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Department of Defense Programs and Policies to Support Military Families with Special Needs

112th Congress (2011-2012)




before the



Department of Defense Programs and Policies to Support Military Families with Special Needs

June 20, 2012

Chairman Webb, Ranking Member Graham, and Members of the Subcommittee, thank you for the opportunity to make a statement on behalf of the Federal Employees Health Benefit (FEHB) Program, administered by the US Office of Personnel Management (OPM). We appreciate the Subcommittee’s interest in our program and its support of families whose children have special needs, specifically those with Autism Spectrum Disorders.

We understand the Subcommittee seeks information about our recent classification of Applied Behavior Analysis (ABA) as medical therapy. In contrast to the single provider model of TRICARE, the FEHB program contracts with 91 insurance carriers to offer health plans to over 8 million Federal employees, annuitants, and families. All plans are required to provide basic services, and may negotiate to offer a range of additional benefits. All FEHB plans are required to provide children with autism access to pediatric care, physical therapy, occupational therapy, speech therapy, mental health treatment, and medications. However, in 2012, ABA is not an FEHB benefit because it is classified as an investigational or educational intervention. This means that the child of a Federal employee cannot access ABA through their health insurance regardless of whether the plan would normally consider such treatment medically necessary and provide it to its non-Federal subscribers.

Beginning in 2010, Members of Congress, families, and other stakeholders asked OPM to re-examine this blanket exclusion. The OPM Benefit Review Panel evaluated the status of ABA for children with autism. Previously, ABA was considered to be an educational intervention and not covered under the FEHB Program. The Benefit Review Panel concluded that there is now sufficient evidence to categorize ABA as medical therapy. Accordingly, plans may propose benefit packages which include ABA.

Over the last two years, the infrastructure to support the delivery of ABA has matured rapidly. Today 30 States require at least some health insurance coverage of ABA, and 14 have licensure procedures for ABA providers. ABA providers most frequently have a graduate degree in Psychology with additional training in ABA, leading to formal Board Certification in Behavior Analysis. States often exercise their supervision of certified or licensed providers through the same pathway which oversees other health care practitioners, such as a Board of Medicine or Psychological Examiners. It is also common practice to require a physician’s or Psychologist’s prescription before a health plan will approve ABA for a specific child.

OPM made a decision to reclassify ABA as a medical therapy rather than an educational service based on the evolving body of clinical research and the maturing provider infrastructure to deliver this modality under a medical model. This reclassification does not presume medical necessity and does not specifically require FEHB plans to add ABA services to their basic benefits package. Rather, it allows families of Federal employees to receive the same treatment as families of non-Federal employees by allowing plans to propose ABA as an additional benefit, under conditions where medical necessity is satisfied and appropriate, qualified providers are available. Medical necessity criteria are evaluated by each health plan in FEHB, not by OPM. Plans assess whether a proposed treatment is safe, supported by sound medical evidence, effective for an individual, more effective than alternative treatments, and conforms to relevant standards of medical practice. Our decision applies only to FEHB, and not to TRICARE programs, and accordingly, was published as technical guidance to our carriers.

The evidence is not yet sufficient to support an official OPM position requiring coverage by all FEHB carriers. In the interval, our administrative change will allow FEHB plans that chose to do so to make ABA services available as the research and provider base mature. OPM will periodically re-review ABA as the research develops. We are grateful for the Subcommittee’s support of Federal employees and their families.

Thank you for this opportunity, I am happy to address any questions that you may have.

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