TRICARE Extended Care Health Option Helps Families with Special Needs
Do you have a family member with special needs? Do they need health care services beyond those covered by their current TRICARE health plan? The TRICARE Extended Care Health Option (ECHO) may be right for them. ECHO provides supplemental health care coverage for active duty family members (ADFMs) with a qualifying mental or physical disability.
“Taking care of a loved one with special needs can be expensive,” said U.S. Navy Capt. Edward Simmer, chief clinical officer of the TRICARE Health Plan at the Defense Health Agency. “In addition to the regular TRICARE benefit, ECHO provides additional coverage to help alleviate some of the financial burden that families may face when caring for their loved one with complex medical needs.”
ECHO provides health care products and services beyond those offered by your TRICARE health plan, like TRICARE Prime or TRICARE Select. When medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition., covered products and services include:
- Durable equipment (including adaptation and maintenance)
- Respite care
- Institutional care
- Special education and training
- Transportation in some circumstances
Registration for ECHO isn’t retroactive. You must get prior authorization from your regional contractor for all ECHO services. And you must get these services from a TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. DS.
If you use ECHO, you may also qualify for ECHO Home Health Care (EHHC). EHHC provides in-home skilled services that are medically necessary. According to the Extended Care Health Option Fact Sheet, EHHC may offer primary caregiversAnyone who takes care of the patient at home and helps with daily activities. respite care up to eight hours per day, five days a week.
ADFMs seeking ECHO services must have one of these health plans:
Qualifying conditions for ECHO may include, but are not limited to:
- Autism spectrum disorder
- Moderate or severe intellectual disability
- Serious physical disability
- Physical or psychological condition that causes the beneficiary to be homeboundTRICARE considers you homebound if you can’t leave your home without a lot of effort.
Adult children may remain eligible for ECHO if they’re determined to be incapacitated. This means they must be unable to support themselves due to a severe mental or physical disability that they have. Their disability must have occurred prior to the loss of eligibility. And their sponsor must be on active duty and responsible for more than 50 percent of their financial support. It’s up to the service member’s service to determine that an adult child is incapacitated.
For more qualifying conditions, check out the Extended Care Health Option Fact Sheet.
You pay a cost-shareA percentage of the total cost of a covered health care service that you pay. for each month that you use your ECHO benefits. The sponsor’s pay grade determines the monthly cost-share. ECHO cost-shares are separate from cost-shares associated with other TRICARE plans. The coverage limit for all ECHO benefits in a calendar year is $36,000 per beneficiary. This coverage limit doesn’t include ECHO Home Health Care. Also, costs under the Autism Care Demonstration are not part of ECHO and not subject to the coverage limit. To learn more, visit ECHO Costs and Coverage Limits.
Getting Started with ECHO
To use ECHO, you’re required to enroll. Sponsors must sign up their family members in their service’s Exceptional Family Member Program (EFMP). Each service branch has its own EFMP. You must also register with your regional contractor.
“Once registered, a record of ECHO registration is included with the beneficiary’s information in the Defense Enrollment Eligibility Reporting System(DEERS) A database of information on uniformed services members (sponsors), U.S.-sponsored foreign military, DoD and uniformed services civilians, other personnel as directed by the DoD, and their family members. You need to register in DEERS to get TRICARE.,” said Simmer. “This ensures they qualify for ECHO services.”
Last Updated 9/1/2020