[Code of Federal Regulations]
[Title 32, Volume 2]
[Revised as of July 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 32CFR199.5]

[Page 157-164]
 
                       TITLE 32--NATIONAL DEFENSE
 
        CHAPTER I--OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED)
 
PART 199_CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES 
 
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 ECHO-eligible 
dependent's qualifying condition. Services include those necessary to 
maintain, minimize or prevent deterioration of function of an ECHO-
eligible dependent.
    (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

[[Page 158]]

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 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, of 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 that is 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 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'

[[Page 159]]

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 benefits 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 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 that is 
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 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 160]]

    (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:

[[Page 161]]

    (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. 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 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 fiscal 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

[[Page 162]]

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 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 in 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 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 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

[[Page 163]]

    (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 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 
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 public 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

[[Page 164]]

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 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) Implementation transition. Pending administrative actions 
necessary for the effective implementation of this section following its 
publication in the Federal Register on August 20, 2004, this section as 
it existed prior to August 20, 2004, shall remain in effect for a period 
of not less than 30 days following its publication in the Federal 
Register.

[69 FR 51564, Aug. 20, 2004, as amended at 71 FR 47092, Aug. 16, 2006; 
72 FR 2447, Jan. 19, 2007]