(a) General.
This section sets forth those persons who,
by the provisions of 10 U.S.C. chapter 55, and the NATO Status of
Forces Agreement, are eligible for CHAMPUS benefits. A determination
that a person is eligible does not automatically entitle such a
person to CHAMPUS payments. Before any CHAMPUS benefits may be extended,
additional requirements, as set forth in other sections of this
part, must be met. Additionally, the use of CHAMPUS may be denied
if a Uniformed Service medical treatment facility capable of providing
the needed care is available. CHAMPUS relies primarily on the Defense
Enrollment Eligibility Reporting System (DEERS) for eligibility
verification.
(b)
CHAMPUS eligibles--
(1) Retiree.
A member or
former member of a Uniformed Service who is entitled to retired,
retainer, or equivalent pay based on duty in a Uniformed Service.
(2) Dependent.
Individuals
whose relationship to the sponsor leads to entitlement to benefits. CHAMPUS
eligible dependents include the following:
(i) Spouse.
A lawful husband
or wife of a member or former member. The spouse of a deceased member
or retiree must not be remarried. A former spouse also may qualify
for benefits as a dependent spouse. A former spouse is a spouse
who was married to a military member, or former member, but whose
marriage has been terminated by a final decree of divorce, dissolution
or annulment. To be eligible for CHAMPUS benefits, a former spouse
must meet the criteria described in paragraphs (b)(2)(i)(A) through
(b)(2)(i)(E) of this section and must qualify under
the group defined in paragraph (b)(2)(i)(F)(1)
or (b)(2)(i)(F)(2) of this section.
(A) Must
be unremarried; and
(B) Must not be covered
by an employer-sponsored health plan; and
(C) Must
have been married to a member or former member who performed at
least 20 years of service which can be credited in determining the
member’s or former member’s eligibility for retired or retainer
pay; and
(D) Must not be eligible
for Part A of Title XVIII of the Social Security Act (Medicare)
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii),
and (f)(3)(ix) of this section; and
(E) Must not be the
dependent of a NATO member; and
(F) Must meet the requirements
of paragraph (b)(2)(i)(F)(
1) or (b)(2)(i)(F)(
2)
of this section:
(1) The former
spouse must have been married to the same member or former member
for at least 20 years, at least 20 of which were creditable in determining
the member’s or former member’s eligibility for retired or retainer
pay. Eligibility continues indefinitely unless affected by any of
the conditions of paragraphs (b)(2)(i)(A) through (b)(2)(i)(E) of
this section.
(i) If the date of the final decree of divorce,
dissolution, or annulment was before February 1, 1983, the former
spouse is eligible for CHAMPUS coverage of health care received
on or after January 1, 1985.
(ii) If the date
of the final decree of the divorce, dissolution, or annulment was
on or after February 1, 1983, the former spouse is eligible for
CHAMPUS coverage of health care which is received on or after the
date of the divorce, dissolution, or annulment.
(2) The former spouse must have been married
to the same member or former member for at least 20 years, and at
least 15, but less than 20 of those married years were creditable
in determining the member’s or former member’s eligibility for retired
or retainer pay.
(i) If the date
of the final decree of divorce, dissolution, or annulment is before
April 1, 1985, the former spouse is eligible only for care received
on or after January 1, 1985, or the date of the divorce, dissolution,
or annulment, whichever is later. Eligibility continues indefinitely
unless affected by any of the conditions of paragraphs (b)(2)(i)(A)
through (b)(2)(i)(E) of this section.
(ii) If the date of the final decree of divorce,
dissolution or annulment is on or after April 1, 1985, but before
September 29, 1988, the former spouse is eligible only for care
received from the date of the decree of divorce, dissolution, or
annulment until December 31, 1988, or for two years from the date
of the divorce, dissolution, or annulment, whichever is later.
(iii) If the date of the final decree of divorce,
dissolution, or annulment is on or after September 29, 1988, the
former spouse is eligible only for care received within the 365
days (366 days in the case of a leap year) immediately following
the date of the divorce, dissolution, or annulment.
(ii) Child.
A dependent
child is an unmarried child of a member or former member who has
not reached his or her twenty-first (21st) birthday, except an incapacitated
adopted child meeting the requirements of paragraph (b)(2)(ii)(H)(2)
of this section, and who bears one of the following relationships
to a member or former member of one of the Uniformed Services:
(A) A
legitimate child; or
(B) An adopted child
whose adoption has been legally completed on or before the child’s
twenty-first (21st) birthday; or
(C) A legitimate stepchild;
or
(D) An illegitimate child of a member or
former member whose paternity/maternity has been determined
judicially, and the member or former member directed to support
the child; or
(E) An illegitimate
child of a member or former member whose paternity/maternity
has not been determined judicially, who resides with or in the home
provided by the member or former member, and is or continues to
be dependent upon the member or former member for over one-half
of his or her support, or who was so dependent on the former member
at the time of the former member’s death; or
(F) An
illegitimate child of a spouse of a member who
resides with or in a home provided by the member and is, and continues
to be dependent upon the member for over one-half of his or her support;
or
(G) An illegitimate child of a spouse of
a former member who resides with or in a home provided
by a former member or the former member’s spouse at the time of
death of the former member, and is, or continues to be, or was,
dependent upon the former member for more than one-half of his or
her support at the time of death; or
(H) An individual who
falls into one of the following classes:
(1) A
student.
A
child determined to be a member of one of the classes in paragraphs
(b)(2)(ii)(A) through (b)(2)(ii)(G) of this section, who is not
married, has passed his or her 21st birthday but has not passed
his or her 23rd birthday, is dependent upon the member or former
member for over 50 percent of his or her support or was dependent
upon the member or former member for over 50 percent of his or her
support on the date of the member’s or former member’s death, and
is pursuing a full-time course of education in an institution of
higher learning approved by the Secretary of Defense or the Department
of Education (as appropriate) or by a state agency under 38 U.S.C.
chapters 34 and 35.
Note: Courses of
education offered by institutions listed in the “Education Directory,”
“Higher Education” or “Accredited Higher Institutions” issued periodically
by the Department of Education meet the criteria approved by the
Administering Secretary or the Secretary of Education. For determination of
approval of courses offered by a foreign institution, by an institution
not listed in either of the above directories, or by an institution
not approved by a state agency pursuant to 38 U.S.C. chapters 34
and 35, a statement may be obtained from the Department of Education,
Washington, D.C. 20202.
(2) An
incapacitated child.
A child determined to be a member of one of
the classes in paragraphs (b)(2)(ii)(A) through (b)(2)(ii)(G) of
this section, who is not married and is incapable of self-support because
of a mental or physical disability that:
(i) Existed before the child’s twenty-first
(21st) birthday; or
(ii) Occurred
between the ages of 21 and 23 while the child was enrolled in a
full-time course of study in an institution of higher learning approved
by the Administering Secretary or the Department of Education (see
NOTE to paragraph (b)(2)(ii)(H)(2)(iii)
of this section), and is or was at the time of the member’s or former
member’s death dependent on the member or former member for over
one-half of his or her support; and
(iii) The incapacity is continuous. (If the
incapacity significantly improves or ceases at any time, CHAMPUS
eligibility cannot be reinstated on the basis of the incapacity,
unless the incapacity recurs and the beneficiary is under age 21,
or is under age 23 and is enrolled as a full-time student under paragraph
(b)(2)(ii)(H)(
2)(
ii) of this section.
If the child was not incapacitated after that date, no CHAMPUS eligibility
exists on the basis of the incapacity. However, incapacitated children
who marry and who subsequently become unmarried through divorce,
annulment, or death of spouse, may be reinstated as long as they
still meet all other requirements).
Note: An institution
of higher learning is a college, university, or similar institution,
including a technical or business school, offering post-secondary
level academic instruction that leads to an associate or higher
degree, if the school is empowered by the appropriate State education
authority under State law to grant an associate, or higher, degree.
When there is no State law to authorize the granting of a degree,
the school may be recognized as an institution of higher learning
if it is accredited for degree programs by a recognized accrediting
agency. The term also shall include a hospital offering educational
programs at the post-secondary level regardless of whether the hospital
grants a post-secondary degree. The term also shall include an educational
institution that is not located in a State, that offers a course
leading to a standard college degree, or the equivalent, and that
is recognized as such by the Secretary of Education (or comparable
official) of the country, or other jurisdiction, in which the institution
is located (38 U.S.C. chapter 34, section 1661, and chapter 35,
section 1701.
Courses of education
offered by institutions listed in the “Education Directory,” “Higher
Education” or “Accredited Higher Institutions” issued periodically
by the Department of Education meet the criteria approved by the
Administering Secretary or the Secretary of Education. For determination
of approval of courses offered by a foreign institution, by an institution
not listed in either of the above directories, or by an institution
not approved by a state agency pursuant to chapters 34 and 35 of
38 U.S.C., a statement may be obtained from the Department of Education,
Washington, D.C. 20202.
(3) A child of
a deceased reservist.
A child, who is determined to be a member
of one of the classes in paragraphs (b)(2)(ii)(A) through (b)(2)(ii)(G)
of this section, of a reservist in a Uniformed Service who incurs
or aggravates an injury, illness, or disease, during, or on the
way to or from, active duty training for a period of 30 days or
less or inactive duty training, and the reservist dies as a result
of that specific injury, illness or disease.
(4) An unmarried
person.
An
unmarried person placed in the home of a member or former member prior
to adoption. To be a dependent child, the unmarried person must
not have reached the age of 21 (or otherwise meets the requirements
of a student or incapacitated child set out in paragraphs (b)(2)((ii)(H)(1)
or (b)(2)(ii)(H)(2) of this section) and has been placed in the
home of the member or former member by a recognized placement agency
or by any other source authorized by State or local law to provide
adoption placement, in anticipation of legal adoption by the member
or former member.
(iii) Abused
dependents.--
(A) Categories
of abused dependents.
An abused dependent may be either a spouse
or a child. Eligibility for either class of abused dependent results
from being either:
(1) The spouse
(including a former spouse) or child of a member who has received
a dishonorable or bad-conduct discharge, or dismissal from a Uniformed
Service as a result of a court-martial conviction for an offense
involving physical or emotional abuse of the spouse or child, or
was administratively discharged as a result of such an offense.
Until October 17, 1998, Medical benefits are limited to care related
to the physical or emotional abuse and for a period of 12 months
following the member’s separation from the Uniformed Service. On
or after October 17, 1998, medical benefits can include all under
the Basic Program and under the Extended Care Health Option for
the period that the spouse or child is in receipt of transitional
compensation under section 1059 of title 10 U.S.C.
(2) The spouse (including a former spouse)
or child of a member or former member who while a member and as
a result of misconduct involving abuse of the spouse or child has
eligibility to receive retired pay on the basis of years of service
terminated.
(B) Requirements for categories of abused dependents--
(1) Abused spouse.
As long as the
spouse is receiving payments from the DoD Military Retirement Fund
under court order, the spouse is eligible for health care under
the same conditions as any spouse of a retired member. The abused
spouse must:
(i) Under paragraph
(b)(2)(iii)(A)(1) of this section, be a lawful
husband or wife or a former spouse of the member; or
(ii) Under paragraph (b)(2)(iii)(A)(
2)
of this section, be a lawful husband or wife or a former spouse
of the member or former member, and the spouse is receiving payments
from the Department of Defense Military Retirement Fund under 10
U.S.C. 1408(h) pursuant to a court order; and
(A) Be a victim of the abuse; and
(B) Have been married to the member or former
member at the time of the abuse; or
(C) Be the natural or adoptive parent of a
dependent child of the member or former member who was the victim
of the abuse.
(2) Abused child.
The abused child
must:
(i) Under paragraph
(b)(2)(iii)(A)(1) of this section, be a dependent
child of the member or former member.
(ii) Under paragraph (b)(2)(iii)(A)(
2)
of this section,
(A) Have been
a member of the household where the abuse occurred; and
(B) Be an unmarried legitimate child, including
an adopted child or stepchild of the member or former member; and
(C) Be under the age of 18; or
(D) Be incapable of self support because of
a mental or physical incapacity that existed before becoming 18
years of age and be dependent on the member or former member for
over one-half of his or her support; or
(E) If enrolled in a full-time course of study
in an institution of higher learning recognized by the Secretary
of Defense (for the purposed of 10 U.S.C. 1408(h)), be under 23
years of age and be dependent on the member or former member for
over one-half of his or her support.
(F) The dependent child is eligible for health
care, regardless of whether any court order exists, under the same
conditions as any dependent of a retired member.
(3) TAMP eligibles.
A former member,
including his or her dependents, who is eligible under the provisions
of the Transitional Assistance Management Program as described in
paragraph (e) of this Sec. 199.3.
(iv) An
unmarried person who is placed in the legal custody of a member
or former member by a court of competent jurisdiction in the United
States (or possession of the United States) for a period of at least
12 consecutive months. The unmarried person shall be considered
a dependent of the member or former member under this section provided
he or she otherwise meets the following qualifications:
(A) Has
not reached the age of 21 unless he or she otherwise meets the requirements
of a student set out in paragraph (b)(2)(ii)(H)(1) of this section
or the requirements for being incapacitated as set out in paragraph
(b)(2)(ii)(H)(2) of this section and the incapacitation occurred
while he or she was a dependent of the member or former member through
court ordered legal custody;
(B) Is dependent on
the member or former member for over one-half of the person’s support;
(C) Resides
with the member or former member unless separated by the necessity
of military service or to receive institutional care as a result
of disability or incapacitation or under such other authorized circumstances;
and,
(D) Is not a dependent of a member or former member
under any other provision of law or regulation.
(3) Eligibility under
TRICARE Senior Pharmacy Program.
Section 711 of the National Defense Authorization
Act for Fiscal Year 2001 (Public Law 106-398, 114 Stat. 1654) established
the TRICARE Senior Pharmacy Program effective April 1, 2001. To
be eligible for this program, a person is required to be:
(i) Medicare
eligible, who is:
(A) 65 years of age or older; and
(B) Entitled
to Medicare Part A; and
(C) Enrolled in Medicare
Part B, except for a person who attained age 65 prior to April 1,
2001, is not required to enroll in Part B; and
(ii) Otherwise
qualified under one of the following categories:
(A) A
retired uniformed service member who is entitled to retired or retainer
pay, or equivalent pay including survivors who are annuitants; or
(B) A
dependent of a member of the uniformed services described in one
of the following:
(1) A member
who is on active duty for a period of more than 30 days or died
while on such duty; or
(2) A member
who died from an injury, illness, or disease incurred or aggravated
while the member was:
(i) On active
duty under a call or order to active duty of 30 days or less, on
active duty for training, or on inactive duty training; or
(ii) Traveling to or from the place at which
the member was to perform or had performed such active duty, active
duty for training, or inactive duty training.
Note to paragraph (b)(3)(ii)(B): Dependent
under Section 711 of the National Defense Authorization Act for
Fiscal Year 2001 includes spouse, unremarried widow/widower, child,
parent/parent-in-law, unremarried former spouse, and unmarried person
in the legal custody of a member or former member, as those terms
of dependency are defined and periods of eligibility are set forth
in 10 U.S.C. 1072(2).
(4) Medal of Honor
recipients.
(i) A former member of the armed forces who is a
Medal of Honor recipient and who is not otherwise entitled to medical
and dental benefits has the same CHAMPUS eligibility as does a retiree.
(ii) Immediate dependents.
CHAMPUS eligible
dependents of a Medal of Honor Recipient are those identified in
paragraphs (b)(2)(i) of this section (except for former spouses)
and (b)(2)(ii) of this section (except for a child placed in legal
custody of a Medal of Honor recipient under (b)(2)(ii)(H)(4) of
this section).
(iii) Effective date.
The CHAMPUS
eligibility established by paragraphs (b)(4)(i) and (ii) of this
section is applicable to health care services provided on or after
October 30, 2000.
(5) Reserve
Component Members Issued Delayed-Effective-Date Orders.
(i) Member.
A member of
a reserve component of the armed forces who is ordered to active
duty for a period of more than 30 consecutive days in support of
a contingency operation under a provision of law referred to in
section 101(a)(13)(B) of Title 10, United States Code, that provides
for active-duty service to begin on a date after the date of the
issuance of the order.
(ii) Dependents.
CHAMPUS eligible
dependents under this paragraph (b)(5) are those identified in paragraphs
(b)(2)(i) (except former spouses) and (b)(2)(ii) of this section.
(iii) Effective date.
The eligibility
established by paragraphs (b)(5)(i) and (ii) of this section shall
begin on or after November 6, 2003, and shall be effective on the
later of the date that is:
(A) The date of issuance
of the order referred to in paragraph (b)(5)(i) of this section;
or
(B) 180 days before the date on which the period
of active duty is to begin.
(iv) Termination
date.
The
eligibility established by paragraphs (b)(5)(i) and (ii) of this
section ends upon entry of the member onto active duty (at which
time CHAMPUS eligibility for the dependents of the member is established
under paragraph (b)(2) of this section) or upon cancellation or
amendment of the orders referred to in paragraph (b)(5)(i) of this
section such that they no longer meet the requirements of that paragraph
(b)(5)(i).
(c) Beginning dates
of eligibility.
(1) Beginning dates of eligibility depend on the
class to which the individual belongs and the date the individual
became a member of the class. Those who join after the class became
eligible attain individual eligibility on the date they join.
(2) Beginning
dates of eligibility for each class of spouse
(excluding
spouses who are victims of abuse and eligible spouses of certain
deceased reservists) are as follows:
(i) A spouse of a member
for:
(A) Medical benefits authorized by the Dependents’
Medical Care Act of 1956, December 7, 1956;
(B) Outpatient
medical benefits under the Basic Program, October 1, 1966;
(C) Inpatient
medical benefits under the Basic Program and benefits
under the Extended Care Health Option, January 1, 1967;
(ii) A
spouse of a former member:
(A) For medical benefits
under the Basic Program, January 1, 1967.
(B) Ineligible
for benefits under the Extended Care Health Option.
(iii) A
former spouse:
(A) For medical benefits under the Basic Program,
dates of beginning eligibility are as indicated for each category
of eligible former spouse identified within paragraph (b)(2)(i)
of this section.
(B) Ineligible for
benefits under the Extended Care Health Option.
(3) Beginning
dates of eligibility for spouses who are victims of abuse
(excluding
spouses who are victims of abuse of certain deceased reservists) are
as follows:
(i) An abused spouse meeting the requirements of
paragraph (b)(2)(iii)(A)(
1) of this section, including
an eligible former spouse:
(A) For medical and
dental care for problems associated with the physical or emotional
abuse under the Basic Program for a period of up to one year (12
months) following the person’s separation from the Uniformed Service,
November 14, 1986.
(B) For all medical
and dental benefits under the Basic Program for the period that
the spouse is in receipt of transitional compensation under section
1059 of title 10 U.S.C., October 17, 1998.
(C) For
medical and dental care for problems associated with the physical
or emotional abuse under the Extended Care Health Option for a period
up to one year (12 months) following the person’s separation from
the Uniformed Service, November 14, 1986.
(D) For
all medical and dental benefits described in section 199.5 for the
period that the spouse is in receipt of transitional compensation
under section 1059 of title 10 U.S.C., October 17, 1998.
(ii) An
abused spouse meeting the requirements of paragraphs (b)(2)(iii)(A)(
2)
of this section, including an eligible former spouse:
(A) For
all benefits under the CHAMPUS Basic Program, October 23, 1992.
(B) Ineligible
for benefits under the Extended Care Health Option.
(4) Beginning
dates of eligibility for spouses of certain deceased reservists,
including
spouses who are victims of abuse of certain deceased reservists,
are as follows:
(i) A spouse meeting the requirements of paragraph
(b)(2)(i) of this section, including an eligible former spouse:
(A) For
benefits under the Basic Program, November 14, 1986.
(B) Ineligible
for benefits under the Extended Care Health Option.
(ii) An
abused spouse of certain deceased reservists, meeting the requirements
of paragraphs (b)(2)(iii) of this section, including an eligible
former spouse,
for the limited benefits and period of eligibility described
in paragraphs (b)(2)(iii) of this section:
(A) For benefits under
the Basic Program, November 14, 1986.
(B) For
benefits under the Extended Care Health Option, November 14, 1986.
(iii) An
abused spouse of certain deceased reservists, including an eligible
former spouse, meeting the requirements of paragraphs (b)(2)(iii)
of this section:
(A) For benefits under the Basic Program, October
23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(5)
Beginning
dates of eligibility for each class of dependent children,
(excluding
dependent children of certain deceased reservists, abused children
and incapacitated children whose incapacity occurred between the
ages of 21 and 23 while enrolled in a full-time course of study
in an institution of higher learning), are as follows:
(i) Legitimate
child, adopted child, or legitimate stepchild of a
member,
for:
(A) Medical benefits authorized by the Dependents’
Medical Care Act of 1956, December 7, 1956;
(B) Outpatient
medical benefits under the Basic Program, October 1, 1966;
(C) Inpatient
medical benefits under the Basic Program and benefits
under the Extended Care Health Option, January 1, 1967;
(ii) Legitimate
child, adopted child or legitimate stepchild of
former members:
(A) For
medical benefits under the Basic Program, January 1, 1967.
(B) Ineligible
for benefits under the Extended Care Health Option.
(iii) Illegitimate
child of a male or female
member or former member whose
paternity/maternity has been determined judicially and the member
or former member has been directed to support the child, for:
(A) All
benefits for which otherwise entitled, August 31, 1972.
(B) Extended
Care Health Option benefits limited to dependent children of members
only, August 31, 1972.
(iv) Illegitimate child
of:
(A) A male member or former member whose paternity has
not been determined judicially:
(B) A
female member or former member who resides with, or in a home provided
by the member or former member, or who was residing in a home provided
by the member or former member at the time of the member’s or former
member’s death, and who is or continues to be dependent on the member for
over one-half of his or her support, or was so dependent on the
member or former member at the time of death;
(C) A
spouse of a member or former member who resides with or in a home
provided by the member or former member, or the parent who is the
spouse of the member or former member or was the spouse of a member
or former member at the time of death, and who is and continues
to be dependent upon the member or former member for over one-half
of his or her support, or was so dependent on the member or former
member at the time of death; for:
(1) All benefits
for which otherwise eligible, January 1, 1969.
(2) Extended Care Health Option limited to
dependent children of members only, January 1,
1969.
(6) Beginning dates
of eligibility for children of certain deceased reservists who meet
the requirements of paragraph (b)(2)(ii)(H)(3) of this section,
excluding
incapacitated children who meet the requirements of paragraph (b)(2)(ii)(H)(
2)
of this section, for:
(i) Benefits under
the Basic program, November 14, 1986.
(ii) Not
eligible for benefits under the Extended Care Health Option.
(7) Beginning
dates of eligibility for children who are victims of abuse,
including
incapacitated children who meet the requirements of paragraph
(b)(2)(ii)(H)(
2) of this section are as follows:
(i) An
abused child meeting the requirements of paragraph (b)(2)(iii)(A)(
1)
of this section:
(A) Medical and dental care for problems associated
with the physical or emotional abuse under the Basic Program for
a period of up to one year (12 months) following the person’s separation
from the Uniformed Service, November 14, 1986.
(B) For
all medical and dental benefits under the Basic Program for the
period that the child is in receipt of transitional compensation
under section 1059 of title 10 U.S.C., October 17, 1998.
(C) Medical
and dental care for problems associated with the physical or emotional
abuse under the Extended Care Health Option for a period up to one
year (12 months) following the person’s separation from the Uniformed
Service, November 14, 1986.
(D) For all medical
and dental benefits described in section 199.5 for the period that
the child is in receipt of transitional compensation under section
1059 of title 10 U.S.C., October 17, 1998.
(ii) An
abused child meeting the requirements of paragraphs (b)(2)(iii)(A)(
2)
of this section:
(A) For all benefits under the CHAMPUS Basic Program,
October 23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(8) Beginning
dates of eligibility for incapacitated children who meet the requirements
of paragraph (b)(2)(ii)(H)(
2) of this section,
whose incapacity occurred between the ages of 21 and 23 while enrolled in
a full-time course of study in an institution of higher learning
approved by the Administering Secretary or the Department of Education,
and, are or were at the time of the member’s or former member’s
death, dependent on the member or former member for over one-half
of their support, for:
(i) All benefits for
which otherwise entitled, October 23, 1992.
(ii) Extended
Care Health Option benefits limited to children of members only,
October 23, 1992.
(9) Beginning dates
of eligibility for a child who meets the requirements of paragraph
(b)(2)(ii)(H)(
4) and:
(i) Has been placed
in custody by a court:
(A) All benefits for
which entitled, July 1, 1994.
(B) Extended Care Health
Option benefits limited to children of members only,
July 1, 1994.
(ii) Has been placed
in custody by a recognized adoption agency:
(A) All benefits for
which entitled, October 5, 1994.
(B) Extended Care Health
Option benefits limited to children of members only,
October 5, 1994.
(iii) Has been placed
in the home of a member by a placement agency or by any other source authorized
by State or local law to provide adoption placement, in anticipation
of the legal adoption of the member:
(A) All benefits for
which entitled, January 6, 2006.
(B) Extended Care Health
Option benefits limited to children of members only, January 6,
2006.
(10) Beginning dates
of eligibility for a retiree for:
(i) Medical benefits
under the Basic Program January 1, 1967.
(ii) Retirees
and their dependents are not eligible for benefits under the Extended
Care Health Option.
(d) Dual eligibility.
Dual eligibility
occurs when a person is entitled to benefits from two sources. For
example, when an active duty member is also the dependent of another
active duty member, a retiree, or a deceased active duty member
or retiree, dual eligibility, that is, entitlement to direct care from
the Uniformed Services medical care system and CHAMPUS is the result.
Since the active duty status is primary, and it is the intent that
all medical care be provided an active duty member through the Uniformed
Services medical care system, CHAMPUS eligibility is terminated
as of 12:01 a.m. on the day following the day the dual eligibility
begins. However, any dependent children in a marriage of two active
duty persons or of an active duty member and a retiree, are CHAMPUS
eligible in the same manner as dependent children of a marriage
involving only one CHAMPUS sponsor. Should a spouse or dependent
who has dual eligibility leave active duty status, that person’s
CHAMPUS eligibility is reinstated as of 12:01 a.m. of the day active
duty ends, if he or she otherwise is eligible as a dependent of
a CHAMPUS sponsor.
Note: No CHAMPUS
eligibility arises as the result of the marriage of two active duty
members.
(e) Eligibility under
the Transitional Assistance Management Program (TAMP).
(1) A
member of the armed forces is eligible for transitional health care
if the member is:
(i) A member who is involuntarily separated from
active duty.
(ii) A member of a
Reserve component who is separated from active duty to which called
or ordered in support of a contingency operation if the active duty
is active duty for a period of more than 30 consecutive days.
(iii) A
member who is separated from active duty for which the member is
involuntarily retained under 10 U.S.C. 12305 in support of a contingency
operation; or
(iv) A member who is
separated from active duty served pursuant to a voluntary agreement
of the member to remain on active duty for a period of less than
1 year in support of a contingency operation.
(v) A
member who receives a sole survivorship discharge (as defined in
section 1174(i) of this title).
(vi) A member who is
separated from Active Duty who agrees to become a member of the
Selected Reserve of the Ready Reserve of a reserve component.
(2) A
spouse (as described in paragraph (b)(2)(i) of this section except
former spouses) and child (as described in paragraph (b)(2)(ii)
of this section) of a member described in paragraph (e)(1) of this section
is also eligible for TAMP benefits under TRICARE.
(3) TAMP
benefits under TRICARE begin on the day after the member is separated
from active duty, and, if such separation occurred on or after November
6, 2003, end 180 days after such date. TRICARE benefits available
to both the member and eligible family members are generally those
available to family members of members of the uniformed services
under this Part. However, during TAMP eligibility, a member of a
Reserve Component as described in paragraph (e)(1)(ii) of this section,
is entitled to dental care to which a member of the uniformed services
on active duty for more than 30 days is entitled. Each branch of
service will determine eligibility for its members and eligible
family members and provide data to DEERS.
(f) Changes in status
which result in termination of CHAMPUS eligibility.
Changes in status which
result in a loss of CHAMPUS eligibility as of 12:01 a.m. of the
day following the day the event occurred, unless otherwise indicated,
are as follows:
(1) Changes in the status of a member.
(i) When
an active duty member’s period of active duty ends, excluding retirement
or death.
(ii) When an active
duty member is placed on desertion status (eligibility is reinstated
when the active duty member is removed from desertion status and
returned to military control).
Note: A member serving a sentence of confinement in
conjunction with a sentence of punitive discharge is still considered
on active duty until such time as the discharge is executed.
(2) Changes in the
status of a retiree.
(i) When a retiree
ceases to be entitled to retired, retainer, or equivalent pay for
any reason, the retiree’s dependents lose their eligibility unless
the dependent is otherwise eligible (e.g., some former spouses,
some dependents who are victims of abuse and some incapacitated
children as outlined in paragraph (b)(2)(ii)(H)(2)
of this section).
(ii) A retiree also
loses eligibility when no longer entitled to retired, retainer,
or equivalent pay.
Note: A retiree who
waives his or her retired, retainer or equivalent pay is still considered
a retiree for the purposes of CHAMPUS eligibility.
(iii) Attainment
of entitlement to hospital insurance benefits (Part A) under Medicare
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii)
and (f)(3)(ix) of this section.
(3) Changes in the status of a dependent.
(i) Divorce,
except for certain classes of former spouses as provided in paragraph
(b)(2)(i) of this section and the member or former member’s
own children
(i.e., legitimate, adopted, and judicially determined illegitimate
children).
Note: An unadopted stepchild loses eligibility
as of 12:01 a.m. of the day following the day the divorce becomes
final.
(ii) Annulment, except
for certain classes of former spouse as provided in paragraph (b)(2)(i)
of this section and the member or former member’s
own children
(i.e., legitimate, adopted, and judicially determined illegitimate
children).
Note: An unadopted stepchild loses eligibility
as of 12:01 a.m. of the day following the day the annulment becomes
final.
(iii) Adoption, except
for adoptions occurring after the death of a member or former member.
(iv) Marriage
of a child, except when the marriage is terminated by death, divorce,
or annulment before the child is 21 or 23 if an incapacitated child
as provided in paragraph (b)(2)(ii)(H)(2) of this section.
(v) Marriage
of a widow or widower, except for the child of the widow or widower
who was the stepchild of the deceased member or former member at
the time of death. The stepchild continues CHAMPUS eligibility as
other classes of dependent children.
(vi) Attainment of
entitlement to hospital insurance benefits (Part A) under Medicare
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii),
and (f)(3)(ix) of this section. (This also applies to individuals
living outside the United States where Medicare benefits are not
available.)
(vii) Attainment of
age 65, except for dependents of active duty members, beneficiaries
not entitled to part A of Medicare, beneficiaries entitled to Part
A of Medicare who have enrolled in Part B of Medicare, and as provided
in paragraph (b)(3) of this section. For those who do not retain
CHAMPUS, CHAMPUS eligibility is lost at 12:01 a.m. on the first
day of the month in which the beneficiary becomes entitled to Medicare.
Note: If the person is not eligible for Part A of Medicare,
he or she must file a Social Security Administration, “Notice of
Disallowance” certifying to that fact with the Uniformed Service
responsible for the issuance of his or her identification card so
a new card showing CHAMPUS eligibility can be issued. Individuals
entitled only to supplementary medical insurance (Part B) of Medicare,
but not Part A, or Part A through the Premium HI provisions (provided
for under the 1972 Amendments to the Social Security Act) retain
eligibility under CHAMPUS (refer to Sec. 199.8 for additional information
when a double coverage situation is involved).
(viii) End
stage renal disease. All beneficiaries, except dependents of active
duty members, lose their CHAMPUS eligibility when Medicare coverage
becomes available to a person because of chronic renal disease unless
the following conditions have been met. CHAMPUS eligibility will
continue if:
(A) The individual is under 65 years old;
(B) The
individual became eligible for Medicare under the provisions of
42 U.S.C. 426-1(a);
(C) The individual
is enrolled in Part B of Medicare; and
(D) The
individual has applied and qualified for continued CHAMPUS eligibility
through the Defense Enrollment Eligibility Reporting System (DEERS).
(ix) Individuals
with certain disabilities. Each case relating to Medicare eligibility
resulting from being disabled requires individual investigation.
All beneficiaries except dependents of active duty members lose
their CHAMPUS eligibility when Medicare coverage becomes available
to a disabled person unless the following conditions have been met.
CHAMPUS eligibility will continue if:
(A) The individual
is under 65 years old;
(B) The individual
became eligible for Medicare under the provisions of 42 U.S.C. 426(b)(2);
(C) The
individual is enrolled in Part B of Medicare except that in the
case of a retroactive determination of entitlement to Medicare Part
A hospital insurance benefits for a person under 65 years of age
there is no requirement to enroll in Medicare Part B from the Medicare
Part A entitlement date until the issuance of such retroactive determination;
and
(D) The individual has applied and qualified for
continued CHAMPUS eligibility through the Defense Enrollment Eligibility
Reporting System (DEERS).
(x) Disabled students,
that is children age 21 or 22, who are pursuing a full-time course
of higher education and who, either during the school year or between
semesters, suffer a disabling illness or injury with resultant inability
to resume attendance at the institution remain eligible for CHAMPUS medical
benefits for 6 months after the disability is removed or until the
student passes his or her 23rd birthday, whichever occurs first.
However, if recovery occurs before the 23rd birthday and there is resumption
of a full-time course of higher education, CHAMPUS benefits can
be continued until the 23rd birthday. The normal vacation periods
during an established school year do not change the eligibility
status of a dependent child 21 or 22 years old in a full time student
status. Unless an incapacitating condition existed before, and at
the time of, a dependent child’s 21st birthday, a dependent child
21 or 22 years old in student status does not have eligibility and may
not qualify for eligibility under the requirements related
to mental or physical incapacity as described in paragraph (b)(2)(ii)(H)(2)
of this section.
(g) Reinstatement of
CHAMPUS eligibility.
Circumstances which result in reinstatement
of CHAMPUS eligibility are as follows:
(1) End Stage renal
disease.
Unless
CHAMPUS eligibility has been continued under paragraph (f)(3)(viii)
of the section, when Medicare eligibility ceases for end-stage renal
disease patients, CHAMPUS eligibility resumes if the person is otherwise
still eligible. He or she is required to take action to be reinstated
as a CHAMPUS beneficiary and to obtain a new identification card.
(2) Disability.
Some disabilities
are permanent, others temporary. Each case must be reviewed individually.
Unless CHAMPUS eligibility has been continued under paragraph (f)(3)(ix)
of this section, when disability ends and Medicare eligibility ceases,
CHAMPUS eligibility resumes if the person is otherwise still eligible.
Again, he or she is required to take action to obtain a new CHAMPUS identification
card.
(3) Enrollment
in Medicare Part B.
For individuals whose CHAMPUS eligibility
has terminated pursuant to paragraph (f)(2)(iii) or (f)(3)(vi) of
this section due to beneficiary action to decline Part B of Medicare,
CHAMPUS eligibility resumes, effective on the date Medicare Part
B coverage begins, if the person subsequently enrolls in Medicare
Part B and the person is otherwise still eligible.
(h) Determination of
eligibility status.
Determination of an individual’s eligibility
as a CHAMPUS beneficiary is the primary responsibility of the Uniformed
Service in which the member or former member is, or was, a member,
or in the case of dependents of a NATO military member, the Service
that sponsors the NATO member. For the purpose of program integrity,
the appropriate Uniformed Service shall, upon request of the Director,
OCHAMPUS, review the eligibility of a specific person when there
is reason to question the eligibility status. In such cases, a report
on the results of the review and any action taken will be submitted
to the Director, OCHAMPUS, or a designee.
(i) Procedures for
determination of eligibility.
Procedures for the determination of eligibility
are prescribed within the Department of Defense Instruction 1000.13
available at local military facilities personnel offices.
(j) CHAMPUS procedures
for verification of eligibility.
(1) Eligibility for
CHAMPUS benefits will be verified through the Defense Enrollment
Eligibility Reporting System (DEERS) maintained by the Uniformed
Services, except for abused dependents as set forth in paragraph
(b)(2)(iii) of this section. It is the responsibility of the CHAMPUS
beneficiary, or parent, or legal representative, when appropriate, to
provide the necessary evidence required for entry into the DEERS
file to establish CHAMPUS eligibility and to ensure that all changes
in status that may affect eligibility be reported immediately to the
appropriate Uniformed Service for action.
(2) Ineligibility
for CHAMPUS benefits may be presumed in the absence of prescribed
eligibility evidence in the DEERS file.
(3) The
Director, OCHAMPUS, shall issue guidelines as necessary to implement
the provisions of this section.
[64 FR 46135, Aug 24, 1999, as amended at
66 FR 9654, Feb 9, 2001; 66 FR 16400, Mar 26, 2001; 66 FR 40606,
Aug 3, 2001; 67 FR 15725, Apr 3, 2002; 68 FR 23032, Apr 30, 2003;
68 FR 32361, May 30, 2003; 69 FR 44947, Jul 28, 2004; 69 FR 51564,
Aug 20, 2004; 69 FR 60554, Oct 12, 2004; 70 FR 12802, Mar 16, 2005; 71
FR 31944, Jun 2, 2006; 72 FR 2447, Jan 19, 2007; 73 FR 30478, May
28, 2008; 75 FR 50883, Aug 18, 2010; 76 FR 81367, Dec 28, 2011;
77 FR 38176, Jun 27, 2012; 80 FR 55254, Sep 15, 2015]