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waived or superseded by the provisions of this chapter, all normal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.