Defense Health Primer: TRICARE Extended Care Health Option (ECHO)

Defense Health Primer: TRICARE Extended Care Health Option (ECHO)

October 10, 2018
Defense Health Primer: TRICARE Extended Care Health
Option (ECHO)
Since the 1950s, Congress has been creating various
Health Plan), enrolled in their service’s Exceptional Family
programs to support military quality of life, including
Member Program, and have a qualifying physical or mental
TRICARE, Transition Assistance Program, Department of
disability/condition. Eligible dependents register for ECHO
Defense (DOD) schools, child care centers, and Morale,
through their respective TRICARE contractor’s case
Welfare, and Recreation programs. Military families who
management program.
have special needs also encounter additional challenges
with accessing and maintaining consistent health care, child
Qualifying Physical or Mental Disabilities/Conditions
care, and education across frequent moves. To address

those issues, Congress created the TRICARE Extended

Autism Spectrum Disorder
Care Health Option (ECHO) in 2001. The purpose of

Moderate or severe intellectual disability
ECHO is to provide supplemental services for military

Serious physical disability
families with special needs, similar to home and

Extraordinary physical or psychological condition that
community-based services offered by state Medicaid
results in a beneficiary being homebound
programs (e.g., rehabilitative services, durable equipment,

assistive technology devices, institutional care, home

Neuromuscular development condition or other
health, autism therapies).
condition in an infant or toddler that is expected to
precede a diagnosis of moderate or severe intellectual
Background
disability or a serious physical disability
From 1967-2004, DOD administered the Program for

Multiple disabilities, which may qualify if there are two or
Persons with Disabilities (PFPWD), which offered health
more disabilities affecting separate body systems
services for military family members with special needs.
In FY2017, there were 18,898 beneficiaries registered for
The purpose of PFPWD was to provide additional non-
the ECHO program, which was a 34% increase in
medical services, not generally covered by TRICARE, to
registrants since FY2013. Army beneficiaries represent the
military families who “face unique challenges in accessing
largest group of ECHO participants. Additionally, autism
special needs services due to the nature of military service.”
spectrum disorder is the most common diagnosis, impacting
Services provided to beneficiaries through PFPWD were
approximately 78% of ECHO participants.
statutorily capped at $2,500 per month. Prior to 1997,
PFPWD was known as the Program for the Handicapped.
Figure 1. Beneficiaries Registered in ECHO, FY2013-
FY2017
As part of a broad effort to reform sub-acute care benefits
(e.g., skilled nursing care, case management, long-term
care, and disability support services), section 701 of the
National Defense Authorization Act for FY2002 (NDAA;
P.L. 107-107) replaced this program by directing DOD to
provide “extended benefits” to assist military family
members with the “reduction of disabling effects” caused
by a physical or mental disability/condition. In 2004, DOD
issued a final rule (i.e., 69 Federal Register 44942-44952)
to replace PFPWD with ECHO, broadening the services
available to allow service members to focus on their
“mission-related responsibilities.” Since then, Congress and
DOD further expanded the types and amounts of available
services (e.g., increasing the annual benefit cap to $36,000
[P.L. 110-417 §721], adding respite care hours, and
covering certain therapies for autism spectrum disorder).

Source: Department of Defense, 2018.
Eligibility & Registration
Notes: Due to their low counts, beneficiaries of the Public Health
Dependents of active duty service members are the only
Service (PHS) and National Oceanic and Atmospheric Administration
category of DOD beneficiaries eligible for ECHO. Neither
(NOAA) registered in ECHO are omitted from this graphic. In
reservists and their dependents nor retirees and their
FY2017, PHS had 95 beneficiaries and NOAA had 4 beneficiaries
dependents are eligible. To participate in ECHO, the
registered in ECHO.
dependent must be enrolled in a TRICARE health plan
(e.g., Prime, Select, or the Uniformed Services Family
https://crsreports.congress.gov

Defense Health Primer: TRICARE Extended Care Health Option (ECHO)
ECHO Features
 Inadequate data collection to assess beneficiary
ECHO pays for services and supplies designed to reduce
satisfaction, utilization of services, and impacts on
the disabling effects of a qualifying condition and generally
military personnel retention.
not covered under a TRICARE health plan. There are three
 Lack of flexibility to select ECHO services without
distinct categories of ECHO benefits: general services and
regard to their age or type/severity of disability, also
supplies, ECHO Home Health Care (EHHC), and applied
known as consumer-directed care.
behavioral analysis for autism spectrum disorder. In
 Lack of access to ECHO benefits for retirees and their
general, beneficiaries are required to access other federal,
dependents.
state, or local services, such as home and community-based
services, prior to utilizing ECHO.
DOD has addressed some of these concerns. In 2015,
TRICARE policy was revised to cover certain incontinence
ECHO-covered Services & Supplies
supplies as an ECHO benefit. In August 2018, DOD
published a proposed rule (i.e., 83 Federal Register 41026)

Assistive interpreter or

Rehabilitative services
to eliminate the requirement for use of another ECHO
translation services
service in order to access respite care. While Congress has
enacted no ECHO-related provisions since the FY2017

Durable equipment,

Training for special
National Defense Authorization Act (P.L. 114-328 §716),
including adaptation and
education and assistive
Congress continues to express concern for ECHO’s current
maintenance equipment
technology devices
limitations. In the Senate report (S.Rept. 115-262)

Applied Behavioral

Transportation to/from
accompanying the FY2019 NDAA (P.L. 115-232), the
Analysis
institutions or facilities
committee strongly encourages DOD to “expand ECHO
respite services to align with the average number of respite

Expanded in-home

Institutional care
hours” provided by state Medicaid programs. Upon
medical services
submission (expected November 2018) of DOD’s final

report on a plan to “improve pediatric care and related

Short-term relief for primary caregivers (Respite care)
services for children of members of the Armed Forces,”
Respite care is a widely-used ECHO service that covers up
Congress may consider additional legislation to address
to 16 hours each month when another ECHO service or
gaps in ECHO coverage, eligibility, and program
supply is being utilized. Beneficiaries may also be eligible
administration.
for additional respite care (i.e., up to 8 hours per day, 5 days
per week) under EHHC.
Relevant Statutes, Regulations, and Policies
Beneficiary Costs
Sections 1079(d) through 1079(f) of Title 10, U.S. Code –
There are no costs to register in ECHO. However, cost-
Contracts of medical care for spouses and children: plans
shares are required for months in which the ECHO benefit
Section 199.5 of Title 32, U.S. Code of Federal Regulations –
was utilized. Cost-shares are based on the sponsor’s pay
TRICARE Extended Care Health Option (ECHO)
grade, ranging from $25 to $250 per month, and do not
count towards a beneficiary’s
TRICARE Policy Manual 6010.60-M, Chapter 9, Section 1.1 –
TRICARE health plan
Extended Care Health Option (ECHO)
deductible or catastrophic cap. ECHO benefits are capped
at $36,000 per beneficiary, per fiscal year. Annual service
and supply costs exceeding this amount are the
CRS Products
responsibility of the beneficiary. Respite care provided
CRS In Focus IF10530, Defense Primer: Military Health System,
under EHHC does not count towards the general benefit
by Bryce H. P. Mendez
cap, however, it is limited to what TRICARE would pay if
CRS Report R43328, Medicaid Coverage of Long-Term Services
the beneficiary resided in a skilled nursing facility.
and Supports, by Kirsten J. Colello
ECHO Concerns & Reform Efforts
Participation in state Medicaid programs often includes a
Other Resources
residency requirement. This can limit eligibility and access
Department of Defense, Report on Efforts Being Conducted by
for military families because of their frequent moves.
the DOD on the Plan to Improve Pediatric Care for Children of the
Members of the Armed Forces, June 2018.
Since ECHO’s creation, there have been multiple program
Military Compensation and Retirement Modernization
evaluations conducted by DOD, advocates of families with
Commission (MCRMC), Report of the MCRMC, January 2015.
special needs, and most recently, the Military
Department of Defense, Report on Including Dependents of
Compensation and Retirement Modernization Commission
Military Retirees in the Extended Care Health Option Program for
(MCRMC). Common concerns highlighted in these reports
a Limited Transitional Period Following Retirement, April 2009.
include:



Disparate home and community-based services

delivered by state Medicaid programs and ECHO (e.g.,

Bryce H. P. Mendez, Analyst in Defense Health Care
limited respite care hours, lack of coverage for custodial
care and incontinence supplies).

Policy
IF11002
https://crsreports.congress.gov

Defense Health Primer: TRICARE Extended Care Health Option (ECHO)

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.

https://crsreports.congress.gov | IF11002 · VERSION 2 · NEW