2.0 POLICY
2.1 The ECHO
is available only to eligible ADFMs. Enrollment in
TRICARE Prime or TRICARE Select is required.
2.2 Eligibility
and registration are prerequisites to ECHO benefits being authorized.
2.3 Written
authorization for ECHO benefits is a prerequisite to claim adjudication.
2.4 ECHO-eligible
beneficiaries who are enrolled in TRICARE Prime or
TRICARE Select shall meet all applicable requirements
of that program, including those regarding the assignment and use
of a Primary Care Manager (PCM) (TRICARE Prime only) when
services are requested and provided through the ECHO.
2.5 TRICARE
is primary payer for medical services and items that are provided
under Part C of the Individuals with Disabilities Education Act
(IDEA) in accordance with the Individualized Family Service Plan
and which are otherwise allowable under the TRICARE Basic Program
or the ECHO.
3.0 EXCLUSIONS
3.1 All benefits
available through the TRICARE Basic Program are excluded from the
ECHO.
3.2 Inpatient care for medical or surgical treatment
of an acute illness, or of an acute exacerbation of the qualifying
condition. These services may be cost-shared through the Basic Program.
3.3 Structural
alterations to living space and permanent fixtures, including alterations
necessary to accommodate installation of equipment or to facilitate
entrance or exit.
3.4 Except as provided by the
ECHO Home Health Care (EHHC) benefit (
Section 15.1)
homemaker services that provide assistance with household chores
are excluded.
3.5 Dental care and orthodontic treatment.
3.6 The price
differential between the price for a type of accommodation which
provides services or features that exceed the requirements of the
beneficiary’s condition for safe transport and the price for a type
of accommodation without those deluxe features. Payment of such
price differential is the responsibility of the beneficiary.
3.7 Durable
equipment is excluded from the ECHO when:
3.7.1 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
3.7.2 The item is available to the
beneficiary from a Uniformed Services Medical Treatment Facility
(USMTF); or
3.7.3 The item has deluxe, luxury, immaterial or
nonessential features that increase the cost to the Government relative
to a similar item without those features; or
3.7.4 The item
is duplicate equipment as defined in
32 CFR 199.2.
3.8 Maintenance
agreements for beneficiary-owned equipment are excluded.
3.9 Services
or items for which the beneficiary or sponsor has no legal obligation
to pay, or for which no charge would be made if the beneficiary
was not eligible for benefits.
3.10 Services or items paid for,
or eligible for payment, directly or indirectly by a Public Facility,
as defined in
32 CFR 199.2,
or by the Federal Government, other than the Department of Defense
(DoD), are excluded, except when such services or items are eligible
for payment under a State plan for medical assistance under Title
XIX of the Social Security Act (Medicaid).
3.11 Services and items provided
as a part of a scientific clinical study, grant, or research program.
3.12 Unproven
services and items whose safety and efficacy have not been established
as described in
32 CFR 199.4.
3.13 Services
or items provided or prescribed by a member of the beneficiary’s
immediate family, or a person living in the beneficiary’s or sponsor’s
household.
3.14 Services or items ordered by a court or other
Government agency that are not otherwise an allowable ECHO benefit.
3.15 Additional
or special charges for excursions, except for other otherwise allowable transportation,
even when they are part of a program offered by an approved provider.
3.16 Drugs and
medicines which do not meet the requirements of
32 CFR 199.4.
3.17 Therapeutic absences from
an inpatient facility.
3.18 Custodial care, as defined
in
32 CFR 199.2, as a stand alone ECHO benefit
is excluded. Services provided in support of activities of daily
living may be cost-shared only when provided through the EHHC benefit
(see
Section 15.1).
3.19 Domiciliary care, as defined
in
32 CFR 199.2, may not be cost-shared through
the ECHO.
3.20 Services for a beneficiary aged 3 to 21 that
are written in the beneficiary’s special education Individualized
Educational Program (IEP) and that are required to be provided without
charge by the local public education facility in accordance with
the IDEA.