Extended Care Health Option (ECHO)
Chapter 9
Section 10.1
Institutional Care
Issue Date: July 3, 1997
Copyright: CPT
only © 2006 American Medical Association (or such other date of
publication of CPT).
All Rights Reserved.
Revision:
1.0 CPT
PROCEDURE CODE
99199
2.0 POLICY
2.1 Institutional
care when the severity of the qualifying condition requires protective
custody or training in a residential environment, may be cost-shared
subject to all applicable Extended Care Health Option (ECHO) requirements.
2.2 In
accordance with Title 10, Section 1079(d)(4), United States Code
(USC), institutional care must be provided in private nonprofit,
public and state institutions and facilities.
2.3 The requirements
of
paragraph 2.2 not
withstanding, institutional care provided by a for-profit entity
may be allowed only when the care for a specific ECHO beneficiary:
2.3.1 Is contracted
for by a public facility, as defined in
32 CFR 199.2,
as part of a publicly funded long-term inpatient care program; and
2.3.2 Is provided
based upon the ECHO beneficiary’s being eligible for the publicly
funded program which has contracted for the care; and
2.3.3 Is authorized
by the public facility as a part of a publicly funded program; and
2.3.4 Would cause
a cost-share liability in the absence of TRICARE eligibility; and
2.3.5 Produces
an ECHO beneficiary cost-share liability that does not exceed the
maximum charge by the provider to the public facility for the contracted
level of care.
3.0 EXCLUSIONS
3.1 Regardless
of the beneficiary’s condition, care within any type of institution
for the primary purpose of providing custodial, domiciliary, hospice,
or respite care is excluded from the ECHO.
3.2 Institutional care available
under the TRICARE Basic Program is not eligible to be cost-shared under
the ECHO.
4.0 EFFECTIVE
DATE
September 1, 2005.
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