(a) General.
(1) The
TRICARE ECHO is essentially a supplemental program to the TRICARE
Basic Program. It does not provide acute care nor benefits available
through the TRICARE Basic Program.
(2) The
purpose of the ECHO is to provide an additional financial resource
for an integrated set of services and supplies designed to assist
in the reduction of the disabling effects of the ECHO-eligible dependent’s
qualifying condition. Services include those necessary to maintain,
minimize or prevent deterioration of function of an ECHO-eligible
dependent.
(3) The Government’s
cost-share for ECHO or ECHO home health benefits during any program
year is limited as stated in this section. In order to transition
the program year from a fiscal year to a calendar year basis, the Government’s
annual cost-share limitation specified in paragraph (f) of this
section shall be prorated for the last quarter of calendar year
2018 as authorized by 10 U.S.C. 1079(f)(2)(A).
(b)
Eligibility.
(1)
The
following categories of TRICARE/CHAMPUS beneficiaries with a qualifying
condition are ECHO-eligible dependents:
(i) A spouse, child,
or unmarried person (as described in Sec. 199.3(b)(2)(i), (b)(2)(ii),
or (b)(2)(iv)) of a member of the Uniformed Services on active duty
for a period of more than 30 days.
(ii) An abused dependent
as described in Sec. 199.3(b)(2)(iii).
(iii) A spouse, child,
or unmarried person (as described in Sec. 199.3(b)(2)(i), (b)(2)(ii),
or (b)(2)(iv)), of a member of the Uniformed Services who dies while
on active duty for a period of more than 30 days and whose death
occurs on or after October 7, 2001. In such case, an eligible surviving
spouse remains eligible for benefits under the ECHO for a period
of 3 years from the date the active duty sponsor dies. Any other
eligible surviving dependent remains eligible for benefits under
the ECHO for a period of three years from the date the active duty
sponsor dies or until the surviving eligible dependent:
(A) Attains 21 years
of age, or
(B) Attains
23 years of age or ceases to pursue a full-time course of study
prior to attaining 23 years of age, if, at 21 years of age, the
eligible surviving dependent is enrolled in a full-time course of
study in a secondary school or in a full-time course of study in
an institution of higher education approved by Secretary of Defense
and was, at the time of the sponsor’s death, in fact dependent on
the member for over one-half of such dependent’s support.
(iv) A spouse, child,
or unmarried person (as defined in paragraphs Sec. 199.3(b)(2)(i),
(b)(2)(ii), or (b)(2)(iv)) of a deceased member of the Uniformed
Services who, at the time of the member’s death was receiving benefits
under ECHO, and the member at the time of death was eligible for
receipt of hostile-fire pay, or died as a result of a disease or
injury incurred while eligible for such pay. In such a case, the
surviving dependent remains eligible for benefits under ECHO through
midnight of the dependent’s twenty-first birthday.
(2) Qualifying
condition.
The following are qualifying
conditions:
(i) Mental retardation.
A diagnosis of moderate or
severe mental retardation made in accordance with the criteria of
the current edition of the “Diagnostic and Statistical Manual of
Mental Disorders” published by the American Psychiatric Association.
(ii) Serious
physical disability.
A serious physical disability
as defined in Sec. 199.2.
(iii) Extraordinary
physical or psychological condition.
An extraordinary
physical or psychological condition as defined in Sec. 199.2.
(iv) Infant/toddler.
Beneficiaries under the age
of 3 years who are diagnosed with a neuromuscular developmental
condition or other condition that is expected to precede a diagnosis
of moderate or severe mental retardation or a serious physical disability,
shall be deemed to have a qualifying condition for the ECHO. The Director,
TRICARE Management Activity or designee shall establish criteria
for ECHO eligibility in lieu of the requirements of paragraphs (b)(2)(i),
(ii) or (iii) of this section.
(v) Multiple
disabilities.
The cumulative effect of multiple
disabilities, as determined by the Director, TRICARE Management
Activity or designee shall be used in lieu of the requirements of
paragraphs (b)(2)(i), (ii) or (iii) of this section to determine
a qualifying condition when the beneficiary has two or more disabilities
involving separate body systems.
(3) Loss
of ECHO eligibility.
Eligibility for ECHO benefits
ceases as of 12:01 a.m. of the day following the day that:
(i) The sponsor ceases
to be an active duty member for any reason other than death; or
(ii) Eligibility based
upon the abused dependent provisions of paragraph (b)(1)(ii) of
this section expires; or
(iii) Eligibility
based upon the deceased sponsor provisions of paragraphs (b)(1)(iii)
or (iv) of this section expires; or
(iv) Eligibility based
upon a beneficiary’s participation in the Transitional Assistance
Management Program ends; or
(v) The
Director, TRICARE Management Activity or designee determines that
the beneficiary no longer has a qualifying condition.
(c)
ECHO benefit.
Items and services that the
Director, TRICARE Management Activity or designee has determined
are capable of confirming, arresting, or reducing the severity of
the disabling effects of a qualifying condition, includes, but are
not limited to:
(1) Diagnostic
procedures to establish a qualifying condition or to measure the
extent of functional loss resulting from a qualifying condition.
(2)
Medical,
habilitative, rehabilitative services and supplies, durable equipment
and assistive technology (AT) devices that assist in the reduction
of the disabling effects of a qualifying condition. Benefits shall
be provided in the beneficiary’s home or another environment, as
appropriate. An AT device may be covered only if it is recommended
in a beneficiary’s Individual Educational Program (IEP) or, if the
beneficiary is not eligible for an IEP, the AT device is an item
or educational learning device normally included in an IEP and is
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.
(i) An AT device may
be covered under ECHO only if it is not otherwise covered by TRICARE
as durable equipment, a prosthetic, augmentation communication device,
or other benefits under Sec. 199.4.
(ii) An AT device may
include an educational learning device directly related to the beneficiary’s
qualifying condition when recommended by an IEP and not otherwise
provided by State or local government programs. If an individual
is not eligible for an IEP, an educational learning device normally
included in the IEP may be authorized as if directly related to
the beneficiary’s qualifying condition and prescribed by a TRICARE
authorized provider as part of the beneficiary’s individual comprehensive
health care services plan.
(iii) Electronic
learning devices may include the hardware and software as appropriate.
The Director, DHA, shall determine the types and (or) platforms
of electronic devices and the replacement lifecycle of the hardware
and its supporting software. All upgrades or replacements shall
require a recommendation from the individual’s IEP or the individual’s
comprehensive health care services plan.
(iv) Duplicative or
redundant hardware platforms are not authorized.
Note to paragraph (c)(2)(iv): When
one or more electronic platforms 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 provision to allow only one
electronic platform that may be chosen by the beneficiary. Duplicative
or redundant platforms are not allowed; however, a second platform
may be obtained, if the individual’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 may
submit a request with the above justification to the Director, TMA,
who may authorize a second device.
(v) AT devices damaged
through improper use of the device may not be replaced until the
device would next be eligible for a lifecycle replacement.
(vi) AT devices do
not include equipment or devices whose primary purpose is to assist
the individual to engage in sports or recreational activities.
(3) Training
that teaches the use of assistive technology devices or to acquire
skills that are necessary for the management of the qualifying condition.
Such training is also authorized for the beneficiary’s immediate
family. Vocational training, in the beneficiary’s home or a facility
providing such, is also allowed.
(4) Special
education as provided by the Individuals with Disabilities Education
Act and defined at 34 CFR 300.26 and that is specifically designed
to accommodate the disabling effects of the qualifying condition.
(5) Institutional
care within a state, as defined in Sec. 199.2, in private nonprofit,
public, and state institutions and facilities, when the severity
of the qualifying condition requires protective custody or training
in a residential environment. For the purpose of this section protective
custody means residential care that is necessary when the severity
of the qualifying condition is such that the safety and well-being
of the beneficiary or those who come into contact with the beneficiary
may be in jeopardy without such care.
(6) Transportation
of an ECHO beneficiary receiving benefits under paragraph (c)(5),
and a medical attendant when necessary to assure the beneficiary’s
safety, to or from a facility or institution to receive authorized
ECHO services or items.
(7) Respite
care. TRICARE beneficiaries
enrolled in ECHO are eligible for a maximum of 16 hours of respite
care per month. Respite care is defined in Sec. 199.2. Respite care
services will be provided by a TRICARE-authorized HHA and will be
designed to provide health care services for the covered beneficiary.
The benefit will not be cumulative, that is, any respite hours not
used in one month will not be carried over or banked for use on
another occasion.
(i) TRICARE-authorized
home health agencies must provide and bill for all authorized ECHO
respite care services through established TRICARE claims’ mechanisms.
No special billing arrangements will be authorized in conjunction
with coverage that may be provided by Medicaid or other federal,
state, community or private programs.
(ii) For authorized
ECHO respite care, TRICARE will reimburse the allowable charges
or negotiated rates.
(iii) The
Government’s cost-share incurred for these services accrues to the
program year benefit limit of $36,000.
(8) Other services.
(i) Assistive
services.
Services of qualified personal
assistants, such as an interpreter or translator for ECHO beneficiaries
who are deaf or mute and readers for ECHO beneficiaries who are
blind, when such services are necessary in order for the ECHO beneficiary
to receive authorized ECHO benefits.
(ii) Equipment
adaptation.
The allowable equipment and
an AT device purchase shall include such services and modifications
to the equipment as necessary to make the equipment usable for a
particular ECHO beneficiary.
(iii) Equipment
maintenance.
Reasonable repairs and maintenance
of the beneficiary owned or rented DE or AT devices provided by
this section shall be allowed while a beneficiary is registered
in the ECHO Program. Repairs of DE and/or AT devices damaged while
using the item in a manner inconsistent with its common use, and replacement
of lost or stolen rental DE are not authorized coverage as an ECHO
benefit. In addition, repairs and maintenance of deluxe, luxury,
or immaterial features of DE or AT devices are not authorized coverage
as an ECHO benefit.
(d) ECHO
Exclusions--
(1) Basic Program.
Benefits allowed under the
TRICARE Basic Program will not be provided through the ECHO.
(2) Inpatient care.
Inpatient acute care for medical
or surgical treatment of an acute illness, or of an acute exacerbation
of the qualifying condition, is excluded.
(3) Structural
alterations.
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, are excluded.
(4) Homemaker
services.
Services that predominantly
provide assistance with household chores are excluded.
(5) Dental
care or orthodontic treatment.
Both are excluded.
(6) Deluxe
travel or accommodations.
The difference between the
price for travel or accommodations that provide services or features
that exceed the requirements of the beneficiary’s condition and
the price for travel or accommodations without those services or
features is excluded.
(7) Equipment.
Purchase or rental of DE and
AT devices otherwise allowed by this section is excluded when:
(i) The
beneficiary is a patient in an institution or facility that ordinarily
provides the same type of equipment or AT devices to its patients
at no additional charge in the usual course of providing services;
or
(ii) The
item is available to the beneficiary from a Uniformed Services Medical
Treatment Facility; or
(iii) The item has
deluxe, luxury, immaterial or nonessential features that increase
the cost to the Department relative to a similar item without those
features; or
(iv) The
item is a duplicate DE or an AT device, as defined in Sec. 199.2.
(v) The
item (or 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,
spa, whirlpool, hot tub, swimming pool, an electronic device used
to locate or monitor the location of the beneficiary, or other similar
items or charges.
(8) Maintenance
agreements.
Maintenance agreements for
beneficiary owned or rented equipment or AT device are excluded.
(9) No
obligation to pay.
Services or items for which
the beneficiary or sponsor has no legal obligation to pay are excluded.
(10) Public
facility or Federal government.
Services or items paid for,
or eligible for payment, directly or indirectly by a public facility,
as defined in Sec. 199.2, or by the Federal government, other than
the Department of Defense, are excluded for training, rehabilitation,
special education, assistive technology devices, institutional care
in private nonprofit, public, and state institutions and facilities,
and if appropriate, transportation to and from such institutions
and facilities, 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). Rehabilitation and assistive
technology services or supplies may be available under the TRICARE
Basic Program.
(11) Study,
grant, or research programs.
Services and items provided
as a part of a scientific clinical study, grant, or research program
are excluded.
(12) Unproven status.
Drugs, devices, medical treatments,
diagnostic, and therapeutic procedures for which the safety and
efficacy have not been established in accordance with Sec. 199.4
are excluded.
(13) Immediate
family or household.
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,
are excluded.
(14) Court
or agency ordered care.
Services or items ordered by
a court or other government agency, which are not otherwise an allowable
ECHO benefit, are excluded.
(15) Excursions.
Excursions are excluded regardless
of whether or not they are part of a program offered by a TRICARE-authorized
provider. The transportation benefit available under ECHO is specified
elsewhere in this section.
(16) Drugs
and medicines.
Drugs and medicines that do
not meet the requirements of Sec. 199.4 or Sec. 199.21 are excluded.
(17) Therapeutic
absences.
Therapeutic absences from an
inpatient facility or from home for a homebound beneficiary are
excluded.
(18) Custodial
care.
Custodial care, as defined
in Sec. 199.2, is not a stand-alone benefit. Services generally rendered
as custodial care may be provided only as specifically set out in
this section.
(19) Domiciliary
care.
Domiciliary care, as defined
in Sec. 199.2, is excluded.
(20) Respite care.
Respite care for the purpose
of covering primary caregiver (as defined in Sec. 199.2) absences due
to deployment, employment, seeking of employment or to pursue education
is excluded. Authorized respite care covers only the ECHO beneficiary,
not siblings or others who may reside in or be visiting in the beneficiary’s residence.
(e)
ECHO
Home Health Care (EHHC).
The EHHC benefit provides coverage
of home health care services and respite care services specified
in this section.
(1) Home health
care.
Covered ECHO home health care
services are the same as, and provided under the same conditions
as those services described in Sec. 199.4(e)(21)(i), except that
they are not limited to part-time or intermittent services. Custodial
care services, as defined in Sec. 199.2, may be provided to the
extent such services are provided in conjunction with authorized
ECHO home health care services, including the EHHC respite care benefit
specified in this section. Beneficiaries who are authorized EHHC
will receive all home health care services under EHHC and no portion
will be provided under the Basic Program. TRICARE-authorized home
health agencies are not required to use the Outcome and Assessment
Information Set (OASIS) to assess beneficiaries who are authorized
EHHC.
(2) Respite care.
EHHC beneficiaries whose plan
of care includes frequent interventions by the primary caregiver(s)
are eligible for respite care services in lieu of the ECHO general
respite care benefit. For the purpose of this section, the term
“frequent” means “more than two interventions during the eight-hour
period per day that the primary caregiver would normally be sleeping.”
The services performed by the primary caregiver are those that can be
performed safely and effectively by the average non-medical person
without direct supervision of a health care provider after the primary
caregiver has been trained by appropriate medical personnel. EHHC
beneficiaries in this situation are eligible for a maximum of eight
hours per day, 5 days per week, of respite care by a TRICARE-authorized
home health agency. The home health agency will provide the health
care interventions or services for the covered beneficiary so that
the primary caregiver is relieved of the responsibility to provide
such interventions or services for the duration of that period of
respite care. The home health agency will not provide baby-sitting
or child care services for other members of the family. The benefit
is not cumulative, that is, any respite care hours not used in a
given day may not be carried over or banked for use on another occasion.
Additionally, the eight-hour respite care periods will not be provided
consecutively, that is, a respite care period on one calendar day
will not be immediately followed by a respite care period the next
calendar day. The Government’s cost-share incurred for these services
accrue to the maximum yearly ECHO Home Health Care benefit.
(3) EHHC eligibility.
The EHHC is authorized for
beneficiaries who meet all applicable ECHO eligibility requirements
and who:
(i) Physically
reside within the 50 United States, the District of Columbia, Puerto
Rico, the Virgin Islands, or Guam; and
(ii) Are homebound,
as defined in Sec. 199.2; and
(iii) Require medically
necessary skilled services that exceed the level of coverage provided
under the Basic Program’s home health care benefit; and/or
(iv) Require frequent
interventions by the primary caregiver(s) such that respite care
services are necessary to allow primary caregiver(s) the opportunity
to rest; and
(v) Are
case managed to include a reassessment at least every 90 days, and
receive services as outlined in a written plan of care; and
(vi) Receive all home
health care services from a TRICARE-authorized home health agency,
as described in Sec. 199.6(b)(4)(xv), in the beneficiary’s primary
residence.
(4) EHHC
plan of care.
A written plan of care is required
prior to authorizing ECHO home health care. The plan must include
the type, frequency, scope and duration of the care to be provided
and support the professional level of provider. Reimbursement will
not be authorized for a level of provider not identified in the
plan of care.
(5) EHHC exclusions--
(i) General.
ECHO Home Health Care services
and supplies are excluded from those who are being provided continuing
coverage of home health care as participants of the former Individual
Case Management Program for Persons with Extraordinary Conditions
(ICMP-PEC) or previous case management demonstrations.
(ii) Respite
care.
Respite care for the purpose
of covering primary caregiver absences due to deployment, employment,
seeking of employment or to pursue education is excluded. Authorized
respite care covers only the ECHO beneficiary, not siblings or others
who may reside in or be visiting in the beneficiary’s residence.
(f)
Cost-share
liability--
(1) No deductible.
ECHO benefits are not subject
to a deductible amount.
(2) Sponsor
cost-share liability.
(i)
Regardless
of the number of family members receiving ECHO benefits or ECHO Home
Health Care in a given month, the sponsor’s cost-share is according
to the following table:
|
Table 1 -- Monthly Cost-Share
by Member’s Pay Grade
|
|
E-1 through E-5............................................................................................
|
$25
|
|
E-6....................................................................................................................
|
30
|
|
E-7 and O-1...................................................................................................
|
35
|
|
E-8 and O-2...................................................................................................
|
40
|
|
E-9, W-1, W-2 and O-3................................................................................
|
45
|
|
W-3, W-4 and O-4........................................................................................
|
50
|
|
W-5 and O-5..................................................................................................
|
65
|
|
O-6...................................................................................................................
|
75
|
|
O-7...................................................................................................................
|
100
|
|
O-8...................................................................................................................
|
150
|
|
O-9...................................................................................................................
|
200
|
|
O-10.................................................................................................................
|
250
|
(ii) The sponsor’s
cost-share shown in Table 1 in paragraph (f)(2)(i) of this section
will be applied to the first allowed ECHO charges in any given month.
The Government’s share will be paid, up to the maximum amount specified
in paragraph (f)(3) of this section, for allowed charges after the
sponsor’s cost-share has been applied.
(iii) The provisions
of Sec. 199.18(d)(1) and (e)(1) regarding elimination of copayments
for active duty family members enrolled in TRICARE Prime do not
eliminate, reduce, or otherwise affect the sponsor’s cost-share
shown in Table 1 in paragraph (f)(2)(i) of this section.
(iv) The sponsor’s
cost-share shown in Table 1 in paragraph (f)(2)(i) of this section
does not accrue to the Basic Program’s Catastrophic Loss Protection
under 10 U.S.C. 1079(b)(5) as shown at Sec. 199.4(f)(10) and 199.18(f).
(3) Government
cost-share liability--
(i) ECHO.
The total Government share
of the cost of all ECHO benefits, except ECHO Home Health Care (EHHC)
and EHHC respite care, provided in a given program year to a beneficiary,
may not exceed $36,000 after application of the allowable payment
methodology.
(ii) ECHO
home health care.
(A) The
maximum annual program year Government cost-share per EHHC-eligible beneficiary
for ECHO home health care, including EHHC respite care may not exceed
the local wage-adjusted highest Medicare Resource Utilization Group
(RUG-III) category cost for care in a TRICARE-authorized skilled
nursing facility.
(B) When
a beneficiary moves to a different locality within the 50 United
States, the District of Columbia, Puerto Rico, the Virgin Islands,
or Guam, the annual program year cap will be recalculated to reflect
the maximum established under paragraph (f)(3)(ii)(A) of this section
for the beneficiary’s new location and will apply to the EHHC benefit
for the remaining portion of that program year.
(g)
Benefit payment--
(1) Transportation.
The allowable amount for transportation
of an ECHO beneficiary is limited to the actual cost of the standard
published fare plus any standard surcharge made to accommodate any person
with a similar disability or to the actual cost of specialized medical
transportation when non-specialized transport cannot accommodate
the beneficiary’s qualifying condition related needs, or when specialized
transport is more economical than non-specialized transport. When
transport is by private vehicle, the allowable amount is limited
to the Federal government employee mileage reimbursement rate in
effect on the date the transportation is provided.
(2) Equipment.
(i) The TRICARE allowable
amount for DE or AT devices shall be calculated in the same manner
as DME allowable through section 199.4 of this title, and accrues
to the program year benefit limit specified in paragraph (f)(3)
of this section.
(ii) Cost-share.
A cost-share, as provided by
paragraph (f)(2) of this section, is required for each month in
which equipment or an AT device is purchased under this section.
However, in no month shall a sponsor be required to pay more than
one cost-share regardless of the number of benefits the sponsor’s
dependents received under this section.
(3) For-profit
institutional care provider.
Institutional care provided
by a for-profit entry may be allowed only when the care for a specific
ECHO beneficiary:
(i) Is
contracted for by a public facility as a part of a publicly funded
long-term inpatient care program; and
(ii) Is provided based
upon the ECHO beneficiary’s being eligible for the publicly funded
program which has contracted for the care; and
(iii) Is authorized
by the public facility as a part of a publicly funded program; and
(iv) Would cause a
cost-share liability in the absence of TRICARE eligibility; and
(v) Produces an ECHO
beneficiary cost-share liability that does not exceed the maximum
charge by the provider to the public facility for the contracted
level of care.
(4) ECHO
home health care and EHHC respite care.
(i) TRICARE-authorized
home health agencies must provide and bill for all authorized home
health care services through established TRICARE claims’ mechanisms.
No special billing arrangements will be authorized in conjunction
with coverage that may be provided by Medicaid or other federal,
state, community or private programs.
(ii) For authorized
ECHO home health care and respite care, TRICARE will reimburse the
allowable charges or negotiated rates.
(iii) The maximum monthly
Government reimbursement for EHHC, including EHHC respite care,
will be based on the actual number of hours of EHHC services rendered
in the month, but in no case will it exceed one-twelfth of the annual
maximum Government cost-share as determined in this section and
adjusted according to the actual number of days in the month the
services were provided.
(h) Other
Requirements--
(1) Applicable part.
All provisions of this part,
except the provisions of Sec. 199.4 unless otherwise provided by
this section or as directed by the Director, TRICARE Management
Activity or designee, apply to the ECHO.
(2) Registration.
Active duty sponsors must register
potential ECHO-eligible beneficiaries through the Director, TRICARE
Management Activity, or designee prior to receiving ECHO benefits.
The Director, TRICARE Management Activity, or designee will determine
ECHO eligibility and update the Defense Enrollment Eligibility Reporting System
accordingly. Unless waived by the Director, TRICARE Management Activity
or designee, sponsors must provide evidence of enrollment in the
Exceptional Family Member Program provided by their branch of Service
at the time they register their family member(s) for the ECHO.
(3) Benefit
authorization.
All ECHO benefits require authorization
by the Director, TRICARE Management Activity or designee prior to
receipt of such benefits.
(i) Documentation.
The sponsor shall provide such
documentation as the Director, TRICARE Management Activity or designee
requires as a prerequisite to authorizing ECHO benefits. Such documentation
shall describe how the requested benefit will contribute to confirming,
arresting, or reducing the disabling effects of the qualifying condition,
including maintenance of function or prevention of further deterioration
of function, of the beneficiary.
(ii) Format.
An authorization issued by
the Director, TRICARE Management Activity or designee shall specify such
description, dates, amounts, requirements, limitations or information
as necessary for exact identification of approved benefits and efficient
adjudication of resulting claims.
(iii) Valid
period.
An authorization for ECHO benefits
shall be valid until such time as the Director, TRICARE Management
Activity or designee determines that the authorized services are
no longer appropriate or required or the beneficiary is no longer
eligible under paragraph (b) of this section.
(iv) Authorization
waiver.
The Director, TRICARE Management
Activity or designee may waive the requirement for a written authorization
for rendered ECHO benefits that, except for the absence of the written
authorization, would be allowable as an ECHO benefit.
(v) Public facility
use.
(A) An ECHO beneficiary
residing within a state must demonstrate that a public facility
is not available and adequate to meet the needs of their qualifying
condition. Such requirements shall apply to beneficiaries who request
authorization for training, rehabilitation, special education, assistive
technology, and institutional care in private nonprofit, public,
and state institutions and facilities, and if appropriate for beneficiaries receiving
institutional care, transportation to and from such institutions
and facilities. The maximum Government cost-share for services that
require demonstration of public facility non-availability or inadequacy
is limited to $36,000 per program year per beneficiary. State-administered
plans for medical assistance under Title XIX of the Social Security
Act (Medicaid) are not considered available and adequate facilities
for the purpose of this section.
(B) The domicile of
the beneficiary shall be the basis for the determination of public
facility availability when the sponsor and beneficiary are separately
domiciled due to the sponsor’s move to a new permanent duty station
or due to legal custody requirements.
(C) Written certification,
in accordance with information requirements, formats, and procedures
established by the Director, TRICARE Management Activity or designee
that requested ECHO services or items cannot be obtained from public
facilities because the services or items are not available and adequate,
is a prerequisite for ECHO benefit payment for training, rehabilitation,
special education, assistive technology, and institutional care
in private nonprofit, public, and state institutions and facilities,
and if appropriate, transportation to and from such institutions
and facilities.
(1) An administrator
or designee of a public facility may make such certification for
a beneficiary residing within the service area of that public facility.
(2) The Director,
TRICARE Management Activity or designee may determine, on a case-by-case
basis, that apparent public facility availability or adequacy for
a requested type of service or item cannot be substantiated for a
specific beneficiary’s request for ECHO benefits and therefore is
not available.
(i) A case-specific
determination shall be based upon a written statement by the beneficiary
(or sponsor or guardian acting on behalf of the beneficiary) which
details the circumstances wherein a specific individual representing
a specific public facility refused to provide a public facility
use certification, and such other information as the Director, TRICARE
Management Activity or designee determines to be material to the determination.
(ii) A case-specific
determination of public facility availability by the Director, TRICARE
Management Activity or designee is conclusive and is not appealable
under Sec. 199.10.
(4) Repair or maintenance
of DE owned by the beneficiary or an AT device is exempt from the
public facility-use certification requirements.
(5) The requirements
of this paragraph (h)(3)(v)(A) notwithstanding, no public facility
use certification is required for services and items that are provided
under Part C of the Individuals with Disabilities Education Act
in accordance with the Individualized Family Services Plan and that
are otherwise allowable under the ECHO.
(i) Implementing
instructions.
The Director, TRICARE Management
Activity or designee shall issue TRICARE policies, instructions,
procedures, guidelines, standards, and criteria as may be necessary
to implement the intent of this section.
(j) Effective
date.
All changes to this section
are effective as of October 14, 2008, and claims for ECHO benefits provided
on or after that date will be reprocessed retroactively to that
date as necessary.
[62 FR 35093, Jun 30, 1997,
as amended at 62 FR 42904, Aug 11, 1997; 66 FR 9655, Feb 9, 2001;
67 FR 18827, Apr 17, 2002; 69 FR 44947, Jul 28, 2004; 69 FR 51564,
Aug 20, 2004; 71 FR 47092, Aug 16, 2006; 72 FR 2447, Jan 19, 2007;
73 FR 30478, May 28, 2008; 75 FR 47711, Aug 9, 2010; 79 FR 78713,
Dec 31, 2014; 81 FR 27329, May 6, 2016; 82 FR 45447, Sep 29, 2017;
86 FR 36217, Jul 9, 2021]