(a) Purpose.
The CHCBP is a premium-based
temporary health care coverage program, authorized by 10 U.S.C.
1078a, and available to individuals who meet the eligibility and
enrollment criteria as set forth in paragraph (d)(1) of this section.
The CHCBP is not part of the TRICARE program. However, as set forth
in this section, it functions under similar rules and procedures
to the TRICARE Select program. Because the purpose of the CHCBP
is to provide a continuation health care benefit for Department
of Defense and the other uniformed services beneficiaries losing
eligibility, it will be administered so that it appears, to the
maximum extent practicable, to be part of the TRICARE Select program.
Medical coverage under this program will be the same as the benefits
payable under the TRICARE Select program. There is a cost for enrollment
to the CHCBP and these premium costs must be paid by CHCBP enrollees
before any care may be cost shared.
(b) General provisions.
Except for any
provisions the Director of the TRICARE Management Activity may exclude,
the general provisions of Sec. 199.1 shall apply to the CHCBP as
they do to TRICARE.
(c) Definitions.
Except
as may be specifically provided in this section, to the extent terms
defined in Sec. 199.2 are relevant to the administration of the
CHCBP, the definitions contained in that section shall apply to
the CHCBP as they do to the TRICARE Select program.
(d) Eligibility and
enrollment.
(1) Eligibility.
Enrollment in
the CHCBP is open to any individual, except as noted in this section,
who:
(i) Ceases to meet the requirements for eligibility
under 10 U.S.C. chapter 55 or 10 U.S.C. 1145, and
(ii) Who
on the day before they cease to meet the eligibility requirements
for such care they were covered under a health benefit plan under
10 U.S.C. chapter 55 or transitional healthcare under 10 U.S.C.
1145, and
(iii) Who would otherwise
not be eligible for any benefits under 10 U.S.C. chapter 55 or 10
U.S.C. 1145 except for CHCBP.
(2) Exceptions.
The following individuals
are not eligible to enroll in CHCBP:
(i) Members
of uniformed services, who are discharged or released from active
duty either voluntarily or involuntarily under conditions that are
adverse.
(ii) Individuals who
lost their eligibility or entitlement to care under 10 U.S.C. chapter
55 or 10 U.S.C. 1145 before October 1, 1994.
(iii) Individuals
who are locked out of other TRICARE programs per that program’s
requirements.
(3) Effective date.
Eligibility in the CHCBP is
limited to individuals who lost their entitlement to benefits under
the MHS on or after October 1, 1994. The effective date of their
coverage under CHCBP shall begin on the day after they cease to
be eligible for care under 10 U.S.C. chapter 55 or 10 U.S.C. 1145.
(4) Notification
of eligibility.
(i) The Department of Defense and the other uniformed
services (National Oceanic and Atmospheric Administration (NOAA),
Public Health Service (PHS), and Coast Guard) will notify persons
in the uniformed services eligible to receive health benefits under
the CHCBP. In the case of a member who becomes (or will become)
eligible for continued coverage, the Department of Defense shall
notify the member of their rights for coverage as part of pre-separation counseling
conducted under 10 U.S.C. 1142.
(ii) In the case of
a dependent of a member or former member who become eligible for
continued coverage under paragraph (d)(1)(ii) of this section:
(A) The
member or former member may submit to the CHCBP contractor a notice
with supporting documentation of the dependent’s change in status
(including the dependent’s name, address, and such other information
needed); and
(B) The CHCBP contractor,
within fourteen (14) days after receiving such information, will
inform the dependent of the dependent’s rights under 10 U.S.C. 1142.
(iii) In
the case of a former spouse of a member or former member who becomes
eligible for continued coverage, the member, former member or former
spouse may submit to the CHCBP contractor a notice of the former
spouse’s change in status. The CHCBP contractor within fourteen
(14) days after receiving such information will notify the individual
of their potential eligibility for CHCBP.
(5) Election of coverage.
In order to
obtain coverage under the CHCBP, a written election by the eligible
beneficiary must be made within a prescribed time period.
(i) In
the case of a member discharged or released from active duty or
full-time National Guard duty (whether voluntarily or involuntarily),
or a RC member formerly eligible for care under 10 U.S.C. chapter 55,
the written election shall be submitted to the CHCBP contractor
before the end of the 60-day period beginning on the later of:
(A) The
date of the discharge or release of the member; or
(B) The
date that the period of transitional health care applicable to the
member under 10 U.S.C. 1145(a) ends; or
(C) The
date the member receives the notification required in paragraph
(d)(3) of this section.
(ii) In the case of
a child who ceases to meet the requirements for being an unremarried
dependent child of a member or former member under 10 U.S.C. 1072(2)(D)
or an unmarried dependent of a member or former member of the uniformed
services under 10 U.S.C. 1072(2)(I), the written election shall
be submitted to the CHCBP contractor before the end of the 60-day
period beginning on the later of:
(A) The date that the
dependent ceases to meet the definition of a dependent under 10
U.S.C. 1072(2)(D) or 10 U.S.C. 1072(2)(I); or
(B) The
date that the dependent receives the notification required in paragraph
(d)(3) of this section,
(iii) In the case of
former spouse of a member or former member, the written election
shall be submitted to the CHCBP contractor before the end of the
60-day period beginning on the date as of which the former spouse
first ceases to meet the requirements for being considered a dependent under
10 U.S.C. 1072(2).
(iv) In the case of
an unmarried surviving spouse of a member or former member of the
uniformed services who on the day before the death of the member
or former member was covered under 10 U.S.C. chapter 55 or 10 U.S.C.
1145(a), the written election shall be submitted to the CHCBP contractor within
60 days of the date of the member or former member’s death.
(v) A
member of the uniformed services who is eligible for enrollment
under paragraph (d)(1) of this section may elect self-only or family
coverage. Family members who may be included in such family coverage
are the spouse and children of the member.
(vi) All
other categories eligible for enrollment under paragraph (d)(1)
of this section must elect self-only coverage.
(6) Enrollment.
To enroll in
the CHCBP, an eligible individual must submit the completed enrollment form
designated by the Director, TRICARE as well as any documentation
as requested on the enrollment form to verify the applicant’s eligibility
for enrolling in CHCBP, and payment to cover the quarter’s premium.
The CHCBP contractor may request additional information and documentation
to confirm the applicant’s eligibility for CHCBP.
(7) Period of coverage.
Except as noted
below CHCBP coverage may not extend beyond 18 months from the date
the individual becomes eligible for CHCBP. Although beneficiaries
have sixty (60) days to elect coverage under the CHCBP, upon enrolling,
the period of coverage must begin the day after entitlement or eligibility
to a military health care plan ends as though no break in coverage
had occurred notwithstanding the date the enrollment form with any
applicable premium is submitted.
(i) Exceptions:
(A) In
the case of a child of a member or former member, the date which
is 36 months after the date on which the person first ceases to
meet the requirements for being considered an unmarried dependent
child under 10 U.S.C. 1072(2)(D) or 10 U.S.C. 1072(2)(I).
(B) In
the case of an unremarried former spouse (as this term is defined
in 10 U.S.C. 1072(2)(G) or (H)) of a member or former member, the
date which is 36 months after the later of:
(1) The date
on which the final decree of divorce, dissolution, or annulment
occurs; or
(2) If applicable,
the date the one-year extension of dependency under 10 U.S.C. 1072(2)(H)
expires.
(C) In the case of
an unremarried surviving spouse (widow or widower) (under 10 U.S.C.
1072(2)(B) or (C)) of a member or former member of the uniformed
services who is not otherwise eligible for care under 10 U.S.C.
chapter 55, the date which is 36 months after the date the surviving
spouse becomes ineligible under 10 U.S.C chapter 55 or 10 U.S.C.
1145(a).
(D)
In
the case of a former spouse of a member or former member (other
than the former spouse whose marriage was dissolved after the separation
of the member from the service unless such separation was by retirement),
the period of coverage under the CHCBP is unlimited, if former spouse:(1) Has not remarried before
age of 55 after the marriage to the member or former member was dissolved;
and
(2) Was
eligible for TRICARE as a dependent or enrolled in CHCBP at any
time during the 18 month period before the date of the divorce,
dissolution, or annulment; and
(3) Is receiving a portion of the retired
or retainer pay of a member or former member or an annuity based
on the retainer pay of the member; or
(4) Has a court order for payment of any portion
of the retired or retainer pay or has a written agreement (whether
voluntary or pursuant to a court order) which provides for an election
by the member or former member to provide an annuity to the former
spouse.
(E) For the beneficiary
who becomes eligible for the CHCBP by ceasing to meet the requirements
for being considered an unmarried dependent child of a member or
former member, health care coverage may not extend beyond the date
which is 36 months after the date the member becomes ineligible
for medical and dental care under 10 U.S.C. 1074(a) and any transitional
health care under 10 U.S.C. 1145(a).
(e) CHCBP benefits.
(1) In general.
Except
as provided in paragraph (e)(2) of this section, the provisions
of Sec. 199.4 shall apply to the CHCBP as they do to TRICARE Select
under Sec. 199.17.
(2) Exceptions.
The following
provisions of Sec. 199.4 are not applicable to the CHCBP:
(i) Section
199.4(a)(2) concerning eligibility.
(ii) All provisions
regarding requirements to use facilities of the uniformed services
because CHCBP enrollees are not eligible to use those facilities.
(3) Beneficiary liability.
For
purposes of CHCBP coverage, the beneficiary deductible, catastrophic cap
and cost share provisions of the TRICARE Select plan applicable
to Group B beneficiaries under Sec. 199.17(l)(2)(ii) shall apply
based on the category of beneficiary (e.g., Active Duty Family Member
or Retiree Family) to which the CHCBP enrollee last belonged, except
that for separating active duty members, amounts applicable to TRICARE
Select Active Duty Family Members shall apply. The premium under
paragraph (q) of this section applies instead of any TRICARE Select
plan enrollment fee under Sec. 199.17.
(f) Authorized providers.
The
provisions of Sec. 199.6 shall apply to the CHCBP as they do to TRICARE
Select program.
(g) Claims submission,
review, and payment.
The provisions of Sec. 199.7
shall apply to the CHCBP as they do to TRICARE Select program except
no provisions regarding nonavailability statements shall apply.
(h) Double coverage.
The
provisions of Sec. 199.8 shall apply to the CHCBP as they do to
TRICARE Select program.
(i) Administrative
remedies for fraud, abuse, and conflict of interest.
The
provisions of Sec. 199.9 shall apply to the CHCBP as they do to
TRICARE Select program.
(j) Appeal and hearing
procedures.
The
provisions of Sec. 199.10 shall apply to the CHCBP as they do to
TRICARE Select program.
(k) Overpayments recovery.
The
provisions of Sec. 199.11 shall apply to the CHCBP as they do to TRICARE
Select program.
(l) Third party recoveries.
The
provisions of Sec. 199.12 shall apply to the CHCBP as they do to TRICARE
Select program.
(m) Provider reimbursement
methods.
The
provisions of Sec. 199.14 shall apply to the CHCBP as they do to
TRICARE Select program.
(n) Quality and Utilization
Review Peer Review Organization Program.
The provisions
of Sec. 199.15 shall apply to the CHCBP as they do to TRICARE Select
program.
(o) [Reserved]
(p) Special programs
not applicable.
(1) In
general.
Special
programs established under this part that are not part of the TRICARE
Select program are not, unless specifically provided in this section, available
to participants in the CHCBP.
(2) Examples.
The special
programs referred to in paragraph (p)(1) of this section include
but are not limited to:
(i) The Extended Care
Health Option under Sec. 199.5;
(ii) The TRICARE Dental
Program or Retiree Dental Program under Sec. 199.13 and 199.22 respectively;
(iii) The
Supplemental Health Care Program under Sec. 199.16; and
(iv) The
TRICARE Prime Program under Sec. 199.17.
(q) Premiums.
(1) Rates.
Premium rates
will be established by the Assistant Secretary of Defense (Health
Affairs) for two rate groups--individual and family. Eligible beneficiaries
will select the level of coverage they require at the time of initial
enrollment (either individual or family) and pay the appropriate
premium payment. The rates are based on Federal Employees Health
Benefits Program employee and agency contributions required for
a comparable health benefits plan, plus an administrative fee. The
administrative fee, not to exceed ten percent of the basic premium
amount, shall be determined based on actual expected administrative
costs for administration of the program. Premiums may be revised
annually and shall be published when the premium amount is changed. Premiums
will be paid by enrollees quarterly.
(2) Effects of failure
to make premium payments.
Failure by enrollees to submit timely and
proper premium payments will result in denial of continued enrollment
and denial of payment of medical claims. Premium payments that are
late thirty (30) days or more past the start of the quarter for
which payment is due will result in the termination of beneficiary
enrollment. Beneficiaries denied continued enrollment due to lack
of premium payments will not be allowed to reenroll. In such a case,
benefit coverage will cease at the end of the ninety (90) day period
for which a premium payment was received. Enrollees will be held
liable for medical costs incurred after losing eligibility.
(r) Procedures.
The Director,
TRICARE Management Activity, may establish other rules and procedures
for the administration of the CHCBP.
[59 FR 49818, Sep 30, 1994, as amended at
62 FR 35097, Jun 30, 1997; 64 FR 46141, Aug 24, 1999; 69 FR 44952,
Jul 28, 2004; 69 FR 51569, Aug 20, 2004; 76 FR 57639, Sep 16, 2011;
82 FR 45457, Sep 29, 2017]