA services, applicable laws and regulations, and payor policies (CASP, 2024).

Tiered Delivery and Staffing

There are two types of tiered models for the delivery of ABA services by provider teams: the two-tiered model and the three-tiered model (CASP, 2024). In the two-tiered model, one or more behavior technicians deliver services to clients under the direction and supervision of a professional behavior analyst—a BCBA, BCBA-D, or someone with similar training. The behavior analyst is responsible for managing or supervising all aspects of each client’s case: designing assessment and treatment plans and procedures, training the technicians and caregivers (where applicable) to implement the procedures, analyzing client data frequently, modifying treatment plans and protocols as needed, collaborating with other providers, and communicating with clients, caregivers, and payors. The technician, in this model, is responsible for implementing assessment and treatment protocols as assigned by and under the close oversight of the supervising behavior analyst.

The three-tiered model adds a mid-level team member—a BCaBA or someone with similar training, if allowed by law or payor policies—who assists the behavior analyst with training and supervision of technicians and may perform other duties under the supervision of the behavior analyst, such as case supervision, assessing and treating clients, reviewing data, developing protocols, and training caregivers. The CASP standards recognize that higher ratios (e.g., two ABA providers to one client) may be necessary implement assessment and/or treatment protocols for behaviors that are dangerous to the client or others (CASP, 2024).

For both models, the CASP standards specify that the behavior analyst be familiar with the client’s characteristics and treatment plan, ensure that all team members are competent to perform responsibilities assigned to them, and observe them implementing the treatment plan regularly (CASP, 2024). These standards also require all practitioners to operate within the profession’s scope of practice and their individual scope of competence, and to comply with standards (e.g., ethics, supervision requirements) specified by the profession and applicable laws and regulations. See Figure 4-2 for an illustration of the tiered delivery model.

FIGURE 4-2

ABA tiered service model. NOTE: BCaBA = Board Certified Assistant Behavior Analyst; BCBA = Board Certified Behavior Analyst; BCBA-D = Board Certified Behavior Analyst, Doctoral Level; RBT = Registered Behavior Technician. SOURCE: CASP, 2014.

Evaluation of Progress

Measuring progress with ABA services is complex, since there is an imprecise relationship between treatment and outcomes on behavior and health. Many factors can affect outcomes. Nonetheless, regular assessment and selection of measures to track individuals’ progress are key components of ABA. Assessments in standard practice often are customized toward clients’ goals and draw on multiple sources of data including direct observations and measurements of behavior, review of clients’ medical history, interviews, and the administration of standardized instruments (CASP, 2024).

Many standardized assessment instruments have been developed for autistic individuals or for behaviors that might be addressed by ABA. However, they are not equivalent in purpose or use. There are even standardized instruments for collecting data on caregivers, their satisfaction with ABA services, as well as indicators of family well-being. Behavior analysts are encouraged to consult with other professionals before determining which instrument(s) are appropriate for particular clients and their families, to select instruments with domains and items that will inform treatment goals, and to use results from standardized instruments in conjunction with data from other sources in assessing an individual’s progress (CASP, 2024). Assessment tools have changed over the past 10 years and continue to evolve and advance as understanding of autism changes and improves.

This is a very heterogeneous population ranging from individuals with high intelligence and good communication skills to those with major cognitive impairment and those who never developed language. Individuals at all levels of communication and cognitive ability also vary on the range and intensity of restricted and repetitive behavior and the level of impairment caused by sensory sensitivities. One specific assessment tool or set of tools will not be appropriate to obtain the information needed to develop an appropriate treatment plan or evaluate progress for every autistic individual.

A combination of standardized assessments that are direct (administered to the client or patient) and some that are indirect (completed by caregivers or other third parties) is preferred. Selection of standardized assessments would need to be guided by the characteristics of the instrument and the individual’s presenting conditions and support needs. Standardized assessments provide guidance in overall cognitive and adaptive level but not enough detail to develop a treatment plan. Non-standardized assessments, such as curriculum assessments, language sampling techniques developed by speech pathologists, and adopted procedures for direct observation and recording of behaviors, are common in delivery of ABA. Such assessments are often accompanied by procedures to determine the accuracy and reliability of human observations. They are used to develop specific measurable goals and to choose the most appropriate strategies to address those goals as well as the intensity of intervention needed. Furthermore, progress toward these measurable goals can be tracked to understand individual progress more accurately than standardized assessments.

A functional behavior assessment is a particular type of behavior analytic assessment to identify environmental events that influence challenging behaviors. Those data can be graphed and reviewed and updated frequently throughout services. This type of assessment is typically the main source of data that behavior analysts use to modify treatment procedures for challenging behaviors and to determine client progress (Horner & Carr, 1997).

Any instruments or assessment tools chosen need to have good psychometric properties, including good reliability and validity, and appropriate norms (where relevant). Ideally, decision support and other practical considerations (online administration, automated scoring, etc.) are available to ABA providers to help with administering the tools and interpreting assessment information, particularly for standardized norm-referenced assessments (Frazier, 2024). In addition, the tool’s sensitivity to track change is important. There are best practices (e.g., growth scale values or growth scores, reliable change indices, decision support for identifying when behaviors have returned to the neurotypical range) that are available for some instruments and not others that facilitate appropriate change detection during intervention. However, because of the heterogeneity among autistic individuals, change detection and expectations for change need to be adjusted for the phenotypic profile (cognitive level, symptom severity, adaptive function deficits, presence of challenging behavior) of the individual. Expecting the same level of change from all individuals is not reasonable and not consistent with the published literature (Frazier et al., 2021).

Most commercial payors encourage regular assessment and reauthorization at six-month intervals; however, they do so without mandating which tools to use. The ACD requires all ABA providers to periodically administer four specific standardized assessment instruments; this is in addition to assessments that ABA providers would normally select to track clients’ progress and extra responsibilities those providers serving families participating in the ACD have. See further discussion of the ACD requirement of periodic assessments in Chapters 6 and 7.

Billing and Reimbursement Exclusions

Billing for ABA services is a complex process. Payors continue to develop their policies and rules as the field evolves and as legislation and regulations change, and currently, requirements vary among payors. While having to adjust to differences in payor policies in the delivery of medical care is not unique to ABA services, ABA providers have expressed challenges in targeting critical health goals because of particular restrictions, notably those administered through the ACD.²⁰

There are several groups working on educating payors and ABA providers about reasonable billing practices for ABA (e.g., ABA Coding Coalition and National Correct Coding Initiative). The committee was not charged to examine billing, and a comprehensive review of coverage policies and billing practices for ABA was beyond the scope of this study. However, during its review of the ACD, the committee heard often about ACD billing restrictions that do not adhere to industry guidelines or practices and are likely affecting access to quality care. These highlighted restrictions include the following:

• Limited authorization of CPT codes that can be billed under the ACD. CPT codes specifically excluded include 97152, 97154, 0362T, and 0373T (see Box 4-2 for code descriptions).
• Limited authorization of CPT code 97155. This code can only be used for 1:1 ABA delivery by professional behavior analyst and not for time spent by behavior analyst supervising a technician delivering ABA.
• Restriction on concurrent billing of 97155 and 97153.
• Utilization expectations of 97155 and 97156 exceed common standards of care.
• Restriction on reimbursement of technician time working toward their 40-hour training requirement for certification.

As a result of these restrictions, care can be constrained. For example, concurrent billing for a technician and a behavior analyst at times is essential for professional supervision of the technician’s administration of ABA; this supervision ensures quality and addresses areas for improved implementation as outlined in the CASP guidelines (CASP, 2024). Concurrent billing of the technician and the ABA supervisor is an expected component of the AMA CPT codes (ABA Coding Coalition, 2022).

According to the ABA providers who presented to the committee, working with the ACD and TRICARE has meant that documentation requirements are more onerous, non-payment of services is common (i.e., claims denied more frequently), and recoupment of services for technical errors is more common in comparison to what is experienced with other payors (Linn, 2024; NASEM, 2024a; Sims, 2024; Thompson, 2024; Waters, 2024). These billing limitations and exclusions are just part of the administrative challenges experienced by ABA providers in serving TRICARE clients and reported to the committee. Other challenges, such as administration of multiple assessments and parenting stress indices and parent training requirements, are discussed elsewhere in this chapter and throughout the report. One provider shared a table of the added burdens that apply to TRICARE’s plan compared to others (see Figure 4-3).

FIGURE 4-3

ABA authorization requirements comparison. SOURCE: Linn, 2024.

Caregiver Engagement and Training

Most ABA providers and researchers would recognize that caregiver engagement and training is important to the success of ABA. Caregiver engagement will help with generalization of learned skills as well as family well-being and empowerment. However, many also recognize that, in practice, caregiver engagement will be limited. Across payors, including the ACD and TRICARE, there is a general expectation of family participation. It is also common for treatment plans to include several objective and measurable goals for parents and other caregivers. Such goals need to be developed with sensitivity toward family dynamics and well-being, culture, values, needs, and resources (CASP, 2024).

Caregiver engagement can take many forms, including, but not limited to, meeting with the behavior analyst, attending and observing ABA sessions, working with the behavior analyst on goals, at-home practice and reinforcement of skills, regular communication with the behavior analyst, training on ABA fundamentals, training on incidental teaching for everyday activities, and regular communication with the behavior analyst. The CASP guidelines describe ways in which family members and other caregivers may be involved in assessment, treatment planning, and ABA delivery. They also offer how behavior analysts may support caregivers by providing training on reinforcing skills, connecting them with others with similar experiences, connecting them to other healthcare professionals when necessary, and maintaining strong communication about ABA goals and progress (CASP, 2024).

With the 2021 policy changes, the ACD aimed to encourage caregiver engagement by mandating a minimum of six parent/caregiver training sessions for every six months of ABA services. Reauthorization of ABA services is contingent on having met the training requirement in the past six months or otherwise documenting why it could not be met. Since the policy began, DHA, drawing on number of claims for parent treatment guidance (CPT codes 97156 and 97157), has reported to Congress a lack of parental engagement with 10 hours or less annually on average (DoD, 2024b; see also Appendix C, Question 12). While other payors do expect caregiver participation in ABA and engagement in goal setting and treatment planning, there is no record of punitive consequences on the provision ABA services or provider reimbursement if parents do not engage in ABA delivery and training. Further, the committee feels that billing code utilization is not a good indicator of parental engagement, given the range of forms of meaningful engagement with ABA and the unique challenges of military families (e.g., deployment). The committee had both ethical and practical concerns about mandated parent/caregiver training hours in order to continue receiving ABA services that individuals need for their health and well-being.

Care Coordination and Service Navigation

Care coordinators and service navigators work with individuals and their families and caregivers to overcome barriers to access to care. As a developing service in healthcare systems, such coordinators are often employed for specific populations or communities to reduce health disparities and/or to support individuals with chronic conditions who have to navigate complex healthcare systems.²¹ According to McKenney et al. (2018), “Depending on the specific needs and resources of the target community, individuals who serve as patient navigators range from lay people, including [. . .] community health workers, to professional healthcare or social services personnel, including case managers, social workers, and nurses” (p. 281). Primary roles for care coordinators and navigators are to provide emotional support by listening to concerns and act as an advocate for patient needs (Association of Maternal & Child Health Programs, 2018). Activities of services navigators for families with children with autism have included care assessment, service coordination, psychosocial support, health education, service advocacy, and logistic assistance (Li et al., 2025).

Some identified best practices for the design and implementation of a navigation system include the following factors (NASEM, 2018):

• Assessing the needs and resources of the community it will serve, making it convenient for patients, and tailoring the program to fit the culture of the communities and individuals served
• Staffing appropriately and defining the navigator role with clear scope of practice
• Building in appropriate metrics and evaluation
• Communicating regularly among navigators, patient advisory councils, and clinicians about navigation program successes and opportunities for improvement

Services navigation works best when it acts as a relational connection to support patients with complex networks and processes in a healthcare system, educate patients about the diagnostic and treatment processes, and support health-related decisions across the continuum of care, from screening to diagnosis and treatment (Gabitova & Burke, 2014). Care services navigation for autistic individuals across different types of services and interventions has helped with scheduling and successfully completing appointments for recommended services, including medical, educational, therapeutic, and parent resource appointments (Roth et al., 2016); early intervention and relationships with providers (DiGuiseppi et al., 2021); and improved parental perspectives on children’s social needs (Gottlieb et al., 2016).

For the ACD, as noted in Chapter 3, assignment of an Autism Services Navigator (ASN) to all ACD participants has slowly replaced prior case management services. In order to receive ABA services, as of January 1, 2025, all families have to agree to accept service navigation. If families do not want to utilize navigation services, their child is no longer eligible to receive ABA services through the ACD. To the committee’s knowledge, no other health benefit program or insurance plan mandates service navigation in order to receive services. The committee heard from several families that the role of the ASN has been unclear and has been less helpful than their previous case managers. Box 4-5 illustrates the experience military families have had with ASNs and accessing care. Best practices for service navigation suggest that uncertainty about the navigator’s role among patients and families is considered a weakness of a navigation program (Gabitova & Burke, 2014).

BOX 4-5

Perspectives on Access to Care.

Since the 2021 ACD policy update, the role of the ASN seems focused on the creation of a comprehensive care plan and documenting discharge plans from ABA. While the comprehensive care plan should, in theory, assist families with identifying other resources and services beyond ABA that could be beneficial for autistic dependents, families have expressed challenges with accessing the comprehensive care plans and communicating with their ASNs, particularly for those that have to relocate to another region with a different TRICARE managing care services contractor and have to restart the assignment of an ASN.

From the committee’s perspective, the role of the ASN should be to support families and attend to individual needs, and include things such as help with (a) navigating the administrative steps necessary to receive and reauthorize ABA services (such as enrollment into the Exceptional Family Member Program [EFMP] and registration in the Extended Care Health Option [ECHO] as currently required under the ACD or similar tasks if ABA coverage is to become a TRICARE Basic benefit); (b) ensuring that referring providers have accurate information necessary to submit referral paperwork to DHA; (c) facilitating warm handoffs and maintaining continuity of care; and (d) ensuring family feedback is heard by contractors and DHA. As a standard of care, if care services navigation is deemed valuable for TRICARE beneficiaries with autism, ASNs should be available to all families with dependents with autism and not just ACD participants or those using ABA. As commonly implemented, care navigation was intended to support those with chronic conditions across a range of services and healthcare providers. While navigators are employed by regional contractors, DHA has the opportunity to set standards for the design of the role in order to maximize beneficiary and family satisfaction.