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Sunday, May 6, 2018

TRICARE Coverage Issues

In The Politics of Autism, I discuss the day-to-day challenges facing autistic people and their families.  As many posts have discussed, the challenges are especially great for military families.

Ariana Cernius has an article at The Journal of Legislation titled “Thou Shalt Not Ration Justice”: The Importance of Autism Insurance Reform for Military Autism Families, and the Economic
and National Security Implications of Improving Access to ABA Therapy Under TRICARE." From the abstract:
The realities of military service—extended family separation, frequent changes of duty stations, and varying access to specialized healthcare—often undermine military autism families’ ability to secure adequate individualized services. These challenges have been compounded by TRICARE’s most recent adjustments in coverage of ABA, which have run counter to trend. In late 2015, TRICARE announced a 15% slash to reimbursement rates for ABA providers, justifying this dramatic change with a statement of the need to bring TRICARE rates, which had previously been higher than Medicaid and commercial rates, in line with other commercial plans. Although the intent behind this rate reduction was to avoid government overpayment, it demonstrated a fundamental misunderstanding about the nature and treatment of autism and the functioning of the health insurance industry, and a lack of recognition of the fact that the commercial insurance, Medicaid, and TRICARE business models are not identical or based solely on revenues. First, simultaneous with its cut to provider reimbursement rates, TRICARE implemented higher credentialing standards for ABA providers, essentially demanding more skilled and educated employees for significantly lower pay. Additionally, because TRICARE does not reimburse providers for certain services that commercial insurance and Medicaid do provide reimbursement for, TRICARE’s move to slash rates was particularly harmful to ABA providers. This combination of policy changes essentially rendered children with autism from military families the least-desirable clients for ABA providers, because the lowered rates and profit margin per autistic child with TRICARE insurance are so significantly below the national average that it is unsustainable for the ABA provider business model to maintain their military autism family clients, and many providers are deterred from taking on new autism families with TRICARE insurance. It is estimated that 23,000 military dependents have a diagnosis of autism, and many stand to join them in the coming years; aside from the harm caused to the children with autism of the families that serve our nation by the increase in hardship in accessing ABA, there are negative implications for broader society as well. Studies show that lack of care and interrupted services have negative impacts to the progress of children with autism, leading to an increase in the economic burden of this population to society due to anticipated higher health costs, and the greater chance that these children with autism will be dependent on society as adults. Furthermore, inadequate or inconsistent access to ABA through TRICARE jeopardizes the health and well-being of military families, which affects national security, given the direct impact family health care plays on military readiness. This article examines the history of TRICARE’s coverage of autism treatment, analyzes the most recent policy missteps, and provides recommendations for policymakers in future efforts to care for and improve the lives of the autism population.