The report, conducted by the National Academies of Sciences, Engineering and Medicine, debunks DHA officials’ repeated assertion that ABA services don’t meet their standards for reliable medical evidence.

The researchers lay out their analysis of why ABA meets Tricare’s own standards, defined in law.

Researchers recommend this major shift in Tricare’s policies for military family members diagnosed with autism spectrum disorder, citing problems with an 11-year-old demonstration project that in effect limits the care available for these children.

“It’s time for ABA to be a basic benefit in the Defense Health Agency,” said Dr. Eric Flake, a retired Air Force colonel who is a member of the committee that conducted the study, during a webinar Tuesday.

Each month, about 1,000 military children receive diagnoses of autism, said Flake, who is adjunct faculty at the DOD Developmental-Behavioral Pediatrics Fellowship at Joint Base Lewis McChord, Washington, and an associate professor at the Uniformed Services University of the Health Sciences and the University of Washington.

The researchers, in their 310-page report released Sept. 9, recommend that DHA end its Autism Care Demonstration program, citing some policies that differ from clinical best practices and impose excessive administrative burdens on military families and ABA providers.

The policies limit providers’ ability to target some skills essential to health and well-being, such as self-care tasks known as “activities of daily living.” The policies also restrict providers from providing ABA services in schools and community settings.

While Tricare covers multiple services for beneficiaries diagnosed with autism spectrum disorder, ABA is specifically offered to military-connected families only through the demonstration program, which began in 2014.

Tricare doesn’t authorize ABA services as a “basic benefit,” meaning a covered service that is determined medically necessary as defined by law.

DOD considers National Academies report

The committee also recommended DHA reduce administrative barriers that limit families’ access to ABA services. Families often express concern that the current policies related to ABA are discriminatory.

Autism is the only diagnosis for which family members are required to enroll in the Exceptional Family Member Program and Extended Care Health Option (ECHO) in order to get access to medically recommended care, committee member Jennifer Penhale, an active-duty Air Force spouse and mother to three teenagers with autism, said during the webinar. Penhale chairs the Colorado Developmental Disabilities Council.

The research committee noted that ABA is now standard practice for many autistic individuals across public and private health systems. Since 2019, all states have adopted laws or issued regulatory guidance requiring certain commercial health plans to cover ABA services for people with autism, they reported.

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Yet in their most recent report to Congress, dated Aug. 19, Defense Health Agency officials stated, “As of now, ABA services do not meet the Tricare hierarchy of reliable evidence standard for proven medical care.”

The Defense Health Agency is reviewing the entire National Academies report, including the recommendations, “to determine our way forward with the Autism Care Demonstration,” officials said in response to questions from Military Times. “Until this review is completed, the Department will continue to provide the services available under the ACD.”

Recommendations remove ‘a lot of barriers’

Dr. Kristi Cabiao, CEO and president of Mission Alpha Advocacy, an organization that advocates for military families within the Exceptional Family Member Program, praised the National Academies committee for its extensive work.

“Here you have this expert committee that says by DOD’s own standards of reliable medical evidence, it’s been met,” Cabiao, the wife of an Air Force retiree and mother of a child with autism, told Military Times.

“The concern is, military families have spent at least 10 years in a demonstration. That’s time that these families will never get back. They had to receive a lower quality ABA services because of really poor policies.”

The National Academies study included a comprehensive review of empirical literature, an analysis of Tricare claims data from 2018 to 2023, an evaluation of policies and procedures and input from military families, researchers and ABA providers.

The committee included experts in behavior analysis, child development, public health, psychology, health services, biostatistics and autism research.

The researchers’ recommendation that DHA formally authorize ABA as a Tricare basic benefit “is the most important recommendation for military families,” said Cabiao. ”It removes a lot of barriers.”

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For example, active-duty families would no longer be mandated to enroll in EFMP and ECHO, she said. “We have families who weren’t able to start ABA services right away, having delays of months because of this administrative burden.”

Cementing ABA as a Tricare benefit would also eliminate the worry of a looming 2028 deadline, when the ABA demonstration program is scheduled to end.

“When you’re depending on this really life-saving service, as it was for my child ... to know that in 2028 it might continue or it might not, or may be even more restricted, you don’t have security in what the future holds,” Cabiao said.

Aspects of the military lifestyle, such as frequent moves and caregiver deployments, can disrupt the stability children with autism need in their care.

One military parent told researchers there’s a two-year waitlist just to be evaluated in El Paso, Texas, “which is absurd for those families that have to change duty stations frequently. This means they will never get the chance to be seen,” the parent is quoted as saying in the report.

Autism rates among military children

In DHA’s annual report to Congress dated Aug. 19, officials said that in fiscal 2023, there were 16,747 beneficiaries with diagnoses of autism participating in the demonstration program, at a cost of $435 million. The average paid cost per participant was $25,948.

While it’s difficult to compare the prevalence of autism between the military community and the general population, the National Academies researchers cited one recent review that identified 1 in every 28 military children, or 3.5%, as being diagnosed with autism in the period from 2019 to 2023.

That rate is slightly higher than the rate in the general population of 1 in 31 children with autism diagnoses, or 3.2%, in 2022, according to the Centers for Disease Control and Prevention.

Cabiao cautions against reading too much into the 0.3% gap between military and civilian populations, stating the difference is minimal and could be partly explained by the consistent system of medical records that keep track of military children’s health care.

Still, she said, “One in 28 is a big number. It clearly demonstrates a readiness and retention issue if we don’t provide quality ABA services.”

During the six-year period from calendar years 2018 to 2023, there were 109,073 children ages 1 to 18 with an autism diagnosis who were eligible for Tricare benefits, according to the committee’s report.

During that time, about one-third of those children had a claim for ABA services. More than half were under age 6, and 89% were under age 12. About four out of five beneficiaries participating in the demonstration are male.

‘New territory’ for the DOD

Other recommendations included in the committee’s report are: aligning Tricare coverage of ABA with clinical best practices; eliminating mandatory assessments that don’t support treatment planning; and establishing an independent advisory council to help guide the transition. Along with many other experts, military families receiving ABA and military family advocacy organizations would be included on the advisory council.

Flake, the retired colonel who sits on the committee, highlighted DHA’s “continued desire to see best practices come forward” in the field of autism treatment over the years.

He noted that many of the recommendations the committee made for DHA to transition from its demonstration program are already put into practice as standard care in other locations.

“We recognize that we may be going into some new territory for DHA, but that also isn’t new for us as a military community,” Flake said. “I have full confidence that with the support of the ABA community, with the support of families and parents, as well as policymakers and guidance from the recommendations of this report, that it can be a relatively smooth transition.”