2.0 Description
2.1 DE, which does not otherwise qualify for
coverage under the TRICARE Basic Program (
Chapter 8, Section 2.1) but has been certified
by an authorized TRICARE individual professional provider, as essential
to the efficient arrest or reduction of functional loss resulting
from the disabling effects of a qualifying condition of an eligible
beneficiary, may be provided under the ECHO under
32 CFR 199.5.
2.2 AT devices are defined in
32 CFR 199.2(b) as equipment that generally
does not treat an underlying injury, illness, disease or their symptoms.
AT devices are authorized only under the ECHO. AT devices help an
ECHO beneficiary overcome or remove a disability and are used to
increase, maintain, or improve the functional capabilities of an
individual. AT devices may include non-medical devices, but do not
include any structural alterations (e.g., permanent structure of
wheelchair ramps or alterations to street curbs), service animals
(e.g., Seeing Eye dogs, hearing/handicapped assistance animals,
etc.), or specialized equipment and devices whose primary purpose
is to enable the individual to engage in sports or recreational
events. AT devices are authorized only under coverage criteria determined
by the Director, Defense Health Agency (DHA) (formerly TRICARE Management
Activity (TMA)) to assist in the reduction of the disabling effects
of a qualifying condition for individuals eligible to receive benefits
under the ECHO program, as provided in
32 CFR 199.5.
3.0 Policy
3.1 A DE or AT device shall only be
covered under ECHO if it is not otherwise covered by TRICARE as DE,
a prosthetic, augmentation communication device, or other benefits
under the Basic Program.
3.2 DE
and AT devices may be cost-shared and provided in the beneficiary’s
home or another environment, as appropriate.
3.3 AT devices may include an educational
learning device and may be cost-shared when:
3.3.1 A TRICARE authorized provider has certified
that an AT device is necessary to assist in the reduction of the
disabling effects of a qualifying condition.
3.3.2 It is recommended in the beneficiary’s
Individual Educational Program (IEP) and is not otherwise provided
by State or local government programs; or
3.3.3 The beneficiary is not eligible
for an IEP, in this case, the AT device;
3.3.3.1 Shall
be authorized as if directly related to the beneficiary’s qualifying
condition;
3.3.3.2 Must
be an educational learning device normally included in an IEP; and
3.3.3.3 Must be 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.
3.4 Benefits allowed for AT electronic
learning devices include the hardware and software as appropriate.
The Director, DHA, or designee, shall determine the types and (or)
platforms of electronic devices.
3.5 Training. When training is required to
allow the use of an AT device, see
Section 8.1.
3.6 Equipment Adaptation. ECHO-authorized
equipment and an AT device purchase shall include such services
and modifications to the equipment that is essential to make the
equipment usable for a particular ECHO beneficiary.
3.7 Equipment Maintenance and Repairs.
Reasonable repairs and maintenance on the beneficiary owned AT device
or DE shall be cost-share while the beneficiary is registered in
the ECHO Program.
3.8 Upgrades and Replacement.
3.8.1 The Director, DHA, or designee,
shall determine replacement lifecycles of the hardware (and its
supporting software).
3.8.2 All upgrades or replacements shall
require a recommendation from the individual’s IEP or the individual’s
comprehensive health care services plan.
3.8.3 A beneficiary owned AT device damaged through
improper use of the device may not be replaced until the device
would next be eligible for a lifecycle replacement.
3.8.4 Benefits are
allowed for replacement of a beneficiary-owned AT device or DE with documentation
that the AT device or DE is lost or stolen and not otherwise covered
by another insurance (such as a homeowner’s policy). A new order
or prescription by a TRICARE authorized provider is required to
reaffirm that the AT device or DE is necessary to assist in the
reduction of the disabling effects of a qualifying condition.
3.9 Cost-share and Allowable Amount:
3.9.1 The TRICARE allowable amount for
AT devices or DE shall be calculated in the same manner as Durable
Medical Equipment (DME) allowable as addressed in
32 CFR 199.4, and accrues to the fiscal year
benefits limit specified in
Section 16.1.
3.9.2 A sponsor/beneficiary cost-share, as described
in
Section 16.1, is required in the month in which
the item is purchased.
3.9.3 A
sponsor/beneficiary is not required to pay more than one cost-share,
regardless of the number of benefits the sponsor’s dependents receive
under the ECHO Program.
4.0 Exceptions
4.1 A second platform may be obtained
if the beneficiary’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 shall submit a request with
the above justification to the Director, DHA, or designee, who may
authorize a second device.
4.2 When one or more electronic platform, 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 policy to allow the beneficiary to choose only one electronic
platform.
5.0 Exclusions
5.1 Purchase or rental of AT devices and DE
is excluded when:
5.1.1 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
5.1.2 The item is available from a local Uniformed
Service Medical Treatment Facility (USMTF); or
5.1.3 The item has deluxe, luxury, immaterial
or nonessential features that increase the cost relative to a similar
item without those features; or
5.1.4 The item is duplicate equipment, as defined
in
32 CFR 199.2.
However, this does not preclude the purchase of a replacement for
an item that is no longer usable; or
5.1.5 The hardware platform is a duplicate or
redundant, except as provided in
paragraphs 4.1 and
4.2;
or
5.1.6 The item is
not necessary to operate the system and is unrelated to the system
or software components (e.g., printer or wireless Internet access
devices); or
5.1.7 The
rental equipment is damaged while using the item in a manner inconsistent
with its common use or has been lost or stolen. See
paragraph 3.8.4 for
beneficiary owned equipment; or
5.1.8 The item (or a 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, spas, whirlpools, hot
tubs, swimming pools, or electronic devices used to locate or monitor
the location of a beneficiary or other similar charges, or item
charges.
5.2 Service
animals (e.g., Seeing Eye dogs, hearing and handicapped assistance
animals, etc.) are excluded.
5.3 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 is excluded.
5.4 Repairs
and maintenance of deluxe, luxury, or immaterial features of AT
device or DE.
5.5 Maintenance
agreements for beneficiary-owned or rented equipment or AT devices
are excluded.
5.6 DE
that is available under the TRICARE Basic Program and an AT device
that is also available under the TRICARE Basic Program as DE, a
prosthetic, augmentation communication device, or other benefit
are excluded.