(a) General.
This section
sets forth those persons who, by the provisions of 10 U.S.C. chapter
55, and the NATO Status of Forces Agreement, are eligible for CHAMPUS
benefits. A determination that a person is eligible does not automatically
entitle such a person to CHAMPUS payments. Before any CHAMPUS benefits
may be extended, additional requirements, as set forth in other
sections of this part, must be met. Additionally, the use of CHAMPUS
may be denied if a Uniformed Service medical treatment facility
capable of providing the needed care is available. CHAMPUS relies
primarily on the Defense Enrollment Eligibility Reporting System
(DEERS) for eligibility verification.
(b)
CHAMPUS eligibles--
(1) Retiree.
A
member or former member of a Uniformed Service who is entitled to
retired, retainer, or equivalent pay based on duty in a Uniformed
Service.
(2) Dependent.
Individuals
whose relationship to the sponsor leads to entitlement to benefits. CHAMPUS
eligible dependents include the following:
(i) Spouse.
A
lawful husband or wife of a member or former member. The spouse
of a deceased member or retiree must not be remarried. A former
spouse also may qualify for benefits as a dependent spouse. A former
spouse is a spouse who was married to a military member, or former
member, but whose marriage has been terminated by a final decree
of divorce, dissolution or annulment. To be eligible for CHAMPUS
benefits, a former spouse must meet the criteria described in paragraphs (b)(2)(i)(A)
through (b)(2)(i)(E) of this section and must qualify
under the group defined in paragraph (b)(2)(i)(F)(1)
or (b)(2)(i)(F)(2) of this section.
(A) Must be unremarried;
and
(B) Must
not be covered by an employer-sponsored health plan; and
(C) Must have been
married to a member or former member who performed at least 20 years
of service which can be credited in determining the member’s or
former member’s eligibility for retired or retainer pay; and
(D) Must not be eligible
for Part A of Title XVIII of the Social Security Act (Medicare)
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii),
and (f)(3)(ix) of this section; and
(E) Must not be the
dependent of a NATO member; and
(F) Must meet the requirements
of paragraph (b)(2)(i)(F)(
1) or (b)(2)(i)(F)(
2)
of this section:
(1) The former spouse must have been married
to the same member or former member for at least 20 years, at least
20 of which were creditable in determining the member’s or former
member’s eligibility for retired or retainer pay. Eligibility continues
indefinitely unless affected by any of the conditions of paragraphs
(b)(2)(i)(A) through (b)(2)(i)(E) of this section.
(i) If the date
of the final decree of divorce, dissolution, or annulment was before
February 1, 1983, the former spouse is eligible for CHAMPUS coverage
of health care received on or after January 1, 1985.
(ii) If the date
of the final decree of the divorce, dissolution, or annulment was
on or after February 1, 1983, the former spouse is eligible for
CHAMPUS coverage of health care which is received on or after the
date of the divorce, dissolution, or annulment.
(2) The former
spouse must have been married to the same member or former member
for at least 20 years, and at least 15, but less than 20 of those
married years were creditable in determining the member’s or former
member’s eligibility for retired or retainer pay.
(i) If the date
of the final decree of divorce, dissolution, or annulment is before
April 1, 1985, the former spouse is eligible only for care received
on or after January 1, 1985, or the date of the divorce, dissolution,
or annulment, whichever is later. Eligibility continues indefinitely
unless affected by any of the conditions of paragraphs (b)(2)(i)(A)
through (b)(2)(i)(E) of this section.
(ii) If the date
of the final decree of divorce, dissolution or annulment is on or
after April 1, 1985, but before September 29, 1988, the former spouse
is eligible only for care received from the date of the decree of
divorce, dissolution, or annulment until December 31, 1988, or for
two years from the date of the divorce, dissolution, or annulment,
whichever is later.
(iii) If the
date of the final decree of divorce, dissolution, or annulment is
on or after September 29, 1988, the former spouse is eligible only
for care received within the 365 days (366 days in the case of a leap
year) immediately following the date of the divorce, dissolution,
or annulment.
(ii) Child.
A dependent
child is an unmarried child of a member or former member who has
not reached his or her twenty-first (21st) birthday, except an incapacitated
adopted child meeting the requirements of paragraph (b)(2)(ii)(H)(2)
of this section, and who bears one of the following relationships
to a member or former member of one of the Uniformed Services:
(A) A legitimate child;
or
(B) An
adopted child whose adoption has been legally completed on or before
the child’s twenty-first (21st) birthday; or
(C) A legitimate stepchild;
or
(D) An
illegitimate child of a member or former member whose
paternity/maternity has been determined judicially,
and the member or former member directed to support the child; or
(E) An illegitimate
child of a member or former member whose paternity/maternity
has not been determined judicially, who resides with or in the home
provided by the member or former member, and is or continues to
be dependent upon the member or former member for over one-half
of his or her support, or who was so dependent on the former member
at the time of the former member’s death; or
(F) An illegitimate
child of a spouse of a member who resides with
or in a home provided by the member and is, and continues to be
dependent upon the member for over one-half of his or her support;
or
(G) An
illegitimate child of a spouse of a former member who
resides with or in a home provided by a former member or the former
member’s spouse at the time of death of the former member, and is,
or continues to be, or was, dependent upon the former member for
more than one-half of his or her support at the time of death; or
(H) An
individual who falls into one of the following classes:
(1) A student.
A child determined
to be a member of one of the classes in paragraphs (b)(2)(ii)(A) through
(b)(2)(ii)(G) of this section, who is not married, has passed his
or her 21st birthday but has not passed his or her 23rd birthday,
is dependent upon the member or former member for over 50 percent of
his or her support or was dependent upon the member or former member
for over 50 percent of his or her support on the date of the member’s
or former member’s death, and is pursuing a full-time course of
education in an institution of higher learning approved by the Secretary
of Defense or the Department of Education (as appropriate) or by
a state agency under 38 U.S.C. chapters 34 and 35.
Note: Courses
of education offered by institutions listed in the “Education Directory,”
“Higher Education” or “Accredited Higher Institutions” issued periodically
by the Department of Education meet the criteria approved by the
Administering Secretary or the Secretary of Education. For determination of
approval of courses offered by a foreign institution, by an institution
not listed in either of the above directories, or by an institution
not approved by a state agency pursuant to 38 U.S.C. chapters 34
and 35, a statement may be obtained from the Department of Education,
Washington, D.C. 20202.
(2) An incapacitated
child.
A child determined
to be a member of one of the classes in paragraphs (b)(2)(ii)(A)
through (b)(2)(ii)(G) of this section, who is not married and is
incapable of self-support because of a mental or physical disability
that:
(i) Existed before the child’s twenty-first
(21st) birthday; or
(ii) Occurred
between the ages of 21 and 23 while the child was enrolled in a
full-time course of study in an institution of higher learning approved
by the Administering Secretary or the Department of Education (see
NOTE to paragraph (b)(2)(ii)(H)(2)(iii)
of this section), and is or was at the time of the member’s or former
member’s death dependent on the member or former member for over
one-half of his or her support; and
(iii) The incapacity is continuous. (If the
incapacity significantly improves or ceases at any time, CHAMPUS
eligibility cannot be reinstated on the basis of the incapacity,
unless the incapacity recurs and the beneficiary is under age 21,
or is under age 23 and is enrolled as a full-time student under paragraph
(b)(2)(ii)(H)(
2)(
ii) of this section.
If the child was not incapacitated after that date, no CHAMPUS eligibility
exists on the basis of the incapacity. However, incapacitated children
who marry and who subsequently become unmarried through divorce,
annulment, or death of spouse, may be reinstated as long as they
still meet all other requirements).
Note: An institution
of higher learning is a college, university, or similar institution,
including a technical or business school, offering post-secondary
level academic instruction that leads to an associate or higher
degree, if the school is empowered by the appropriate State education
authority under State law to grant an associate, or higher, degree.
When there is no State law to authorize the granting of a degree,
the school may be recognized as an institution of higher learning
if it is accredited for degree programs by a recognized accrediting
agency. The term also shall include a hospital offering educational
programs at the post-secondary level regardless of whether the hospital
grants a post-secondary degree. The term also shall include an educational
institution that is not located in a State, that offers a course
leading to a standard college degree, or the equivalent, and that
is recognized as such by the Secretary of Education (or comparable
official) of the country, or other jurisdiction, in which the institution
is located (38 U.S.C. chapter 34, section 1661, and chapter 35,
section 1701.
Courses of education offered by institutions
listed in the “Education Directory,” “Higher Education” or “Accredited
Higher Institutions” issued periodically by the Department of Education
meet the criteria approved by the Administering Secretary or the
Secretary of Education. For determination of approval of courses
offered by a foreign institution, by an institution not listed in
either of the above directories, or by an institution not approved
by a state agency pursuant to chapters 34 and 35 of 38 U.S.C., a statement
may be obtained from the Department of Education, Washington, D.C.
20202.
(3) A child of
a deceased reservist.
A
child, who is determined to be a member of one of the classes in paragraphs
(b)(2)(ii)(A) through (b)(2)(ii)(G) of this section, of a reservist
in a Uniformed Service who incurs or aggravates an injury, illness,
or disease, during, or on the way to or from, active duty training for
a period of 30 days or less or inactive duty training, and the reservist
dies as a result of that specific injury, illness or disease.
(4) An unmarried
person.
An unmarried
person placed in the home of a member or former member prior to
adoption. To be a dependent child, the unmarried person must not
have reached the age of 21 (or otherwise meets the requirements
of a student or incapacitated child set out in paragraphs (b)(2)((ii)(H)(1)
or (b)(2)(ii)(H)(2) of this section) and has been placed in the
home of the member or former member by a recognized placement agency
or by any other source authorized by State or local law to provide
adoption placement, in anticipation of legal adoption by the member
or former member.
(iii) Abused
dependents.--
(A) Categories of
abused dependents.
An
abused dependent may be either a spouse or a child. Eligibility
for either class of abused dependent results from being either:
(1) The spouse
(including a former spouse) or child of a member who has received
a dishonorable or bad-conduct discharge, or dismissal from a Uniformed
Service as a result of a court-martial conviction for an offense
involving physical or emotional abuse of the spouse or child, or
was administratively discharged as a result of such an offense.
Until October 17, 1998, Medical benefits are limited to care related
to the physical or emotional abuse and for a period of 12 months
following the member’s separation from the Uniformed Service. On
or after October 17, 1998, medical benefits can include all under
the Basic Program and under the Extended Care Health Option for
the period that the spouse or child is in receipt of transitional
compensation under section 1059 of title 10 U.S.C.
(2) The spouse
(including a former spouse) or child of a member or former member
who while a member and as a result of misconduct involving abuse
of the spouse or child has eligibility to receive retired pay on
the basis of years of service terminated.
(B) Requirements for categories of abused dependents--
(1) Abused spouse.
As long as the
spouse is receiving payments from the DoD Military Retirement Fund
under court order, the spouse is eligible for health care under
the same conditions as any spouse of a retired member. The abused
spouse must:
(i) Under paragraph (b)(2)(iii)(A)(1)
of this section, be a lawful husband or wife or a former spouse
of the member; or
(ii) Under paragraph
(b)(2)(iii)(A)(
2) of this section, be a lawful
husband or wife or a former spouse of the member or former member,
and the spouse is receiving payments from the Department of Defense Military
Retirement Fund under 10 U.S.C. 1408(h) pursuant to a court order;
and
(A) Be a victim of the abuse; and
(B) Have been
married to the member or former member at the time of the abuse;
or
(C) Be the natural or adoptive parent of a
dependent child of the member or former member who was the victim
of the abuse.
(2) Abused child.
The abused child
must:
(i) Under paragraph (b)(2)(iii)(A)(1)
of this section, be a dependent child of the member or former member.
(ii) Under paragraph
(b)(2)(iii)(A)(
2) of this section,
(A) Have been
a member of the household where the abuse occurred; and
(B) Be an unmarried
legitimate child, including an adopted child or stepchild of the
member or former member; and
(C) Be under
the age of 18; or
(D) Be incapable of self support because of
a mental or physical incapacity that existed before becoming 18
years of age and be dependent on the member or former member for
over one-half of his or her support; or
(E) If enrolled
in a full-time course of study in an institution of higher learning
recognized by the Secretary of Defense (for the purposed of 10 U.S.C.
1408(h)), be under 23 years of age and be dependent on the member
or former member for over one-half of his or her support.
(F) The dependent
child is eligible for health care, regardless of whether any court
order exists, under the same conditions as any dependent of a retired
member.
(3) TAMP eligibles.
A former member,
including his or her dependents, who is eligible under the provisions
of the Transitional Assistance Management Program as described in
paragraph (e) of this Sec. 199.3.
(iv) An
unmarried person who is placed in the legal custody of a member
or former member by a court of competent jurisdiction in the United
States (or possession of the United States) for a period of at least
12 consecutive months. The unmarried person shall be considered
a dependent of the member or former member under this section provided
he or she otherwise meets the following qualifications:
(A) Has not reached
the age of 21 unless he or she otherwise meets the requirements
of a student set out in paragraph (b)(2)(ii)(H)(1) of this section
or the requirements for being incapacitated as set out in paragraph
(b)(2)(ii)(H)(2) of this section and the incapacitation occurred
while he or she was a dependent of the member or former member through
court ordered legal custody;
(B) Is dependent on
the member or former member for over one-half of the person’s support;
(C) Resides with the
member or former member unless separated by the necessity of military
service or to receive institutional care as a result of disability
or incapacitation or under such other authorized circumstances;
and,
(D) Is
not a dependent of a member or former member under any other provision
of law or regulation.
(3) Eligibility under TRICARE Senior Pharmacy
Program.
Section 711
of the National Defense Authorization Act for Fiscal Year 2001 (Public
Law 106-398, 114 Stat. 1654) established the TRICARE Senior Pharmacy
Program effective April 1, 2001. To be eligible for this program,
a person is required to be:
(i) Medicare eligible,
who is:
(A) 65
years of age or older; and
(B) Entitled to Medicare Part A; and
(C) Enrolled in Medicare
Part B, except for a person who attained age 65 prior to April 1,
2001, is not required to enroll in Part B; and
(ii) Otherwise qualified
under one of the following categories:
(A) A retired uniformed
service member who is entitled to retired or retainer pay, or equivalent
pay including survivors who are annuitants; or
(B) A dependent of
a member of the uniformed services described in one of the following:
(1) A member
who is on active duty for a period of more than 30 days or died
while on such duty; or
(2) A member who died from an injury, illness,
or disease incurred or aggravated while the member was:
(i) On active
duty under a call or order to active duty of 30 days or less, on
active duty for training, or on inactive duty training; or
(ii) Traveling
to or from the place at which the member was to perform or had performed
such active duty, active duty for training, or inactive duty training.
Note
to paragraph (b)(3)(ii)(B): Dependent under Section 711
of the National Defense Authorization Act for Fiscal Year 2001 includes
spouse, unremarried widow/widower, child, parent/parent-in-law, unremarried
former spouse, and unmarried person in the legal custody of a member
or former member, as those terms of dependency are defined and periods
of eligibility are set forth in 10 U.S.C. 1072(2).
(4) Medal of Honor recipients.
(i) A former member
of the armed forces who is a Medal of Honor recipient and who is
not otherwise entitled to medical and dental benefits has the same
CHAMPUS eligibility as does a retiree.
(ii) Immediate dependents.
CHAMPUS eligible
dependents of a Medal of Honor Recipient are those identified in
paragraphs (b)(2)(i) of this section (except for former spouses)
and (b)(2)(ii) of this section (except for a child placed in legal
custody of a Medal of Honor recipient under (b)(2)(ii)(H)(4) of
this section).
(iii) Effective date.
The CHAMPUS
eligibility established by paragraphs (b)(4)(i) and (ii) of this
section is applicable to health care services provided on or after
October 30, 2000.
(5) Reserve
Component Members Issued Delayed-Effective-Date Orders.
(i) Member.
A
member of a reserve component of the armed forces who is ordered
to active duty for a period of more than 30 consecutive days in
support of a contingency operation under a provision of law referred
to in section 101(a)(13)(B) of Title 10, United States Code, that
provides for active-duty service to begin on a date after the date
of the issuance of the order.
(ii) Dependents.
CHAMPUS eligible
dependents under this paragraph (b)(5) are those identified in paragraphs
(b)(2)(i) (except former spouses) and (b)(2)(ii) of this section.
(iii) Effective date.
The eligibility
established by paragraphs (b)(5)(i) and (ii) of this section shall
begin on or after November 6, 2003, and shall be effective on the
later of the date that is:
(A) The date of issuance
of the order referred to in paragraph (b)(5)(i) of this section;
or
(B) 180
days before the date on which the period of active duty is to begin.
(iv) Termination
date.
The eligibility
established by paragraphs (b)(5)(i) and (ii) of this section ends upon
entry of the member onto active duty (at which time CHAMPUS eligibility
for the dependents of the member is established under paragraph
(b)(2) of this section) or upon cancellation or amendment of the
orders referred to in paragraph (b)(5)(i) of this section such that
they no longer meet the requirements of that paragraph (b)(5)(i).
(c) Beginning dates of eligibility.
(1) Beginning dates
of eligibility depend on the class to which the individual belongs
and the date the individual became a member of the class. Those
who join after the class became eligible attain individual eligibility
on the date they join.
(2) Beginning dates of eligibility for each class
of spouse
(excluding spouses who are victims of abuse and
eligible spouses of certain deceased reservists) are as
follows:
(i) A
spouse of a member for:
(A) Medical benefits authorized by the Dependents’
Medical Care Act of 1956, December 7, 1956;
(B) Outpatient medical
benefits under the Basic Program, October 1, 1966;
(C) Inpatient medical
benefits under the Basic Program and benefits under
the Extended Care Health Option, January 1, 1967;
(ii) A spouse of a
former member:
(A) For
medical benefits under the Basic Program, January 1, 1967.
(B) Ineligible for
benefits under the Extended Care Health Option.
(iii) A former spouse:
(A) For medical benefits
under the Basic Program, dates of beginning eligibility are as indicated
for each category of eligible former spouse identified within paragraph
(b)(2)(i) of this section.
(B) Ineligible for benefits under the Extended Care
Health Option.
(3) Beginning dates
of eligibility for spouses who are victims of abuse
(excluding
spouses who are victims of abuse of certain deceased reservists) are
as follows:
(i) An
abused spouse meeting the requirements of paragraph (b)(2)(iii)(A)(
1)
of this section, including an eligible former spouse:
(A) For medical and
dental care for problems associated with the physical or emotional
abuse under the Basic Program for a period of up to one year (12
months) following the person’s separation from the Uniformed Service,
November 14, 1986.
(B) For all medical and dental benefits under the
Basic Program for the period that the spouse is in receipt of transitional
compensation under section 1059 of title 10 U.S.C., October 17,
1998.
(C) For
medical and dental care for problems associated with the physical
or emotional abuse under the Extended Care Health Option for a period
up to one year (12 months) following the person’s separation from
the Uniformed Service, November 14, 1986.
(D) For all medical
and dental benefits described in section 199.5 for the period that
the spouse is in receipt of transitional compensation under section
1059 of title 10 U.S.C., October 17, 1998.
(ii) An abused spouse
meeting the requirements of paragraphs (b)(2)(iii)(A)(
2)
of this section, including an eligible former spouse:
(A) For all benefits
under the CHAMPUS Basic Program, October 23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(4) Beginning dates
of eligibility for spouses of certain deceased reservists,
including
spouses who are victims of abuse of certain deceased reservists,
are as follows:
(i) A
spouse meeting the requirements of paragraph (b)(2)(i) of this section,
including an eligible former spouse:
(A) For benefits under the Basic Program, November
14, 1986.
(B) Ineligible for benefits under the Extended Care
Health Option.
(ii) An abused spouse of certain deceased reservists,
meeting the requirements of paragraphs (b)(2)(iii) of this section,
including an eligible former spouse,
for the limited benefits
and period of eligibility described in paragraphs (b)(2)(iii)
of this section:
(A) For
benefits under the Basic Program, November 14, 1986.
(B) For benefits under
the Extended Care Health Option, November 14, 1986.
(iii) An abused spouse
of certain deceased reservists, including an eligible former spouse,
meeting the requirements of paragraphs (b)(2)(iii) of this section:
(A) For benefits under
the Basic Program, October 23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(5)
Beginning
dates of eligibility for each class of dependent children,
(excluding
dependent children of certain deceased reservists, abused children
and incapacitated children whose incapacity occurred between the
ages of 21 and 23 while enrolled in a full-time course of study
in an institution of higher learning), are as follows:
(i) Legitimate child,
adopted child, or legitimate stepchild of a
member,
for:
(A) Medical
benefits authorized by the Dependents’ Medical Care Act of 1956,
December 7, 1956;
(B) Outpatient medical benefits under the Basic
Program, October 1, 1966;
(C) Inpatient medical benefits under the Basic Program and benefits
under the Extended Care Health Option, January 1, 1967;
(ii) Legitimate child,
adopted child or legitimate stepchild of
former members:
(A) For medical benefits
under the Basic Program, January 1, 1967.
(B) Ineligible for
benefits under the Extended Care Health Option.
(iii) Illegitimate
child of a male or female
member or former member whose
paternity/maternity has been determined judicially and the member
or former member has been directed to support the child, for:
(A) All benefits for
which otherwise entitled, August 31, 1972.
(B) Extended Care Health
Option benefits limited to dependent children of members only, August 31,
1972.
(iv) Illegitimate child of:
(A) A male member or
former member whose paternity has not been determined
judicially:
(B) A female member or former member who resides
with, or in a home provided by the member or former member, or who
was residing in a home provided by the member or former member at
the time of the member’s or former member’s death, and who is or
continues to be dependent on the member for over one-half of his
or her support, or was so dependent on the member or former member
at the time of death;
(C) A spouse of a member or former member who resides
with or in a home provided by the member or former member, or the
parent who is the spouse of the member or former member or was the spouse
of a member or former member at the time of death, and who is and
continues to be dependent upon the member or former member for over
one-half of his or her support, or was so dependent on the member
or former member at the time of death; for:
(1) All benefits
for which otherwise eligible, January 1, 1969.
(2) Extended
Care Health Option limited to dependent children of members only,
January 1, 1969.
(6) Beginning dates
of eligibility for children of certain deceased reservists who meet
the requirements of paragraph (b)(2)(ii)(H)(3) of this section,
excluding
incapacitated children who meet the requirements of paragraph (b)(2)(ii)(H)(
2)
of this section, for:
(i) Benefits under the Basic program, November 14,
1986.
(ii) Not
eligible for benefits under the Extended Care Health Option.
(7) Beginning dates
of eligibility for children who are victims of abuse,
including
incapacitated children who meet the requirements of paragraph
(b)(2)(ii)(H)(
2) of this section are as follows:
(i) An abused child
meeting the requirements of paragraph (b)(2)(iii)(A)(
1)
of this section:
(A) Medical
and dental care for problems associated with the physical or emotional
abuse under the Basic Program for a period of up to one year (12
months) following the person’s separation from the Uniformed Service,
November 14, 1986.
(B) For all medical and dental benefits under the
Basic Program for the period that the child is in receipt of transitional
compensation under section 1059 of title 10 U.S.C., October 17,
1998.
(C) Medical
and dental care for problems associated with the physical or emotional
abuse under the Extended Care Health Option for a period up to one
year (12 months) following the person’s separation from the Uniformed
Service, November 14, 1986.
(D) For all medical and dental benefits described
in section 199.5 for the period that the child is in receipt of
transitional compensation under section 1059 of title 10 U.S.C.,
October 17, 1998.
(ii) An abused child meeting the requirements of
paragraphs (b)(2)(iii)(A)(
2) of this section:
(A) For all benefits
under the CHAMPUS Basic Program, October 23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(8) Beginning dates
of eligibility for incapacitated children who meet the requirements
of paragraph (b)(2)(ii)(H)(
2) of this section,
whose incapacity occurred between the ages of 21 and 23 while enrolled in
a full-time course of study in an institution of higher learning
approved by the Administering Secretary or the Department of Education,
and, are or were at the time of the member’s or former member’s
death, dependent on the member or former member for over one-half
of their support, for:
(i) All benefits for which otherwise entitled, October
23, 1992.
(ii) Extended Care Health Option benefits limited
to children of members only, October 23, 1992.
(9) Beginning dates
of eligibility for a child who meets the requirements of paragraph
(b)(2)(ii)(H)(
4) and:
(i) Has been placed
in custody by a court:
(A) All benefits for which entitled, July 1, 1994.
(B) Extended Care Health
Option benefits limited to children of members only,
July 1, 1994.
(ii) Has been placed in custody by a recognized adoption
agency:
(A) All
benefits for which entitled, October 5, 1994.
(B) Extended Care Health
Option benefits limited to children of members only,
October 5, 1994.
(iii) Has been placed
in the home of a member by a placement agency or by any other source authorized
by State or local law to provide adoption placement, in anticipation
of the legal adoption of the member:
(A) All benefits for which entitled, January 6,
2006.
(B) Extended
Care Health Option benefits limited to children of members only,
January 6, 2006.
(10) Beginning dates
of eligibility for a retiree for:
(i) Medical benefits under the Basic Program January
1, 1967.
(ii) Retirees and their dependents are not eligible
for benefits under the Extended Care Health Option.
(d) Dual eligibility.
Dual eligibility occurs when a person is
entitled to benefits from two sources. For example, when an active
duty member is also the dependent of another active duty member,
a retiree, or a deceased active duty member or retiree, dual eligibility,
that is, entitlement to direct care from the Uniformed Services
medical care system and CHAMPUS is the result. Since the active
duty status is primary, and it is the intent that all medical care
be provided an active duty member through the Uniformed Services
medical care system, CHAMPUS eligibility is terminated as of 12:01
a.m. on the day following the day the dual eligibility begins. However,
any dependent children in a marriage of two active duty persons
or of an active duty member and a retiree, are CHAMPUS eligible
in the same manner as dependent children of a marriage involving
only one CHAMPUS sponsor. Should a spouse or dependent who has dual
eligibility leave active duty status, that person’s CHAMPUS eligibility
is reinstated as of 12:01 a.m. of the day active duty ends, if he
or she otherwise is eligible as a dependent of a CHAMPUS sponsor.
Note: No
CHAMPUS eligibility arises as the result of the marriage of two
active duty members.
(e) Eligibility under
the Transitional Assistance Management Program (TAMP).
(1) A member of the
armed forces is eligible for transitional health care if the member
is:
(i) A
member who is involuntarily separated from active duty.
(ii) A member of a
Reserve component who is separated from active duty to which called
or ordered in support of a contingency operation if the active duty
is active duty for a period of more than 30 consecutive days.
(iii) A member who
is separated from active duty for which the member is involuntarily
retained under 10 U.S.C. 12305 in support of a contingency operation;
or
(iv) A
member who is separated from active duty served pursuant to a voluntary
agreement of the member to remain on active duty for a period of
less than 1 year in support of a contingency operation.
(v) A member who receives
a sole survivorship discharge (as defined in section 1174(i) of
this title).
(vi) A member who is separated from Active Duty who
agrees to become a member of the Selected Reserve of the Ready Reserve
of a reserve component.
(2) A spouse (as described
in paragraph (b)(2)(i) of this section except former spouses) and
child (as described in paragraph (b)(2)(ii) of this section) of
a member described in paragraph (e)(1) of this section is also eligible
for TAMP benefits under TRICARE.
(3) TAMP
benefits under TRICARE begin on the day after the member is separated
from active duty, and, if such separation occurred on or after November
6, 2003, end 180 days after such date. TRICARE benefits available
to both the member and eligible family members are generally those
available to family members of members of the uniformed services
under this Part. However, during TAMP eligibility, a member of a
Reserve Component as described in paragraph (e)(1)(ii) of this section,
is entitled to dental care to which a member of the uniformed services
on active duty for more than 30 days is entitled. Each branch of
service will determine eligibility for its members and eligible
family members and provide data to DEERS.
(f) Changes in status
which result in termination of CHAMPUS eligibility.
Changes in status which
result in a loss of CHAMPUS eligibility as of 12:01 a.m. of the
day following the day the event occurred, unless otherwise indicated,
are as follows:
(1) Changes in the status of a member.
(i) When an active
duty member’s period of active duty ends, excluding retirement or
death.
(ii) When
an active duty member is placed on desertion status (eligibility
is reinstated when the active duty member is removed from desertion
status and returned to military control).
Note: A
member serving a sentence of confinement in conjunction with a sentence
of punitive discharge is still considered on active duty until such
time as the discharge is executed.
(2) Changes in the status of a retiree.
(i) When a retiree
ceases to be entitled to retired, retainer, or equivalent pay for
any reason, the retiree’s dependents lose their eligibility unless
the dependent is otherwise eligible (e.g., some former spouses,
some dependents who are victims of abuse and some incapacitated
children as outlined in paragraph (b)(2)(ii)(H)(2)
of this section).
(ii) A retiree also loses eligibility when no longer
entitled to retired, retainer, or equivalent pay.
Note: A
retiree who waives his or her retired, retainer or equivalent pay
is still considered a retiree for the purposes of CHAMPUS eligibility.
(iii) Attainment of
entitlement to hospital insurance benefits (Part A) under Medicare
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii)
and (f)(3)(ix) of this section.
(3) Changes in the status of a dependent.
(i) Divorce, except
for certain classes of former spouses as provided in paragraph (b)(2)(i)
of this section and the member or former member’s
own children
(i.e., legitimate, adopted, and judicially determined illegitimate
children).
Note: An unadopted stepchild loses eligibility
as of 12:01 a.m. of the day following the day the divorce becomes
final.
(ii) Annulment, except for certain classes of former
spouse as provided in paragraph (b)(2)(i) of this section and the
member or former member’s
own children (i.e., legitimate,
adopted, and judicially determined illegitimate children).
Note: An
unadopted stepchild loses eligibility as of 12:01 a.m. of the day
following the day the annulment becomes final.
(iii) Adoption, except
for adoptions occurring after the death of a member or former member.
(iv) Marriage of a
child, except when the marriage is terminated by death, divorce,
or annulment before the child is 21 or 23 if an incapacitated child
as provided in paragraph (b)(2)(ii)(H)(2) of this section.
(v) Marriage of a widow
or widower, except for the child of the widow or widower who was
the stepchild of the deceased member or former member at the time
of death. The stepchild continues CHAMPUS eligibility as other classes
of dependent children.
(vi) Attainment of entitlement to hospital insurance
benefits (Part A) under Medicare except as provided in paragraphs
(b)(3), (f)(3)(vii), (f)(3)(viii), and (f)(3)(ix) of this section.
(This also applies to individuals living outside the United States
where Medicare benefits are not available.)
(vii) Attainment of
age 65, except for dependents of active duty members, beneficiaries
not entitled to part A of Medicare, beneficiaries entitled to Part
A of Medicare who have enrolled in Part B of Medicare, and as provided
in paragraph (b)(3) of this section. For those who do not retain
CHAMPUS, CHAMPUS eligibility is lost at 12:01 a.m. on the first
day of the month in which the beneficiary becomes entitled to Medicare.
Note: If
the person is not eligible for Part A of Medicare, he or she must
file a Social Security Administration, “Notice of Disallowance”
certifying to that fact with the Uniformed Service responsible for
the issuance of his or her identification card so a new card showing
CHAMPUS eligibility can be issued. Individuals entitled only to
supplementary medical insurance (Part B) of Medicare, but not Part A,
or Part A through the Premium HI provisions (provided for under
the 1972 Amendments to the Social Security Act) retain eligibility
under CHAMPUS (refer to Sec. 199.8 for additional information when
a double coverage situation is involved).
(viii) End
stage renal disease. All beneficiaries, except dependents of active
duty members, lose their CHAMPUS eligibility when Medicare coverage
becomes available to a person because of chronic renal disease unless
the following conditions have been met. CHAMPUS eligibility will
continue if:
(A) The
individual is under 65 years old;
(B) The individual
became eligible for Medicare under the provisions of 42 U.S.C. 426-1(a);
(C) The individual
is enrolled in Part B of Medicare; and
(D) The individual
has applied and qualified for continued CHAMPUS eligibility through
the Defense Enrollment Eligibility Reporting System (DEERS).
(ix) Individuals
with certain disabilities. Each case relating to Medicare eligibility
resulting from being disabled requires individual investigation.
All beneficiaries except dependents of active duty members lose
their CHAMPUS eligibility when Medicare coverage becomes available
to a disabled person unless the following conditions have been met.
CHAMPUS eligibility will continue if:
(A) The individual is under 65 years old;
(B) The individual
became eligible for Medicare under the provisions of 42 U.S.C. 426(b)(2);
(C) The individual
is enrolled in Part B of Medicare except that in the case of a retroactive determination
of entitlement to Medicare Part A hospital insurance benefits for
a person under 65 years of age there is no requirement to enroll
in Medicare Part B from the Medicare Part A entitlement date until
the issuance of such retroactive determination; and
(D) The individual
has applied and qualified for continued CHAMPUS eligibility through
the Defense Enrollment Eligibility Reporting System (DEERS).
(x) Disabled students,
that is children age 21 or 22, who are pursuing a full-time course
of higher education and who, either during the school year or between
semesters, suffer a disabling illness or injury with resultant inability
to resume attendance at the institution remain eligible for CHAMPUS medical
benefits for 6 months after the disability is removed or until the
student passes his or her 23rd birthday, whichever occurs first.
However, if recovery occurs before the 23rd birthday and there is resumption
of a full-time course of higher education, CHAMPUS benefits can
be continued until the 23rd birthday. The normal vacation periods
during an established school year do not change the eligibility
status of a dependent child 21 or 22 years old in a full time student
status. Unless an incapacitating condition existed before, and at
the time of, a dependent child’s 21st birthday, a dependent child
21 or 22 years old in student status does not have eligibility and may
not qualify for eligibility under the requirements related
to mental or physical incapacity as described in paragraph (b)(2)(ii)(H)(2)
of this section.
(g) Reinstatement of CHAMPUS eligibility.
Circumstances
which result in reinstatement of CHAMPUS eligibility are as follows:
(1) End Stage renal disease.
Unless CHAMPUS eligibility has been continued
under paragraph (f)(3)(viii) of the section, when Medicare eligibility
ceases for end-stage renal disease patients, CHAMPUS eligibility
resumes if the person is otherwise still eligible. He or she is
required to take action to be reinstated as a CHAMPUS beneficiary
and to obtain a new identification card.
(2) Disability.
Some disabilities are permanent, others
temporary. Each case must be reviewed individually. Unless CHAMPUS
eligibility has been continued under paragraph (f)(3)(ix) of this
section, when disability ends and Medicare eligibility ceases, CHAMPUS
eligibility resumes if the person is otherwise still eligible. Again,
he or she is required to take action to obtain a new CHAMPUS identification
card.
(3) Enrollment in Medicare Part B.
For individuals
whose CHAMPUS eligibility has terminated pursuant to paragraph (f)(2)(iii)
or (f)(3)(vi) of this section due to beneficiary action to decline
Part B of Medicare, CHAMPUS eligibility resumes, effective on the
date Medicare Part B coverage begins, if the person subsequently
enrolls in Medicare Part B and the person is otherwise still eligible.
(h) Determination of
eligibility status.
Determination of an individual’s
eligibility as a CHAMPUS beneficiary is the primary responsibility
of the Uniformed Service in which the member or former member is,
or was, a member, or in the case of dependents of a NATO military
member, the Service that sponsors the NATO member. For the purpose
of program integrity, the appropriate Uniformed Service shall, upon
request of the Director, OCHAMPUS, review the eligibility of a specific
person when there is reason to question the eligibility status.
In such cases, a report on the results of the review and any action
taken will be submitted to the Director, OCHAMPUS, or a designee.
(i) Procedures for determination of eligibility.
Procedures for
the determination of eligibility are prescribed within the Department
of Defense Instruction 1000.13 available at local military facilities personnel
offices.
(j) CHAMPUS procedures
for verification of eligibility.
(1) Eligibility for
CHAMPUS benefits will be verified through the Defense Enrollment
Eligibility Reporting System (DEERS) maintained by the Uniformed
Services, except for abused dependents as set forth in paragraph
(b)(2)(iii) of this section. It is the responsibility of the CHAMPUS
beneficiary, or parent, or legal representative, when appropriate, to
provide the necessary evidence required for entry into the DEERS
file to establish CHAMPUS eligibility and to ensure that all changes
in status that may affect eligibility be reported immediately to the
appropriate Uniformed Service for action.
(2) Ineligibility for
CHAMPUS benefits may be presumed in the absence of prescribed eligibility evidence
in the DEERS file.
(3) The Director, OCHAMPUS,
shall issue guidelines as necessary to implement the provisions
of this section.
[64
FR 46135, Aug 24, 1999, as amended at 66 FR 9654, Feb 9, 2001; 66
FR 16400, Mar 26, 2001; 66 FR 40606, Aug 3, 2001; 67 FR 15725, Apr
3, 2002; 68 FR 23032, Apr 30, 2003; 68 FR 32361, May 30, 2003; 69 FR
44947, Jul 28, 2004; 69 FR 51564, Aug 20, 2004; 69 FR 60554, Oct
12, 2004; 70 FR 12802, Mar 16, 2005; 71 FR 31944, Jun 2, 2006; 72
FR 2447, Jan 19, 2007; 73 FR 30478, May 28, 2008; 75 FR 50883, Aug
18, 2010; 76 FR 81367, Dec 28, 2011; 77 FR 38176, Jun 27, 2012;
80 FR 55254, Sep 15, 2015]