Military Personnel
Medical, Family Support, and Educational Services Are Available for Exceptional Family Members Gao ID: GAO-07-317R March 16, 2007The Department of Defense's (DOD) Exceptional Family Member Program (EFMP) is a mandatory enrollment program for active duty servicemembers who have family members with special medical needs. When military servicemembers are considered for assignment to an installation within the United States, EFMP enrollment is used to determine whether needed services, such as specialized pediatric care, are available through the military health system at the proposed location. Due to this consideration, each military service assigns servicemembers with exceptional family members who have significant needs to certain locations because of the resources available through DOD's health care system in these communities. Further, DOD policy allows (but does not require) the military services to provide family support services specifically for exceptional family members. State and local medical, family support, and educational services in these communities may also serve the military's exceptional family members as part of providing services to local residents. The Ronald W. Reagan National Defense Authorization Act for Fiscal Year 2005 directed us to evaluate the effect of EFMP on health, support, and education services in selected civilian communities with a high concentration of EFMP enrollees. As discussed with the committees of jurisdiction, this report describes (1) the services provided by the military health and family support systems that are available to meet the needs of exceptional family members within the United States, and (2) state and local services--including medical, family support, and educational services--available for the exceptional family members in select communities.
Through TRICARE and its supplementary coverage program, DOD provides exceptional family members located at installations within the United States with basic medical services--including inpatient and outpatient care, drugs, and durable medical equipment--and, when needed, additional medical services such as health care provided in the home and respite care. However, DOD officials with whom we spoke in all four communities said that certain medical services requested by exceptional family members may be difficult to obtain because of a limited number of specialists available in DOD's health care system in these communities. Due to a lack of data on exceptional family members and their medical conditions, we were unable to determine the extent to which medical services are utilized by exceptional family members. Family support services are also available to exceptional family members through military service family centers, which provide information about specialized services--including day care, after-school care, and recreational programs. However, some family support services may not be available to accommodate exceptional family members with certain medical conditions. State and local medical, family support, and educational services are available to exceptional family members. Some of the services available include mental health counseling, respite care, therapies for children with developmental delays, and therapy for autism. However, state and local agency officials in the four communities we visited were unable to provide data that could be used to determine the specific service needs of exceptional family members or their utilization of services. Even though data on EFMP were not collected, local officials said that it may be difficult to obtain some services because of the limited number of specialist providers practicing in the community. The availability of services also may depend on the laws and policies of the state where the exceptional family member resides. In addition, under federal law, exceptional family members attending a U.S. public school may be eligible for special education and related services from age 3 through 21. However, we could not identify the type or amount of special education services used by exceptional family members in the communities that we visited due to the absence of specific data on exceptional family members.
GAO-07-317R, Military Personnel: Medical, Family Support, and Educational Services Are Available for Exceptional Family Members
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March 16, 2007:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Minority Member:
Committee on Armed Services:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable Duncan Hunter:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives:
Subject: Military Personnel: Medical, Family Support, and Educational
Services Are Available for Exceptional Family Members:
The Department of Defense's (DOD) Exceptional Family Member Program
(EFMP) is a mandatory enrollment program for active duty servicemembers
who have family members with special medical needs.[Footnote 1] When
military servicemembers are considered for assignment to an
installation within the United States, EFMP enrollment is used to
determine whether needed services, such as specialized pediatric care,
are available through the military health system at the proposed
location. Due to this consideration, each military service assigns
servicemembers with exceptional family members who have significant
needs to certain locations because of the resources available through
DOD's health care system in these communities.[Footnote 2] Further, DOD
policy allows (but does not require) the military services to provide
family support services specifically for exceptional family
members.[Footnote 3] State and local medical, family support, and
educational services in these communities may also serve the military's
exceptional family members as part of providing services to local
residents.
The Ronald W. Reagan National Defense Authorization Act for Fiscal Year
2005 directed us to evaluate the effect of EFMP on health, support, and
education services in selected civilian communities with a high
concentration of EFMP enrollees.[Footnote 4] As discussed with the
committees of jurisdiction, this report describes (1) the services
provided by the military health and family support systems that are
available to meet the needs of exceptional family members within the
United States, and (2) state and local services--including medical,
family support, and educational services--available for the exceptional
family members in select communities.
To describe the services provided by the military health and family
support systems that are available to meet the needs of exceptional
family members within the United States, we reviewed federal law and
regulations, TRICARE policies, agency documentation, and other sources
related to EFMP.[Footnote 5] In addition, we interviewed TRICARE
Management Activity (TMA) officials and EFMP officials for each
military service--Army, Navy, Air Force--and the Marine Corps.[Footnote
6] We interviewed local military officials in the following four
selected communities to obtain information on the EFMP administrative
process, types of medical conditions typically associated with
exceptional family members in these communities, types of services
needed, and whether services are available to meet these needs within
the military health and family support systems: San Diego, California
(Navy and Marine Corps); Fayetteville, North Carolina (Army and Air
Force); San Antonio, Texas (Army and Air Force); and the Hampton Roads
area, Virginia (Army, Navy, and Air Force). (See app. I for site
selection methodology.)
To describe state and local services--including medical, family
support, and educational--available to exceptional family members in
these four communities, we interviewed officials from state and local
agencies that provide these services within the four communities we
selected. Because local government officials from one of the selected
communities had previously expressed concern to the Secretary of
Defense that EFMP was placing an undue financial burden on its local
resources, we also requested data on the number of exceptional family
members these agencies serve, types of services provided, and
associated costs. We conducted our work from June 2005 through January
2007 in accordance with generally accepted government auditing
standards. (For more detail on our scope and methodology, see app. II.)
Results in Brief:
Through TRICARE and its supplementary coverage program, DOD provides
exceptional family members located at installations within the United
States with basic medical services--including inpatient and outpatient
care, drugs, and durable medical equipment--and, when needed,
additional medical services such as health care provided in the home
and respite care. However, DOD officials with whom we spoke in all four
communities said that certain medical services requested by exceptional
family members may be difficult to obtain because of a limited number
of specialists available in DOD's health care system in these
communities. For example, the only developmental pediatrician on staff
at Naval Medical Center San Diego told us that, in addition to seeing
patients from San Diego, he also sees patients from other
installations, including a Nevada Air Force base, because these
installations do not have a developmental pediatrician on staff. Due to
a lack of data on exceptional family members and their medical
conditions, we were unable to determine the extent to which medical
services are utilized by exceptional family members. Family support
services are also available to exceptional family members through
military service family centers, which provide information about
specialized services--including day care, after-school care, and
recreational programs. However, some family support services may not be
available to accommodate exceptional family members with certain
medical conditions. For example, at one installation that we visited, a
military official reported that an exceptional family member with
severe autism could not be enrolled in an after-school program located
on base because the program was unable to meet the child's supervisory
needs.
State and local medical, family support, and educational services are
available to exceptional family members. Some of the services available
include mental health counseling, respite care, therapies for children
with developmental delays, and therapy for autism. However, state and
local agency officials in the four communities we visited were unable
to provide data that could be used to determine the specific service
needs of exceptional family members or their utilization of services.
Even though data on EFMP were not collected, local officials said that
it may be difficult to obtain some services because of the limited
number of specialist providers practicing in the community. For
example, in all four communities that we visited, local officials
reported that there were very few child psychologists or psychiatrists
in their communities, which resulted in difficulties accessing care due
to such factors as lengthy wait times for appointments for exceptional
family members or any other local residents who require mental health
counseling. The availability of services also may depend on the laws
and policies of the state where the exceptional family member resides.
For example, some services may be easier to obtain in states with laws
and policies requiring the provision of those services for a specific
population, which may include exceptional family members. In addition,
under federal law, exceptional family members attending a U.S. public
school may be eligible for special education and related services from
age 3 through 21. However, we could not identify the type or amount of
special education services used by exceptional family members in the
communities that we visited due to the absence of specific data on
exceptional family members.
We provided a draft of this report to DOD and the Department of
Education for their review. Both agencies provided technical comments,
which we have incorporated as appropriate.
Background:
To help with personnel recruitment and retention, DOD established EFMP,
which takes into consideration the special needs of family members
during the process of assigning servicemembers to an installation. The
Army set up the first EFMP in 1979; since that time, the Navy, Air
Force, and Marine Corps incorporated EFMP into their assignment
processes. Each service's EFMP considers the availability of DOD's
specialized medical services for family members when making assignment
decisions for servicemembers within the United States. The educational
needs of exceptional family members are not taken into consideration
within the United States because federal law requires the availability
of a free, appropriate public education, which may include specialized
instruction and related services, for all eligible children attending
U.S. public schools.[Footnote 7] EFMP applies to all eligible, active-
duty servicemembers. Currently, federally appropriated funds are not
separately earmarked for EFMP. Rather, the military services must
allocate funds for its administration from within other budget sources,
such as personnel or family support programs.
EFMP has two components--personnel assignment and family support
services. Under the personnel component, the military services identify
exceptional family members, document the services needed by exceptional
family members, and then take into consideration those needs during the
personnel assignment process. Additionally, DOD policy allows (but does
not require) the military services to provide family support services
specifically for exceptional family members at family centers on
military installations with an EFMP.[Footnote 8] When the family
centers provide support services for exceptional family members, the
assistance generally includes providing information about and referrals
to programs and services that can accommodate an exceptional family
member.
Enrollment in EFMP is mandatory for servicemembers with eligible family
members. In 2006, there were an estimated 102,596 exceptional family
members enrolled in EFMP.[Footnote 9] A family member is identified as
a potential candidate for EFMP through self-reporting, screening, or
routine medical care. After a family member is identified as a
potential candidate, a medical summary is prepared by a qualified
medical authority. Once the summary is completed, each military service
has its own medical review process to validate eligibility for EFMP.
The medical review process identifies specific diagnoses and medical
conditions such as cancer, sickle cell disease, insulin-dependent
diabetes, asthma, current and chronic mental health conditions, and
attention deficit/hyperactivity disorder that would allow an individual
to become eligible for EFMP. Conditions that require adaptive equipment
(e.g., wheelchair, hearing aid, home oxygen therapy, home ventilator),
assistive technology devices (e.g., communication devices) or
environmental and architectural considerations (e.g., wheelchair
accessibility) are also included. (See app. III for further details on
DOD's definition of special medical needs.)
The services differ in how they maintain data on exceptional family
members once they are enrolled in EFMP. For instance, the Army and the
Navy maintain specific medical data on each exceptional family member
and are able to electronically generate reports by location on the
number of exceptional family members and their medical diagnoses. The
Air Force and Marine Corps, however, while maintaining complete
individual paper files on each exceptional family member, are only able
to electronically generate reports on the number of servicemembers who
may have one or more family members enrolled in EFMP and the
installation where these servicemembers are located (see table 1).
Table 1: EFMP Data Fields:
Military service: Army;
By exceptional family member: Check;
By servicemember with exceptional family member(s): Check;
By installation: Check[A];
Medical diagnosis of exceptional family member by installation: Check.
Military service: Navy;
By exceptional family member: Check[A];
By servicemember with exceptional family member(s): Check;
By installation: Check[A];
Medical diagnosis of exceptional family member by installation:
Check[A].
Military service: Air Force;
By exceptional family member: [Empty];
By servicemember with exceptional family member(s): Check;
By installation: Check;
Medical diagnosis of exceptional family member by installation:
[Empty].
Military service: Marine Corps;
By exceptional family member: [Empty];
By servicemember with exceptional family member(s): Check;
By installation: Check[A];
Medical diagnosis of exceptional family member by installation:
[Empty].
Source: Army, Navy, Air Force, and Marine Corps.
[A] The data system can provide current data, which are routinely
updated; the system cannot provide historical data.
[End of table]
DOD provides medical services to servicemembers and their family
members through its TRICARE program, which encompasses both the
military services' hospitals and clinics as well as civilian providers
who agree to accept TRICARE beneficiaries as patients. As a supplement
to TRICARE's basic program, the DOD health care system has provided
additional medical coverage for family members with certain medical
conditions. For example, in 1997, DOD established the Program for
Persons with Disabilities (PFPWD), which replaced the former Program
for the Handicapped, to provide a mechanism for obtaining diagnostic
procedures, services, equipment, treatment, and training. In September
2005, TMA replaced PFPWD with the Extended Care Health Option
(ECHO).[Footnote 10] Similar to PFPWD, ECHO is a supplementary health
care option that offers additional coverage for exceptional family
members. In order to qualify for ECHO, servicemembers with exceptional
family members must be enrolled in EFMP and the exceptional family
member must have a qualifying condition.[Footnote 11] Enrollment in
ECHO requires a monthly payment ranging from $25 to $250, depending on
the servicemember's rank.[Footnote 12] After an exceptional family
member is enrolled, TRICARE will pay up to $2,500 per month for a
number of authorized benefits such as respite care and therapy for
autism.[Footnote 13] As of December 2006, approximately 1,980
exceptional family members were enrolled in ECHO.[Footnote 14]
DOD does not limit assignments based on special educational needs when
making assignments for servicemembers within the United States because
eligible, exceptional family members are entitled to receive special
education and related services from their local school system. Public
school systems in the United States are subject to the provisions of
section 504 of the Rehabilitation Act of 1973,[Footnote 15] title II of
the Americans with Disabilities Act (ADA),[Footnote 16] and the
Individuals with Disabilities Education Act (IDEA).[Footnote 17] Under
these laws and related regulations, public school districts must make
available a free, appropriate public education to elementary and
secondary school students with disabilities. Where appropriate to meet
a particular child's needs, this education will include special
education and related services, such as physical therapy and speech
therapy. IDEA provides partial federal funding for special education
and related services through federal formula grants made to
states.[Footnote 18] Public local educational agencies meeting certain
criteria may also receive federal funding for special education and
related services through Impact Aid,[Footnote 19] a program which was
established to provide financial assistance to compensate local
educational agencies for tax revenue lost due to the presence of
federal properties in communities.[Footnote 20] In addition, DOD is
authorized to supplement Impact Aid to compensate for the cost of
providing educational services to children with severe disabilities and
for the reduction to the local tax base, among other things.[Footnote
21]
Medical and Family Support Services Are Available but Exceptional
Family Members May Face Difficulties Obtaining Some Needed Services:
Through TRICARE, DOD provides exceptional family members with basic
medical services, such as inpatient and outpatient care, drugs, mental
health services, and durable medical equipment. In addition to basic
medical care, some exceptional family members require additional
supplemental medical services, such as health care provided in the
home, therapies for autism, and respite care. DOD provides these
services through TRICARE and ECHO. (See table 2.)
Table 2: Selected DOD Benefits for Exceptional Family Members:
Selected benefits: Home health care;
The following medically necessary services may be covered when provided
in the beneficiary's home by a TRICARE-authorized home health agency
that participates in the TRICARE program:
* skilled nursing care from a registered nurse, or by a licensed or
vocational nurse under the direct supervision of a registered nurse;
* services provided by a home health aid under the direct supervision
of a registered nurse;
* physical therapy, occupational therapy, and speech-language pathology
services;
* medical social services under the direction of a physician;
* teaching and training activities; and;
* medical supplies;
TRICARE benefit: Up to 28 to 35 hours per week of medically necessary
services provided under a plan of care established and approved by a
physician;
Extended Care Health Option (ECHO) supplemental medical services: ECHO
home health care benefits provide medically necessary services to
eligible homebound beneficiaries who generally require more than 28 to
35 hours per week of home health services and are being routinely
followed by a case manager. Beneficiaries are considered homebound if
their condition is such that they do not have the normal ability to
leave home and consequently leaving home requires considerable and
taxing effort. Coverage for the home health care benefit is capped on
an annual basis. The cap is based on the beneficiary's geographic
location and is equivalent to what TRICARE would pay if the beneficiary
resided in a skilled nursing facility. The home health care cap does
not count toward the $2,500 monthly ECHO cap.
Selected benefits: Mental health services; Psychotherapy provided on an
outpatient basis or at a hospital;
TRICARE benefit: Eight outpatient sessions without prior approval. If
there is a need for more than eight outpatient sessions in a fiscal
year, approval is required. If more than two sessions a week are needed
as an outpatient, a review of the medical necessity for care is
conducted; Up to two medication management visits per month are covered
without preauthorization when provided as an independent procedure and
rendered by a TRICARE- authorized provider. Medication management
sessions exceeding two visits per month must be preauthorized; If more
than five sessions are needed in a hospital, a review of the medical
necessity for care is conducted. Inpatient care is limited to 45 days
per fiscal year for patients under the age of 19 and 30 days per fiscal
year for patients 19 years old and over; Residential treatment center
stays, which are available only for beneficiaries under 21 who require
mental health care, are limited to 150 days per fiscal year or per
admission;
Extended Care Health Option (ECHO) supplemental medical services: No
additional benefits.
Selected benefits: Therapy for autism; Early, intense education for
children, which may include the structured teaching of skills that help
the child talk, interact, play, and learn;
TRICARE benefit: No benefit;
Extended Care Health Option (ECHO) supplemental medical services:
Applied behavioral analysis when provided by an authorized TRICARE
provider.[A].
Selected benefits: Respite care; Short-term care of a beneficiary in
order to provide rest and change for those who have been caring for the
patient at home;
TRICARE benefit: Not a stand-alone benefit but may be provided through
other benefits such as hospice care;
Extended Care Health Option (ECHO) supplemental medical services: ECHO
respite care- 16 hours per month when receiving other authorized ECHO
benefits. Unused hours from one week cannot be carried over into
another week; ECHO beneficiaries who also qualify for the ECHO home
health care benefit may receive up to 40 hours per week (8 hours per
day, 5 days per week) of respite care under certain circumstances.
However, only one ECHO respite care benefit can be used in a calendar
month. The 16- hour respite care benefit and the 40-hour respite care
benefit cannot be used in the same calendar month.
Source: GAO analysis of DOD documents.
[A] Applied behavior analysis is a behavior modification approach to
learning that uses a highly structured, systematic, and consistent
teaching method.
[End of table]
However, DOD officials whom we spoke with in all four communities said
that access to certain medical services requested by exceptional family
members may be difficult to obtain because of a limited number of
specialists available in DOD's health care system in these communities.
For example, the only developmental pediatrician on staff at the Naval
Medical Center San Diego told us that in addition to seeing patients
from San Diego, he also sees patients from Camp Pendleton and from as
far away as Nellis Air Force Base, Nevada, because neither of these
installations has a developmental pediatrician on staff. Consequently,
his patients must schedule their appointments months in advance. Due to
the lack of data on exceptional family members and their medical
conditions, we could not identify the medical services being utilized
or the difficulties experienced by exceptional family members in
accessing care in the four communities we visited.
Exceptional family members also have access to family support services.
In providing services to exceptional family members, family centers and
some military treatment facilities deliver family support services such
as information about specialized services--including day care, after-
school care, and recreational and cultural programs---that can
accommodate an exceptional family member with special needs. Family
centers and some military treatment facilities may also provide
information about relevant support groups, available advocacy services,
and housing to accommodate special needs. We found that the military
services vary in their approach towards assisting exceptional family
members. For instance, at one Air Force location and at each of the two
naval locations we visited, the installations employ one staff member
who, in addition to helping identify needed services for exceptional
family members, has other duties not related to EFMP. At another Air
Force installation and the Marine Corps and Army locations we visited,
dedicated staff are available to assist servicemembers in finding
needed services.[Footnote 22] Additionally, the Army brings together
staff from different areas, such as medical command and recreational
services, to meet directly with the servicemember to determine the
needs of the exceptional family member.
According to officials with whom we spoke, some family support services
may not be available to accommodate exceptional family members with
certain medical conditions. For example, at one installation that we
visited, a military official reported that an exceptional family member
with severe autism could not enroll in an after-school program located
on-base because the program was unable to meet the child's supervisory
needs.
State and Local Services--Including Medical, Family Support, and
Educational Services--Are Available to Exceptional Family Members, but
Availability Can Vary By Community:
Medical and family support services provided by state or local agencies
are available to exceptional family members in the locations we
visited. Some of the services available include mental health
counseling, respite care, therapies for children with developmental
delays, and therapy for autism. However, we found that agencies
providing medical and family support services do not collect data on
whether the clients they serve are enrolled in EFMP. Local officials in
each state that we visited--including agency officials in one community
that expressed concern over the financial impact of EFMP on local
resources--were unable to provide data on the specific service needs of
exceptional family members or their use of these services. Therefore,
we could not assess the extent to which exceptional family members were
using these services. Even though data on EFMP were not collected,
local officials said that it may be difficult to obtain some medical
services because of the limited number of specialist providers
practicing in the community--reasons similar to those cited by DOD
officials for the limited availability of some medical services
provided by DOD's health care system. For example, in all four
communities that we visited, local officials reported that there were
very few child psychologists or psychiatrists in their communities,
which resulted in difficulties accessing care. Problems included
lengthy wait times for appointments and delays in obtaining an initial
mental health assessment for exceptional family members or other local
residents under the age of 3 years who require mental health counseling
or have a behavioral health disability. In addition, two of the four
states we visited reported to the Department of Education problems in
the timely provision of certain services, due in part to a lack of
available providers.
We also found in the four communities we visited that the availability
of medical and family support services for specific populations, which
could include exceptional family members, may also depend on state laws
and policies. For instance, Texas law requires that certain children
younger than 21 years of age with a chronic physical or developmental
condition be provided services such as rehabilitative, case management,
and family support by local agencies.[Footnote 23] In California, a
state law provides that all individuals with developmental
disabilities--regardless of their age--are eligible to receive a
variety of services including counseling and case management from the
Department of Developmental Services' regional centers.[Footnote 24] In
North Carolina, the Department of Social Services provides subsidized
child day care services through the age of 17 to eligible parents if
the child meets certain criteria, such as having a special need.
Virginia law requires counties and cities to establish community
service boards for the purpose of providing mental health, mental
retardation, and substance abuse services. However, the only services
those boards must offer by law are emergency services and case
management.[Footnote 25] As a result, some services may be easier to
obtain in states in which the provision of those services is required
for a specific population, which might include exceptional family
members.
Federal law requires that eligible exceptional family members attending
U.S. public schools must be provided with a free, appropriate public
education. This includes access to special education and related
services, such as physical therapy and speech therapy, to meet each
child's unique needs. School officials in the four communities we
visited told us that while they collect data on children with special
education needs, they were unable to identify which of those children
were exceptional family members or the costs associated with providing
educational services to them. Therefore, we could not identify the type
or amount of special education services used by exceptional family
members in the communities that we visited.
Agency Comments and Our Evaluation:
DOD and Department of Education officials reviewed a draft of this
report and provided technical comments, which we incorporated as
appropriate.
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties. We
also will make copies available to others upon request. In addition,
this report will be available at no charge on GAO's Web site at
http://www.gao.gov.
If you or your staff have any questions about this report, please
contact me at (202) 512-7119 or at crossem@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Key contributors to this report
included Bonnie Anderson, Arthur Merriam Jr., Christina Ritchie, Seth
Wainer, and Julianna Weigle.
Signed by:
Marcia Crosse:
Director, Health Care:
Site Selection Methodology:
The Ronald W. Reagan National Defense Authorization Act for Fiscal Year
2005 mandated that we examine at least four communities with each
community having multiple military installations representing at least
two different military services and high concentrations of exceptional
family members.[Footnote 26] To identify communities with high
concentrations of exceptional family members, we interviewed TRICARE
Management Activity (TMA) and Department of Defense (DOD) officials
from each military service responsible for the Exceptional Family
Member Program (EFMP).[Footnote 27] Based on interviews with DOD
officials and available data collected from the military services, we
identified communities with high numbers of either exceptional family
members or servicemembers with exceptional family members. With this
information, we used the following criteria to select the four sites,
as shown in table 3:
* high numbers of exceptional family members,
* more than one military service present in the community,
* at least one installation from each military service among the four
sites, and:
* geographic dispersion.
Table 3: Description of Sites Selected:
Community: San Diego, California; San Diego area Naval Bases; Camp
Pendleton;
Number of exceptional family members by community[A]: 4,959;
Percentage of exceptional family member population[B]: 4.8%;
Criteria met:
* More than one military service present in the community;
* Second largest number of Navy exceptional family members;
* Largest number of Marine exceptional family members.
Community: Fayetteville, North Carolina; Fort Bragg; Pope Air Force
Base;
Number of exceptional family members by community[A]: 3,951;
Percentage of exceptional family member population[B]: 3.8%;
Criteria met:
* More than one military service present in the community;
* Second largest number of Army exceptional family members.[C].
Community: San Antonio, Texas; Fort Sam Houston; Brooks City Base;
Lackland Air Force Base; Randolph Air Force Base;
Number of exceptional family members by community[A]: 2,332;
Percentage of exceptional family member population[B]: 2.2%;
Criteria met:
* More than one military service present in the community;
* Largest number of Air Force servicemembers with exceptional family
members.
Community: Hampton Roads community, Virginia[D]; Fort Eustis; Fort
Monroe; Fort Story; Norfolk Naval Bases; Langley Air Force Base;
Number of exceptional family members by community[A]: 6,152;
Percentage of exceptional family member population[B]: 5.9%;
Criteria met:
* More than one military service present in the community;
* Largest number of Navy exceptional family members;
* Second largest number of Air Force servicemembers with exceptional
family members.
Source: GAO analysis of DOD data.
[A] Since the Navy and Air Force only provided exceptional family
member data by servicemember, and a servicemember might have more than
one exceptional family member, the number of exceptional family members
provided is the minimal number of exceptional family members and is
based on the number of servicemembers with an exceptional family member
designation at each installation in the communities we visited. Data
were provided as of March 2005 for the Army, September 2005 for the Air
Force, and September 2005 for the Marine Corps. The most recent data
available for the Navy at the time of our site selection were for
August 2004.
[B] These percentages are an estimate since the number of exceptional
family members provided by the Navy and Air Force is based on the
number of servicemembers with an exceptional family member designation
at each installation in the communities we visited and servicemembers
might have more than one exceptional family member.
[C] Fort Hood, Texas, had the highest number of Army exceptional family
members in 2005, but was not selected for our study since it did not
meet two of the site selection criteria.
[D] The Hampton Roads community encompasses the cities of Chesapeake,
Franklin, Hampton, Newport News, Norfolk, Portsmouth, Poquoson,
Suffolk, Virginia Beach, and Williamsburg, and the Counties of
Gloucester, Isle of Wight, James City, Southampton, Surry, and York.
[End of table]
Scope and Methodology:
To describe the services provided by the military health and family
support systems that are available to meet the needs of exceptional
family members, we reviewed federal laws and regulations, TRICARE
policy, agency documentation, and other sources related to EFMP. In
addition, we interviewed TMA officials and EFMP officials from each
military service. We also obtained and reviewed data from each military
service on the number of exceptional family members or servicemembers
by location to identify four communities that each had high numbers of
exceptional family members from more than one military service. Given
that the service data are used for background and methodological
purposes only, we did not assess the reliability of these data. (See
app. I for site selection methodology.) Among the communities that met
these criteria, officials from one of our selected sites had previously
expressed concern to the Secretary of Defense that EFMP was placing an
undue financial burden on its local resources. We interviewed local
military officials in this community and the other selected communities
to obtain information on the EFMP administrative process, types of
medical conditions typically associated with exceptional family members
in these communities, types of services needed, and whether services
were available to meet these needs within the military health and
family support systems.
To describe state and local services--including medical, family
support, and educational--available to exceptional family members, we
interviewed officials from state and local agencies that provide these
services within the four communities we selected. These agencies
included the state departments of social services, public school
systems, and other similar organizations that address needs such as
mental health and early childhood intervention. We also requested
available data on the number of exceptional family members these
agencies serve, types of services provided, and associated costs. We
conducted our work from June 2005 through January 2007 in accordance
with generally accepted government auditing standards.
DOD's Definition of Special Medical Needs:
Family members of active-duty servicemembers who meet certain criteria
set out in DOD Instruction 1315.19 are identified as family members
with special medical needs.[Footnote 28] The criteria include one or
more of the following:
* Potentially life-threatening conditions and/or chronic medical/
physical conditions--such as high-risk newborns, patients with a
diagnosis of cancer within the last 5 years, sickle cell disease,
insulin-dependent diabetes--requiring follow-up support more than once
a year or specialty care.
* Current and chronic (duration of 6 months or longer) mental health
condition (such as bi-polar, conduct, major affective, or thought/
personality disorders); inpatient or intensive outpatient mental health
service within the last 5 years, or intensive (greater than one visit
monthly for more than 6 months) mental health services required at the
present time. This includes medical care from any provider, including a
primary health care provider.
* A diagnosis of asthma or other respiratory-related diagnosis with
chronic, recurring wheezing which meets one of the following criteria:
- scheduled use of inhaled anti-inflammatory agents and/or
bronchodilators,
- history of emergency room use or clinic visits for acute asthma
exacerbations within the last year,
- history of one or more hospitalizations for asthma within the past 5
years, or:
- history of intensive care unit admissions for asthma within the past
5 years.
* A diagnosis of attention deficit disorder/attention deficit
hyperactivity disorder that meets one of the following criteria:
- a co-morbid psychological diagnosis,[Footnote 29]
- requires multiple medications, psycho-pharmaceuticals (other than
stimulants), or does not respond to normal doses of medication,
- requires management and treatment by mental health provider (e.g.,
psychiatrist, psychologist, social worker),
- requires specialty consultant, other than a family practice physician
or general medical officer, more than twice a year on a chronic basis,
or:
- requires modifications of the educational curriculum or the use of
behavioral management staff.
* Requires adaptive equipment (such as an apnea home monitor, home
nebulizer, wheelchair, splints, braces, orthotics, hearing aids, home
oxygen therapy, or home ventilator).
* Requires assistive technology devices (such as communication devices)
or services.
* Requires environmental/architectural considerations (such as limited
numbers of steps, wheelchair accessibility, and air conditioning).
(290465):
FOOTNOTES
[1] While EFMP also considers educational needs when assigning service
members outside the United States, this report only focuses on EFMP
within the United States. Within the United States, federal law ensures
that a free, appropriate public education is made available to all
eligible children. This education may include special education and
related services, as appropriate.
[2] Throughout this report we refer to family members with special
needs as "exceptional family members."
[3] See DOD Instruction 1342.22, Family Centers, December 30, 1992.
[4] See Pub. L. No. 108-375, § 712, 118 Stat. 1811, 1984-85 (2004).
[5] TRICARE is the managed health care program established by the
Department of Defense under the authority of title 10, U.S. Code.
[6] TMA officials are responsible for overseeing TRICARE.
[7] For purposes of this report, we do not include DOD-operated schools
in the terms "public schools" or "public school systems." However, DOD
operated elementary and secondary schools are required to provide a
free appropriate public education to eligible children attending those
schools. See 32 C.F.R. Part 80 and DOD Instruction 1342.12, Provision
of Early Intervention and Special Education Services to Eligible DOD
Dependents, April 11, 2005.
[8] Family centers provide support services--such as career planning
and personal financial management--to assist all military families.
These centers include the Army Community Service (Army), Fleet and
Family Support (Navy), Airmen and Family Readiness Centers (Air Force),
and Community Service (Marine Corps).
[9] The Army was able to report the actual number of exceptional family
members as of September 2006. The Navy, Air Force, and Marine Corps
reported EFMP enrollment data by servicemember as of October 2006,
September 2006, and December 2006, respectively. Therefore, this is the
minimum number of exceptional family members, since a servicemember
might have more than one family member enrolled in the program. Because
of limitations in the Army, Navy, and Marine Corps data systems, these
systems could not provide separate 2006 EFMP enrollment data for
installations located within and outside the United States. Therefore,
we could only report a total EFMP enrollment figure that includes
enrollment at military installations both within and outside the United
States.
[10] See 32 C.F.R. § 199.5.
[11] Qualifying conditions include moderate or severe mental
retardation, certain physical disabilities, or physical or
psychological conditions that result in the exceptional family member
being homebound.
[12] Even if a servicemember has more than one exceptional family
member enrolled in ECHO, the servicemember is only required to make a
monthly payment for one exceptional family member.
[13] Instead of the monthly limit, ECHO home health care, including
home health care respite services, is subject to an annual fiscal year
maximum that is based on the amount TRICARE would pay if the
beneficiary resided in a TRICARE-authorized skilled nursing facility.
[14] Enrollment includes exceptional family members located at
installations both within and outside the United States.
[15] Pub. L. No. 93-112, § 504, 87 Stat. 355, 394 (codified as amended
at 29 U.S.C. § 794).
[16] Pub. L. No. 101-336, §§ 201-205, 104 Stat. 327, 337-38 (1990)
(codified as amended at 42 U.S.C. §§ 12131-12134)
[17] Pub. L. No. 91-230, title VI, as added Pub. L. No. 105-17, 111
Stat. 37 (1997) (codified as amended at 20 U.S.C. §§ 1400-1482). The
purposes of IDEA include assisting States and other agencies with the
provision of an education to all children (generally ages 3 through 21)
with disabilities and assisting States with the implementation of
comprehensive systems of early intervention services for infants and
toddlers (generally under the age of 3) with disabilities and their
families.
[18] See 20 U.S.C. § 1411-1419. These grants are for the provision of
services to children with disabilities aged 3 through 21. In addition,
federal grants are available to state agencies to provide early
intervention services to infants and toddlers with disabilities and
their families. See 20 U.S.C. § 1431-1444.
[19] See 20 U.S.C. §§ 7701-7714. In order to be eligible for Impact Aid
payments, a local educational agency must have at least 400 federally-
connected students enrolled or the number of those children must be at
least 3 percent of the average daily attendance at the agency's
schools. In addition to basic support payments, eligible local agencies
receive funding for special education and related services using a
formula that is based on the number of certain IDEA-eligible students
served by a particular agency.
[20] Federal property is exempt from local property taxes.
[21] See 20 U.S.C. §§ 7703a and 7703b.
[22] An Air Force official stated that only a few Air Force bases have
staff dedicated to EFMP. For most bases, EFMP is an additional
responsibility.
[23] See Tex. Health & Safety Code §§ 35.001-35.012 (2006).
[24] The Lanterman Developmental Disabilities Services Act of 1969
states that persons with developmental disabilities have the same legal
rights and responsibilities guaranteed all other persons by federal and
state constitutions and laws, and charges the regional center with
advocacy for, and protection of, these rights. Regional centers are
nonprofit, private corporations that are under contract to the
Department of Developmental Services to provide or coordinate services
and support for individuals with developmental disabilities. See
generally Cal. Welf. & Inst. Code §§ 4400-4906 (2006).
[25] See Va. Code Ann. § 37.2-500 (2006).
[26] Pub. L. No. 108-375, § 712, 118 Stat. 1811, 1984-85 (2004).
[27] TMA officials are responsible for overseeing TRICARE, which is
DOD's health care system.
[28] DOD Instruction 1315.19, Authorizing Special Needs Family Members
Travel Overseas at Government Expense, December 20, 2005. DOD officials
stated that while this guidance was intended for overseas travel, DOD
also uses it to identify family members with special medical needs
within the United States.
[29] A co-morbid psychological diagnosis is the diagnosis of a
psychological condition in the presence of additional diseases.
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