2.0 Description
2.1 DE, which does not otherwise
qualify for coverage under the TRICARE Basic Program (
Chapter 8, Section 2.1) but has been certified
by an authorized TRICARE individual professional provider, as essential
to the efficient arrest or reduction of functional loss resulting
from the disabling effects of a qualifying condition of an eligible
beneficiary, may be provided under the ECHO under
32 CFR 199.5.
2.2 AT devices are defined in
32 CFR 199.2(b) as equipment that generally
does not treat an underlying injury, illness, disease or their symptoms.
AT devices are authorized only under the ECHO. AT devices help an
ECHO beneficiary overcome or remove a disability and are used to
increase, maintain, or improve the functional capabilities of an
individual. AT devices may include non-medical devices, but do not
include any structural alterations (e.g., permanent structure of
wheelchair ramps or alterations to street curbs), service animals
(e.g., Seeing Eye dogs, hearing/handicapped assistance animals,
etc.), or specialized equipment and devices whose primary purpose
is to enable the individual to engage in sports or recreational
events. AT devices are authorized only under coverage criteria determined
by the Director, Defense Health Agency (DHA) (formerly TRICARE Management
Activity (TMA)) to assist in the reduction of the disabling effects
of a qualifying condition for individuals eligible to receive benefits
under the ECHO program, as provided in
32 CFR 199.5.
3.0 Policy
3.1 A DE or AT device shall only
be covered under ECHO if it is not otherwise covered by TRICARE
as DE, a prosthetic, augmentation communication device, or other
benefits under the Basic Program.
3.2 DE and AT devices may be cost-shared
and provided in the beneficiary’s home or another environment, as
appropriate.
3.3 AT devices may include an educational learning
device and may be cost-shared when:
3.3.1 A TRICARE authorized provider
has certified that an AT device is necessary to assist in the reduction
of the disabling effects of a qualifying condition.
3.3.2 It is recommended in the beneficiary’s
Individual Educational Program (IEP) and is not otherwise provided
by State or local government programs; or
3.3.3 The beneficiary is not eligible
for an IEP, in this case, the AT device;
3.3.3.1 Shall be
authorized as if directly related to the beneficiary’s qualifying
condition;
3.3.3.2 Must be an educational learning device normally
included in an IEP; and
3.3.3.3 Must be
preauthorized under ECHO as an integral component of the beneficiary’s individual
comprehensive health care services plan (including rehabilitation),
as prescribed by a TRICARE authorized provider.
3.4 Benefits allowed for AT electronic
learning devices include the hardware and software as appropriate.
The Director, DHA, or designee, shall determine the types and (or)
platforms of electronic devices.
3.5 Training. When training is
required to allow the use of an AT device, see
Section 8.1.
3.6 Equipment Adaptation. ECHO-authorized
equipment and an AT device purchase shall include such services
and modifications to the equipment that is essential to make the
equipment usable for a particular ECHO beneficiary.
3.7 Equipment Maintenance and
Repairs. Reasonable repairs and maintenance on the beneficiary owned
AT device or DE shall be cost-share while the beneficiary is registered
in the ECHO Program.
3.8 Upgrades and Replacement.
3.8.1 The Director, DHA, or designee,
shall determine replacement lifecycles of the hardware (and its
supporting software).
3.8.2 All upgrades or replacements shall require
a recommendation from the individual’s IEP or the individual’s comprehensive
health care services plan.
3.8.3 A beneficiary owned AT device
damaged through improper use of the device may not be replaced until
the device would next be eligible for a lifecycle replacement.
3.8.4 Benefits
are allowed for replacement of a beneficiary-owned AT device or
DE with documentation that the AT device or DE is lost or stolen
and not otherwise covered by another insurance (such as a homeowner’s
policy). A new order or prescription by a TRICARE authorized provider
is required to reaffirm that the AT device or DE is necessary to
assist in the reduction of the disabling effects of a qualifying
condition.
3.9 Cost-share and Allowable Amount:
3.9.1 The TRICARE allowable amount
for AT devices or DE shall be calculated in the same manner as Durable
Medical Equipment (DME) allowable as addressed in
32 CFR 199.4, and accrues to the fiscal year
benefits limit specified in
Section 16.1.
3.9.2 A sponsor/beneficiary cost-share,
as described in
Section 16.1, is required in the month in which
the item is purchased.
3.9.3 A sponsor/beneficiary is not required to pay
more than one cost-share, regardless of the number of benefits the
sponsor’s dependents receive under the ECHO Program.
4.0 Exceptions
4.1 A second platform may be obtained
if the beneficiary’s IEP recommends one platform such as a computer
for the majority of the learning objectives, but there exists another
objective, which cannot be performed on that platform. In these
limited circumstances, the beneficiary shall submit a request with
the above justification to the Director, DHA, or designee, who may
authorize a second device.
4.2 When one or more electronic
platform, such as a desktop computer, laptop, notebook or tablet, can
perform the same functions in relation to the teaching or educational
objective directly related to the qualifying condition, it is the
intent of this policy to allow the beneficiary to choose only one electronic
platform.
5.0 Exclusions
5.1 Purchase or rental of AT devices
and DE is excluded when:
5.1.1 The beneficiary is a patient in an institution
or facility that ordinarily provides the same type of equipment
to its patients at no additional charge in the usual course of providing
services; or
5.1.2 The item is available from a local Uniformed
Service Medical Treatment Facility (USMTF); or
5.1.3 The item has deluxe, luxury,
immaterial or nonessential features that increase the cost relative
to a similar item without those features; or
5.1.4 The item is duplicate equipment,
as defined in
32 CFR 199.2.
However, this does not preclude the purchase of a replacement for
an item that is no longer usable; or
5.1.5 The hardware platform is a
duplicate or redundant, except as provided in
paragraphs 4.1 and
4.2;
or
5.1.6 The item
is not necessary to operate the system and is unrelated to the system
or software components (e.g., printer or wireless Internet access
devices); or
5.1.7 The rental equipment is damaged while using
the item in a manner inconsistent with its common use or has been
lost or stolen. See
paragraph 3.8.4 for beneficiary owned equipment;
or
5.1.8 The item
(or a charge for access to such items through health club membership
or other activities) is exercise equipment including an item primarily
and customarily designed for use in sports or recreational activities,
spas, whirlpools, hot tubs, swimming pools, or electronic devices
used to locate or monitor the location of a beneficiary or other
similar charges, or item charges.
5.2 Service animals (e.g., Seeing
Eye dogs, hearing and handicapped assistance animals, etc.) are excluded.
5.3 Alterations to living space
and permanent fixtures attached thereto, including alterations necessary
to accommodate installation of equipment or AT devices to facilitate
entrance or exit is excluded.
5.4 Repairs and maintenance of
deluxe, luxury, or immaterial features of AT device or DE.
5.5 Maintenance agreements for
beneficiary-owned or rented equipment or AT devices are excluded.
5.6 DE that is available under
the TRICARE Basic Program and an AT device that is also available under
the TRICARE Basic Program as DE, a prosthetic, augmentation communication
device, or other benefit are excluded.