Many Florida military families have two health plans: TRICARE, plus a civilian plan through a spouse's job or a sponsor's post-military employer. When your autistic child needs ABA, two plans can lower what you pay, but only if both plans' rules are followed. A missed authorization on either side can lead to a denied claim. This guide explains which plan pays first, how TRICARE handles ABA when you have other insurance, and how to set things up so claims go through.
Which plan pays first for ABA, TRICARE or my employer plan?
Your employer plan pays first. tricare.mil's page on other health insurance (OHI) says: "By law, TRICARE pays after all other health insurance," with a short list of exceptions such as TRICARE supplements. TRICARE calls any health insurance you have in addition to TRICARE "other health insurance," and that includes employer-sponsored plans.
In practice this means:
- The ABA provider bills your employer plan first.
- After the employer plan processes the claim, the remaining amount goes to TRICARE.
- If TRICARE receives a claim before your other plan has processed it, TRICARE will deny it.
- If TRICARE pays first and later learns you had other insurance, it will take back the payment and reprocess the claim after your other plan does.
Does TRICARE still need to authorize ABA if my employer plan pays first?
Yes. Humana Military's 2026 TRICARE East provider handbook says beneficiaries with OHI usually do not need TRICARE referrals or prior authorizations for covered services, but it lists services that "require prior authorization even when OHI coverage exists." Applied Behavior Analysis is on that list, along with ECHO services and psychological testing.
So for ABA, plan on two sets of approvals:
- Your employer plan's prior authorization, following its own rules on providers, hours and reviews.
- TRICARE's referral and pre-authorization through the Autism Care Demonstration, which Humana Military handles for Florida. Each TRICARE authorization covers six months, and a new referral is needed every two years. See how the ACD works.
Because TRICARE still authorizes the ABA, expect its ACD requirements too, such as the outcome measures. Ask Humana Military (1-800-444-5445) which ACD steps apply when TRICARE is your second payer.
What happens if my employer plan denies an ABA claim?
It depends on why it was denied.
| Situation | What TRICARE says | What to do |
|---|---|---|
| Employer plan covers ABA and pays part of the claim | File the rest with TRICARE: "If your other plan doesn't cover the entire cost, file a claim with TRICARE." | Make sure the provider sends the employer plan's explanation of benefits with the TRICARE claim. |
| Employer plan does not cover ABA at all | "If your other plan doesn't cover the particular service at all and you think TRICARE might cover it, file a claim with TRICARE." | Keep the plan document or denial that shows ABA is excluded. |
| Employer plan denies because its rules were not followed (for example, no authorization, or an out-of-network provider) | "If your other health insurance denied your claim because its rules weren't followed, TRICARE may also deny the claim." You could then owe the provider the full billed amount. | Get the employer plan's authorization before services start, and use a provider in its network. |
| Employer plan benefits for the year are used up | Humana Military's handbook: if OHI benefits are exhausted, TRICARE becomes the primary payer, and additional referral or authorization requirements may apply. | Tell Humana Military and the provider right away. |
| You lose the employer plan | "If you lose your other health insurance, TRICARE becomes your primary payer." You must tell your doctor and contractor using the OHI form. | Send the OHI form to Humana Military and update the ABA provider's billing records. |
If a denial looks wrong, you can appeal it with the plan that denied it. See our guide to ABA denial appeals in Florida.
How much does TRICARE pay as the second plan?
As second payer, TRICARE helps with what is left after the employer plan pays, within limits. Humana Military's handbook explains that, for most providers, TRICARE pays the lesser of:
- 115 percent of the TRICARE allowed amount minus what the other insurance paid;
- the amount TRICARE would have paid without the other insurance; or
- the beneficiary's liability under the other plan (its copay, cost-share or deductible).
In many cases that leaves the family with little or nothing for the claim, but it is not guaranteed, and it depends on the allowed amounts and your plans. The handbook also notes that the TRICARE cost-share that would have applied without other insurance is shown on the remittance to document the amount credited to the beneficiary's catastrophic cap. Ask Humana Military how this applies to your family's cap.
Does my employer plan have to cover ABA in Florida?
It depends on the type of plan, which is why two families with the same employer can have different answers.
- Large-group, fully insured plans and HMOs issued in Florida fall under Florida's autism coverage law (Fla. Stat. 627.6686 and 641.31098). The law also lets these plans apply coordination of benefits, network rules and utilization review.
- Self-funded employer plans are governed by federal ERISA rules, not the Florida mandate. Many cover ABA by choice.
- Small-group and individual plans are not covered by the Florida ABA mandate, though some include ABA.
- Federal employee plans (FEHB) have their own ABA rules. See FEHB and ABA.
Our guide to fully insured vs self-funded plans shows how to tell which one you have. If both plans in your family are civilian plans, the rules for ordering them are different; see coordination of benefits with two plans.
Is the active duty service member's own coverage different?
Yes, but this mostly matters for the service member, not the child. tricare.mil says an active duty service member may use other health insurance only under certain circumstances, is responsible for all costs, and gets no coordination of benefits between the OHI and TRICARE. Family members, including your autistic child, follow the regular OHI rules above.
How do I set up ABA with both plans? A checklist
- Tell TRICARE about the other plan. tricare.mil asks you to keep your contractor and doctors updated and to submit your region's other health insurance form. For Florida that is Humana Military.
- Read the employer plan's ABA terms. Look in the summary plan description or certificate of coverage for "applied behavior analysis" or "autism," prior authorization rules, visit or hour limits, and network requirements.
- Choose a provider that works with both plans. It should be in your employer plan's network and TRICARE-authorized for the ACD.
- Get the diagnosis paperwork both plans need. TRICARE requires a diagnosis from an approved provider and a referral with a DSM-5 checklist. Your employer plan may ask for a diagnostic report and a treatment plan.
- Get both authorizations before services start. Ask the provider to confirm in writing that each plan has approved the assessment and the treatment hours.
- Calendar both renewal dates. The two plans' authorization periods may not line up. TRICARE authorizations are six months.
- Check each explanation of benefits. If TRICARE denies a claim saying another plan should pay first, confirm the employer plan processed it.
- Report changes quickly. A new job, a lost plan, or open enrollment changes can change who pays first.
Should we keep the employer plan if we have TRICARE?
That is a family decision, and the answer depends on premiums, what each plan covers, and your TRICARE costs. Some questions to weigh:
- What is the employer plan's monthly premium compared with your TRICARE costs and catastrophic cap? See TRICARE Prime vs Select costs.
- Does the employer plan cover ABA, and at what deductible and coinsurance?
- Does it cover other care your family needs, such as speech therapy or other specialists?
- Does having two sets of authorizations slow down your child's start date with the provider you want?
The employer's benefits office and Humana Military can both answer plan-specific questions before open enrollment.
How Hope Center can help
Hope Center for Behavior Change is in network with TRICARE East (Humana Military), Blue Cross Blue Shield (Florida Blue), Aetna, Cigna (Evernorth), UMR and Personify Health. Our free benefits check can look at both of your plans before services begin, and costs always depend on your plans. Our BCBAs write each treatment plan and our clinical director reviews every plan before it goes to insurance. See our insurance page and TRICARE ABA page, contact us or call 561-337-8865.