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Tricare would expand its coverage of applied behavioral therapy for children of beneficiaries with autism and other developmental disabilities under an amendment approved as part of the Senate version of the 2013 defense authorization bill.
The amendment, sponsored by Sen. Kirsten Gillibrand, D-N.Y., would extend coverage for ABA to families of military retirees, who currently are ineligible, and increase services across the board for all beneficiaries, eliminating a $36,000 annual cap on benefits.
"It is alarming that our military families who have sacrificed so much are denied essential services for their children suffering from autism and other disabilities," Gillibrand said during Senate debate on the measure.
Autism affects an estimated 23,000 military children; another 10,000 families have a child with a moderate to severe developmental disability for which ABA, an intensive form of behavior modification, may be prescribed.
Tricare has maintained that ABA is an educational intervention, not a medical therapy, and thus should not be a broadly covered service. Tricare has offered ABA to active-duty service members' families through a special program that covers about six to 15 hours a week.
Children with severe autism or other mental impairments often are advised to receive up to 40 hours of treatment per week.
In June, the federal Office of Personnel Management issued guidance declaring ABA a "medical therapy" and said insurers who provide health care plans for government workers could offer it under their plans. Many states also have passed legislation requiring state-regulated insurance companies to offer it.
But companies have been slow to adopt coverage, which can cost up to $5,000 a month.
In arguing against Gillibrand's proposal, Sen. Tom Coburn, R-Okla., a doctor, pointed out that the measure would cost the Pentagon $1.9 billion over the next 10 years.
Without a way to pay for what he acknowledged is a "well-intentioned and proper thing," Coburn said funds likely would have to be cut from the military's operations and maintenance accounts.
"All it would take to pay for it is a $2 a month increase in premiums for those on Tricare Prime," he proposed.
Gillibrand argued that the bipartisan amendment would be in effect only for one year as a way to help those who need coverage now while Congress and the Defense Department work on a long-term solution.
In July, a federal judge ordered Tricare to cover the intensive therapy for affected children of service members and retirees. Following the ruling, Tricare notified beneficiaries it would pay for the treatment, offered by "masters-level board-certified behavior analysts."
But critics say the stipulation has actually reduced access to care. They point out that masters-level trained analysts often oversee those with bachelor's degrees or occupational therapists and speech therapists who work one-on-one with patients and don't actually conduct the treatment themselves.
"They've actually twisted the judge's ruling and are using it to cover fewer children who need it, not more," said Dawn Berge, a plaintiff in the class-action lawsuit that prompted Judge Reggie Walton's ruling.
A House version of the defense authorization bill also would require Tricare to pay for ABA treatment for children of Defense Department active-duty and retirees diagnosed with autism.
But the Senate's version is broader, including the Coast Guard, National Oceanic and Atmospheric Administration and the Public Health Service, as well as children with other developmental disabilities.