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TRICARE Policy Manual 6010.60-M, April 1, 2015
Extended Care Health Option (ECHO)
Chapter 9
Section 14.2
Durable Equipment (DE) And Assistive Technology (AT) Devices On Or After January 30, 2015: Extended Care Health Option (ECHO) Program
Issue Date:  November 20, 2015
Revision:  C-1, March 10, 2017
1.0  HCPCS CODES
All valid codes.
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.
6.0  Effective Date
January 30, 2015.
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