TRICARE Report Validates Making ABA Benefits Permanent for Military Families

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A new report could help make the case for TRICARE to cover applied behavior analysis (ABA) for its beneficiaries on a permanent basis.

ABA has been a covered benefit for TRICARE beneficiaries through a demonstration program in 2014. But the new report published by the National Academy of Sciences recommends ending the demonstration program and adding ABA to TRICARE as a basic benefit.

The U.S. Department of Defense’s Defense Health Agency contracted with the National Academy of Sciences as part of a directive within the National Defense Authorization Act for Fiscal Year 2022 to examine the Autism Care Demonstration. On Sept. 9, the National Academy of Sciences released a report that, in part, finds that applied behavior analysis clinically effective and that the policies within the Autism Care Demonstration complicated care for beneficiaries and providers.

The report pushed back on an annual report produced by the Department of Defense in 2019 that found that ABA was not effective and did not meet TRICARE’s standard for proven medical care, contrary to many interpretations of the wider experience of treatment providers and present research.

“In terms of what this does for advocacy and next steps, it’s resounding,” Mariel Fernandez, vice president of government affairs at the Council of Autism Service Providers (CASP), told Behavioral Health Business. Those next steps will include further advocacy with Congress to follow the recommendations of the National Academy of Sciences report.

“It’s not going to happen overnight,” she added. “But this allows us to be able to point congressional offices to a key set of findings that then can be incorporated into the next National Defense Authorization Act as soon as possible, which will then direct the DHA to make these changes. It’s an incredible first step, but it is just a first step.”

The Council of Autism Service Providers is a nonprofit trade association and accrediting entity.

The Department of Defense has largely kept up with the idea that ABA is not effective and does not meet TRICARE standards for treatment benefits despite advocate’s and expert’s protests.

“All of our military families were making the same consistent progress that we see in their civilian counterparts, and that made us wonder how TRICARE came to such a different conclusion,” Julie Kornack, a board member for the nonprofit advocacy group National Coalition for Access to Autism Services (NCAAS), told BHB about that 2019 report. “It became clear to us that we were going to have to do something different than just going to TRICARE and asking them to understand that they weren’t using the data correctly. That’s how we ended up advocating for this [National Academies] committee to review this independently.”

Kornack is also the chief government and payer relations officer at the Center for Autism and Related Disorders (CARD). CARD is an autism therapy provider that operates 108 locations across the U.S. and is headquartered in Marco Island, Florida.

She also said that the arrival of an independent review came with some degree of trepidation for industry advocates. It wasn’t clear to what degree an independent review would ultimately weigh the findings of the Department of Defense’s assessments against existing literature.

The report presented five core findings:

— ABA is widely recognized as an effective, evidence-based treatment for autism, but it is not necessary for everyone.

— Military families face more administrative hurdles than civilians in accessing ABA, challenging access.

— Rigid documentation requirements limit providers’ ability to tailor care and challenge providers’ ability to treat TRICARE patients in the first place.

— The mandated standardized assessments don’t align with tailoring care in a heterogeneous population and provide limited use individually or across the program.

— Current restrictions prevent targeting essential life skills and limit service settings.

“ABA is extremely data-driven: every good provider is going to be able to have data that shows how every patient is benefiting from the program,” Kornack said. “We understand that [TRICARE] want to have some standardized measures to look at. There is a way to do this without creating a burden.”

On top of making ABA a basic benefit, the report recommends that TRICARE eliminate its standardized assessment requirements and allow providers to pick the right assessments for each child, encourage but not require parent training, make the use of autism service navigators by parents optional and approve all CPT codes used by the industry to track and bill for care.

Additionally, the report recommends that TRICARE establish an independent advisory council to facilitate the transition from demonstration to a basic benefit.

“I really want to reiterate again for everyone that this does not mean that the benefit is changing tomorrow. There is a lot of work that will go into getting these recommendations enacted,” Fernandez said. “The best thing that the larger ABA industry and autism service industry can do right now is just say thank you to the [National Academies] committee for their hard work, and if there’s the need for, more focused advocacy to get this done, I am sure that there will be lots of grassroots efforts in the future.”