4

ABA Industry Guidelines and Standards of Care

This chapter reviews the recent professionalization of the applied behavior analysis (ABA) industry and integration into healthcare systems and industry guidelines and standards of care for ABA services. It also discusses the extent in which the policies and practices of the Comprehensive Autism Care Demonstration (ACD) adhere with these guidelines and standards of care in response to the committee’s charge to review guidelines and standards of care (see Chapter 1, Box 1-3).

It is important to note that the committee recognizes that TRICARE is a statutorily defined health benefit program managed by the Defense Health Agency (DHA) under the leadership of the Assistant Secretary of Defense, Health Affairs, and that it is not a health insurance plan and does not operate the same as commercial and public insurance plans. This includes not being subject to mandates or provisions included in the Affordable Care Act, the Employee Retirement Income Security Act (ERISA), or the Mental Health Parity and Addiction Equity Act (MHPAEA). However, in practice, military-connected families receiving coverage under TRICARE and ABA providers delivering services to these beneficiaries experience the health benefit program in similar ways as one might experience other healthcare coverage. As such, the committee examines available guidelines and standards of care as if they could apply to all types of health benefits and healthcare plans.

GENERALLY ACCEPTED STANDARDS OF CARE

This section reviews the history and development of generally accepted standards of care (GASC) for the delivery of ABA services. It draws on background provided to the committee through a commissioned paper (Green, 2025) and public presentations (National Academies of Sciences, Engineering, and Medicine [NASEM], 2024a). For behavioral and mental health, the term GASC is defined broadly as delineation of the best practices for serving patients with a specified condition that are widely accepted by professionals in the relevant clinical specialty. They are developed and revised periodically by subject matter experts in that profession, who typically base the standards on an analysis of the applicable scientific research and the consensus of clinicians who serve the patient population.

There are several national nonprofit organizations that have set guidelines related to ABA, including the Association for Behavior Analysis International (ABAI); the Applied Behavior Analysis Coding Coalition; the Autism Commission on Quality; the Association for Professional Behavior Analysts; Autism Speaks; the Behavior Analyst Certification Board (BACB); and the Council of Autism Service Providers (CASP).

Within health care, standards of care can be broadly defined and may include clinical practice guidelines, quality and safety standards, and ethical codes of conduct. While compliance is often voluntary, guidelines and standards can be essential for ensuring quality, regulatory adherence, and creating trust among stakeholders (Dubuque, 2024). MHPAEA, and some state mental health parity laws and rules, require healthcare plans to base determinations of medically necessary services for beneficiaries with mental health and substance use disorders on GASC, also called generally recognized independent standards of current medical practice (U.S. Department of Labor, n.d., 2024). These laws and rules designate valid sources of such standards, including peer-reviewed scientific studies, clinical practice guidelines, and recommendations of nonprofit healthcare provider associations in the relevant clinical specialty, specialty societies, and federal government agencies. See Box 4-1 for more information about MHPAEA.

The mental health parity provisions under MHPAEA currently do not apply to the TRICARE health benefit program. However, the Department of Defense (DoD) has committed to fair access to behavioral healthcare services in its health benefit program (see, for example, DoD final rule in TRICARE; Mental Health and Substance Use Disorder Treatment, 2016).

The first standards of ABA health care for autistic individuals were laid out in Guidelines: Health Plan Coverage of Applied Behavior Analysis Treatment for Autism Spectrum Disorder, published by the BACB in 2012 (BACB, 2012). These guidelines were updated in 2014 and retitled Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for

Healthcare Funders and Managers (BACB, 2014). In 2020, the BACB transferred the development of the guidelines to CASP, a nonprofit trade association for organizations that provide ABA services to people with autism. Based on review and input from subject matter experts in behavior analysis, psychology, medicine, healthcare laws, and public policies and consumers of ABA services, a third edition was released in 2024, Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorders: Guidance for Healthcare Funders, Regulatory Bodies, Service Providers, and Consumers

TABLE 4-1 Adoption of Key Standards and Public Policies

SOURCE: Green, 2025.

(3rd ed.) (CASP, 2024). Table 4-1 illustrates the rollout of guidelines and revised editions in relation to other developments in the ABA industry. The CASP guidelines have been recently cited as an accepted source of clinical criteria in regulations for implementing the provision in the California Mental Health Parity Act (Cal. Code Regs. tit. 28 § 1300.74.721).

ABA PROVIDERS

As interest in using ABA grew, more programs for certifying professionals in the practice of ABA were developed. One of the first programs, the Florida Behavior Analysis Certification Program, started in 1983 and operated until 1998, when it transitioned into the nonprofit BACB. Since 1999, the BACB has served as a certification organization for behavior analyst professionals. The BACB’s mission is to protect consumers of behavior-analytic services by systematically establishing, promoting, and disseminating professional standards of practice.

Throughout the years, BACB has conducted four job task analyses; updated examination contents and eligibility requirements (degrees, coursework, supervised experiential training) accordingly; converted exams from pencil-and-paper to a computer-based format; developed and enforced ethical standards; and certified thousands of professional behavior analysts. It has also developed a paraprofessional credentialing program, the Registered Behavior Technician (RBT) credential, which is described in more detail below (Carr & Nosik, 2017; Johnston, Carr, & Mellichamp, 2017).

BACB Certification

BACB requirements for certification include specifications for the levels of education, training, experience, examination, adherence to an ethics code, and in some cases ongoing supervision. The BACB currently certifies professional practitioners of ABA at two levels:

• BCBA—an independent practitioner who can provide ABA services and supervise delivery of those services by others. Requires at least a master’s degree, university coursework in specified topics, supervised experiential training, and passage of the BCBA professional examination in behavior analysis. BCBAs with doctoral degrees can apply for the Board Certified Behavior Analyst-Doctoral (BCBA-D) designation.¹
• Board Certified Assistant Behavior Analyst (BCaBA)—a practitioner who can provide ABA services under the supervision of a BCBA or BCBA-D. Requires a bachelor’s degree, university coursework in specified topics in behavior analysis, supervised experiential training, and passage of the BCaBA professional examination in behavior analysis.²

Both of these certification programs have been accredited since 2007 by the National Commission for Certifying Agencies (NCCA) of the Institute for Credentialing Excellence (Carr & Nosik, 2017; Johnston, Carr, & Mellichamp, 2017). To maintain their certifications, BCBAs and BCaBAs need to complete continuing education requirements and adhere to an ethics code (BACB, 2020, 2025).

The BACB currently certifies paraprofessional practitioners of ABA at one level:

• RBT—a paraprofessional practitioner required to work under the direction and close supervision of professional behavior analysts who have met BACB requirements for serving as supervisors. Current requirements are at least a high school education or equivalent, passage of a criminal background check, completion of a BACB-approved 40-hour training program, passage of an initial competency assessment, and passage of the RBT examination in behavior analysis.

The RBT program was developed in 2017 by the BACB. It is also accredited by the NCCA. To maintain their credential, RBTs are asked to adhere to an ethics code (BACB, 2021) and their supervisors document that they have fulfilled the supervision requirements.

As of the end of 2023, certifications totaled more than 66,000 BCBAs, more than 5,600 BCaBAs, and more than 163,000 RBTs, with the vast majority located in the United States (Luke, 2024). There has been tremendous growth in certificants across the three areas in the past decade (see Figure 4-1). Growth in the field was likely spurred by availability of funding, which led to industry development and university-level training. Notably, more than 70% of certified professionals purport to working with autistic individuals.

State Licensure

Starting in 2009, U.S. states began adopting laws that require individuals to hold a state-issued license in order to use a specified title (e.g., Licensed Behavior Analyst) and, in all but two states, to practice ABA professionally (the Oregon and Wisconsin laws are title acts only). At this writing, 39 states have adopted behavior analyst licensure laws (BACB, n.d.). All of these states license behavior analysts with graduate degrees to practice ABA independently. Several states also license assistant behavior analysts with bachelor’s degrees to practice under the supervision of licensed behavior analysts. Most states exempt behavior technicians and other paraprofessionals

from direct regulation by the state as long as they are supervised properly by a licensed behavior analyst or assistant behavior analyst. At present, five states require ABA paraprofessionals to be registered or certified by the state licensing entity in addition to being supervised by a licensed professional behavior analyst.

Behavior analyst licensure programs are administered by governmental entities that vary across states (e.g., stand-alone behavior analyst licensing boards, omnibus licensing boards, licensing boards of other professions, state agencies with no licensing board). In all states, however, behavior analysts are licensed in their own right, not as members of other professions. Because the requirements for the BACB’s professional certifications parallel requirements for licenses in many professions—degree(s), university coursework, experiential training, professional exam in the subject matter—most of the licensure laws and/or the associated rules make current BACB certification a qualification for obtaining the state-issued license. In the remaining states, BACB certifications are written into various laws and rules as qualifications for designing, overseeing, and/or delivering ABA services (e.g., health insurance laws or rules, Medicaid policies, developmental disability services laws or rules, education laws or rules).³

Health Care Provider Taxonomy Codes

Adoption of the public policies described above made it possible for many ABA providers to have their services funded by health insurance and placed them squarely within the category of behavioral healthcare providers. Several additional actions were required, however, to enable health insurance reimbursement for ABA services. One was the establishment of Health Care Provider Taxonomy codes, which are unique 10-digit numbers used to classify a set of healthcare providers by their areas of specialization. Healthcare providers use these codes to apply for the National Provider Identification (NPI) numbers that are required to bill health plans, including Medicare. These taxonomy codes are issued and owned by the American Medical Association (AMA) National Uniform Claim Committee. Codes for behavioral analysts and technicians were issued in 2016 pursuant to an application submitted by the BACB and Association of Professional Behavior Analysts.⁴

Current Procedural Terminology Codes

To be reimbursed by public and commercial health plans in the United States, healthcare providers use billing codes linking to procedures and services. When the first state laws requiring health plans to cover ABA services for autistic beneficiaries were adopted, there were no billing codes that were specific to those services. Health plans and providers used existing codes, selected mainly from the Healthcare Common Procedure Coding System maintained by the Centers for Medicare & Medicaid Services, that came reasonably close to describing ABA services (e.g., H2019, “therapeutic behavioral services”). To enable ABA providers to bill health plans appropriately, it was necessary to obtain Current Procedural Terminology (CPT) codes for ABA services.⁵

In 2014, the AMA CPT Editorial Panel issued 16 Category III (temporary) CPT codes for adaptive behavior/ABA services pursuant to a process initiated by the ABAI. In 2019, the Panel issued eight revised codes as Category I with two revised codes remaining Category III, replacing the original Category III code set. Of these 10 revised codes, three are for adaptive behavior/ABA assessment services and seven are for treatment services; and of the seven treatment services codes, there are three for services delivered to a single individual, two for services delivered in small groups, and two for guidance to families. See Box 4-2 for descriptions of these codes. Some

codes are for services administered by behavior technicians under the direction of qualified health professionals. Qualified health professionals are considered licensed behavioral analysts, BCBAs, or licensed psychologists who have competence in behavior analysis (American Medical Association, 2018). None of the code descriptors for ABA are restricted to any specific diagnoses or patient populations.⁶

Commercial and Public Insurance Coverage for ABA Services

Since 2019, all 50 states have adopted laws or issued regulatory guidance requiring certain commercial health insurance plans to cover ABA services for individuals with autism (Autism Speaks, 2020b). These state mandates typically apply to fully insured plans, including those sold through the individual and small group markets, and state employee health benefit plans. In addition, private health insurance plans purchased through the Health Insurance Marketplace in 33 states and the District of Columbia include coverage for ABA services (Autism Speaks, 2022a).

Self-funded employer-sponsored health plans, which are regulated under ERISA and not subject to state insurance mandates, vary in their ABA coverage (Autism Speaks, 2022c). As of 2018, approximately 45% of companies with 500 or more employees included coverage for ABA or similar behavioral health services for individuals with autism (Autism Speaks, 2022c).

At the federal level, all plans within the Federal Employees Health Benefits Program have been required to cover ABA services for individuals

TABLE 4-2 Comparison of Criteria for ABA Services (CASP Guidelines, Commercial Insurance, ACD Policies)

^aThe information in the table is a generalized description of coverage for ABA services across the seven payors reviewed. See Appendix G for specific details by payor.

^bMany commercial payors require a standardized scale of functioning to demonstrate functional impairment. No particular scale is required but some are suggested (see Appendix G).

key aspects of ABA delivery. For more details on this review of policies, coverage, and requirements, see CASP guidelines (CASP, 2024), our review of commercial insurance plans (Appendix G), and TRICARE Operations Manual (DHA, 2023a).

Determination of Medical Necessity

Medical necessity is a term that payors use to describe the process for determining whether they will cover a specific service or treatment. While specific criteria for determining medical necessity vary between payors, determinations generally adhere to common principles described by American Medical Association (2023) and American Academy of Pediatrics (AAP) (Giardino et al., 2022) to ensure treatment is

• in accordance with generally accepted standards of medical practice;
• clinically appropriate for the individual in terms of type, frequency, extent, site, and duration;
• not primarily for the economic benefit of the health plans and purchasers or for the convenience of the individual, treating physician, or other healthcare provider;
• based on the best scientific evidence, considering the available hierarchy of medical evidence; and
• likely to produce incremental (and/or future) health benefits relative to the next best alternative that justify any added cost.

Additionally, all 50 states’ Medicaid programs have definitions of medical necessity that are used in determining coverage for EPSDT benefits that states are required to cover under federal law.⁸ In general, states define medically necessary services as those that improve health or lessen the impact of a condition, prevent a condition, or restore health (National Academy for State Health Policy, 2021).

When determining medical necessity for ABA treatment, payors typically followed principles set out by the AMA, AAP, and state Medicaid programs. However, payors tend to have medical necessity guidelines that are specific to ABA coverage, as is the case with other specialty treatments.

The following list of medical necessity criteria is summarized from publicly available health plan guidelines from Cigna Healthcare,⁹ Anthem Blue

Scope and Goal Development

As discussed further in Chapter 5, the scope of intervention may be comprehensive (targeting multiple behaviors in multiple domains such as self-care, language and communication, and reduction of challenging behavior) or focused (targeting a limited number of behaviors). Comprehensive ABA treatment typically seeks to enable the client to develop and/or maintain many adaptive behaviors and may also address any maladaptive behaviors that jeopardize the client’s health or safety. Focused ABA treatment may address only a small number of adaptive behaviors from one or two domains, such as specific self-care skills. If one or more maladaptive behaviors are targeted, the professional ethical standards guide ABA providers to also target one or more adaptive behaviors that compete with or are alternatives to the maladaptive behavior(s) (CASP, 2024).

Goals refer to the aim(s) of treatment—that is, the behaviors that are targeted for treatment and the nature and amount of improvement that is sought. Individual goals or targets are determined by ABA providers drawing on information about a client’s and family’s needs, strengths, and life circumstances. Treatment plans often include short-term and long-term goals. Protocols or written procedures in the treatment plans can guide ABA providers in implementing assessment and treatment of each goal (CASP, 2024).

Many healthcare professionals recognize activities of daily living (ADLs) are valid targets for ABA. While ADLs can refer to a range of functional tasks individuals complete regularly and independently (Matson, Hattier, & Belva, 2012), for healthcare contexts and medical decision making, ADLs often refer to critical health and safety tasks. These fundamental self-care tasks have been codified in 26 U.S.C. § 7702B(c)(2) under the Health Insurance Portability and Accountability Act as activities related to eating, toileting, transferring, bathing, dressing, and continence. In some circumstances, these fundamental tasks are known as basic ADLs in contrast to instrumental ADLs that are less crucial to daily functioning but useful for independent living (e.g., meal preparation and money management). Medical conditions, such as autism, can affect one’s ability to perform ADLs.

The ACD currently limits goals of ABA services to those targeting the core symptoms of autism and specifically excludes ADLs. Commercial payors generally cover a broader set of goals that meet individual health needs, including ADLs or adaptive living skills. The committee heard quite a bit from ABA providers and military-connected families on the importance of targeting goals around basic ADLs. See Box 4-3.

Amount of ABA (ABA Intensity)

In many ABA outcome studies as well as in the CASP standards (CASP, 2024), the amount of ABA (also referred to as ABA intensity or ABA

dosage) is defined as the number of hours per week an individual is directly engaged in receiving ABA services. This engagement includes direct face-to-face assessment as well as treatment services because the two are intertwined. In some studies, the amount of ABA received also includes services delivered by parents and other caregivers. In other studies or reviews, it may only include ABA services delivered by behavior analysts and technicians or other paraprofessionals. The time the behavior analyst spends on indirect assessment (reviewing notes and data and revising written plans) and on training caregivers is generally not considered a component of ABA intensity for a particular individual.

There appears to be no standard of reporting amount of ABA based on the committee’s review. Practices vary in regard to diagnosing professionals’ recommendations for ABA services for people with autism; many may not specify or consider what proportions of time will be spent on direct versus indirect services or caregiver training. In practice, even some ABA providers and payors may consider the amount of ABA to include all services encompassed by CPT and other billing codes. Others may adhere more closely to the published studies and separate the time the client is directly engaged in receiving assessment and treatment services from indirect assessment and caregiver training.

Many commercial plans cap the amount of ABA to 40 hours per week. The CASP guidelines offer that 30–40 hours per week of direct ABA is best for comprehensive ABA and that 10–25 hours per week may be appropriate for focused ABA (CASP, 2024). Current practice tends toward individualizing treatment intensity based on the time deemed necessary to make progress toward goals, and practice guidelines tend to recommend 25 or more hours of services generally, inclusive of ABA,

Safety Measures and Crisis Management

Children with autism and intellectual and developmental disabilities are at increased risk for potentially harmful behaviors that can pose serious and immediate risk for injury for self and others (Farmer & Aman, 2011; Kurtz, Leoni, & Hagopian, 2020; McClintock, Hall, & Oliver, 2003; Simó-Pinatella et al., 2019; Soke et al., 2016; Steenfeldt-Kristensen, Jones, & Richards, 2020; Wachtel et al., 2024).¹⁵ Synthesized data from 37 studies of autism yielded pooled prevalence estimate of self-injury of 42% (Steenfeldt-Kristensen, Jones, & Richards, 2020). A recent study showed that among children with profound autism, nearly 37% had self-injurious behavior (Hughes et al., 2023); another found that children and adults with autism were three times more likely to self-harm than people without autism (Blanchard et al., 2021).

Restraints of various kinds are sometimes used in situations where an autistic child engages in behaviors that can lead to self-harm and harm to others. Before discussing restraints and their use, it is important to note that proper training is essential for the safe and compassionate use of restraints in crisis situations. In 2010, the ABAI published a statement on restraint and seclusion outlining guiding principles and the careful application of

of ABA. Assessments in standard practice often are customized toward clients’ goals and draw on multiple sources of data including direct observations and measurements of behavior, review of clients’ medical history, interviews, and the administration of standardized instruments (CASP, 2024).

Many standardized assessment instruments have been developed for autistic individuals or for behaviors that might be addressed by ABA. However, they are not equivalent in purpose or use. There are even standardized instruments for collecting data on caregivers, their satisfaction with ABA services, as well as indicators of family well-being. Behavior analysts are encouraged to consult with other professionals before determining which instrument(s) are appropriate for particular clients and their families, to select instruments with domains and items that will inform treatment goals, and to use results from standardized instruments in conjunction with data from other sources in assessing an individual’s progress (CASP, 2024). Assessment tools have changed over the past 10 years and continue to evolve and advance as understanding of autism changes and improves.

This is a very heterogeneous population ranging from individuals with high intelligence and good communication skills to those with major cognitive impairment and those who never developed language. Individuals at all levels of communication and cognitive ability also vary on the range and intensity of restricted and repetitive behavior and the level of impairment caused by sensory sensitivities. One specific assessment tool or set of tools will not be appropriate to obtain the information needed to develop an appropriate treatment plan or evaluate progress for every autistic individual.

A combination of standardized assessments that are direct (administered to the client or patient) and some that are indirect (completed by caregivers or other third parties) is preferred. Selection of standardized assessments would need to be guided by the characteristics of the instrument and the individual’s presenting conditions and support needs. Standardized assessments provide guidance in overall cognitive and adaptive level but not enough detail to develop a treatment plan. Non-standardized assessments, such as curriculum assessments, language sampling techniques developed by speech pathologists, and adopted procedures for direct observation and recording of behaviors, are common in delivery of ABA. Such assessments are often accompanied by procedures to determine the accuracy and reliability of human observations. They are used to develop specific measurable goals and to choose the most appropriate strategies to address those goals as well as the intensity of intervention needed. Furthermore, progress toward these measurable goals can be tracked to understand individual progress more accurately than standardized assessments.

A functional behavior assessment is a particular type of behavior analytic assessment to identify environmental events that influence challenging behaviors. Those data can be graphed and reviewed and updated frequently throughout services. This type of assessment is typically the main source of

Caregiver Engagement and Training

Most ABA providers and researchers would recognize that caregiver engagement and training is important to the success of ABA. Caregiver engagement will help with generalization of learned skills as well as family well-being and empowerment. However, many also recognize that, in practice, caregiver engagement will be limited. Across payors, including the ACD and TRICARE, there is a general expectation of family participation. It is also common for treatment plans to include several objective and measurable goals for parents and other caregivers. Such goals need to be developed with sensitivity toward family dynamics and well-being, culture, values, needs, and resources (CASP, 2024).

Caregiver engagement can take many forms, including, but not limited to, meeting with the behavior analyst, attending and observing ABA sessions, working with the behavior analyst on goals, at-home practice and reinforcement of skills, regular communication with the behavior analyst, training on ABA fundamentals, training on incidental teaching for everyday activities, and regular communication with the behavior analyst. The CASP guidelines describe ways in which family members and other caregivers may be involved in assessment, treatment planning, and ABA delivery. They also offer how behavior analysts may support caregivers by providing training on reinforcing skills, connecting them with others with similar experiences, connecting them to other healthcare professionals when necessary, and maintaining strong communication about ABA goals and progress (CASP, 2024).

With the 2021 policy changes, the ACD aimed to encourage caregiver engagement by mandating a minimum of six parent/caregiver training sessions for every six months of ABA services. Reauthorization of ABA services is contingent on having met the training requirement in the past six months or otherwise documenting why it could not be met. Since the policy began, DHA, drawing on number of claims for parent treatment guidance (CPT codes 97156 and 97157), has reported to Congress a lack of parental engagement with 10 hours or less annually on average (DoD, 2024b; see also Appendix C, Question 12). While other payors do expect caregiver participation in ABA and engagement in goal setting and treatment planning, there is no record of punitive consequences on the provision ABA services or provider reimbursement if parents do not engage in ABA delivery and training. Further, the committee feels that billing code utilization is not a good indicator of parental engagement, given the range of forms of meaningful engagement with ABA and the unique challenges of military families (e.g., deployment). The committee had both ethical and practical concerns about mandated parent/caregiver training hours in order to continue receiving ABA services that individuals need for their health and well-being.

Care Coordination and Service Navigation

Care coordinators and service navigators work with individuals and their families and caregivers to overcome barriers to access to care. As a developing service in healthcare systems, such coordinators are often employed for specific populations or communities to reduce health disparities and/or to support individuals with chronic conditions who have to navigate complex healthcare systems.²¹ According to McKenney et al. (2018), “Depending on the specific needs and resources of the target community, individuals who serve as patient navigators range from lay people, including [. . .] community health workers, to professional healthcare or social services personnel, including case managers, social workers, and nurses” (p. 281). Primary roles for care coordinators and navigators are to provide emotional support by listening to concerns and act as an advocate for patient needs (Association of Maternal & Child Health Programs, 2018). Activities of services navigators for families with children with autism have included care assessment, service coordination, psychosocial support, health education, service advocacy, and logistic assistance (Li et al., 2025).

Some identified best practices for the design and implementation of a navigation system include the following factors (NASEM, 2018):

• Assessing the needs and resources of the community it will serve, making it convenient for patients, and tailoring the program to fit the culture of the communities and individuals served
• Staffing appropriately and defining the navigator role with clear scope of practice
• Building in appropriate metrics and evaluation
• Communicating regularly among navigators, patient advisory councils, and clinicians about navigation program successes and opportunities for improvement

Services navigation works best when it acts as a relational connection to support patients with complex networks and processes in a healthcare system, educate patients about the diagnostic and treatment processes, and support health-related decisions across the continuum of care, from screening to diagnosis and treatment (Gabitova & Burke, 2014). Care services navigation for autistic individuals across different types of services and interventions has helped with scheduling and successfully completing appointments for recommended services, including medical, educational, therapeutic, and

CONCLUSION

As discussed in Chapter 3, ABA services have been provided to TRICARE-eligible beneficiaries through different mechanisms in the Military Health System since 2001. Over time, policy decisions, particularly those around the creation and revisions of the ACD, added steps and conditions that created challenges toward accessing ABA services and extra burdens for military families with autistic dependents already living stressful lives. These additions and conditions have been met with pushback from military-connected families, ABA providers, and advocacy organizations. In addition, there has been congressional attention on the ACD regarding concerns over policy decisions that do not seem to align with industry standards (DoD 2023b, 2024a; Shaheen & Gillibrand, 2021).

Conclusion: Military-connected families experience increased burdens to maintain eligibility and enrollment in the Comprehensive Autism Care Demonstration to access applied behavior analysis (ABA) services as well as restrictions on settings in which ABA can be provided.

While policies for ABA services under the ACD can be viewed as favorable in comparison to other health plan benefits on dollar limits and maximum weekly amount of ABA allowed as well as no age restriction (DoD,