The Comprehensive Autism Care Demonstration: Solutions for Military Families (2025)
Chapter: 7 Keeping Pace with Autism and ABA Developments
7
Keeping Pace with Autism and ABA Developments
As directed under section 737 of Public Law 117-81, as amended, the committee was asked to provide an independent analysis of the Comprehensive Autism Care Demonstration (ACD). In doing so, we were asked to examine the methods used under the demonstration and the utilization of the ACD by military-connected families and review industry guidelines for providing applied behavior analysis (ABA). This analysis also required assessing the state of evidence on ABA.
The ACD was created in 2014. It was originally set to expire in 2018, but since the Defense Health Agency (DHA) was unable to determine if ABA met Department of Defense’s (DoD’s) hierarchy of evidence criteria, the demonstration was extended. This extension allowed DHA to continue to provide ABA services to military-connected families while also continuing to evaluate the appropriateness of ABA under TRICARE.1 During the past decade of ACD’s existence, much has transpired in the autism and ABA communities.
In undertaking this study, the committee gathered information from military families, ABA providers, researchers, and other stakeholders in the autism community in addition to conducting its own review of the scientific literature and data available on ACD participants and the program. During its review, the committee recognized that the unique experiences of military-connected families needed to be considered as well as three major
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1 TRICARE is the federal healthcare benefit program for military-connected families administered through the DHA in DoD, serving approximately 9.6 million beneficiaries including active-duty personnel, reserve component personnel, military retirees, and their families.
developments: (a) the advancing understanding of autism, its diagnosis, and interventions; (b) professional growth in the ABA industry; and (c) changes in ACD operation and policy over time.
SUPPORTING MILITARY FAMILIES
For military-connected families with autistic dependents, there are many challenges and stressors that come with maintaining a military career and being of service to the nation and simultaneously managing the healthcare needs of autistic individuals and the well-being of the entire family. The committee heard from families about a variety of stressors; these can include frequent relocations with adjustments in care and reassignment to healthcare providers, changes in schools and educational environments, deployed parents, increased responsibilities for non-deployed caregiver(s), lapses in care, challenges for siblings, etc. Such stressors are not limited to the list above nor pertinent to all families, but they can have a significant impact on many families. The nature of services and supports available to military-connected families plays a large role into whether these challenges and stressors affect a service member’s readiness for duty and focus on the mission as well as the decision to remain in the military (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019).
Many active-duty families, those in the reserves, and retired military families who are TRICARE-eligible have chosen to use the ACD to access ABA services for their autistic dependents. These beneficiaries include not only young children but adolescents and dependent adults as well. As discussed throughout this report, many family members as well as ABA providers have expressed concerns about navigating the policies and requirements of the ACD. Some of these concerns involve (a) the multiple steps to enroll in the ACD and maintain access to ABA services (see Chapter 3), (b) availability and turnover in ABA providers who serve TRICARE clients, (c) requirements for caregiver training and a specified set of assessments that add extra burdens to receipt of care, and (d) restrictions that prohibit delivery of ABA to meet individuals’ health needs (discussed in Chapter 4 and below). It is worth noting that, despite these concerns, many families and ABA providers have persisted in participating in the ACD because they value the positive progress their children/clients often make when supported with ABA, they have seen ongoing improvements in the delivery of ABA, and they have a sense of dedication to military families and such service to the nation.
A prior report (NASEM, 2019) determined that the structure of DoD’s family support systems, notably policies that allow for greater flexibility to accommodate diverse needs and preferences, has important implications for service member retention and readiness. Military-connected families
and their advocates reported to this committee that having the flexibility to seamlessly access and administer ABA services in ways appropriate to their children’s needs would be valuable. Steps taken to ensure that services and supports are in place wherever the family may be located would also be critical. In the current environment, active-duty military families are more likely now than in the past to live off-installation and tend to be geographically dispersed (DoD, 2017a, 2022a; NASEM, 2019).
AUTISM DIAGNOSIS AND INTERVENTIONS
A significant shift occurred with the release of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (APA, 2013) in 2013 (Yaylaci & Miral, 2017), which consolidated previous subtypes Asperger’s Syndrome, Pervasive Developmental Disorder–Not Otherwise Specified, and Autistic Disorder into a single diagnosis of Autism Spectrum Disorder. This change reflected a growing understanding that autism spectrum disorder or autism, as used in this report, manifests across a spectrum of symptoms and severities rather than as distinct conditions. Expanding standardized diagnostic tools and clinical guidance has enabled a broader range of licensed providers to diagnose children with autism and manage their care and referrals (see Chapter 2).
Ten years ago, the Centers for Disease Control and Prevention (CDC) reported the prevalence of autism among eight-year-olds as 1 in 67 (based on 2010 data) and now it is 1 in 31 (based on 2022 data). Prevalence estimates among children under age 18 in the United States have varied by data source, but all indicate an upward trend in the diagnosis of autism.2 Of note, a recent study found that the percentage of eight-year-olds with profound autism (highest severity) among those with autism was 26.7% using CDC data from 2000–2016 (Hughes et al., 2023). Data to compare the prevalence of autism within the military population to that within the general population are limited (see discussion in Chapter 2).
For children and individuals diagnosed with autism, there are many appropriate interventions that span behavioral, developmental, educational, social-relational, pharmacological, and psychological supports. Some services, including occupational therapy, physical therapy, and speech language pathology, are covered as TRICARE Basic benefits under TRICARE. ABA is currently provided to TRICARE-eligible beneficiaries only through the ACD because DHA has yet to determine if ABA meets its hierarchy of evidence criteria to be covered as a Basic benefit (see criteria in Chapter 1, Box 1-1, and Appendix E).
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2 For a description of autism prevalence estimates and data sources, see https://www.cdc.gov/ncbddd/autism/data/index.html
State of Evidence for ABA
Since the inception of the ACD, DHA has consistently indicated there is not sufficient evidence of the efficacy or effectiveness of ABA for autistic individuals. As the ABA field has developed over the past decade, research on ABA has progressed as well. The committee’s conclusion is that there now is a substantial body of literature, supported by multiple meta-analyses, indicating strong evidence of efficacy and effectiveness (see Chapter 5). The positive effects of comprehensive ABA programs have been replicated across multiple controlled trials, including randomized trials, systematic reviews, and meta-analyses, and the strength of that evidence is increased when inclusive of focused intervention practices.
Conclusion: There is a substantial body of literature, supported by multiple meta-analyses, indicating strong evidence of efficacy and effectiveness of applied behavior analysis (ABA) as an appropriate intervention to support autistic individuals with a range of ABA practices suitable for older individuals as well as younger children. While additional studies will be useful, the totality of evidence for ABA is robust and meets standards of the evidence-based practice framework and Department of Defense’s own criteria of reliable evidence.
Range of ABA Practices
ABA is the use of behavioral practices—applied singly (e.g., reinforcement, prompting) or in combinations (e.g., functional communication training, naturalistic intervention)—to promote important health and behavioral outcomes. A common misconception is that ABA is one practice, but it is in fact a set of different intervention practices grounded in the science of learning. There are two classifications of interventions: (a) focused intervention practices and (b) comprehensive programs (see Chapter 5). Focused interventions use sets of ABA strategies to address specific goal areas (e.g., communication, toileting). Comprehensive programs address goals across developmental areas but vary in terms of structure, setting, and goal focus. Therapists, clinicians, and other trained professionals employ ABA practices to address autistic individuals’ personalized learning, behavioral, and health goals. ABA program developers sometimes establish a guiding conceptual framework to organize the focused intervention practices into formal comprehensive programs. As a result, there are a broad range of ABA-based approaches that can be adapted to address the complex health outcomes (e.g., communication, behavior, adaptive skills) of autistic individuals. ABA has been used to complement other medically necessary services as part of a holistic developmental plan for optimal health outcomes (see Chapter 2).
Health Outcomes
To address the charge to examine health outcomes, it was important for the committee to agree on a working definition of health outcomes. The committee adopted the definition Lamberski (2022) provided: “A health outcome refers to both physical and psychological well-being and takes into account the length of life as well as the quality of life” (p. 1). Notably, there are interactions between physical health and psychological well-being that can have significant effects on behavioral health (National Research Council & Institute of Medicine, 2009). Examples of such outcomes related to autism include improvement in cognitive skills and executive functioning (i.e., which reflect a broad range of problem-solving in daily life), social communication, activities of daily living (ADLs) and other adaptive skills, reduction of sleep disorders, reduction and replacement of behaviors that may be harmful (e.g., self-injurious behaviors, meltdowns), as well as amelioration of depression, anxiety, and other mood states. Such outcomes, as well as others that address physical and psychological well-being, may well be viewed as outcomes for ABA services.
Perspective on Dose Response
DHA emphasis on dose response of ABA, similar to measuring out a vaccine that can cure or prevent disease, reflects a misunderstanding of ABA services and practice. It conveys a perspective that ABA is one entity that is delivered in units, with the expectation that there will be a similar dose response across autistic individuals. This conceptualization under represents the heterogeneity of the autism population as well as the heterogeneity of ABA practices that can be used in the pursuit of individual therapeutic goals. Interpretations and positions on the amount of ABA necessary are still under debate by both practitioners and researchers (see Chapters 4 and 5). Given the heterogeneity of the population as well as ABA practices, the committee does not endorse a blanket recommendation that all individuals with autism should receive a uniform amount of ABA. The decision about the number of hours per week of direct ABA services necessary to support changes in health outcomes should be developed by a professional behavior analyst based on (a) the number and type of goals being addressed in the intervention, (b) consideration of other services being provided to the client, (c) the client’s learning rate, and (d) family and client input. The standard practice of regularly evaluating progress toward goals (discussed in Chapter 4 and below) is seen as a critical step for determining if the treatment intensity is serving the client and family well and whether the intensity should be adjusted.
DEVELOPMENTS IN THE ABA INDUSTRY
In the past 10 years, the ABA industry has seen developments in ways to professionalize the delivery of ABA services and establish its position within the healthcare system. See Chapter 4 for details on the following:
- In 2019, Category I Current Procedural Terminology (CPT) codes were issued for ABA services, replacing the temporary Category III billing codes issued in 2014. This process through the American Medical Association CPT Editorial Panel required extensive documentation of research demonstrating the efficacy of the services in order to meet its evidence hierarchy.
- In 2016, healthcare provider taxonomy codes for Behavior Analyst, Assistant Behavior Analyst, and Behavior Technician were issued by the American Medical Association National Uniform Claim Committee.
- Starting in 2007 through 2019, all 50 states had adopted laws or had guidance requiring certain commercial health plans to cover ABA for autistic individuals. As of 2018, 45% of companies with more than 500 employees included coverage for ABA services for their beneficiaries with autism. ABA services are covered care under Medicaid, the Civilian Health and Medical Program of the Department of Veterans Affairs, the Federal Employees Health Benefits Program, the Children’s Health Insurance Program (CHIP), and a majority of self-funded health plans.
- From 2009 to 2024, 38 states adopted behavior analyst licensure laws.
- Requirements for credentialing of ABA providers developed by the Behavior Analyst Certification Board, a national nonprofit organization, have been promulgated. The organization issues two professional-level certifications, the Board Certified Behavior Analyst and Board Certified Assistant Behavior Analyst, as well as a credential for paraprofessionals, the Registered Behavior Technician (RBT). All of the requirements for certification include levels of education, training, experience, examination, adherence to an ethics code, and, in some cases, ongoing supervision.
- The first edition of guidelines and standards of ABA services for autistic individuals was published in 2012 by the nonprofit Behavior Analyst Certification Board. Upon transfer of the responsibility to review and update guidelines and standards to the nonprofit trade association Council of Autism Service Providers, the third edition was published in May 2024.
Tiered Delivery of Services
Routine implementation of ABA services in clinical settings involves tiered delivery of ABA interventions to clients, with technicians (e.g., RBTs) often acting as the direct service providers while professional behavior analysts monitor and supervise their service delivery (see Chapter 4). While the introduction of the tiered delivery model and role for RBTs was created to address ABA provider shortages and increasing caseloads, this delivery model has become a common approach to delivering ABA in the United States and is accepted by private insurance companies and federally administered programs such as Medicaid. Additionally, a tiered delivery model is often used within the context of published controlled trials of ABA comprehensive programs (Cohen, Amerine-Dickens, & Smith, 2006; Rodgers et al., 2020; Waters et al., 2020).
When implemented appropriately, a tiered delivery model improves provider availability and increases opportunities to support autistic individuals in cost-effective ways.
Caregiver Involvement
While caregiver involvement in ABA programs can be beneficial for autistic individuals, parents and families vary in their capacity for implementing and/or supporting ABA therapeutic practice. For some families with limited resources, such enforced involvement could be iatrogenic in that it could lead to greater family stress rather than less. The uniqueness of the military lifestyle with frequent relocations and deployments likely creates additional challenges in caregiver involvement.
The ACD currently requires parent training in ABA interventions as a condition for reauthorizing ABA services for their children (see Chapter 4). Incentivizing caregiver involvement and providing coverage for caregiver training delivered by ABA providers is valuable. However, requiring such parent participation, with penalties to the ABA providers if not completed, in order to receive ABA services is concerning, especially when research indicates that the most effective forms of caregiver involvement will vary, moderated by families’ capacity to engage and the nature of personalized ABA services (Rovane, Hock, & January, 2020; Stahmer et al., 2015).
Best Practices for Individual Assessment of Progress with ABA
As discussed in Chapter 4, there is convergence in the ABA field that assessment of a client, particularly initial assessment, should be comprehensive and individualized, aimed at identifying each person’s strengths, needs, and preferences, and those of their families. This involves review of
information from many sources and assessments of the individual’s skills across developmental and adaptive domains (including any existing medical and developmental records, interviews of clients as feasible and their caregivers, and standardized and non-standardized assessments) as input to developing treatment plans. Within the autism community, there has been concern expressed that healthcare delivery and funding systems are trying to mandate the use of specific assessment tools for diagnosis and treatment (Bishop & Lord, 2023). This can be harmful for a number of reasons. Given the heterogeneity of the population, the diagnosis itself is less likely to be useful for treatment planning and progress monitoring than a complete profile of the person’s cognitive, communication, and adaptive behavior skills, and other co-occurring behavioral and medical conditions. Additionally, many of the tools are not normed on minoritized communities, who can present differently in the diagnostic setting.
ABA standards (see Chapter 4) encourage ABA providers to push back if the funder or their employer is requiring assessments that are not appropriate for the client. The selection of instruments, procedures, and sources of assessment should always be driven by what is appropriate and meaningful for the individual client (Green, 2024).
ACD OPERATION AND POLICY
The ACD was created and continued to operate during a period of significant changes within the autism and ABA communities. Like for any complex chronic condition, there have been significant changes in the understanding of autism and treatments and supports for it over the past decade. At the time the ACD was initiated, ABA had emerged as a promising intervention for autism. Since then, ABA has been recognized as an evidence-based practice for health and well-being needs for autistic individuals, and the practice field has taken steps to establish ABA services in the healthcare system.
During its history of providing ABA services to military-connected families through the ACD and other mechanisms, DHA has had to be responsive to external feedback, be it from congressional oversight, legal challenge, or parent advocacy efforts (see Chapter 3). While some of the publicly reported rationale for the 2021 policy revisions and clarifications claimed to shape the ACD as a more beneficiary- and family-centered program (DoD, 2023c), the impact of the administration of the 2021 changes has resulted in significant burdens for families and ABA providers (see Chapters 3 and 4). The 2021 changes included a number of mandatory requirements in order to participate in the ACD and access ABA services: (a) coordination with an Autism Services Navigator (ASN) and completion of a comprehensive care plan prior to initiating and continuing ABA services, (b) completion of
a specified set of assessments prior to and during receipt of ABA in order to access and maintain such services, and (c) a minimum number of hours of caregiver training every six months during receipt of ABA. These changes and clarifications also included some restrictions on how ABA could be delivered to ACD participants: (a) treatment goals are limited to the core symptoms of autism; (b) ABA services in community settings other than the home, clinical office, school, or telehealth are prohibited; (c) ABA services provided in schools by registered technicians are prohibited (can only be delivered in schools by supervising behavior analysts with prior approval); and (d) only some of the CPT codes approved for ABA are authorized for use with ACD participants (see details in Chapters 3 and 4).
In its review, the committee determined that some of the restrictions on services do not adhere to industry guidelines and standards of care. It further found that other policies align with industry guidelines but include stringent requirements or extra administrative burden that may affect access to care. It felt that the newly established role of ASN was not being used in ways consistent with the purpose of care coordination and navigation (see Chapter 4). It also questioned the extensive collection of data from ACD participants and their families. The committee identified several issues that raised ethical concerns about the data collection practices associated with the ACD: (a) requiring parents/caregivers to complete time-consuming and at times intrusive assessments (questionnaires and instruments) without feedback on how the data will be useful in the ABA services and treatment planning; (b) requiring the completion of the specific set of assessments prior to the delivery of ABA and at regular intervals thereafter, and withholding ABA if that is not done; and (c) failure to match data collection with a well-articulated purpose. As discussed further below (and in Chapter 6), the data collected are largely without value for evaluative purpose or treatment planning.
Assessment Tools (aka “Outcome Measures”)
DHA’s collection and analyses of data from a set of standardized assessment tools (the Vineland Adaptive Behavior Scales, Third Edition [Vineland-3]; Social Responsiveness Scale [SRS]; Pervasive Developmental Disorder Behavior Inventory [PDDBI]; and Parenting Stress Index–Short Form [PSI-SF] or Stress Index for Parents of Adolescents [SIPA]) has been highly criticized on several grounds: (a) the psychometric value for the ACD population (Frazier, 2024), (b) the practical value of requiring them for treatment planning (Green, 2024), (c) the appropriateness or feasibility of using them to assess the outcomes of ABA services (NASEM, 2025), and (d) misuse and misinterpretation of data from the measures and improper conclusions drawn (Cohen, 2019, 2020). See Chapter 6.
The use of the term “outcome measures” by the ACD to describe this collection of assessments is a misnomer and misleading. Through its review, the committee determined that this set of assessments was not validated for the purpose of measuring outcomes in the ACD population nor was the rationale for requiring this specific set of assessments for the delivery of ABA and clinical care or for program evaluation ever clearly articulated or justified. Rationales in the TRICARE Operations Manual and public information online point to the general need for treatment planning. However, as reported to and observed by the committee, much of the data collected since 2017 has yet to be examined.
The committee argues against the continuation of data collection from these assessment tools. We generally think the dataset is not useful enough to address questions around ABA, autism, or the effectiveness of the ACD program to be worth the burden of administering the assessments periodically to participating families. There are a number of problems with these data, including the absence of a data collection plan, missing dates, and varied observations (assessments) among individuals, that limit the usefulness of these data to assess effects of ABA on health outcomes. There is also a range of concerns about these particular instruments for treatment planning and an assessment-driven approach to the delivery of ABA. See Chapter 6 for further elaboration on these points.
ACD’s Analytic Methods Are Not Research
The analyses in the reports by DoD to Congress were not set up to drive scientific findings because they did not have appropriately matched comparison samples from which to draw generalizable conclusions. They also did not take into account the individual goals of the intervention for each client, possible mitigating factors, and the clinical significance of the scoring (Cohen, 2020, 2024). DHA’s analyses have relied primarily on data from the PDDBI, notably the changes in the parent-reported composite score (PACS), since the PDDBI was the only tool administered every six months over significant periods of data collection (see quarterly reports to Congress on the ACD for FY 2018, Q4; FY 2019, Q1–Q4; and FY 2020, Q1 [DoD, 2019c,d,e, 2020b,c,d] and annual reports for FY 2019 and FY 2020 [DoD, 2020a, 2021b]).
These analyses have been criticized by scientists, the autism community, and the PDDBI co-developer as poorly designed and presenting flawed observations and conclusions (Cohen, 2020, 2024). Nonetheless, initial findings from these analyses may have played a role in significant changes to the ACD, given that DHA observed, “[T]hese findings demonstrate the current format of the ACD and delivery of ABA services is not working for most TRICARE beneficiaries in the ACD” (DoD, 2020d).
To date, DHA’s analyses have been primarily descriptive and limited to one measure (PDDBI PACS). There has been no comparison group, nor could there be, and there is limited consideration of covariates and confounding factors.3 The analyses appear to be ad hoc and limited to simple change analysis, based more on a specific reporting period (three months or a year) and extenuating circumstances (e.g., hiccups in data collection and changes to ACD policy) than on a rigorous plan to determine variables that affect outcomes. Given the exceptional heterogeneity in autism and the limited samples from the ACD population analyzed by DHA, any generalizations about ABA effectiveness in these reports are inappropriate. DHA has appropriately called attention to limitations to the data and recognized that no determinations of effectiveness can be made from their analyses and that any findings reported should be interpreted with caution (DoD, 2024b). Furthermore, DHA has specifically reported that it is not conducting research (DoD, 2024b) nor evaluating effectiveness of ABA for supporting the needs of autistic individuals (see Appendix C, Questions 34, 37, 38, and 39).
Program Evaluation
Demonstrations can be a useful way to test new approaches to providing coverage and delivering services that could reduce costs and improve beneficiaries’ outcomes. Evaluations are essential to determining whether demonstrations are having their intended effects (GAO, 2018a).
In response to questions from the committee about the existence of an evaluation plan for the ACD, DHA said that announcements in the Federal Register Notices since 2014 outline the objectives of the demonstration and represent DHA’s public evaluation plan for the ACD (see Appendix C, Questions 35 and 36 for DHA’s response, and see Appendix E for excerpts from the Federal Register Notices on the ACD’s purpose and objectives). These objectives include such items as examining provider qualifications, patient safety, fraud prevention measures, reimbursement methodology and rate for ABA services, and feasibility of beneficiary cost share. It is not clear to the committee how data from the specific set of assessments required as part of the ACD would address these particular objectives.
Successful program evaluations are preceded by development and adoption of a solid evaluation plan with clearly stated objectives and timeline, measurable questions tied to the objectives, quantifiable hypotheses, and
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3 While receiving ABA and participating in the ACD, scores on assessments for autistic individuals can be impacted by a number of factors, such as inconsistencies in their environment (e.g., moving), medications, co-occurring conditions, and location of treatment (e.g., geographic areas with limited services).
methodology outlining data to be collected and appropriate analyses to test the hypotheses. Development of an effective evaluation plan should also consider the risks and benefits to participants in undertaking the evaluation. The risks of program evaluation should be no more likely than usual care, and therefore, participation, whether known or unknown in program evaluation, would be unlikely to restrict reasonable decision making or involve any restriction on the care provided. There is no requirement for obtaining informed consent if risks are low, though notification at entry is respectful. DHA did not have an evaluation plan that tied the collection of data from selected assessment tools to clearly stated objectives and that considered the risks to the delivery of care.
Conclusion: The current approach and use of assessment tools under the Comprehensive Autism Care Demonstration (ACD) is not appropriate for the ACD purposes. Neither an evaluation plan nor research study has been appropriately designed and articulated to inform how data from these tools will address questions of interest for the demonstration or Congress. Further, their required use has placed additional burden on families and providers with limited benefit for treatment planning.
RECOMMENDATIONS
The committee offers the following recommendations to improve the delivery of ABA services to TRICARE-eligible beneficiaries within military-connected families.
Scientific evidence has shown that ABA is an appropriate intervention to support health and medical needs of autistic individuals. It is the committee’s view that ABA fits DoD’s Criteria for Reliable Evidence of Proven Medical Effectiveness (see Chapter 5).
Recommendation 1: The Defense Health Agency should discontinue the Comprehensive Autism Care Demonstration and authorize coverage of applied behavior analysis (ABA) as a Basic benefit under the TRICARE program. It should also immediately take steps to identify authorized ABA providers (to include coverage of the tiered service model and behavior technicians) and define their authority, move ABA Current Procedural Terminology codes off the No Government Pay List, establish reimbursement rates consistent with other TRICARE benefits, and ensure its policies align with current generally accepted standards of care.
Since 2017, the ACD has engaged in an onerous collection of data from participants without clear purpose for doing so. Such data derive from
required assessment tools administered periodically. These tools include the PDDBI (both parent and teacher forms), the Vineland-3 (parent or teacher form), the SRS-2 (parent form), and the PSI-4-SF or SIPA. The committee recommends removing the requirement to administer these particular assessment tools and ceasing the data collection from them. These tools have not been used appropriately for purposes of research or program evaluation, and there are many concerns about their utility for treatment planning. One specific assessment tool or set of tools will not be appropriate to obtain the information needed to develop an appropriate treatment plan or evaluate progress with ABA for every autistic individual given the heterogeneity of autism. The committee recognizes, however, that regular assessment and use of assessment tools are valuable to the delivery of ABA. Determination of appropriate tools to measure progress on goals for individual clients should be made by supervising behavior analysts in consultation with other healthcare or measurement professionals and families. For military families who are likely to relocate often, behavior analysts should also consider assessment approaches and goals from prior ABA providers to maintain continuity in care and track developmental progress over time.
Recommendation 2: The Defense Health Agency (DHA) should immediately halt the requirement to periodically administer a specific set of assessment tools (PDDBI, Vineland-3, and SRS) purported to monitor health-related outcomes of applied behavior analysis (ABA) and the administration of parenting stress indices. There is no well-designed evaluation plan for the demonstration program that justifies the use of the assessments, and this data collection has placed growing burdens on military-connected families, ABA providers, and DHA itself in the delivery of ABA services.
DHA should establish policies and practices that ensure ABA services are safe and delivered in ways that are in the best interest of the beneficiaries and their families and in a manner consistent with industry standards. However, steps should be taken to ensure that the chosen policies and practices are implemented in ways that are truly useful, with particular effort made to avoid administrative practices that place undue burdens on access to care.
Currently, in addition to the required assessments discussed above, there are two other requirements that must be met for the delivery of ABA through the ACD: the minimum expectations for caregiver training and the use of an ASN. While both caregiver training and care navigation have been shown to be beneficial in healthcare settings, the ways in which such services are implemented can affect the benefits (see Chapter 4). Under the ACD, the execution and requirements around caregiver training and care navigation have been problematic (see Chapter 4 for more details).
Within the ACD, there is a requirement to bill parental training CPT codes at least six times for each six-month authorization. Services should not be contingent on caregiver participation in ABA services, and providers should not be penalized for nonparticipation by caregivers. While other payors do support options for parental engagement, there is no evidence of punitive consequences on the ABA services if parents do not engage. Further, the committee does not think billing code utilization is a good indicator of parental engagement.
Currently, in order to receive ABA services under the ACD, families must agree to accept service navigation. If families do not want to utilize navigation services, their child is no longer eligible to receive ABA services through the ACD. Care coordination or service navigation is traditionally an optional service used to aid families in underserved communities or with chronic care needs who need help navigating complex health systems. Making the ASN a mandatory service has turned care coordination into another barrier to receiving ABA.
As discussed in Chapter 3, military families also viewed the enrollment in the Exceptional Family Member Program (EFMP) and registration in Extended Care Health Option (ECHO) as burdensome and contributing to delays in accessing ABA services through the ACD. The committee understands that EFMP enrollment may still be required for families with dependents with special needs for military service assignments but registration in ECHO may not be needed when ABA becomes a TRICARE Basic benefit.
Recommendation 3: In providing coverage for applied behavior analysis (ABA) to TRICARE beneficiaries, the Defense Health Agency (DHA) should take steps to ensure that administrative processes do not impede access to care. In particular, DHA should eliminate required aspects of the demonstration that limit flexibility to support individual health needs and are burdensome to military-connected families and ABA providers. Specifically, DHA should do the following:
- Allow ABA providers the flexibility to choose assessment instruments appropriate to their clients’ needs, goals, and continuity of care as it halts the mandates around the use of specific assessment tools for all clients and caregivers
- Discontinue administration of the Parenting Stress Index–Short Form and Stress Index for Parents of Adolescents
- Continue support for caregiver training as part of receipt and reimbursement of ABA services but allow flexibility in caregiver engagement and eliminate specific requirements for training
- Make the use of the Autism Services Navigator or similar care coordination or navigation services optional for families
While policies for ABA services under the ACD can be viewed as favorable in comparison to other health plan benefits on dollar limits and maximum weekly amount of ABA allowed as well as no age restriction (DoD, 2024b), there are important areas where the ACD policy does not adhere to generally accepted standards of care and areas where the ACD policy aligns but has more stringent requirements. These differences present administrative burdens and may prevent TRICARE beneficiaries from accessing quality services (see Chapter 4). Key areas for improvement include specified exclusions for ABA services that affect the development of treatment plans that support clients’ health needs, including the ability to target ADLs necessary for health and well-being and to deliver ABA in schools and community settings, and billing limitations. DHA should update its policies for ABA services to better align with industry guidelines and standards of care to ensure quality services designed to meet individuals’ needs.
RECOMMENDATION 4: In providing coverage for applied behavior analysis (ABA) to TRICARE beneficiaries, the Defense Health Agency (DHA) should update its health benefit and coverage policies for ABA services to align with generally accepted standards of care and industry guidelines. Specifically, DHA should do the following:
- Allow ABA services to address maladaptive behaviors and activities of daily living affecting health and well-being as determined necessary by an ABA provider
- Approve use of all Current Procedural Terminology codes for ABA services
- Allow reimbursement for higher staff-to-client ratio and crisis intervention procedures where deemed necessary by the ABA provider
- Remove restrictions on settings where ABA services can be delivered, allowing for the authorized supervisor to seek treatment plan approval for the technician to deliver clinically necessary ABA services in school and community settings for purposes of targeting skills outside the home
In order to assist DHA in transitioning ABA services from the demonstration to a Basic benefit and ensuring accessible quality care, the committee recommends an independent advisory council be established to provide guidance on implementation and monitoring service delivery. The establishment of the council should not delay the urgent need to cease data collection from the PDDBI, Vineland-3, SRS, and parent stress indices nor the transition to a Basic benefit. The council can provide insight on potential risks and disruptions to care during the transition. It can also serve as a
point of information and advice as DHA, ABA providers, and military-connected families navigate further developments in the autism and ABA communities. The expertise on the council should be sufficient to provide technical and practical input on ABA frameworks, service fidelity and monitoring, short-term and long-term health outcomes, lived experience of autistic individuals, and program evaluation.
Recommendation 5: The Defense Health Agency should establish an independent advisory council to provide guidance on implementing these recommendations and monitoring delivery of applied behavior analysis (ABA) services to ensure high-quality care and minimal disruptions to continuity of care. Members of the council should include representatives from (a) families with dependents receiving ABA; (b) nonprofit organizations that represent military families receiving ABA; (c) ABA providers; (d) physicians experienced in holistic, longitudinal care for autistic individuals; (e) academia or nonprofit research organizations with expertise on autism interventions; and (f) academia or nonprofit research organizations with expertise on healthcare measurement or program evaluation.
CONCLUSION
In undertaking its independent analysis of the ACD, the committee sought to appreciate changes in autism diagnosis and interventions available to support those with autism. One of those interventions is ABA, which is currently only available to military-connected families through the ACD and not as a TRICARE Basic benefit. The committee reviewed the history of the ACD and its policy changes around the delivery of ABA as well as the different mechanisms to provide ABA to military-connected families prior to the creation of the ACD in 2014. The committee also considered available industry guidelines and standards of care that have notably had significant developments in the last 10 years during the existence of the ACD and will likely continue to evolve. The committee further examined the state of scientific evidence on the effectiveness of ABA as an intervention for autism and weighed whether this evidence met DoD’s own criteria for reliable evidence of proven medical effectiveness.
While additional research is warranted to improve the measurement of health outcomes for autism interventions and the application of ABA to individualized goals and in connection with other interventions, currently there is a substantial body of literature indicating strong evidence of efficacy and effectiveness of ABA. As such, the committee has recommended making ABA a Basic benefit under the TRICARE program and ceasing the demonstration. In doing so, DHA should take steps to eliminate or minimize
administrative burdens and adhere to the standards of care to ensure that military-connected families have timely and continuous access to a range of ABA services for those that need them. Further, the committee feels strongly that the receipt of health care should never be contingent on data collection that is not germane to the delivery of care nor contingent on participation requirements of caregivers.
It is important to emphasize that not all individuals with autism will need or want ABA and that the amount of ABA should vary with individualized goals and the use of other interventions. Developments in the evidence base do not support the global necessity of high-intensity interventions. However, the evidence of positive outcomes for less than 10 hours per week of ABA is limited; more research is needed to understand outcomes of low-level intensity interventions.
It is also important to recognize that the science and practice of ABA and autism will continue to advance. There are legitimate concerns and debates that require continued attention. Such concerns were beyond the scope of this report but include issues around underdiagnosing or misdiagnosing autism, an evolving ethical landscape in broader domains of autism care, changing views of the goals of autism interventions, and growing advocacy and research on trauma-informed, neurodiversity affirming, and culturally competent care.
DHA should be poised to be responsive to future developments as it delivers ABA services to military-connected families. Important steps in this regard include engaging an advisory council with diverse expertise, lived experience, and involvement with ABA and soliciting regular feedback from families receiving care.
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