The Fine Print: A question of what Tricare should cover

Who should pay for costly special treatment for autistic children in families of active and retired military service personnel?

This is no idle question. It relates to the Pentagon budget before Congress and, in a broader sense, to the “fiscal cliff” and Americans’ view of government spending.

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In May, the Republican-controlled House approved a bipartisan amendment to transfer $30 million from the Army research and development account in the fiscal 2013 defense authorization bill to create a new section under the Pentagon’s Tricare health-care program. The section would broaden the availability of funds for applied behavior analysis (ABA) treatment of autistic children when prescribed by a physician.

Until recently, the Defense Department considered ABA treatment an educational intervention, not a medical therapy, so it was not broadly covered under Tricare. It is an expensive treatment “generally begun by age 31 _/2 and consists of up to 40 hours per week of intensive therapy for two years or longer,” according to the Congressional Research Service.

Tricare’s Extended Health Care Option program, under which ABA was permitted, was limited to active-duty personnel and had an annual cap of $36,000 per enrollee. The American Academy of Pediatrics recommended at least 25 hours a week of intense therapy for children newly diagnosed with autism, but the Tricare cap permitted less than 20 hours a week for therapy.

During the House debate on the measure, Rep. John B. Larson (D-Conn.), co-sponsor of the amendment, said the cap had to be removed and coverage needed to be expanded to include retired military personnel as well as those on active duty.

Also in May, the Senate Armed Services Committee voted down a similar amendment — sponsored by Sen. Kirsten Gillibrand (D-N.Y.) — to the authorization bill. But after a Senate Armed Services subcommittee hearing in June, Gillibrand decided to reintroduce the amendment when the bill came to the Senate floor.

On Thursday, the Democratic-controlled Senate voted overwhelmingly for the Gillibrand amendment, which shifted $45 million from the Defense Department operations and maintenance account in the fiscal 2013 authorization bill to pay for ABA treatment under Tricare. Her amendment increased the House amount and also covered the Coast Guard, the Commissioned Corps of the National Oceanic and Atmospheric Administration, and the Commissioned Corps of the Public Health Service.

Gillibrand said she was speaking for “30,000 military families who have loved ones with disabilities, including those on the autism spectrum.” She said that “military families with children on the autistic spectrum are receiving fewer services than their civilian governmental counterparts across the country,” noting that “the Office of Personnel Management has determined that such treatments may be covered as medical therapies for federal civilian employees.”

She also pointed out that “Guard and Reserve families receive intermittent care, and children of retirees can’t even get coverage at all.” One result is that some current and former service members turn to state Medicaid programs for help. But ABA and other services are often unavailable because of waiting lists — seven years long in Maryland and 10 years in Virginia — according to Gillibrand.