Defense Health Primer: TRICARE Comprehensive Autism Care Demonstration

Defense Health Primer: TRICARE Comprehensive Autism Care Demonstration

March 14, 2023
Defense Health Primer: TRICARE Comprehensive Autism
Care Demonstration
Since the 1950s, Congress has enacted numerous
have been facilitated or directed by Congress. These
Department of Defense (DOD) health entitlements and
expansions include:
benefits under the TRICARE program to support
 ABA services through the TRICARE Extended Care
servicemembers, military retirees, and their dependent
Health Option (ECHO). In 2001, DOD added ABA
family members. The Defense Health Agency (DHA)
services as part of the supplemental services offered
administers the TRICARE program, which offers or pays
through TRICARE ECHO (previously known as the
for a range of services for military families who have
Program for Persons with Disabilities) to military
special needs, including those diagnosed with autism
families with special needs.
spectrum disorder (ASD).
 Enhanced Access to Autism Services Demonstration
In Fiscal Year (FY) 2020, DOD estimated that a total of
(i.e., ECHO Autism Demo). DOD established the
35,473 dependent family members have an ASD diagnosis.
ECHO Autism Demonstration in 2008 in response to
TRICARE policies authorize coverage of certain health
Section 717 of the FY2007 National Defense
care and support services to mitigate the effects of ASD;
Authorization Act (NDAA; P.L. 109-364). The ECHO
however, not all available therapies have been covered
Autism Demo expanded coverage of intensive
under the basic TRICARE benefit. Over the past two
behavioral intervention and ABA services for military
decades, Congress has directed permanent or temporary
families with ASD using a tiered delivery and
TRICARE coverage policy modifications to include
reimbursement model.
additional autism care services for military families. DOD
 ABA Pilot. DOD established a one-year ABA pilot as
administers part of these services under the Comprehensive
required by Section 705 of the FY2013 NDAA (P.L.
Autism Care Demonstration (ACD).
112-239). The pilot extended coverage of ABA services
to eligible dependent family members of military
This In Focus describes the evolution of DOD’s coverage
retirees.
of autism care services, the ACD, and certain ACD
challenges for potential congressional consideration.
Comprehensive Autism Care Demonstration
Background
In 2014, DHA recognized that ABA services were offered
“under a patchwork” of TRICARE coverage and announced
According to the U.S. Centers for Disease Control and
the consolidation of these expanded services under the
Prevention (CDC), an estimated 1 in 44 children in the
ACD. The ACD began on July 25, 2014, and is scheduled
United States lives with ASD. The National Institute of
to conclude on December 31, 2023. DHA’s goals for the
Mental Health defines ASD as a “neurological and
ACD are to:
developmental disorder that affects how people interact
with others, communicate, learn, and behave.” Individuals
 evaluate the appropriateness of the ACD;
with ASD may present with a range of signs and symptoms,
 determine the appropriate provider qualifications for
including challenges with social communication, interaction
diagnosing and delivering ABA services;
skills, restrictive or repetitive behaviors, and other
 assess the effects of using different ABA delivery
characteristics.
models;
 understand which beneficiaries utilize ABA services and
Generally, there is no known cure for ASD. CDC identifies
its effect on those with ASD;
a number of treatment types (e.g., behavioral, educational,
 assess the relationship between ABA services and other
pharmacological, psychological) that can be tailored by
health care providers to help “reduce symptoms that
interventions to treat ASD; and,

interfere with daily functioning and quality of life.”
assess the “feasibility and advisability” of establishing a
These
beneficiary cost share for ABA services.
interventions often involve an interdisciplinary team of
medical providers, allied health professionals, and
The ACD features an ABA services navigator which is
behavioral health therapists. Parents and families of
designed to help coordinate medical and non-medical care,
children with ASD also play a role in these interventions.
a comprehensive care plan, and parent and family support
Treatment and therapy can take place in a variety of settings
resources.
(e.g., a health care facility, school, playground, or at home).
ACD Eligibility and Participation
Since 2001, DOD has offered certain autism care services,
To be eligible for the ACD, DHA requires a dependent
including a behavior modification and learning therapy
child to be (1) enrolled in a TRICARE health plan; (2)
known as Applied Behavior Analysis (ABA). These
diagnosed with ASD by a qualified health care provider
services have been incorporated as part of permanent or
(e.g., primary care provider, clinical psychologist,
temporary TRICARE coverage expansions, some of which
developmental-behavioral pediatrician); and (3) referred to
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Defense Health Primer: TRICARE Comprehensive Autism Care Demonstration
the ACD by the health care provider and preauthorized for
service. However, DOD continues to assert that “ABA
ABA services. Children of active duty servicemembers
services do not meet the TRICARE hierarchy of evidence
must also enroll in the Exceptional Family Member
standard for medical and proven care.” Congress could
Program and TRICARE ECHO.
consider the permanency of coverage for ABA services,
including codification in statute, extension of the ACD’s
In FY2020, DHA estimated that 16,160 beneficiaries
temporary coverage, or deferring to DOD’s determination
participated in the ACD with over 80% being between the
of medical necessity process.
ages of 0 and 12 years old. DHA observed that at the start
of FY2022, the total number of participants grew to 17,324.
Participant Concerns and Access to Care. In 2021, DHA
Figure 1 shows that in FY2020, 75% of ACD participants
revised its ACD policy to clarify health care provider
were active duty family members, while 25% participants
qualifications for ASD diagnosis and treatment, specify
were non-active duty family members (i.e., dependents of
referral and authorization requirements, add a new outcome
military retirees and other beneficiaries).
measurement, increase quality monitoring and program
Figure 1. ACD Participants, FY2015-FY2020
oversight, and introduce the autism services navigator and
comprehensive care plan features. In response to certain
aspects of this policy revision, military family advocates
have raised concerns on the updated diagnosis criteria for
ABA services, introduction of a parenting stress outcome
measure, and the elimination of coverage for behavioral
technician support in school settings.
Participants have also expressed concern with accessing
ABA services in a timely manner. In 2022, DHA reported
that across all states, the average wait-time from the referral
date to the first ABA appointment ranged from 0 days to 56
days. ACD participants in 36 states and Washington, DC,
were able to obtain their first ABA appointment within
TRICARE’s 28-day access standard for specialty care. In
total, the TRICARE network includes 20,557 authorized
Source: CRS graphic based on DHA, Comprehensive Autism Care
ABA supervisors who may receive referrals for new
Demonstration Annual report 2021, December 3, 2021, p. 6.
patients. DHA also noted that at the start of FY2022, 582
Beneficiary Costs
new ABA supervisors were added to the network, while
Eligible beneficiaries incur no out-of-pocket costs to
654 left the network in the last quarter.
participate in the ACD. However, participants are subject to
Congressional oversight considerations for these issues
cost-sharing requirements for ABA services based on their
could include enhanced reporting or briefing requirements
TRICARE health plan, beneficiary category, and type of
to monitor DHA’s response to participant concerns and
medical or support service received.
their effects on access to care and beneficiary satisfaction.
Recent Legislation
Relevant Policies
Congress has held a sustained interest in the provision of
autism care services for military families. The 117th
Chapter 18, Section 4 of the TRICARE Operations Manual
Congress enacted two provisions (P.L. 117-81 §737; P.L.
6010.59-M
117-263 §732) that direct the Secretary of Defense to
DOD, “Comprehensive Autism Care Demonstration,” 79
partner with the National Academies of Sciences,
Federal Register 34291-34296, June 16, 2014
Engineering, and Medicine (NASEM) to conduct an
“analysis of the effectiveness” of the ACD and develop
CRS Products
recommendations on the program’s delivery. These
CRS In Focus IF11002, Defense Health Primer: TRICARE
provisions also require NASEM to submit a report to
Extended Care Health Option (ECHO), by Bryce H. P. Mendez
Congress no later than 31 months after the Secretary
CRS In Focus IF11049, Defense Primer: Exceptional Family
establishes the partnership with NASEM for this study.
Member Program (EFMP), by Bryce H. P. Mendez
Considerations for Congress
Other Resources
Congress may consider legislation or conduct oversight
activities to address the ACD, including on selected issues
DHA, Comprehensive Autism Care Demonstration Annual Report
identified by various stakeholders and observers.
2021, December 3, 2021
GAO, Federal Autism Activities: Agencies Are Encouraging Early
ABA Medical Necessity and Coverage Policies. By law
Identification and Providing Services, and Recent Actions Could
(10 U.S.C. §1079(a)(12)), TRICARE may only cover
“medically or psychologically necessary” services
Improve Coordination, GAO-16-446, May 2016
as part of
the permanent benefit. DOD currently offers ABA as a

temporary covered service under the ACD. Offering ABA
as a permanent TRICARE covered service would require
Bryce H. P. Mendez, Analyst in Defense Health Care
DOD to make a determination of medical necessity. A
Policy
growing number of commercial and Medicaid health
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insurance plans have incorporated ABA as a covered
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Defense Health Primer: TRICARE Comprehensive Autism Care Demonstration

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