Exceptional Families of the Military (EFM) has reviewed the recent treatment changes issued in the latest TRICARE Operations Manual (TOM) for the TRICARE Autism Care Demonstration (ACD) program (Found here).  We remain grateful to the Defense Health Agency (DHA) for their oversight of the ACD program, and their continued stewardship over the implementation of applied behavior analysis (ABA) services. However, we have serious concerns that some of these changes will decrease access to care for military families while putting the families in difficult positions. Our major areas of concern are noted below with recommendations for follow up with your legislators. Please review these and let us know if you have any questions or would like guidance on how to reach out. 

ABA in the school and community setting 

According to section 8.10.15.2, after May 1, 2021, no new authorizations will be given for ABA services in the school allowing BTs to deliver the 1:1 service. Rather, services in the school will be restricted to being implemented only and solely by the BCBA (8.10.15), should the BCBA deem that in school services are clinically necessary. 

The EFM would like to urge families to request that the 1:1 services in school be delivered by a behavior technician in accordance with the tiered model approved for the other service settings. Limiting the delivery of 1:1 services to a BCBA in a school restricts every child’s access to care. BCBAs often manage caseloads of 6 - 10 clients and implementing school-based services for a few children on their caseload would require the other clients to receive less services from the BCBA. Additionally, it should be to the discretion of the ABA Supervisor who implements the services in accordance with how the tiered model is implemented across other locations (e.g. home, school) and not dictated by a policy. 

When children return to school in the fall of 2021, the EFM recommends that the TOM allow best practices to dictate who implements services in the school setting. This means that the BCBA should be able to first assess whether or not services in school are clinically necessary via an assessment, develop individualized treatment for that setting, and create a clear fade out plan for services from that location.  

Please advocate for the following: 

• Removal of the restriction of ABA services implemented by BTs in school settings
• Provision for the BCBA to perform a clinical assessment, develop individualized treatment for the school setting, and create a clear fade out plan for services from that location

According to section 8.10.11, services will no longer be authorized across community settings such as “sporting events, camps, and other settings as determined by the contractor.” Additionally, it states “any location not listed must be reviewed and approved by the contractor.” This limitation prevents the child from receiving the individualized and specific treatment consistent with their diagnosis. Families will be left to figure out how best to support their child in community events like dental appointments, getting haircuts, and interacting with their peers at sporting events. 

The EFM acknowledges that the ACD benefit is not at all meant to supplant care provided by a nanny, caregiver, or parent. However, a child’s diagnosis is not experienced in only certain settings approved by the TOM, but in all settings that they encounter. 

Please advocate for the following: 

• Removal of the restriction of ABA services across settings identified in 8.10.11 and 8.10.12
• Provision for the BCBA to perform a clinical assessment, develop individualized treatment for the community settings that may be challenging for the child, and create a clear fade out plan for services from that location
• Clarification about what criteria the contractor will use to review and approve service settings not listed in the TOM (section 8.10.11)

Autism Service Navigator

In section 6.1 and beyond, the role of the Autism Service Navigator (ASN) is discussed at length. The ASN will be the mandatory single point of contact for the military family.  This individual has the sole responsibility for creating a comprehensive care plan (CCP). The CCP is required to be developed prior to ABA services starting and is to include a discharge and transition plan. The TOM does not specify whether or not this plan is specific to ABA services but implies such information.  Moreover, the TOM does not specify that they are required to have training or certifications to develop the CCP, which includes identification of a treatment trajectory for the child receiving services.  The ASN is responsible for reviewing and incorporating all autism assessments into the care plan. The TOM provides the ASN with a 90-day window to complete these activities. This must occur prior to the beneficiary starting ABA services. This requirement coupled with the requirement for beneficiaries to first be enrolled in the ECHO program poses additional and significant delays to access to clinically necessary care. 

Please advocate for the following: 

• Removal of the requirement for ABA services to start contingent on the completion of the CCP (6.2.4)
• Clarification about the role of the ASN to complete a discharge and transition plan in the CCP (6.2.1) and whether or not this is separate from the ABA Supervisor’s plan 

Diagnostic Criteria to Begin ABA

In section 4.2.1.2, it indicates that a diagnosis must be made using one of their “validated assessment tools” from the provided list. What is not specified is whether or not starting ABA services is contingent on completion of one of the assessments. Some of them are time and labor intensive, requiring the diagnosing provider to have a particular set of clinical skills as well as resources. The current TOM, in section 8.2.5, reflects that if the specialized diagnosing provider was unable to complete one or more of the outcome measures at the time of the initial diagnosis, that a year is given to allow for the outcome measures to be completed, but that services could begin. 

Please advocate for the following: 

• Clarification on whether or not one of these assessment tools must be completed with the results submitted to the contractor prior to ABA services starting
• Request that the family has a year for the diagnosing provider to complete the assessment tool to confirm their clinical interview findings, so that this does not impede access to care  

New Outcome Measures Required

In section 8.6.4.4 and 8.6.4.5, there are two new mandatory parent assessments are being required to monitor the parent and parent-child relationship.  We are concerned with how this information will be used in relation to the service member’s career in the military.  The Parenting Stress Index, Fourth Edition (PSI-4) and Stress Index for Parents of Adolescents (SIPA) are required to be administered to the parent every 6 months. These assessments will also evaluate the stress between the parent and spouse/partner.  TRICARE is requesting ABA providers deliver these assessments and report results to the ASN.  TRICARE does not specify how this information will be used or if the information will be shared outside of the ACD program.  

Please advocate for the following: 

• Removal of the requirement for these outcome measures from the ACD program

We are committed to advocating on behalf of military families with autistic dependents.  We believe the changes will limit access to ABA services and negatively impact the lives of families with autistic loved ones.  Military families have a strong voice and can contact their legislators to raise awareness of how these changes will affect the daily care for TRICARE beneficiaries.  

We are working on templates that can be used to contact legislators by email, phone, or letter.  When contacting legislators, ask to speak with the military legislative assistant.  Each legislator has a designated person on staff for this position who is the main point of contact for constituents in the military.

Finally, the public and legislators need to know the personal impact these changes will have on military families.  Please consider sharing your story with us so we may highlight families affected by TRICARE’s ABA service changes on our blog posts.  If your family wishes to speak to the media regarding your concerns, we are here to give guidance on talking points with reporters.

Sincerely,

Autism Family Advisory Committee - Exceptional Families of the Military