Military Personnel: Medical, Family Support, and Educational	 
Services Are Available for Exceptional Family Members (16-MAR-07,
GAO-07-317R).							 
                                                                 
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. 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.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-317R					        
    ACCNO:   A66926						        
  TITLE:     Military Personnel: Medical, Family Support, and	      
Educational Services Are Available for Exceptional Family Members
     DATE:   03/16/2007 
  SUBJECT:   Health care programs				 
	     Health care services				 
	     Home health care services				 
	     Managed health care				 
	     Mental health					 
	     Mental health care services			 
	     Military facilities				 
	     Military personnel 				 
	     Special education					 
	     DOD Exceptional Family Member Program		 

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GAO-07-317R

   

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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.^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.^2 Further, DOD
policy allows (but does not require) the military services to provide
family support services specifically for exceptional family members.^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.

^1While 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.

^2Throughout this report we refer to family members with special needs as
"exceptional family members."

^3See DOD Instruction 1342.22, Family Centers, December 30, 1992.

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.^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.^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.^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.

^4See Pub. L. No. 108-375, S 712, 118 Stat. 1811, 1984-85 (2004).

^5TRICARE is the managed health care program established by the Department
of Defense under the authority of title 10, U.S. Code.

^6TMA officials are responsible for overseeing TRICARE.

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.^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.^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.^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.)

^7For 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.

^8Family 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).

^9The 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.

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

                                                           Medical diagnosis  
                            By servicemember                of exceptional    
Military  By exceptional with exceptional      By       family member by   
service   family member  family member(s) installation    installation     
Army                                           ^a                          
Navy            ^a                             a               ^a          
Air Force                                                                  
Marine                                         a                           
Corps                                                                      

Source: Army, Navy, Air Force, and Marine Corps.

aThe data system can provide current data, which are routinely updated;
the system cannot provide historical data.

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).^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.^11 Enrollment
in ECHO requires a monthly payment ranging from $25 to $250, depending on
the servicemember's rank.^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.^13 As of
December 2006, approximately 1,980 exceptional family members were
enrolled in ECHO.^14

10See 32 C.F.R. S 199.5.

^11Qualifying conditions include moderate or severe mental retardation,
certain physical disabilities, or physical or psychological conditions
that result in the exceptional family member being homebound.

^12Even 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.

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,^15 title II of the
Americans with Disabilities Act (ADA),^16 and the Individuals with
Disabilities Education Act (IDEA).^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.^18 Public local educational agencies meeting
certain criteria may also receive federal funding for special education
and related services through Impact Aid,^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.^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.^21

13Instead 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.

^14Enrollment includes exceptional family members located at installations
both within and outside the United States.

^15Pub. L. No. 93-112, S 504, 87 Stat. 355, 394 (codified as amended at 29
U.S.C. S 794).

^16Pub. L. No. 101-336, SS 201-205, 104 Stat. 327, 337-38 (1990) (codified
as amended at 42 U.S.C. SS 12131-12134)

^17Pub. 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. SS 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.

^18See 20 U.S.C. S 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. S 1431-1444.

^19See 20 U.S.C. SS 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.

^20Federal property is exempt from local property taxes.

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

                                                    Extended Care Health      
                                                    Option (ECHO)             
                                                    supplemental medical      
Selected benefits        TRICARE benefit         services                  
Home health care         Up to 28 to 35 hours    ECHO home health care     
                            per week of medically   benefits provide          
The following medically  necessary services      medically necessary       
necessary services may   provided under a plan   services to eligible      
be covered when provided of care established and homebound beneficiaries   
in the beneficiary's     approved by a           who generally require     
home by a                physician.              more than 28 to 35 hours  
TRICARE-authorized home                          per week of home health   
health agency that                               services and are being    
participates in the                              routinely followed by a   
TRICARE program:                                 case manager.             
                                                    Beneficiaries are         
      o skilled nursing                             considered homebound if   
      care from a                                   their condition is such   
      registered nurse, or                          that they do not have the 
      by a licensed or                              normal ability to leave   
      vocational nurse                              home and consequently     
      under the direct                              leaving home requires     
      supervision of a                              considerable and taxing   
      registered nurse;                             effort. Coverage for the  
      o services provided                           home health care benefit  
      by a home health aid                          is capped on an annual    
      under the direct                              basis. The cap is based   
      supervision of a                              on the beneficiary's      
      registered nurse;                             geographic location and   
      o physical therapy,                           is equivalent to what     
      occupational therapy,                         TRICARE would pay if the  
      and speech-language                           beneficiary resided in a  
      pathology services;                           skilled nursing facility. 
      o medical social                              The home health care cap  
      services under the                            does not count toward the 
      direction of a                                $2,500 monthly ECHO cap.  
      physician;                                                              
      o teaching and                                                          
      training activities;                                                    
      and                                                                     
      o medical supplies.                                                     
Mental health services   Eight outpatient        No additional benefits.   
                            sessions without prior                            
Psychotherapy provided   approval. If there is a                           
on an outpatient basis   need for more than                                
or at a hospital.        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.                                        
Therapy for autism       No benefit.             Applied behavioral        
                                                    analysis when provided by 
Early, intense education                         an authorized TRICARE     
for children, which may                          provider.^a               
include the structured                                                     
teaching of skills that                                                    
help the child talk,                                                       
interact, play, and                                                        
learn.                                                                     
Respite care             Not a stand-alone       ECHO respite care-16      
                            benefit but may be      hours per month when      
Short-term care of a     provided through other  receiving other           
beneficiary in order to  benefits such as        authorized ECHO benefits. 
provide rest and change  hospice care.           Unused hours from one     
for those who have been                          week cannot be carried    
caring for the patient                           over into another week.   
at home.                                                                   
                                                    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.  

^21See 20 U.S.C. SS 7703a and 7703b.

Source: GAO analysis of DOD documents.

aApplied behavior analysis is a behavior modification approach to learning
that uses a highly structured, systematic, and consistent teaching method.

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.^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.

^22An Air Force official stated that only a few Air Force bases have staff
dedicated to EFMP. For most bases, EFMP is an additional responsibility.

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.^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.^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.^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.

^23See Tex. Health & Safety Code SS 35.001-35.012 (2006).

^24The 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 SS
4400-4906 (2006).

^25See Va. Code Ann. S 37.2-500 (2006).

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 [email protected] . 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.

Marcia Crosse
Director, Health Care

Appendix I
                           
									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.^1 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).^2 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:

           o high numbers of exceptional family members,

           o more than one military service present in the community,

           o at least one installation from each military service among the
           four sites, and

           o geographic dispersion.

^1Pub. L. No. 108-375, S 712, 118 Stat. 1811, 1984-85 (2004).

^2TMA officials are responsible for overseeing TRICARE, which is DOD's
health care system.

Table 3: Description of Sites Selected

                          Number of Percentage of                             
                        exceptional   exceptional                             
                     family members family member                             
Community         by community^a  population^b Criteria met                
San Diego,                 4,959          4.8%    o More than one military 
California                                        service present in the   
                                                     community.               
San Diego area                                    o Second largest number  
Naval Bases                                       of Navy exceptional      
                                                     family members.          
Camp Pendleton                                    o Largest number of      
                                                     Marine exceptional       
                                                     family members.          
Fayetteville,              3,951          3.8%    o More than one military 
North Carolina                                    service present in the   
                                                     community.               
Fort Bragg                                        o Second largest number  
                                                     of Army exceptional      
Pope Air Force                                    family members.^c        
Base                                                                       
San Antonio,               2,332          2.2%    o More than one military 
Texas                                             service present in the   
                                                     community.               
Fort Sam Houston                                  o Largest number of Air  
                                                     Force servicemembers     
Brooks City Base                                  with exceptional family  
                                                     members.                 
Lackland Air                                                               
Force Base                                                                 
                                                                              
Randolph Air                                                               
Force Base                                                                 
Hampton Roads              6,152          5.9%    o More than one military 
community,                                        service present in the   
Virginia^d                                        community.               
                                                     o Largest number of Navy 
Fort Eustis                                       exceptional family       
                                                     members.                 
Fort Monroe                                       o Second largest number  
                                                     of Air Force             
Fort Story                                        servicemembers with      
                                                     exceptional family       
Norfolk Naval                                     members.                 
Bases                                                                      
                                                                              
Langley Air Force                                                          
Base                                                                       

Source: GAO analysis of DOD data.

aSince 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.

bThese 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.

cFort 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.

dThe 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.

Appendix II

                             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.

Appendix III

                   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.^1 The criteria include one or more of the
following:

           o 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.

           o 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.

           o A diagnosis of asthma or other respiratory-related diagnosis
           with chronic, recurring wheezing which meets one of the following
           criteria:

                        o scheduled use of inhaled anti-inflammatory agents
                        and/or bronchodilators,

                        o history of emergency room use or clinic visits for
                        acute asthma exacerbations within the last year,

                        o history of one or more hospitalizations for asthma
                        within the past 5 years, or

                        o history of intensive care unit admissions for
                        asthma within the past 5 years.

           o A diagnosis of attention deficit disorder/attention deficit
           hyperactivity disorder that meets one of the following criteria:

                        o a co-morbid psychological diagnosis,^2

                        o requires multiple medications,
                        psycho-pharmaceuticals (other than stimulants), or
                        does not respond to normal doses of medication,

                        o requires management and treatment by mental health
                        provider (e.g., psychiatrist, psychologist, social
                        worker),

                        o requires specialty consultant, other than a family
                        practice physician or general medical officer, more
                        than twice a year on a chronic basis, or

                        o requires modifications of the educational
                        curriculum or the use of behavioral management staff.

           o Requires adaptive equipment (such as an apnea home monitor, home
           nebulizer, wheelchair, splints, braces, orthotics, hearing aids,
           home oxygen therapy, or home ventilator).

           o Requires assistive technology devices (such as communication
           devices) or services.

           o Requires environmental/architectural considerations (such as
           limited numbers of steps, wheelchair accessibility, and air
           conditioning).
			  
^1DOD 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.

^2A co-morbid psychological diagnosis is the diagnosis of a psychological
condition in the presence of additional diseases.			  

           (290465)

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