United States Government Accountability Office

Washington, DC 20548 

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. 

 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. 

 GAO-07-317R DOD Exceptional Family Member Program 
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 

 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. 

2 GAO-07-317R DOD Exceptional Family Member Program
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, afterschool 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, 

3 GAO-07-317R DOD Exceptional Family Member Program
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.) 

 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. 

4 GAO-07-317R DOD Exceptional Family Member Program
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 

By exceptional 

family member

By servicemember 

with exceptional 

family member(s) By installation 

Medical diagnosis of

exceptional family 

member by installation

Army 9 9 9a9

Navy 9a9 9a9a

Air Force 9 9

Marine Corps 9 9a

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. 

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 

 10See 32 C.F.R. § 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. 

5 GAO-07-317R DOD Exceptional Family Member Program
as respite care and therapy for autism.13 As of December 2006, approximately 1,980 

exceptional family members were enrolled in ECHO.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 1973,15 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 

 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, § 504, 87 Stat. 355, 394 (codified as amended at 29 U.S.C. § 794).

16Pub. L. No. 101-336, §§ 201-205, 104 Stat. 327, 337-38 (1990) (codified as amended at 

42 U.S.C. §§ 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. §§ 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. § 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. 

19See 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. 

20Federal property is exempt from local property taxes.

6 GAO-07-317R DOD Exceptional Family Member Program
services to children with severe disabilities and for the reduction to the local tax base, among 

other things.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 TRICARE benefit 

Extended Care Health Option (ECHO) 

supplemental medical services 

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. 

Up to 28 to 35 hours per 

week of medically necessary 

services provided under a 

plan of care established and 

approved by a physician. 

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. 

 21See 20 U.S.C. §§ 7703a and 7703b. 

7 GAO-07-317R DOD Exceptional Family Member Program
Selected benefits TRICARE benefit 

Extended Care Health Option (ECHO) 

supplemental medical services 

Mental health services 

Psychotherapy provided on an

outpatient basis or at a hospital. 

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. 

No additional 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. 

No benefit. Applied behavioral analysis when provided by

an authorized TRICARE provider.a

 

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. 

Not a stand-alone benefit but 

may be provided through 

other benefits such as 

hospice care. 

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. 

8 GAO-07-317R DOD Exceptional Family Member Program
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 onbase 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, 

 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. 

9 GAO-07-317R DOD Exceptional Family Member Program
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.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 §§ 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 §§ 4400-4906 (2006). 

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

10 GAO-07-317R DOD Exceptional Family Member Program
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. 

Marcia Crosse 

Director, Health Care 

11 GAO-07-317R DOD Exceptional Family Member Program
Appendix I 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: 

• 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. 

1

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

2

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

12 GAO-07-317R DOD Exceptional Family Member Program 
Appendix I Appendix I

Table 3: Description of Sites Selected

Community 

Number of 

exceptional 

family members 

by communitya

Percentage of

exceptional 

family member

populationb

Criteria met 

San Diego, California 

San Diego area Naval 

Bases

Camp Pendleton 

4,959 4.8% • More than one military service present 

in the community. 

• Second largest number of Navy 

exceptional family members.

• Largest number of Marine exceptional 

family members. 

Fayetteville, North Carolina

Fort Bragg 

Pope Air Force Base 

3,951 3.8% • More than one military service present 

in the community. 

• Second largest number of Army 

exceptional family members.c 

San Antonio, Texas 

Fort Sam Houston 

Brooks City Base 

Lackland Air Force Base 

Randolph Air Force Base 

2,332 2.2% • More than one military service present 

in the community. 

• Largest number of Air Force 

servicemembers with exceptional 

family members. 

Hampton Roads community, 

Virginiad

Fort Eustis 

Fort Monroe 

Fort Story 

Norfolk Naval Bases 

Langley Air Force Base 

6,152 5.9% • 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. 

13 GAO-07-317R DOD Exceptional Family Member Program
Appendix II 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. 

14 GAO-07-317R DOD Exceptional Family Member Program 
Appendix III 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: 

• 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 bipolar, 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,2

• 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 

1

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.

2

A co-morbid psychological diagnosis is the diagnosis of a psychological condition in the presence of

additional diseases. 

15 GAO-07-317R DOD Exceptional Family Member Program 
Appendix III Appendix III 

• 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) 

16 GAO-07-317R DOD Exceptional Family Member Program
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