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TRICARE Policy Manual 6010.60-M, April 1, 2015
Extended Care Health Option (ECHO)
Chapter 9
Section 1.1
General
Issue Date:  July 3, 1997
Authority:  32 CFR 199.5, 10 USC 1079(g)
Revision:  C-27, July 26, 2018
1.0  DESCRIPTION
The Extended Care Health Option (ECHO) is a supplemental program to the TRICARE Basic Program and provides eligible Active Duty Family Members (ADFMs) with an additional financial resource for an integrated set of services and supplies designed to assist in the reduction of the disabling effects of the beneficiary’s qualifying condition (see Sections 2.1 through 2.4). The ECHO is not an enrollment program but does require registration (see Section 3.1).
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.
4.0  EFFECTIVE DATE
September 1, 2005.
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