Late Breaking News
TRICARE Limits Autism Coverage, Classifies Popular Therapy as ‘Educational’
OPM Director of Healthcare and Insurance John O’ Brien said at the hearing that OPM’s decision to reclassify ABA as a medical therapy was based on the “evolving body of clinical research and the maturing provider infrastructure to deliver this modality under a medical model.” This reclassification, however, does not require FEHB plans to add ABA services to the basic benefits package.
“The evidence is not yet sufficient to support an official OPM position requiring coverage by all FEHB carriers. In the interval, our administrative change will allow FEHB plans that choose to do so to make ABA services available as the research and provider base mature. OPM will periodically re-review ABA as the research develops,” he said.
Karen Guice, principal deputy assistant secretary of defense for health affairs, told the committee that DoD’s most recent review, in 2010, found that ABA is an educational intervention.
“Our determination is consistent with the 2011 [Agency for Healthcare Research and Quality] comparative-effectiveness review of therapies with children with ASD,” she said. “In this review, the investigators found the literature to be highly variable in quality and limited in most areas and inconclusive. They identified the need for more research to determine which children benefit from a particular intervention.”
In light of OPM’s recent reclassification of ABA, however, DoD will revisit the issue and has “formally requested that OPM provide [DoD] the evidence so that it can evaluate it against its coverage criteria,” Guice said at the hearing. As part of that process, DoD also will invite stakeholders to submit information and evidence.
Advocates told the committee about the benefits of ABA to families. Vera Tait, MD, who testified on behalf of the American Academy of Pediatrics, explained that ABA can teach new skills to autistic children and generalize them to new environments or situations.
“The effectiveness of ABA-based interventions in autism has been well documented through a long history of research,” Tait said. “Children who receive early intensive behavioral treatment have been shown to make substantial gains in cognition, language, academic performance and adaptive behavior as well as some measures of social behavior. And their outcomes have been significantly better than those of children in control groups.”
While advocates would like to see TRICARE reclassify ABA as a medical therapy, TRICARE issued interim guidance expanding coverage in August as a result of the court order but didn’t make that change.
Under the policy, ABA services under the basic TRICARE medical benefit will require a specific autism spectrum disorder diagnosis by a TRICARE authorized primary care provider or specialized ASD provider. The implementation of the benefit under the TRICARE medical benefit is separate from the autism services available to active duty family members enrolled in the ECHO program. Beneficiaries with an autism diagnosis already receiving ABA services under the ECHO program will not experience any changes.
Meanwhile, DoD filed a defendant’s motion to amend the court’s judgment regarding the injunction it imposed on TRICARE. It reiterated that ABA is not offered as a basic TRICARE benefit because of lack of evidence of effectiveness.
“Plaintiffs can point to no formal determination by DoD that ABA is ‘proven’ medical care because none exists. Although DoD has found ABA to be effective at managing the effects of ASD for purposes of ECHO, that does not mean that DoD has made any determination that ABA is ‘proven’ ‘medical’ care for purposes of the TRICARE Basic Program.”
The agency asked in its motion for “an opportunity to provide further explanation for its ECHO and Basic Program ABA determinations or potentially revise those determinations.”
Meanwhile, the U.S. House of Representatives approved a bipartisan amendment to the pending National Defense Authorization Act, clarifying that TRICARE coverage should include medically necessary behavioral health treatments for autism. The amendment removes dollar limitations on care and works to provide ABA coverage for DoD military dependents with autism regardless of the primary beneficiary’s duty status.
“Today, the House of Representatives affirmed its commitment that just as we leave no soldier behind, we leave no military family behind either,” said the sponsor, Rep. John Larson, (D-CT).