---
title: "Martin’s Point USFHP ABA coverage under the ACD."
url: "https://carelu.com/payers/martins-point-usfhp"
markdown_url: "https://carelu.com/payers/martins-point-usfhp.md"
state: NY (New York)
payer: "Martin’s Point US Family Health Plan"
kind: Commercial insurance
description: "Martin’s Point US Family Health Plan is a TRICARE Prime designated provider across ME, NH, VT, upstate and western NY, northern and western PA and parts of OH. How it administers ABA under the Autism Care Demonstration."
last_reviewed: September 2026
---

# Martin’s Point USFHP ABA coverage under the ACD.

_Payer Guide · Martin’s Point US Family Health Plan · Last updated September 2026 · 7 primary sources_

> TRICARE Prime designated provider across northern New England, upstate NY, northern PA and Ohio — administers the ACD directly.

Martin’s Point Health Care runs one of the six Uniformed Services Family Health Plans — TRICARE Prime delivered through a civilian health system’s own network rather than through a regional contractor. Its service area is the northern tier: Maine, New Hampshire, Vermont, upstate and western New York, the northern tier and western Pennsylvania, and northeastern and central Ohio.

Martin’s Point answers the question that matters most about USFHP and ABA directly, in its own provider training: "The US Family Health Plan is contracted with the Defense Health Agency to administer the Autism Care Demonstration benefits in accordance with TRICARE’s Program Manuals." So the rules are the ACD’s — the TRICARE Operations, Policy, Reimbursement and Systems Manuals — but the plan is the entity that certifies providers, authorizes services and pays claims. That combination is what an intake team has to hold in its head.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — ABA supervisors complete the initial assessment under CPT 97151 with the required outcome measures, and the plan authorizes it [4][2]
- **Prior auth for treatment**: Required — six-month treatment authorizations; reauthorization must be submitted at least 30 days before the current one expires [2][4]
- **Autism diagnosis required?**: Yes — ASD (F84.0) diagnosis by a TRICARE-authorized PCM or specialized ASD diagnosing provider, with a completed DSM-5 checklist and an approved validated assessment tool [2][4]

## At a glance

- **Plan type:** TRICARE Prime designated-provider option (USFHP), run by Martin’s Point Health Care
- **Service area:** ME, NH, VT, upstate and western NY, northern tier and western PA, northeastern and central OH
- **Covers ABA?:** Yes — under the Autism Care Demonstration, administered by the plan under contract with DHA
- **Demonstration authority:** ACD in effect since 2014; expires Dec. 31, 2028 unless extended
- **Prior auth:** Required; reauthorization submitted at least 30 days before the current authorization expires
- **Outcome measures:** PDDBI and PSI-4 or SIPA every six months; Vineland-3 and SRS-2 annually
- **Parent training:** Six parent/caregiver training sessions required every six months
- **Discharge notice:** A provider terminating services must notify the plan at least 45 calendar days in advance
- **Costs:** Same out-of-pocket costs as TRICARE Prime; ABA bills as outpatient specialty care

## Who the plan covers, and where

Martin’s Point describes its USFHP as "one of six Department of Defense-sponsored TRICARE Prime options nationwide," offering the full TRICARE Prime benefits package to eligible military retirees and their families, certain active-duty family members, and dependents aged 21 to 26 through TRICARE Young Adult. Care is delivered through Martin’s Point’s own civilian provider network rather than through TRICARE’s. [1][3]

TRICARE’s own USFHP listing gives the service area as Maine, New Hampshire, Vermont, upstate and western New York, the northern tier and western Pennsylvania, and northeastern and central Ohio — which matches the plan’s description of "Maine, New Hampshire, Vermont, upstate and western New York, northern Pennsylvania, and parts of Ohio." Three of those states are partial, so confirm by ZIP rather than by state name. The standard USFHP limits apply: members get most care from a plan-network PCP, cannot use TRICARE network providers, and cannot use military hospitals and clinics except for emergency care. [1][3]

## Eligibility and the diagnosis gate

Martin’s Point can authorize ABA under the ACD only where the beneficiary is a dependent of an active duty service member enrolled in the US Family Health Plan and registered for ECHO; a retiree or retiree family member enrolled in TRICARE Prime or TRICARE Select; covered under the Transitional Assistance Management Program; covered under TRICARE For Life; a TRICARE Young Adult participant; a NATO or Partnership for Peace participant; or a Continued Health Care Benefit Program participant. For active duty families, EFMP enrollment is the prerequisite for ECHO, and ECHO registration is the prerequisite for the ACD. [2][4]

Diagnostically, the beneficiary must have an ASD (F84.0) diagnosis from a TRICARE-authorized PCM or specialized ASD diagnosing provider, with the diagnosis made under the TRICARE basic benefit. The enrollment packet needs a referral or diagnostic evaluation stating the diagnosis, the date of the initial ASD diagnosis, a completed DSM-5 diagnostic checklist, and complete results of an approved validated assessment tool. [2][4]

The validated assessment tool list is closed: the STAT, the ADOS-2, the ADI-R, the CARS-2 or the GARS-3 — with the caveat that "completion of the GARS alone is not sufficient for diagnostic documentation" and an approved diagnosing provider must submit a diagnostic evaluation alongside it. A general observation interview alone is not a valid diagnostic tool. Two exceptions are published and worth knowing: for beneficiaries younger than 12 months the diagnosing provider may choose an appropriate age-based tool, and the plan may accept a diagnosis through source verification on a case-by-case basis where the diagnosing provider was not TRICARE-authorized but would otherwise have qualified and the diagnosis meets the requirements. [2][4]

## Authorization, outcome measures and parent training

The initial referral must include a complete assessment, the level of support needed, and the ASD diagnosis. ABA supervisors complete the initial assessment under CPT 97151, and that assessment includes the required outcome measures — the PDDBI, Vineland-3, SRS-2 and either the PSI-4 or the SIPA. Treatment plans are then updated every six months, documenting progress on behavior targets, adjusting goals, and carrying the outcome measures required for that interval. [2][6]

The cadence Martin’s Point publishes matches DHA’s: the PSI-4 or SIPA and the PDDBI every six months, and the Vineland-3 and SRS-2 annually. Reauthorizations must be submitted at least 30 days before the current authorization expires, with progress reports and updated outcome measures. [2][6]

Two requirements here have no commercial analogue and both belong on an intake checklist. Parent/caregiver involvement is mandatory: "Six parent/caregiver training sessions are required every six months to teach treatment protocols." And discharge is regulated — discharge criteria include meeting ABA goals or a lack of measurable progress across several assessments, and if the corporate services provider or sole provider terminates services with a beneficiary for any reason, they must notify the contractor a minimum of 45 calendar days before termination. [2][6]

## Provider standards the plan enforces

- **Authorized ABA supervisors:** Master’s degree or higher in a relevant field, state licensed and/or BACB certified. [2]
- **Assistant behavior analysts:** Bachelor’s degree with appropriate state licensure or BACB/QABA certification, working under a qualified ABA supervisor. [2]
- **Behavior technicians:** RBT, ABAT or BCAT certification, operating under the direct supervision of an authorized ABA supervisor. [2]
- **CPR/BLS:** Cardiopulmonary resuscitation and basic life support certification must be completed and maintained through approved courses. [2]
- **Criminal history background check:** Providers with felony convictions or crimes against children are ineligible. Supervisors provide a criminal history review; assistants and technicians provide federal, state and county reports covering the last 10 years. [2]
- **Liability insurance:** Corporate services providers and sole providers must maintain $1 million per claim and $3 million in aggregate. [2]

## Exclusions, claims and the school question

Martin’s Point lists as non-reimbursable: behavior technician training, non-ABA services, travel time unless authorized, academic services and school-based ABA, services provided by family members, and services rendered by a non-authorized ABA provider. Note the tension worth resolving in writing before you schedule anything: the plan’s training lists school-based ABA among the exclusions, while DHA’s ACD Q&A says technician-delivered school ABA is not covered but a BCBA may be authorized for a focused, time-limited, contractor-approved goal. Treat school delivery for a Martin’s Point member as a plan-level question and get the answer from the plan, not from another contractor’s guidance. [2][5][7]

On claims: all claims must be submitted electronically with the correct HIPAA taxonomy codes and the ABA provider’s valid NPI. Contractors audit provider records annually, monitor documentation and billing compliance, and watch for high-dollar claims and inconsistent billing — providers with irregularities face recoupment or additional monitoring. ABA is coordinated care, not a silo: providers are expected to coordinate with OT, PT and speech, and to align ABA with the comprehensive care plan. [2][5][7]

Costs are TRICARE Prime costs, because USFHP carries Prime out-of-pocket amounts. ABA bills as outpatient specialty care and one copayment covers all ABA services on a single day — currently $0 for active duty family members and $39 for retirees and others for network specialty care. There are no yearly or lifetime dollar caps on ABA under the ACD. [2][5][7]

## Intake gates

The questions that decide whether a family can start with Martin’s Point US Family Health Plan, and what they have to bring.

- **Age limit**: No age limit and no yearly or lifetime dollar cap on ABA under the demonstration. Eligibility rather than age is the gate: Martin’s Point can authorize ABA only where the beneficiary is a dependent of an active duty service member enrolled in the US Family Health Plan and registered for ECHO; a retiree or retiree family member on TRICARE Prime or Select; covered under TAMP; covered under TRICARE For Life; a TRICARE Young Adult participant; a NATO or Partnership for Peace participant; or a Continued Health Care Benefit Program participant. Age does decide the stress measure — the PSI-4 below, the SIPA for adolescents. [2][4]
- **Diagnosis recency**: The ACD clocks apply: a diagnosis more than two years old requires an updated diagnostic assessment, and the referral runs two years. The enrollment packet must carry the date of the initial ASD diagnosis alongside the referral or diagnostic evaluation, so capture that date at intake rather than at reauthorization. Reauthorizations must be submitted at least 30 days before the current authorization expires, with progress reports and updated outcome measures. USFHP families have no Autism Services Navigator, so the renewal calendar is your team’s to keep. [2][4][3]
- **Who may diagnose**: The diagnosis must come from a TRICARE-authorized PCM or specialized ASD diagnosing provider and must be made under the TRICARE basic benefit — the ACD’s closed list of family practice physicians, pediatricians and pediatric or family nurse practitioners on the primary-care side, and developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry, doctoral-level licensed clinical psychologists and qualifying DNPs on the specialist side. One published mercy: the plan may accept a diagnosis through source verification on a case-by-case basis where the diagnosing provider was not TRICARE-authorized but would otherwise have qualified and the diagnosis meets the requirements. Worth asking about before you turn a family away. [2][4]
- **Diagnostic tools required**: The closed validated-tool list in this directory, and it is worth memorising: the STAT, the ADOS-2, the ADI-R, the CARS-2 or the GARS-3 — with the caveat that “completion of the GARS alone is not sufficient for diagnostic documentation” and an approved diagnosing provider must submit a diagnostic evaluation alongside it. A general observation interview alone is not a valid diagnostic tool. For beneficiaries younger than 12 months the diagnosing provider may choose an appropriate age-based tool. On top of that sit the four ACD outcome measures, which the ABA supervisor folds into the initial 97151 assessment: the PDDBI and the PSI-4 or SIPA every six months, the Vineland-3 and the SRS-2 annually. [2][6]
- **Referral required?**: Required, and the enrollment packet is specific: a referral or diagnostic evaluation stating the diagnosis, the date of the initial ASD diagnosis, a completed DSM-5 diagnostic checklist, and complete results of an approved validated assessment tool. The initial referral must also include a complete assessment and the level of support needed. For active duty families, EFMP enrollment is the prerequisite for ECHO and ECHO registration is the prerequisite for the ACD. Two plan-level requirements with no commercial analogue belong on the same checklist: six parent/caregiver training sessions are required every six months to teach treatment protocols, and a provider terminating services with a beneficiary for any reason must notify the contractor at least 45 calendar days in advance. [2][4]
- **Prior-auth decision time**: Martin’s Point publishes no USFHP-specific ABA decision clock (the 72-hour/7-day decision times on its site are for its Medicare Advantage plans), so the DHA ACD rule for USFHP governs: the plan completes clinical-necessity review of a compliant treatment plan “within the five business days for authorization processing standards.” Martin’s Point’s own lead times: “Reauthorizations: Submit at least 30 days before the authorization expires, with progress reports and updated outcome measures,” and prior authorization requests generally “should be submitted at least 14 calendar days prior to date of service.” The DHA rule lets reauths go in as early as 60 calendar days before expiry, and late submissions are not backdated. [2][8][9]
- **Other insurance (who pays first)**: “The US Family Health Plan is primary to the Medicaid program and secondary to all commercial health insurance plans such as Aetna, CIGNA, or Anthem. Federally sponsored health plans (e.g., Federal Blue Cross and Mail Handlers) are employee benefits and are primary to the US Family Health Plan.” Bill the commercial plan first, then submit to Martin’s Point with the primary EOB “within 120 calendar days from the remittance date of the primary payer’s payment or denial”; a claim without it is denied (“OHI must process claim first, resubmit with primary EOB”). 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 commercial plan is primary. [10][9]

## Delivery and billing rules

Coverage decides whether Martin’s Point US Family Health Plan pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Authorized ABA supervisors hold a master’s degree or higher in a relevant field and are state licensed and/or BACB certified. Assistant behavior analysts hold a bachelor’s degree with appropriate state licensure or BACB/QABA certification and must work under a qualified ABA supervisor. Behavior technicians must hold RBT, ABAT or BCAT certification and must operate under the direct supervision of an authorized ABA supervisor. Supervisors, assistants and technicians must also clear criminal history background checks — a felony conviction or a crime against children is disqualifying — and maintain CPR/BLS certification. Behavior technician training is not a reimbursable service. [2]
- **Bill as provider**: All claims must be submitted electronically, must use the proper HIPAA taxonomy codes for the provider type (behavior analyst, assistant behavior analyst, behavior technician), and must carry the ABA provider’s valid NPI. Services rendered by a non-authorized ABA provider are not reimbursable. Records are audited annually and irregular billing draws recoupment or added monitoring. [2]
- **Place of service** _(plan-dependent)_: The plan’s ABA provider training lists academic services and school-based ABA as non-reimbursable, alongside services provided by family members, non-ABA services and travel time unless authorized. DHA’s ACD guidance is narrower rather than contradictory — technician-delivered school ABA is not covered, while a BCBA may be authorized for a focused, time-limited, pre-authorized goal after clinical necessity review. Because Martin’s Point administers the demonstration itself, treat any school or community request as a plan-level decision and obtain it in writing before scheduling. [2][5]
  - Ask the plan: Martin’s Point USFHP provider services, 888-241-4556, before scheduling school or community sessions
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Martin’s Point USFHP provider services, 888-241-4556 — ask whether 97155 pays alongside 97153 for the same clock time and request the manual citation. [2]

## What intake should collect for Martin’s Point US Family Health Plan

- **Confirm USFHP, then the ZIP:** Martin’s Point USFHP is not regional TRICARE — the referral goes to the plan. New York, Pennsylvania and Ohio are partial states, so check the ZIP against the plan service area before promising anything.
- **Beneficiary category:** Retiree or retiree family member, active duty family member with ECHO registration, TAMP, TFL, TRICARE Young Adult, NATO/PfP or CHCBP. Active duty families need EFMP first, then ECHO.
- **Validated assessment tool used:** STAT, ADOS-2, ADI-R, CARS-2 or GARS-3 — and if it is the GARS-3, a separate diagnostic evaluation from an approved diagnosing provider must come with it. A general observation interview alone will not do.
- **DSM-5 checklist and referral date:** Both are part of the enrollment packet, along with the date of the initial ASD diagnosis. Diary the two-year referral renewal at the same time.
- **Parent/caregiver availability:** Six parent training sessions are required every six months. Establish at intake who the trainable caregiver is and when they are free — this is a reauthorization condition, not a nice-to-have.
- **Requested setting:** School-based ABA sits on the plan’s exclusion list while DHA allows a narrow BCBA pathway. Ask the family where they want services and get the plan’s written answer before scheduling.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does Martin’s Point US Family Health Plan cover ABA?

Yes. Martin’s Point states that the US Family Health Plan is contracted with the Defense Health Agency to administer Autism Care Demonstration benefits in accordance with TRICARE’s program manuals. The ACD has been in effect since 2014 and expires Dec. 31, 2028 unless extended.

### Which assessment tools will Martin’s Point accept for the ASD diagnosis?

The STAT, ADOS-2, ADI-R, CARS-2 or GARS-3. The GARS-3 alone is not sufficient — an approved ASD diagnosing provider must also submit a diagnostic evaluation. A general observation interview alone is not a valid diagnostic tool. For children under 12 months the diagnosing provider may choose an appropriate age-based tool.

### How much parent training does the plan require?

Six parent/caregiver training sessions every six months, to teach treatment protocols. Parent/caregiver involvement is mandatory and the treatment plan must document it.

### Can ABA be delivered in school for a Martin’s Point member?

The plan’s own ABA provider training lists academic services and school-based ABA among non-reimbursable services, while DHA’s ACD guidance allows a narrow BCBA pathway for focused, time-limited, pre-authorized goals. Because the plan administers the demonstration itself, get its written answer before scheduling a school session.

### What does the plan require before a provider can stop seeing a child?

At least 45 calendar days’ notice to the contractor before terminating services, for any reason. Discharge criteria are meeting the ABA goals or a lack of measurable progress across several assessments.

### What does a Martin’s Point USFHP family pay for ABA?

TRICARE Prime amounts, since USFHP has the same out-of-pocket costs as Prime. ABA bills as outpatient specialty care and one copayment covers all ABA on a single day — currently $0 for active duty family members and $39 for retirees and others in network. There is no annual or lifetime cap on ABA.

## Primary sources

1. [Martin’s Point — US Family Health Plan](https://www.martinspoint.org/US-Family-Health-Plan)
2. [Martin’s Point — USFHP Training for ABA Providers: TRICARE Autism Care Demonstration (PDF)](https://martinspoint.org/-/media/Files/Documents-and-Forms/Provider-and-Internal-Forms/Provider-Documents/Provider-Education/TRICARE-ACD-Provider-Training.ashx)
3. [TRICARE — Uniformed Services Family Health Plan](https://tricare.mil/Plans/HealthPlans/USFHP)
4. [TRICARE — Autism Care Demonstration](https://tricare.mil/Plans/SpecialPrograms/ACD)
5. [TRICARE — Autism Care Demonstration Q&A](https://tricare.mil/Plans/SpecialPrograms/ACD/QandA)
6. [TRICARE — Understanding Outcome Measures for ABA Services](https://tricare.mil/About/Regions/West-Region/Find-Care/Autism-Care-Demonstration/Outcome-Measures)
7. [TRICARE — Compare Health Plan Costs](https://tricare.mil/Costs/Compare)
8. [Martin’s Point — Authorizations and Referrals](https://www.martinspoint.org/For-Providers/Tools/Authorizations-and-Referrals)
9. [TRICARE Operations Manual 6010.59-M (2015 ed.), Ch. 18 Sec. 4 — Autism Care Demonstration (Change 139, Jun 10, 2024)](https://manuals.health.mil/pages/DisplayManualHtmlFile/2024-06-10/AsOf/TO15/C18S4.html)
10. [Martin’s Point Provider Manual — Claims (updated January 1, 2026)](https://www.martinspoint.org/For-Providers/Provider-Manual/Claims)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.