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TRICARE Policy Manual 6010.60-M, April 1, 2015
Eligibility And Enrollment
Chapter 10
Section 6.1
TRICARE For Life (TFL) And Other Medicare-Eligible Beneficiaries
Issue Date:  September 25, 2001
Authority:  10 USC 1086(d)
Revision:  C-9, October 20, 2017
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.
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