(a) General.
(1) The
TRICARE ECHO is essentially a supplemental program to the TRICARE
Basic Program. It does not provide acute care nor benefits available
through the TRICARE Basic Program.
(2) The
purpose of the ECHO is to provide an additional financial resource
for an integrated set of services and supplies designed to assist
in the reduction of the disabling effects of the ECHO-eligible dependent’s
qualifying condition. Services include those necessary to maintain,
minimize or prevent deterioration of function of an ECHO-eligible
dependent.
(3) The Government’s cost-share
for ECHO or ECHO home health benefits during any program year is limited
as stated in this section. In order to transition the program year
from a fiscal year to a calendar year basis, the Government’s annual
cost-share limitation specified in paragraph (f) of this section
shall be prorated for the last quarter of calendar year 2018 as
authorized by 10 U.S.C. 1079(f)(2)(A).
(b)
Eligibility.
(1)
The
following categories of TRICARE/CHAMPUS beneficiaries with a qualifying condition
are ECHO-eligible dependents:
(i) A spouse, child,
or unmarried person (as described in Sec. 199.3(b)(2)(i), (b)(2)(ii),
or (b)(2)(iv)) of a member of the Uniformed Services on active duty
for a period of more than 30 days.
(ii) An abused dependent
as described in Sec. 199.3(b)(2)(iii).
(iii) A
spouse, child, or unmarried person (as described in Sec. 199.3(b)(2)(i),
(b)(2)(ii), or (b)(2)(iv)), of a member of the Uniformed Services
who dies while on active duty for a period of more than 30 days
and whose death occurs on or after October 7, 2001. In such case,
an eligible surviving spouse remains eligible for benefits under
the ECHO for a period of 3 years from the date the active duty sponsor
dies. Any other eligible surviving dependent remains eligible for
benefits under the ECHO for a period of three years from the date
the active duty sponsor dies or until the surviving eligible dependent:
(A) Attains
21 years of age, or
(B) Attains 23 years
of age or ceases to pursue a full-time course of study prior to
attaining 23 years of age, if, at 21 years of age, the eligible
surviving dependent is enrolled in a full-time course of study in
a secondary school or in a full-time course of study in an institution
of higher education approved by Secretary of Defense and was, at
the time of the sponsor’s death, in fact dependent on the member
for over one-half of such dependent’s support.
(iv) A
spouse, child, or unmarried person (as defined in paragraphs Sec.
199.3(b)(2)(i), (b)(2)(ii), or (b)(2)(iv)) of a deceased member
of the Uniformed Services who, at the time of the member’s death
was receiving benefits under ECHO, and the member at the time of
death was eligible for receipt of hostile-fire pay, or died as a
result of a disease or injury incurred while eligible for such pay.
In such a case, the surviving dependent remains eligible for benefits
under ECHO through midnight of the dependent’s twenty-first birthday.
(2) Qualifying
condition.
The
following are qualifying conditions:
(i) Mental retardation.
A diagnosis
of moderate or severe mental retardation made in accordance with
the criteria of the current edition of the “Diagnostic and Statistical
Manual of Mental Disorders” published by the American Psychiatric
Association.
(ii) Serious
physical disability.
A serious physical disability as defined in
Sec. 199.2.
(iii) Extraordinary
physical or psychological condition.
An extraordinary physical
or psychological condition as defined in Sec. 199.2.
(iv) Infant/toddler.
Beneficiaries
under the age of 3 years who are diagnosed with a neuromuscular developmental
condition or other condition that is expected to precede a diagnosis
of moderate or severe mental retardation or a serious physical disability,
shall be deemed to have a qualifying condition for the ECHO. The
Director, TRICARE Management Activity or designee shall establish
criteria for ECHO eligibility in lieu of the requirements of paragraphs
(b)(2)(i), (ii) or (iii) of this section.
(v) Multiple
disabilities.
The
cumulative effect of multiple disabilities, as determined by the
Director, TRICARE Management Activity or designee shall be used
in lieu of the requirements of paragraphs (b)(2)(i), (ii) or (iii)
of this section to determine a qualifying condition when the beneficiary
has two or more disabilities involving separate body systems.
(3) Loss
of ECHO eligibility.
Eligibility for ECHO benefits ceases as of
12:01 a.m. of the day following the day that:
(i) The
sponsor ceases to be an active duty member for any reason other
than death; or
(ii) Eligibility based
upon the abused dependent provisions of paragraph (b)(1)(ii) of
this section expires; or
(iii) Eligibility based
upon the deceased sponsor provisions of paragraphs (b)(1)(iii) or
(iv) of this section expires; or
(iv) Eligibility based
upon a beneficiary’s participation in the Transitional Assistance
Management Program ends; or
(v) The Director, TRICARE
Management Activity or designee determines that the beneficiary
no longer has a qualifying condition.
(c)
ECHO benefit.
Items and services
that the Director, TRICARE Management Activity or designee has determined
are capable of confirming, arresting, or reducing the severity of
the disabling effects of a qualifying condition, includes, but are
not limited to:
(1) Diagnostic
procedures to establish a qualifying condition or to measure the
extent of functional loss resulting from a qualifying condition.
(2)
Medical,
habilitative, rehabilitative services and supplies, durable equipment
and assistive technology (AT) devices that assist in the reduction
of the disabling effects of a qualifying condition. Benefits shall
be provided in the beneficiary’s home or another environment, as
appropriate. An AT device may be covered only if it is recommended
in a beneficiary’s Individual Educational Program (IEP) or, if the
beneficiary is not eligible for an IEP, the AT device is an item
or educational learning device normally included in an IEP and is
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.
(i) An
AT device may be covered under ECHO only if it is not otherwise
covered by TRICARE as durable equipment, a prosthetic, augmentation
communication device, or other benefits under Sec. 199.4.
(ii) An
AT device may include an educational learning device directly related
to the beneficiary’s qualifying condition when recommended by an
IEP and not otherwise provided by State or local government programs.
If an individual is not eligible for an IEP, an educational learning
device normally included in the IEP may be authorized as if directly
related to the beneficiary’s qualifying condition and prescribed
by a TRICARE authorized provider as part of the beneficiary’s individual
comprehensive health care services plan.
(iii) Electronic
learning devices may include the hardware and software as appropriate.
The Director, DHA, shall determine the types and (or) platforms
of electronic devices and the replacement lifecycle of the hardware
and its supporting software. All upgrades or replacements shall
require a recommendation from the individual’s IEP or the individual’s
comprehensive health care services plan.
(iv) Duplicative
or redundant hardware platforms are not authorized.
Note to paragraph (c)(2)(iv): When
one or more electronic platforms 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 provision to allow only one electronic platform
that may be chosen by the beneficiary. Duplicative or redundant
platforms are not allowed; however, a second platform may be obtained,
if the individual’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 may submit a request with
the above justification to the Director, TMA, who may authorize
a second device.
(v) AT devices damaged
through improper use of the device may not be replaced until the
device would next be eligible for a lifecycle replacement.
(vi) AT
devices do not include equipment or devices whose primary purpose
is to assist the individual to engage in sports or recreational
activities.
(3) Training
that teaches the use of assistive technology devices or to acquire
skills that are necessary for the management of the qualifying condition.
Such training is also authorized for the beneficiary’s immediate
family. Vocational training, in the beneficiary’s home or a facility
providing such, is also allowed.
(4) Special
education as provided by the Individuals with Disabilities Education
Act and defined at 34 CFR 300.26 and that is specifically designed
to accommodate the disabling effects of the qualifying condition.
(5) Institutional
care within a state, as defined in Sec. 199.2, in private nonprofit,
public, and state institutions and facilities, when the severity
of the qualifying condition requires protective custody or training
in a residential environment. For the purpose of this section protective
custody means residential care that is necessary when the severity
of the qualifying condition is such that the safety and well-being
of the beneficiary or those who come into contact with the beneficiary
may be in jeopardy without such care.
(6) Transportation
of an ECHO beneficiary receiving benefits under paragraph (c)(5),
and a medical attendant when necessary to assure the beneficiary’s
safety, to or from a facility or institution to receive authorized
ECHO services or items.
(7) Respite care.
ECHO beneficiaries
are eligible for 16 hours of respite care per month in any month during
which the beneficiary otherwise receives an ECHO benefit(s). Respite
care is defined in Sec. 199.2. Respite care services will be provided
by a TRICARE-authorized home health agency and will be designed
to provide health care services for the covered beneficiary, and
not baby-sitting or child-care services for other members of the
family. The benefit will not be cumulative, that is, any respite
care hours not used in one month will not be carried over or banked
for use on another occasion.
(i) TRICARE-authorized
home health agencies must provide and bill for all authorized ECHO
respite care services through established TRICARE claims’ mechanisms.
No special billing arrangements will be authorized in conjunction
with coverage that may be provided by Medicaid or other federal,
state, community or private programs.
(ii) For
authorized ECHO respite care, TRICARE will reimburse the allowable
charges or negotiated rates.
(iii) The
Government’s cost-share incurred for these services accrues to the
program year benefit limit of $36,000.
(8) Other services.
(i) Assistive
services.
Services
of qualified personal assistants, such as an interpreter or translator
for ECHO beneficiaries who are deaf or mute and readers for ECHO
beneficiaries who are blind, when such services are necessary in
order for the ECHO beneficiary to receive authorized ECHO benefits.
(ii) Equipment
adaptation.
The
allowable equipment and an AT device purchase shall include such services
and modifications to the equipment as necessary to make the equipment
usable for a particular ECHO beneficiary.
(iii) Equipment
maintenance.
Reasonable
repairs and maintenance of the beneficiary owned or rented DE or
AT devices provided by this section shall be allowed while a beneficiary
is registered in the ECHO Program. Repairs of DE and/or AT devices
damaged while using the item in a manner inconsistent with its common
use, and replacement of lost or stolen rental DE are not authorized coverage
as an ECHO benefit. In addition, repairs and maintenance of deluxe,
luxury, or immaterial features of DE or AT devices are not authorized
coverage as an ECHO benefit.
(d) ECHO Exclusions--
(1) Basic Program.
Benefits allowed
under the TRICARE Basic Program will not be provided through the
ECHO.
(2) Inpatient care.
Inpatient acute
care for medical or surgical treatment of an acute illness, or of
an acute exacerbation of the qualifying condition, is excluded.
(3) Structural
alterations.
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, are excluded.
(4) Homemaker services.
Services that
predominantly provide assistance with household chores are excluded.
(5) Dental care or
orthodontic treatment.
Both are excluded.
(6) Deluxe
travel or accommodations.
The difference between the price for travel
or accommodations that provide services or features that exceed
the requirements of the beneficiary’s condition and the price for
travel or accommodations without those services or features is excluded.
(7) Equipment.
Purchase or
rental of DE and AT devices otherwise allowed by this section is
excluded when:
(i) The
beneficiary is a patient in an institution or facility that ordinarily
provides the same type of equipment or AT devices to its patients
at no additional charge in the usual course of providing services;
or
(ii) The item is available
to the beneficiary from a Uniformed Services Medical Treatment Facility;
or
(iii) 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
(iv) The
item is a duplicate DE or an AT device, as defined in Sec. 199.2.
(v) The
item (or 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,
spa, whirlpool, hot tub, swimming pool, an electronic device used
to locate or monitor the location of the beneficiary, or other similar
items or charges.
(8) Maintenance
agreements.
Maintenance
agreements for beneficiary owned or rented equipment or AT device
are excluded.
(9) No obligation to pay.
Services or items for which
the beneficiary or sponsor has no legal obligation to pay are excluded.
(10) Public
facility or Federal government.
Services or items paid for, or eligible for
payment, directly or indirectly by a public facility, as defined
in Sec. 199.2, or by the Federal government, other than the Department
of Defense, are excluded for training, rehabilitation, special education,
assistive technology devices, institutional care in private nonprofit,
public, and state institutions and facilities, and if appropriate,
transportation to and from such institutions and facilities, 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). Rehabilitation and assistive technology services
or supplies may be available under the TRICARE Basic Program.
(11) Study, grant,
or research programs.
Services and items provided as a part of a
scientific clinical study, grant, or research program are excluded.
(12) Unproven status.
Drugs, devices,
medical treatments, diagnostic, and therapeutic procedures for which
the safety and efficacy have not been established in accordance
with Sec. 199.4 are excluded.
(13) Immediate family
or household.
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, are excluded.
(14) Court or agency
ordered care.
Services
or items ordered by a court or other government agency, which are
not otherwise an allowable ECHO benefit, are excluded.
(15) Excursions.
Excursions are
excluded regardless of whether or not they are part of a program offered
by a TRICARE-authorized provider. The transportation benefit available
under ECHO is specified elsewhere in this section.
(16) Drugs and medicines.
Drugs and medicines
that do not meet the requirements of Sec. 199.4 or Sec. 199.21 are
excluded.
(17) Therapeutic
absences.
Therapeutic
absences from an inpatient facility or from home for a homebound
beneficiary are excluded.
(18) Custodial care.
Custodial care,
as defined in Sec. 199.2, is not a stand-alone benefit. Services generally
rendered as custodial care may be provided only as specifically
set out in this section.
(19) Domiciliary
care.
Domiciliary
care, as defined in Sec. 199.2, is excluded.
(20) Respite care.
Respite care
for the purpose of covering primary caregiver (as defined in Sec.
199.2) absences due to deployment, employment, seeking of employment
or to pursue education is excluded. Authorized respite care covers
only the ECHO beneficiary, not siblings or others who may reside
in or be visiting in the beneficiary’s residence.
(e)
ECHO
Home Health Care (EHHC).
The EHHC benefit provides coverage of home
health care services and respite care services specified in this
section.
(1) Home health
care.
Covered
ECHO home health care services are the same as, and provided under the
same conditions as those services described in Sec. 199.4(e)(21)(i),
except that they are not limited to part-time or intermittent services.
Custodial care services, as defined in Sec. 199.2, may be provided to
the extent such services are provided in conjunction with authorized
ECHO home health care services, including the EHHC respite care
benefit specified in this section. Beneficiaries who are authorized
EHHC will receive all home health care services under EHHC and no
portion will be provided under the Basic Program. TRICARE-authorized
home health agencies are not required to use the Outcome and Assessment
Information Set (OASIS) to assess beneficiaries who are authorized
EHHC.
(2) Respite care.
EHHC beneficiaries
whose plan of care includes frequent interventions by the primary
caregiver(s) are eligible for respite care services in lieu of the
ECHO general respite care benefit. For the purpose of this section,
the term “frequent” means “more than two interventions during the eight-hour
period per day that the primary caregiver would normally be sleeping.”
The services performed by the primary caregiver are those that can
be performed safely and effectively by the average non-medical person
without direct supervision of a health care provider after the primary caregiver
has been trained by appropriate medical personnel. EHHC beneficiaries
in this situation are eligible for a maximum of eight hours per
day, 5 days per week, of respite care by a TRICARE-authorized home
health agency. The home health agency will provide the health care
interventions or services for the covered beneficiary so that the
primary caregiver is relieved of the responsibility to provide such interventions
or services for the duration of that period of respite care. The
home health agency will not provide baby-sitting or child care services
for other members of the family. The benefit is not cumulative,
that is, any respite care hours not used in a given day may not
be carried over or banked for use on another occasion. Additionally,
the eight-hour respite care periods will not be provided consecutively,
that is, a respite care period on one calendar day will not be immediately
followed by a respite care period the next calendar day. The Government’s
cost-share incurred for these services accrue to the maximum yearly
ECHO Home Health Care benefit.
(3) EHHC eligibility.
The EHHC is
authorized for beneficiaries who meet all applicable ECHO eligibility requirements
and who:
(i) Physically
reside within the 50 United States, the District of Columbia, Puerto
Rico, the Virgin Islands, or Guam; and
(ii) Are
homebound, as defined in Sec. 199.2; and
(iii) Require
medically necessary skilled services that exceed the level of coverage
provided under the Basic Program’s home health care benefit; and/or
(iv) Require
frequent interventions by the primary caregiver(s) such that respite
care services are necessary to allow primary caregiver(s) the opportunity
to rest; and
(v) Are case managed
to include a reassessment at least every 90 days, and receive services
as outlined in a written plan of care; and
(vi) Receive
all home health care services from a TRICARE-authorized home health
agency, as described in Sec. 199.6(b)(4)(xv), in the beneficiary’s
primary residence.
(4) EHHC plan of care.
A written plan of care is
required prior to authorizing ECHO home health care. The plan must
include the type, frequency, scope and duration of the care to be
provided and support the professional level of provider. Reimbursement
will not be authorized for a level of provider not identified in
the plan of care.
(5) EHHC exclusions--
(i) General.
ECHO Home Health
Care services and supplies are excluded from those who are being
provided continuing coverage of home health care as participants
of the former Individual Case Management Program for Persons with
Extraordinary Conditions (ICMP-PEC) or previous case management
demonstrations.
(ii) Respite care.
Respite care
for the purpose of covering primary caregiver absences due to deployment,
employment, seeking of employment or to pursue education is excluded.
Authorized respite care covers only the ECHO beneficiary, not siblings
or others who may reside in or be visiting in the beneficiary’s
residence.
(f)
Cost-share
liability--
(1) No deductible.
ECHO benefits
are not subject to a deductible amount.
(2) Sponsor
cost-share liability.
(i)
Regardless
of the number of family members receiving ECHO benefits or ECHO
Home Health Care in a given month, the sponsor’s cost-share is according
to the following table:
|
Table
1 -- Monthly Cost-Share by Member’s Pay Grade
|
|
E-1 through E-5............................................................................................
|
$25
|
|
E-6....................................................................................................................
|
30
|
|
E-7 and O-1...................................................................................................
|
35
|
|
E-8 and O-2...................................................................................................
|
40
|
|
E-9, W-1, W-2
and O-3................................................................................
|
45
|
|
W-3, W-4 and O-4........................................................................................
|
50
|
|
W-5 and O-5..................................................................................................
|
65
|
|
O-6...................................................................................................................
|
75
|
|
O-7...................................................................................................................
|
100
|
|
O-8...................................................................................................................
|
150
|
|
O-9...................................................................................................................
|
200
|
|
O-10.................................................................................................................
|
250
|
(ii) The sponsor’s
cost-share shown in Table 1 in paragraph (f)(2)(i) of this section
will be applied to the first allowed ECHO charges in any given month.
The Government’s share will be paid, up to the maximum amount specified
in paragraph (f)(3) of this section, for allowed charges after the
sponsor’s cost-share has been applied.
(iii) The
provisions of Sec. 199.18(d)(1) and (e)(1) regarding elimination
of copayments for active duty family members enrolled in TRICARE
Prime do not eliminate, reduce, or otherwise affect the sponsor’s cost-share
shown in Table 1 in paragraph (f)(2)(i) of this section.
(iv) The
sponsor’s cost-share shown in Table 1 in paragraph (f)(2)(i) of
this section does not accrue to the Basic Program’s Catastrophic
Loss Protection under 10 U.S.C. 1079(b)(5) as shown at Sec. 199.4(f)(10)
and 199.18(f).
(3) Government
cost-share liability--
(i) ECHO.
The
total Government share of the cost of all ECHO benefits, except
ECHO Home Health Care (EHHC) and EHHC respite care, provided in
a given program year to a beneficiary, may not exceed $36,000 after
application of the allowable payment methodology.
(ii) ECHO home health
care.
(A) The maximum annual program year
Government cost-share per EHHC-eligible beneficiary for ECHO home
health care, including EHHC respite care may not exceed the local
wage-adjusted highest Medicare Resource Utilization Group (RUG-III)
category cost for care in a TRICARE-authorized skilled nursing facility.
(B) When
a beneficiary moves to a different locality within the 50 United
States, the District of Columbia, Puerto Rico, the Virgin Islands,
or Guam, the annual program year cap will be recalculated to reflect
the maximum established under paragraph (f)(3)(ii)(A) of this section
for the beneficiary’s new location and will apply to the EHHC benefit
for the remaining portion of that program year.
(g)
Benefit payment--
(1) Transportation.
The allowable
amount for transportation of an ECHO beneficiary is limited to the
actual cost of the standard published fare plus any standard surcharge made
to accommodate any person with a similar disability or to the actual
cost of specialized medical transportation when non-specialized
transport cannot accommodate the beneficiary’s qualifying condition
related needs, or when specialized transport is more economical
than non-specialized transport. When transport is by private vehicle,
the allowable amount is limited to the Federal government employee
mileage reimbursement rate in effect on the date the transportation
is provided.
(2) Equipment.
(i) The
TRICARE allowable amount for DE or AT devices shall be calculated
in the same manner as DME allowable through section 199.4 of this
title, and accrues to the program year benefit limit specified in
paragraph (f)(3) of this section.
(ii) Cost-share.
A cost-share,
as provided by paragraph (f)(2) of this section, is required for
each month in which equipment or an AT device is purchased under
this section. However, in no month shall a sponsor be required to
pay more than one cost-share regardless of the number of benefits
the sponsor’s dependents received under this section.
(3) For-profit institutional
care provider.
Institutional
care provided by a for-profit entry may be allowed only when the
care for a specific ECHO beneficiary:
(i) Is
contracted for by a public facility as a part of a publicly funded
long-term inpatient care program; and
(ii) Is
provided based upon the ECHO beneficiary’s being eligible for the
publicly funded program which has contracted for the care; and
(iii) Is
authorized by the public facility as a part of a publicly funded
program; and
(iv) Would cause a
cost-share liability in the absence of TRICARE eligibility; and
(v) 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.
(4) ECHO
home health care and EHHC respite care.
(i) TRICARE-authorized
home health agencies must provide and bill for all authorized home
health care services through established TRICARE claims’ mechanisms.
No special billing arrangements will be authorized in conjunction
with coverage that may be provided by Medicaid or other federal,
state, community or private programs.
(ii) For
authorized ECHO home health care and respite care, TRICARE will
reimburse the allowable charges or negotiated rates.
(iii) The
maximum monthly Government reimbursement for EHHC, including EHHC
respite care, will be based on the actual number of hours of EHHC
services rendered in the month, but in no case will it exceed one-twelfth
of the annual maximum Government cost-share as determined in this
section and adjusted according to the actual number of days in the
month the services were provided.
(h) Other Requirements--
(1) Applicable part.
All provisions
of this part, except the provisions of Sec. 199.4 unless otherwise
provided by this section or as directed by the Director, TRICARE
Management Activity or designee, apply to the ECHO.
(2) Registration.
Active duty
sponsors must register potential ECHO-eligible beneficiaries through the
Director, TRICARE Management Activity, or designee prior to receiving
ECHO benefits. The Director, TRICARE Management Activity, or designee
will determine ECHO eligibility and update the Defense Enrollment
Eligibility Reporting System accordingly. Unless waived by the Director,
TRICARE Management Activity or designee, sponsors must provide evidence
of enrollment in the Exceptional Family Member Program provided
by their branch of Service at the time they register their family member(s)
for the ECHO.
(3) Benefit
authorization.
All
ECHO benefits require authorization by the Director, TRICARE Management
Activity or designee prior to receipt of such benefits.
(i) Documentation.
The sponsor
shall provide such documentation as the Director, TRICARE Management
Activity or designee requires as a prerequisite to authorizing ECHO
benefits. Such documentation shall describe how the requested benefit
will contribute to confirming, arresting, or reducing the disabling
effects of the qualifying condition, including maintenance of function
or prevention of further deterioration of function, of the beneficiary.
(ii) Format.
An authorization
issued by the Director, TRICARE Management Activity or designee
shall specify such description, dates, amounts, requirements, limitations
or information as necessary for exact identification of approved
benefits and efficient adjudication of resulting claims.
(iii) Valid period.
An authorization
for ECHO benefits shall be valid until such time as the Director, TRICARE
Management Activity or designee determines that the authorized services
are no longer appropriate or required or the beneficiary is no longer
eligible under paragraph (b) of this section.
(iv) Authorization
waiver.
The
Director, TRICARE Management Activity or designee may waive the requirement
for a written authorization for rendered ECHO benefits that, except
for the absence of the written authorization, would be allowable
as an ECHO benefit.
(v) Public facility
use.
(A) An ECHO beneficiary residing within
a state must demonstrate that a public facility is not available
and adequate to meet the needs of their qualifying condition. Such requirements
shall apply to beneficiaries who request authorization for training,
rehabilitation, special education, assistive technology, and institutional
care in private nonprofit, public, and state institutions and facilities,
and if appropriate for beneficiaries receiving institutional care,
transportation to and from such institutions and facilities. The
maximum Government cost-share for services that require demonstration
of public facility non-availability or inadequacy is limited to
$36,000 per program year per beneficiary. State-administered plans
for medical assistance under Title XIX of the Social Security Act
(Medicaid) are not considered available and adequate facilities
for the purpose of this section.
(B) The
domicile of the beneficiary shall be the basis for the determination
of public facility availability when the sponsor and beneficiary
are separately domiciled due to the sponsor’s move to a new permanent
duty station or due to legal custody requirements.
(C) Written
certification, in accordance with information requirements, formats,
and procedures established by the Director, TRICARE Management Activity
or designee that requested ECHO services or items cannot be obtained
from public facilities because the services or items are not available
and adequate, is a prerequisite for ECHO benefit payment for training,
rehabilitation, special education, assistive technology, and institutional
care in private nonprofit, public, and state institutions and facilities,
and if appropriate, transportation to and from such institutions
and facilities.
(1) An administrator or designee of a public
facility may make such certification for a beneficiary residing
within the service area of that public facility.
(2) The Director, TRICARE Management Activity
or designee may determine, on a case-by-case basis, that apparent
public facility availability or adequacy for a requested type of
service or item cannot be substantiated for a specific beneficiary’s
request for ECHO benefits and therefore is not available.
(i) A case-specific determination shall be
based upon a written statement by the beneficiary (or sponsor or
guardian acting on behalf of the beneficiary) which details the
circumstances wherein a specific individual representing a specific
public facility refused to provide a public facility use certification,
and such other information as the Director, TRICARE Management Activity
or designee determines to be material to the determination.
(ii) A case-specific determination of public
facility availability by the Director, TRICARE Management Activity
or designee is conclusive and is not appealable under Sec. 199.10.
(4) Repair
or maintenance of DE owned by the beneficiary or an AT device is
exempt from the public facility-use certification requirements.
(5) The
requirements of this paragraph (h)(3)(v)(A) notwithstanding, no
public facility use certification is required for services and items
that are provided under Part C of the Individuals with Disabilities
Education Act in accordance with the Individualized Family Services
Plan and that are otherwise allowable under the ECHO.
(i) Implementing instructions.
The Director,
TRICARE Management Activity or designee shall issue TRICARE policies,
instructions, procedures, guidelines, standards, and criteria as
may be necessary to implement the intent of this section.
(j) Effective date.
All changes
to this section are effective as of October 14, 2008, and claims
for ECHO benefits provided on or after that date will be reprocessed
retroactively to that date as necessary.
[62 FR 35093, Jun 30, 1997, as amended at
62 FR 42904, Aug 11, 1997; 66 FR 9655, Feb 9, 2001; 67 FR 18827,
Apr 17, 2002; 69 FR 44947, Jul 28, 2004; 69 FR 51564, Aug 20, 2004;
71 FR 47092, Aug 16, 2006; 72 FR 2447, Jan 19, 2007; 73 FR 30478,
May 28, 2008; 75 FR 47711, Aug 9, 2010; 79 FR 78713, Dec 31, 2014; 81
FR 27329, May 6, 2016; 82 FR 45447, Sep 29, 2017]