A release from Senator Kirsten Gillibrand (D-NY):
The recent announcement of new federal rules to the military health insurance program (TRICARE) would put thousands of military children with developmental disabilities such as autism at-risk of losing critical behavioral treatment and care. Today, Senators Kirsten Gillibrand (D-NY), a member of the Senate Armed Services Committee, and Patty Murray (D-WA), a member of the Senate Veterans’ Affairs Committee, expressed their outrage over the new policy which cuts off care for children who do not show progress over a six month period. The new policy reveals a complete lack of understanding of the needs of children with developmental disabilities. The Senators urged the head of TRICARE to explain how the restrictive rules that require standardized testing, limit the eligibility of treatment, and set an age limit on receiving the care were determined and urged the agency to consult with experts before the new rules go into effect on July 25th.
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The Senators wrote in a letter to Assistant Secretary of Defense for Health Affairs & Director of TRICARE Management Activity, Dr. Jonathan Woodson, “We are writing to express complete frustration and dismay over the recent changes to coverage of applied behavior analysis (ABA) for all TRICARE eligible beneficiaries with autism. Prior to last year, children with developmental disabilities other than autism were also receiving and making progress from ABA services. However, new policies last year resulted in these children losing access to ABA services. The policies we write about today are another step in the wrong direction... The apparent lack of understanding of the needs of children with developmental disability, including autism, when drafting the recent TRICARE policy changes is astounding. The departure from how TRICARE covers all other medical care is also very concerning. Before these new policies are in effect, we strongly urge you to consult with experts in developmental disabilities such as autism and ABA treatment practices.”
Under the new policy, key restrictions include:
- Discharge from care if military children do not demonstrate progress over a limited period of time
- Limits care to patients age 16 and under
- Limits treatment to 2 years (requests beyond 2 years must go through a waiver process)
- Requires standardized testing every 6 months to receive care
- Places significant administrative burden on the care provider which will impact the number of providers willing to accept TRICARE
- The Senators emphasized that children of military families often experience regression due to life events such as deployment, relocation, and new school environment and returning from periods of regression often take significant time and effort. The Senators also requested prompt responses to their list of questions, including on what basis these rules were determined.
Autism is the fastest growing developmental disability in the country, with over 23,000 TRICARE beneficiaries diagnosed with autism. Nationwide, this disease affects 1 in 88 children and 1 in 54 boys, according to the Centers for Disease Control.
Referral and authorization of services are required for all ABA care. We have outlined the following steps to help walk you through this complicated process:
1. Parents must get a referral for ABA from their Physician Primary Care Manager (P-PCM) or from a specialized autism provider.
2. The Managed Care Support Contractor (MCSC) will then refer beneficiaries for an “ABA assessment” to be conducted by an ABA provider.
3. The ABA assessment must include psychometric testing using the Autism Diagnostic Observations Scale, second edition (ADOS-2), and the Vineland Behavioral Scale II (VBS-II).
4. Based on the results of the ABA assessment, the referring provider must submit a referral to the MCSC for an authorization of ABA. Please note there are significant changes to the minimum information that the referring physician or psychologist must include as part of your referral. All authorizations are good for one year.
What if my ABA provider is not qualified to administer the ADOS-2 or VBS-II?
If the ABA provider conducting the ABA assessment is not qualified to administer the ADOS-2 or the VBS-II tests, your referring provider must provide you with an additional referral to qualified TRICARE provider that can administer the tests (such as a developmental pediatrician, licensed clinical psychologist, etc.).
What happens if there are wait lists for these providers or I am unable to find a provider in my area to deliver this testing?
The TRICARE policy is silent on this issue. Autism Speaks is aware there is a shortage of specialty care providers in many of our military communities, especially in rural areas. We are very concerned that the absence of available provides will impede access to care for children.
How often are these psychometric tests required?
The VBS-II must be administered every 180 days and the ADOS-2 is required annually.
Why are all of these testing requirements necessary?
TRICARE is now requiring psychometric testing to verify progress on a beneficiary’s treatment plan. Autism Speaks is very concerned about the new testing requirements and that TRICARE is using the results of the psychometric testing for purposes they were not validated for.
So, my child has to show progress on the psychometric tests to continue ABA services?
Yes. We understand that this represents a significant shift in how TRICARE covers all other medical services and fails to address the challenges and needs individuals with autism often experience.
