[Federal Register: July 28, 2004 (Volume 69, Number 144)]
[Rules and Regulations]
[Page 44942-44952]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr28jy04-10]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
RIN 0720-AA78
TRICARE; Individual Case Management Program; Program for Persons
With Disabilities; Extended Benefits for Disabled Family Members of
Active Duty Service Members; Custodial Care
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: The Department is publishing this final rule to implement
requirements enacted by Congress in section 701(g) of the National
Defense Authorization Act for Fiscal Year 2002 (NDAA-02), which
terminates the Individual Case Management Program. The Department
withdraws its proposed rule published at 66 FR 39699 on August 1, 2001,
regarding the Individual Case Management Program. This rule also
implements section 701(b) of the NDAA-02 which provides additional
benefits for certain eligible active duty dependents by amending the
TRICARE regulations governing the Program for Persons with
Disabilities. The Program for Persons with Disabilities is now called
the Extended Care Health Option. Other administrative amendments are
included to clarify specific policies that relate to the Extended Care
Health Option, custodial care, and to update related definitions.
DATES: Termination of the Individual Case Management Program (Sec.
199.4(i)) became effective December 28, 2001. The remainder of this
rule is effective July 1, 2004.
ADDRESSES: TRICARE Management Activity, Medical Benefits and
Reimbursement Systems, 16401 East Centretech Parkway, Aurora, CO 80011.
FOR FURTHER INFORMATION CONTACT: Michael Kottyan, Medical Benefits and
Reimbursement Systems, TRICARE Management Activity, telephone (303)
676-3520. Questions regarding payment of specific claims should be
addressed to the appropriate TRICARE contractor.
SUPPLEMENTARY INFORMATION:
I. Background
The Individual Case Management Program (ICMP). Under the provisions
of section 704(3) of the NDAA-93 [Pub. L. 102-484], 10 U.S.C.
1079(a)(17) was enacted which allowed the DoD to establish the ICMP,
also known as the Individual Case Management Program for Persons with
Extraordinary Conditions (ICMP-PEC). This allowed a reasonable
deviation from the restrictive statutory coverage of health services
for patients who had exceptionally serious, long-range, costly and
incapacitating conditions. The ICMP was officially implemented in March
1999 as a waiver program that provided coverage for care and services
that were normally restricted from coverage under the Basic Program.
Specifically, when a beneficiary was determined to meet the TRICARE
definition of custodial care, coverage under the Basic Program was
limited to one hour of skilled nursing care per day, twelve physician
visits per year related to the custodial condition, durable medical
equipment and prescription medications. The Department recognized that
the exclusion of coverage when a family member is deemed to be a
custodial care patient is both a financial and emotional burden.
Consequently, the Department used the ICMP/ICMP-PEC authority to cover
medically necessary care and to
[[Page 44943]]
enable TRICARE case managers to maximize available resources for these
beneficiaries.
Repeal of the ICMP. Section 701(g) of the NDAA-02 repealed 10
U.S.C. 1079(a)(17), the statutory authority for the ICMP. However,
section 701(d) allows the Department to continue to provide payment for
home health care or custodial care services not otherwise authorized
under the Basic Program as if the ICMP were still in effect. Payment
may occur when a determination is made that discontinuation of payment
would result in the provision of services inadequate to meet the needs
of the eligible beneficiary and would be unjust to the beneficiary.
Eligible beneficiaries are defined in section 701(d)(3) as covered
beneficiaries who were regarded as custodial care patients under the
ICMP/ICMP-PEC and received medically necessary skilled services for
which the Secretary provided payment before December 28, 2001.
Custodial Care. Section 701(c) of the NDAA-02 provides a statutory
definition of custodial care that is more consistent with other federal
programs. The change also results in the narrowing of the statutory
exclusions of custodial care that has the effect of eliminating current
program restrictions on paying for certain medically necessary care.
Note: The statutory definition of custodial care under section
701(c) began on December 28, 2001, the effective date of the NDAA-
02. Public notice of the substitution of the new statutory
definition of the former custodial care definition in 32 CFR 199.2
was published in the Federal Register at 67 FR 40597 on June 13,
2002.
Program for Persons with Disabilities (PFPWD). This program is now
renamed the Extended Health Care Option (ECHO). The PFPWD was
established by Congress in 1966 and was originally called the Program
for the Handicapped (PFTH). The name was changed to PFPWD in 1997 to
reflect the national shift away from the label of handicapped and in an
effort to be more sensitive to our beneficiaries with special needs.
The program was established to provide financial assistance for active
duty family members who are moderately or severely mentally retarded or
have a serious physical disability. The purpose of the program was to
help defray the cost of services not available either through the Basic
Program or through other public agencies as a result of state residency
requirements. Section 701(b) of the NDAA-02 strikes 10 U.S.C. 1079(d),
(e), and (f), which were the statutory authority for the PFPWD, and re-
authorizes the program with new sub-sections (d), (e), and (f). These
new sub-sections add an extraordinary physical or psychological
condition as a qualifying condition and limits the requirement to use
public facilities to the extent that they are available and adequate to
certain benefits under sub-section (e). They also include discretion to
increase the monthly Government cost-share for allowable services from
a maximum of $1,000 per month and expand the benefit to allow for
coverage of ECHO home health care and services beyond the Basic
program. Section 701(e) also includes the discretion to allow coverage
for custodial care and respite care.
II. The Extended Care Health Option (ECHO)
Purpose. The primary purpose of the ECHO is to provide extended
benefits to eligible beneficiaries that assist in the reduction of the
disabling effects of an ECHO qualifying condition and that are not
available through the Basic Program. Under 10 U.S.C. 1079(e), ECHO
benefits may be provided only to the extent such service, supply or
equipment is not a covered benefit under the Basic Program. This may
include comprehensive health care services, including services
necessary to maintain, minimize or prevent deterioration of, function
of an eligible beneficiary.
Eligibility. Participation in the ECHO is voluntary and is
available only for TRICARE-eligible family members of active duty
service members who have a qualifying condition. Qualifying conditions
are limited under 10 U.S.C. 1079(d)(3)(B) to beneficiaries who have
(a) Moderate or severe mental retardation; or
(b) A serious physical disability, as defined in 32 CFR 199.2; or
(c) An extraordinary physical or psychological condition, as
defined in 32 CFR 199.2.
ECHO Benefits. ECHO benefits established herein include diagnostic
procedures to establish a qualifying condition, inpatient, outpatient,
and comprehensive home health care supplies and services, training,
habilitative or rehabilitative services, special education, assistive
technology devices, institutional care within a State when a
residential environment is required, transportation under certain
circumstances, certain other services such as assistive services of a
qualified interpreter or translator for deaf or blind beneficiaries in
conjunction with receipt of other allowed ECHO benefits, equipment
adaptation and maintenance, and respite care, and ECHO home health
care.
ECHO Respite Care. Under 10 U.S.C. 1079(e)(6), the Department may
provide respite care under the ECHO program. Respite care is defined in
32 CFR 199.2 as short term care for a patient in order to provide rest
and change for those who have been caring for the patient at home,
usually the patient's family. DoD recognizes that caring for a special
needs beneficiary poses special challenges, especially for active duty
families. This rule establishes an ECHO benefit to provide a maximum of
16 hours per month of respite care. The respite care benefit is
available for ECHO beneficiaries in any month during which the
beneficiary receives ECHO benefits other than respite care under the
ECHO Home Health Care benefit. Respite care services will be provided
by a TRICARE-authorized home health agency and will provide health care
services for the covered beneficiary, and not 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 one-month will
not be carried over or banked for a subsequent month(s). The
Government's cost-share incurred for the ECHO respite care services
accrue to the ECHO maximum monthly benefit of $2,500.
Government Cost-share Liability for ECHO. The Government's monthly
cost-share of all benefits provided to a beneficiary in a particular
month under the PFPWD was statutorily limited to $1,000 by 10 U.S.C.
1079(e)(2). The Government's monthly cost-share of any benefits
provided under ECHO is now statutorily limited to $2,500 by section
701(b) of the NDAA-02 (10 U.S.C. 1079(f)(2)(A)) for benefits related to
training, rehabilitation, special education, assistive technology
devices, and institutional care in private, non-profit, public, and
state institutions and facilities, and if appropriate, transportation
to and from such institutions and facilities. Because the NDAA-02
provided no statutory limitation concerning the amount of the
Government's monthly cost-share for all other benefits under ECHO, the
Department has discretion to determine the maximum monthly Government
cost-share. Therefore, this rule increases the monthly Government cost-
share from $1,000 to $2,500 for all benefits under ECHO, except for the
new ECHO Home Health Care (EHHC) benefit as established herein. The
primary reason for this increase is that the maximum government cost-
share has not been adjusted since 1980. We will continue to review this
issue to insure that the
[[Page 44944]]
government's cost-share reasonably meets the needs of beneficiaries.
ECHO Home Health Care (EHHC). Under 10 U.S.C. 1079(e), extended
benefits may be provided to eligible beneficiaries to the extent such
benefits are not provided under provisions of chapter 55, title 10,
United States Code, other than under this section. Under 10 U.S.C.
1079(e)(2), the ECHO may include ``comprehensive home health care
supplies and services which may include cost effective and medically
appropriate services other than part-time or intermittent services
(within the meaning of such terms as used in the second sentence of
section 1861(m) of the Social Security Act).'' Section 701(a) of the
NDAA-02 requires home health care services under the Basic Program be
provided in the manner and under the conditions described in section
1861(m) of the Social Security Act. Therefore, this rule establishes an
ECHO Home Health Care (EHHC) benefit for qualifying beneficiaries.
EHHC Eligibility. To qualify for EHHC, the beneficiary must meet
all general ECHO program eligibility requirements and must
(a) Physically reside within the 50 United States, the District of
Columbia, Puerto Rico, the Virgin Islands, or Guam; and
(b) Be homebound, as defined in Sec. 199.2 and as modified in this
rule; and
(c) Require medically necessary skilled services that exceed the
maximum level of coverage provided under the Basic Program's home
health care benefit, or
(d) Require frequent interventions, other than skilled medical
services, by the primary caregiver(s) (as ``primary caregiver'' is
defined in Sec. 199.2) such that EHHC services are necessary to allow
primary caregiver(s) the opportunity to rest; and
(e) Be case managed (as ``case management'' is defined in Sec.
199.2), including a periodic assessment of needs, and receive services
as outlined in a written plan of care; and
(f) Receive home health care services from a TRICARE-authorized
home health agency as described in Sec. 199.6(b)(4)(xv).
EHHC Benefit. Covered TRICARE-authorized home health agency
services are the same as, and provided under the same conditions as,
those services provided under the TRICARE Basic Program under Sec.
199.4(e)(21), with the exception that the EHHC benefit is not limited
to part-time or intermittent home health care. Therefore, this rule
sets out that TRICARE beneficiaries who are eligible for the ECHO and
require home health care services beyond the coverage limits under the
Basic Program will receive all home health care services under EHHC and
no portion will be provided under the Basic Program.
EHHC Plan of Care. The level of ECHO home health care services
authorized will be based on a written plan of care that supports the
medical necessity of those services in excess of what can be authorized
by the Basic Program, or, in the case of a beneficiary who requires
frequent interventions, the need for EHHC in order to allow the primary
caregiver(s) the opportunity to rest. The plan of care must include
identification of the professional qualifications or skill level of the
person required to provide the care. Reasonable justification for the
medical necessity of the level of provider must be included in the plan
of care, otherwise, reimbursement will not be authorized for that level
of provider.
EHHC Respite Care. This rule establishes respite care within the
EHHC benefit specifically tailored for families with a beneficiary who
has a medical condition(s) that requires frequent interventions by the
primary caregiver. For the purpose of this respite care, the term
``frequent'' means ``more than two interventions during the eight-hour
per day period that the primary caregiver would normally be sleeping.''
The service performed during the interventions may have been taught to
the primary caregiver by a medical professional, but the services
performed by the primary caregiver are such that they can be performed
safely and effectively by the average non-medical person without direct
supervision of a licensed nurse or other health care provider.
Therefore, when an eligible beneficiary's care plan reflects a need for
frequent interventions by the primary caregiver, the beneficiary is
eligible for EHHC respite care services in lieu of the ECHO respite
care benefit. EHHC beneficiaries in this situation are eligible for
eight hours per day for five (5) days per week of respite care by a
TRICARE-authorized home health agency. The home health agency will
provide health care services for the covered beneficiary so that the
primary caregiver is relieved of his/her responsibility for providing
such care for the duration of that period of respite care in order that
the primary caregiver(s) may rest. The TRICARE-authorized 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, respite
care hours not used in a given day will not be carried over or banked
for use on another occasion. Also, EHHC respite care periods will not
be provided consecutively, that is, a respite care period on one day
will not be immediately followed by an EHHC respite care period the
next day, thus prohibiting a continuous sixteen hour period of respite
care. The government's cost-share incurred for these services accrue to
the fiscal year maximum ECHO Home Health Care benefit.
Government Cost-share Liability for EHHC. TRICARE-authorized home
health agencies who provide services under the Basic Program are
reimbursed under Sec. 199.14(h) using the same methods and rates as
used under the Medicare home health agency prospective payment system
under section 1895 of the Social Security Act (42 U.S.C. 1385fff) and
42 CFR part 484, subpart E, except for children under age ten and
except as otherwise necessary to recognize distinct characteristics of
TRICARE beneficiaries and as described in instructions issued by the
Director, TRICARE Management Activity. However, the Medicare home
health agency prospective payment system is designed to reimburse
providers who provide part-time or intermittent services; it is not
designed to reimburse providers for services that exceed those limits.
Therefore, this rule set outs that the Department will reimburse home
health agencies the allowable charges or negotiated rates. The maximum
annual fiscal year cap for EHHC services is what the highest locally
wage-adjusted maximum Medicare Resource Utilization Grouping (RUG-III)
category cost to the Department would be if such services were provided
in a TRICARE-authorized skilled nursing facility. (See Federal Register
67 FR 40597, June 13, 2002, concerning the TRICARE Sub-Acute Care
Program; Uniform Skilled Nursing Facility Benefit; Home Health Care
Benefit; Adopting Medicare Payment Methods for Skilled Nursing
Facilities and Home Health Care Providers). Because the highest RUG-III
category is used to determine the EHHC fiscal year cap, the Department
will not attempt to determine what RUG-III category would apply to the
beneficiary if such beneficiary were in fact admitted for care into a
TRICARE-authorized skilled nursing facility. The fiscal year cap will
be recalculated each year following publication of the ``Medicare
Program; Prospective Payment System and Consolidated Billing for
Skilled Nursing Facilities--Update; Notice'', or similar, by the
Centers for Medicare and Medicaid Services in the Federal Register.
The maximum monthly Government cost-share to be paid to the home
health agency for ECHO home health care will
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be the allowable charges or negotiated rates, but in no case will such
payment exceed one-twelfth of the fiscal year cap calculated as above.
When EHHC beneficiaries move within the 50 United States, the
District of Columbia, Puerto Rico, the Virgin Islands, or Guam, the
annual fiscal year cap will be recalculated as above to reflect the
correct wage-adjusted maximum RUG-III category cost for the
beneficiary's new location and will apply for the remaining portion of
that fiscal year.
EHHC Reimbursement. A TRICARE-authorized home health agency must
bill for all authorized ECHO home health care services through
established TRICARE claims mechanisms. No special billing arrangements
will be authorized in coordination with coverage that may be provided
by Medicaid (subject to any State Agency Billing Agreements), or other
Federal, State, community or private programs.
For authorized ECHO home health care and respite care, TRICARE will
reimburse the allowable charges or negotiated rates.
Beneficiary Cost-share Liability for ECHO, including EHHC. Under 10
U.S.C. 1079(f), members are required to share in the cost of any
benefits provided to their dependents under ECHO. ECHO benefits are not
subject to a deductible amount. Regardless of the number of ECHO
eligible family members, the sponsor's monthly cost-share for allowed
ECHO benefits is based upon the rank of the uniformed service member.
Under 10 U.S.C. 1079(f)(1)(A), members with a rank of E-1 are required
to pay the first $25 incurred per month, and members with a rank of O-
10 are required to pay the first $250 incurred per month. This rules
sets out the cost-share for members with ranks in-between such that the
majority will pay less than $100 per month, with the most senior
enlisted member paying less than $50 per month.
Sponsor rank-based cost-sharing (refer to Table 1, 32 CFR 199.5)
applies to benefits covered by the ECHO and these cost-shares do not
apply toward the Basic Program's catastrophic cap under 10 U.S.C.
1079(b)(5). Also, the waiver of cost-shares for active duty family
members enrolled in TRICARE Prime does not apply to ECHO as the
statutory basis for the ECHO program and its cost-shares is separate
and distinct from the Basic Program, including TRICARE Prime.
Other Requirements. Other ECHO requirements are as follows:
Registration. Sec 701(b) of the NDAA-02 (10 U.S.C. 1079(d)(1))
requires registration to receive ECHO benefits. Sponsors of potentially
qualifying beneficiaries will seek to register their family member(s)
for ECHO benefits through the applicable Managed Care Support
Contractor (MCSC). The MCSC will determine eligibility and update the
Defense Enrollment Eligibility Reporting System (DEERS) to reflect the
beneficiary's ECHO eligibility. No ECHO benefits may be authorized
unless the beneficiary is registered in DEERS as ECHO-eligible.
EFMP Enrollment. Each of the Military Services has its own
Exceptional Family Member Program (EFMP). Although the EFMPs can
interface with the Military Health System, they are actually military
personnel programs. The purpose of those programs is to require
military personnel offices to evaluate the ability of a military and
civilian community to provide appropriate medical and/or educational
services to service members' dependents who have special medical or
educational needs before the Service re-assigns the member to a new
location. Although each Service requires its members who have family
members with special needs to enroll in the EFMP, some members do not
comply with this requirement. The result is that some members arrive at
assignment locations that are unable to accommodate the special medical
and/or educational needs of their dependent(s). Dependents of members
required to be enrolled in EFMP are similar if not identical to those
who qualify for the ECHO program. The Services do not routinely provide
EFMP enrollments to TRICARE, therefore, to provide a greater degree of
coordination of services for TRICARE beneficiaries, this rules sets out
that members will be required to provide evidence they are enrolled in
their Services' Exceptional Family Member Program when registering for
ECHO benefits. This requirement will enhance the probability that
personnel are assigned to locations where there are sufficient
qualified individual or institutional providers to provide the ECHO
benefit to their dependents.
Use of Public Facilities. For ECHO benefits related to training,
rehabilitation, special education, assistive technology devices, and
institutional care in private, non-profit, public, and state
institutions and facilities, and if appropriate, transportation to and
from such institutions and facilitates, the statute expressly requires
use of public facilities to be the extent such facilities are available
and adequate as determined under this regulation.
III. Public Comments
We provided a 60-day public comment period following publication of
the Proposed Rule in the Federal Register at 68 FR 46526 on August 6,
2003. Two individuals provided several comments, summarized below.
Comment: The first commentor questioned the Department's decision
regarding where the ECHO, in particular ECHO Home Health Care and
respite care, will be available.
Response: The ECHO will generally be available wherever there are
TRICARE beneficiaries eligible for the ECHO and appropriate TRICARE-
authorized providers.
The focus of the ECHO Home Health Care benefit is to provide ECHO
beneficiaries with the same benefit structure as provided by the Basic
Program's Home Health Agency Prospective Payment System (HHA-PPS) but
without its limitation that the services be provided on a ``part-time
or intermittent'' basis. In order to assure the quality of care for
TRICARE beneficiaries, the HHA-PPS provides that only Medicare-
authorized Home Health Agencies are eligible for designation as
TRICARE-authorized providers. Likewise, the Department also elected to
utilize those same home health agencies to provide the ECHO respite
care. Consequently, ECHO respite care and the ECHO Home Health Care
benefits are limited to locations where there are Medicare-authorized
home health agencies. Currently that is limited to the 50 United
States, the District of Columbia, Puerto Rico, the Virgin Islands, and
Guam.
Comment: That commentor also remarked about the cost of
transportation to receive ECHO-authorized benefits.
Response: This rule sets out that costs for public and private
transportation necessary to receive authorized ECHO benefits will be
reimbursed subject to the limits herein.
Comment: The second commentor requested the Department provide the
ECHO respite care benefit to multiple TRICARE beneficiaries within
group settings, such as a day care center, and prorate the allowable
cost among those receiving the respite care.
Response: The Department has identified several issues regarding
the comment. First, other than when allowed by specific exceptions to
its policies, TRICARE professional outpatient benefits are provided
one-on-one, that is, one patient with one provider per episode of care.
Consequently, there is no general provision for ``group'' type
episodes-of-care or settings.
[[Page 44946]]
Second, the regulatory language at 32 CFR 199.2 defines respite
care as `` * * * short-term care for a patient in order to provide rest
and change for those who have been caring for the patient at home,
usually the patient's family.'' Although there is no statutory
restriction on where respite care services are provided, it is the
Department's decision that such care be provided in the beneficiary's
primary residence.
Last, as set out in this rule, both the ECHO respite care and the
ECHO Home Health Care respite care benefits will be provided by
TRICARE-authorized home health agencies. These providers will be
reimbursed on the basis of allowable charges or negotiated rates,
neither of which provides pro-rated assignment of TRICARE benefits nor
pro-rated payments based on multiple TRICARE beneficiaries receiving
care in a group setting.
IV. Summary of Regulatory Modifications
The following modifications were made as a result of developing the
implementing instructions:
(1) We clarified that TRICARE reimbursement for ECHO home health
care and respite care will be the allowable charges or negotiated
rates.
V. Regulatory Procedures
Executive Order (EO) 12866
Executive Order 12866 requires that a comprehensive regulatory
impact analysis be performed on any economically significant regulatory
action, defined as one that would result in an annual effect of $100
million or more on the national economy or which would have other
substantial impacts. The Regulatory Flexibility Act (RFA) requires that
each Federal agency prepare, and make available for public comment, a
regulatory flexibility analysis when the agency issues a regulation
which would have a significant impact on a substantial number of small
entities. This rule is not an economically significant regulatory
action and will not have a significant impact on a substantial number
of small entities for purposes of the RFA. This rule, although not
economically significant under Executive Order 12866, is a significant
rule under Executive order 12866 and has been reviewed by the Office of
Management and Budget.
Paperwork Reduction Act
This rule will not impose additional information collection
requirements on the public under the Paperwork Reduction Act of 1995
(44 U.S.C. 3501-3511). Existing DoD information systems to include the
Defense Enrollment Eligibility Reporting System (DEERS) will be
upgraded to reflect ECHO registration.
List of Subjects in 32 CFR part 199
Case management, Claims, Custodial care, Health insurance,
Individuals with disabilities, Military personnel.
0
For the reasons set out in the preamble, the Department of Defense
amends 32 CFR part 199 as follows:
PART 199--[AMENDED]
0
1. The authority citation for part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
0
2. Section 199.2 is amended in paragraph (b) by removing the
definitions of ``Program for Persons with Disabilities (PFPWD)'' and
``Extraordinary condition'', by revising paragraph (v) of the
definition of ``Double coverage plan'', by revising the definitions of
``Durable equipment'', ``Homebound'', and ``Primary caregiver'', and by
adding the definitions of ``Duplicate equipment'', ``Extended Care
Health Option (ECHO)'', and ``Extraordinary physical or psychological
condition'' in alphabetical order to read as follows:
Sec. . 199.2 Definitions.
* * * * *
(b) * * *
Double coverage plan. * * *
(v) Part C of the Individuals with Disabilities Education Act for
services and items provided in accordance with Part C of the IDEA that
are medically or psychologically necessary in accordance with the
Individual Family Service Plan and that are otherwise allowable under
the CHAMPUS Basic Program or the Extended Care Health Option (ECHO).
* * * * *
Duplicate equipment. An item of durable equipment or durable
medical equipment, as defined in this section that serves the same
purpose that is served by an item of durable equipment or durable
medical equipment previously cost-shared by TRICARE. For example,
various models of stationary oxygen concentrators with no essential
functional differences are considered duplicate equipment, whereas
stationary and portable oxygen concentrators are not considered
duplicates of each other because the latter is intended to provide the
user with mobility not afforded by the former. Also, a manual
wheelchair and an electric wheelchair, both of which otherwise meet the
definition of durable equipment or durable medical equipment, would not
be considered duplicates of each other if each is found to provide an
appropriate level of mobility. For the purpose of this part, durable
equipment or durable medical equipment that are essential to provide a
fail-safe in-home life support system or that replaces in like kind an
item of equipment that is not serviceable due to normal wear,
accidental damage, a change in the beneficiary's condition, or has been
declared adulterated by the U.S. FDA, or is being or has been recalled
by the manufacturer, is not considered duplicate equipment.
Durable equipment. A device or apparatus which does not qualify as
durable medical equipment and which is essential to the efficient
arrest or reduction of functional loss resulting from, or the disabling
effects of a qualifying condition as provided in Sec. 199.5.
* * * * *
Extended Care Health Option (ECHO). The TRICARE program of
supplemental benefits for qualifying active duty family members as
described in Sec. 199.5.
* * * * *
Extraordinary physical or psychological condition. A complex
physical or psychological clinical condition of such severity which
results in the beneficiary being homebound as defined in this section.
* * * * *
Homebound A beneficiary's condition is such that there exists a
normal inability to leave home and, consequently, leaving home would
require considerable and taxing effort. Any absence of an individual
from the home attributable to the need to receive health care
treatment, including regular absences for the purpose of participating
in therapeutic, psychosocial, or medical treatment or in an adult day-
care program certified by a state, or accredited to furnish adult day-
care services in the state shall not disqualify an individual from
being considered to be confined to his home. Any other absence of an
individual from the home shall not disqualify an individual if the
absence is infrequent or of relatively short duration. For the purposes
of the preceding sentence, any absence for purpose of attending a
religious service shall be deemed to be an absence of infrequent or
short duration. Also, absences from the home for non-medical purposes,
such as an occasional trip to the barber, a walk around the block or a
drive, would not necessarily negate the beneficiary's homebound status
if the absences are undertaken on an
[[Page 44947]]
infrequent basis and are of relatively short duration. In addition to
the above, absences, whether regular or infrequent, from the
beneficiary's primary residence for the purpose of attending an
educational program in a public or private school that is licensed and/
or certified by a state, shall not negate the beneficiary's homebound
status.
* * * * *
Primary caregiver. An individual who renders to a beneficiary
services to support the activities of daily living (as defined in Sec.
199.2) and specific services essential to the safe management of the
beneficiary's condition.
* * * * *
Sec. 199.3 [Amended]
0
3. Section 199.3 is amended by revising the term ``Program for Persons
with Disabilities'' or the acronym ``PFPWD'' to read ``Extended Care
Health Option'' or the acronym ``ECHO,'' respectively, in paragraphs
(b)(2)(iii)(A)(1), (c)(2)(i)(C), (c)(2)(ii)(B), (c)(2)(iii)(B),
(c)(3)(i)(C), (c)(3)(ii)(B), (c)(4)(i)(B), (c)(4)(ii)(B),
(c)(4)(iii)(B), (c)(5)(i)(C), (c)(5)(ii)(B), (c)(5)(iii)(B),
(c)(5)(iv)(C)(2), (c)(6)(ii), (c)(7)(i)(C), (c)(7)(ii)(B), (c)(8)(ii),
(c)(9)(i)(B), (c)(9)(ii)(B), and (c)(10)(ii) wherever they appear.
0
4. Section 199.4 is amended by removing and reserving paragraph
(e)(20); adding paragraph (g)(59); revising paragraph (g)(73); and
removing paragraph (i) Case management program in its entirety; to read
as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(g) * * *
(59) Duplicate equipment. As defined in Sec. 199.2, duplicate
equipment is excluded.
* * * * *
(73) Economic interest in connection with mental health admissions.
Inpatient mental health services (including both acute care and RTC
services) are excluded for care received when a patient is referred to
a provider of such services by a physician (or other health care
professional with authority to admit) who has an economic interest in
the facility to which the patient is referred, unless a waiver is
granted. Requests for waiver shall be considered under the same
procedure and based on the same criteria as used for obtaining
preadmission authorization (or continued stay authorization for
emergency admissions), with the only additional requirement being that
the economic interest be disclosed as part of the request. The same
reconsideration and appeals procedure that apply to day limit waivers
shall also apply to decisions regarding requested waivers of the
economic interest exclusion. However, a provider may appeal a
reconsidered determination that an economic relationship constitutes an
economic interest within the scope of the exclusion to the same extent
that a provider may appeal determination under Sec. 199.15(i)(3). This
exclusion does not apply to services under the Extended Care Health
Option (ECHO) in Sec. 199.5 or provided as partial hospital care. If a
situation arises where a decision is made to exclude CHAMPUS payment
solely on the basis of the provider's economic interest, the normal
CHAMPUS appeals process will be available.
* * * * *
0
5. Section 199.5 is revised to read as follows:
Sec. 199.5 TRICARE Extended Care Health Option (ECHO).
(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 beneficiary's
qualifying condition. Services include those necessary to maintain,
minimize or prevent deterioration of function of an ECHO-eligible
beneficiary.
(b) Eligibility. (1) The following categories of TRICARE/CHAMPUS
beneficiaries with a qualifying condition are eligible for ECHO
benefits:
(i) A child or spouse (as described in 10 U.S.C. 1072(2)(A), (D),
or (I)) of a member of one of the Uniformed Services; or
(ii) An abused dependent as described in Sec. 199.3(b)(2)(iii); or
(iii) A child or spouse (as described in 10 U.S.C. 1072(2)(A), (D),
or (I)) of a member of one of the Uniformed Services who dies while on
active duty. In such case the child or spouse remain eligible for
benefits under the ECHO for a period of three years from the date the
active duty sponsor dies; or
(iv) A child or spouse (as described in 10 U.S.C. 1072(2)(A), (D),
or (I)) of a deceased member of one 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 case the child or spouse remain eligible
through midnight of the beneficiary'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.
(4) Continuity of eligibility. A TRICARE beneficiary who has an
outstanding Program for Persons with Disabilities (PFPWD) benefit
authorization on the date of
[[Page 44948]]
implementation of the ECHO program shall continue receiving such
services for the duration of that authorization period provided the
beneficiary remains eligible for the PFPWD. Upon termination of an
existing PFPWD authorization, or if the beneficiary seeks benefits
under this section before such termination, the beneficiary shall
establish eligibility for the ECHO in accordance with this section.
(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 durable medical equipment that are related to the
qualifying condition. Benefits may be provided in the beneficiary's
home or other environment as appropriate.
(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, 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. ECHO beneficiaries are eligible for 16 hours of
respite care per month in any month during which the qualified
beneficiary otherwise receives an ECHO benefit(s). Respite care is
defined in Sec. 199.2. Respite care services will be provided by a
TRICARE-authorized home health agency and will be designed to provide
health care services for the covered beneficiary, and not baby-sitting
or child-care services for other members of the family. The benefit
will not be cumulative, that is, any respite care 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
accrue to the maximum monthly benefit of $2,500.
(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 purchase shall
include such services and modifications to the equipment as necessary
to make the equipment useable for a particular ECHO beneficiary.
(iii) Equipment maintenance. Reasonable repairs and maintenance of
beneficiary owned or rented durable equipment or durable medical
equipment provided by this section shall be allowed while a beneficiary
is registered in the ECHO.
(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 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 durable equipment and durable
medical equipment, which are otherwise allowed by this section, are
excluded when:
(i) 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
(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 duplicate equipment as defined in Sec. 199.2.
(8) Maintenance agreements. Maintenance agreements for beneficiary
owned or rented equipment 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.
[[Page 44949]]
(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 herein. 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; 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
Care 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
[[Page 44950]]
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. 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
and EHHC respite care, provided in a given month to a beneficiary may
not exceed $2,500 after application of the allowable payment
methodology.
(ii) ECHO home health care. (A) The maximum annual Government cost-
share 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 fiscal 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 fiscal 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 durable
equipment and durable medical equipment shall be calculated in the same
manner as durable medical equipment allowable through Sec. 199.4.
(ii) Allocating equipment expense. The ECHO beneficiary (or sponsor
or guardian acting on the beneficiary's behalf) may, only at the time
of the request for authorization of equipment, specify how the
allowable cost of the equipment is to be allocated as an ECHO benefit.
The entire allowable cost of the authorized equipment may be allocated
in the month of purchase provided the allowable cost does not exceed
the ECHO maximum monthly benefit of $2,500 or it may be prorated
regardless of the allowable cost. Prorating permits the allowable cost
of ECHO-authorized equipment to be allocated such that the amount
allocated each month does not exceed the maximum monthly benefit.
(A) Maximum period. The maximum number of consecutive months during
which the allowable cost may be prorated is the lesser of:
(1) The number of months calculated by dividing the allowable cost
for the item by 2,500 and then doubling the resulting quotient, rounded
off to the nearest whole number; or
(2) The number of months of expected useful life of the equipment
for the requesting beneficiary, as determined by the Director, TRICARE
Management Activity or designee.
(B) Alternative allocation period. The allowable equipment cost may
be allocated monthly in any amount such that the maximum allowable
monthly ECHO benefit of $2,500 or the maximum period under paragraph
(g)(2)(ii)(A) of this section, is not exceeded.
(C) Authorization. (1) The amount allocated each month as
determined in accordance with paragraph (g)(2)(ii) of this section will
be separately authorized as an ECHO benefit.
(2) An item of durable equipment or durable medical equipment shall
not be authorized when such authorization would allow cost-sharing of
duplicate equipment, as defined in Sec. 199.2, for the same
beneficiary.
(D) Cost-share. A cost-share, as provided by paragraph (f)(2) of
this section, is required for each month in which a prorated amount is
authorized.
(E) Termination. The sponsor's monthly cost-share and the prorated
equipment expense provisions provided by paragraphs (f) and (g) of this
section, shall be terminated as of the first day of the month following
the death of a beneficiary or as of the effective date of a
beneficiary's loss of ECHO eligibility for any other reason.
(3) For-profit institutional care provider. Institutional care
provided by a for-profit entity 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.
(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 (DEERS)
accordingly. 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
[[Page 44951]]
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
paragragh(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
requirement 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, transportation to and from such
institutions and facilities. The maximum Government cost-share for
services that require demonstration of pubic facility non-availability
or inadequacy is limited to $2,500 per month 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 beneficiary owned durable equipment
and durable medical equipment is exempt from the public facility use
certification requirements.
(5) The requirements of this paragraph (i)(4)(v) 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 Individual 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) Implementation transition. Pending administrative actions
necessary for the effective implementation of this section on or after
July 1, 2004, this section, as it existed prior to July 1, 2004, shall
remain in effect. The dates on or after July 1, 2004, on which this
section will be implemented in particular regions of the United States
and elsewhere will be established by Federal Register notice(s) during
2004.
0
6. Section 199.6 is amended by revising the section heading and
paragraphs (e)(1)(ii), (e)(2) and (e)(3) to read as follows:
Sec. 199.6 TRICARE--authorized providers.
* * * * *
(e) * * *
(1) General. * * *
(ii) A Program for Persons with Disabilities (PFPWD) provider with
TRICARE-authorized status on the effective date for the Extended Care
Health Option (ECHO) Program shall be deemed to be a TRICARE-authorized
provider until the expiration of all outstanding PFPWD benefit
authorizations for services or items being rendered by the provider.
(2) ECHO provider categories. (i) ECHO inpatient care provider. A
provider of residential institutional care, which is otherwise an ECHO
benefit, shall be:
(A) A not-for-profit entity or a public facility; and
(B) Located within a state; and
(C) Be certified as eligible for Medicaid payment in accordance
with a state plan for medical assistance under Title XIX of the Social
Security Act (Medicaid) as a Medicaid Nursing Facility, or Intermediate
Care Facility for the Mentally Retarded, or be a TRICARE-authorized
institutional provider as defined in paragraph (b) of this section, or
be approved by a state educational agency as a training institution.
(ii) ECHO outpatient care provider. A provider of ECHO outpatient,
ambulatory, or in-home services shall be:
(A) A TRICARE-authorized provider of services as defined in this
section; or
(B) An individual, corporation, foundation, or public entity that
predominantly renders services of a type uniquely allowable as an ECHO
benefit and not otherwise allowable as a benefit of Sec. 199.4, that
meets all applicable licensing or other regulatory requirements of the
state, county, municipality, or other political jurisdiction in which
the ECHO service is rendered, or in the absence of such licensing or
regulatory requirements, as determined by the Director, TRICARE
Management Activity or designee.
(iii) ECHO vendor. A provider of an allowable ECHO item, such as
supplies or equipment, shall be deemed to be a TRICARE-authorized
vendor for the provision of the specific item, supply or equipment when
the vendor supplies such information as the Director, TRICARE
Management Activity or
[[Page 44952]]
designee determines necessary to adjudicate a specific claim.
(3) ECHO provider exclusion or suspension. A provider of ECHO
services or items may be excluded or suspended for a pattern of
discrimination on the basis of disability. Such exclusion or suspension
shall be accomplished according to the provisions of Sec. 199.9.
* * * * *
0
7. Section 199.7 is amended by revising paragraphs (a)(2) and
(b)(2)(xii) to read as follows:
Sec. 199.7 Claims submission, review, and payment.
(a) * * *
(2) Claim required. No benefit may be extended under the Basic
Program or Extended Care Health Option (ECHO) Program without
submission of an appropriate, complete and properly executed claim
form.
* * * * *
(b) * * *
(2) * * *
(xii) Other authorized providers. For items from other authorized
providers (such as medical supplies), an explanation as to the medical
need must be attached to the appropriate claim form. For purchases of
durable equipment and durable medical equipment under the ECHO, it is
necessary also to attach a copy of the preauthorization.
* * * * *
0
8. Section 199.8 is amended by revising paragraphs (d)(4) and (d)(5) to
read as follows:
Sec. 199.8 Double coverage.
* * * * *
(d) * * *
(4) Extended Care Health Option (ECHO). For those services or
supplies that require use of public facilities, an ECHO eligible
beneficiary (or sponsor or guardian acting on behalf of the
beneficiary) does not have the option of waiving the full use of public
facilities which are determined by the Director, TRICARE Management
Activity or designee to be available and adequate to meet a disability
related need for which an ECHO benefit was requested. Benefits eligible
for payment under a state plan for medical assistance under Title XIX
of the Social Security Act (Medicaid) are never considered to be
available in the adjudication of ECHO benefits.
(5) Primary payer. The requirements of paragraph (d)(4) of this
section notwithstanding, TRICARE is primary payer for services and
items that are provided in accordance with the Individualized Family
Service Plan as required by Part C of the Individuals with Disabilities
Education Act and that are medically or psychologically necessary and
otherwise allowable under the TRICARE Basic Program or the Extended
Care Health Option.
* * * * *
0
9. Section 199.20 is amended by revising paragraph (p)(2)(i) to read as
follows:
Sec. 199.20 Continued Health Care Benefits Program (CHCBP).
* * * * *
(p) * * *
(2) * * *
(i) The Extended Care Health Option (ECHO) under Sec. 199.5.
* * * * *
0
10. Appendix A to part 199 is amended by adding the term ``ECHO'' and
removing the term ``PFPWD'' to read as follows:
Appendix A to Part 199--Acronyms
* * * * *
ECHO--Extended Care Health Option
* * * * *
Dated: July 20, 2004.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 04-16932 Filed 7-27-04; 8:45 am]
BILLING CODE 5001-06-P