The Comprehensive Autism Care Demonstration: Solutions for Military Families (2025)
Chapter: 3 History of ABA Services in the Military Health System
3
History of ABA Services in the Military Health System
The Comprehensive Autism Care Demonstration (ACD) is the current program through which Defense Health Agency (DHA) covers applied behavior analysis (ABA) services for military-connected families, but it is not the first mechanism through which DHA authorized this sort of coverage. This chapter traces the history of coverage of ABA services within the Military Health System,1 services which first began in 2001 under the Program for Persons with Disabilities (PFPWD). The policy history provided in this chapter is useful in understanding the structure and goals of the ACD in its current form, which have evolved in response to experiences and feedback in earlier demonstrations and programs, as well as research. The history of coverage mechanisms recounted in this chapter illuminates a shifting relationship between policy, data, and practice, reflective of developments in understanding and diagnosing autism (discussed in Chapter 2) and in the ABA industry (discussed in Chapter 4) as well as military family efforts to ensure coverage of ABA for their children. The report as a whole considers the needs of the current moment, with this chapter providing important context and description of how DHA has identified and responded to needs for adjustments and revisions to coverage of ABA services in the past.
___________________
1 Where applicable, this chapter will refer to the Military Health System to denote the broader context of the health benefit system that is operated within the Department of Defense (DoD) and provides health care to active-duty and retired U.S. military personnel and their dependents.
OVERVIEW
This section provides a timeline of key dates in the history of ABA coverage within the Military Health System. It then briefly explains why ABA has not been included as a TRICARE Basic benefit. In the last part of this section, the committee notes some changes in terminology that occur over the period under discussion here.
Timeline of Coverage of ABA Services
Key dates in the evolution of the coverage of ABA services within the Military Health System (Bienia, 2021, 2023a; DHA, 2023a; TMA, 2001, 2005b, 2008, 2012, 2013b) include the following:
- 2001: ABA services first provided for active-duty family members (ADFMs) by DoD under the PFPWD. The PFPWD had a $1,000/month limit on services.
- 2005: ABA services provided under the Extended Care Health Option (ECHO) for ADFMs only by certified ABA providers with a bachelor’s degree or above. The benefit was not limited to beneficiaries diagnosed with autism.
- 2008: ABA services provided for ADFMs diagnosed with autism under ECHO Enhanced Access to Autism Services Demonstration, which added tiered model services. A diagnosis of Autism Disorder, Pervasive Developmental Disorder Not Otherwise Specified, Asperger’s Disorder, or Childhood Disintegrative Disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) was necessary for eligibility.
- 2012: ABA services available as a TRICARE Basic benefit for all beneficiaries diagnosed with autism to include retiree family members (non-ADFMs) as a result of Berge vs. United States. Service delivery was limited to master’s-level and above ABA providers only. ABA for all other diagnoses besides autism and Pervasive Developmental Disorder was excluded.
- 2013: One-year ABA Pilot for non-ADFM beneficiaries diagnosed with autism offering the tiered service delivery model implemented.
- 2014: ACD begins.
- 2021: ACD policy revision published (March 23, 2021).
In the sections below, the committee presents this history in four phases:
- 2001–2013: Coverage of ABA services prior to the ACD. During this period, ABA services are covered under a variety of programs
- in place prior to the ACD. The conclusion of this phase is marked by Berge vs. United States a class action lawsuit brought by retired uniformed service members and their dependent children regarding the refusal of ABA services through TRICARE.
- 2014: The creation of the ACD by DHA. This includes coverage of ABA, consolidating a patchwork of authorities prior to the creation of the ACD in July 2014 as well as policies and practices for providing ABA services from the inception of the ACD to 2021.
- 2021: Changes made to the ACD. Important changes are made to show how the ACD program has evolved in response to congressional action, parental advocacy, and lessons learned through the administration of the demonstration.
- 2021–present: Current implementation of the ACD. This section describes the current version of the program and highlights experiences of military families and ABA providers navigating it.
Throughout the chapter, the committee has included discussions of the relevant authorities and mechanisms for covering ABA services.
Statutes and Regulations Relevant to Delivery of ABA
Statutes and regulations in the U.S. code that establish TRICARE Basic benefits, including 10 U.S.C. § 1079 (Contracts for Medical Care) and 10 U.S.C. § 1086 (Contracts for Health Benefits), allow cost-sharing for medically or psychologically necessary services provided to ADFMs and retirees and their dependents to diagnose or treat an illness or injury. Such care needs to be proven safe and effective, pursuant to reliable evidence as defined in 32 C.F.R. § 199. As discussed in Chapter 2, TRICARE’s Basic and pharmacy program benefits cover a variety of medical services for the treatment of autism, including occupational therapy, physical therapy, speech therapy, psychological services and testing, and prescription drugs (DHA, 2025). However, DHA has yet to determine if reliable evidence for ABA meets the legal requirements for TRICARE coverage (see Chapter 1); thus, throughout the majority of its history, ABA coverage has been excluded from the TRICARE Basic benefits. Instead, these services have been covered under various pilot and demonstration programs within the Military Health System; currently, these services are provided by DHA to military-connected families through the ACD authorized under 10 U.S.C. § 1092, which gives limited authority to test alternative approaches to the financing, delivery, or administration of health care. See Appendix E for relevant legislation and Federal Notices on the demonstration and TRICARE authorizations.
Terminology Changes
This chapter traces the provision of benefits across a 20-year period, during which the names of various agencies and programs have changed even as the structures and services have remained the same. Similarly, at times, the committee refers to documents that include names no longer in use. Thus, before describing the history of ABA services for military-connected families, a brief note of changes in terminology is in order.
The TRICARE program has been managed by DHA, under the authority of the Assistant Secretary of Defense for Health Affairs, since the inception of DHA in 2013 as part of efforts to reform the governance of the Military Health System (DHA, 2013; DoD, 2013a,b). Prior to the creation of DHA, TRICARE was managed by the TRICARE Management Activity (TMA), also under the authority of the Assistant Secretary of Defense for Health Affairs. When DHA was created, TMA was disestablished, and its functions were transferred to DHA. Thus, auspices and titles have changed over the years, and documents—whether in law, rule, regulation, or issuance—dealing with ABA services in the Military Health System that reference the TMA are treated as referring to DHA (DHA, 2013; DoD, 2013a,b).
COVERAGE OF ABA SERVICES PRIOR TO THE ACD
This section discusses ABA services within the Military Health System from 2001 to 2014, before the establishment of the ACD on July 25, 2014. As reviewed above, during this time frame, these services were provided under a patchwork of authorities and programs. They include the PFPWD; ECHO; the ECHO Enhanced Access to Autism Services Demonstration; coverage that resulted from the Berge vs. United States court case against DHA (then TMA); and the one-year ABA Pilot Program that began in 2013 and ended when the ACD began.
2001: Program for Persons with Disabilities
In 2001, ABA services for autism were covered as “special education” under the PFPWD. Pursuant to 10 U.S.C. § 1079(a)(9), special education services may not be provided as TRICARE Basic program benefits; thus at the time, ABA services were provided through the PFPWD, which provided financial assistance for ADFMs who were moderately or severely mentally or physically disabled to help defray the cost of services not available through TRICARE Basic program benefits or through other public agencies as a result of state residency requirements. ABA remained a covered service under PFPWD until 2004 when it was it was renamed the ECHO program (TRICARE; Individual Case Management Program; Program for
Persons With Disabilities; Extended Benefits for Disabled Family Members of Active Duty Service Members; Custodial Care, 2004). ECHO services are available to dependents of active-duty service members who are enrolled in a TRICARE health plan option, who have a qualifying physical or mental condition, including autism, and are generally also enrolled in the Military Services’ Exceptional Family Member Program (EFMP) (DHA, 2023b; DoD, 2021a), which the Services require for individuals with special healthcare and education needs (DoD, 2023a). Autism remained one of several qualifying conditions, and ABA as special education continued to be covered as an ECHO service (TMA, 2013a). When ECHO was created, existing policy was revised to specify that only TRICARE-authorized providers could render services under the ECHO program (TMA, 2005a).
2008: ECHO Enhanced Access to Autism Services Demonstration
ABA services continued to be covered as special education under the ECHO program until 2008 when Congress, through Section 717 of the National Defense Authorization Act (NDAA) for FY 2007, called for the Secretary of Defense to submit to Congress a plan to provide services to military dependent children diagnosed with autism under the authority for an extended healthcare services program relating to delivery of health and medical care (10 U.S.C. § 1079(d) & (e)). Congress required that this plan include the following: (a) requirements for the education, training, and supervision of individuals providing services for military dependent children with autism; (b) standards for identifying and measuring the availability, distribution, and training of individuals of various levels of expertise to provide such services; and (c) procedures that were necessary to ensure that such services were needed in addition to other publicly provided services to such children (NDAA, 2006).
In response to Congress, DoD proposed a demonstration program under 10 U.S.C. § 1092 titled the ECHO Enhanced Access to Autism Services Demonstration, which began on March 15, 2008, with the intent of improving the quality, efficiency, convenience, and cost-effectiveness of providing ABA services to eligible beneficiaries of ADFMs diagnosed with autism (Autism Services Demonstration Project for TRICARE Beneficiaries Under the Extended Care Health Option Program, 2007; NDAA, 2006). The program was originally slated to end after a two-year period, in early 2010. However, it was extended until March 14, 2012, under the same terms and conditions. This is because the demonstration was originally created to collect data necessary to provide DoD with information necessary to make sound judgments regarding payment for ABA services (Autism Services Demonstration Project for TRICARE Beneficiaries Under the Extended Care Health Option Program Extension, 2010), and DoD determined that
more time was necessary to collect comprehensive data. The ECHO Enhanced Access to Autism Services Demonstration covered the tiered delivery model of ABA services, which employs individuals who are not otherwise authorized under the TRICARE Basic program. In April 2009, as part of section 732 of the NDAA for FY 2009, the limit of government liability for certain benefits, including special education, was increased from $2,500 per month to $36,000 per year (DoD, 2012b).
For context, at the time of the ECHO Enhanced Access to Autism Services Demonstration, the tiered delivery for ABA service used “ABA Tutors.” (The behavior technician certification was not yet established [see Chapter 4]; therefore, TRICARE established minimum education and training standards in lieu of no industry standard.) ABA tutors provided much of the one-on-one behavior reinforcement interventions with patients under the supervision of a behavior analyst.
Because the education level of the ABA tutors fell below the provider qualification standards as defined for the TRICARE program’s private sector authorized providers in regulation, the ECHO Enhanced Access to Autism Services Demonstration provided a mechanism to support the tiered delivery model and for direct ABA services to be administered by an ABA tutor (TMA, 2013a). For more information on provider credentialing in the ACD, see Chapter 4.
In addition to the congressional requests for the demonstration listed above, there were also objectives to test whether this sort of tiered delivery and reimbursement methodology for ABA services would (TMA, 2013a)
- provide increased access to ABA services;
- provide ABA services to those most likely to benefit from them;
- ensure the quality of ABA services by utilizing a professional community of providers including providers certified by the Behavior Analyst Certification Board (BACB); and
- determine whether requirements are being met for state licensure or certification where such exist.
Berge vs. United States Class Action Lawsuit Regarding ABA Coverage
In March 2010, a class action lawsuit (Berge v. U.S., 879 F. Supp. 2d 98, 135–36 (D.D.C. 2012)) was filed against the U.S. government, alleging TRICARE wrongfully refused to provide coverage for ABA services to family member beneficiaries of military retirees. Arguments surrounding the case were regulatory limitations of TRICARE coverage, which allow for authorizing only “medically or psychologically necessary” treatments; the disputed classification of ABA as “proven” medical care; and the exclusion of ABA services from TRICARE Basic benefits (TMA, 2010, p. 9).
In July 2012, the district court granted the plaintiff’s motion for summary judgment finding that the rationale for DHA’s denial of ABA coverage under the Basic program was “arbitrary and capricious” (Berge v. U.S., DKT# 119, p. 59). This determination was made in part due to “the Agency’s decision to enforce its stringent regulatory standards to withhold ABA therapy coverage under the Basic Program, while exercising its statutorily-granted discretion to extend ABA therapy coverage under ECHO” (Berge v. U.S., DKT# 119, p. 59) and that “the Agency has failed to articulate a reasoned explanation for its determination that ABA therapy is unproven, particularly in light of evidence before it suggesting the contrary” (Berge v. U.S., DKT# 119, p. 64).
The court ruled that remand to the agency for further review of the matter would be “an unnecessary formality” (Berge v. U.S., DKT# 119, p. 65) because “the Agency’s policy that ABA treatment is proven for the purpose of the ECHO program, but not for the Basic Program” could not be cured by such action (Berge v. U.S., DKT# 119, p.64). The court issued an injunction requiring the Agency to provide coverage for ABA therapy under the Basic program to any beneficiary who would otherwise qualify for it (Berge at 135-36; Berge v. U.S., DKT# 119, p. 65).
On August 10, 2012, in response to the order of the district court, TMA published an interim section to its TRICARE Policy Manual allowing coverage of ABA services under the TRICARE Basic program for any eligible beneficiary with a diagnosis of autism from a state-certified Applied Behavioral2 Analyst or individual certified by the BACB as a Board Certified Behavior Analyst (BCBA), whether dependents of active-duty service members or military retirees (TMA, 2012). This coverage was retroactive, effective March 5, 2010 (March 5, 2008, for overseas). Payable services included initial beneficiary assessment, development of a treatment plan, one-on-one ABA interventions with an authorized provider, training of immediate family members to provide services in accordance with the treatment plan, and monitoring of the beneficiary’s progress toward treatment goals (TMA, 2013b). TMA stated that this interim benefit would stay in place until litigation was complete (DoD, 2012b). This policy revision did not impact the ECHO Enhanced Access to Autism Services Demonstration, and ADFMs enrolled in this demonstration continued to have access to ABA services under the tiered delivery model (DoD, 2013c).
TMA further filed a motion with the court on August 23, 2012, asking it to “vacate its injunction and accompanying instructions, and remand the matter to the agency for further action” (Berge v. U.S., DKT #122, p. 9),
___________________
2 This was the term used for this benefit at the time; it has since been renamed Applied Behavior Analyst.
arguing that the “Court’s conclusion [. . .] was based on a misunderstanding of the agency’s ECHO coverage determination” (Berge v. U.S., DKT #122, p. 6). In its motion, TMA argued the court misunderstood the particulars of the ECHO regulations, specifically that “ECHO and the Basic Program have two different purposes and although a treatment can be effective in assisting with a disabling condition as a non-medical service, it can also be viewed as not being ‘proven’ as a ‘medical’ therapy to treat the underlying condition. Otherwise, the ECHO program is subsumed into the Basic Program” (p. 7). TMA stated that remand would allow it to “provide further explanation for its ECHO and Basic Program ABA determinations or potentially revise those determinations” (Berge v. U.S., DKT #122, pp. 8–9).
On January 4, 2013, TMA notified the court of the recently passed NDAA for FY 2013, in which Congress provided DoD a one-year authority to assess ABA coverage for non-ADFMs independent from the then ongoing legal proceedings and in parallel to ABA coverage under the ECHO Enhanced Access to Autism Services Demonstration (Berge v. U.S. DKT# 128). The statute required the Secretary of Defense to submit a report to the House and Senate Armed Services Committees that included an assessment of the feasibility and advisability of establishing a beneficiary cost share for the treatment of autism, and a comparison of providing ABA services under the ECHO demonstration, the Basic Program, and this new pilot. TMA stated in its notification to the court that “given that Congress has recognized that TMA is to further assess the scope of ABA coverage, and rejected mandating coverage beyond this pilot program, defendants renew their request that the injunction be vacated” (Berge v. U.S., DKT #128, p. 1).3
TMA noted that there would be no immediate change to TRICARE coverage of ABA services and that it would continue under revised interim guidance with the addition of services authorized under the new pilot to launch July 2013 (Berge v. U.S., DKT# 128; NDAA, 2012; TMA, 2013b). Therefore, at the beginning of 2013, TMA’s course of action regarding ABA services included the following:
- For all beneficiary categories, TRICARE covered ABA as a Basic Benefit for services provided by certified providers with master’s degrees and above.
- For ADFMs in the ECHO Enhanced Access to Autism Services Demonstration, TRICARE covered ABA services from supervised
___________________
3 For more information about the 2013 NDAA, see https://www.congress.gov/112/plaws/publ239/PLAW-112publ239.pdf
- assistant providers at the bachelor’s degree level and non-degree level ABA tutors (the tiered delivery model).
- For non-ADFMs, TRICARE covered ABA services in the tiered delivery model, similar to those for ADFMs in the ECHO Enhanced Access to Autism Services Demonstration, under the new pilot authority to begin July 2013. (TMA, 2013a)
On June 5, 2013, the court granted TMA’s motion to amend judgment and remanded the matter to TMA for further action. In granting TMA’s motion, the court reasoned that it was “conceivable that the Agency could, after considering all relevant factors, satisfactorily articulate how the same decision is rationally related to the evidence before it, particularly in light of the fact that the Agency’s reconsideration will take into account new literature published since the Agency last considered the matter” in October 2010 (Berge v. U.S., DKT#134, p.13). Additionally, the court stated that “even if the Agency were to find that ABA therapy constitutes ‘medical’ care and that it is a proven treatment, there are additional statutory and regulatory determinations that need to be made in order to determine whether ABA therapy is a covered benefit under the Basic Program” (Berge v. U.S., DKT#134, p. 13).
In response to the court’s ruling, on June 28, 2013, TMA developed an interim detailed analysis of its determination of whether ABA was a medically or psychologically necessary intervention for autism within its statutory regulations, its interpretation of the reliable evidence standard, as well as a review of relevant literature on ABA for autism. The analysis consisted of a review of TRICARE statutes; an internal review; an external review of the literature on ABA; and a review of published reports by national professional medical associations, national medical policy organizations, and national expert opinion organizations (TMA, 2013a). Box 3-1 summarizes TMA’s conclusions as detailed in this 2013 analysis.
2013: Initiation of One-Year ABA Pilot Program
As noted above, Congress provided DoD a one-year authority to assess full ABA coverage for non-ADFMs through a pilot program to begin July 2013. This pilot program provided for direct ABA services from bachelor’s-level assistant behavior analysts and paraprofessionals working under the supervision of masters-level or above behavior analysts. The pilot program’s coverage of ABA reinforcement for non-ADFMs was implemented as a separate interim benefit from the coverage of ABA benefits provided, as part of the Berge vs. United States decision, under the TRICARE Basic program to both ADFMs and non-ADFMs and separate from the ECHO Enhanced
BOX 3-1
TMA’s 2013 Interim Analysis of ABA Services
In this interim 2013 analysis by TMA to determine whether ABA was a medically or psychologically necessary intervention for autism within its statutory regulations, four conclusions were drawn that argued against determining ABA as medically or psychologically necessary:
- ABA does not “pertain to” or have a nexus of belonging with other forms of medical or behavioral healthcare delivered by TRICARE.
- The above determination is consistent with (a) the American Medical Association, which does not recognize ABA as medical or behavioral health treatment, as evidenced by the absence of a CPT code for ABA; (b) Medicare, which does not establish a national coverage determination for ABA under Medicare Part A for persons with disabilities; and (c) the states’ coverage of ABA, which falls under the Medicaid Home and Community-Based Waiver Program instead of the Medicaid Health Plan.
- ABA is not practiced by “licensed or certified healthcare professionals,” as evidenced by the low number of states licensing ABA providers and the noted absence of healthcare delivery knowledge and skill standards required for BCBA national certification by the BACB.
- ABA does not pertain to the practice of “psychological” care as evidenced by various statements by the BACB, which include (a) self-description as a discipline separate from the practice of clinical psychology and related behavioral healthcare disciplines; (b) rejection of traditional behavioral healthcare training as part of its curriculum; and (c) active lobbying for ABA practitioners not to be licensed or regulated by state Boards of Psychology.
SOURCE: TMA, 2013a.
Access to Autism Services Demonstration available by law only to ADFMs (TMA, 2013b).
A planned evaluation was also a part of the pilot program. As part of Section 705 of NDAA FY 2013, Congress required a report be submitted by December 31, 2013, that addressed
- an assessment of the feasibility and advisability of establishing a beneficiary cost share for ABA;
- a comparison of providing ABA reinforcement under ECHO and providing such ABA under a TRICARE program other than ECHO; and,
- any recommendations for changes in legislation and additional information for consideration. (NDAA, 2012)
TMA noted specific outcomes that would be assessed as part of the pilot in addition to the requirements set out by Congress. These will include the following:
- Utilization – of Basic Program ABA and Enhanced Access ABA reinforcement for ADFMs and non-ADFMs; and
- Access to care – as measured by wait times and reported availability of ABA providers and ABA Tutors (as parent/care-giver “extenders” of ABA reinforcement techniques); and
- Cost – of providing appropriate ABA under the Basic Program, and ABA reinforcement under the ECHO Autism Demonstration (for ADFMs), and the ABA Pilot (for non-ADFMs); and
- Feasibility of assessing treatment progress – as measured by improvement in communication, social, and behavioral functioning from baseline for beneficiaries with autism receiving ABA, plus ABA reinforcement under TRICARE. (TMA, 2013b)
At the end of 2013, DoD announced that this pilot program would be extended and conclude in 2015 (Extension of Autism Services Demonstration Project for TRICARE Beneficiaries Under the Extended Care Health Option, 2013). However, in 2014, the creation of the ACD superseded this extension. DoD determined that a more comprehensive program than the ABA pilot would better “support analysis and comparisons of the most appropriate standards, procedures and protocols for the delivery and financing of ABA services under TRICARE,” as noted in the Federal Register notice (Comprehensive Autism Care Demonstration, 2014) establishing the ACD:
- Evaluate the adequacy of procedure changes made to date concerning coverage provided to non-ADFMs as well as implement additional planned adjustments,
- Test the acceptance and applicability of the ABA coverage requirements and procedures developed for the ABA Pilot for the larger ADFM beneficiary population currently receiving ABA services under the ECHO Autism Demonstration, and
- Compare options for treating autism under the TRICARE Basic Program generally. (p. 34293)
2014: CREATION OF THE ACD
In 2014, DHA4 sought to consolidate the patchwork of programs and pilots providing ABA services to military-connected families and incorporate lessons learned. DHA published the Federal Register Notice for the
___________________
4 On October 1, 2013, DoD established the DHA which replaced the TMA. From here on, the report will refer to DHA rather than TMA.
ACD in June 2014, with an effective date of July 25, 2014 (Comprehensive Autism Care Demonstration, 2014). The ACD launched with the purpose of “analyz[ing] and evaluat[ing] the appropriateness of the ABA services tiered-delivery model under TRICARE [the medical benefit]” (Comprehensive Autism Care Demonstration, 2014, p. 34291) while providing such services to TRICARE beneficiaries diagnosed with autism (Extension of the Comprehensive Autism Care Demonstration for TRICARE Eligible Beneficiaries Diagnosed With Autism Spectrum Disorder, 2022). To this end, the program was authorized to cover “clinically necessary and appropriate ABA services” that target the core symptoms of autism (DHA, 2025, p. 1).
ACD objectives appeared in the initial Federal Register Notice creating the ACD in 2014 and were reiterated in part in the latest extension of the ACD in 87 FR 47731 without changes (Extension of the Comprehensive Autism Care Demonstration for TRICARE Eligible Beneficiaries Diagnosed With Autism Spectrum Disorder, 2022). These objectives establish the purpose of the ACD and also distinguish it from earlier mechanisms of coverage. They are as follows:
- To further analyze and evaluate the appropriateness of the ABA services tiered delivery model under TRICARE generally in light of current and future Behavior Analyst Certification Board (BACB) Guidelines.
- To determine the appropriate provider qualifications for the proper diagnosis of [autism spectrum disorder] and the provision of ABA, and assess the added value of ABA Tutors, or Behavioral Technicians, beyond ABA provided by BCBAs.
- To assess, across the three TRICARE regions [East Region, West Region, and Overseas Region], the [autism] characteristics associated with full utilization of the ABA tiered delivery model versus utilization of BCBA services only or non-utilization of any ABA services, and isolating factors contributing to significant variation across TRICARE regions in delivery of ABA.
- To determine what beneficiary age groups utilize and benefit most from ABA interventions.
- To assess the relationship between receipt of ABA services and utilization of established medical interventions for children with [autism spectrum disorder], such as speech and language pathology therapy (SLP), occupational therapy (OT), physical therapy (PT), and pharmacotherapy.
- To assess the feasibility and advisability of establishing a beneficiary cost share for the treatment of [autism]. (Comprehensive Autism Care Demonstration, 2014, p. 34293)
Pre-2021 Revisions to the ACD
Early in its implementation, policies of the ACD were amended to address concerns from military-connected families and other stakeholders: (a) that the beneficiary cost-sharing provisions under the ACD could have an adverse financial impact on beneficiaries since coverage did not accrue to the catastrophic cap and thus would put ABA “out of reach” for some families; and (b) that the reduced reimbursement rate of $125/hour for ABA one-on-one services from professional behavior analysts to $68/hour could cause providers to disengage TRICARE beneficiaries, leading to decreased access to ABA services (DoD, 2016).
In 2015, DHA amended the ACD to have beneficiary cost-shares for ABA services apply toward the catastrophic cap; align ABA cost-shares with then-existing TRICARE program cost-shares under the TRICARE Standard and Extra health plan options; and adjust ABA reimbursement rates under the ACD to be more consistent with other payors and implement geographic adjustments.
Congressional Requirements
Through NDAA provisions in the intervening years (FY 2015–FY 2017), Congress made several requests for analysis and reporting on the ACD including information on lessons learned and identification of any new legislative authorities required to improve the provision of services for autistic individuals (NDAA, 2015). As of this writing, DoD has issued eight annual reports on the results of the ACD (DoD, 2016, 2017b, 2018a, 2019a, 2020a, 2021b, 2023c, 2024b) in response to Senate Report 114-49 and 24 quarterly reports, running from FY 2017 Quarter 1 through FY 2022 Quarter 4, in response to Senate Report 114-255 accompanying the NDAA for FY 2017 (NDAA, 2016). See Appendix E for excerpted legislative language on these requests.
The quarterly reports for the ACD were intended to monitor timely access to care. They required DHA to, at a minimum, provide the following information by state (DoD, 2022a):
- the number of new referrals for services under the program;
- the number of total beneficiaries enrolled in the program;
- the average wait-time from time of referral to the first appointment for services under the program;
- the number of providers accepting new patients under the program;
- the number of providers who no longer accept new patients for services under the program;
- the average number of treatment sessions required by beneficiaries; and
- the health-related outcomes for beneficiaries under the program. (Senate Report 114-255, S. 2943, p. 205 [NDAA, 2016])
As of 2017, DHA took a specific approach to gathering data around health-related outcomes (item 7) and reporting them to the Committees on Armed Services of the Senate and the House of Representatives. In 2016, the TRICARE Operations Manual was revised to include the required collection of data on ACD participants through a set of standardized assessment tools. This set of tools is referred to as “outcome measures” in the TRICARE Operations Manual, and data collection began January 1, 2017 (DHA, 2023a). Since this time, the specific tools and frequency of administration have changed, but collection of data on ACD participants has continued through 2025.5 Some scores from these measures have been aggregated for analyses presented in the quarterly and annual reports to Congress. See Box 3-2 for a list of the current required assessments and their frequency of administration.
Program Extensions
The authority for the ACD was originally set to expire on December 31, 2018. A five-year extension through December 31, 2023, was determined necessary “to include further research and evaluation of the results, whether Board Certified Behavior Analysts may appropriately be recognized and treated as independent TRICARE authorized providers of a proven medical benefit, and what authorities are required to add ABA services as a permanent benefit under the TRICARE program—whether as a proven medical benefit or otherwise” (Extension of the Comprehensive Autism Care Demonstration for TRICARE Eligible Beneficiaries Diagnosed With Autism Spectrum Disorder, 2017, p. 58186). Following the publication of program revisions in 2021 predicated on lessons learned, an additional extension was enacted through December 31, 2028 (Extension of the Comprehensive Autism Care Demonstration for TRICARE Eligible Beneficiaries Diagnosed With Autism Spectrum Disorder, 2022).
___________________
5 Administration of assessments began January 1, 2017. At that time, the ACD initially required a set of tools predominantly used in research studies—the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2); the Vineland Adaptive Behavior Scales, Third Edition (Vineland-3); and the Wechsler Intelligence Scales or Test of Non-Verbal Intelligence Scale, Fourth Edition (TONI-4). However, after significant feedback from stakeholders, the requirements were revised in May 2017, retaining the Vineland-3 and subsequently adding the Social Responsiveness Scale (SRS) and Pervasive Developmental Disorder Behavior Inventory (PDDBI) in January 2018.
BOX 3-2
Current Required Assessments under the ACD
- Pervasive Developmental Disorder Behavior Inventory (PDDBI) Parent Form: Required at baseline, prior to start of ABA services, and every six months.
- PDDBI Teacher Form (administered by the behavior analyst): Required every six months.
- Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) Parent Interview (if completed by a TRICARE-authorized provider) or Teacher Form: Required at baseline and every year.
- Social Responsiveness Scale, Second Edition (SRS-2) Parent Form: Required at baseline and every year.
- [Added in 2021] Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF): Required at baseline and every six months. Or Stress Index for Parents of Adolescents (SIPA) Profile Form: Required at baseline and every six months.
The PDDBI, Vineland-3, and SRS are tools used by clinicians to evaluate behaviors and characteristics of individuals with atypical neurodevelopment. The PDDBI is an evaluation of change in functioning, assessment of response to intervention, and an assessment of adaptive and maladaptive behavior characteristics of autistic individuals designed so clinicians can measure results of tailored therapies for those behaviors. The Vineland-3 is a measure of adaptive behavior for individuals diagnosed with intellectual disabilities and developmental disabilities (to include autism), applicable for ages birth to 90 years. The SRS-2 is a measure of deficits in social behavior associated with autism, applicable for ages 2 ½ through 99 years. The PSI-4-SF is a screening tool to detect stress areas that may lead to problems in a child’s or parent’s behavior, applicable for caregivers of children age birth through 12 years old. The SIPA is a screening tool to detect stress areas within parent-adolescent interactions, applicable for caregivers of children aged 11–19 years old.
SOURCE: DHA, 2023a.
2021: ACD POLICY REVISIONS
In 2021, DHA released an extensive policy revision for the ACD. Planning for the policy update was a multi-year process that, according to DHA (see Appendix C, Question 33), included incorporating lessons learned and feedback from advocates and organizations as well as interested parties, including families, mental health providers, military medical treatment facility providers, professionals from other healthcare disciplines, the managed support contractors, contract oversight, and other TRICARE program oversight personnel. A timeline of the implementation of revisions can be
SOURCE: Bienia, 2021.
found in Figure 3-1. Notably, the implementation of the policy revisions and changes to ACD operations coincided with the COVID-19 pandemic and its impact on health care and families (see Box 3-3). Some of these policy revisions include the following (DHA, 2023a):
- Amended definitions of referring and diagnosing providers;
- Required collection of completed DSM-5 checklist from the referring provider prior to ACD enrollment for new beneficiaries and at two-year referral cycle for existing participants;
- Required assignment of Autism Services Navigator (ASN) after ACD enrollment;
- Required completion of comprehensive care plan (CCP) with ASN within first 90 days and prior to each reauthorization;
- Provided a parent toolkit on the ACD;
- Implemented active provider placement for all ABA referrals submitted and required confirmation of availability of ABA providers within access to care standards;
- Adjusted “outcome measures” (standardized assessment tools) cycle by administering Vineland-3 and SRS every year instead of every two years;
- Added new “outcome measures” by requiring parent stress indices (PSI-SF or SIPA) prior to first treatment and for all reauthorizations (every six months);
BOX 3-3
Impacts of the COVID-19 Pandemic on the ACD
The COVID-19 pandemic hit during a period of high enrollment for the ACD, with 2,153 new referrals at the end of fiscal year 2019 (DoD, 2020c) and 1,686 new referrals at the beginning of fiscal year 2020 (DoD, 2020d). There was a total of 16,292 beneficiaries enrolled in the ACD at the end of 2019. New referrals decreased slightly in the second quarter (January to March 2020) to 1,655, and total enrolled dropped to 16,180 during that time (DoD, 2020e). After the start of the pandemic, the number of new referrals and total enrollments dropped to 1,131 and 15,450, respectively (DoD, 2021c). New referrals did not reach pre-pandemic levels again until the end of fiscal year 2021 (DoD, 2022c).
As may be expected, the COVID-19 pandemic led to delays in access to ABA services and according to DHA, may have had an impact on the overall utilization (DoD, 2022c). In order to adapt to the difficulties of the pandemic, two major changes to ACD policy were implemented: (1) Starting March 31, 2020, TRICARE authorized the unlimited use of Current Procedural Terminology (CPT) code 97156 “Family Adaptive Behavior Treatment Guidance” via only synchronous (real-time, Health Insurance Portability and Accountability Act compliant two-way audio and video) telehealth services to ACD beneficiaries with an authorization from their regional contractors. The initial period of allowing this unlimited use exception was authorized through May 31, 2020, but was subsequently extended through the end of the public health emergency on May 11, 2023. (2) A pause was implemented in 2020 on reporting “health-related outcomes” in the quarterly reports to Congress in order to assess potential impacts on data validity.
Prior to the COVID-19 pandemic, TRICARE had expanded its coverage to include telehealth services to help with the diagnosis of autism and support families in remote locations. However, as a result of the authorization of unlimited telehealth for family guidance/training (CPT code 97156), there was a marked increase in the utilization of telehealth, which DHA noted showed an increase in parent engagement with treatment. However, both the in-person and telehealth use of family guidance quickly declined as the pandemic continued—peaking at 46% of beneficiaries (for both in person and telehealth) and then showing steady decline to 24% of total beneficiaries by August 2020 (DoD, 2022c).
Outside the ACD, decreased access to necessary health care and support needs, school closures, isolation, and lack of respite put enormous strain on the mental health of caregivers and children with disabilities and special needs (Brown et al., 2022; National Academies of Sciences, Engineering, and Medicine [NASEM], 2022). Individuals with autism may have been particularly vulnerable to the effects of the pandemic due to exacerbation of symptoms, limited access to support services and interventions, and added responsibilities placed on caregivers (Ashbury et al., 2021; Bellamo et al., 2020; Furar et al., 2022; Vasa et al., 2021). For military families engaged in the ACD, the stressors of the pandemic coincided with the roll out of the new 2021 policies.
- Required completion of all “outcome measures,” as cycled, prior to authorizing first treatment and for all reauthorizations;
- Required 100% review of treatment plans by contractor for clinical necessity prior to authorization;
- Added new accepted CPT codes 97157, 97158, 99366, and 99368;
- Clarified role of behavior technicians and assistant behavior analysts performing ABA services in school and certain community settings;
- Required ABA providers to conduct a minimum of six parent training sessions per authorization period;
- Required annual ABA provider audits; and
- Revised beneficiary eligibility requirements including revised requirements for children aged eight and older receiving a diagnosis, a streamlined two-year re-referral process, and assignment of a non-clinical outreach coordinator for new beneficiaries interested in participating in the ACD who require assistance in meeting eligibility requirements.
In response to these policy revisions, military families and their advocates have raised several concerns. Some of these have been documented by the Congressional Research Service in its recent primer on the ACD, and include “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 and community settings [. . . as well as] accessing ABA services in a timely manner” (Mendez, 2023, p. 2).
During the course of this study, the committee heard similar concerns from military families and ABA providers (as outlined in Chapter 1). These public comments and presentations centered on particular requirements of the ACD, including enrollment in EFMP and ECHO, assignment of the ASN, the periodic assessments (“outcome measures”), and mandatory parent training sessions. Military parents lamented over the steps and processes they had to adhere to enroll in the ACD and maintain ABA services. They reported delays and expressed fears of losing ABA services if deadlines were not met.6 While a DHA representative noted in an orientation video that the removal of the additional 90-day extension for ECHO registration was due to finding “very few situations where families requested [exceptions] beyond the original 90-day [registration window]” (DHA, 2021b), families have expressed continued difficulty and stress around the 90-day limit.7
___________________
6 Additional information on listening sessions held with military families can be found at https://www.nationalacademies.org/event/41985_04-2024_independent-analysis-of-the-comprehensive-autism-care-demonstration-program-virtual-information-gathering-session-3
7 See above footnote.
They were frustrated with communication, reporting a perceived lack of information and reminders available to families and lack of coordination between contractors, ASNs, and EFMP (NASEM, 2024a).8
INITIAL STEPS TO PARTICIPATE IN THE ACD
Thus far, this chapter has focused on the statutory, regulatory, and operational requirements that form the historical basis of how the ACD presently operates. This section provides an overview of the current initial steps needed to enroll in and receive care through the ACD along with the ways these steps are understood, and experienced, by military families seeking ABA for autistic dependents.
At the time of this study, the enrollment process requires beneficiaries to follow a multi-step process to receive ABA services. Some details of the initial ACD participation process are discussed below, including (a) diagnosis and referral, (b) enrollment in EFMP and registration in ECHO, (c) assignment to an ASN, (d) the Active Provider Placement process, and (e) completion of baseline outcome measures and initial treatment plan. DHA, families enrolled in the program, and publicly available information from regional DoD contractors provided the information used to detail the full enrollment process.
Diagnosis and Referral
As noted in Chapter 2, since the 2021 program revisions, DHA has expanded the list of TRICARE-approved validated assessment tools to include the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2); the Autism Diagnostic Interview-Revised (ADI-R); the Screening Tool for Autism in Toddlers & Young Children (STAT); the Gilliam Autism Rating Scale (GARS); and the Childhood Autism Rating Scale, Second Edition (CARS-2). DHA has also expanded the types of healthcare providers authorized to make a diagnosis using these tools. In addition to these tools, diagnosing clinicians need to complete a DHA-approved diagnostic checklist based upon the DSM-5 diagnosing criteria (APA, 2013) in order to help standardize documentation of the diagnosis process and to demonstrate that the full diagnostic criteria were considered.
TRICARE-enrolled beneficiaries may begin participating in the ACD when the diagnosing provider submits a complete initial ACD referral, which includes the DHA-approved diagnostic checklist, to the regional contractor for the area in which the beneficiary lives, along with proof of
___________________
8 Additional information on listening sessions held with military families and ABA providers can be found at https://www.nationalacademies.org/our-work/independent-analysis-of-department-of-defenses-comprehensive-autism-care-demonstration-program#sectionPastEvents
a definitive diagnosis specifying that ABA services are necessary. Once the ABA referral is verified, the managed care support contractor authorizes an initial ABA assessment, after which a six-month period of treatment for ABA services may be authorized. ABA services may continue to be reauthorized in six-month increments if continued services are determined to be clinically necessary and appropriate as demonstrated in the treatment plan completed by the ABA provider and ACD requirements are met during the two-year period while the referral is valid. Near the end of that two-year period, beneficiaries’ referring physicians need to submit a new referral for ABA services and an updated DHA-approved diagnostic checklist. Referrals remain valid for two years when changing providers or moving within or outside the TRICARE region in which they are obtained.
The creation of this DHA-approved checklist was intended to ensure standardized documentation across all beneficiaries. However, in the period since its implementation, there has been confusion around the purpose of its use. In addition, required completion and deadlines of the checklist seem to have created bottlenecks in the delivery of ABA services, as described in Box 3-4 below.
BOX 3-4
Perspectives—DSM-5 Diagnostic Checklist
The committee’s information gathering included listening sessions and a call for public input to understand experiences with the ACD and ABA. While not designed to be representative and reflect the full range of perspectives or experiences of individuals and military families, this information provided important context for understanding the experience of those enrolled in the ACD and those receiving or providing ABA services, as well as the experience of those living with autism. This input served as a backdrop for the committee’s review and assessment of the available empirical literature and provided context for, though not the basis of, its conclusions and recommendations. This box presents some of the comments that the committee received regarding the ACD’s DSM-5 diagnostic checklist.
“We moved, and so the provider who did our initial diagnosis was not the same provider we saw for our two-year reauthorization. That new provider said, ‘I have to do a new evaluation before I do this diagnostic checklist.’ After our next move, I had to call continuously for three days before I found a provider who had an opening in five months to do our next reauthorization checklist.” ~ Public comment from Air Force parent at April 12, 2024, public session
“[My] primary care doctor did not feel comfortable completing the checklist [for reauthorization]. So, we were referred to a developmental pediatrician [. . .] It took over a year from the initiation of a referral [to have the appointment . . .] and for the developmental pediatrician to complete the checklist. The checklist just confirms that my son has autism. Autism is a lifelong diagnosis.” ~ Public comment made by a military spouse at the November 15, 2023, public session
Participation in ECHO and EFMP
If the beneficiary is not already enrolled in EFMP and registered in ECHO, the contractor’s verification of referral to the ACD also initiates the process for ADFMs. Enrollment in EFMP is necessary to qualify for registration in ECHO (DHA, 2023b). For the majority of enrollees, the process for enrolling in the Services’ EFMP currently takes 30–90 days (Office of People Analytics, 2022). TRICARE beneficiaries have 90 days to enroll in ECHO while concurrently pursuing ABA services.
EFMP was established to help ensure that the special needs of family members are considered during the assignment process. To aid with a permanent change of station (PCS) move, families are to receive support navigating changes in care and education services by the local Service EFMP offices at both the losing and gaining military installations throughout their relocation process. The Office of Special Needs, not DHA, oversees each
“[. . .] We also have a 2 year recertification of our daughter’s [autism] diagnosis due in March 2025. This is an appointment where her developmental pediatrician has to use the DSM-5 checklist or other approved method to certify that our daughter does still have [autism. . . . Autism] is not something that any person simply gets ‘cured’ from and the ACD treats it as though it is. [. . .] The ACD gatekeeps our access to this therapy and when there are issues as I described above, we have no recourse or anyone who can help us because of the way this system is setup.” ~ Written comment to committee from military parent in Texas
“[. . .] Another area of difficulty has been the requirement of the DSM checklist. I have had three different families have a delay in the approval of their authorization and therefore a delay in receiving ABA services because of this requirement. Providers do not know what the checklist is and do not even understand how to fill it out. I have had phone calls from doctor offices asking me how to fill out this form. I have had nurses telling me that I should fill out the form myself. Parents are having to repeatedly call the doctor’s office and the TRICARE representative trying to go between and figure out first, what the form is and where to find it; second, explaining to the doctor or nurse that they are supposed to fill out the form; [and] third, going back and forth between TRICARE and the doctor office to get it completed and sent back to TRICARE. I typically will send this form to the doctor office myself and get them to send it to me so I can send it directly to TRICARE. This is a burden on both the providers and the family and causes unnecessary delays in services. The diagnosis and referral alone should be adequate information . [. . .]” ~ Written comment to committee from BCBA in Tennessee
SOURCE: Committee generated from public input.
Services’ EFMP.9 The Office of Special Needs can provide additional assistance to military families through educational resources and other services.
Family members have expressed concerns that both enrolling in EFMP and registering for ECHO can exceed 90 days and that they were not notified or were unaware of the 90-day provisional ECHO registration between getting the autism diagnosis and receiving ABA services (NASEM, 2024a).10 See Figure 3-2 for an illustration of steps required to participate in both programs.
Of concern, many duty locations have been shown to be oversaturated with EFMP families cleared to make a PCS (GAO, 2018b). In addition, a survey of families enrolled in EFMP found 25% noted that based on services received through EFMP, their families favored leaving the active-duty military (Office of People Analytics, 2022). See Box 3-5 for additional discussion on EFMP enrollment and barriers to care.
Assignment to an Autism Services Navigator
Assignment of an ASN was added in the March 2021 ACD policy update. Initially, ASNs were only assigned to new enrollees. As of January 2025, all ACD participants are required to have an ASN to obtain ABA services.
The ASN is employed by the regional contractor and holds a current, valid, unrestricted license (e.g., registered nurse, clinical psychologist, or other licensed mental health professionals with experience in care management and pediatrics, behavioral health, and/or autism). Of note, both professional behavior analysts and assistant behavior analysts are excluded from serving as an ASN (DHA, 2023a). While the ASN is intended to be the primary health advocate and point of contact for the beneficiary and that person’s family, their primary function during enrollment is to develop and update the CCP. CCPs are developed by the ASN in conjunction with the family after the regional contractor verifies the beneficiary’s referral. The CCP is used to set goals, track timelines for outcome measures and authorization dates, connect patients with additional clinical and nonclinical resources (including those beyond ABA), and provide discharge, moving, or transition support. There is a 90-day window for the ASN and the parents/family to devise the CCP. ABA services can begin during this time; however, if the CCP is not completed within 90 calendar days as a result of family/beneficiary noncompliance, ABA services are suspended
___________________
9 Established in 10 U.S.C. § 1781c.
10 See additional comments from the virtual public session from April 12, 2024, where military families were invited to share their experiences with ACD at https://www.nationalacademies.org/event/41985_04-2024_independent-analysis-of-the-comprehensive-autism-care-demonstration-program-virtual-information-gathering-session-3
BOX 3-5
Illustrative Example of Family Experience with the ACD
As someone who has been involved with the ACD since its inception and even before, during the ECHO Autism Care Demonstration, I have experienced the various iterations of ABA coverage available to military-connected families. Over the course of the last 16 years, three of my four children have enrolled in ABA services through TRICARE. For all three, we have experienced numerous challenges and barriers to receiving care; however, services were impacted the most for my twin daughters, now adults, who both have profound autism.
The greatest difficulty we faced was when we would go through a PCS. First, when we would try to coordinate with the Air Force EFMP, we were offered duty assignments that would lack sufficient services and supports for ABA, despite the information the EFMP office had. The out-of-date TRICARE provider network directories were a constant issue. I had to personally work with EFMP offices on updates to the providers to show that they weren’t actually available. Other times, the directories would list location assignments as “expedited” despite only having a small number of in-network providers, which would lead to an oversaturation of EFMP families and in turn lead to increased wait times for families in the area.
My daughters engage in self-injurious behavior, particularly when faced with abrupt changes to their daily schedules. The disruptions we experienced in receiving ABA services were extremely detrimental to my daughters’ ability to progress with their treatment goals and reduction in self-injurious behaviors. As a result, our entire family was adversely impacted as we tried to help them maintain a sense of consistency in their lives.
In 2021, the ACD policy update further limited our options of providers by excluding reimbursement for the use of crisis management and 2:1 support—both of which have been essential for my daughters’ safety and ability to thrive. ABA
“through the duration of the existing authorization or until the CCP is complete, whichever occurs first” (DHA, 2023a, para. 6.2.2).
See further discussion in Chapter 4 on best practices for care navigation or care coordination and the process of the ASN assignment through the ACD.
Active Provider Placement
TRICARE has access-to-care standards, which are specified in regulation. In the relevant part, 32 C.F.R. 199.17(p)(5) requires that the wait time for an appointment for a specialty care referral shall not exceed four weeks. Additionally, the travel time for specialty care shall not exceed one hour under normal circumstances, unless a longer time is necessary because of the absence of providers (including providers not part of the network) in the area. Within the ACD, DHA further requires that beneficiaries be
providers in the TRICARE network who are willing to work with my daughters’ severity level became scarce, as they would have to do so without being able to ensure their safety or that of their peers and therapists. This policy change has made it all that much more challenging for my family to continue ABA services that my daughters continue to need.
Transition from ABA services is not possible for my daughters, as doing so would essentially leave them homebound. Currently, we continue ABA through the ACD with the help of supplemental Medicaid insurance that covers those services TRICARE will not reimburse. Many other military-connected families are unable to access Medicaid waiver services and do not have this option.
Before we were able to utilize Medicaid, our daughters would sit for over three months after a PCS waiting to restart their ABA services after being turned away by providers unable to support their needs. During that time, my daughters regressed and engaged in an even higher-intensity level of self-injurious behaviors, and our family suffered as a result.
I have received questions whether my daughters’ age is a factor and whether continuing ABA would be beneficial. Thanks to their dual coverage, my daughters have continued to move forward and thrive in their acquisition of skills and greater independence as adults.
We decided to retire after 20 years of service even though my husband could have stayed in an additional four years. We did so in order to avoid another PCS and another round of trying to find providers that could care for our family. In a few years, we will lose Medicaid coverage and have to rely solely on TRICARE to cover ABA services once again, putting my daughters’ progress at risk. Our family served the country with the promise from DoD that the most medically fragile and vulnerable of our military community would be taken care of, and we feel that promise has been broken.
SOURCE: Personal experience of committee member Jennifer Penhale.
placed with the first available ABA provider who meets the criteria for accepting new referrals. The managed care support contractors are required to complete the active provider placement process within 15 business days (DHA, 2023a, para. 9.3.11.6.1). Families are able to decline the assigned initial provider if they have other preferences (e.g., location, time of day, or day(s) of services; DHA, 2023a) and instead can, as identified in a parent toolkit, utilize the TRICARE ABA Provider Directory to select an available ABA provider in the network (HNFS, 2024, p. 17).
DHA provided that the average number of days between verified referral and the first date of services for an assessment was 23–43 days in 2023 (see Appendix C, Question 7). Throughout the ACD history, however, wait times have been longer—for example, reaching a peak of 68 days in FY 2022 (DoD, 2023d). In 2023, 68% of beneficiaries with authorized care accessed ABA services within the 28-day access-to-care requirement regardless of waiver status.
Of note, 47% of the new referrals declined an available provider in favor of waiting for a preference (location, provider, or date). About 9% of families referred to the ACD did not complete enrollment. Reasons for lack of completion include but are not limited to the following: beneficiary did not meet ACD eligibility requirements (i.e., no diagnosis of autism), beneficiary ineligible for TRICARE, or parents declined ABA services (see Appendix C, Questions 8 and 9).
Families have expressed concerns that the provider directory is out-of-date, duplicative, and inconsistent with the availability of actual care, primarily since approval for a PCS depends on the availability of directory-indexed services (these perspectives appear in Box 3-6).11 This can affect military transfers. A recent report from the United States Marine Corps (USMC) compared TRICARE’s online provider directory with provider log data maintained and
___________________
11 A PCS is a long-term assignment or transfer of a service member to a new duty station that typically lasts between two and four years. This means that in addition to the stress of moving, families need to navigate finding ABA care at their new duty station. The EFMP was established to ease the difficulties surrounding station assignment and moving for families with dependents with special needs; however, in practice, assistance is not seamless, and several challenges persist (GAO, 2018b; Office of People Analytics, 2022).
BOX 3-6
Family Perspectives—Permanent Changes of Station
The committee’s information gathering included listening sessions and a call for public input to understand experiences with the ACD and ABA. While not designed to be representative and reflect the full range of perspectives or experiences of individuals and military families, this information provided important context for understanding the experience of those enrolled in the ACD and those receiving or providing ABA services, as well as the experience of those living with autism. This input served as a backdrop for the committee’s review and assessment of the available empirical literature and provided context for, though not the basis of, its conclusions and recommendations. This box presents some of the comments that the committee received regarding PCS and the challenges of navigating continuity of care and finding new diagnosing and ABA providers.
“We almost were denied [moving] to Fort Jackson, even though [my husband] was told that he needed to come here. They said [. . .] ‘We don’t have any services for you’ [. . .] And so since I had [the] flexibility to reach out to ABA services, we were able to get a letter assuring that our son would receive services in a year [. . .] Due to all of those barriers to care, we had to fight for a couple of months, just to be able to move to where the Army said we were supposed to go.” ~ Public comment from Army parent of a son with profound autism at April 12, 2024, public session
regularly updated by the USMC EFMP and found a drastic difference in the actual availability of ABA providers (Starego, 2023). A recent U.S. Government Accountability Office (GAO) report pointed to disparities between military installations regarding the availability of services, which can hinder beneficiaries’ searches for providers. This can leave families feeling the impact of inaccurate provider networks as they are already dealing with challenges in maintaining continuity of care in education, health care, and family support (Hill & Blue-Banning, 2023). The report recommended that DoD (a) assess the accuracy of behavioral health provider listings and ensure they are comparable to the overall directory accuracy and (b) periodically monitor the accuracy (GAO, 2024).
Completion of Baseline Measures and the Initial Treatment Plan
All baseline measures are completed prior to initiation of ABA treatment services (see Box 3-2 for required assessments). The PDDBI-Parent Form is to be administered by the ABA Supervisor conducting the assessment. If any of the other measures were not complete by the diagnosing provider, another authorized provider including the beneficiary’s ABA provider can administer the remaining measures (DHA, 2023a).
“[My daughter’s] provider didn’t know how to do the EFMP forms to get her into the program, and we were facing a PCS [. . . and] in the nine months between being diagnosed and moving, she was not enrolled in EFMP. She did not receive any ABA services because we had this barrier of our provider [not knowing] what to do.” ~ Public comment from Navy parent of a young child with autism at April 12, 2024, public session
“It’s now been half of our three-year tour here in New York, and we’ve only just begun ABA therapy in-home a few weeks ago. Our family has felt the emotional toll that has come with all the waiting [. . .]” ~ Public comment from military spouse at March 6, 2024, public session
“[. . .] The waitlist in El Paso to just be evaluated is almost a two-year waitlist, which is absurd for those families that have to change duty stations frequently. This means they will never get the chance to be seen.” ~ Written public comment from a military parent in Texas
“[. . .] Once both children had new [diagnoses] in July 2023, [we] began the fight to find an ABA provider that accepts TRICARE. It has cost our family 16 months of time that could have been served with treatment. Sixteen months waiting after coming out of COVID and a new PCS; our children have struggled in so many ways. [. . .]” ~ Written public comment from Coast Guard parent in New York
SOURCE: Committee generated from public input.
The initial ABA assessment also includes the development of a treatment plan and goals that will be worked on during ABA. Treatment plans also contain goals for parents including participation in their child’s treatment. Once the initial ABA assessment is complete, including the development of an initial treatment plan, the ABA provider submits a request for ABA services to the regional contractor. The regional contractor then completes a clinical necessity review and subsequently approves for a six-month treatment authorization.
Families have expressed concerns about additional delays between the initial assessments, authorizations of services, and eventual receipt of ABA.12
CONCLUSION
Coverage of ABA services through the Military Health System has evolved since 2001 when first introduced under the PFPWD. Such changes have been responsive to developments in the delivery of ABA for autistic individuals as well as to external feedback, be it from congressional oversight, legal challenge, or parent advocacy efforts. Several changes have improved military families’ access to ABA services including the 2015 removal of dollar caps on care, the alignment of cost-sharing with other specialty medical care, as well as applying cost-shares for ABA services toward the TRICARE catastrophic cap that helped ease the financial burden on military families pursuing ABA services. The 2021 policy revision allowed current referrals to ABA to transfer with beneficiaries during moves, without requiring a new appointment with a diagnosing/referring provider, easing some of the stress associated with family relocations. Additionally, ACD participation does not restrict ABA services based on age and extends to all beneficiaries regardless of whether they are active-duty or retired.
As discussed in Chapter 4, advances in the field of ABA are relatively new, most beginning after the start of the ECHO Enhanced Access to Autism Services Demonstration in 2008. ABA is carried out by providers who were not typically certified or licensed in the past but now can be. ABA is more intense than other interventions for autism and often is administered outside of clinics. There have been important changes in providing access to ABA through medical systems and insurance that have occurred after the ACD began (see Chapter 4).
___________________
12 The committee received multiple written comments from military parents, as well as ABA providers, on some of the delays they experienced in accessing ABA. See also comments from the virtual public session held April 12, 2024, at https://www.nationalacademies.org/event/41985_04-2024_independent-analysis-of-the-comprehensive-autism-care-demonstration-program-virtual-information-gathering-session-3
As DHA has yet to determine if ABA services meet the standards of reliable evidence to be considered medically effective or proven care, ABA services are covered under the ACD while DHA continues to evaluate how to characterize ABA for coverage as a TRICARE Basic benefit.
Participation in the ACD to access ABA requires ADFMs to enroll in EFMP and ECHO. Families have raised issues of delays in EFMP enrollment, ECHO registration, and clinical reviews of treatment plans in addition to the wait times that currently exist in healthcare systems regarding diagnosing autism and identifying qualified ABA providers. Military-connected families dealing with a new autism diagnosis report feeling burdened by completing all the necessary enrollment requirements to participate in the ACD.
DHA’s 2021 policy revision aimed to shape the ACD to become a more beneficiary- and family-centered program. Some revisions to the policy did result in positive perceptions on the access to and delivery of ABA services, including the revised definitions for referring and diagnosing providers, availability of parent toolkits, and the adoption of new CPT codes. However, other policy revisions have resulted in significant burdens for participating families as well as the ABA providers that serve them (see further discussion of these burdens in the chapters that follow).
This page intentionally left blank.
