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. 

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. 
• 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. 
• 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. 

Exceptional Families of the Military 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. 

 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. 

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.

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.