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.