(a) Establishment.
The TRICARE
Young Adult (TYA) program offers options of medical benefits provided
under the TRICARE program to qualified unmarried adult children
of TRICARE-eligible uniformed service sponsors who do not otherwise
have eligibility for medical coverage under a TRICARE program at
age 21 (23 if enrolled in a full-time course of study at an approved
institution of higher learning, and the sponsor provides over 50
percent of the student’s financial support), and are under age 26.
(1) Purpose.
As specified
in paragraph (c) of this section, TYA is a premium-based health
option that is available for purchase by any qualified adult child
as that term is defined in paragraph (b) of this section. The TYA
program allows a qualified adult child to purchase TRICARE coverage.
(2) Statutory authority.
TYA is authorized
by 10 U.S.C. 1110b.
(3) Scope of the program.
TYA is geographically applicable
to the same extent as specified in Sec. 199.1(b)(1).
(4) Major features
of TYA.
(i) TRICARE rules
applicable.
(A) Unless specified in this section or otherwise prescribed
by the Assistant Secretary of Defense (Health Affairs) (ASD (HA)),
provisions of this part apply to TYA.
(B) The
TRICARE Dental Program (Sec. 199.13) and the TRICARE Retiree Dental
Program (Sec. 199.22) are not covered under TYA.
(C) TRICARE
Select is available to all TYA-eligible young adult dependents.
(D)
TRICARE
Prime is available to TYA-eligible young adult dependents, provided
that TRICARE Prime (including the Uniformed Services Family Health
Plan) is available in the geographic location where the TYA enrollee
resides. TYA-eligible young adults are:(1) Dependents of sponsors on active duty
orders written, or otherwise continuously, for more than 30 days
or covered by TAMP (under Sec. 199.3(e));
(2) Dependents of sponsors who are retired
members other than retired members of the Retired Reserve; and
(3) Survivors of members who died while on
active duty for more than 30 days or while receiving retired or
retainer pay.
(ii) Premiums.
TYA
coverage is a premium based program that an eligible young adult
dependent may purchase. There is only individual coverage, and a
premium shall be charged for each dependent even if there is more
than one qualified dependent in the uniformed service sponsor’s
family that qualifies for TYA coverage. Dependents qualifying for
TYA status can purchase individual TRICARE Select or TRICARE Prime
coverage (as applicable) according to the rules governing the TRICARE
option for which they are qualified on the basis of their uniformed
service sponsor’s TRICARE-eligible status (active duty, retired,
Selected Reserve, or Retired Reserve) and the availability of a
desired option in their geographic location. Premiums shall be determined
in accordance with paragraph (c) of this section.
(iii) Procedures.
Under TYA, qualified
dependents under paragraph (b) of this section may purchase individual
TYA coverage by submitting a completed request in the appropriate
format along with an initial payment of the applicable premium.
Procedures for purchasing coverage and paying applicable premiums
are prescribed in paragraph (d) of this section.
(iv) Benefits.
When
their TYA coverage becomes effective, qualified beneficiaries receive
the benefit of the TRICARE option that they selected, including,
if applicable, access to military treatment facilities and pharmacies.
TYA coverage features the cost share, deductible and catastrophic
cap provisions applicable to Group B beneficiaries based on the
program selected, i.e., the TRICARE Select program under Sec. 199.17(l)(2)(ii)
or the TRICARE Prime program under Sec. 199.17(l)(ii), as well as
the status of their military sponsor. Access to military treatment
facilities under the system of access priorities in Sec. 199.17(d)(1)
is also based on the program selected as well as the status of the
military sponsor. Premiums are not credited to deductibles or catastrophic
caps; however, TYA premiums shall apply instead of any applicable
TRICARE Prime or Select enrollment fee.
(b) Eligibility for
TRICARE Young Adult coverage.--
(1) Young Adult Dependent.
A young adult dependent
qualifies to purchase TYA coverage if the dependent meets the following
criteria:
(i) Would be a dependent
child under 10 U.S.C. 1072, but for exceeding the age limit under
that section (abused dependents and NATO dependents are not eligible
for TYA coverage); and
(ii) Is a dependent
under the age of 26; and
(iii) Is not enrolled,
or eligible to enroll, for medical coverage in an eligible employer-sponsored health
plan as defined in section 5000A(f)(2) of the Internal Revenue Code
of 1986; and
(iv) Is not otherwise
eligible under Sec. 199.3; and
(v) Is not a member
of the uniformed services.
(2) The dependents’
sponsor is responsible for keeping the Defense Enrollment Eligibility
Reporting System (DEERS) current with eligibility data through the
sponsor’s Service personnel office. Using information from the DEERS,
the TRICARE regional contractors have the responsibility to validate
a dependent’s qualifications to purchase TYA coverage.
(c) TRICARE Young Adult
premiums.
Qualified
young adult dependents are charged premiums for coverage under TYA
that represent the full cost of the program, including reasonable
administrative costs, as determined by the Director utilizing an
appropriate actuarial basis for the provision of TRICARE benefits
for the TYA-eligible beneficiary population. Separate premiums shall
be established for TRICARE Select and Prime plans. There may also
be separate premiums based on the uniformed services sponsor’s status.
Premiums are to be paid monthly, except as otherwise provided through administrative
implementation, pursuant to procedures established by the Director.
The monthly rate for each month of a calendar year is one-twelfth
of the annual rate for that calendar year.
(1) Annual establishment
of rates.--
(i) Monthly premium rates shall be established and
updated annually on a calendar year basis by the ASD(HA) for TYA
individual coverage.
(ii) The appropriate
actuarial basis used for calculating premium rates shall be one
that most closely approximates the actual cost of providing care
to a similar demographic population (based on age and health plans)
as those enrolled in TYA, as determined by the ASD(HA). TYA premiums
shall be based on the actual costs of providing benefits to TYA
dependents during the preceding years if the population of TYA enrollees
is large enough during those preceding years to be considered actuarially
appropriate. Until such time that actual costs from those preceding
years become available, TYA premiums shall be based on the actual
costs during the preceding calendar years for providing benefits
to the population of similarly aged dependents to make the underlying
group actuarially appropriate. An adjustment may be applied to cover
overhead costs for administration of the program.
(2) Premium adjustments.
In addition
to the determinations described in paragraph (c)(1) of this section,
premium adjustments may be made prospectively for any calendar year
to reflect any significant program changes mandated by legislative
enactment, including but not limited to significant new programs
or benefits.
(d) Procedures.
The
Director may establish procedures for the following.
(1) Purchasing coverage.
Procedures may
be established for a qualified dependent to purchase individual
coverage. To purchase TYA coverage for effective dates of coverage
described below, qualified dependents must submit a request in the
appropriate format, along with an initial payment of the applicable
premium required by paragraph (c) of this section in accordance
with established procedures.
(i) Continuation coverage.
Procedures may be established
for a qualified dependent to purchase TYA coverage with an effective
date immediately following the date of termination of coverage under another
TRICARE program. Application for continuation coverage must be made
within 30 days of the date of termination of coverage under another
TRICARE program.
(ii) Enrollment. Procedures
for enrollment in TRICARE plans under Sec. 199.17(o) shall apply
to a qualified dependent purchasing TYA coverage. Generally, the
effective date of coverage will coincide with the first day of a
month unless enrollment is due to a qualifying event and a different
date on or after the qualifying event is required to prevent a lapse
in health care coverage.
(2) Termination. Procedures
may be established for TYA coverage to be terminated as follows.
(i) Loss
of eligibility or entitlement for coverage by the sponsor will result
in termination of the dependent’s TYA coverage unless otherwise
specified. The effective date of the sponsor’s loss of eligibility
for care will also be the effective date of termination of benefits
under the TYA program unless specified otherwise.
(A) Active duty military sponsor.
TYA coverage
ends effective the date of military sponsor’s separation from military
service, unless the dependent would be eligible under section 199.3(e)
of this Part but for the dependent’s age, for the duration of the
Transitional Assistance Management Program (TAMP) eligibility or
until reaching age 26, whichever comes first. Upon the death of
an active duty sponsor, dependents eligible for Transitional Survivor
coverage may purchase TYA coverage if otherwise qualified.
(B) Selected Reserve
(Sel Res) Sponsor.
Sel Res sponsors must be currently enrolled
in TRICARE Reserve Select (TRS) before a young adult dependent is
eligible to purchase TYA. If TRS coverage is terminated by the sponsor,
TYA coverage ends effective the same termination date as the sponsor.
If the Sel Res sponsor dies while enrolled in TRS, the young adult
dependent is eligible to purchase TYA coverage for six months after
the date of death of the Sel Res sponsor, if otherwise qualified.
(C) Retired Reserve
Sponsor.
Retired
Reserve members not yet eligible for retired or retainer pay must be
enrolled in TRICARE Retired Reserve (TRR) to establish TYA eligibility
for their young adult dependents. If TRR coverage is terminated
by the sponsor, the TYA coverage for the young adult dependent ends
effective the same date as the sponsor’s termination of coverage
under TRR. If the retired reserve sponsor dies while enrolled in
TRR, the young adult dependent may continue to purchase TYA coverage
until the date on which the deceased member would have attained
age 60, if otherwise qualified. If the Retired Reserve member dies
and is not enrolled in TRR, there is no eligibility for TYA coverage
until the sponsor would have reached age 60. On the date the Retired
Reserve member would have reached 60, a young adult dependent who
otherwise qualifies for TYA qualifies as a dependent of a deceased
retired sponsor and can purchase TYA coverage.
(ii) Failure
of a young adult dependent to maintain the eligibility qualifications
in paragraph (b) of this section shall result in the termination
of coverage under the TYA program. The effective date of termination
shall be the date upon which the adult young dependent failed to
meet any of the prerequisite qualifications. If a subsequent change
in circumstances re-establishes eligibility (such as losing eligibility
for an eligible employer-sponsored plan), the young adult dependent
may re-enroll for coverage under the TYA program.
(iii) Coverage
may also be terminated due to a change in the sponsor’s status,
and the young adult dependent must re-qualify and reapply for TYA
coverage within 30 days of termination to preclude a gap in coverage.
(iv) Termination
of coverage results in denial of claims for services with a date
of service after the effective date of termination.
(v) Coverage
may be terminated for young adult dependents upon request at any
time by submitting a completed request in the appropriate format
in accordance with established procedures.
(vi) In
accordance with the provisions of Sec. 199.17(o)(2), coverage terminates
for young adult dependents who fail to make premium payments in
accordance with established procedures.
(vii) Absent
a new qualifying event, young adults are not eligible to re-enroll
in TYA until the next annual open season.
(3) Eligibility for
the Continued Health Care Benefit Program.
Upon termination of eligibility
to purchase TYA coverage, dependents may purchase coverage for up
to 36 months through the Continued Health Care Benefit Program under
Sec. 199.20 unless locked out of TYA.
(4) Changing coverage.
Upon application
and payment of appropriate premiums, qualified dependents already
enrolled in and who are current in their premium payments may elect
to change to another TRICARE program for which the qualified dependent
is eligible based on the sponsor’s eligibility and the geographic
location of the qualified young adult dependent. Upon change in sponsor
status (for example, active duty to retired status), TYA coverage
may be automatically transferred to the appropriate TRICARE option
consistent with the sponsor’s new status. Recurring TYA premiums
may be adjusted accordingly. Administrative processes may be established
for changes in program enrollment; however, no change shall be effective
until the applicable premium has been paid.
(e) Preemption of State
laws.--
The preemption provisions of Sec. 199.17(a)(7)
are applicable to the TYA program.
(f) Administration.
The
Director may establish other processes, policies and procedures
for the effective administration of the TYA Program and may authorize
exceptions to requirements of this section, if permitted.
[76 FR 23483, Apr 27, 2011; 78 FR 32119,
May 29, 2013; 82 FR 45460, Sep 29, 2017]