1.0 ISSUE
Section 1079(d)(1) of Title 10 United
States Code (USC) requires that TRICARE beneficiaries must be “registered”
in order to receive the benefits provided under Section 1079(d)-(f)
of Title 10, United States Code (USC). This registration policy
will enhance the efforts to provide an integrated set of services
and supplies to eligible TRICARE beneficiaries and insure effective
utilization of program resources.
2.0 POLICY
2.1 The active
duty sponsor (or other authorized individual acting on behalf of
the beneficiary) will submit the following to the
enrolling contractor
(Managed
Care Support, TRICARE Overseas or Uniformed Services Family Health
Plan), hereafter referred to as ‘contractor
’, responsible
for administering the Extended Care Health Option (ECHO) in the
geographic area where the beneficiary resides:
2.1.1 Evidence that the sponsor is a Service
member in one of the Uniformed Services.
2.1.2 Medical records, as determined necessary
by the contractor
which demonstrate
that the Active Duty Family Member (ADFM) has a qualifying condition
in accordance with
Sections 2.2 through
2.4, and who otherwise meets all applicable
ECHO requirements.
2.1.3 Evidence, as provided by the sponsor’s
branch of service, that the family, or family member seeking ECHO
registration, is enrolled in the Exceptional Family Member Program
(EFMP) provided by the sponsor’s branch of service.
2.1.3.1 This requirement
is waived when either:
2.1.3.1.1 The sponsor’s
branch of service does not provide the EFMP; or
2.1.3.1.2 The beneficiary
seeks ECHO eligibility based on the “deceased sponsor” provisions listed
in
Section 2.1; or
2.1.3.1.3 Other circumstances
exist that make enrollment in the EFMP unnecessary or inappropriate,
such as when an individual resides with the custodial parent who
is not the active duty sponsor.
2.1.3.2 To
avoid delaying receipt of ECHO services while completing the ECHO
registration process, in particular awaiting completion of enrollment
in the EFMP of the sponsor’s service, the contractor or TAO Director
may grant otherwise ECHO-eligible beneficiaries a provisional eligibility
status for a period of not more than 90 days during which ECHO benefits
will be authorized and payable. This provisional status is portable
across contract regions
. However, the
ECHO Home Health Care (EHHC) benefit is not available through the
TRICARE Overseas Program (TOP).
Note: The provisional
status will terminate upon completion of the registration process
or at the end of the 90 day period, whichever occurs first. The
Government liability for ECHO benefits will terminate at the end
of the 90 day period. The Government will not recoup claims paid
for ECHO benefits provided during the provisional period.
2.1.4 Such other information
as may be required by the contractor or TAO Director in order to determine
whether or not the requesting beneficiary is eligible for the ECHO.
2.1.5 In locations
outside the 50 United States (U.S.) and the District of Columbia,
the TOP contractor shall advise the appropriate TRICARE Area Office
(TAO) Director of all ECHO eligibility determinations.
2.2 Upon determination
that an ADFM is eligible for the ECHO, the contractor
will
use the Government furnished web-based enrollment system/application
to annotate the beneficiary’s Defense Enrollment Eligibility Reporting
System (DEERS) record to reflect ECHO eligibility.
2.2.1 The
contractor
will provide the sponsor/beneficiary with written notification of
the eligibility determination and that the beneficiary is registered
in ECHO. Except as otherwise provided in
paragraph 2.1.3.2, the beneficiary
is eligible to receive ECHO benefits as of the date of registration.
Note: The
DEERS Eligibility Response will return the Health Care Delivery
Plan (HCDP) code “400”, which indicates the beneficiary is registered
and eligible to receive ECHO benefits.
2.2.2 Determination
that a beneficiary is not eligible for the ECHO is factual, therefore,
such determination can not be appealed.
2.3 At the
time of registration, the contractor
will also provide the sponsor/beneficiary with informational materials
that, at a minimum, emphasize the ECHO is an optional program for
ADFMs only and has unique qualifying and cost-sharing requirements.
2.4 The eligibility
determination will remain in effect until such time as the contractor
determines the beneficiary is no longer eligible for the ECHO. This
may result from a loss of TRICARE eligibility, remediation of the
qualifying condition, or a determination that the beneficiary does
not otherwise meet the eligibility requirements of the ECHO. The
contractor is responsible for notifying the beneficiary when their
eligibility ends.
2.5 TRICARE does not charge a fee for
registering in the ECHO, however, the sponsor/beneficiary may incur
costs associated with the determination of eligibility for the ECHO.
For example, the sponsor of a beneficiary who uses TRICARE Standard
or Extra (through December 31, 2017) or TRICARE Select (starting
January 1, 2018) to receive diagnostic
services that result in a diagnosis that is an ECHO qualifying condition,
is liable for all relevant cost-shares associated with receipt of
those diagnostic services. Those cost-shares are not reimbursable
under the ECHO. Additionally, TRICARE does not provide separate
or additional reimbursement to providers for completion of forms,
such as the DoD form DD 2792, Exceptional Family Member Medical
Summary, or for reproducing, copying or transmitting records
necessary to register in the ECHO. TRICARE will deny claims for
such services.