Military health insurer's new rules will affect kids with autism

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by MEG COYLE / KING 5 News

Bio | Email | Follow: @MegCoyleKING

KING5.com

Posted on July 15, 2013 at 7:13 PM

Updated Monday, Jul 15 at 8:01 PM

TRICARE, the military’s health insurer, is about to implement new rules that will seriously affect thousands of children with autism.

Dena Radcliffe’s daily reality is constant fits and tantrums—as many as 80 per day. Her nearly 3-year-old son Brogan has autism.

“All kids throw tantrums. But a child with autism does not have the ability to comprehend changes,” said Radcliffe.

Even the smallest change has a huge impact on Brogan: “He has seizures and he still doesn’t talk—things moms look forward to hearing like, ‘I love you,’ we don’t hear that from him.”

Radcliffe hadn't heard any words from older brother Jameson until a few months ago. You see, Jameson has autism too.

“He couldn’t talk, couldn’t potty train, he couldn’t use utensils. Now he’s 4-and-a-half going on 5 and he speaks beautifully.”

Radcliffe credits something called Applied Behavioral Analysis or ABA-- trained caregivers who help families understand the mysteries of autism.

“They really break down the ABC’s of behavior. They teach parents why this is happening, how can we manage it, and how can we teach these children to overcome their struggle.”

Now Radcliffe and her soldier husband face a new struggle. New rules under TRICARE make ABA much harder for military families to access.

“Losing that, I feel like I’m losing the ability to connect, in a way, with my child.”

The new rules would require children with autism be assessed every six months. And they would have to prove they’re making progress in order to receive the specialized benefit Radcliffe’s children receive. Any family who wants more than two years of the ABA therapy must go through a waiver process.

Sen. Patty Murray, along with New York Sen. Kirsten Gillibrand, are demanding answers from TRICARE on the policy changes.

“That is not what we should be doing,” said Murray, “It’s the wrong-headed approach and I intend on following up all the way to the end on this and make sure our kids get the care and support they need.”

Radcliffe says children with autism from military families tend to regress more because of multiple deployments and relocation. Radcliffe says the ABA helps provide something that can often be impossible—stability.

TRICARE didn’t address the specific changes to qualifying for the ABA program but in a statement said “The Department of Defense is greatly expanding applied behavior analysis (ABA) services with introduction of the ABA Pilot for non-active duty family members.”

Full statement released from TRICARE to KING 5:

"The Department of Defense is greatly expanding applied behavior analysis (ABA) services with introduction of the ABA Pilot for non-active duty family members. These changes are being made to provide non active duty family members, including retirees, with access to additional areas of ABA reinforcement.  There is no change in the services available to active duty family members.

"Currently, TRICARE provides one of the most generous ABA benefits in the United States, with low out-of-pocket costs. The implementation of this pilot means that aspects of ABA reinforcement will be available to non-active duty family members including retirees. TRICARE also continues to provide all medically necessary treatment for autism spectrum disorders such as physician and psychological services; testing; speech, occupational and physical therapy and pharmacy and there is no cap or maximum for the care or treatment provided for this medically necessary care.

"ABA reinforcement will continue to be provided for active duty family members in the Extended Care Health Option Program and in the ABA Pilot for retirees and other non-active duty family members who are covered by TRICARE. Few, if any, beneficiaries will exceed the $36,000 annual cap paid by TRICARE that is applicable to ABA reinforcement provided outside of the Basic Program under the and the ABA Pilot Program.

"Our goal, first and always, is to support our beneficiaries and we actively work with our managed care support contractors to assure access to all types of care including applied behavior analysis. TRICARE consulted with autism experts in autism spectrum disorder research, clinical care, and psychometrics when drafting its policy following passage of the Fiscal Year 2013 National Defense Authorization Act. Additionally, it consulted with Autism Speaks; the Behavior Analyst Certification Board (BACB), the professional organization for behavior analysts; Military Health System subject matter experts from the Exceptional Family Member Program (EFMP), the DoD Office of Special Needs, the managed care support contractors, and the TRICARE Management Activity Office of Program Integrity (which investigates cases of potential health care fraud); the North Carolina State Psychology Board; Hayes Inc., and the Office of Personnel Management (OPM) among  others."

 

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