(a) Establishment.
TRICARE
Reserve Select offers the TRICARE Select self managed, preferred-provider
network option under Sec. 199.17 to qualified members of the Selected
Reserve, their immediate family members, and qualified survivors
under this section.
(1) Purpose.
TRICARE
Reserve Select is a premium-based health plan that is available
for purchase by members of the Selected Reserve and certain survivors
of Selected Reserve members as specified in paragraph (c) of this
section.
(2) Statutory Authority.
TRICARE Reserve Select is authorized by
10 U.S.C. 1076d.
(3) Scope of the Program.
TRICARE Reserve Select is applicable in
the 50 United States, the District of Columbia, Puerto Rico, and,
to the extent practicable, other areas where members of the Selected Reserve
serve. In locations other than the 50 states of the United States
and the District of Columbia, the Assistant Secretary of Defense
(Health Affairs) may authorize modifications to the program rules and
procedures as may be appropriate to the area involved.
(4) Major Features
of TRICARE Reserve Select.
The
major features of the program include the following:
(i) TRICARE Select rules applicable. (A) Unless
specified in this section or otherwise prescribed by the Director,
provisions of TRICARE Select under Sec. 199.17 apply to TRICARE
Reserve Select.
(B) Certain special
programs established in 32 CFR part 199 are not available to members
covered under TRICARE Reserve Select. These include the Extended
Care Health Option (Sec. 199.5), the Special Supplemental Food Program
(see Sec. 199.23), and the Supplemental Health Care Program (Sec. 199.16),
except when referred by a Military Treatment Facility (MTF) provider
for incidental consults and the MTF provider maintains clinical
control over the episode of care. The TRICARE Dental Program (Sec. 199.13)
is independent of this program and is otherwise available to all
members of the Selected Reserve and their eligible family members
whether or not they purchase TRICARE Reserve Select coverage. The
Continued Health Care Benefits Program (Sec. 199.20) is also independent
of this program and is otherwise available to all members who qualify.
(ii) Premiums.
TRICARE
Reserve Select coverage is available for purchase by any Selected
Reserve member if the member fulfills all of the statutory qualifications.
A member of the Selected Reserve covered under TRICARE Reserve Select
shall pay 28 percent of the total amount that the ASD(HA) determines
on an appropriate actuarial basis as being appropriate for that
coverage. There is one premium rate for member-only coverage and
one premium rate for member and family coverage.
(iii) Procedures.
Under TRICARE
Reserve Select, Reserve Component members who fulfilled all of the statutory
qualifications may purchase either the member-only type of coverage
or the member-and-family type of coverage by submitting a completed
request in the appropriate format along with an initial payment
of the applicable premium. Rules and procedures for purchasing coverage
and paying applicable premiums are prescribed in this section.
(iv) Benefits.
When
their coverage becomes effective, TRICARE Reserve Select beneficiaries
receive the TRICARE Select benefit including access to military
treatment facility services and pharmacies, as described in Secs.
199.17 and 199.21. TRICARE Reserve Select coverage features the
deductible, catastrophic cap and cost share provisions of the TRICARE
Select plan applicable to Group B active duty family members under
Sec. 199.17(l)(2)(ii) for both the member and the member’s covered
family members; however, the TRICARE Reserve Select premium under
paragraph (c) of this section applies instead of any TRICARE Select
plan enrollment fee under Sec. 199.17. Both the member and the member’s
covered family members are provided access priority for care in
military treatment facilities on the same basis as active duty service
members’ dependents who are not enrolled in TRICARE Prime as described
in Sec. 199.17(d)(1)(i)(D).
(b) Qualifications for TRICARE Reserve Select coverage--
(1) Ready Reserve member.
A Ready Reserve member qualifies to purchase
TRICARE Reserve Select coverage if the Service member meets both
the following criteria:
(i) Is a member of the Selected Reserve of the Ready
Reserve of the Armed Forces, or a member of the Individual Ready
Reserve of the Armed Forces who has volunteered to be ordered to
active duty pursuant to the provisions of 10 U.S.C. 12304 in accordance
with section 10 U.S.C. 10144(b); and
(ii) Is not enrolled
in, or eligible to enroll in, a health benefits plan under 5 U.S.C.
chapter 89. That statute has been implemented under 5 CFR part 890
as the Federal Employees Health Benefits (FEHB) program. For purposes
of the FEHB program, the terms “enrolled,” “enroll” and “enrollee”
are defined in 5 CFR 890.101. Further, the member (or certain former
member involuntarily separated) no longer qualifies for TRICARE
Reserve Select when the member (or former member) has been eligible
for coverage to be effective in a health benefits plan under the
FEHB program for more than 60 days.
(2) TRICARE Reserve Select survivor.
If a qualified
Service member dies while in a period of TRICARE Reserve Select
coverage, the immediate family member(s) of such member is qualified
to purchase new or continue existing TRICARE Reserve Select coverage
for up to six months beyond the date of the member’s death as long
as they meet the definition of immediate family members as specified
in paragraph (g)(2) of this section. This applies regardless of
type of coverage in effect on the day of the TRICARE Reserve Select
member’s death.
(c) TRICARE Reserve
Select premiums.
Members
are charge premiums for coverage under TRICARE Reserve Select that
represent 28 percent of the total annual premium amount that the Director
determines on an appropriate actuarial basis as being appropriate
for coverage under the TRICARE Select benefit for the TRICARE Reserve
Select eligible population. 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.
TRICARE
Reserve Select monthly premium rates shall be established and updated
annually on a calendar year basis for each of the two types of coverage, member-only
and member- and-family as described in paragraph (d)(1) of this
section. Starting with calendar year 2009, the appropriate actuarial
basis for purposes of this paragraph (c) shall be determined for
each calendar year by utilizing the actual reported cost of providing
benefits under this section to members and their dependents during
the calendar years preceding such calendar year. Reported actual
TRS cost data from calendar years 2006 and 2007 was used to determine
premium rates for calendar year 2009. This established pattern will
be followed to determine premium rates for all calendar years subsequent
to 2009.
(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 or any actual experience in the costs of administering
TRICARE Reserve Select.
(3) Survivor premiums.
A surviving family member of a Reserve
Component service member who qualified for TRICARE Reserve Select
coverage as described in paragraph (b)(2) of this section will pay premium
rates as follows. The premium amount shall be at the member-only
rate if there is only one surviving family member to be covered
by TRICARE Reserve Select and at the member and family rate if there
are two or more survivors to be covered.
(d) Procedures.
The
Director may establish procedures for the following.
(1) Purchasing coverage.
Procedures may
be established for a qualified member to purchase one of two types
of coverage: Member-only coverage or member and family coverage.
Immediate family members of a qualified member as specified in paragraph
(g)(2) of this section may be included in such family coverage.
To purchase either type of TRICARE Reserve Select coverage for effective
dates of coverage described below, members and survivors qualified
under either paragraph (b)(1) or (2) of this section 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
member or qualified survivor to purchase TRICARE Reserve Select
coverage with an effective date immediately following the date of
termination of coverage under another TRICARE program.
(ii) Qualifying
event. Procedures for qualifying
events in TRICARE Select plans under Sec. 199.17(o) shall apply
to TRICARE Reserve Select coverage. Additionally, the Director may
identify other events unique to needs of the Reserve Components
as qualifying events.
(iii) Enrollment. Procedures
for enrollment in TRICARE Select plans under Sec. 199.17(o) shall
apply to TRICARE Reserve Select enrollment. 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.
(iv) Survivor coverage
under TRICARE Reserve Select.
Procedures may be established for
a surviving family member of a Reserve Component service member
who qualified for TRICARE Reserve Select coverage as described in
paragraph (b)(2) of this section to purchase new TRICARE Reserve
Select coverage or continue existing TRICARE Reserve Select coverage
for up to six months beyond the date of the member’s death. The
effective date of coverage will be the day following the date of
the member’s death.
(2) Termination. Termination
of coverage for the TRS member/survivor will result in termination
of coverage for the member’s/survivor’s family members in TRICARE
Reserve Select. Procedures may be established for coverage to be
terminated as follows.
(i) Coverage
shall terminate when members or survivors no longer qualify for
TRICARE Reserve Select as specified in paragraph (b) of this section,
with one exception. If a member is involuntarily separated from
the Selected Reserve under other than adverse conditions, as characterized
by the Secretary concerned, and is covered by TRICARE Reserve Select
on the last day of his or her membership in the Selected Reserve,
then TRICARE Reserve Select coverage may terminate up to 180 days
after the date on which the member was separated from the Selected
Reserve. This applies regardless of type of coverage. This exception
expires December 31, 2018.
(ii) Coverage may terminate
for members, former members, and survivors who gain coverage under another
TRICARE program.
(iii) In
accordance with the provisions of Sec. 199.17(o)(2) coverage terminates
for members/survivors who fail to make premium payments in accordance
with established procedures.
(iv) Coverage may be terminated
for members/survivors upon request at any time by submitting a completed
request in the appropriate format in accordance with established
procedures.
(3) Re-enrollment following termination. Absent
a new qualifying event, members/survivors (subject to paragraph
(d)(1)(iv) of this section) are not eligible to re-enroll in TRICARE
Reserve Select until the next annual open season.
(4) Processing.
Upon receipt
of a completed request in the appropriate format, enrollment actions will
be processed into DEERS in accordance with established procedures.
(5) Periodic revision.
Periodically,
certain features, rules or procedures of TRICARE Reserve Select
may be revised. If such revisions will have a significant effect
on members’ or survivors’ costs or access to care, members or survivors
may be given the opportunity to change their type of coverage or terminate
coverage coincident with the revisions.
(e) Preemption of State
laws.
(1) Pursuant
to 10 U.S.C. 1103, the Department of Defense has determined that
in the administration of chapter 55 of title 10, U.S. Code, preemption
of State and local laws relating to health insurance, prepaid health
plans, or other health care delivery or financing methods is necessary
to achieve important Federal interests, including but not limited
to the assurance of uniform national health programs for military
families and the operation of such programs, at the lowest possible
cost to the Department of Defense, that have a direct and substantial
effect on the conduct of military affairs and national security
policy of the United States. This determination is applicable to
contracts that implement this section.
(2) Based on the determination
set forth in paragraph (f)(1) of this section, any State or local
law or regulation pertaining to health insurance, prepaid health
plans, or other health care delivery, administration, and financing
methods is preempted and does not apply in connection with TRICARE Reserve
Select. Any such law, or regulation pursuant to such law, is without
any force or effect, and State or local governments have no legal
authority to enforce them in relation to TRICARE Reserve Select.
(However, the Department of Defense may, by contract, establish
legal obligations on the part of DoD contractors to conform with
requirements similar to or identical to requirements of State or local
laws or regulations with respect to TRICARE Reserve Select.)
(3) The
preemption of State and local laws set forth in paragraph (f)(2)
of this section includes State and local laws imposing premium taxes
on health insurance carriers or underwriters or other plan managers,
or similar taxes on such entities. Such laws are laws relating to
health insurance, prepaid health plans, or other health care delivery
or financing methods, within the meaning of 10 U.S.C. 1103. Preemption,
however, does not apply to taxes, fees, or other payments on net
income or profit realized by such entities in the conduct of business
relating to DoD health services contracts, if those taxes, fees or
other payments are applicable to a broad range of business activity.
For the purposes of assessing the effect of Federal preemption of
State and local taxes and fees in connection with DoD health services
contracts, interpretations shall be consistent with those applicable
to the Federal Employees Health Benefits Program under 5 U.S.C.
8909(f).
(f) Administration.
The Director may establish
other rules and procedures for the effective administration of TRICARE
Reserve Select, and may authorize exceptions to requirements of
thissection, if permitted by law.
(g) Terminology.
The
following terms are applicable to the TRICARE Reserve Select program.
(1) Coverage.
This
term means the medical benefits covered under the TRICARE Select
program as further outlined in § 199.17 whether delivered in military
treatment facilities or purchased from civilian sources.
(2) Immediate family member.
This term means spouse (except former spouses)
as defined in Sec. 199.3(b)(2)(i), or child as defined in Sec. 199.3(b)(2)(ii).
(3) Qualified member.
This term means a member who has satisfied
all the criteria that must be met before the member is authorized
for TRS coverage.
(4) Qualified survivor.
This term means an immediate family member
who has satisfied all the criteria that must be met before the survivor
is authorized for TRS coverage.
[70
FR 12802, Mar 16, 2005; 71 FR 31944; Jun 2, 2006; 71 FR 35532, Jun
21, 2006; 72 FR 46383, Aug 20, 2007; 76 FR 57641, Sep 16, 2011;
80 FR 55254; Sep 15, 2015; 82 FR 45458, Sep 29, 2017]