1.0 Continued
Health Care Benefit Program (CHCBP)
1.1 The CHCBP is a health care
program that allows certain groups of former Military Health System (MHS)
beneficiaries to continue receiving health care coverage when they
lose eligibility for military health care under the TRICARE programs.
This temporary health program is supported by premium revenue collected
from the participants in the program. The Managed Care Support Contractor
(MCSC) for the East Region (herein referred to as the “CHCBP contractor”
unless otherwise specified) shall provide all services necessary
to support the CHCBP as outlined in
32 CFR 199.20.
Other references describing the CHCBP that are to be used by the
CHCBP contractor in fulfilling its responsibilities are applicable
sections of the TRICARE Policy Manual (TPM), TRICARE Operations
Manual (TOM), TRICARE Reimbursement Manual (TRM), TRICARE Systems
Manual (TSM), and the
Federal Register dated September
30, 1994 (pg. 49817ff), February 11, 1997 (pg. 6225ff), February
24, 1997 (pg. 8312), and September 16, 2011 (pg. 57637ff). The CHCBP
contractor shall perform these functions for CHCBP beneficiaries
on a worldwide basis, irrespective of the geographic area in which
the beneficiary resides or the area in which health care services
are received.
1.2 The legislative basis for the program is Section
4408 of the National Defense Authorization Act (NDAA) of 1993 (Public
Law 102-484) which added Section 1078a to Chapter 55 of 10 United
States Code (USC). Beneficiaries who may be eligible to purchase
the continued health program after eligibility for coverage ends
under a health benefits plan under 10 USC Chapter 55 or 10 USC §
1145(a) are described in 10 USC § 1078a. For those covered under
premium-based TRICARE health benefits plans such as TRICARE Reserve
Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young Adult
(TYA), etc., such coverage must have been purchased and in place
the day before the loss of eligibility.
1.3 CHCBP is not part of the TRICARE
Program; therefore, the CHCBP contractor shall adhere to the following
requirements for those areas in which the CHCBP instructions and
processing requirements are different than TRICARE.
2.0
Validate
Eligibility For CHCBP
2.1 Upon receipt of a Department of Defense (DoD)
(DD) Form 2837, CHCBP Application, from a prospective beneficiary,
the CHCBP contractor shall validate eligibility on the Defense Enrollment
and Eligibility Reporting System (DEERS). If additional documentation
is required to validate CHCBP eligibility then the CHCBP contractor
will contact the applicant. The supporting documentation that the
CHCBP contractor shall request from the applicant differs depending
on the category of individual who is applying for enrollment as
shown below:
2.1.1 Individual Uniformed Service sponsor (herein
referred to as “sponsor”) and his/her family: a copy of the DD Form
214, Certificate of Release or Discharge from Active Duty, or a
copy of the sponsor’s active duty orders.
2.1.2 Unremarried Former Spouse (URFS) and
stepchildren of the sponsor: a copy of the final divorce decree.
2.1.3 Child who
loses TRICARE coverage due to marriage: a copy of marriage certificate.
2.1.4 Child
who loses TRICARE coverage on his/her 21st birthday (age 23 if enrolled
in a full-time course of study at an approved institution of higher
learning and dependent on the uniformed service sponsor for more
than half of their financial support): a copy of the front and back
of the Uniformed Services identification (ID) card.
2.1.5 Child who
loses TRICARE coverage due to college graduation: a copy of college
transcript.
2.1.6 Child over the age of 21 and before the age
of 23 who loses TRICARE coverage when no longer enrolled in a full-time
course of study at an approved institution of higher learning or
no longer dependent on the uniformed service sponsor for more than
half of their financial support: a letter from the institution of
higher learning stating the student’s status or a written statement
from the dependent that he/she is no longer dependent on the uniformed
services sponsor for more than half of their financial support.
2.1.7 Child
that was previously placed in sponsor’s legal custody and then loses
TRICARE coverage: a copy of the court order.
Note: Children who lose TRICARE coverage under
paragraphs 2.1.4 through
2.1.7 may
qualify to purchase TYA coverage until reaching the age of 26 (see
Chapter 25). If qualified to purchase TYA coverage,
the child cannot purchase CHCBP as an individual. Also, if the child
does not qualify to purchase TYA because he or she qualifies for
employer sponsored coverage, he or she is ineligible to purchase
CHCBP.
2.1.8 Child who loses eligibility
for TYA coverage. However, if the TYA coverage was terminated due
to eligibility for employer-sponsored health care coverage based
on their own employment or failure to pay TYA premiums, then the
child is not eligible to purchase CHCBP coverage (see
Chapter 25).
2.1.9 For any other situations in
which an individual loses TRICARE coverage and may potentially be
eligible for CHCBP, the contractor shall request information needed
to verify eligibility.
2.2 Family Members Not Identified
on DEERS
2.2.1 When a contractor receives a CHCBP claim which
includes a family member not identified on DEERS as enrolled, but
the sponsor indicates CHCBP family coverage, the contractor is to
take the following action: If the claim includes a copy of an appropriately
marked CHCBP coverage card for the beneficiary, the claim is to
be processed. If the claim is for a beneficiary who is less than
60 days old, the claim is to be processed, even if no copy of a CHCBP
coverage card is attached as long as at least one member of the
sponsor’s family is currently enrolled in CHCBP. In all other cases,
the claim is to be denied.
2.2.2 In order to be enrolled in
the CHCBP, the beneficiary will be disenrolled from any TRICARE programs
in which enrolled. This will require no action on the beneficiary’s
part.
2.3 Disputes
Regarding Enrollment
2.3.1 Confirmation of a person’s eligibility as a
CHCBP beneficiary is the responsibility of the CHCBP contractor.
Disputed questions of fact concerning a beneficiary’s eligibility
will not be considered an appealable issue, but must be resolved
with the appropriate Uniformed Service.
2.3.2 If the contractor determines
the applicant does not appear eligible due to an ineligible response
from DEERS (i.e., no history segments or record of previous DoD
entitlement) or failure of the applicant to provide the documentation
requested to verify eligibility the contractor shall deny the application
in writing within 10 business days of the reason for the denial.
3.0 Application
Period And Premiums
3.1 CHCBP
Application Period
There is a 60-day application
period for CHCBP, beginning the day following the end date of the beneficiary’s
eligibility for TRICARE coverage. The contractor shall deny any
applications received after the 60-day period. The contractor shall
apply the following business rules when determining the start of
the 60-day application period.
3.1.1 Members and Former Members,
Their Families, and Other Individuals Losing TRICARE Coverage
The Government routinely notifies beneficiaries
prior to their loss of TRICARE coverage (Active Duty (AD) members
are notified of the CHCBP during outprocessing; other beneficiaries
who lose TRICARE coverage are notified by the Defense Manpower Data
Center (DMDC) in writing of the availability of the CHCBP). However,
if an eligible beneficiary advises the contractor that he/she was
not notified of this program and submits documentation to support
their position, the contractor shall forward the documentation to
the Director, TRICARE Regional Office-East (TRO-E) or designee,
who shall provide direction on the start-date of the 60-day application
period.
3.1.2 URFSs
There is no formal mechanism established to
promptly identify URFSs that may qualify for this program, therefore
the contractor shall process all applications from URFSs upon receipt.
3.2 Coverage
Categories
CHCBP offers two coverage categories.
Individual coverage is available to the member or former member,
an URFS, an adult child, a surviving spouse, or other qualified
individuals. Family coverage is only available to the member or
former member and his/her dependents. Dependents cannot be covered
under family coverage unless the member or former member is also
covered by family coverage.
3.3 CHCBP Application
DD Form 2837, CHCBP Application, shall be accepted
as the application form for CHCBP coverage. Should DD Form 2837
be revised or renumbered in the future, the contractor shall use
the latest version.
3.4 Dates of Coverage & Premiums
3.4.1 Coverage
will begin the day following the beneficiary’s loss of TRICARE coverage
and will end the last day of premium coverage.
3.4.2 Due to
the documentation requirements for purchasing coverage, most coverage
will be retroactive; however, there may be some coverage that will
be prospective. Prospective coverage must be accompanied by a premium
payment for one quarter. Retroactive coverage must be accompanied by
full premium payment retroactive to the effective date of coverage
through the end coverage date in the quarter in which the individual
is applying.
3.4.3 Premiums are as stated in
paragraph 3.5 of these instructions.
Examples of the premiums required for retroactive
and prospective coverage:
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Military
Benefits End
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Application
Received
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Quarters of
Premium Due
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CHCBP
Coverage Begins
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Example 1:
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10/01/2010
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11/15/2010
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1 quarter
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10/02/2010
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Example 2:
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09/15/2010
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02/10/2011
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2 quarters
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09/16/2010
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Example 3:
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11/05/2010
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10/01/2010
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1 quarter
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11/06/2010
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Example 4:
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03/01/2011
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11/01/2010
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1 quarter
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03/02/2011
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3.5
Premium Rates
3.5.1 The amount
of the CHCBP premiums shall be established by the Government and
may be adjusted each fiscal year.
3.5.2 The contractor shall begin
charging the adjusted quarterly premiums on the date specified in
Addendum A.
3.5.3 Upon receipt of adjusted rates from the Government,
the contractor shall issue a written notice to the beneficiary of
the changes in premium amounts, to include the effective date of
the change. This notification should be done at least 30 days prior
to the effective date directed by the Contracting Officer (CO).
3.5.4 When qualifying
events occur that change the sponsor from individual to family coverage or
vice versa, coverage and premiums shall be changed effective with
the date of the qualifying event. The contractor, within 10 business
days of receiving such information, shall issue a written notice
to the beneficiary of the changes in the coverage category and premium
amount, including the effective date of the changes.
3.6 Form of Payment
3.6.1 Checks,
money orders, or credit cards are allowable forms of payment for
CHCBP beneficiaries to use in paying their premiums. The contractor
may propose additional payment mechanisms, to include electronic
processes for premium payments. Proposed electronic processes shall
maintain the integrity and security of the application processes
which includes important documentation required to validate eligibility
for CHCBP.
3.6.2 As a minimum, the contractor shall accept VISA
and MasterCard® for credit card payments, and may, but is not required
to, accept additional nationally recognized major credit cards as
a form of premium payment.
3.6.3 The contractor shall not accept
premiums submitted by, or on behalf, of a health care provider for
any beneficiary other than (a) the provider him/herself and (b)
a member of the provider’s immediate family. Should a provider submitted
payment be received, the contractor shall return the payment to
the provider with a written notice advising the provider that submission
of premium payments by health care providers is prohibited. A copy
of the letter should also be sent to the beneficiary. The contractor
shall submit documentation to the Defense Health Agency (DHA) Program Integrity
Office to include the following: a copy of contractor’s notification
to the provider, copy of front and back of premium (money order
or check), originals of all documentation submitted by the provider (to
include mailing envelope), documentation of all conversations and
communications the contractor had with the provider on the subject
of paying premiums, and any other information that the contractor
has in its files or records concerning the provider that might be
of assistance in Government follow-up action on this issue.
3.7 Insufficient
Funds
3.7.1 In the case of insufficient funds, the contractor
shall, within three business days, issue a written notice to the
applicant (for initial applications) or beneficiary (in the case
of renewal premiums), advising the applicant or beneficiary of the
insufficient funds, the amount of the premium due, and the date
by which a valid premium must be received by the contractor. For
initial application requests, the notice shall also advise the beneficiary
that if premium payment is not received in full by the due date (the
last day of the 60-day application period), the applicant will not
be covered in CHCBP. For renewals, the notice shall advise the beneficiary
that if the contractor does not receive valid payment in full within
30 days of the date of the contractor’s letter, that coverage will
be terminated. That notice shall also provide the effective date
of termination if payment is not received. If the premium payment
has not been received by the contractor within the specified time
frame, the contractor shall terminate the CHCBP coverage and issue
a written Termination Notice (TN) to the beneficiary confirming
the termination of coverage.
3.7.2 In the event that there are
insufficient funds to process a premium payment, the contractor may
assess CHCBP applicant/purchaser a fee of up to 20 U.S. dollars
($20.00) which is retained by the contractor.
3.8
Refunds
Premiums shall be refunded if the applicant
is no longer eligible for CHCBP coverage, i.e., beneficiary regains
TRICARE eligibility; ex-spouse remarries; death of beneficiary;
prospective member who has prepaid premium but fails to provide
required eligibility documentation; and sponsor change in coverage
from family to individual. Voluntary termination because the beneficiary
obtained Other Health Insurance (OHI) does not constitute grounds
for a refund of unused premiums. When refunds are appropriate, the
contractor shall prorate the refund from the date of loss of eligibility
for program benefits through the last coverage date for which the
premium was paid.
3.9 Limits of CHCBP Coverage
The length of a beneficiary’s CHCBP coverage
varies according to the category of individual. Coverage lengths
and categories are listed in the TPM,
Chapter 10, Section 4.1, Figure 10.4.1-1,
CHCBP Eligibility Table.
3.10 Processing Applications
3.10.1 Once the
contractor has verified eligibility and approved the application
request, the contractor shall enter the CHCBP enrollment into DEERS
through the applicable on-line interface. As DEERS does not allow
individuals to be added to a sponsor’s record after the sponsor’s
TRICARE coverage ends, there will be a small number of CHCBP beneficiaries
that the contractor cannot complete the CHCBP enrollment in DEERS.
The majority will be newborns whose birth occurred after the sponsor’s
TRICARE coverage ends, but there will occasionally be other beneficiaries
as well. The contractor should not rely on DEERS as being the sole
determinant of whether or not an individual is eligible for CHCBP
coverage as these individuals would not be reflected on DEERS (see
paragraph 2.0). The
contractor’s systems shall accommodate these unique cases in which
the beneficiary is covered under CHCBP but not reflected on DEERS
to ensure these beneficiaries are provided with all required CHCBP
benefits and accurate processes, i.e., claims processing, issuing
authorizations, accessing services, etc.
3.10.2 DEERS will
not allow a CHCBP enrollment to be entered if the sponsor and/or
dependents are still showing as eligible for TRICARE coverage. In
these cases, the contractor shall pend the application and advise
the applicant in writing for the sponsor to contact the nearest
Uniformed Services ID card issuing office (Real-Time Automated Personnel
Identification System (RAPIDS)) to rectify the situation. The contractor
shall complete the processing of the application when DEERS has been
updated to reflect that the sponsor and/or dependents are no longer
eligible for services under TRICARE.
3.10.3 Once the
application has been fully processed, the contractor shall issue
the beneficiaries a CHCBP coverage ID card within 10 business days.
The card provides the beneficiaries with (a) confirmation that the
individual is covered and the effective dates; and (b) documentation
that the beneficiary on how to access health care services. The
card shall contain sufficient information to facilitate access to
health care. Coverage dates on the card shall be limited to those
dates for which a valid quarterly premium has been received by the
contractor. Cards shall be issued each quarter for all subsequent
quarterly payments received by the contractor. The card shall reflect
that coverage is for the CHCBP and at a minimum provides the contractor’s
name, address, toll-free telephone number, and claims center mailing
address.
3.10.4 Once an application has been fully processed,
the contractor shall issue a letter to the applicant confirming
CHCBP coverage (including the dates of coverage) within 10 business
days. The letter shall advise the beneficiary of the requirements
that must be met for continued coverage in the program, including
information regarding future contractor billings and premium payments
that the beneficiary will be required to make. The contractor shall
also issue either a CHCBP coverage policy or such other sufficient
written information regarding the CHCBP for beneficiaries’ reference
should they have any questions regarding benefits and program requirements.
3.11 Coverage
and Renewals
3.11.1 The contractor shall mail initial premium renewal
notices to beneficiaries no later than 30 days before the expiration
of the coverage. The beneficiary’s coverage in CHCBP is based on
the documentation that the applicant submits to verify eligibility,
therefore, the contractor shall not routinely query DEERS for renewal
coverages and quarterly billings. Absent information or evidence
to the contrary, the contractor shall assume that the individual
continues to meet the requirements for CHCBP. Renewal notices shall
clearly specify the premium amount due, the date by which the premium must
be received, and the mailing address to which the premium payment
must be sent. Renewal notices shall specify that failure to submit
the premium due will result in denial of continued coverage and
termination from the program.
3.11.2 The contractor
shall provide a 30 calendar day grace period following the premium
due date in which the beneficiary may submit his/her premium and
continue benefits with no break in coverage. If the premium is not
received following the initial renewal notice to the beneficiary requesting
premium for the next quarter, the contractor shall issue a second
renewal notice to the beneficiary within 10 business days of the
start of the grace period. The second renewal notice shall indicate
that this is the second and final billing notice and that if payment
is not received by the due date specified in the notice, that CHCBP
coverage will be terminated as of that date. The notice shall also
advise the beneficiary that if coverage is terminated due to nonpayment
of premium, that he/she will be permanently locked-out of CHCBP.
3.11.3 If the
premium is not received by the end of the grace period, the contractor
shall terminate the beneficiary’s coverage in CHCBP and send a TN
to the beneficiary confirming the termination within 10 business
days, to include the effective date and basis for the termination.
The contractor shall enter all CHCBP terminations into DEERS.
3.11.4 Beneficiaries
who desire to voluntarily withdraw from the CHCBP prior to the end
of their paid up period shall send a written request to the contractor.
Beneficiaries who voluntarily disenroll from the CHCBP are not permitted
to re-enroll until they gain and then once again lose TRICARE coverage.
Refund of unused premiums is only allowed for items covered in
paragraph 3.8.
3.11.5 Following
a beneficiary’s termination from the CHCBP, except for those who
have re-established TRICARE coverage, the contractor shall issue
a TN to the beneficiary within 10 business days from the termination
date and upon request up to 24 months after the termination date.
3.11.6 In preparing
and mailing all written notices and correspondence to applicants
and beneficiaries, the contractor shall use the most current address
on file or available.
3.12 CHCBP Coverage Data and Report
The contractor shall maintain systems and databases
to collect, track and process applications. The
contractor shall have the capability to retroactively retrieve pertinent
coverage information on any individual who has been accepted or
denied coverage in the program, to include the basis for such denials.
9.0 Patient
Protection And Affordable Care Act (ACA) Of 2010 Information Reporting
9.1 When purchased, CHCBP coverage is Minimum Essential
Coverage (MEC) and meets the individual coverage requirement of
the ACA.
9.2 The CHCBP contractor shall perform
all Section 6055 information reporting to the Internal Revenue Service
(IRS) and provide statements to individuals with CHCBP coverage
during the reporting tax period in the manner, time frames, and
forms specified in Section 6055 of the Internal Revenue Code (IRC)
and associated IRS regulations. The CHCBP contractor shall notify
the Contracting Officer’s Representative (COR) when completed each
year.
9.3 Because
not all CHCBP enrollments are recorded in DEERS, the CHCBP contractor
shall use coverage data from the contractor’s enrollment system
to generate the required information reports and statements. Only
CHCBP coverage information shall be reported to the IRS by the CHCBP contractor.