Does Tricare really care? Anyone following recent policy changes and the meager and conflicting public statements from Tricare Management Activity, the government-run provider of military health care, may have cause to doubt.
Following the policy developments has been difficult, but a few vigilant military spouses, news outlets and advocacy groups have been watching and reporting on the health care news and its impact on military families.
Most concerning are changes quietly made to Tricare policy in June regarding applied behavioral analysis (ABA), a widely used and commonly accepted therapy for autism and intellectual and developmental disabilities.
ABA is a treatment strategy tailored to fit a patient’s individual needs and has been covered by Tricare as an educational therapy for several years, at least for active-duty family members.
Last year, after a federal judge found fault with Tricare’s ABA policy excluding retiree family members, Tricare reduced the scope of ABA coverage to include only beneficiaries with an autism diagnosis. No medical reason was given for the exclusion of those with disabilities like Down syndrome and cerebral palsy, who had previously been covered.
The National Defense Authorization Act of 2013 mandated a one-year pilot program to provide ABA to all eligible Tricare beneficiaries. The pilot program, finally initiated last month, resulted in a patchwork of ABA coverage, divided between Tricare and Tricare’s Extended Care Health Option, each with differing requirements for therapists’ education levels, benefit access and fees, depending on whether the military member is active duty or not.
As if all this was not confusing enough, the policy change that included the pilot program added, among other stipulations, a cost-share, a two-year limit on ABA therapy and an upper age limit of 16 for patients. Beyond those parameters, states the policy, additional ABA is available only with a waiver.
Explanations of these changes should have been quickly disseminated to caregivers and beneficiaries. Instead, information was sparse and contradictory, with Tricare’s website offering broad terms and omitting specifics. The age limitations are outlined only in Tricare’s online policy manual. Fortunately, some advocates were watching closely, otherwise some beneficiaries might have found out only when they were denied care.
As news began to spread via social media, individuals and groups began speaking out, contacting lawmakers and Tricare, voicing their concerns that the policy is, at best, not in keeping with best practices for treatment, and at worst, discriminatory to those with special needs. For example, ABA is the only treatment where the cost-share does not apply toward a deductible or catastrophic cap.
U.S. Senators Kirsten Gillibrand and Patty Murray sent a letter on July 10 to Dr. Jonathan Woodson, assistant secretary of defense for Health Affairs and director of Tricare, asking him to explain the policy changes and to state the authoritative sources and reasons for conditions placed on the treatments.
Secretary of Defense Chuck Hagel addressed the issue in response to a question at a town hall meeting last week, saying he was aware of the issue and would give it high priority.
Woodson and other Tricare representatives finally released some information, saying the policy was not faulty, just misunderstood, and that the provisions in question would apply only to non-active duty members. Some breathed a sigh of relief, but not everyone is completely reassured by the statements, some of which still don’t coincide with officially recorded Tricare policy.
“We hope that the policy is also fixed for our retiree families,” said Jeremy Hilton, an Air Force spouse and parent of a special needs child. “Bad policy is still bad policy. We are optimistic that future policy decisions involving our children will be more carefully thought through.”
Perhaps military families without special needs members don’t think they need to be concerned, but these events beg the question: Who holds Tricare accountable?
In court cases and in legislation, Tricare’s policies have in the past been deemed worthy of revision and improvement, but the necessary changes are often left to the determination of Tricare. The agency’s actions have not inspired confidence that it is up to the challenge of explaining its own policy, let alone evaluating it.
“If Tricare can do this on this issue, they can do it on any issue,” said Hilton.“Imagine if they did something like this with mental health (and) wouldn’t have to justify their reasons. Obviously they have that power. Why would you trust them with other issues your family might care about?”
Tricare Policy Manual change regarding ABA:
Explanation of ABA coverage on Tricare website:
Two stories from Amy Bushatz at Military.com regarding ABA:
American Military Families Autistm Support posts Tricare email about changes:
Also from AMFAS, assessment and concerns about the new policy:
Assessment of policy by "Autism Speaks" advocacy organization:
A parent speaks out on "Age of Autism" website:
Healthcare provider and military spouse Megan Miller's video about ABA:
Letter from Sen. Kirsten Gillibrand and Sen. Patty Murray to Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs and director of Tricare Management Activity:
Letter to Secretary of Defense expressing concerns about the efficacy of Tricare in caring for the needs of children, and special needs individuals from these organizations:
American Academy of Pediatrics
Children's Hospital Association
March of Dimes
Military Officer's Association of America
Military Special Needs Network
National Military Family Association: