2.0 POLICY
2.1 The ECHO
is available only to eligible ADFMs. Enrollment in
TRICARE Prime or TRICARE Select is required.
2.2 Eligibility and registration
are prerequisites to ECHO benefits being authorized.
2.3 Written authorization for ECHO
benefits is a prerequisite to claim adjudication.
2.4 ECHO-eligible beneficiaries
who are enrolled in TRICARE Prime or TRICARE Select shall
meet all applicable requirements of that program, including those
regarding the assignment and use of a Primary Care Manager (PCM) (TRICARE
Prime only) when services are requested and provided
through the ECHO.
2.5 TRICARE
is primary payer for medical services and items that are provided
under Part C of the Individuals with Disabilities Education Act
(IDEA) in accordance with the Individualized Family Service Plan
and which are otherwise allowable under the TRICARE Basic Program
or the ECHO.
3.0 EXCLUSIONS
3.1 All benefits
available through the TRICARE Basic Program are excluded from the
ECHO.
3.2 Inpatient care for medical
or surgical treatment of an acute illness, or of an acute exacerbation of
the qualifying condition. These services may be cost-shared through
the Basic Program.
3.3 Structural
alterations to living space and permanent fixtures, including alterations
necessary to accommodate installation of equipment or to facilitate
entrance or exit.
3.4 Except
as provided by the ECHO Home Health Care (EHHC) benefit (
Section 15.1) homemaker services that provide
assistance with household chores are excluded.
3.5 Dental care and orthodontic
treatment.
3.6 The price differential between
the price for a type of accommodation which provides services or
features that exceed the requirements of the beneficiary’s condition
for safe transport and the price for a type of accommodation without
those deluxe features. Payment of such price differential is the responsibility
of the beneficiary.
3.7 Durable
equipment is excluded from the ECHO when:
3.7.1 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
3.7.2 The item is available to the
beneficiary from a Uniformed Services Medical Treatment Facility
(USMTF); or
3.7.3 The item has deluxe, luxury,
immaterial or nonessential features that increase the cost to the
Government relative to a similar item without those features; or
3.7.4 The item is duplicate equipment
as defined in
32 CFR 199.2.
3.8 Maintenance agreements for
beneficiary-owned equipment are excluded.
3.9 Services
or items for which the beneficiary or sponsor has no legal obligation
to pay, or for which no charge would be made if the beneficiary
was not eligible for benefits.
3.10 Services
or items paid for, or eligible for payment, directly or indirectly
by a Public Facility, as defined in
32
CFR 199.2, or by the Federal Government, other than the
Department of Defense (DoD), are excluded, except when such services
or items are eligible for payment under a State plan for medical
assistance under Title XIX of the Social Security Act (Medicaid).
3.11 Services and items provided
as a part of a scientific clinical study, grant, or research program.
3.12 Unproven services and items
whose safety and efficacy have not been established as described in
32
CFR 199.4.
3.13 Services
or items provided or prescribed by a member of the beneficiary’s
immediate family, or a person living in the beneficiary’s or sponsor’s
household.
3.14 Services or items ordered by
a court or other Government agency that are not otherwise an allowable
ECHO benefit.
3.15 Additional or special charges
for excursions, except for other otherwise allowable transportation,
even when they are part of a program offered by an approved provider.
3.16 Drugs and medicines which do
not meet the requirements of
32
CFR 199.4.
3.17 Therapeutic
absences from an inpatient facility.
3.18 Custodial
care, as defined in
32 CFR 199.2,
as a stand alone ECHO benefit is excluded. Services provided in
support of activities of daily living may be cost-shared only when
provided through the EHHC benefit (see
Section 15.1).
3.19 Domiciliary care, as defined
in
32 CFR 199.2,
may not be cost-shared through the ECHO.
3.20 Services
for a beneficiary aged 3 to 21 that are written in the beneficiary’s
special education Individualized Educational Program (IEP) and that
are required to be provided without charge by the local public education
facility in accordance with the IDEA.