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.