1.0 DESCRIPTION
1.1 Eligible surviving
family members whose sponsor died while on active duty for a period
of more than 30 days (to include those who die while on delayed-effective-date
active duty orders) may continue their TRICARE eligibility and their
status is reflected as either Transitional Survivor or Survivor.
1.2 Transitional
Survivor and Survivor are terms used to reflect the status of certain
otherwise eligible TRICARE beneficiaries. The status determines
the appropriate payment rate and benefit level used in claims processing.
Transitional Survivor status reflects Active Duty Family Member
(ADFM) payment rates and provisions. Survivor status reflects retiree
payment rates.
1.3 TRICARE
Eligibility rules have priority over the rules that apply to those
in Transitional Survivor or Survivor status.
2.0 BACKGROUND
2.1 Family members
of Active Duty Service Members (ADSMs) who
died while on active duty have always been eligible for TRICARE;
however, their payment rates/cost-sharing provisions have changed over
time. Initially, their cost-sharing provisions were at the retiree
payment rate for all care received.
2.2 Section 707(c) of the National Defense
Authorization Act for Fiscal Year 1995 (NDAA FY 1995), Public Law
103-337 provided for two changes.
2.2.1 For dependents of active duty members who
died while on active duty between January 1, 1993 and October 1,
1993, only care for pre-existing conditions was cost-shared at the
active duty dependent payment rate.
2.2.2 Effective October 1, 1993, active duty
dependent payment rate was limited to a one-year period.
2.3 Section 704
of the Floyd D. Spence NDAA FY 2001 created a three year period,
beginning with the date of death, for health care to be cost-shared
at the active duty dependent payment rate. After three years, survivors
remained eligible for TRICARE, but at the retiree payment rate.
This provision was effective October 30, 2000.
2.4 Section 715
of the NDAA for FY 2006, as codified in 10 United States Code (USC)
1079(g)(2), extended the transitional survivor status for the dependent
children as outlined in
paragraph 3.0. It made this benefit retroactive
to October 7, 2001.
2.5 Section 701 of the NDAA for FY 2017, changed
how enrollment fees are calculated for Chapter 61 retirees that
are medically retired after December 31, 2017 and their family members,
and ADSM survivors whose sponsor died
after December 31, 2017. Enrollment fees for this group may be adjusted each
year based on Cost-of-Living Adjustments (COLA) to pay.
2.6 Section 702 of the NDAA for FY
2018 states that pharmaceutical agents for survivors shall be equal
to the cost-sharing amount for 2017.
3.0
POLICY
3.1 Effective with
respect to deaths occurring on or after October 7, 2001, Section
715 of the NDAA FY 2006, Public Law 109-163, extended the time frame
that certain eligible dependents (children and unmarried persons)
remain in Transitional Survivor status. See
paragraph 3.2.
3.2 Time
Frames for Transitional Survivor Status.
3.2.1 Spouse. Transitional Survivor status is
retained for three years from the date of death of the sponsor.
After three years, the surviving spouse converts to Survivor status
and TRICARE benefits may continue at retiree payment rates and rules.
3.2.2 Children and
unmarried persons (those defined in 10 USC 1072(2)(D) or (I)) whose
sponsor died on or after October 7, 2001. Transitional survivor
status ends at age 21 or 23 if enrolled in a full-time course of
study in a secondary school or in a full-time course of study in
an institution of higher education (subject to the eligibility limitations
as described in the
Note:).
3.2.3 Incapacitated Children and Incapacitated
Unmarried Persons (those defined in 10 USC 1072(2)(D) or (I)) whose
sponsor died on or after October 7, 2001. Transitional Survivor
status (subject to the eligibility limitations as described in the
Note:)
is the greater of:
• Three years
from the sponsor’s date of death; OR
• The date on which such dependent attains
21 years of age; OR
• The date on which the dependent attains
23 years of age if enrolled in a full-time course of study in a
secondary school or in a full-time course of study in an institution
of higher education.
Note: A
status of Transitional Survivor or Survivor status does not impact
eligibility rules. Loss of eligibility as a result of any condition
which routinely results in loss of TRICARE eligibility such as reaching
age limits, marriage, remarriage, etc. also results in loss of Transitional
Survivor/Survivor status. Individuals are considered to be eligible
for TRICARE if they are shown as eligible on the Defense Enrollment
Eligibility Reporting System (DEERS). The DEERS record will indicate
the dates of eligibility and the status.
3.3 Actions
necessary due to retroactive implementation of 10 USC 1079(g)(2).
3.3.1 Status
Conversion. Dependent children whose sponsor’s death occurred on
or after October 7, 2001, and who, upon implementation of this policy
are:
3.3.1.1 In Transitional Survivor status
shall remain in Transitional Survivor status in accordance with time
frames found in
paragraph 3.2. The Transitional Survivor’s
Health Care Plan (HCP) (e.g., Prime, Standard, etc.) shall continue
until such time it is changed by the beneficiary.
3.3.1.2 In
Survivor status shall have their Transitional Survivor status reinstated
and shall remain in Transitional Survivor status in accordance with
paragraph 3.2.
The HCP (e.g., Prime, Standard, etc.) that the beneficiary was in
as a Survivor shall continue to apply and will be carried over when
the status is changed to Transitional Survivor until such time the
beneficiary elects to choose another plan.
3.3.1.3 In
Survivor status and who have since lost TRICARE eligibility shall
have their Transitional Survivor status end date changed to the
date they lost eligibility for TRICARE. The HCP (e.g., Prime, Standard,
etc.) that the beneficiary was in as a Survivor shall also be applied
to the period of Transitional Survivor status.
3.3.2 Refunds -
General
3.3.2.1 The contractor shall process refunds
of enrollment fees proactively.
3.3.2.2 The contractor
shall reprocess claims either based on proactive contact with the beneficiary,
upon the beneficiary’s request, or when contacted by a beneficiary’s
parent or legal guardian.
3.3.2.3 The contractor
shall confirm the beneficiary’s mailing address before mailing any
refunds.
3.3.2.4 A letter will be sent to beneficiaries
affected by changes found in Section 715, NDAA FY 2006. The letter
will advise them of the extended Transitional Survivor time frames
and will direct them to contact the contractor for further information.
Once contacted by the beneficiary or beneficiary’s parent or legal
guardian, the contractor shall assist the beneficiary with actions
necessary in order to correctly reprocess claims in accordance with
this policy.
3.3.3 Refunds - Enrollment Fees
3.3.3.1 Upon
contact by a beneficiary, beneficiary’s parent, or legal guardian
or when the contractor initiates contact with those due a refund
of enrollment fees, the contractor shall issue an enrollment fee
refund for all individuals described in
paragraphs 3.3.1.2 and
3.3.1.3.
3.3.3.2 Since
the Prime Health Care Delivery Program (HCDP) that the beneficiary
was in during the Survivor status shall be carried over and applied
during the Transitional Survivor status, refunds are necessary.
Refunds shall be:
3.3.3.2.1 The
difference between Prime enrollment fee for family versus Prime
enrollment fee for individual (if a spouse was enrolled); or
3.3.3.2.2 Refund of all
applicable enrollment fees (if a spouse was not enrolled).
3.3.3.3 The contractor
shall include a written explanation, with any applicable refund
of enrollment fees.
3.3.4 Refunds - Claims
3.3.4.1 The contractor
shall reprocess claims and issue refunds to the family for those
individuals described in
paragraphs 3.3.1.2 and
3.3.1.3.
Since the HCDP (e.g., Prime, Standard, etc.) that the beneficiary
was in as a Survivor shall be carried over and applied during the
Transitional Survivor status, refunds shall be the difference between
any retiree payment rates the beneficiary may have paid and the
active duty payment rates that now apply. For example, those Survivors
who were in TRICARE Standard and had paid retiree cost-shares for
covered care may now be entitled to refunds of the difference between
Standard retiree cost-shares and active duty dependent cost-shares.
3.3.4.2 Waiver of timely
filing.
32 CFR 199.7(d)(2)(i)(A) permits an exception
for the timely filing waiver of claims in the event of retroactive
eligibility. Consequently, timely filing waivers apply to those whose
status is changed from Survivor to Transitional Survivor.
3.3.5 Refunds -
PFPWD/ECHO
3.3.5.1 Upon
request, contractors shall reprocess Survivor Basic Program claims
that otherwise would have been processed as Program For Persons
With Disabilities (PFPWD) claims had Transitional Survivor status
been in effect at the time the benefit was received and will issue
appropriate refunds.
3.3.5.2 Upon
request, contractors shall reprocess denied Survivor
Basic Program claims that otherwise would have been processed as
PFPWD claims had Transitional Survivor status been in effect at
the time the benefit was received and will issue appropriate refunds.
3.3.5.3 The
contractor shall assist those Transitional Survivors who are otherwise
eligible for the Extended Care Health Option (ECHO) to register
in ECHO. Contractors will also reprocess claims for services or
items that were previously denied and claims for services or items
that were not previously submitted because the beneficiary was not
eligible for ECHO due to his/her Survivor status at the time such
services or items were received by the beneficiary.
3.3.5.4 For the
purpose of
paragraphs 3.3.5.1,
3.3.5.2, and
3.3.5.3 contractors
shall waive the requirement for prior authorization of a PFPWD benefit
and the requirement for the “Public Facility Use Certification.”
For the purpose of
paragraph 3.3.5.3, contractors shall waive
the ECHO requirement that the beneficiary demonstrate enrollment
in the Exceptional Family Member Program (EFMP).
3.3.5.5 Claims
processing under
paragraphs 3.3.5.1,
3.3.5.2, and
3.3.5.3,
shall be done in accordance with the claims adjustment policies
in effect at the time the claim was originally processed. In no
case will reprocessing result in a greater cost-share to the sponsor/beneficiary
than what was determined when the claims were originally processed.
3.4
TRICARE Prime
And
TRICARE Prime Select Enrollment
3.4.1 Transitional Survivors shall retain
eligibility to enroll in TRICARE Prime, TRICARE Prime Remote Active
Duty Family Member (TPRADFM), TRICARE Overseas Program (TOP) Prime
and
TOP TPRADFM (if available), and TRICARE Select at
the ADFM payment rate and shall receive the ADFM health care benefit.
For Overseas enrollments, see the TRICARE Operations Manual (TOM),
Chapter 24, Section 5.
3.4.2 Survivors are
eligible to enroll in TRICARE Prime
(if available)
or TRICARE Select at retiree payment rates.
(See
TRICARE Reimbursement Manual (TRM), Chapter 2, Sections 1,
and 2). TPRADFM and
TOP Prime are not available to Survivors and Survivors are covered
by TRICARE Standard (effective January 1, 2018, replaced by TRICARE
Select
if the survivor chooses to enroll).
3.5 Benefits
3.5.1 Transitional
Survivors receive the same TRICARE benefits that are available to
ADFMs subject to any exclusions. This includes those TRICARE benefits
that are restricted to ADFMs such as, but not limited to, hearing
aids and eye examinations.
3.5.2 Survivors receive the same TRICARE benefits
that are available to retirees.
3.6 ECHO
3.6.1 Transitional Survivors may register in
the ECHO program subject to all ECHO rules and policies. See
Chapter 9, Section 2.1 for further information
on ECHO eligibility.
3.6.2 Survivors are excluded from the ECHO registration.
This is because the ECHO is not available to retirees and Survivors
are treated as retirees.
3.7 Payment Rates (e.g., Catastrophic Cap,
Cost-Shares, Copayments, Deductibles, etc.)
3.7.1 Transitional Survivors. Payment rates are
the same as ADFM payment rates for their respective TRICARE health
plan. See the
TRM,
Chapter 2, Sections 2 and
4.
3.7.2 Survivors. Payment rates are the same as
retiree payment rates for their respective TRICARE health plan.
See the TRM,
Chapter 2, Sections 2 and
4.