1.0 DESCRIPTION
Medicare eligibles who are beneficiaries based
on age and whose TRICARE eligibility is determined by 10 United
States Code (USC) Section 1086, are eligible for Medicare Part A,
and who are enrolled in Medicare Part B, are eligible for the TFL
benefit.
TRICARE beneficiaries
eligible
under Section 1086(d) under age 65 who are also Medicare
eligible, are also eligible for TFL (see the TRICARE Operations
Manual (TOM),
Chapter 20, Section 1, paragraphs 2.4 and
2.5).
2.0 POLICY
2.1 Introduction
Section 1086(d) extends
TRICARE eligibility to persons who would otherwise have lost their TRICARE
eligibility due to attainment of entitlement to hospital insurance
benefits under Part A of Medicare based on age. In order for these
individuals to retain their TRICARE eligibility, they must have Medicare
Part B (Supplementary Medical Insurance (SMI)). In general, when
medical care or, adjunctive dental care is provided to these individuals
and payment may be made under both Medicare and TRICARE, Medicare
is the primary payer and TRICARE will normally pay the actual out-of-pocket
costs incurred by the person.
2.2 Eligibility
The
contractors shall determine from the Defense Enrollment Eligibility
Reporting System (DEERS) if the individual is eligible for TFL.
TFL claims are processed in accordance with TRICARE Operations Manual
(TOM),
Chapter 20.
2.3 TFL beneficiaries, in most
cases, are not eligible to enroll in TRICARE Prime (i.e., retirees
and their family members who are 65 years of age or older, and who
are entitled to Medicare Part A and who have Medicare Part B). See
the
TOM,
Chapter 6, Section 1 for exceptions.
Note: Retirees,
retiree family members, and survivors (other than survivors of deceased
members who died on active duty) with any Medicare coverage at any
age are not eligible to enroll in TRICARE Select because they are
excluded from the “Retired Category” definition for TRICARE Select
(10 USC 1075(b)(1)(B)).
2.4 Appeal
rights are covered in the TOM,
Chapter 12.
3.0 Other
Dual Eligible Beneficiaries
In addition to
TFL beneficiaries, there are other categories of beneficiaries who
have dual eligibility under both TRICARE and Medicare:
3.1 TRICARE
beneficiaries who are age 65 or older and who are not entitled to
premium-free Medicare Part A on their own record or the record of
their current, former, or deceased spouse, but have Medicare Part
B, remain TRICARE eligible and are eligible to enroll in TRICARE
Prime or TRICARE Select.
3.2 Active
Duty Family Members (ADFMs) who are age 65 or older and who are
entitled to premium-free Medicare Part A only remain TRICARE eligible
and are eligible to enroll in TRICARE Prime or TRICARE
Select.
3.3 TRICARE beneficiaries (retirees
and family members under age 65) who are entitled to premium-free
Medicare Part A and have Medicare Part B are eligible to enroll
in TRICARE Prime.
3.4 ADFMs under the age of 65
who are entitled to premium-free Medicare Part A remain TRICARE eligible
and eligible to enroll in TRICARE Prime or TRICARE
Select. (See Note regarding special enrollment periods
for certain ADFMs.)
3.5 TRICARE eligible individuals
who are entitled to premium-free Medicare Part A because of a disability,
where Social Security Disability Insurance (SSDI) is awarded on
appeal and there is a minimum six month gap between Medicare Part
A and Part B effective dates, remain TRICARE eligible for the period
where only Part A was effective. If a beneficiary declines Part
B coverage, he/she will be ineligible for TRICARE from the original
effective date of Part B until Part B coverage is established.
3.6 TRICARE
beneficiaries eligible for premium-free Medicare Part A generally
must have Medicare Part B to remain TRICARE eligible. If Part B
coverage is required, but the beneficiary does not have it, the beneficiary
is not eligible for any TRICARE benefits. If the beneficiary refused
or declined Part B coverage when they first became eligible and
subsequently enroll in Part B at a later date, TRICARE eligibility
is restored on the Part B effective date of coverage. In the following
circumstances, Part B is not required:
• Family members of
Service members;
• Enrollment in the
Uniformed Services Family Health Plan (USFHP);
• Enrollment in the
TRICARE Retired Reserve (TRR); or
• Enrollment in TRICARE
Reserve Select (TRS).
Note: ADFMs whose Medicare entitlement is based on a
disability are not required to have Part B until the sponsor retires
and may enroll in Part B during a special enrollment period. The
special enrollment period is available anytime the sponsor is on
active duty or within the first eight months of the sponsor’s retirement.
If the family member enrolls in Part B after the sponsor’s retirement
date, there will be a break in TRICARE coverage. This special enrollment
period does not apply to ADFMs whose Medicare entitlement is based
on End Stage Renal Disease (ESRD).
While ADFMs with ESRD and USFHP/TRS enrollees are not required to
have Medicare Part B, enrollment in Part B when the individual is
first eligible is encouraged. ESRD patients and USFHP/TRS enrollees
may be required to pay the 10% Medicare surcharge for each 12-month
period they were eligible to enroll in Part B, but did not. When USFHP/TRS
beneficiaries are no longer enrolled in these programs, or when
the sponsor of an ADFM with ESRD retires, they are not eligible
for other TRICARE coverage without Part B.