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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Rules and Regulations
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without receiving another ECHO benefit during the same month the respite care is received.
B. Summary of Major Provisions The Department of Defense the Department remains committed to supporting Service members and their family members with special needs.
Together, the Office of Community Support for Military Families with Special Needs, the Services, and the Military Health System are working to enhance and improve support for these families, including everything from complex medical management to nonclinical case management and family support services. The Department is also committed to eliminating unnecessary requirements that act as barriers to care.
The requirement to receive a concurrent ECHO benefit in order to be entitled to ECHO respite care was originally imposed as a medical management tool.
We now conclude that this specific requirement is no longer necessary and may serve as an inappropriate barrier to receipt of respite services for some families. Respite services for ECHOeligible covered beneficiaries may still be appropriate and necessary even when no other ECHO services are provided i.e., where all needed care is otherwise covered under the TRICARE Basic Program or under demonstration authority.
The elimination of the requirement for a simultaneous ECHO benefit will provide maximum flexibility to families without sacrificing the goal of ensuring the safe and effective management of the beneficiarys ECHO qualifying condition. First, we note that TRICARE
beneficiaries with complex medical needs may receive case management services including medical management, disease management and chronic care coordination, under the TRICARE Basic Program, regardless of whether the beneficiary is an ECHO
eligible beneficiary. As the TRICARE
program has evolved over time, continuing to require an ECHO eligible beneficiary to receive a concurrent ECHO benefit as a medical management tool is no longer necessary. Based on our current program structure, beneficiaries should already be receiving medical management services and the receipt of any ECHO benefit, including ECHO respite care, provides an additional opportunity to ensure the safe and effective management of the beneficiarys qualifying condition.
Furthermore, in accordance with 32
CFR 199.5h3, all ECHO benefits, including ECHO respite care, require authorization prior to receipt of such benefits. Paragraph 199.5i discusses
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required documentation as a prerequisite to authorizing ECHO
benefits. As a practical matter, the Home Health Aide HHA providing the respite services must document the health care services needed by the ECHO beneficiary in the absence of the family caregiver and the schedule for the services during the provision of respite care in order to ensure an appropriately trained provider is sent and the beneficiarys needs are met.
Additional details regarding required documentation to be provided to the Managed Care Support Contractor and HHA for authorization of ECHO respite services will be published in the TRICARE Policy Manual available at http manuals.tricare.osd.mil. We believe that this approach will provide greater flexibility and eliminate unnecessary barriers for families to access ECHO respite care services while still ensuring the safe and effective medical management of the beneficiarys qualifying conditions.
C. Legal Authority for This Program The ECHO program is authorized by 10 United States Code U.S.C. 1079d f, and has been implemented through regulation at 32 CFR 199.5 available at https www.govregs.com/regulations/
title32_chapterI_part199_section199.5.
Per 32 CFR 199.5c7, ECHO
beneficiaries are eligible for a maximum of 16 hours of respite care per month in any month during which the beneficiary otherwise receives an ECHO other than the ECHO Home Health Care EHHC
benefits. This regulation is finalized under the authority of 5 U.S.C. 301
available at https www.govregs.com/
uscode/title5_partI_chapter3_
subchapterI, which allows the Secretary of Defense to prescribe regulations for the government; and 10
U.S.C. 1079d and e available at https www.govregs.com/uscode/
title10_subtitleA_partII_chapter55, which directs the Secretary of Defense to establish a program to provide extended benefits for eligible active duty dependents, which may include the provision of comprehensive health care services, including case management services, to assist in the reduction of the disabling effects of a qualifying condition of an eligible dependent. The Department is authorized to provide respite care for the primary caregiver of the eligible dependent as one of the specifically enumerated extended benefits under the ECHO program pursuant to 10 U.S.C.
1079e6.

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II. Public Comments Comments were received from thirtyone individuals, medical affiliated organizations, and military and veterans associations via www.regulations.gov.
We have carefully considered all public comments, and specific matters raised by those comments are summarized below. We reaffirm the policies and procedures contained in the proposed rule and maintain the rationale presented in the preamble of the proposed rule.
A. Analysis of Public Comments The government received many comments that were in favor of the elimination of the concurrent ECHO
benefit requirement. Many comments also noted that a minimum increase of four hours to the current sixteen hours total of twenty hours per month was reasonable.
Response: Increasing the number of respite hours per month from 16 to 20
is a major change and under the law we must give the public notice and an opportunity for comment. Therefore, an increase in respite hours will not be incorporated under this final rule. A
separate rule will be considered by the Department when further analysis of the appropriate number of hours of respite is conducted.
Two of these comments recommended consideration that the respite program be open to more providers than just HHAs as some beneficiaries do not require a home health nurse or aide to provide respite care to children with autism.
Response: Respite care consists of providing skilled and non-skilled services to a beneficiary such that in the absence of the primary caregiver, management of the beneficiarys ECHO
qualifying condition and safety are provided. Therefore, 32 CFR part 1079
requires a TRICARE-authorized HHA
provide the services under the ECHO
program. This is critical to ensure the safety of our beneficiaries.
Twenty-four comments were received in which commenters requested that the ECHO respite benefit be aligned with the Medicaid Home and Community waiver per the 2015 MCRMC which asked that a transitional benefit be made available to cover families that are separating or retiring from active duty AD service.
Response: By law, ECHO is available only to ADFMs and therefore a transitional benefit to cover families that are separating or retiring from AD
service would require legislation.
We received two comments indicating that there are several geographic areas
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