TRICARE Limits Autism Coverage, Classifies Popular Therapy as Educational

By Sandra Basu

WASHINGTON — Is a commonly used autism therapy a medical or educational intervention?

TRICARE’s position on that issue continues to be controversial among some advocates and beneficiary families.        

Earlier this year, the U.S Office of Personnel Management reclassified an autism treatment known as Applied Behavioral Analysis (ABA) as a medical therapy. This allows the Federal Employees Health Benefits Program (FEHBP) insurance carriers, beginning in January, to cover behavioral treatments based on ABA, if they choose.

Autism Speaks Chief Science Officer Geraldine Dawson (left) talks with Sen. Kirsten Gillibrand (D-NY) at a hearing on autism and TRICARE this summer.

In contrast, military families have more restricted access to the treatment, because TRICARE classifies ABA as an educational intervention. As a result, it is available only through a supplement to the basic TRICARE program known as the Extended Care Health Option (ECHO). Annual services through the program for an individual are capped at $36,000 and end when the active duty servicemember retires.

TRICARE’s classification of ABA had already put TRICARE at odds with disgruntled advocates and families, when a U.S. District Court got involved with the issue.

 This summer the U.S. District Court for the District of Columbia called DoD’s coverage approach of ABA therapy  “arbitrary and capricious” and ordered TRICARE to cover the therapy for all TRICARE beneficiaries, not just those on active duty. In response, TRICARE agreed to expand coverage without reclassifying the condition, and DoD lawyers, on behalf of TRICARE, are seeking to amend the court’s decision.

Congressional Hearing

The contrast between Tricare’s policy on ABA and other federal and civilian coverage was highlighted at a congressional hearing this summer prior to the court ruling. While, in 2001, only one state required insurance coverage of ABA, as of the congressional hearing, 30 states required coverage of ABA treatment as medical care. Until recently, neither OPM nor DoD classified ABM as medical therapy.

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