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Services Are Available for Exceptional Family Members' which was 
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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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