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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Rules and Regulations that cannot obtain service due to a lack of providers, or that providers have declined to accept a beneficiary when limited to 16 hours per month.
Response: As previously stated, in order to assure the quality of care for ECHO beneficiaries, all ECHO respite care services will be provided only by Medicare or Medicaid certified HHAs who have in effect at the time of services a valid agreement to participate in the TRICARE program. Consequently, ECHO respite services are available only in locations where there are Medicare or Medicaid certified HHAs.
Four comments included requests for the benefit to allow sibling care from the same HHA that is providing ECHO
respite care.
Response: While this request is understandable, 32 CFR 199.5 requires respite care services be provided by a TRICARE-authorized HHA and are designed to provide health care services for the covered beneficiary. Child-care services for other members of the family is not authorized medical care.
One comment sought clarification on the amount of respite hours and impact on yearly cost, and specifically asked whether the respite hours would be incorporated into the yearly benefit limitations.
Response: Yes, by law, the cost of respite care under ECHO will be calculated into the yearly benefit. The Governments share of the total cost of providing such benefits in any year shall not exceed $36,000.
B. Provisions of the Final Rule The final rule is consistent with the proposed rule. No changes were made to the rule text as a result of comments received; however, certain provisions discussed in the proposed rule have been deleted from the final rule e.g., increasing authorized hours beyond 16
per month.
III. Regulatory Analysis
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A. Cost Estimate: No Concurrent Care Requirement and 16 Hours per Month Limit Current Policy Baseline Costs Baseline current policy respite care costs incurred for those ECHO
beneficiaries were estimated using respite care in FY18 the latest full fiscal year data available. Out of a total of 1,267 ECHO users diagnosed with ASD, there were 66 respite care users who incurred $48,022 in paid costs for respite care billing codes S9122, S9123, and S9124. Of these 66 users, 17
incurred the maximum of 16 hours per month over an average of 1.7 months total paid amount of $10,969 and 49

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incurred an average of 11.3 hours per month over an average of 2.8 months total paid amount of $37,053. Out of a total of 3,689 ECHO users with non-ASD
diagnoses, there were 9 respite care users who incurred $19,533 in paid costs for the three respite care billing codes. Of these 9 users, 4 incurred the maximum of 16 hours per month over an average of 7.5 months total paid amount of $12,262 and 5 incurred an average of 13.0 hours per month over an average of 4.4 months total paid amount of $7,271. Because these users are not in the EHHC program, most of these expenditures were for respite-like services. As a result, FY18 baseline costs for ECHO respite care were $67,555 $10,969 + $37,053 + $12,262 +
$7,271; see Table 1.
Cost of an Expanded Non-Concurrent Respite BenefitIncremental respite costs were estimated under the proposed policy change that would not require concurrent care for two groups of ECHO beneficiaries: 1 Those who used ECHO respite care in FY18 and 2
those who only used non-respite ECHO
care in FY18. The costs associated with ADFMs using the Autism Care Demonstration ACD, who are not currently using the respite care benefit, were also estimated. All of these ADFM
beneficiaries using the ACD are enrolled in ECHO and would be eligible to use respite care under the non-concurrent policy change.
In estimating the potential costs of the policy change, beneficiaries who used ECHO respite care in FY18 were first examined. As discussed above, in FY18
there were a total of 75 respite care users: 66 diagnosed with ASD and 9
with non-ASD diagnoses. It was assumed that their average number of respite care hours per month and the paid amount per month would not change under the new benefit. However, it was also assumed that the average number of months that they would utilize respite care would increase because the number of respite care months after the change would now be unconstrained up to a maximum of 12
months due to the absence of concurrency. To estimate the average number of respite care months per user, FY18 data from the Comprehensive Autism Care Demonstration ACD was examined. It was determined that ADFM patients had an average and median of 8 months of care in the ACD
during FY18. As a result, 8 months is a reasonable proxy for the number of months of respite care an average patient would use if the number of months were not constrained. Therefore, it was assumed that the average patients family would use respite care
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services for 8 months on average.
Baseline respite users were multiplied first by average months per year of respite care per user, then by average respite hours per month, and lastly by average paid amount per hour for respite care. This results in an estimated total of $182,235 in paid costs under the new benefit for baseline respite care users $51,441 + $104,495 + $13,079 +
$13,220.
Then, added costs for those beneficiaries currently using only nonrespite ECHO care during FY18 were estimated. In order to estimate respite care user uptake rates under the expanded benefit, it is important to understand why current rates for nonEHHC ECHO users are so low between 0.2 percent for patients not diagnosed with autism and 5 percent for patients diagnosed with autism. The National Respite Coalition Task Force has surveyed families in the civilian world on the reasons why respite care uptake is low. Five reasons possibly apply to ECHO beneficiaries: Restrictive eligibility criteria, lack of information about respite program availability, inadequate supply of trained providers, inability to relate to or trust non-family caregivers, and guilt. The Department concludes that a revised policy for ECHO respite care would be largely influenced by the first two reasons: The extent to which restricted eligibility criteria will be reduced in our case concurrency will no longer be required and the extent to which the current lack of information about ECHOs respite benefit is reduced. Consequently, the Department concludes that utilization rates under the revised ECHO respite benefit will largely be dependent upon 1 the fact that the respite benefit will now be available in all 12 months of the year independent of non-respite care ECHO use, and 2 the extent to which the new respite benefit would be promoted by the MCSCs, the Exceptional Family Member Program EFMP, DHA, and related advocacy groups.
Some new beneficiaries may be drawn into the program because of the value of the new benefit i.e., that it can be used in any month. Also, others could be drawn to use respite care because of promotion of the benefit through various media by interested parties. The MCSCs, EFMP, advocacy groups e.g., Autism Speaks and DHA will likely provide information by means of newsletters, web page postings, and other media. This information would then spread by word of mouth and online chat groups. While some studies have suggested respite care uptake rates of 15 to 20 percent, it is likely that these
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