1.0 DESCRIPTION
Medicare
eligibles who are beneficiaries based on age and whose TRICARE eligibility
is determined by 10 United States Code (USC) Section 1086, are eligible
for Medicare Part A, and who are enrolled in Medicare Part B, are
eligible for the TFL benefit.
TRICARE beneficiaries
eligible
under Section 1086(d) under age 65 who are also Medicare
eligible, are also eligible for TFL (see the TRICARE Operations
Manual (TOM),
Chapter 20, Section 1, paragraphs 2.4 and
2.5).
2.0 POLICY
2.1 Introduction
Section 1086(d) extends
TRICARE eligibility to persons who would otherwise have lost their TRICARE
eligibility due to attainment of entitlement to hospital insurance
benefits under Part A of Medicare based on age. In order for these
individuals to retain their TRICARE eligibility, they must have Medicare
Part B (Supplementary Medical Insurance (SMI)). In general, when
medical care or, adjunctive dental care is provided to these individuals
and payment may be made under both Medicare and TRICARE, Medicare
is the primary payer and TRICARE will normally pay the actual out-of-pocket
costs incurred by the person.
2.2 Eligibility
The contractors
shall determine from the Defense Enrollment Eligibility Reporting
System (DEERS) if the individual is eligible for TFL. TFL claims
are processed in accordance with TRICARE Operations Manual (TOM),
Chapter 20.
2.3 TFL beneficiaries, in most cases, are not
eligible to enroll in TRICARE Prime (i.e., retirees and their family
members who are 65 years of age or older, and who are entitled to
Medicare Part A and who have Medicare Part B). See
the
TOM,
Chapter 6, Section 1 for exceptions.
Note: Retirees,
retiree family members, and survivors (other than survivors of deceased
members who died on active duty) with any Medicare coverage at any
age are not eligible to enroll in TRICARE Select because they are
excluded from the “Retired Category” definition for TRICARE Select
(10 USC 1075(b)(1)(B)).
2.4 Appeal rights
are covered in the TOM,
Chapter 12.
3.0 Other Dual
Eligible Beneficiaries
In addition to TFL beneficiaries, there
are other categories of beneficiaries who have dual eligibility
under both TRICARE and Medicare:
3.1 TRICARE beneficiaries who are age 65 or
older and who are not entitled to premium-free Medicare Part A on
their own record or the record of their current, former, or deceased
spouse, but have Medicare Part B, remain TRICARE eligible and are
eligible to enroll in TRICARE Prime or TRICARE Select.
3.2 Active Duty
Family Members (ADFMs) who are age 65 or older and who are entitled
to premium-free Medicare Part A only remain TRICARE eligible and
are eligible to enroll in TRICARE Prime or TRICARE
Select.
3.3 TRICARE beneficiaries (retirees and family
members under age 65) who are entitled to premium-free Medicare
Part A and have Medicare Part B are eligible to enroll in TRICARE
Prime.
3.4 ADFMs
under the age of 65 who are entitled to premium-free Medicare Part
A remain TRICARE eligible and eligible to enroll in TRICARE Prime or
TRICARE Select. (See Note regarding special enrollment
periods for certain ADFMs.)
3.5 TRICARE eligible individuals who are
entitled to premium-free Medicare Part A because of a disability,
where Social Security Disability Insurance (SSDI) is awarded on
appeal and there is a minimum six month gap between Medicare Part
A and Part B effective dates, remain TRICARE eligible for the period
where only Part A was effective. If a beneficiary declines Part
B coverage, he/she will be ineligible for TRICARE from the original
effective date of Part B until Part B coverage is established.
3.6 TRICARE
beneficiaries eligible for premium-free Medicare Part A generally
must have Medicare Part B to remain TRICARE eligible. If Part B
coverage is required, but the beneficiary does not have it, the beneficiary
is not eligible for any TRICARE benefits. If the beneficiary refused
or declined Part B coverage when they first became eligible and
subsequently enroll in Part B at a later date, TRICARE eligibility
is restored on the Part B effective date of coverage. In the following
circumstances, Part B is not required:
• Family members of Service members;
• Enrollment in
the Uniformed Services Family Health Plan (USFHP);
• Enrollment in
the TRICARE Retired Reserve (TRR); or
• Enrollment in
TRICARE Reserve Select (TRS).
Note: ADFMs
whose Medicare entitlement is based on a disability are not required
to have Part B until the sponsor retires and may enroll in Part
B during a special enrollment period. The special enrollment period
is available anytime the sponsor is on active duty or within the
first eight months of the sponsor’s retirement. If the family member
enrolls in Part B after the sponsor’s retirement date, there will
be a break in TRICARE coverage. This special enrollment period does
not apply to ADFMs whose Medicare entitlement is based on End
Stage Renal Disease (ESRD).
While ADFMs with ESRD and USFHP/TRS enrollees are not required to
have Medicare Part B, enrollment in Part B when the individual is
first eligible is encouraged. ESRD patients and USFHP/TRS enrollees
may be required to pay the 10% Medicare surcharge for each 12-month
period they were eligible to enroll in Part B, but did not. When USFHP/TRS
beneficiaries are no longer enrolled in these programs, or when
the sponsor of an ADFM with ESRD retires, they are not eligible
for other TRICARE coverage without Part B.