(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]
