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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
Chapter 20
Section 1
General
Revision:  
1.0  General
The TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) encompasses the processing of all TRICARE claims for services rendered within the 50 United States (U.S.) and the District of Columbia, as well as Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands, to individuals who have dual eligibility under both TRICARE and Medicare.
2.0  Dual Eligibles
There are six general categories of beneficiaries who have dual eligibility under both TRICARE and Medicare and whose claims will be processed under TDEFIC:
2.1  TRICARE beneficiaries, who are 65 or older and who are entitled to premium-free Medicare Part A and who have Medicare Part B;
2.2  TRICARE beneficiaries who are 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;
2.3  Active Duty Family Members (ADFMs) who are 65 or older and who are entitled to premium-free Medicare Part A only;
2.4  TRICARE beneficiaries who are entitled to premium-free Medicare Part A because of a disability or End Stage Renal Disease (ESRD) and who have Medicare Part B;
2.5  ADFMs who have a disability or ESRD and are entitled to premium-free Medicare Part A only (While those with Medicare based on disability get a special enrollment period and therefore are not subject to the Part B premium surcharge, the special enrollment period does not apply to those with ESRD. ESRD patients who do not keep Medicare Part B when first eligible may have to pay a surcharge of 10% for each 12 month period that they could have enrolled in Part B but did not.); and
2.6  TRICARE beneficiaries, who are entitled to premium-free Medicare Part A because of a disability, where Social Security Disability Insurance (SSDI) is awarded on appeal. These beneficiaries will have a Medicare Part B effective date of October 1, 2009, or later and a six-month minimum gap between their Medicare Part A and Medicare Part B effective dates and will 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 Part B effective date until Part B coverage is established.
3.0  Applicability Of TRICARE Requirements
Unless specifically waived or superseded by the provisions of this chapter, all normal TRICARE requirements set forth in the TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), and TRICARE Systems Manual (TSM) apply to claims processed under TDEFIC.
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