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, United States Code (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
necessary 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
) Executive Director
may grant otherwise ECHO-eligible beneficiaries a provisional eligibility
status for a period of not more than 90 days during which ECHO benefits
will be authorized and payable. This provisional status is portable
across contract regions. 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 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 Executive Director
in order to determine whether or not the requesting beneficiary
is eligible for the ECHO.
2.1.5 In locations
outside the 50 United States (U.S.) and the District of Columbia,
the TOP contractor shall advise the appropriate TAO Executive Director
of all ECHO eligibility determinations.
2.2 Upon determination that an
ADFM is eligible for the ECHO, the contractor will 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
will 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 can not be appealed.
2.3 At the time of registration,
the contractor will also 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. The contractor is responsible
for notifying the beneficiary when their eligibility ends.
2.5 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 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.