Military health plan limits autism therapy many private insurers cover

TRICARE restrictions adopted in 2021 have limited access to applied behavior analysis therapy for some children in military families, NBC News reported. The limits matter because ABA is widely used to help autistic children build daily living skills and reduce harmful behaviors, and many private insurers are required by state law to cover it.

One family affected is the Cabiao family of Niceville, Florida. Kristi and Mario Cabiao told NBC News their 10-year-old son, Logan, has severe autism, is nonverbal and needs constant supervision.

According to his parents, Logan cannot independently brush his teeth or use the bathroom, and medical visits can become so difficult that sedation is sometimes needed. They said he may also bolt in crowded places without warning.

Logan was diagnosed with autism at age 2, NBC News reported. His parents then turned to ABA, which gave him access to a therapist who worked with him during the day.

Coverage narrowed after 2021 changes

Logan is covered through TRICARE because his father, Mario Cabiao, is a retired Air Force pilot, according to NBC News. In 2021, the military health program added new conditions for ABA coverage, including more documentation, required assessments, limits on some services and the use of autism services navigators who must approve overall care plans before TRICARE pays.

NBC News reported that TRICARE also stopped covering most ABA services provided in school settings. Logan still receives some ABA at a nearby center, but his mother said the most practical sessions aimed at activities such as dressing, toothbrushing and handwashing are no longer paid for.

Kristi Cabiao, described by NBC News as a nonpracticing physician, said ABA changed life at home for the family. She said Logan’s early years left her feeling unable to help him, including one incident in which she had to perform the Heimlich maneuver after he put objects in his mouth and began choking.

Mario Cabiao told NBC News he is worried about Logan’s adulthood and said his son has the functional life skills of a 2-year-old. The family has built a small house in the backyard in hopes Logan may someday be able to live there independently, NBC News reported.

Advocates point to federal gap

Alycia Halladay, chief science officer at the Autism Science Foundation, told NBC News that ABA teaches skills by breaking tasks into smaller steps and reinforcing progress. She said many states require private insurers to cover ABA or similar behavioral treatment for autistic children.

Those state mandates do not bind the federal government or programs such as TRICARE, Halladay told NBC News. NBC News reported that some federal programs, including Medicaid and the Federal Employees Health Benefits program, do cover ABA for children.

Kristi Cabiao founded Mission Alpha in 2021 to press TRICARE and Congress to restore broader ABA coverage, NBC News reported. She also pushed for an independent review by the National Academies of Sciences, Engineering, and Medicine.

The National Academies released a 336-page report last September that found ABA should be treated as a basic TRICARE benefit without what it described as excessive administrative barriers, according to NBC News. The report said the evidence supporting ABA is robust and meets the Defense Department’s criteria for reliable evidence.

Last fall, NBC News reported, the American Academy of Pediatrics, the Council for Autism Service Providers and several autism and military family advocacy groups signed a letter asking Congress to act on the report’s findings. TRICARE has not done so, according to NBC News.

David Sitcovsky, vice president of advocacy at Autism Speaks, told NBC News that denying services carries costs for people who could benefit from them. The Defense Health Agency, which oversees TRICARE, did not respond to NBC News’ request for comment.

This story draws on original reporting from NBC News.