2.4.2 Benefit Coverage
Comparable To The Extended Care Health Option (ECHO) For Seriously
Ill Or Injured Service Members
2.4.2.1 Under
10 USC 1074(c)(4)(A) and (B), seriously ill/injured Service members
shall receive services comparable to those provided to dependents
of Service members under 10 USC 1079(d) and (e), the TRICARE ECHO
Program. Statutory authority for these benefits for retirees ended
December 31, 2012. Former Service members that utilized this benefit
will continue to be covered by this provision for benefits received
before December 31, 2012 (e.g., anti-rejection medication for a
limb transplant). The contractors shall ensure all TED requirements
outlined in the TRICARE Systems Manual (TSM),
Chapter 2 are
met including appropriate use of
SPC PF to
identify TED records for care rendered under the ECHO benefit for
seriously ill or injured Service members.
2.4.2.2 There
are no cost-shares, copayments, or financial caps for any of these
ECHO-like benefits when these services are authorized. There is
no requirement to register in the Exceptional Family Member Program
(EFMP). There is no time limit with disability/illness requirement.
These benefits shall be preauthorized, to include documentation
of Category II/III designation per Department of Defense Instruction
(DoDI) 1300.24; and, documentation that the Service member has been
referred to a Medical Evaluations Board (MEB).
2.4.2.3 The following
categories of care listed under 10 USC 1079(e) are authorized (see
10 USC 1079(e)(1-7):
2.4.2.3.1 Diagnosis.
2.4.2.3.2 Inpatient, outpatient,
and comprehensive Home Health Care (HHC) supplies and services which
may include cost effective and medically appropriate services other
than part-time or intermittent services, as these terms are currently
used under the TRICARE ECHO Program.
2.4.2.3.3 Training, rehabilitation,
special education, and assistive technology devices.
2.4.2.3.4 Institutional
care in private nonprofit, public, and state institutions and facilities
and, if appropriate, transportation to and from such institutions
and facilities.
2.4.2.3.5 Home
health services, including custodial care in conjunction with authorized
home health services.
2.4.2.3.6 Seriously ill or injured Service members
are defined as Category II or III per DoDI 1300.24.
2.4.2.3.6.1 Category
II:
• Has a serious injury or illness.
• Is unlikely to return to duty within a
time specified by his or her military department.
• May be medically separated from the military.
2.4.2.3.6.2 Category
III:
• Has a severe
or catastrophic injury or illness.
• Is highly unlikely
to return to duty.
• Will most
likely be medically separated from the military.
2.4.2.4 The Service
member’s primary care provider or primary specialty care provider
shall document and provide the Service member’s category status
on a referral as well as documentation of a referral to an MEB.
Preauthorization is required. If the documentation supports the
category designation of Category II/III, the Service member is eligible
for benefits comparable to ECHO. Using the Government furnished
web-based enrollment application, the contractor shall apply the
ECHO Health Care Delivery Plan (HCDP) code of 400 to the Service
member. The provider’s documentation of Category II/III status is
the authorizing document allowing the contractor to apply the ECHO
HCDP code to the Service member. The contractor shall ensure all
TED requirements outlined in the TSM,
Chapter 2 are
met, including appropriate use of
SPC PF to
identify TED records for care rendered under the ECHO benefit for
seriously ill or injured Service members.
2.4.2.5 The contractor
shall collaborate with all DVA/VHA case managers along with the
Service member’s healthcare team to ensure continuity of care and
transition to DVA/VHA care and management upon retirement or separation.
2.4.2.6 As much as practical,
these benefits should mirror the ECHO Program and be coordinated between
the contractor and the health care team. Benefits for these Service
members arise from any physiological disorder or condition or anatomical
loss affecting one or more body system and which precludes the person
with the disorder, condition, or anatomical loss from unaided performance
of at least one of the following major life activities: breathing,
cognition, hearing, seeing, and ability to bathe, dress, eat, groom,
speak, stair use, toilet use, transferring, and walking. Benefits
include services for rehabilitative, habitative care as well as
Durable Equipment (DE) and Durable Medical Equipment (DME).
2.4.2.7 Designation
of comparable to ECHO benefits for Service members.
2.4.2.7.1 Requests
for benefits under the comparable to ECHO will come from the Service member’s
PCM or specialty provider with documentation of the category description
(II/III) along with documentation to support that category description.
2.4.2.7.2 Documentation
of a referral to an MEB must be provided.
2.4.2.8 Provision
Of Respite Care
2.4.2.8.1 The eligibility
rules and exclusions contained in
32 CFR 199.5(b)(3) and
(5) do not apply to the provision of respite
benefits for a Service member. See
Appendix A for
definitions, terms, and limitations applicable to the respite care
benefit.
2.4.2.8.2 Seriously
ill or injured Service members shall qualify for respite care benefits
regardless of their enrollment status. Service members in the 50
U.S. and the District of Columbia shall qualify if they are enrolled
in TRICARE Prime, TPR, or not enrolled and receiving services in
accordance with the non-enrolled/non-referred provisions for the
use of SHCP funds. Service members outside the 50 U.S. and the District
of Columbia shall qualify if they are enrolled to
TOP
Prime
(with enrollment to an MTF/eMSM), TOP Prime Remote, or not enrolled
and receiving services in accordance with the non-enrolled/non-referred
provisions for Service member care overseas (see TPM,
Chapter 12, Section 1.1).
Note: Respite
care benefits must be performed by a TRICARE-authorized Home Health
Agency (HHA), regardless of the Service member’s location (see
32 CFR 199.6(b)(4)(xv) for HHA definition).
2.4.2.8.3 There are no
cost-shares or copays for Service member respite benefits when those services
are approved by the Service member’s Direct Care System (DCS) case
manager or other appropriate DCS authority (i.e., SAS, the enrolled
or referring MTF/eMSM, TRICARE Area Office (TAO), or Community Care
Units (CCUs)).
2.4.2.8.4 All SHCP
requirements and provisions of
Chapters 16 and
17 apply to this benefit unless changed or
modified by this paragraph. The appropriate chapter for the status
of the Service member shall apply. Contractors shall follow the
requirements and provisions of these chapters, to include:
• MTF/eMSM or SAS referrals and authorizations;
• Receipt and control of claims;
• Authorization, verification, reimbursement
and payment mechanisms to providers;
• Reimbursement specifying no cost-share,
copay, or deductible to be paid by the Service member or their lawful
spouse; and
• Use of CHAMPUS
Maximum Allowable Charges (CMACs)/Diagnosis Related Groups (DRGs)
when applicable.
2.4.2.8.5 Contractors shall follow the provisions
of the TSM,
Chapter 2, Sections 2.8 and
6.4 regarding the TED SPC for the Service
member respite benefit. Claims should indicate an appropriate procedure
code for respite care (CPT 99600 or HCPCS S9122-S9124) and shall
be reimbursed based upon the allowable charge or the negotiated
rate.
2.4.2.8.6 Respite
care services and requirements are as follows:
2.4.2.8.6.1 Respite
care is authorized for a Service member of the Uniformed Services
on active duty and has a qualifying condition as defined in
Appendix A.
2.4.2.8.6.2 Respite
care is available if a Service member’s plan of care includes frequent interventions
by the primary caregiver(s).
2.4.2.8.6.3 Service
members receiving respite care are eligible to receive a maximum
of 40 respite hours in a calendar week, no more than five days per
calendar week and no more than eight hours per calendar day. No
additional benefit caps apply.
2.4.2.8.6.4 Respite benefits shall be provided
by a TRICARE-authorized HHA and are intended to mirror the benefits
under the TRICARE ECHO Home Health Care (EHHC) program described
in the TPM,
Chapter 9, Section 15.1.
Note: Contractors
are not required to enroll Service members in the ECHO program (or
a comparable program) for this respite benefit.
2.4.2.8.6.5 Authorized respite
care does not cover care for other dependents or others who may reside
in or be visiting the Service member’s residence.
2.4.2.8.6.6 In addition,
consistent with the requirement that respite care services shall
be provided by a TRICARE-authorized HHA, services or items provided
or prescribed by a member of the patient’s family or a person living
in the same household are excluded from respite care benefit coverage.
2.4.2.8.6.7 The contractor
shall follow the reimbursement methodology for the similar respite
care benefit found in the TPM,
Chapter 9,
as modified by Service member SHCP reimbursement methodology contained
in
Chapters 16 and
17 (for Service
members located in the 50 U.S. and the District of Columbia) or
TOP reimbursement methodology contained in the TPM,
Chapter 12 (for Service members located outside
the 50 U.S. and the District of Columbia).
2.4.2.8.7 Should
other services or supplies not outlined above, or those otherwise
available under the TRICARE program, be considered necessary for
the care or treatment of a Service member, a request shall be submitted
to the SAS, MTF/eMSM, or TAO for authorization of payment. When preauthorization
is possible it shall be done.
2.4.2.9 Customized
Hand Crank Bikes
2.4.2.9.1 There is a cap
of $5,500.
2.4.2.9.2 Bike must be
custom fitted for the Service member’s unique injury.
2.4.2.9.3 Must be preauthorized
and evidence of a Category II/III illness or injury must accompany
the request. No request should be for more than the $5,500 cap.
2.4.2.10 Custodial Care
2.4.2.10.1 Limited
to 30 days if Service member has not been referred to an MEB.
2.4.2.10.2 At the MTF/eMSM
case manager’s request, the appropriate regional Medical Director, Clinical
Operations Division (COD), TRICARE Health Plans may extend an additional
30 days if Service member is due to return to duty at the end of
the additional 30 days.
2.4.2.10.3 Any
additional extensions must be with a waiver from the Director, DHA
for those Service members that have not been referred to a MEB.
2.4.2.10.4 For Service
members who have been referred to an MEB, authorization is valid
until Service member retires, separates, or returns to duty. No
waiver is required.
2.4.2.10.5 May
be provided in the home or authorized provider/facility. Use of
an unauthorized provider/facility would require a waiver.
2.4.2.10.6 Custodial
care services may be provided up to 24/7. The health care team will periodically
review Service member’s care plan to revise amount of custodial
care required.
2.4.2.10.7 The Service
member’s health care team will determine the requirements of the
Service member for Custodial Care, including the number of hours
and duration of the service and will adjust these requirements accordingly
as the Service member’s requirements change.
2.4.2.10.8 As required the contractors shall
collaborate with DoD and DVA/VHA case managers along with the Service
member’s health care team to ensure continuity of care and transition
to DVA/VHA care and management upon retirement or separation.
2.4.2.10.9 Care must be
preauthorized with documentation of Category II/III illness or injury
and other inclusion criteria in this section accompanying the request.
2.4.2.11 Cryopreservation And Reproductive Services
2.4.2.11.1 Policy Guidelines
For Cyropreservation Of Sperm/Oocytes/Embryos For Service Members
With A Diagnosis Of Cancer
2.4.2.11.1.1 Service member
must be either Category II or III as a result of their cancer at
the time of retrieval. The Service member must be scheduled to undergo
a gonadotoxic treatment for their cancer.
2.4.2.11.1.1.1 For
females cyropreservation of eggs at age 49 or under at the time
of retrieval.
2.4.2.11.1.1.2 For males cyropreservation
of sperm at 61 or under at time of retrieval.
2.4.2.11.1.2 Are
on a period of active duty greater than 30 days and are scheduled
to remain on active duty for the duration of the retrieval and freezing
process.
2.4.2.11.1.3 Have capacity
to provide informed consent (i.e., third party consent is not authorized).
Note: Prior surgical
sterilization does not disqualify a Service member from participating.
2.4.2.11.1.4 Mature Oocyte
Retrieval
2.4.2.11.1.4.1 Referral by
PCM (or referral by primary care provider for TPR enrollees) or
specialist involved in a Service member’s cancer care is required
for each cycle. No more than three completed retrieval cycles are
covered. Services and supplies covered for mature oocyte retrieval
include the following.
2.4.2.11.1.4.1.1 Consultation
and subsequent office visits as indicated.
2.4.2.11.1.4.1.2 Laboratory
tests and ultrasound imaging as indicated.
2.4.2.11.1.4.1.3 Provider-administered
medications as indicated for oocyte retrieval.
2.4.2.11.1.4.1.4 Self-administered
medications as indicated for oocyte retrieval are covered under
Chapter 23.
2.4.2.11.1.4.1.5 Surgical
retrieval and anesthesia.
2.4.2.11.1.4.1.6 Medically necessary
services and supplies associated with complications.
2.4.2.11.1.4.2 The
benefit is limited to the retrieval of 20 oocytes or three completed
cycles, whichever occurs first. There may be a total of four attempts
to accomplish three completed cycles.
2.4.2.11.1.4.3 Additional retrieval beyond one
cycle shall be authorized by the contractor only if the cumulative
number of oocytes retrieved of all previous cycles is less than
20. For instance, if 12 oocytes are retrieved in the first cycle,
the contractor may approve a second cycle. If 11 more oocytes are
retrieved in the second cycle, the contractor shall not approve
a third cycle.
2.4.2.11.1.5 Sperm Collection
And Retrieval
2.4.2.11.1.5.1 Referral by
PCM (or referral by primary care provider for TPR enrollees) or
specialist involved in a Service member’s cancer care is required.
If indicated, invasive procedures for sperm retrieval beyond simple
collection of semen (or urine for retrograde ejaculation) must be
specified in the referral. Services and supplies covered for sperm
collection and retrieval includes the following.
2.4.2.11.1.5.1.1 Consultation
and subsequent office visits as indicated.
2.4.2.11.1.5.1.2 Laboratory
tests as indicated including semen analysis.
2.4.2.11.1.5.1.3 Provider-administered
medications as indicated for sperm retrieval.
2.4.2.11.1.5.1.4 Self-administered
medications indicated for sperm retrieval are covered under
Chapter 23.
2.4.2.11.1.5.1.5 Invasive
procedures for sperm retrieval (e.g., electro-ejaculation, epididymal aspiration)
likely to produce viable sperm.
2.4.2.11.1.5.1.6 Medically
necessary services and supplies associated with complications.
2.4.2.11.1.5.2 The
benefit is limited to either two simple specimen collections or
one invasive procedure for sperm retrieval.
2.4.2.11.1.6 Cryopreservation
2.4.2.11.1.6.1 Services
and supplies associated with cryopreservation of all mature oocytes
and sperm retrieved, and embryos.
2.4.2.11.1.6.2 Storage Of
Retrieved/Collected Oocyte/Sperm And Embryos
2.4.2.11.1.6.2.1 Storage
is covered for 36 months from date of first retrieval of all mature
oocytes and sperm. The cost of storage is incurred on the first
day of the initial period of storage and the first day of any subsequent
year of storage.
2.4.2.11.1.6.2.2 The Service
member is responsible for all costs incurred after 36 months or
when the Service member separates/retires (whichever comes first).
Arrangements for disposition are the responsibility of Service members
subject to state regulation on disposal and abandonment of frozen specimens.
2.4.2.11.1.6.2.3 The contractor shall ensure that
oocytes, sperm, and embryos shall be stored at facilities listed
and registered in accordance with 21 CFR 1271.
2.4.2.11.1.6.3 Ownership
And Disposition
Issues regarding ownership, future
use, donation, and/or destruction shall be governed by applicable
state law and shall be the responsibility of the Service member
and their lawful spouse and the facility storing the cryopreserved
oocytes/sperm/embryos. DoD’s role is limited to paying for this
benefit when requested by the consenting Service member. DoD will
not have ownership or custody of cryopreserved oocytes/sperm/embryos.
DoD will not be involved in the ultimate disposition of excess cryopreserved
oocytes/sperm/embryos. Ultimate disposition or destruction of excess
cryopreserved oocytes/sperm/embryos is not separately reimbursed.
2.4.2.11.2 Policy Guidelines
For Assisted Reproductive Technology (ART)
2.4.2.11.2.1 The policy provides for the provision
of ART which includes embryo cryopreservation and storage, to assist
in the reduction of the disabling effects of the Service member’s
qualifying condition. The authority for this policy for care outside
of the basic medical benefit is derived from Section 1633 of the
2008 National Defense Authorization Act (NDAA). This section allows
the Service member to receive services that are outside the definition
of “medical care.” This benefit is provided through the authorization
of the expenditure of SHCP funds and delivery of the needed services
in either MTFs/eMSMs that offer assisted reproductive technologies
or in the purchased care sector that are outside the medical benefit.
Although purchased care is available for this benefit depending
on the Service member’s circumstances not allowing him or her to
travel, the use of MTFs/eMSMs shall be encouraged, with Service
members eligible for this benefit given priority for care at MTFs/eMSMs
if there is a waiting list. If the Service member receives care
or medications in the civilian sector, participating network providers
shall be used if available. Preauthorization for every IVF cycle
is required.
2.4.2.11.2.2 Assisted reproductive
services, including sperm retrieval, oocyte retrieval, IVF, artificial insemination,
and blastocyst implantation is offered based on the condition of
the seriously or severely ill/injured Service member not the spouse;
therefore, the use of the SHCP is authorized.
2.4.2.11.2.3 The
benefit is limited to permitting a qualified Service member to procreate
with their lawful spouse, as defined in federal statute and regulation.
2.4.2.11.2.4 Consent
must be able to be given by the Service member and his or her lawful
spouse. Third party consent is not authorized under this policy.
2.4.2.11.2.5 Third
party donations and surrogacy are not covered benefits. The benefit
is designed to allow the Service member and their spouse to become
biological parents through reproductive technologies.
2.4.2.11.3 Cancer
2.4.2.11.3.1 The policy applies to Service members,
regardless of gender, who are seriously or severely ill (Category
II, III) as a result of their cancer and will or have undergone
cancer therapy that may have effected their fertility. The Service
member will use their cryopreserved sperm/oocytes or embryos for
the ART services such as IVF.
2.4.2.11.3.2 The ART
benefit will be available for 36 months from the date of sperm or
oocyte retrieval.
2.4.2.11.3.3 If the
Service member proceeds with embryo cryopreservation and storage
during this 36 month period, these services will be covered only
during the 36 month period.
2.4.2.11.4 Transportation, shipping and handling
costs of oncocryopreserved sperm and oocytes shall be covered when:
2.4.2.11.4.1 Relocating
the specimen from a local cryobank to a local fertility clinic;
or
2.4.2.11.4.2 Relocating the
specimen from a cryobank to a distant fertility clinic closer to
where the Service member currently resides.
2.4.2.11.5 Urogenital
Trauma
2.4.2.11.5.1 The policy applies
to Service members, regardless of gender, who have sustained a serious
or severe illness/injury while on active duty that led to the loss
of their natural procreative ability. It is the intent of this policy
to provide ART services, including embryo cryopreservation and storage
without limitation while on active duty, only to consenting male
Service members whose illness or injury to their urogenital system
prevents the successful delivery of their sperm to their spouse’s
egg and to consenting female Service members whose illness or injury
to their urogenital system prevents their egg from being successfully
fertilized by their spouse’s sperm, but who maintain ovarian function
and have a patent uterine cavity. This includes, but is not limited
to, those suffering neurological, physiological, and/or anatomical
injuries.
2.4.2.11.5.2 Male Service
members must be able to produce sperm, but need alternative sperm collection
technologies as they can no longer ejaculate in a way that allows
for egg fertilization. Ill/injured female Service members require
ovarian function and a patent uterine cavity that would allow them
to successfully carry a fetus even if unable to conceive naturally
(e.g., thorough damage to their fallopian tubes).
2.4.2.11.5.3 Embryo cryopreservation and storage
will be covered as long as the Service member remains on active
duty.
2.4.2.11.5.4 The Service
member is responsible for all storage costs when the Service member separates/retires.
Arrangements for disposition are the responsibility of Service members
subject to state regulation on disposal and abandonment of frozen
specimens.
2.4.2.11.6 Procedures
2.4.2.11.6.1 Prediction of fertility potential
(Ovarian Reserve) shall be conducted in accordance with the provider
clinic’s practice guidelines. (This may include a Clomiphene Citrate
Challenge Test (CCCT) and evaluation of the uterine cavity.) Beneficiaries
with a likelihood of success, based on the specific clinic’s guidelines,
shall be provided IVF cycles under this benefit. Infertility testing
and treatment, including correction of the physical cause of infertility,
are covered in accordance with the TPM,
Chapter 4, Section 17.1.
2.4.2.11.6.2 Three
completed IVF cycles shall be provided for the seriously or severely
ill/injured female Service member or lawful spouse of the seriously
or severely ill/injured male Service member. No more than six IVF
cycles shall be initiated for the seriously or severely ill/injured
female Service member or legal spouse of the seriously or severely
ill/injured male Service member. There may be a total of six attempts
to accomplish three completed IVF cycles. If the ill/ injured Service
member has used initiated IVF cycles, subsequently remarries and
desires this benefit with the new spouse, the number of cycles available
is dependent on prior cycles used.
2.4.2.11.6.3 Assisted reproductive service centers
with capability to provide full services including alternative methods
of sperm aspiration will be invited to participate and accept payment
at the network discount rate. (Membership in the American Society
for Reproductive Medicine (ASRM), with associated certification(s),
is highly recommended for network providers. Reporting outcomes
to the Centers for Disease Control and Prevention (CDC) is mandatory.)
When a network provider is not available, the benefits provided
under this policy may be provided by any TRICARE-authorized provider,
including those authorized pursuant to
32 CFR 199.6(e).
2.4.2.11.6.4 IVF cycles
shall be accomplished in accordance with the practice guideline
for the provider clinic using gonadotropins which are concentrated
mixtures of Follicle Stimulating Hormone (FSH) or FSH and Luteinizing
Hormone (LH) given as an injection to stimulate the ovary to produce multiple
oocytes in preparation for egg retrieval. These medications shall
be purchased through the TPharm contract (to include home delivery,
non-network retail pharmacy, and network retail pharmacy options)
or MTF/eMSM.
2.4.2.11.6.5 Anesthesia
or conscious sedation will be provided for the oocyte retrieval
and sperm aspiration in accordance with the TPM,
Chapter 3, Section 1.1 and
1.2. For males, sperm aspiration through Microsurgical
Epididymal Sperm Aspiration (MESA), Percutaneous Epididymal Sperm Aspiration
(PESA), or non-surgical fine needle aspiration will be accomplished
in conjunction with egg retrieval. Vibratory stimulation or electro-ejaculation
may be used if appropriate for the seriously or severely ill/injured
Service member.
2.4.2.11.6.6 Intracytoplasmic
sperm injection will be accomplished for all viable oocytes.
2.4.2.11.6.7 Embryo
transfer in accordance with guidelines provided by the ASRM shall
be accomplished in accordance with specific clinic practices at
either cleavage stage or blastocyst stage of the embryo.
2.4.2.11.6.8 Healthy embryos
that progress to an appropriate stage, as assessed by the embryologist,
in excess of those used for the fresh embryo transfer may be cryopreserved.
2.4.2.11.6.9 In the
event that frozen embryos are available for transfer, TRICARE will
authorize frozen embryo transfer cycles to facilitate the utilization
of these embryos. Frozen embryo transfers may be accomplished in
fresh ovulatory cycles or in medicated transfer cycles in order
to provide the optimal uterine environment for embryo implantation.
2.4.2.11.7 Process For Participating In Assisted
Reproductive Services Program
2.4.2.11.7.1 For
a Service member to be eligible, there must be documentation of
Category II or III illness or injury designation as defined in DoDI
1300.24.
2.4.2.11.7.2 The referral
to the contractor will contain the following information:
• Service member’s qualifying diagnosis(es);
• Category (II
or III);
• Summary of relevant
medical information supporting category designation;
• Name of provider
of reproductive services requested to be used;
• Number of initiated
IVF cycles; and
• Number of cancelled
IVF cycles.
2.4.2.11.7.3 All TED records for this benefit
shall include Enrollment/Health Plan Code “
SR SHCP
- Referred Care” regardless of the enrollment status returned by
DEERS. The contractor shall follow all applicable TED coding requirements
in accordance with TSM,
Chapter 2.
2.4.2.11.7.4 All SHCP
requirements and provisions of
Chapters 16 and
17 apply to this benefit unless changed or
modified by this paragraph. The appropriate chapter for the status
of the Service member shall apply. Contractors shall follow the
requirements and provisions of these chapters, to include MTF/eMSM
or SAS referrals and authorizations, receipt and control of claims,
authorization verification, reimbursement and payment mechanisms
to providers, reimbursement specifying no cost-share, copay, or
deductible to be paid by the Service member or their lawful spouse,
and use of CMACs/DRGs when applicable.
2.4.2.11.8 Exclusions
2.4.2.11.8.1 Third
party donations or surrogacy cannot be cost-shared.
2.4.2.11.8.2 Cryopreservation
of gametes in anticipation of deployment.
2.4.2.11.8.3 Services related to gender selection
will NOT be cost-shared.
2.4.2.12 Incontinence
Supplies
Personal incontinence supplies (i.e., diapers)
that support skin integrity and prevent deterioration of skin due
to incontinence are covered. Also covered are other types of incontinence supplies
such as diaper creams, bed pads, etc. that are necessary for skin
protection.