(a) Establishment.
TRICARE
Retired Reserve offers the TRICARE Select self managed, preferred-provider
network option under Sec. 199.17 to qualified members of the Retired
Reserve, their immediate family members, and qualified survivors
under this section.
(1) Purpose.
As
specified in paragraph (c) of this section, TRICARE Retired Reserve
is a premium-based health plan that is available for purchase by
any Retired Reserve member who is qualified for non-regular retirement,
but is not yet 60 years of age, unless that member is either enrolled
in, or eligible to enroll in, a health benefit plan under Chapter
89 of Title 5, United States Code, as well as certain survivors
of Retired Reserve members.
(2) Statutory Authority.
TRICARE Retired Reserve is authorized by
10 U.S.C. 1076e.
(3) Scope of the Program.
TRICARE Retired Reserve is geographically
applicable to the same extent as specified in 32 CFR 199.1(b)(1).
(4) Major Features
of TRICARE Retired Reserve.
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 ASD(HA),
provisions of TRICARE Select under Sec. 199.17 apply to TRICARE
Retired Reserve.
(B) Certain special
programs established in 32 CFR part 199 are not available to members
covered under TRICARE Retired Reserve. The Extended Health Care
Option (ECHO) program (sec. 199.5) is not included. The Supplemental
Health Care Program (sec. 199.16) is not included, except when a
TRICARE Retired Reserve covered beneficiary is 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 Retiree Dental Program (sec. 199.13) is independent
of this program and is otherwise available to all members who qualify
for the TRICARE Retiree Dental Program whether or not they purchase TRICARE
Retired Reserve coverage. The Continued Health Care Benefits Program
(sec. 199.13) is also independent of this program and is otherwise
available to all members who qualify for the Continued Health Care
Benefits Program.
(ii) Premiums.
TRICARE
Retired Reserve coverage is available for purchase by any Retired
Reserve member if the member fulfills all of the statutory qualifications
as well as certain survivors. A member of the Retired Reserve or
qualified survivor covered under TRICARE Retired Reserve shall pay
the amount equal to 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
Retired Reserve, Retired Reserve members (or their survivors) 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. Procedures for purchasing coverage
and paying applicable premiums are prescribed in this section.
(iv) Benefits.
When
their coverage becomes effective, TRICARE Retired Reserve beneficiaries
receive the TRICARE Select benefit including access to military
treatment facilities on a space available basis and pharmacies,
as described in Sec. 199.17. TRICARE Retired Reserve coverage features
the deductible, cost sharing, and catastrophic cap provisions of
the TRICARE Select plan applicable to Group B retired members and
dependents of retired members under Sec. 199.17(l)(2)(ii); 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 retired members and their dependents who are
not enrolled in TRICARE Prime as described in Sec. 199.17(d)(1)(i)(E).
(b) Qualifications
for TRICARE Retired Reserve coverage--
(1) Retired Reserve Member.
A Retired Reserve member qualifies to purchase
TRICARE Retired Reserve coverage if the member meets both the following
criteria:
(i) Is a member of a Reserve component of the armed
forces who is qualified for a non-regular retirement at age 60 under
chapter 1223 of title 10, U.S.C., but who is not yet age 60 and
(ii) Is not enrolled
in, or eligible to enroll in, a health benefits plan under chapter
89 of title 5, U.S.C. That statute has been implemented under part
890 of title 5, CFR as the Federal Employee Health Benefits (FEHB)
program. For purposes of the FEHB program, the terms “enrolled”,
“enroll” and “enrollee” are defined in Sec. 890.101 of title 5,
CFR.
(2) Retired Reserve
Survivor.
If a
qualified member of the Retired Reserves dies while in a period
of TRICARE Retired Reserve coverage, the immediate family member(s)
of such member shall remain qualified to purchase new or continue
existing TRICARE Retired Reserve coverage until the date on which
the deceased member of the Retired Reserve would have attained age
60 as long as they meet the definition of immediate family members
specified in paragraph (g)(2) of this section. This applies regardless
whether either member-only coverage or member and family coverage
was in effect on the day of the TRICARE Retired Reserve member’s
death.
(c) TRICARE Retired
Reserve premiums.
Members
are charged for coverage under TRICARE Retired Reserve that represent
the full cost of the program as determined by the Director utilizing
an appropriate actuarial basis for the provision of the benefits
provided under the TRICARE Select program for the TRICARE Retired
Reserve eligible beneficiary 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.--
(i) TRICARE Retired
Reserve monthly premium rates shall be established and updated annually
on a calendar year basis by the ASD(HA) for each of the two types
of coverage, member-only coverage and member-and-family coverage
as described in paragraph (d)(1) of this section.
(ii) The
appropriate actuarial basis used for calculating premium rates shall
be one that most closely approximates the actual cost of providing
care to the same demographic population as those enrolled in TRICARE
Retired Reserve as determined by the ASD(HA). TRICARE Retired Reserve
premiums shall be based on the actual costs of providing benefits
to TRICARE Retired Reserve members and their dependents during the
preceding years if the population of Retired Reserve members enrolled
in TRICARE Retired Reserve is large enough during those preceding
years to be considered actuarially appropriate. Until such time
that actual costs from those preceding years becomes available,
TRICARE Retired Reserve premiums shall be based on the actual costs
during the preceding calendar years for providing benefits to the
population of retired members and their dependents in the same age categories
as the retired reserve population in order to make the underlying
group actuarially appropriate. An adjustment may be applied to cover
overhead costs for administration of the program by the government.
(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
the TRICARE Retired Reserve Program.
(3) Survivor Premiums.
A surviving
family member of a Retired Reserve member who qualified for TRICARE
Retired Reserve coverage as described herein will pay premium rates
at the member-only rate if there is only one surviving family member
to be covered by TRICARE Retired Reserve 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 the Retired Reserve member as specified
in paragraph (g)(2) of this section may be included in such family
coverage. To purchase either type of TRICARE Retired Reserve coverage
for effective dates of coverage described below, Retired Reserve
members and survivors qualified under either paragraph (b)(1) or
(b)(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 Retired Reserve
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 Retired Reserve coverage.
(iii) Enrollment. Procedures
for enrollment in TRICARE Select plans under Sec. 199.17(o) shall
apply to TRICARE Retired Reserve 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 Retired Reserve.
Procedures
may be established for a surviving family member of a qualified
Retired Reserve member who qualified for TRICARE Retired Reserve coverage
as described in paragraph (b)(2) of this section to purchase new
TRICARE Retired Reserve coverage or continue existing TRICARE Retired
Reserve coverage. Procedures similar to those for qualifying life
events may be established for a qualified surviving family member
to purchase new or continuing coverage with an effective date coinciding
with the day of the member’s death. Procedures similar to those
for open enrollment may be established for a qualified surviving
family member to purchase new coverage at any time with an effective
date coinciding with the first day of a month.
(2) Termination. Termination
of coverage for the TRR member/survivor will result in termination
of coverage for the member’s/survivor’s family members in TRICARE
Retired Reserve. Procedures may be established for coverage to be
terminated as follows.
(i) Coverage
shall terminate when members or survivors no longer qualify for
TRICARE Retired Reserve as specified in paragraph (c) of this section.
For purposes of this section, the member or their survivor no longer
qualifies for TRICARE Retired Reserve when the member has been eligible
for coverage in a health benefits plan under Chapter 89 of Title
5, U.S.C. for more than 60 days. Further, coverage shall terminate
when the Retired Reserve member attains the age of 60 or, if survivor coverage
is in effect, when the deceased Retired Reserve member would have
attained the age of 60.
(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 are not eligible to re-enroll
in TRICARE Retired Reserve 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 Retired Reserve 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 Retired
Reserve. 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 Retired Reserve.
(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 Retired Reserve).
(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 of 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
Retired Reserve, and may authorize exceptions to requirements of
this section, if permitted by law.
(g) Terminology.
The
following terms are applicable to the TRICARE Retired Reserve program.
(1) Coverage.
This
term means the medical benefits covered under the TRICARE Select
program as further outlined in Sec. 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 paragraph 199.3(b)(2)(i) of this part, or child as
defined in paragraph 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 TRR 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 TRR coverage.