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Senate Armed Services Grills DoD on TRICARE Autism Coverage

June 21, 2012

WASHINGTON, DC (June 21, 2012) -- A Senate Armed Services subcommittee sharply questioned representatives from the Department of Defense (DoD) today on why they offer limited autism insurance benefits to military families, particularly in light of the federal government's decision to begin coverage for the nation's 8 million civilian employees, retirees and dependents.

Autism Speaks Chief Science Officer Geraldine Dawson (left, with Sen. Kirsten Gillibrand) testified at the Subcommittee on Personnel that the DoD's exclusion of Applied Behavior Analysis (ABA) from basic TRICARE coverage on the basis that it was educational rather than medical relied on outdated and incomplete research. She said what limited ABA coverage the DoD does offer is restricted to active duty members and falls short in providing a sufficient level of coverage.

The federal government's civilian workforce will be offered autism insurance benefits starting in 2013 as a result of a decision by the U.S. Office of Personnel Management (OPM) that ABA was medical and therefore an eligible benefit.

Sen. Jim Webb (D-VA), the subcommittee chairman, asked the DoD when it would begin reviewing the OPM decision to determine if it should apply as well to military families. Dr. Karen S. Guice, principal deputy assistant Secretary of Defense for Health Affairs, said, "it could take us a very long time, six months."

Sen. Kirsten Gillibrand (D-NY) said six months was too long and argued that ABA met the same criteria as the treatment for Post-Traumatic Stress Disorder which is covered as a medical benefit. "The fact that these therapies (ABA) actually work is the greatest hope that we have," she said. "So we shouldn't be denying them to any child, certainly not the child of a military family and certainly not the child of a wounded warrior."

Dr. Vera Tait, representing the American Academy of Pediatrics (AAP), said the effectiveness of ABA-based interventions "has been well-documented through a long history of research in university and community settings." Although more research is required, Tait said, "AAP has endorsed the use of ABA treatments when determined appropriate by physicians within a medical home, in close consultation with families."

John. O'Brien, OPM's director of healthcare and insurance, said the agency decided to reclassify ABA as a medical therapy "based on the evolving body of clinical research and the maturing provider infrastructure to deliver this (treatment) under a medical model.” He explained that "over the last two years, the infrastructure to support the delivery of ABA has matured rapidly. Today 30 States require at least some health insurance coverage of ABA, and 14 have licensure procedures for ABA providers.”

U.S. Navy veteran and military spouse Jeremy Hilton presented letters from over 80 families attesting to their difficulties accessing ABA treatment through TRICARE. Hilton said all of the families had found ABA had helped  their children with autism.

The TRICARE insurance program managed by the DoD has made ABA, the most commonly used behavioral intervention for autism, available only through the supplemental Extended Care Health Option (ECHO.) ECHO benefits are cumulatively capped at $36,000 per year and are restricted to dependents of active-duty service members. The $36,000 covers about 11 hours of ABA per week, Dawson said, well below what is commonly prescribed.

Dependents of retirees -- including dependents of wounded warriors retired due to injuries sustained in combat -- are unable to access ABA under TRICARE. Guard/Reserve families receive intermittent care as they move between active and non-active duty status. 

"This is not a matter for further study," Dawson told the subcommittee. "Action is needed to provide the quality of care our military families deserve and have earned. On behalf of the thousands of military families affected by autism, we ask that Congress require TRICARE to provide behavioral health treatment, including ABA, to military families regardless of duty status and without a dollar cap."

The U.S. House of Representatives, through a floor amendment to the DoD budget, has approved better autism insurance benefits for military families. The Senate has yet to complete action.