TRICARE Manuals - Display Chap 9 Sect 14.1 (Change 72, Oct 16, 2020)

Extended Care Health Option (ECHO)

Chapter 9

Section 14.1

Durable Equipment (DE) Prior To January 30, 2015

Issue Date: December 29, 1982

Authority: 32 CFR 199.2(b), 32 CFR 199.5(c)(2), (d)(7), and (g)(2)

Revision: C-1, March 10, 2017

1.0 HCPCS CODES

All valid codes.

2.0 DESCRIPTION

Prior to January 30, 2015, DE was defined in 32 CFR 199.2(b) as a device or apparatus which does not qualify as Durable Medical Equipment (DME) under the TRICARE Basic Program but which is essential to the efficient arrest or reduction of functional loss resulting from, or the disabling effects of a qualifying condition as provided in Sections 2.2 through 2.4. Examples of DE, at the time, were special computer peripheral devices (keyboard, mouse, etc.) or software that makes a computer functional to an Extended Care Health Option (ECHO) beneficiary with a qualifying condition that would otherwise limit or prohibit the beneficiary’s ability to use the computer; or an electrical/mechanical lifting device that raises an ECHO beneficiary in a wheelchair from ground level to first floor level of the beneficiary’s residence.

3.0 POLICY

3.1 DE may be cost-shared when:

3.1.1 A physician has certified that the item is necessary for the treatment, habilitation, or rehabilitation of the beneficiary or to reduce the disabling effects of the qualifying condition.

3.1.2 A written authorization to purchase the item has been issued by the appropriate contractor or the TRICARE Overseas Program (TOP) contractor prior to the purchase.

3.2 Customization of ECHO-authorized DE and any accessory or item of supply for any DE may be provided if such customization, accessory, or supply item is essential for:

3.2.1 Achieving therapeutic benefit for the beneficiary; or

3.2.2 Making the equipment usable; or

3.2.3 Otherwise assuring the proper functioning of the equipment; and

3.2.4 Is not otherwise excluded from coverage by regulation or policy.

3.3 Installation of authorized DE may also be cost-shared through the ECHO, however, alterations, such as those made to living spaces or vehicles to accommodate installation of such equipment, cannot be cost-shared through the ECHO.

3.4 A sponsor/beneficiary cost-share, as described in Section 16.1, is required in the month in which the item is purchased.

3.5 Reasonable repairs and maintenance on authorized beneficiary-owned DE may be cost-shared.

4.0 EXCLUSIONS

4.1 Purchase or rental of DE is excluded when:

4.1.1 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

4.1.2 The item is available from a local Uniformed Service Medical Treatment Facility (USMTF); or

4.1.3 The item has deluxe, luxury, immaterial or nonessential features that increase the cost to the Department relative to a similar item without those features; or

4.1.4 When the item is duplicate equipment, as defined in 32 CFR 199.2. This does not preclude the purchase of a replacement for an item that is no longer usable.

4.2 Exercise equipment, spas, whirlpools, hot tubs, swimming pools, health club membership, electronic devices used to locate or monitor the location of a beneficiary, and other similar charges or items are not considered DE.

4.3 Rental of equipment is excluded unless it can be shown to be more cost-effective than purchase.

4.4 DME that is available under the TRICARE Basic Program is not eligible to be cost-shared under this issuance.

5.0 EFFECTIVE DATE

September 1, 2005.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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