Extended Health Care Option (ECHO) Costs

Coverage Limits

There is a maximum dollar-amount limit for ECHO benefits. This limit is set by Congress and is either a monthly limit or a fiscal year (from October 1 to September 30) limit.

Fiscal Year Cap

The fiscal year limit is $36,000 for certain ECHO services (excluding ECHO Home Health Care and Rehabilitation) for eligible services starting on October 14, 2008.

All but seven services remain subject to the $2,500 monthly cap. The following seven types of services accrue to the $36,000 fiscal year limit:

• training
• rehabilitation
• special education
• assistive technology devices
• institutional care
• certain transportation
• Autism Services Demonstration

This fiscal year cap change was implemented on April 1, 2009. The change to the $36,000 annual cap removed the monthly limit for the above seven types of services, but the cost of reimbursement for these services count towards the fiscal year cap.

Since this change is retroactive, if you received any of the above seven types of service between October 14, 2008 and April 1, 2009, reached your monthly limit and had to pay the balance out-of-pocket, you may be eligible to file a retroactive claim.

Retroactive claims can be filed for services:

• received between October 14, 2008 and April 1, 2009
• provided by an ECHO provider (or certified Supervisor/Tutor, if received as part of the Autism Services Demonstration) who was certified at the date of service
• eligible, covered services under ECHO (and the Autism Services Demonstration, if applicable)
• if the beneficiary was eligible for and enrolled in ECHO (and the Autism Services Demonstration, if applicable) at the date of service.

Follow these directions to file a claim with TriWest (be sure to include proof of payment). You can also contact your ECHO case manager to make sure you are eligible to file a retroactive claim.

Monthly Cap

All other ECHO services (except ECHO Home Health Care and Rehabilitation) remain subject to the $2,500 monthly cap. The reimbursement costs of these services also count toward the fiscal year limit, but any costs above the monthly limit will be your responsibility. Unused monthly amounts cannot be transferred from one month to another or from one ECHO enrollee to another.

Cost Shares

You will pay part of the monthly expenses for authorized ECHO services. This monthly cost share is based on the sponsor’s pay grade:

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

• There is only one cost share per sponsor; if a sponsor has multiple family members receiving ECHO benefits, the sponsor owes only one cost share per month.
• You only pay the cost share if you use ECHO benefits during the calendar month.