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TRICARE Policy Manual 6010.60-M, April 1, 2015
Extended Care Health Option (ECHO)
Chapter 9
Section 2.2
Eligibility - Qualifying Condition: Mental Retardation
Issue Date:  July 3, 1997
Authority:  32 CFR 199.5(b)(2)(i), 10 USC 1079(d)(3)
Revision:  
1.0  POLICY
1.1  A diagnosis of moderate or severe mental retardation in accordance with the criteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is an Extended Care Health Option (ECHO) qualifying condition.
1.2  For a beneficiary less than three years of age, the following conditions (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes cited for services provided before the mandated date, as directed by Health and Human Services (HHS), for International Classification of Diseases, 10th Revision (ICD-10) implementation, or ICD-10-CM codes cited for services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation) may be presumed to precede a diagnosis of moderate or severe mental retardation:
•  Rett’s syndrome: ICD-9-CM 330.8 / ICD-10-CM F84.2
•  Down syndrome: ICD-9-CM 758.0 / ICD-10-CM Q90.0-Q90.9
•  Fragile X syndrome: ICD-9-CM 759.83 / ICD-10-CM Q99.2
•  Fetal alcohol syndrome: ICD-9-CM 760.71 / ICD-10-CM Q86.0
1.3  For a beneficiary less than three years of age, a developmental delay qualifies as moderate or severe mental retardation when standardized diagnostic psychometric tests demonstrate developmental delay equivalent to two standard deviations below the mean in adaptive, cognitive, or language function.
2.0  EXCLUSIONS
2.1  Unless the requirements of paragraph 1.3 are met, the spectrum of Attention-Deficit and Disruptive Behavior Disorders are not considered qualifying conditions for the ECHO.
2.2  Learning disorders, individually and collectively, are not qualifying conditions for eligibility under the ECHO.
3.0  EFFECTIVE DATE
September 1, 2005.
- END -

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