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TRICARE Policy Manual 6010.60-M, April 1, 2015
Extended Care Health Option (ECHO)
Chapter 9
Section 10.1
Institutional Care
Issue Date:  July 3, 1997
Authority:  32 CFR 199.5(c)(5)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODE
99199
2.0  POLICY
2.1  Institutional care when the severity of the qualifying condition requires protective custody or training in a residential environment, may be cost-shared subject to all applicable Extended Care Health Option (ECHO) requirements.
2.2  In accordance with Title 10, Section 1079(d)(4), United States Code (USC), institutional care must be provided in private nonprofit, public and state institutions and facilities.
2.3  The requirements of paragraph 2.2 not withstanding, institutional care provided by a for-profit entity may be allowed only when the care for a specific ECHO beneficiary:
2.3.1  Is contracted for by a public facility, as defined in 32 CFR 199.2, as part of a publicly funded long-term inpatient care program; and
2.3.2  Is provided based upon the ECHO beneficiary’s being eligible for the publicly funded program which has contracted for the care; and
2.3.3  Is authorized by the public facility as a part of a publicly funded program; and
2.3.4  Would cause a cost-share liability in the absence of TRICARE eligibility; and
2.3.5  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.
3.0  EXCLUSIONS
3.1  Regardless of the beneficiary’s condition, care within any type of institution for the primary purpose of providing custodial, domiciliary, hospice, or respite care is excluded from the ECHO.
3.2  Institutional care available under the TRICARE Basic Program is not eligible to be cost-shared under the ECHO.
4.0  EFFECTIVE DATE
September 1, 2005.
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