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, 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
as needed 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 TRICARE
Area Office (TAO) Director may grant otherwise ECHO-eligible beneficiaries
a provisional eligibility status for a period of not more than 90
calendar days during which ECHO benefits will be authorized and
payable. This provisional status is portable across contract geographic
areas of responsibility. 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 calendar 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 The TOP contractor shall advise
the appropriate TAO Director of all ECHO eligibility determinations,
in locations outside the 50 United States (US) and the District
of Columbia.
2.2 The contractor
shall determine whether an ADFM is eligible for the ECHO and 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
shall 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 cannot be appealed.
2.3 The contractor shall, at the
time of of registration, 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.
2.5 The contractor shall notify
the beneficiary when their eligibility ends.
2.6 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 TRICARE 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.