Summary

In 2014, the Defense Health Agency (DHA), an agency within the Department of Defense (DoD), established the Comprehensive Autism Care Demonstration (ACD) to provide applied behavior analysis (ABA) services to TRICARE-eligible beneficiaries with a diagnosis of autism while evaluating the appropriateness of the ABA services tiered delivery model under TRICARE for military-connected families.¹

Under section 737 of Public Law 117-81 as amended, the National Academies of Sciences, Engineering, and Medicine was charged with establishing a committee of experts to conduct an independent analysis of the ACD and submit a report to Congress and the public with its findings and recommendations. The appointed committee includes individuals with expertise in a wide range of areas, including behavior analysis research, psychology, human/child development, public policy, autism spectrum disorder research, lived experience of autistic individuals and parents of autistic children, healthcare systems and public health, clinical care, neurodevelopment, and biostatistics/outcome measurement.

In conducting its independent analysis, the committee was tasked with providing an assessment of methods used under the demonstration, particularly in relation to assessing autism domains, measuring effectiveness of ABA, and adhering to guidelines and industry standards of care. It was also tasked with examining utilization of the demonstration by TRICARE beneficiaries. Further, the committee was asked to consider whether the occurrence, diagnosis, and treatment of autism among children of military families varied from that in the general population.

KEY FEATURES OF AUTISM

Autism is a lifelong, complex neurodevelopmental condition, presenting as challenges with social communication and interaction and with restricted or repetitive behaviors, and often accompanied by other morbidities. The latest prevalence estimate from the Centers for Disease Control and Prevention (CDC) of autism in the United States among children aged eight is 1 in 31.² Autistic individuals can be found among all racial, ethnic, and sociodemographic groups, including within military-connected families.

CDC has monitored the prevalence of autism in select areas of the United States since 2000. This work has been useful for monitoring trends in the prevalence of autism among the general population. Estimates from a national survey of parents and a recent study of autism diagnosis among TRICARE beneficiaries during the pandemic suggest that the prevalence of autism among military families may be slightly higher than the general population (about 3.5–4.5% compared to 3.2%); however, since each study takes a different approach, these estimates are not directly comparable (see further discussion in Chapter 2).

Many individuals with autism have difficulties coping with change and prefer stable routines. For military-connected families, change is inherent in the lifestyle due to frequent relocations and deployments of one or more caregivers. While relocations are difficult and stressful for all families for a variety of reasons, they present additional challenges for families with individuals with autism or other disabilities who have increased care needs and amplified challenges in the face of change. These challenges can affect the well-being and stability of the entire family, especially when there are additional barriers in accessing medical, educational, and therapeutic supports. Family well-being is essential to those serving in the military because the ability of service members to focus on the mission at hand is largely dependent on the stability of the family.

Broader understanding of autism over the past decades has led to more nuanced diagnostic criteria and ongoing efforts toward better-tailored interventions that address the complex, heterogeneous nature of this neurodevelopmental condition. Recognizing the primary characteristics (often referred to as core symptoms) is just the start of the process for supporting autistic individuals. The medical community now appreciates that clinically identifiable symptoms of autism do not, in and of themselves, offer causal explanations for health outcomes. In the context of developmental conditions such as autism, health outcomes can be affected by skill development in multiple areas such as communication (e.g., able to indicate when feeling ill), activities of daily living (able to practice self-care in areas such as safety, nutrition, and adaptive behavior (able to refrain from maladaptive or injurious behavior). For some individuals with autism, maintaining stability in their daily functioning through interventions is viewed as a positive outcome. Improved understanding has encouraged comprehensive, holistic support systems for autistic individuals that focus more on overall well-being rather than treating specific symptoms. While holistic support can include medical care in addition to educational and community support services, this report is focused on medically necessary care.

Current interventions for autism offer a range of approaches including, but not limited to, behavioral, communicative, developmental, pharmacological, and psychological. These interventions seek to respond to challenges that interfere with individual functioning and to develop skills that improve daily living and quality of life. The support needs of people with autism can vary significantly, and the types of services and accommodations required vary as well. Autistic individuals and their families, in consultation with healthcare providers, can determine appropriate supports and interventions that best support their needs and goals, which can vary throughout an individual’s life.

ABA, a behavioral therapeutic approach, is one such intervention. The ACD is a temporary demonstration that provides coverage for ABA to military beneficiaries with an autism diagnosis. ABA is a set of intervention practices grounded in the science of learning. Behavioral analysts select specific individual practices (e.g., reinforcement, prompting) or combinations of practices (e.g., functional communication training, naturalistic intervention) when designing personalized ABA services that address individual behavioral, health, and learning goals. ABA represents only one autism intervention or support type and is not necessarily appropriate for all individuals with autism nor an exclusive intervention for those with medical support needs. It is, however, the intervention covered by the ACD and therefore the focus of this report.

COMPREHENSIVE AUTISM CARE DEMONSTRATION

Since 2001, military beneficiaries with autism have been eligible to receive ABA services through various mechanisms offered by DoD. For most of that time and during this study, ABA has been considered non-medical and has not been covered as a TRICARE Basic benefit.³ Today, roughly 16,000 TRICARE-eligible beneficiaries are enrolled in the ACD to receive ABA services.

The demonstration project authority began on July 25, 2014, and is found in 10 U.S.C. § 1092 as implemented by 32 C.F.R. § Section 199.1(o). Over the years, the ACD and related mechanisms for the provision of ABA services have evolved. Notably, in 2021, DHA revised its ACD policy in a number of ways (discussed more fully in Chapter 3).⁴ ABA providers and military family advocates have raised concerns in response to certain aspects of this policy revision. These aspects include the mandatory assignment of an Autism Services Navigator (ASN), the required administration of parental stress indices, parent involvement requirements, more frequent and strict administration of assessment tools, and the clarification of coverage in school and certain community settings (see Chapters 3 and 4 for more details).

DEFENSE HEALTH AGENCY EVIDENCE STANDARDS

The authority duration of the ACD has been extended twice and is now set to expire December 31, 2028. Such extensions were made to allow time for DHA to conduct additional evaluation on the objectives of the ACD and to incorporate findings from this study and other independent research. To date, DHA has maintained that ABA services do not meet the hierarchy of reliable evidence standards for proven medical care as defined in the Code of Federal Regulations for the TRICARE program under Title 32 (see Box S-1).

DHA reports that more data collection and analyses are needed to determine whether ABA can be considered medically necessary. While such assertion made sense when the ACD was created, there have been significant developments in the ABA field in the past decade that have made ABA a standard of care for many autistic individuals. In its review of the evidence, the committee finds that DHA’s position deviates from these developments in several ways:

• DHA’s position is counter to the scientific and medical perspectives on the current evidence for health outcomes from ABA. The positive effects of comprehensive ABA programs (> 10 hours per week of programming across multiple developmental domains)

• have been replicated across multiple trials, systematic reviews, and meta-analyses, and the strength of that evidence is increased when inclusive of focused intervention practices.
• The current position of DHA is not aligned with positions of other major medical and healthcare groups that have identified ABA services as research-supported practices appropriate for autistic individuals.
• The demonstration limits health benefits of military-connected families compared to civilians. Coverage of ABA services for autistic persons is now widely available under non-military medical insurance plans as well as state and federal programs (e.g., Medicaid and Federal Employees Health Benefits Program).
• DHA applies a higher standard of evidence to ABA services than other therapy services, such as speech, occupational, and physical therapy that autistic individuals may access as Basic benefits through TRICARE.

DEVELOPMENTS IN THE FIELD

There has been tremendous growth in both the science and practice of ABA in the last 10 years. During this time, ABA services have been available to TRICARE beneficiaries through the ACD.

Empirical Evidence for Applied Behavior Analysis

ABA is often equated with a single practice or singular application of prompting and/or reinforcement, but there are 20 focused interventions based on principles of behavior analysis that have been designated as

• more than 500 employees included coverage for ABA services for their beneficiaries with autism. ABA services are covered care under Medicaid, the Civilian Health and Medical Program of the Department of Veterans Affairs, the Federal Employees Health Benefits Program, the Children’s Health Insurance Program, and a majority of self-funded health plans.
• From 2009 to 2024, 38 states have adopted behavior analyst licensure laws.
• Requirements for credentialing of ABA providers developed by a national nonprofit organization have been promulgated. The organization issues two professional-level certifications as well as a credential for paraprofessionals or technicians. All of the requirements for certification include levels of education, training, experience, examination, adherence to an ethics code, and, in some cases, ongoing supervision.
• The first edition of guidelines and standards of ABA services for autistic individuals was published in 2012. The third edition was published in May 2024.

ANALYSIS OF THE DEMONSTRATION

In undertaking an independent, objective analysis of the ACD, the committee took a multi-perspective approach examining the scientific literature on ABA, as discussed above, as well as the experiences of military-connected families, experiences of ABA providers, industry guidelines, and best practices for research and program evaluation. Over the course of the study, the committee heard testimony and received comments from military families, ABA providers, and autistic individuals. It also invited researchers to present on autism diagnosis, frameworks for autism interventions, measurement development and outcome assessment, and appropriate and ethical use of clinical care data. It reviewed surveys, historical documents, and practice guidelines from autism, ABA, and military-relevant organizations, and reviewed public documents on the ACD, including several reports to Congress by DoD. Further, the committee undertook its own analyses with de-identified data from claims activity and ACD assessments of TRICARE beneficiaries diagnosed with autism from 2018 to 2023.

Characterization of Participants

For a six-year period from calendar years 2018 to 2023, there were 109,073 children, ages 1–18, with an autism diagnosis and eligible for TRICARE benefits. During this time, 35,034 (32%) of these children had a claim for ABA services. More than half (58%) were under age six and a

These personal experiences mirrored concerns of ABA providers as well as those identified in the committee’s review of assessment practices and industry guidelines.

Conclusion: Military-connected families experience increased burdens to maintain eligibility and enrollment in the Comprehensive Autism Care Demonstration to access applied behavior analysis (ABA) services as well as restrictions on settings in which ABA can be provided.

Experiences of Providers

The committee also heard from ABA providers. ABA providers expressed concerns with the 2021 ACD policy changes and the quality of communication around processes between them, regional contractors, and DHA. The revised auditing process and returned treatment plans for minor corrections have been viewed as overly burdensome, they reported. In addition, ABA providers reported that they are concerned with the lack of flexibility in choosing the timing and the most appropriate assessment tools for their clients. Some ABA providers have reported that they have either limited, dropped, or decided not to serve TRICARE clients due to the 2021 changes to the ACD.

Conclusion: Applied behavior analysis (ABA) providers serving military families experience administrative burdens and limited flexibility to target individual needs through the Comprehensive Autism Care Demonstration (ACD). Overly prescriptive policies and practices are likely limiting the quality of ABA delivery and the ability to adequately assess the implementation of the ACD program. These policies, if continued, may affect the network and availability of ABA providers who are willing to serve TRICARE beneficiaries, consequently limiting access to ABA services for families who need it.

Assessment Tools

Regular assessment is a critical part of ABA services. In general practice, the assessment approach and appropriate tools are selected by ABA providers and will vary by individual needs and goals. ACD participants, however, must complete a battery of assessment tools prior to the start of ABA services and periodically thereafter in order to process authorization requests for ABA services. DHA selected four standardized assessment tools used in the autism and healthcare communities: the Pervasive Developmental Disorder Behavior Inventory (PDDBI); the Vineland Adaptive Behavior Scales, Third edition (Vineland-3); the Social Responsiveness Scale (SRS);

Industry Guidelines

There are important areas where the ACD policy does not adhere to generally accepted standards of care and areas where the ACD policy aligns but has stringent requirements. These differences present administrative burdens and may prevent TRICARE beneficiaries from accessing quality services (see Chapter 4). Key areas for improvement are as follows:

1. Treatment Plans and Exclusions for ABA Services: For ABA services to be reimbursable under the ACD, treatment plans and goals are limited to the core autism symptoms. ABA providers are explicitly prohibited from targeting activities of daily living. This policy does not adhere to industry standards. In general practice, behavior analysts select goals that are necessary for the individual client health outcomes, which may necessitate targeting a broader set of autism domains than core symptoms. AMA CPT codes include services that address core symptoms as well as those that build adaptive skills and reduce maladaptive behaviors. The ACD also prohibits delivery of services in certain community settings and limits delivery of services in schools to certified behavioral analysts (not registered technicians) without specific authorization. Industry guidelines emphasize that care can be delivered in any setting for the client to achieve goals.
2. Assessment Tools: As noted above, the ACD requires all ABA providers to periodically administer four standardized assessment instruments, regardless of whether or not they are relevant to the treatment plan and outcome assessment for the individual. This differs from general practice, where assessment for ABA planning and monitoring includes a customized mixture of standardized and non-standardized assessments and direct observation and measurement of target behaviors by ABA providers.
3. Billing Limitations: Under the ACD, only some of the AMA CPT codes are authorized, while others are defined in ways different than as issued by the AMA. As such, ABA providers cannot be reimbursed for delivering ABA services in accordance with industry guidelines and AMA policies.

RECOMMENDATIONS

The committee was charged with developing recommendations related to the measurement, effectiveness, and increased understanding of the ACD and its effect on beneficiaries under the TRICARE program. Four recommendations are shown here with additional details and a fifth recommendation provided in Chapter 7.

Scientific evidence indicates that ABA is an appropriate intervention to support health outcomes of autistic individuals. It is the committee’s view that ABA fits DoD’s Criteria for Reliable Evidence of Proven Medical Effectiveness.

Recommendation 1: The Defense Health Agency should discontinue the Comprehensive Autism Care Demonstration and authorize coverage of applied behavior analysis (ABA) as a Basic benefit under the TRICARE program. It should also immediately take steps to identify authorized ABA providers (to include coverage of the tiered service model and behavior technicians) and define their authority, move ABA Current Procedural Terminology codes off the No Government Pay List, establish reimbursement rates consistent with other TRICARE benefits, and ensure its policies align with current generally accepted standards of care.

Since 2017, the ACD has engaged in an onerous collection of data on participants without clear purpose or plan for doing so. Such data derive from required assessment tools administered periodically. Notably, the added requirement in 2021 to administer parenting stress indices seems to have increased stress among military-connected families with no evidence of their value to the delivery of ABA or to additional support services for families.

Recommendation 2: The Defense Health Agency (DHA) should immediately halt the requirement to periodically administer a specific set of assessment tools (PDDBI, Vineland-3, and SRS) purported to monitor health-related outcomes of applied behavior analysis (ABA) and the administration of parenting stress indices. There is no well-designed evaluation plan for the demonstration program that justifies the use of the assessments, and this data collection has placed growing burdens on military-connected families, ABA providers, and DHA itself in the delivery of ABA services.

DHA should establish policies and practices that ensure ABA services are safe and delivered in ways that are in the best interest of the beneficiaries and their families. Particular care should be taken to change administrative practices that place undue burden on access to care.

Recommendation 3: In providing coverage for applied behavior analysis (ABA) to TRICARE beneficiaries, the Defense Health Agency (DHA) should take steps to ensure that administrative processes do not impede access to care. In particular, DHA should eliminate required aspects

of the demonstration that limit flexibility to support individual health needs and are burdensome to military-connected families and ABA providers. Specifically, DHA should do the following:

1. Allow ABA providers the flexibility to choose assessment instruments appropriate to their clients’ needs, goals, and continuity of care as it halts the mandates around the use of specific assessment tools for all clients and caregivers
2. Discontinue administration of the Parenting Stress Index–Short Form and Stress Index for Parents of Adolescents
3. Continue support for caregiver training as part of receipt and reimbursement of ABA services but allow flexibility in caregiver engagement and eliminate specific requirements for training
4. Make the use of the Autism Services Navigator or similar care coordination or navigation services optional for families

Recommendation 4: In providing coverage for applied behavior analysis (ABA) to TRICARE beneficiaries, the Defense Health Agency (DHA) should update its health benefit and coverage policies for ABA services to align with generally accepted standards of care and industry guidelines. Specifically, DHA should do the following:

1. Allow ABA services to address maladaptive behaviors and activities of daily living affecting health and well-being as determined necessary by an ABA provider
2. Approve use of all Current Procedural Terminology codes for ABA services
3. Allow reimbursement for higher staff-to-client ratio and crisis intervention procedures where deemed necessary by the ABA provider
4. Remove restrictions on settings where ABA services can be delivered, allowing for the authorized supervisor to seek treatment plan approval for the technician to deliver clinically necessary ABA services in school and community settings for purposes of targeting skills outside the home

CONCLUDING REMARKS

The military medical system was one of the first healthcare systems to embrace ABA services and provide such services to military beneficiaries with autism. Initial programs and pilots and lessons learned helped influence efforts to develop guidelines and standards to improve the quality of services and establish ABA within a broad set of healthcare systems. Despite this initial leading role, the ACD has not kept pace with scientific and medical developments related to autism and ABA. Recent policy changes