TRICARE Extended Care Health Option (ECHO)

The TRICARE Extended Care Health Option (ECHO) provides financial assistance to ADFMs 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, and TRICARE Standard.

Potential ECHO beneficiaries must be ADFMs, have qualifying conditions, and be registered in the Exceptional Family Member Program (EFMP). Each service branch has its own EFMP and enrollment process. Under certain circumstances,

this requirement may be waived. To learn more, contact your service branch’s EFMP representative or visit www.tricare.mil. A record of ECHO registration is stored with a beneficiary’s DEERS information.

Conditions qualifying an ADFM for ECHO coverage include, but are not limited to:

•     A serious physical disability

•     Moderate or severe mental retardation

•     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 (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) may inform the patient’s sponsor about the ECHO benefit. Beneficiaries should be referred to TriWest for assistance with eligibility determination and ECHO registration. This ensures that the beneficiary and provider have an understanding of

the benefit and have taken the necessary steps for efficient claims processing. Active duty sponsors with family members seeking ECHO registration must enroll in their service’s Exceptional Family Member Program (EFMP) as required by their service branch. Retroactive registration into the ECHO program is not allowed.

ECHO Provider Responsibilities

ECHO providers have certain responsibilities:

•     Prior authorization must be obtained from TriWest for all care provided under the ECHO program or providers run the risk of having ECHO claims denied.

•     Providers may be requested to provide medical records or assist beneficiaries with completing EFMP documents.

•     Network and participating providers must submit ECHO claims to WPS.

•     A provider rendering applied behavior analysis (ABA) must be a TRICARE-certified provider that meets one of the following criteria:

•     Has a current state license to provide ABA services

•     Is certified by the Behavior Analyst Certification Board as either a Board Certified Behavior Analyst or Board Certified Assistant Behavior Analyst. Note: Non-certified paraprofessional providers may render certain educational intervention services and ABA under close supervision. For more information, see “DoD Enhanced Access to Autism Services Demonstration” later in this section.

TRICARE may pay for “hands-on” ABA services when provided by a TRICARE-certified provider. However, TRICARE will not pay for such services

when provided by family members, trainers, or other individuals who are not TRICARE- certified providers