Tricare Extended Care Health Option (ECHO) and Branch of Service Respite

• EFM is closely following the Office of Special Needs (OSN) branch of service standardization for respite from the 2021 NDAA.  The policy has not been released.  We are also monitoring the Defense Health Agency (DHA)’s policy on ECHO respite.  The increase from 16 to 32 hours in the 2021 NDAA has yet to be implemented.  We are looking for a champion to follow up with OSD and DHA respectively in order for respite care to be accessible to EFMP families. There is a huge disconnect between the programs presented by DoD and DHA versus what the families can access. 

EFMP Advisory Council

• EFM supports and thanks legislators on the expansion of the EFMP Advisory Council in the 2022 NDAA.  We are seeking transparency for EFMP stakeholders to provide feedback to the Council members.  EFM requests updates on council activities to be made available to the family member stakeholders.

EFMP Assignment Transparency

• EFM supports and thanks legislators on the assignment verbiage allowing for two location options in the 2022 NDAA.  Many branches are automating the EFMP assignment process.  We request OSN or branch specific updates to family stakeholders on the assignment process.  The Air Force has set a great example for regular updates on social media with their new processes.  This form of transparency could be replicated across all the branches.  Where is OSN and the Services at with implementing programmatic change within the EFMP assignment process? 

Guard and Reserve families should have permanent or reasonable access to EFMP while on orders. It would directly affect readiness, resiliency, and retention by establishing a much needed chain of support for programs that require EFMP enrollment to benefit the most vulnerable in the military community.  The first step we ask for is sponsoring 2023 NDAA language for the GAO study to identify Guard and Reserve families that are eligible for EFMP. If you'd like to contact us about the the EFMP programing for Guard and Reserve Families, please contact us via the "contact us tab" or email us at guardandreserve@exceptionalmilitaryfam.com. 

We support  the  independent  review  of the  ACD in the 2022 NDAA  and  recommend  the implementation  of  the  policy  changes should  be  put  on  hold  pending  the outcome  of  the  independent  review. Military  families  have  already  had therapy  services  disrupted, negatively impacting Autistic loved ones.  The changes  may  not  survive  the  scrutiny  of the  review  by the National Academies of Sciences, Engineering and Medicine (NASEM).  EFM is concerned that stakeholders will not be heard during this review.  We ask for the restrictions to the community and school settings to be reversed and the Activities of Daily Living (ADLs) such as toileting to be allowed back into the ACD.  Lastly, we are asking for the parent stress assessments to be eliminated entirely.  There is an equity barrier for Autisic families as no other disability category is required to fill out these assessments as a requirement to receive care.  If you'd like to contact us about the Autism Demonstration changes, please contact us via the "contact us tab" or email us at Autism@exceptionalmilitaryfam.com.

The Defense Health Board concluded that military children are disadvantaged from receiving necessary services because Tricare does not utilize a pediatric specific medical necessity standard and hierarchy of evidence.  Nor do military children enjoy the same standard of care as civilian children covered by Medicaid’s EPSDT requirement which ensures necessary health care, diagnostic services, treatment, and screenings. Ostensibly, DHA adopted the AAP timeline for preventive care, Bright Futures, in 2018, however, it has been difficult to know whether or how the new policy has been implemented.

These failures to account for the unique needs of kids is especially harmful in the context of the mental health crisis facing our nation’s children and youth because these specific pediatric coverages are crucial to the prevention, screening and early intervention that can help reduce need for higher acuity and crisis care down the road. 

• Require DHA to adopt the AAP recommended pediatric medical necessity definition
• Align standard of care with Medicaid by requiring Tricare to adopt the EPSDT standard
• Require DoD to take appropriate steps to ensure Tricare alignment with Bright Futures. 

 Children in military and veteran families face all the typical stressors impacting their civilian counterparts, as well as unique factors such as a parent regularly in harm’s way, or a parent's service-related injuries. While some challenges such as provider shortages are universal, there are barriers that Congress can fix. For example, Tricare mental health copays have more than doubled since 2017. Also, recent changes to the Autism Care Demonstration have disrupted care for families, even while those controversial changes are undergoing independent review ordered by the FY22 NDAA.

The Coalition urges continued focus on strengthening commitment to MEB health for children of military families.

• Institute T-5 requirement for appointment availability as part of network adequacy, as well as enhanced provider directory information and functionality, as detailed in number 3, below. 
• Ensure contractors continually accept MEB health providers into network regardless of overall network adequacy status; require improved transparency and clarity around authorization process for institutional providers. 
• Reduce Tricare MEB health copays to address financial barriers to access (H.R. 4824 Stop Copay Overpay Act).
• Place moratorium on 2021 changes to Autism Care Demo pending outcome of review ordered by FY22 NDAA
• Make permanent the viable reimbursement and telehealth flexibilities implemented during the COVID national emergency, including across state lines (details tbd awaiting results of feasibility study required by FY22 NDAA).
• Ensure Tricare alignment with Bright Futures so that children receive recommended periodic screenings
• Continue to monitor reports required by, and analyze steps taken in, recent NDAAs to make additional changes and improvements as opportunities are identified. This is critical to trying to get up to speed and then stay ahead of future needs.

Military families must be able to easily access current and accurate directory information for Tricare authorized providers.  Often, the categories are not specific enough to contemplate the universe of pediatric specialties, subspecialties and age ranges that are necessary information when seeking care for children with complex and chronic conditions. Problems for institutional providers are exacerbated by lack of ability to search outside a fixed area, and inconsistency with TRICARE policy identifying provider types. There will not be adequate, if any, institutional providers in most zip codes or communities, and families should be able to see the geographic locations relative to family members, friends, or other trusted resources if the treatment placement is not close to home.

Furthermore, because basing decisions for Exceptional Family Member Program (EFMP) participants rely on provider directories, the fact they are often inaccurate, incomplete, or not specific enough, results in denials of duty stations unnecessarily, or placements where children’s needs cannot be met. When care can be found using directories, extensive wait times are not taken into account, flooding the market with additional care needs resulting in longer wait times for both military and civilian patients.

• Institute T-5 enhanced provider directory accuracy requirements specific to MEB care to eliminate duplicates, providers no longer practicing, wrong provider types and contact information. 
• Specify that Tricare require a nationwide list of institutional and highly specialized providers 
• Require provider directory specificity with respect to specialty focus and ages served
• Upon assignment to a duty station, require EFMP assignment coordinators to provide families with results of their provider queries confirming availability of services within the relevant access standards, that were used to determine the basing decision.

The ECHO program, created by Congress to guarantee that military families would be able to utilize the same type of home and community-based services that are offered through the states but generally too difficult for mobile military families to access, must be updated to ensure those services are comparable to those offered through the states.  The FY 2022 NDAA directed a study of ECHO continuity of care, due in March 2022. Pending its outcome, additional solution sets may be identified. Meanwhile, the following issues are still unresolved.

Habilitation is intended to help “attain, keep or improve” skills or functions and critical for developing children, but is not covered by ECHO, nor are residence and vehicle adaptations, especially egregious given the shortage of ADA accessible military housing. ECHO may cover service and modification of durable equipment and assistive technology but this has not been codified, which would ensure its application. 

Certain medical equipment or services for rare or unusual conditions, even when covered, are not available. They remain unfulfilled because there are no providers willing or able to contract to provide them. This issue appears to be almost entirely one of reimbursement.  This is a small volume but a key constituency – the most vulnerable whose needs most often go unmet to the detriment of their health and wellbeing.

Additionally, there is a great deal of confusion and misinformation for Guard and Reserve families who may become eligible for ECHO and EFMP, regarding their eligibility and responsibilities. Because there is not a defined universe of those eligible, it is difficult to disseminate correct information to combat the misunderstandings.

• Require ECHO to cover habilitative services, durable medical equipment (DME) and residence and vehicle modifications that are medically necessary for children. 
• Address the problem within ECHO that certain medical equipment or services for rare conditions, which are ostensibly covered, are rarely fulfilled, usually because of reimbursement or failure to pay.
• Direct a GAO study to determine the universe of Guard and Reserve eligibility for ECHO/EFMP.

Adult incapacitated children (AIC) of service members and retirees are dependents, which ensures Uniformed Services IDs, Tricare eligibility and any other rights and privileges afforded to military families, but DoD policy and practice is inconsistent and out of step with existing civilian dependency and guardianship principles.

At the very least, the process for determining dependency for adult incapacitated children must be clear, streamlined, nondiscriminatory, consistent and provide due process.  However, we believe determinations of disability are more appropriately made pursuant to established disability law and policy, as it is not a core DoD expertise, allowing DoD to simply recognize and accept determinations made by federal and state authorities with jurisdiction and expertise.

An FY22 NDAA required report, due February 2022, has not yet been made available as of March 18. Without that report it is unclear whether or when families will see relief. Clearly, no action has yet been taken, resulting in continued “increased hardships for military families” per the June 2020 GAO report that cataloged many of the issues and led to the FY22 NDAA provision.

Also of great concern is the MHS inconsistency in policy and practice for incapacitated adult patients. Often, parents are told they cannot be given laboratory results or ask about consults, even with documented dependency and guardianship. 

• Recognize and align with existing federal law defining and governing adult incapacitation status and recognizing dependency determinations by civilian courts of jurisdiction.
• Address the inconsistency of the MHS system relative to incapacitated patients and their families.

Congress should improve accountability by directing DHA to stand up a mechanism for beneficiaries/families and purchased and direct care providers to report complaints and concerns about Tricare coverage, denials, incorrect provider directories, network adequacy, access to specialized care, overdue or consistently inaccurate payments, and other related issues. 

• Direct DHA to implement a simple reporting tool for military families/beneficiaries and providers to report issues, that follows a simple flow chart for levying complaints, and require accountability for monitoring and addressing them appropriate to their level of acuity or urgency.

Align Tricare with a benefit that has been available to civilian families since 2010. This coverage into young adulthood is more important now than ever for military-connected youth, as the nation emerges from 1) twenty years of war, the burden of which has been borne squarely on the shoulders of their families and communities, and 2) a pandemic that has upended teens’ routines, plans and disrupted their typical trajectories with ramifications that we have yet to fully evaluate or understand.

• Require Tricare to allow children up to age 26 on their parent’s plan. 

Medical billet cuts and restructuring could harm families’ access to care and potentially have negative unintended and long-term consequences, including disruptions to the medical education pipelines that are integral to training pediatricians for military connected children and all children. We strongly support the precautions and pauses in previous NDAAs and continued Congressional oversight.

• Maintain the current status for review of medical billet cuts pending comprehensive analyses of impact.