Provider Handbook

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TRICARE Extended Care Health Option

Effective September 1, 2005, the TRICARE Extended Care Health Option (ECHO) replaced the Program for Persons with Disabilities (PFPWD). TRICARE ECHO continues the provision of financial assistance to beneficiaries who qualify based on specific mental or physical disabilities and offers beneficiaries an integrated set of services and supplies beyond the basic TRICARE programs—TRICARE Prime, TPRADFM, TRICARE Standard, or TRICARE Extra.

Potential ECHO beneficiaries must be ADFMs, have a qualifying condition, and be registered to receive ECHO benefits. A record of ECHO registration is stored with a beneficiary’s DEERS information.

Conditions qualifying an ADFM for TRICARE ECHO coverage include:
 

• Moderate or severe mental retardation
• A serious physical disability
• An extraordinary psychological condition of such complexity that the beneficiary is homebound
• A diagnosis of a neuromuscular developmental condition or other condition in an infant or toddler (under age 3) that is expected to precede a diagnosis of moderate or severe mental retardation or a serious physical disability
• Multiple disabilities, which may qualify if there are two or more disabilities affecting separate body systems

TRICARE providers, especially PCMs, are responsible for managing care for TRICARE beneficiaries. Any TRICARE provider (PCM or specialist) can inform the patient’s sponsor about the ECHO benefit. Beneficiaries should be referred to Humana Military for assistance with eligibility determination and ECHO registration. This ensures that the beneficiary and provider have taken the necessary steps for efficient claims processing.

Here are some additional important points about the TRICARE ECHO program:
 

• The monthly benefit allowance is $2,500 with ECHO. The monthly cost-share is based on grade and is separate from cost-shares under TRICARE Prime, TPRADFM, TRICARE Standard, or TRICARE Extra.

Note: ECHO sponsor/beneficiary liabilities do not accrue toward the catastrophic cap.

• Active duty sponsors with family members seeking ECHO registration must enroll in their service’s Exceptional Family Member Program (EFMP) in order to be eligible for the new ECHO benefits.

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ECHO Basic Benefits:

• Medical and rehabilitative services
• Training to use assistive technology devices
• Special education
• Institutional care when a residential environment is required
• Transportation under certain circumstances, i.e., to receive an authorized ECHO benefit. It also includes coverage for a medical attendant when needed to ensure safe transport of the beneficiary.
• Assistive services, when needed to receive an authorized ECHO benefit, such as those from a qualified interpreter or translator
• Durable equipment (e.g., adaptation of a vehicle or residence for accessibility purposes)
• ECHO Respite care—provides 16 hours per month break for primary caregivers*

        
ECHO Home Health Care Benefits:

• Expanded respite care and in-home medically necessary skilled services through TRICARE ECHO Home Health Care*
• ECHO Respite care—provides 16 hours per month break for primary caregivers
• EHHC Respite care—provides up to eight hours per day, five days per week to provide relief for the primary caregivers to allow them rest/sleep
• EHHC provides homebound beneficiaries requiring skilled care extended in-home health care services that are:
  • Not limited to part-time or intermittent
  • Capped by cost, not by hours (using the skilled nursing facility reimbursement rate.)

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