Logan Cabiao has a severe form of autism and is nonverbal. At 10 years old, his parents say, he needs round-the-clock support and supervision.
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Logan cannot brush his teeth or use the bathroom on his own. Routine doctor’s appointments can become so overwhelming that his parents sometimes need to sedate him. In crowded places he may run off without warning, they say.
When he was diagnosed with autism at the age of 2, his parents turned to applied behavior analysis, or ABA, a therapy commonly used to help children learn daily life skills and limit harmful behaviors. The treatment gave Logan access to a therapist who worked with him throughout the day.
“I was so desperate to start ABA,” said his mother, Kristi Cabiao, of Niceville, Florida. “We were tired. We hadn’t been sleeping.”
But in 2021, TRICARE — the military’s healthcare program that covers Logan through his father, Mario Cabiao, a retired Air Force pilot — imposed new requirements for ABA coverage. It added roadblocks to access and significantly narrowed the range of services available.
The new rules included stricter paperwork, mandatory assessments, limits on certain services and the use of “autism services navigators,” who must approve a child’s overall care plan before TRICARE will pay for treatment. The program also stopped covering most services in school settings.
While Logan continues to receive some ABA care at a nearby center, his most hands-on sessions involving basic activities — such as toothbrushing, handwashing and getting dressed — are no longer covered.
“They said that’s babysitting,” Kristi Cabiao said, recalling a virtual Q&A she attended with the Defense Health Agency, which oversees TRICARE. “It was really offensive.”
NBC News reported last month that many TRICARE beneficiaries in a different part of the country have faced persistent challenges with coverage — including widespread billing errors, delayed reimbursement and denied claims— after the Defense Health Agency changed over the contractor responsible for administering benefits in its Western region. Several weeks after NBC’s report, that contractor, TriWest Healthcare Alliance, issued a public apology for problems with its coverage. The Defense Health Agency is part of the Defense Department.
The Defense Health Agency did not respond to a request for comment.
Kristi Cabiao, who is a nonpracticing physician, said access to ABA therapy had been “life-changing” for her family.
She said that, despite her medical training, she felt powerless during Logan’s early years. At one point, she said, she had to perform the Heimlich maneuver on Logan because he began choking on objects he put in his mouth. After starting ABA, everyday activities became a lot more manageable, she said.
“I had a lot of guilt because I felt like I couldn’t help him,” Cabiao said. “And then when our therapist came in, finally she’s like, ‘It’s not your fault,’ and she helped us.”
Mario Cabiao said he worries about what will happen when Logan becomes an adult, when he’ll need to start doing more on his own. He said Logan currently has the functional life skills of a 2-year-old.
“Time is of the essence, and eight years is not a lot of time,” he said, alluding to the time when he will be 18 years old.
ABA helps children with autism to develop important life skills, said Alycia Halladay, chief science officer at the Autism Science Foundation, a nonprofit advocacy group.
“It’s all about breaking things down into smaller steps, and then also providing the appropriate reinforcement for things,” Halladay said.
“This is how we all learn, by the way,” she added. “We all learn to go to the potty by somebody reinforcing us by going to the bathroom on the potty. We learned to be on time by people reinforcing us and giving us positive accolades for being on time. Kids with autism, they get it more intensely and they get it more directed based on the skill they need help with.”
Most states have mandates requiring private insurers to cover ABA or other behavioral interventions for children with autism, Halladay said.
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Those mandates, however, don’t apply to the federal government, including federal programs such as TRICARE, she said. (Some federal programs do cover the therapy for children, including Medicaid and the Federal Employees Health Benefit, the government’s health insurance program for federal employees, retirees and their families.)
In 2021, Kristi Cabiao started a nonprofit called Mission Alpha aimed at pressuring both TRICARE and members of Congress to restore broad coverage of ABA. She lobbied Congress for an independent study reviewing the effectiveness of the therapy, which was launched that same year and conducted by the National Academies of Sciences, Engineering, and Medicine. Last September, the group published a 336-page report affirming that ABA should be included as a basic benefit under TRICARE, without the excessive administrative barriers that have disrupted treatment for children in military families.
The report stated the evidence to support ABA therapy “is robust” and meets “the Department of Defense’s own criteria of reliable evidence.”
Last fall, the American Academy of Pediatrics, along with the Council for Autism Service Providers, a trade group, and the advocacy groups Autism Speaks, Exceptional Family Members of the Military, the National Military Family Association, TRICARE for Kids and Cabiao’s Mission Alpha, signed a letter to Congress urging implementation. TRICARE has still declined to do so.
“There’s a cost to people not being able to get services that they would potentially benefit from,” said David Sitcovsky, vice president of advocacy at Autism Speaks. “And while of course, every healthcare service costs some amount of money, this has been proven to be an effective intervention for a lot of autistic individuals.”
Kristi Cabiao said she and her husband have built a small house in their backyard, hoping that one day Logan will be able to live there on his own. Logan is currently being homeschooled.“It makes me mad, yeah, makes me emotional,” she said.
As a member of the military, Mario Cabiao said it feels like a betrayal.
“We’ve just been denied that opportunity for him to progress,” he said.
ABA “is evidence-based and it is based on science,” Halladay said. “It makes me sick to think that military veterans and their families are getting less than what other people are getting.”