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Extended Care Health Option
(ECHO)
and
The Autism Demonstration
Sandi Johnson, R.N.
Special Needs/Case Management Coordinator
TRICARE Regional Office – North
703 – 588 – 1834
sandi.johnson@tma.osd.mil
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DISCLAIMER
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This presentation is designed to provide you
with general program information only.
Nothing said can be construed as a factual
determination of benefits coverage in any
specific case. Such determinations
are made solely by the contractors in
accordance with their contract and as
provided in the policy.
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What does a
Special Needs/Case Mgmt Coordinator
for the TRO do?
 Monitor the performance of the MCSC
 Act as a liaison between the MCSC and each service, and
between the MTFs and the MCSC
 Assist with the coordination of services for beneficiaries
transferring from one region to another
 Assist with the coordination of services for beneficiaries
in ICMP-PEC and CCTP
 Provide training on programs and benefits pertaining to
the special needs population to MTFs, our MCSC, state
agencies, EFMP staff and parents/caregivers
 Manage special projects related to the special needs
population
 Assist with the resolution of challenging situations
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Extended Care Health Option
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Supplements the TRICARE basic program by:
 providing access to benefits/services not otherwise
available through TRICARE;
 providing financial assistance (up to $2,500 per month)
to beneficiaries who qualify, based on specific mental or
physical disabilities.
 NDAA 2009, Sect.732 changed this to “not to exceed
$36,000 per year”. This bill was signed by the President
14 Oct 2008, but it still requires Agency decisions
regarding implementation and publication of a rule in the
Federal Register before we will see it implemented.
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Who is eligible for ECHO benefits?
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 Active Duty family members (including some
activated Reservists and those in TAMP) who are
enrolled in EFMP
 Survivors of a deceased service member
 3 years from the date an AD sponsor dies, or
 Through age 21 if the sponsor died while receiving
hostile-fire pay
AND WHO
 have a Qualifying Condition (QC)
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What is a Qualifying Condition?
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 Moderate or severe mental retardation
 Serious physical disability
 unable to accomplish unaided performance of at least
one major life activity (Autism Spectrum Disorders)
 Extraordinary physical or psychological
condition
 Multiple disabilities – cumulative effect
 Infants & toddlers under 3 yrs with a diagnosis
of developmental delay
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What are the ECHO benefits?
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 Diagnosis
 Treatment
 Medical, habilitative, rehabilitative services/supplies




Durable Equipment
Assistive technology devices including training
Assistive services
Special Education (IDEA)

Applied Behavior Analysis (ABA)
 Vocational training
 Institutional Care
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Additional benefits under
ECHO
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ECHO Home Health Care
 Not limited to part time or intermittent
 Capped by cost, not by hours
(SNF reimbursement rate)
EHHC Respite Care
 8 hrs/day, 5 days per week
 Eligible beneficiary requires frequent
interventions (requires training by
medical personnel-but doesn’t have to
be “skilled” interventions
 Sleep benefit
ECHO Respite Care
 “dinner & a movie” benefit
 16 hrs/month break for primary
caregivers
 Can ONLY be used in a month when
another ECHO benefit is being received
Must use a Medicare certified
agency
RESPITE LIMITATIONS
The Respite Benefits cannot be used
for siblings, employment, deployment,
or pursuing education
AND they are not accumulative.
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What is NOT an ECHO benefit?
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 Anything that is covered under Basic
TRICARE including:
 PT, OT, and Speech therapy
 Hearing Aides – under Basic but still only for
ADFMs –but FM systems are DE under ECHO
 All Durable MEDICAL Equipment
 Augmentative communication devices and
(speech generating devices)
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Durable MEDICAL Equipment
versus
Durable Equipment

Durable Medical Equipment - primarily serves a medical purpose; can
improve, restore, or maintain function . . . or prevent the deterioration of
the patient’s function or condition. Also covers customization and
accessories for DME if it makes the DME useable or more useable for the
beneficiary – not the caregiver. All DME is covered under Basic TRICARE
benefits.

Durable Equipment – doesn’t qualify as DME but does reduce the
functional loss or disabling effects of a QC. MCSC can determine any item,
that meets the criteria for a given patient, to be covered as long as it is not
specifically excluded (spas, hot tubs, equipment with deluxe, immaterial, or
non-essential features). Durable equipment is only covered by ECHO.
The Bottom Line for DE
“Is this something that would be purchased in the absence of the qualifying
condition?” The response will tell you if it is covered.
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ECHO Registration
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 Call the ECHO Coordinator in your area.
 Fax a copy of the entire DD 2792 or DD 2792-1 or the
CG 55494 to Health Net.**
 Fax a copy of the child’s IEP or IFSP to Health Net.
 Health Net registers the beneficiary into DEERS through
the HN Enrollment Dept with a code indicating ECHO
eligibility.
 You do not need to re-enroll if you change regions but
you do need to notify your ECHO coordinator –
preferably before you relocate!
** NOAA and USPHS are exempt from this. Also beneficiaries
who do not reside with the sponsor (i.e. parents are
divorced)
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ECHO Referral & Authorization
Process
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 Acceptance into ECHO does not guarantee
approval/authorization for a requested service or
benefit even if it is ordered by a physician.
 A physician’s order is required for all ECHO and
EHHC services.
 Prior authorization is required for all ECHO,
ECHO Respite, EHHC and EHHC Respite services.
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Costs
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Pay Grade
Monthly Cost Share
E1 to E5
$25
E6
$30
E7, O1
$35
E8, O2
$40
E9, W1, W2, O3
$45
W3, W4, O4
$50
W5, O5
$65
O6
$75
O7
$100
O8
$150
O9
$200
O10
$250
 TRICARE will pay up to $2500 per month
for benefits, (exclusive of EHHC) after the
monthly cost-share is paid.
 If the costs exceed $2,500 in any month,
the beneficiary is responsible for the
balance.
 If there are two or more persons with
the same sponsor who receive services
under ECHO, TRICARE requires
payment of only one monthly cost share
by the sponsor and TRICARE will pay up
to $2500 for each ECHO-eligible
beneficiary for ECHO benefits, exclusive
of EHHC benefits.
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DoD Autism Demonstration
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 The Enhanced Access to Autism Services
Demonstration, went into effect 3/15/08.
 Designed to improve access to special ed
services for eligible children with ASD.
 TMA has created a new class of provider
which permits reimbursement of ABA
services delivered by non-certified, but
intensely supervised paraprofessionals
whom we have called “Tutors”.
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DoD Autism Demo (con’t)
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 Provider must be a TRICARE-authorized provider and will
function as an Autism Corporate Services Provider.
 Must sign a Participation Agreement.
 Educational Interventions for ASD Supervisor (EIA) will
provide supervisory oversight to EIA Tutors.
 Reimbursements are established by TMA : in 15 minute
increments: Supervisors, $125/hour and Tutors,
$50/hour
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DoD Autism Demo (con’t)
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Eligibility
 Must have a diagnosis of Autistic Disorder,
Pervasive Developmental Delay Not
Otherwise Specified, Asperger’s Disorder
or Childhood Disintegrative Disorder
 Must be registered in ECHO
 Must be receiving special ed services
 Must be over the age of 18 months
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CHECKLIST FOR PARENTS/GUARDIANS SEEKING
SERVICES THROUGH THE AUTISM SERVICES DEMO
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The Parents/Guardians Should:
1. Ensure the beneficiary’s Defense Enrollment Eligibility Reporting System (DEERS) record is current.
2. Enroll the beneficiary in the sponsor’s branch of service’s Exceptional Family Member Program
(EFMP). Keep a hard copy of the DD-2792-1, signed by the EFMP representative, to submit to the
Managed Care Support Contractor (MCSC) for your region.
2. Register the beneficiary in the Extended Care Health Option (ECHO) program with the ECHO case
manager of your MCSC.
3. To begin services, the beneficiary must be 18 months or older.
4. Submit the beneficiary’s Individualized Family Service Plan (IFSP) or Individualized Education
Program (IEP) documentation to the MCSC.
If the beneficiary is homeschooled and your state does not require an IFSP or IEP, you must provide a
letter from the beneficiary’s Primary Care Provider or Specialized ASD provider verifying that the
disability related to Autism results in dysfunction severe enough to require special education and
other support services.
5. Submit the beneficiary’s behavioral plan, developed by the Educational Interventions for Autism
Spectrum Disorders (EIA) Supervisor to the MCSC for review prior to Demonstration services
being authorized.
The Medical Provider Should:
1. Submit verification and date of a DSM-IV diagnosis, made by a TRICARE-authorized Primary Care
Provider or Specialized ASD Provider, of Autistic Disorder, Pervasive Developmental Disorder Not
Otherwise Specified, Asperger’s Disorder or Childhood Disintegrative Disorder to the MCSC.
2. Submit additional information as may be requested by the MCSC to confirm eligibility.
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Permanent Dependent Status
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 Start the process at least 6 months before
the child turns 21
 Sponsor must be providing more than
50% of the child’s support
 Onset of the disability must have been
before the age of 21
 Child must be incapable of self-sufficiency
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Permanent Dependent Status
(con’t)
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Must submit: (addresses on handout)
 a current medical statement, preferably from the child's
PCM, explaining in narrative format:
 the onset of the disability,
 the child's current physical and cognitive status,
 functional level (what the child cannot do or needs
assistance doing is better than what the child can do)
 why the child is incapable of self support
 a copy of the child's birth certificate
 DD Form 1172 (Application for Uniformed Services ID
card)
 DD Form 137-5 (Dependency Statement - Incapacitated
Child Over Age 21)
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A word about SSI and Medicaid . . .
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 If at first you don’t succeed, try, try again
 If you are medically eligible for one, you
are medically eligible for the other
 When the child turns 18, financial
eligibility is based on the child’s income
not the parent’s
 Always make the adult child pay rent
even if living at home
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TRICARE policies and benefits are
governed by public law. Changes to
TRICARE programs are continuous,
and new benefits are often added or
existing policies are changed . . . to
make TRICARE a better program.
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Additional Resources
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www.hnfs.com
www.militaryhomefront.dod.mil for access to the DOD
Special Needs Parent Toolkit –type that in under SEARCH
www.militaryonesource.com
Stateside: 1-800-342-9647
Overseas: 1-800-342-96477 (yes, dial all those numbers)
www.tricare.mil/specialneeds/default.cfm for access to the
Special Needs Smart Book and the Special Care
Organization Record (SCOR)
www.nichcy.org NICHCY – National Information Center for
Handicapped Children and Youth. Clearing house of
information – mostly free
www.washingtonpave.org - Specialized Training of Military
Families (STOMP) 1-800-5-PARENT or 253-565-2266
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QUESTIONS
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