ECHO--The Extended Care Health Option: more healthcare options for military families.

Are you struggling with caring for a family member with physical or mental disabilities and wondering how to tap into more resources and pay for additional quality care? If so, ECHO is just a call away.

The Extended Care Health Option (ECHO) is a supplemental portion of the TRICARE military health program, available to active duty family members (ADFMs) who qualify based on specific physical and mental disabilities. The program provides financial assistance to qualified beneficiaries and offers an integrated set of services and supplies beyond the basic TRICARE program.

The ECHO program evolved from previous government programs designed to assist those with special needs. In 1966, Congress passed the Military Medical Benefits Amendments, which established the Program for the Handicapped, originally developed to provide financial assistance to ADFMs with serious disabilities. This program was replaced with the Program for Persons with Disabilities (PFPWD) in 1997. In 2001, the Department of Defense (DoD) worked through the National Defense Authorization Act to establish the current program known as the Extended Care Health Option (ECHO), which was implemented on September 1, 2005.

As a result, some benefits previously available only under PFPWD are now available under the basic TRICARE program, allowing more TRICARE beneficiaries to access those services, while enhancing services available to ECHO-eligible beneficiaries.

What follows are questions and answers about the ECHO program, to help parents and professionals navigate the program.

Who is eligible for ECHO?

ADFMs are eligible for the ECHO program when they have one or more of the following qualifying conditions:

* A serious physical disability that may include infantile cerebral palsy, spina bifida, loss of vision or loss of hearing

* Moderate or severe mental retardation 

* Any physiological disorder, condition, or anatomical loss affecting one or more body systems, which has lasted, or with reasonable certainty, is expected to last for a minimum of twelve contiguous months and which precludes the person with the disorder, condition, or anatomical loss from unaided performance of a major life activity

* Beneficiaries less than three years of age with a developmental delay equivalent to two standard deviations below the mean in adaptive, cognitive, or language function; Down syndrome or fetal alcohol syndrome 

* An extraordinary physical or 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 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

ECHO benefits are available to family members of a deceased active duty sponsor until midnight of the beneficiary's twenty-first birthday, as long as the sponsor was eligible at the time of death.

ADFMs can also access ECHO benefits under the Transitional Assistance Management Program (TAMP). Please visit www.tricare.mil for more information about TAMP.

Who is not eligible for ECHO?

Retirees and their family members, as well as North Atlantic Treaty Organisation (NATO) family members, are not eligible for ECHO benefits.

How do qualifying beneficiaries register for ECHO?

To begin the registration process, beneficiaries must enroll in the Exceptional Family Member Program (EFMP). This program was established through the Department of Defense (DoD) and is a mandatory enrollment program for active duty personnel who have a family member(s) with special needs.

When military service members are considered for assignment to an installation within the United States, EFMP enrollment is used to determine whether needed services, such as specialized pediatric care, are available through the military health system at the proposed location. This program provides a single point of contact that facilitates a family's relocation. The program ensures that they are stationed in a geographical area where their family members can receive the services they need.

Although some programs may have a different name, each uniformed service branch--Army, Air Force, Navy, Marine Corps, Coast Guard, and National Guard and Reserve--has an EFMP.

The EFMP:

* Identifies family members with special medical and/or educational needs.

* Documents the services they require.

* Considers those special needs during the personnel assignment process (especially when approving family members for accompanied travel to overseas locations).

* Involves the personnel and medical commands and the educational system.

How do beneficiaries enroll in the EFMP?

To enroll in the EFMP, beneficiaries should complete the demographics/certification sections of the required forms, DD Forms 2792 (medical services) and 2792-1 or CG 5494 (special education/early intervention summary). The provider must complete and sign the medical summary section. These forms may be obtained at a local recruiting office, through a TRICARE Service Center, online at www.militaryhomefront.dod.mil, or at a Military Treatment Facility (MTF) EFMP office.

Beneficiaries will need to submit the EFMP forms to the appropriate EFMP manager. Enrollment in this program is required for most beneficiaries prior to requesting ECHO services; however, enrollment will be waived for those branches of service, such as the National Oceanic & Atmospheric Administration (NOAA) and Public Health Service (PHS), which do not have an EFMP.

Additional information about the EFMP can be found at www.militaryhomefront.dod.mil/efm (Select Exceptional Family Member) or by speaking to a Special Needs Coordinator at an MTF.

Who can beneficiaries contact if they have questions regarding the EFMP?

For more information about the EFMP, beneficiaries may visit www.militaryhomefront.dod.mil/efm, visit the TRICARE Service Center, or speak to a Special Needs Coordinator at an MTF.

What do beneficiaries need to do after they register in the EFMP?

Once beneficiaries have registered with the EFMP, they must register with the regional managed care support contractor having jurisdiction where they reside.

Beneficiaries must provide the regional contractor with documentation of an active duty sponsor, qualifying condition, and enrollment in the EFMP, from their sponsor's branch of service. Upon completion of registration and approval, the beneficiary's Defense Enrollment Eligibility Reporting System (DEERS) record will be updated to indicate that he or she is eligible for ECHO benefits.

Can beneficiaries receive ECHO services prior to completing the ECHO registration process?

To avoid delaying receipt of ECHO services while completing the ECHO registration process, the regional managed care support contractor or TRICARE Overseas Program Regional Director may grant ECHO-eligible beneficiaries a provisional eligibility status for a period of not more than ninety days, during which ECHO benefits will be authorized and payable. This provisional status is only granted once the EFMP manager has accepted the EFMP paperwork for enrollment and has forwarded it for processing.

Is there any cost related to ECHO registration?

TRICARE does not charge a fee for registering in ECHO; however, the sponsor/beneficiary may incur costs associated with the determination of ECHO eligibility. For example, the sponsor of a TRICARE Standard or Extra beneficiary may be required to obtain diagnostic services to verify an ECHO qualifying condition. The sponsor/beneficiary is liable for all relevant TRICARE Standard or Extra cost-shares associated with the receipt of those services. These cost-shares are not reimbursable under ECHO.

The PFPWD program had a maximum monthly benefit of $1000. Is the benefit the same under ECHO?

With ECHO, the monthly benefit has increased from $1,000 to $2,500 per beneficiary, regardless of the number of family members with the same sponsor receiving ECHO benefits.

What are the costs associated with ECHO benefits?

TRICARE ECHO beneficiaries are eligible for $2,500 of ECHO services per calendar month, with a monthly cost-share based on the sponsor's pay grade.

How are beneficiaries notified when they are registered for ECHO?

The regional managed care support contractor or TRICARE Overseas Program Regional Director will provide the sponsor/beneficiary with written notification of his or her eligibility determination and the information that the beneficiary is registered in ECHO. Generally, the beneficiary is eligible to receive ECHO benefits as of the date of registration.

What services are provided through the ECHO program that are not available through the basic TRICARE program?

The following benefits are exclusive to the ECHO program. Beneficiaries enrolled in TRICARE Prime who receive ECHO benefits must comply with all requirements of TRICARE Prime, such as using a primary care manager for routine care and obtaining referrals for specialty care.

* Medical and rehabilitative services

* Training on the use of assistive technology devices for parents and siblings, when required as an integral part of the management of the qualifying condition and vocation training

* Special education--Applied Behavior Analysis ABA) Therapy

* Payable services, which include periodic evaluation of the beneficiary, development of a treatment plan, and training of individuals to provide services in accordance with the treatment plan

* Institutional care when a residential environment is required due to the severity of the qualifying condition

* Transportation under certain circumstances to and from ECHO-authorized services. The reimbursed amount for the use of a privately owned vehicle is limited to the Federal government employee mileage reimbursement rate in effect on the trip date.

* Assistive services, such as those from a qualified interpreter or translator

* Durable equipment (DE), including adaptation and maintenance. DE is a device or apparatus that does not qualify as durable medical equipment (DME) under the TRICARE Basic program, but is essential to the elimination or reduction of functional loss resulting from, or the disabling effects of, a qualifying condition. DE can only be covered under the ECHO program with an appropriate diagnosis and need.

* Expanded in-home medical services through TRICARE ECHO Home Health Care (EHHC). EHHC provides care for beneficiaries who need services from a licensed person such as an LVN/LPN or RN. The services they need from a licensed person are more frequent, often more than one to two times an hour. An example of this type of care is the suctioning of a tracheotomy tube.

* In-home respite care services (short-term care for a beneficiary that provides relief to full-time caregivers)

* ECHO respite care--16 hours per month when receiving other authorized ECHO benefits

* TRICARE EHHC respite care--up to 40 hours per week (eight hours per day, five days per week) for those who qualify

* Beneficiaries eligible for EHHC respite may need care that occurs frequently (more than two times in an eight-hour period), but does not require a licensed person to perform the care, or care that does not require direct supervision of a licensed person to perform. An example of that type of care is suctioning the mouth, or giving medication or formula through a feeding tube.

Note: Only one of the above respite care benefits can be used in a calendar month. They cannot be used together.

Is custodial care covered under ECHO?

Custodial care, which is defined as room and board and assistance with daily living activities provided in a nursing home, is not included under ECHO; however, services provided in support of daily living activities may be cost-shared when they are provided through the EHHC benefit.

What respite care options are available through ECHO?

ECHO provides two respite care programs. The first benefit, ECHO Respite, allows registered beneficiaries a maximum of sixteen hours of respite care from a TRICARE Certified Home Health Agency care provider to manage a beneficiary's required skilled and non-skilled services in the absence of the primary caregiver.

Beneficiaries are eligible for this care during any calendar month in which they also receive any other ECHO-authorized benefit. For example, a beneficiary who is receiving a prorated authorization for durable equipment for three months is also eligible to receive ECHO respite care benefits during the same three months.

The second benefit is known as EHHC Respite or the Sleep Benefit, which allows qualified beneficiaries up to forty hours per week (eight hours per day, five days per week) of respite care. To qualify for this service, the beneficiary must have frequent, required interventions more than two times during the eight-hour period the primary caregiver would normally be sleeping.

Beneficiaries may not use both forms of respite care within the same calendar month.

Is the cost for ECHO respite care included in the $2,500 benefit limit?

Yes, the available sixteen hours per calendar month of ECHO respite care is included in the $2,500 benefit limit.

The sponsor/beneficiary is responsible for the appropriate amount shown in the above table, in addition to any amount in excess of the government's maximum monthly coverage for any benefits received in a month, including the ninety-day provisional period extended to the beneficiary.

The sponsor/beneficiary cost-shares under ECHO are in addition to those incurred for services and items received through TRICARE Prime, Extra and Standard options.

The sponsor/beneficiary cost-shares under ECHO do not apply toward the catastrophic cap in the basic TRICARE program or the EHHC fiscal year benefit cap.

What is the difference between ECHO Home Health Care (EHHC) and EHHC respite care?

* The EHHC benefit provides medically necessary skilled services by a licensed professional to eligible homebound beneficiaries whose needs exceed the limits of the Home Health Agency-Prospective Payment System (HHA-PPS) as described in the TRICARE Reimbursement Manual (TRM). Also included in the EHHC is respite care under certain circumstances.

* EHHC respite care services are provided to eligible beneficiaries who require frequent interventions (defined below). Beneficiaries may receive eight hours of respite care services five days per calendar week.

The respite care services will relieve the primary caregiver(s) of the responsibility of providing such services, in order to allow them the opportunity to rest or sleep.

Frequent Interventions: For a homebound ECHO-eligible beneficiary, frequent interventions refer to services, as included in the beneficiary's plan of care, which are required more than two times during the eight-hour period the primary caregiver(s) would normally be sleeping. These services consist of skilled services that can be performed safely and effectively by the average non-medical primary caregiver(s) without direct supervision of a healthcare provider after such individual(s) have been trained by appropriate medical personnel.

What is the difference between durable medical equipment (DME) and durable equipment (DE)?

Durable medical equipment is defined as equipment that:

* Can withstand repeated use

* Is primarily and customarily used to serve a medical purpose

* Generally is not useful to an individual in the absence of an illness or injury

Durable equipment is a device or apparatus that does not qualify as durable medical equipment under the basic TRICARE program but is essential to minimize functional loss or disabling effects resulting from a qualifying condition. DE can only be covered under the ECHO program with an appropriate diagnosis and need.

Examples of DE are special computer peripheral devices (keyboard, mouse, etc.) or software that makes a computer functional to an ECHO beneficiary with a qualifying condition that would otherwise limit or prohibit the beneficiary's ability to use the computer; or an electrical/mechanical lifting device that raises an ECHO beneficiary in a wheelchair from ground level to first floor level of the beneficiary's residence.

Is durable medical equipment covered under ECHO?

DME, defined as medically necessary equipment primarily used for medical purposes, is not covered under the ECHO program. DME is covered under the basic TRICARE program and requires a prior authorization. Durable equipment that does not qualify as DME may be available for beneficiaries registered in ECHO, providing there is a need. DE also requires prior authorization.

What is the Custodial Care Transition Program (CCTP)?

The National Defense Authorization Act for fiscal year 2002, Section 701, changed the definition of custodial care. Custodial care is no longer defined by the condition of the beneficiary but by the type of services being rendered. The CCTP was created as an interim strategy to provide all medically necessary skilled care to beneficiaries receiving custodial care prior to the custodial care definition change and up to the implementation of new sub-acute programs.

Upon implementation, CCTP beneficiaries will be transitioned into the new programs as medically appropriate. Included in the new sub-acute programs is the transition of the PFPWD to the ECHO program. As PFPWD/ECHO benefits are only available to family members of active duty sponsors, retirees and their family members currently in CCTP will continue to receive the same level of services through CCTP, as long as they are medically necessary.

How will the CCTP coverage transfer over to the EHHC benefit?

For ADFMs who are receiving home healthcare services under the CCTP, EHHC will replace CCTP as a means of providing intensive home healthcare services. For ADFMs needing part-time or intermittent home health services (thirty-five hours or fewer each week, and respite care not provided), the TRICARE Home Health Agency-Prospective Payment System (TRICARE HHA-PPS) is available as part of the basic TRICARE program.

ADFMs who are receiving medically necessary inhome skilled services through the CCTP at the start of healthcare delivery are eligible to continue receiving those skilled services in-home through the CCTP, pending meeting the following conditions:

* Healthcare delivery began under the new TRICARE contracts in each former region, under the previous managed care support contracts.

* The beneficiary requires in-home skilled services beyond the limits of the Home Health Agency-Prospective Payment System.

Retirees and their family members currently in CCTP will not transfer to EHHC benefits. They will continue to receive the same level of services through CCTP, as long as the services are medically necessary.

ECHO at Work--Helping Families with Children with Special Needs

ECHO provides durable equipment benefits

A six-year-old child with cerebral palsy required specialty durable equipment not covered under the TRICARE Basic program; unfortunately, the child was not enrolled in ECHO. The provider's initial request was denied under basic benefits. As a result, the ECHO coordinator was notified, who determined the beneficiary was eligible for ECHO, and the requested equipment was then covered. The coordinator contacted the beneficiary's parent to inform her of the benefits for which her child qualified under the ECHO program. As a result, the beneficiary was successfully enrolled and obtained the required equipment, which decreased the effects of her disability and increased her mobility.

EHHC respite care reduces the day-to-day challenges for caregivers

A set of triplets was born prematurely at twenty-four weeks. All three babies required ventilation support and care in a pediatric rehabilitation facility for several months. The first of the triplets was sent home with intermittent nursing care, followed by the other two triplets, who were approved for EHHC respite care.

The ECHO case manager negotiated for an RN to provide respite services for the two triplets with the greatest needs, and will continue to monitor and evaluate the progress of the triplets and request additional services if needed.

ECHO provides continuity of care

A family living in the Walter Reed area was receiving forty hours of respite care per week to assist with their child's care. The child's father was transferred to Camp Lejeune, in North Carolina. To provide the family with continuity of care, the EHHC case managers from the Walter Reed and Camp Lejeune areas coordinated to make sure all authorizations and MTF referrals were completed. The family deeply appreciated the transparency of care during the transition, and the case manager continues to communicate with the family to ensure that all their needs are met.

Regional Contractors

Health Net Federal Services

www.healthnetfederalservices.com

1-877-TRICARE (1-877-874-2273)

Illinois, Indiana, Iowa, Kentucky, Maryland (excluding the National Capital area), (Rock Island Arsenal area), Michigan, Missouri (St. Louis area), Ohio, the western portion of Pennsylvania, Tennessee (Fort Campbell area), West Virginia, and Wisconsin: Marilyn Ault--800-977-7910, Ext. 62038

North Carolina and Virginia (excluding the National Capital area): Elaine Abrams--800-977-7531, Ext. 64735

Delaware, District of Columbia, Maryland (National Capital area), the southern portion of Pennsylvania, and Virginia (National Capital area): Jolene Neff--800-977-7961, Ext. 55840 or Addie Simpson--800-977-7635, Ext. 63239

Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, the eastern and northern portions of Pennsylvania, Rhode Island, and Vermont: Rita Uhren--800-977-7961, Ext. 55806

Humana Military

South Region and Overseas

www.humana-military.com

1-800-444-5445

Southeast (Augusta) Market--Florida (excluding the Panhandle), Georgia, and South Carolina--800- 447-6072

GulfSouth (Biloxi) Market--Alabama, Florida (Panhandle), Louisiana (New Orleans area), Mississippi, and Tennessee--866-323-7155

Southwest (San Antonio) Market--Arkansas, Louisiana (excluding New Orleans area), Oklahoma, and Texas (excluding extreme western El Paso area)--800-447-8808

TRICARE Latin America and Canada--Special Needs Coordinator--706-787-2080

TRICARE Area Office Europe--Case Manager--(49) (0)6302-67-6362 or 6336; DSN--496-6362 or 6336

TRICARE Area Office Pacific--Special Needs Coordinator--888-777-8343, option 4; DSN--315-643-2036

TriWest

www.triwest.com

1-888-TRIWEST (1-888-874-9378) TRICARE West--Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except 82 Iowa zip codes in the Rock Island/Illinois area), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner, including El Paso only), Utah, Washington, and Wyoming--602-644-8124 or 866-876-2384, Ext. 48124

Additional Resources

For additional information about the ECHO program, please refer to the TRICARE Extended Care Health Option brochure available on Health Net's Web site, at http://www.healthnetfederalservices.com, or at a TRICARE Service Center, or refer to the following resources:

DoD Information

www.militaryhomefront.dod.mil

Click on Troops and Families, then Special Needs/EFMP. The Special Needs Parent Tool Kit will provide a great deal of detailed information.

TRICARE

http://www.tricare.mil

ECHO Program through TRICARE

http://www.tricare.mil/echo/default.cfm

Military OneSource 

www.militaryonesource.com

CONUS 1-800-342-9647

OCONUS 800-3429-6477

Specialized Training of Military Parents (STOMP)

http://www.stompproject.org

Jolene Neff is a Case Management Supervisor for Health Net Federal Services, the government operations division of Health Net. She has more than 10 years experience in the medical field and has worked with special needs families for the past three years.

As the managed care support contractor for the TRICARE North Region, Health Net provides healthcare services to over three million uniformed services beneficiaries, active and retired, and their families. Health Net has a long history of providing cost-effective and quality managed healthcare programs for government agencies, including the Department of Defense and Veterans Affairs.

Pay Grade            Monthly Cost-Share

    E-1 to E-5              $25
       E-6                  $30
     E-7, O-1               $35
     E-8, O-2               $40
E-9, W-1, W-2, O-3          $45
  W-3, W-4, O-4             $50
     W-5, O-5               $65
       O-6                  $75
       O-7                 $100
       O-8                 $150
       O-9                 $200
       O-10                $250