TRICARE Manuals - Display Chap 22 Sect 2 (Change 101, Nov 17, 2021)

Reserve Component Health Coverage Plans

Chapter 22

Section 2

TRICARE Retired Reserve (TRR)

Revision: C-100, November 12, 2021

1.0 General

TRR is a premium-based TRICARE health plan available for purchase by qualified members of the Retired Reserve and qualified survivors that offers health coverage for Retired Reserve members and their eligible family members. The Reserve Components (RCs) will validate members’ and survivors’ qualifications to purchase TRR coverage and will identify qualified members/survivors in the Defense Enrollment Eligibility Reporting System (DEERS). The term “contractor” in this Section refers to the Managed Care Support Contractors (MCSCs) and the TRICARE Overseas Program (TOP) contractor.

1.1 Benefits/Scope Of Care

The TRR health plan delivers the TRICARE Select benefit to all covered individuals, including access to Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs) and pharmacies with the same MTF/eMSM access priority as retirees and their family members not enrolled in TRICARE Prime. TRR features TRICARE Select cost-shares, deductibles and catastrophic caps applicable to retirees and their eligible family members for all individuals (including Retired Reserve members themselves) covered under TRR. TRR members, their covered family members, and TRR survivors are eligible for space-available care in a MTF/eMSM, including MTF/eMSM pharmacies with the same access priority as retirees, their family members and survivors who are not enrolled in TRICARE Prime. Premiums are not credited to deductibles or catastrophic caps. The provisions of 32 CFR 199.16(a)(3) concerning the Supplemental Health Care Program (SHCP) for dependents under the care of the MTF/eMSM apply to TRR. The contractor shall review and modify MTF/eMSM Memorandums of Understanding (MOUs)/Statement of Responsibilities (SORs) as necessary to reflect MTF/eMSM requirements for accommodating and ensuring that TRR members, family members and survivors are provided the same level of service as retirees and their eligible family members under TRICARE Select.

Note: Effective January 1, 2018, TRICARE Select cost-shares, copayments, deductibles, and catastrophic caps applicable to retirees and their dependents at the Group B rate replaces the previous TRICARE Standard/Extra coverage. See the TRICARE Reimbursement Manual (TRM), Chapter 2.

1.2 Specific Programs Not Available Under TRR

Specific programs not available under TRR include those listed below:

• TRICARE Retiree Dental Program (TDP) is not part of the medical programs under 10 United States Code (USC) Chapter 55 and, therefore, not covered under TRR

• TRICARE Prime Programs including the Uniformed Services Family Health Plan (USFHP)

• Supplemental Health Care Program (SHCP) funds, except for civilian care referred by Military Health System (MHS) Facilities as specified in Chapter 17 to the same extent that SHCP covers civilian care for MHS beneficiaries who are not Active Duty Service Members (ADSMs)

• Extended Care Health Option (ECHO)

2.0 TRR Coverage And Premiums

2.1 TRR offers two types of coverage: TRR member-only coverage and TRR member-and-family coverage. Effective January 1, 2018, TRICARE Standard/ Extra coverage is replaced by TRICARE Select.

2.2 Each year the Government will determine premium rates payable monthly by the member/survivor for each type of coverage. The Government will provide the premium rates to the contractor no later than 60 calendar days prior to the effective date. TRR premium rates are specified in Addendum A, Figure 22.A-2. Unless otherwise specified, the premium rates will be in effect for a full calendar year effective the first day of January. A surviving family member who qualifies to purchase (or continue) TRR coverage, as described in paragraph 3.2 shall pay the member-only rate if there is only one covered survivor and the member-and-family rate if there are two or more survivors to be covered.

3.0 Qualifying To Purchase TRR Coverage

The RCs will validate member’s and survivor’s qualifications to purchase TRR coverage and will identify qualified members/survivors in DEERS. The contractor shall rely solely upon DEERS to identify members/survivors who have been qualified to purchase TRR coverage. The contractor shall refer Retired Reserve members/survivors to their respective RC for issues concerning qualifying to purchase TRR coverage. The qualifications unique to TRR are listed below for contractor information purposes only.

3.1 Retired Member Qualifications For Purchase Of TRR Coverage

A member qualifies to purchase TRR coverage if the member meets both of the following conditions:

• is a member of the Retired Reserve of a RC of the armed forces who is qualified for a non-regular retirement under 10 USC Chapter 1223, but is not age 60; and

• is not enrolled, or eligible to enroll, in a health benefits plan under 5 USC Chapter 89, the Federal Employees Health Benefit Program (FEHBP).

3.2 Survivor Qualifications For Purchase Of TRR Coverage

If the qualified member of the Retired Reserve dies while in a period of TRR coverage, the eligible surviving family member(s) of such member shall remain qualified to purchase new or continue existing TRR coverage until the date on which the deceased member of the Retired Reserve would have attained age 60. For survivor qualification, there is no exclusionary criterion involving a health benefits plan under 5 USC Chapter 89, the FEHBP. If a member of the Retired Reserve is not covered by TRR on the date of his or her death, his or her surviving dependents do not qualify for TRR survivor coverage at any time.

4.0 Coverage-Related Procedures

The TOP contractor shall perform these services for TRR members/survivors residing outside of the 50 United States (U.S.) or the District of Columbia.

4.1 Coverage Requests

4.1.1 To purchase, change or terminate TRR coverage, qualified Retired Reserve members and qualified survivors must present a completed request within deadlines specified in the following paragraphs. The contractor shall not accept handwritten TRR requests. The contractor shall accept completed TRR requests presented from the Government-furnished web-based self-service enrollment system (when it becomes available for TRR) as well as those presented, by phone, by mail, at overseas TRICARE Service Centers (TSCs), and by other means determined by the contractor.

4.1.2 If a lockout is in place, the contractor may accept and process requests up to 90 days before the end of the 12 month lockout period for new coverage to begin after the 12 month lockout period ends. The procedures for determining the effective date of coverage are specified in the following paragraphs. The contractor shall reject and return incomplete requests along with any incorrect premium payments to the member, within 10 business days, with an explanation of what is needed for the contractor to accept the application for processing.

4.1.3 Each of the following requirements shall be met in order for a request to be complete.

4.1.3.1 When purchasing initial coverage, the contractor shall collect a payment equal to two months of monthly premium applicable for the type of coverage requested. The initial payment may be made with a personal check, cashier’s check, money order, or credit/debit card (i.e., Visa/MasterCard). When purchasing continuous coverage, the contractor shall collect a payment up to three months of premium applicable for the type of coverage requested; contingent on the method and date the request is submitted.

4.1.3.2 The request shall contain account information for collection of ongoing monthly premium payments by either a Recurring Credit Card/Debit Card (RCC) (i.e. Visa/MasterCard) payment or an Electronic Funds Transfer (EFT). The contractor is not required to validate the account information at the time of receipt.

4.1.3.3 When a lockout is in effect as specified in paragraph 4.9 and its subordinate paragraphs, the contractor shall accept completed requests for new coverage up to 90 days before the end of the 12 month lockout period for new coverage to begin after the 12 month lockout period ends.

4.1.3.4 Requests generated from the web application and presented (by mail or in-person) as hard copy shall contain an original signature.

4.1.3.5 Requests generated from the web application and presented electronically shall be signed electronically.

4.1.3.6 For requests presented verbally on the phone, the contractor shall review all information in the signature block on the applicable form with the requestor. (Contact the Contracting Officer (CO) or Contracting Officer Representative (COR) for a copy of the applicable form.) If the request is for survivor coverage, the statements about “a health coverage plan under 5 USC Chapter 89 (FEHB)” do not apply. The contractor shall ask if the requestor agrees to the terms and conditions presented to them. If the requestor does not agree, the contractor shall reject the request and document in the contractor’s call notes accordingly. If the requestor agrees, the contractor shall document agreement in the contractor’s call notes accordingly and continue with processing the request.

4.1.4 For new coverage, see paragraph 4.2.

4.1.5 For continuation coverage, see paragraph 4.3.

4.2 Open Enrollment

A qualified member or qualified survivor may purchase TRR coverage throughout the year unless locked out from TRR coverage. Prior to January 1, 2018, the effective date of coverage was the first of the month following the month of receipt. Effective January 1, 2018, the effective date of TRR coverage is the date received by the contractor or a date up to 90 days in the future as specified by the requestor.

4.3 Continuation Coverage

A qualified Retired Reserve member or qualified survivor may purchase TRR coverage with an effective date immediately following the termination of coverage under another TRICARE program. The completed TRR request required by paragraph 4.1 must be either received by the contractor by phone, entered into the Government-furnished web-based self-service enrollment system, or postmarked no later than 90 days after the termination of other TRICARE coverage. If the qualified member or qualified survivor does not meet the requirement for continuation coverage, the request is processed as a new request.

4.4 Qualifying Life Events (QLEs)

A qualified Retired Reserve member may purchase TRR coverage in connection with a QLE. First, qualified members are responsible to report all changes in family composition to military personnel officials who update DEERS. Second, the request identifying the QLE must be received by the contractor or postmarked within 90 days from the date of the QLE. See TRICARE Policy Manual (TPM), Chapter 10, Section 2.1 for a list of QLEs.

4.5 Survivor Coverage Under TRR

4.5.1 If a Retired Reserve member dies while in a period of TRR coverage, the surviving family members may purchase (or continue) TRR coverage until the date on which the deceased member of the Retired Reserve would have attained age 60. Except for automatic transfers specified in paragraph 4.5.2, effective dates and deadlines specified in paragraphs 4.2, 4.3, and 4.4 apply. The effective date of TRR survivor coverage is the day after the date of death. Applicable premium rates are specified in paragraph 2.0.

4.5.2 If TRR member-and-family coverage was in effect on the date of the member’s death, DEERS will automatically transfer covered family members to TRR survivor coverage with an effective date of the day after the date of death and establish an end-eligibility date in DEERS that is the date on which the deceased member of the Retired Reserve would have attained age 60. The Defense Manpower Data Center (DMDC) will notify survivors of their continued coverage and their option to terminate coverage, if so desired, by presenting a completed TRR request form as specified in paragraph 4.1.

4.5.3 If TRR member-only coverage was in effect on the date of the member’s death, DEERS will terminate coverage with an effective date coinciding with the date of death. Eligible family members may purchase coverage by presenting a completed TRR request as specified in paragraph 4.1. The TRR request required by paragraph 4.1 must be either received by the contractor or postmarked no later than 90 days after the date of death of the Retired Reservist. DMDC will notify survivors advising them of the option to purchase coverage.

4.6 Changes In TRR Coverage

Once TRR coverage is in effect, TRR members (including TRR-covered survivors) may request the following types of changes.

4.6.1 Type of Coverage Changes

A TRR member/survivor may change TRR type of coverage following procedure for a QLE as in paragraph 4.4 or procedures for open enrollment specified in paragraph 4.2. The contractor shall follow procedures specified in paragraph 5.4 for premium adjustments resulting from changes in coverage.

4.6.2 Addition of Family Members to TRR Member and Family Coverage

TRR members/survivors may request to add eligible family members to an existing TRR member-and-family coverage plan at any time, once eligibility for the family is established. Eligibility is established by going to a military personnel office staffed by military personnel officials who update DEERS. The effective date of coverage for the added family member(s) shall follow procedures specified in paragraphs 4.2 or 4.4. The TRR request must be either received by the contractor or postmarked no later than 90 days after that date.

4.6.3 TRR Newborn/Adopted Child Policy

4.6.3.1 For newborns or adopted children added to existing TRR Member Only coverage, a request to enroll the newborn/adopted child must be submitted as specified in paragraph 4.4; as well as a required monthly premium payment that equals Member and Family coverage from the newborn’s/adopted child’s date of birth/adoption. The contractor shall pend claims for the newborn/adopted child prior to receiving the request. If the request and required monthly premium payment are not submitted by the 90th day (120 days if overseas) of the birth/adoption, the contractor shall deny claims and process the coverage date effective the date the request is received/postmarked.

4.6.3.2 For newborns or adopted children added to existing TRR Member and Family coverage, a request to enroll the newborn/adopted child must be submitted as specified in paragraph 4.4. The contractor shall pend claims for the newborn/adopted child under TRS Member and Family coverage. If the request is not submitted by the 90th day (120 days if overseas), the contractor shall deny claims and process the coverage date effective the date the request is received/postmarked.

4.7 Automatic Eligibility Updates

DEERS will automatically update start and/or end dates of coverage when a beneficiary’s eligibility is updated by the military services; i.e., an adjustment to the effective date of active duty, retirement date changes, divorces. The contractor will receive a Government furnished policy notification advising them of all changes.

4.8 Processing

4.8.1 The contractor shall process all TRR transactions through the Government furnished web-based system/application for members or survivors with a DEERS residential address as indicated by the requestor on the TRR request in the contractor’s jurisdiction. Premium-related transactions shall be reported through the enrollment fee payment interface. or Catastrophic Cap and Deductible (CC&D) Fee Web (see the TRICARE Systems Manual (TSM), Chapter 3, Section 4.2). The contractor shall process completed TRR requests (see paragraph 4.1) no later than 10 calendar days after receipt.

4.8.2 The contractor shall process all TRR transactions using the Government furnished web-based system/application due to either:

• A 90-day future enrollment limitation;

• DEERS not reflecting eligibility; or

• Any other Government furnished web-based system/application limitation:

The contractor shall notify the requestor within 10 business days and offer to return any premium payments to the member, within 10 business days, with an explanation of what is needed for the contractor to accept the application for processing.

4.8.3 See the TSM, Chapter 2, Addendum L for a full list of TRS Health Care Delivery Plan (HCDP) coverage code values.

4.9 Termination Of TRR Coverage

The contractor shall initiate return of any excess premium amounts paid prorated to the day as indicated no later than 10 business days after the effective date of the termination or after receipt of a Government furnished policy notification notifying the contractor of a termination, whichever is later. Premium refunds, to include an explanation of the premium refund, will be sent to member’s/survivor’s residential address unless an alternate mailing address has been provided. The contractor shall also update DEERS with any premium amount refunded within 30 calendar days. The contractor shall include an explanation for the premium refund. The following paragraphs specify when the contractor shall apply a lockout on the occasion of termination of TRR coverage. When applied, a lockout shall remain in effect for 12 months after the last paid through date.

4.9.1 Loss of TRR Qualification

No lockout shall be applied for termination due to loss of TRR qualification. At any time a member/survivor ceases to meet all eligibility qualifications, coverage under the TRR program shall terminate. The effective date of termination for a member or survivor covered under TRR shall be the effective date of the loss of his or her qualification for TRR coverage.

4.9.1.1 Sponsor Loss of Eligibility

No lockout shall be applied for sponsor loss of eligibility when a sponsor’s eligibility is terminated at a date other than the anticipated end date, DEERS will send the contractor an unsolicited Government furnished policy notification advising the contractor of the terminated coverage. When a sponsor’s eligibility is terminated at the anticipated end date, DEERS will not send the contractor an unsolicited Government furnished policy notification advising the contractor of the terminated coverage.

4.9.1.2 Individual Family Member or Survivor Loss of Eligibility

No lockout shall be applied for individual family member or survivor loss of eligibility in the case of a family member or survivor losing eligibility in DEERS. DEERS will send the contractor an unsolicited Government furnished policy notification advising the contractor to terminate coverage for that individual. When an individual family member’s or survivor’s eligibility is terminated at the anticipated end date, DEERS will not send the contractor an unsolicited Government furnished policy notification advising the contractor of the terminated coverage. The contractor shall update the fee system based on the terminated coverage for the family member(s) or survivor(s) as appropriate.

4.9.2 Member Gains Other TRICARE Coverage

No lockout shall be applied for termination due to a gain of other TRICARE coverage.

4.9.2.1 If a TRR member gains other TRICARE coverage for a period of 30 days or less, TRR coverage will continue unchanged.

4.9.2.2 If a TRR member or survivor gains other TRICARE coverage for a period of more than 30 days; DEERS will terminate TRR coverage in accordance with paragraph 4.9.1.1. The contractor must be aware of the fact that DEERS may reflect ADSM and Active Duty Family Member (ADFM) TRICARE coverage before the ADSM actually reports for active duty.

4.9.2.3 If a TRR member gains other TRICARE coverage via a family member, the member and family members may terminate coverage under TRR without incurring a lockout.

4.9.3 Failure to Make Payment

4.9.3.1 Failure or refusal to pay monthly premiums and/or any outstanding insufficient funds fees in accordance with the procedures in this chapter shall result in termination of coverage and lockout shall be applied as specified in paragraph 4.9. The effective date of termination is the paid-through date. The contractor shall automatically terminate coverage of the TRR member, all covered family members and survivors if the monthly premium payment is not received by the last day of the month following the due date for the monthly premium payment. After the last day of the month, the contractor shall terminate coverage with a termination effective date retroactive to the paid-through date.

4.9.3.2 Failure to provide information to establish or maintain a recurring EFT/RCC for monthly premium payment will result in coverage being terminated for failure to comply with paragraph 5.2 and subordinate paragraphs.

4.9.3.3 DMDC sends written notification of the termination, the effective date, the reason and the lockout period from the last paid-through date to the member or survivor.

4.9.3.4 Until the termination action is processed, the contractor may pend any claims received for health care furnished to the retired member, family members and/or survivors during the period for which premiums have yet to be paid, to avoid creating recoupment of health care costs for ineligible beneficiaries. The TRR member, family members and/or survivors will be responsible for the cost of any health care received after the termination date following retroactive termination of coverage. If claims are not pended, the contractor shall initiate recoupment of health care costs following the procedures in Chapter 10, Section 4.

4.9.4 Request for Voluntary Termination

The contractor shall apply a lockout as specified in paragraph 4.9 for voluntary termination requested by the member/survivor. The DMDC sends written notification of the termination, the effective date, the reason and the lockout period from the last paid-through date to the member/survivor.

4.9.4.1 Termination of Existing Plan(s)

The contractor shall accept requests for termination of coverage from TRR members/survivors at anytime. The effective date of termination is either (a) the last day of the month in which the request was postmarked or received by the contractor or (b) the last day of a future month as specified in the request given that the request was postmarked or received by the contractor in the month preceding the requested month of termination.

4.9.4.2 Termination of an Individual’s Coverage

The contractor shall accept requests for termination of coverage for individual family members or survivors from TRR members/survivors at anytime. The effective date of termination is either (a) the last day of the month in which the request was postmarked or received by the contractor, or (b) the last day of a future month as specified in the request given that the request was postmarked or received by the contractor in month preceding the requested month of termination, or (c) as otherwise specified. The contractor shall apply a TRR purchase lockout to individual family members or survivors whose TRR coverage was terminated upon request for a period of 12 months from the effective date of terminations initiated by the TRR member or survivor. The DMDC written notification of termination (see paragraph 4.9.3.1) includes notice of the 12 month lockout period.

4.9.5 Canceled Eligibility and Enrollment

No lockout shall be applied for a canceled enrollment. When the contractor receives a Government furnished policy notification for a canceled enrollment, the contractor shall notify the covered member/survivor of the cancellation and refund any unused portion of the premium payment. The contractor shall update DEERS with any premium amount refunded within 30 calendar days. No lockout shall be applied for a canceled enrollment. The contractor shall include an explanation for the premium refund.

4.9.6 TRR Survivor Coverage Termination

If TRR coverage is continued as described in paragraph 4.5.2 and the survivors do not wish to keep the coverage, the survivors must submit a request in writing in accordance with procedures described in paragraph 4.5.2 for receipt by the contractor no later than 90 days after the date of death in order to terminate coverage retroactive to the day after the member’s death and no lockout is applied. Alternatively, the survivor may request to terminate coverage in accordance with paragraph 4.9.4. Otherwise, DEERS will terminate TRR survivor coverage on the date on which the deceased member of the Retired Reserve would have attained age 60. Refunds of premiums will be handled as specified in paragraph 4.9.

4.10 Exceptions

4.10.1 Administrative Issues

The TRO or TAO, or their designee, will notify the contractor when the Government determines that an administrative situation (i.e., delay in RC personnel transaction) occurred that prevented a retired member’s or survivor’s request from being accepted for processing according to submission deadlines specified in this section.

4.10.2 Reinstatement Of Terminated TRR Coverage (Retroactive Coverage)

4.10.2.1 A qualified member/survivor may request the contractor to reinstate terminated TRR coverage retroactive to the last paid-through date with no justification needed. The contractor shall accept the request if the request meets all of the following conditions:

• The request is received by the contractor or postmarked NLT the first business day of the fourth month after the paid-through date;

• Payment of all premiums from the last paid-through date through the current month, plus the amount for the following two months is included (to include any administrative fees); and

• Information is provided to establish recurring electronic premium payments as specified in paragraph 5.2.2.

Note: If the member/survivor contacts the contractor via telephone for reinstatement of previous coverage, up to two months of additional premiums are required as determined by the contractor, to reestablish a monthly billing cycle (plus any administrative fees).

4.10.2.2 The contractor shall reject the request to reinstate coverage retroactively if any of the conditions above are not met and inform the member/survivor of their option to purchase new coverage after the 12-month lockout period as specified in paragraph 4.9.

5.0 Premium Collection

The contractor shall perform all premium functions required for TRR. Retired Reserve members or survivors are responsible for all premium payments for the type of coverage elected (i.e., TRR member-only or TRR member-and-family). After enrollment, only monthly premium payments are permitted. Premium-related transactions shall be reported through the enrollment fee payment interface or Catastrophic Cap and Deductible (CC&D) Fee Web (see the TSM, Chapter 3).

5.1 Jurisdiction For Premium Collection

5.1.1 The particular contractor servicing the residential address for the TRR member or survivor shall perform premium collection functions for the TRR member or survivor. The contractor shall identify the financially responsible individual for survivor plans from the survivors actually covered by TRR in descending order of precedence:

• Spouse.

• Oldest Enrolled Child (or Legal Guardian as applicable).

5.1.2 Any time the servicing contractor notices that a new residential address is in the servicing area of another TRICARE contractor, the losing contractor shall notify the TRR member or survivor within 10 calendar days that they need to contact the servicing contractor in their new area to transfer their coverage to the new area. A TRR member or survivor may elect to provide an alternate mailing address, but the servicing contractor shall be based on the TRR member’s or financially responsible survivor’s residential, not alternate mailing address. Any TRR member/financially responsible survivor may transfer regions at any time. The gaining contractor shall perform the premium collections for future payments.

5.1.3 All unsolicited Government furnished policy notifications for TRR members or survivors will be evaluated to determine if residential address changes require a notification to the TRR member or survivor (see paragraph 5.1.2).

5.2 Premium Collection Processes

5.2.1 The contractor shall credit the TRR member or survivor for premium payments received. In the case of a start date of coverage at anytime other than the first of a month, the first payment collected by the contractor shall include the prorated amount on a daily basis necessary to synchronize billing to the last day of the month. The daily prorated amount shall be equal to 1/30th of the appropriate premium (rounded to the penny) regardless of how many days are actually in the month. DEERS will automatically prorate the premium due for the mid-month enrollments from the effective date of coverage to the end of that first enrollment month, e.g., from the 18th of the month to the 31st.

5.2.2 The contractor shall collect monthly premium payments from TRR members or survivors as appropriate and shall report the premium amount paid for those payments to DEERS (see the TSM, Chapter 3), including any overpayments that are not refunded to the TRR member or survivor. In the event that there are insufficient funds to process a premium payment, the contractor may assess the account holder a fee of up to 20 U.S. dollars ($20.00) which is retained by the contractor. The contractor shall provide commercial payment methods for TRR premiums that best meet the needs of beneficiaries while conforming to paragraphs 5.2.3 through 5.2.8.

5.2.3 Monthly premiums must be paid through an automated, recurring electronic payment through an Electronic Funds Transfer (EFT) or Recurring Credit/Debit Card (RCC) (i.e., Visa/MasterCard) from a designated financial institution. These are the only acceptable payment methods for the recurring monthly premiums. An EFT payment or a RCC payment shall be processed within the first five business days of the month of coverage. The contractor shall advise TRR member or survivors at the time of EFT/RCC election that an insufficient funds fee of up to $20 U.S. may be assessed, if sufficient funds are not available.

5.2.4 TRR members or survivors must make the required initial payment (as specified in paragraph 4.1) at the time the TRR application is submitted to allow time for the EFT/RCC to be established for subsequent monthly premium payments. The contractor shall accept payment of the first installment by personal check, cashier’s check, traveler’s check, money order, or credit card (e.g., Visa/MasterCard).

5.2.5 The contractor shall establish recurring monthly EFTs/RCCs and is responsible for obtaining and verifying the information necessary to do so.

5.2.6 The contractor shall initiate action to modify EFT/RCC payment amounts to support premium changes.

5.2.7 When an administrative issue arises that stops or prevents an automated monthly payment from being received by the contractor (e.g., incorrect or transposed number provided by the beneficiary, credit card expired, bank account closed, etc.), the contractor shall grant the TRS member or survivor 30 days after the paid-through date to provide information for a new automated monthly payment method. The contractor may accept payment in accordance with paragraph 4.1 during this 30 day period in order to preserve the TRS member’s or survivor’s enrollment status.

5.2.8 The contractor shall directly bill the TRR member or survivor only when a problem occurs in setting up or maintaining the EFT or RCC payment; to include a fee of up to $20 U.S. due to insufficient funds. Bills may be sent to the residential or alternate mailing address designated by the TRR member or survivor. All bills shall specify that the premium payment is due for receipt by the contractor no later than the first business day of the month for the month of coverage. Premium payments shall be made payable to the contractor servicing the member’s or survivor’s coverage as specified in paragraph 5.1. The contractor shall terminate billing once the problem with EFT/RCC payment is resolved.

5.3 Annual Premium Adjustment

5.3.1 Contractors shall notify current TRR members or survivors in writing of any annual premium adjustments no later than 30 days after the contractors receive notification of the updated premiums.

5.3.2 For premium adjustments that go into effect at any time other than January the first, the Government will provide instructions about notification of TRR members or survivors.

5.4 Premium Adjustments From Changes Associated With QLEs

5.4.1 When a QLE is processed that changes the premium, the effective date of the premium change shall be the date of the QLE.

5.4.2 If the change from a QLE results in an increase in the premium, the contractor shall notify the TRR member or survivor of the increase and adjust the next premium amount due, to include any underpaid amount (prorated to the day as specified in paragraph 5.2), to the effective date of the change.

5.4.3 If the change from a QLE results in a decrease in the premium, the contractor shall retain any overpaid amount and apply it to subsequent electronic payments until all of the overpayment is exhausted.

5.5 Terminations

The contractor shall initiate the process to refund any premium amounts applied for coverage after the date of termination as specified in paragraph 4.9.

5.6 Online Transactions

In addition to requirements specified in paragraph 5.0 and its subordinate paragraphs, the contractor may provide on-line capability for TRR members or survivors to conduct business related to premium collection and other applicable administrative services through secure access to the contractor’s web site.

6.0 Claims Processing

6.1 The contractor shall process TRR claims under established TRICARE Standard/Extra retiree cost-sharing rules and guidance through December 31, 2017. Starting January 1, 2018, the contractor shall process TRR claims using TRICARE Select retiree cost-sharing rules and guidance. Normal TRICARE Other Health Insurance (OHI) processing rules apply to TRR.

6.2 The contractor shall process all claims for health care provided to a newborn/adopted child of a TRR member as specified in paragraph 4.6.3. If the contractor becomes aware that a TRR member has an unregistered newborn/adopted child, the contractor shall notify the TRR member of the requirement to register the newborn/adopted child in DEERS and submit a request for the newborn/adopted child to be enrolled under TRR coverage within 90 days (120 days if overseas) from birth/adoption. When the member completes the process specified in paragraph 4.6.3, the contractor shall process any claims associated with the newborn/adopted child’s health care. If the member fails to complete the process as specified in paragraph 4.6.3, the contractor shall deny any claims associated with the newborn/adopted child’s health care.

6.3 Premium payments made for TRR coverage shall not be applied to the calendar year deductible or catastrophic cap limit.

6.4 If a Retired Reserve member purchases TRR coverage during the same calendar year that the member had a TRICARE Reserve Select (TRS) plan in effect, the catastrophic cap, deductibles and cost-shares shall not be recalculated.

6.5 Medicare is the primary payer for TRICARE beneficiaries who are entitled to Medicare. Claims under the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) will be adjudicated under the rules set forth in the TRM, Chapter 4, Section 4. The contractors shall follow procedures established in Chapter 8, Section 2 regarding claims jurisdiction for dual-eligibles.

6.6 If the contractor receives a Government furnished policy notification notifying them of a retroactive TRR disenrollment the contractor shall initiate recoupment of claims paid if appropriate as specified in Chapter 10.

6.7 If at any time the contractor discovers that the Retired Reserve member may be eligible for or enrolled in the FEHBP, the contractor shall report the discovery to the appropriate TRO or TAO no later than one business day after discovery. As applicable, the contractor shall follow paragraph 4.9.1 and its subordinate paragraphs for loss of TRR qualification. If any other actions are to be taken by the contractor as a result of this discovery, the TRO or TAO will send instructions to the contractor.

7.0 Communications And Customer Service (C&CS)

In addition to C&CS functions specified throughout this chapter, the contractor shall perform C&CS responsibilities to the same extent as they do for TRICARE Select.

7.1 Customer Education

The contractor shall distribute information materials relevant to TRR as specified in Chapter 2, Section 5, paragraph 4.0 and Chapter 11, Section 1, paragraph 4.0 for TRICARE Select. Upon start of coverage under TRR, the DMDC-generated enrollment notification will include information on how purchasers can obtain TRR-specific and other TRICARE plan information.

7.2 Customer Service

The contractor shall provide all customer service support in a manner equivalent to that provided TRICARE Select enrollees. When the contractor receives an inquiry involving TRR qualifications, the contractor shall refer the individual to the appropriate RC.

8.0 Analysis And Reporting

TRR workload shall be included, but not separately identified, in all reports.

9.0 Payments For Contractor Services Rendered

9.1 Claims Reporting

The contractor shall report TRR program claims according to Chapter 3. The contractor shall process payments on a non-financially underwritten basis for the health care costs incurred for each TRR claim processed to completion according to the provisions of Chapter 3.

9.2 Fiduciary Responsibilities

9.2.1 The contractor shall act as a fiduciary for all funds acquired from TRR premium collections, which are Government property. The contractor shall develop strict funds control processes for its collection, retention and transfer of premium funds to the Government. All premium collections received by the contractor shall be maintained in accordance with these procedures.

9.2.2 Either a separate non-interest bearing account shall be established for the collection and disbursement of TRR premiums or the account used for TRS premium collections shall be used for TRR premiums as well. The contractor shall deposit premium collections to the established account within one business day of receipt.

9.2.3 The contractor shall wire-transfer the premium collections, net of refund payments, monthly to a specified Government account as directed by the DHA Contract Resource Management (CRM) office. The Government will provide the contractor with information for this Government account. The contractor shall notify the DHA CRM by e-mail, within one business day of the deposit, specifying the date and amount of the deposit as well as its purpose (i.e. TRR premiums). Premiums for TRS and TRR may be sent as a single wire as long as CRM is notified of the amounts of each type of premium. Collections for delinquency cases that have been transferred to DHA Office of General Counsel (OGC) shall be wire-transferred separately. The contractor shall notify DHA CRM and DHA OGC by e-mail within one business day of the day of deposit, specifying the sponsor name, sponsor Social Security Number (SSN) (last four digits), payment amount, payment date, date case was transferred to DHA OGC and the date and amount of the deposit.

9.2.4 The contractor shall maintain a system for tracking and reporting premium billings, collections, and starts of coverage. The system is subject to Government review and approval.

9.2.5 The contractor shall electronically submit monthly reports of premium activity supporting the wire transfer of dollars to the CO.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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