1.0 Continued Health Care Benefit
Program (CHCBP)
1.1 The
CHCBP is a health care program that allows certain groups of former
Military Health System (MHS) beneficiaries to continue receiving
health care coverage when they lose eligibility for military health
care under the TRICARE programs. This temporary health program is
supported by premium revenue collected from the
program participants
. The
Managed Care Support Contractor (MCSC) for the East Region (herein
referred to as the “CHCBP contractor” unless otherwise specified)
shall provide all services necessary to support the CHCBP as outlined
in
32 CFR 199.20.
In
addition to this Section, the CHCBP contractor shall also use the
applicable Sections of the TRICARE Policy Manual
(TPM), TRICARE Operations Manual (TOM), TRICARE Reimbursement Manual
(TRM), TRICARE Systems Manual (TSM), and the
Federal Register dated
September 30, 1994 (pg. 49817ff), February 11, 1997 (pg. 6225ff), February
24, 1997 (pg. 8312), and September 16, 2011 (pg. 57637ff)
to
fulfill its responsibilities. The CHCBP contractor
shall perform these functions for CHCBP beneficiaries on a worldwide
basis, irrespective of the geographic area in which the beneficiary
resides or the area in which health care services are received.
1.2 The legislative basis for the
program is Section 4408 of the National Defense Authorization Act (NDAA)
of 1993 (Public Law 102-484) which added Section 1078a to Chapter
55 of 10 United States Code (USC). Beneficiaries, who
may be eligible to purchase the continued health program after eligibility
for coverage ends under a health benefits plan under 10 USC Chapter
55 or 10 USC § 1145(a) are described in 10 USC § 1078a. Beneficiaries covered
under premium-based TRICARE health benefits plans such as TRICARE
Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young
Adult (TYA), etc., must purchase coverage and have
it in place the day before the loss of eligibility.
1.3 CHCBP is not part of the TRICARE
Program; therefore, the CHCBP contractor shall adhere to the following
requirements for those areas in which the CHCBP instructions and
processing requirements are different than TRICARE.
2.0
Validate
Eligibility For CHCBP
2.1 Upon
receipt of a Department of Defense (DoD) (DD) Form 2837, CHCBP Application,
from a prospective beneficiary, the CHCBP contractor shall validate
eligibility on the Defense Enrollment and Eligibility Reporting
System (DEERS). If additional documentation is required to validate
CHCBP eligibility
, the CHCBP contractor
shall contact
the applicant. The
CHCBP contractor shall request supporting
documentation
from the applicant
based on
the category of individual who is applying for enrollment as shown
below:
2.1.1 Individual Uniformed Service
sponsor (herein referred to as “sponsor”) and his/her family. The
contractor shall obtain a copy of the DD Form 214,
Certificate of Release or Discharge from Active Duty, or a copy
of the sponsor’s active duty orders from the applicant.
2.1.2 Unremarried Former Spouse (URFS)
and stepchildren of the sponsor. The
contractor shall obtain a copy of the final divorce
decree from the applicant.
2.1.3 Child who loses TRICARE coverage
due to marriage. The
contractor shall obtain a copy of marriage certificate
from the applicant.
2.1.4 Child
who loses TRICARE coverage on his/her 21st birthday (age 23 if enrolled
in a full-time course of study at an approved institution of higher
learning and dependent on the uniformed service sponsor for more
than half of their financial support). The
contractor shall obtain a copy of the front and back
of the Uniformed Services identification (ID) card from
the applicant.
2.1.5 Child
who loses TRICARE coverage due to college graduation. The
contractor shall obtain a copy of college transcript from
the applicant.
2.1.6 Child
over the age of 21 and before the age of 23 who loses TRICARE coverage
when no longer enrolled in a full-time course of study at an approved
institution of higher learning or no longer dependent on the uniformed
service sponsor for more than half of their financial support. The contractor
shall obtain a letter from the institution of higher
learning stating the student’s status or a written statement from
the dependent that he/she is no longer dependent on the uniformed
services sponsor for more than half of their financial support from
the applicant.
2.1.7 Child
that was previously placed in sponsor’s legal custody and then loses
TRICARE coverage
. The
contractor shall obtain a copy of the court order
from
the applicant.
Note: Children who lose TRICARE coverage
under
paragraphs 2.1.4 through
2.1.7 may
qualify to purchase TYA coverage until reaching the age of 26 (see
Chapter 25). If qualified to purchase TYA coverage,
the
contractor shall not allow the child
to purchase
CHCBP as an individual. Also, if the child does not qualify to purchase
TYA because he or she qualifies for employer sponsored coverage,
the contractor
shall not enroll them in CHCBP.
However,
if the TYA coverage was terminated due to eligibility for employer-sponsored
health care coverage based on their own employment or failure to pay
TYA premiums, then
the contractor shall not enroll the
child
in CHCBP
(see
Chapter 25).
2.1.8 For
any other situations in which an individual loses TRICARE coverage
and may potentially be eligible for CHCBP, the contractor shall
request information it needs to verify
eligibility.
2.2 Family
Members Not Identified on DEERS
2.2.1 Cases
where a contractor receives a CHCBP claim which includes
a family member not identified on DEERS as enrolled, but the sponsor
indicates CHCBP family coverage. If
the claim includes a copy of an appropriately marked CHCBP coverage
card for the beneficiary, the contractor shall process
the claim. If the claim
is for a beneficiary who is less than 60 days old, the
contractor shall process the claim, even
if no copy of a CHCBP coverage card is attached as long as at least
one member of the sponsor’s family is currently enrolled in CHCBP.
In all other cases, the contractor shall deny the claim.
2.2.2 When a beneficiary
is enrolled in the CHCBP, the contractor
shall disenroll the beneficiary from all
other TRICARE programs. The
contractor shall not require the beneficiary to take any action.
2.3 Disputes Regarding Enrollment
2.3.1 The CHCBP contractor
shall confirm a person’s eligibility for CHCBP. The
contractor shall not consider disputed questions
of fact concerning a beneficiary’s eligibility an
appealable issue, and the contractor shall resolve the
issue with the appropriate Uniformed Service.
2.3.2 If the contractor determines
the applicant does not appear eligible due to an ineligible response
from DEERS (i.e., no history segments or record of previous DoD
entitlement) or failure of the applicant to provide the documentation
requested to verify eligibility the contractor shall deny the application
in writing within 10 business days of the reason for the denial.
3.0 Application Period And Premiums
3.1 CHCBP Application Period
There
is a 60-day application period for CHCBP, beginning the day following
the end date of the beneficiary’s eligibility for TRICARE coverage.
The contractor shall deny any applications received after the 60-day
period. The contractor shall apply the following business rules
when determining the start of the 60-day application period.
3.1.1 Members and Former Members,
Their Families, and Other Individuals Losing TRICARE Coverage
The
Government routinely notifies beneficiaries prior to their loss
of TRICARE coverage. The Government (Uniformed Service) informs Active
Duty (AD) members of the CHCBP during outprocessing. The
Defense Manpower Data Center (DMDC) notifies other
beneficiaries in writing of CHCBP availability. However,
if an eligible beneficiary advises the contractor that he/she was
not notified of this program and submits documentation to support
their position, the contractor shall forward the documentation to
the Chief, Managed Care Support Program Section (MCSPS) or
designee, who shall provide direction on the start-date of the 60-day
application period.
3.1.2 URFSs
There
is no formal mechanism established to promptly identify URFSs that
may qualify for this program, therefore the contractor shall process
all applications from URFSs upon receipt.
3.2 Coverage Categories
CHCBP offers two coverage categories.
Individual coverage is available to the member or former member,
an URFS, an adult child, a surviving spouse, or other qualified
individuals. Family coverage is only available to the member or
former member and their family members. Family members cannot
be covered under family coverage unless the member or former member
is also covered by family coverage.
3.3 CHCBP
Application
The
contractor shall accept the DD Form 2837, CHCBP Application as
the application form for CHCBP coverage. Should DD Form 2837 be
revised or renumbered in the future, the contractor shall use the
latest version.
3.4 Dates
of Coverage & Premiums
3.4.1 Coverage
will begin the day following the beneficiary’s loss of TRICARE coverage
and will end the last day of premium coverage.
3.4.2 Due to the documentation requirements
for purchasing coverage, most coverage will be retroactive; however,
there may be some coverage that will be prospective. The
contractor shall ensure prospective coverage is accompanied
by a premium payment for one quarter. The contractor
shall ensure retroactive coverage is accompanied
by full premium payment retroactive to the effective date of coverage
through the end coverage date in the quarter in which the individual
is applying.
3.4.3 Examples of the premiums
the
contractor shall require for retroactive and prospective coverage:
|
|
Military
Benefits End
|
Application
Received
|
Quarters
of
Premium Due
|
CHCBP
Coverage Begins
|
|
Example 1:
|
10/01/2010
|
11/15/2010
|
1 quarter
|
10/02/2010
|
|
Example 2:
|
09/15/2010
|
02/10/2011
|
2 quarters
|
09/16/2010
|
|
Example 3:
|
11/05/2010
|
10/01/2010
|
1 quarter
|
11/06/2010
|
|
Example 4:
|
03/01/2011
|
11/01/2010
|
1 quarter
|
03/02/2011
|
3.5
Premium
Rates
3.5.1 The
Government
establishes CHCBP premium
amounts and the
Government
may
adjust them each
Fiscal
Year
(FY).
The
Government will establish premium amounts and may adjust them on
a Calendar Year (CY) basis beginning January 1.Note: The typical CHCBP
FY is a twelve-month period from October 1 to September 30; however, CHCBP
FY 2022 includes the three-month period between October 1, 2022,
and December 31, 2022.
3.5.2 The contractor shall charge the
adjusted quarterly premiums on the date specified in Addendum A. The
CHCBP will transition to CY operation on January 1, 2023, to allow
premium collection to align with the CY collection of the CHCBP
out-of-pocket expenses. The one-time transition period from FY to
CY will be in effect for the quarterly premium collection period
from October 1, 2022 through December 31, 2022.
3.5.3 During the one-time
transition period, the contractor shall:
• Continue to charge
FY 2022 quarterly premiums.
• Upon receipt
of adjusted rates from the Government, issue a written notice to
the beneficiary to notify them of the premium amount changes, the
effective date of the change and the transition to CY premium collection.
The contractor shall provide this notification at least 30 days
prior to the effective date directed by the Contracting Officer
(CO).
3.5.4 Starting
January 1, 2023, the contractor shall:
• Collect quarterly
CHCBP premiums on a CY basis.
• Upon receipt
of adjusted rates from the Government, issue a written notice to
the beneficiary to notify them of the premium amount changes, and
the effective date of the change. The contractor shall provide this
notification at least 30 days prior to the effective date directed
by the CO.
3.5.5 When
qualifying events occur that change the sponsor from individual
to family coverage or vice versa, the contractor shall change coverage
and premiums effective with the date of the qualifying event. The
contractor shall, within 10 business days of receiving such information,
notify the beneficiary in writing of the changes in the coverage
category and premium amount, including the effective date of the
changes.
3.6 Form
of Payment
3.6.1 The
contractor shall accept checks, money orders, or
credit cards as forms of premium payment. The
contractor may propose additional payment mechanisms, to include
electronic processes for premium payments. The contractor
shall ensure proposed electronic processes shall maintain
the integrity and security of the application processes which includes documentation required
to validate eligibility for CHCBP.
3.6.2 As
a minimum, the contractor shall accept VISA and MasterCard® for
credit card payments, and may, but is not required to, accept additional
nationally recognized major credit cards for premium payment.
3.6.3 The contractor shall not accept
premiums submitted by, or on behalf, of a health care provider for
any beneficiary other than (a) the provider him/herself and (b)
a member of the provider’s immediate family. If the
contractor receives a payment from a provider, the
contractor shall return the payment to the provider with a written
notice advising the provider that submission of premium payments
by health care providers is prohibited. The contractor
shall also send a copy of the letter to the
beneficiary. The contractor shall submit documentation to the Defense
Health Agency (DHA) Program Integrity Office to include the following:
a copy of contractor’s notification to the provider, copy of front
and back of premium (money order or check), originals of all documentation
submitted by the provider (to include mailing envelope), documentation
of all conversations and communications the contractor had with
the provider on the subject of paying premiums, and any other information
that the contractor has in its files or records concerning the provider
that might be of assistance in Government follow-up action on this
issue.
3.7 Insufficient Funds
3.7.1 In the case of insufficient
funds, the contractor shall, within three business days, issue a written
notice to the applicant (for initial applications) or beneficiary
(in the case of renewal premiums), advising the applicant or beneficiary
of the insufficient funds, the amount of the premium due, and the date the
contractor must receive a valid premium payment.
For initial application requests, the contractor shall advise
the beneficiary that if the contractor does not receive
the premium payment in full
by the due date (the last day of the 60-day application period),
the applicant will not be covered in CHCBP. For renewals, the contractor shall
advise the beneficiary in writing that
if the contractor does not receive valid payment in full within
30 days of the date of the contractor’s letter, the
contractor will terminate CHCBP coverage. The
contractor shall provide the effective date of termination
if payment is not received. If the premium payment has not been
received by the contractor within the specified time frame, the
contractor shall terminate the CHCBP coverage and issue a written
Termination Notice (TN) to the beneficiary confirming the termination
of coverage.
3.7.2 In the event that there are
insufficient funds to process a premium payment, the contractor may
assess and retain a fee of up to 20
U.S. dollars ($20.00) from the CHCBP applicant/purchaser.
3.8
Refunds
The
contractor shall refund premiums if
the applicant is no longer eligible for CHCBP coverage, i.e., beneficiary
regains TRICARE eligibility; ex-spouse remarries; death of beneficiary;
prospective member who has prepaid premium but fails to provide
required eligibility documentation; and sponsor change in coverage
from family to individual. The contractor shall not
refund unused premiums if the beneficiary voluntarily terminated
CHCBP coverage because they obtained Other Health
Insurance (OHI). When refunds are appropriate,
the contractor shall prorate the refund from the date of loss of eligibility
for program benefits through the last coverage date for which the
premium was paid.
3.9 Limits
of CHCBP Coverage
The length
of a beneficiary’s CHCBP coverage varies according to the category
of individual. Coverage lengths and categories are listed in the
TPM,
Chapter 10, Section 4.1, Figure 10.4.1-1,
CHCBP Eligibility Table.
3.10 Processing
Applications
3.10.1 Once
the contractor has verified eligibility and approved the application
request, the contractor shall enter the CHCBP enrollment into DEERS
through the applicable on-line interface. As DEERS does not allow
individuals to be added to a sponsor’s record after the sponsor’s
TRICARE coverage ends, there will be a small number of CHCBP beneficiaries
that the contractor cannot complete the CHCBP enrollment in DEERS.
The majority will be newborns whose birth occurred after the sponsor’s
TRICARE coverage ends, but there will occasionally be other beneficiaries
as well.
Because of this, the contractor
shall not
rely on DEERS as
the sole determinant
of whether or not an individual is eligible for CHCBP coverage
(see
paragraph 2.0).
The contractor
shall
ensure
its systems accommodate these unique cases in which
the beneficiary is covered under CHCBP but not reflected on DEERS
to ensure these beneficiaries are provided with all required CHCBP
benefits and accurate processes, i.e., claims processing, issuing
authorizations, accessing services, etc.
3.10.2 DEERS will not allow the
contractor to enter a CHCBP enrollment if
the sponsor or family members are
still showing as eligible for TRICARE coverage. In these cases,
the contractor shall pend the application and advise the applicant
in writing for the sponsor to contact the nearest Uniformed Services
ID card issuing office (Real-Time Automated Personnel Identification
System (RAPIDS)) to rectify the situation. The contractor shall
complete the processing of the application when DEERS has been updated
to reflect that the sponsor or family
members are no longer eligible for services under TRICARE.
3.10.3 Once the application has been
fully processed, the contractor shall issue the beneficiaries a CHCBP
coverage ID card within 10 business days. The card provides the
beneficiaries with (a) confirmation that the individual is covered
and the effective dates; and (b) documentation that the beneficiary
on how to access health care services. The contractor
shall ensure the card contains sufficient
information to facilitate access to health care. The
contractor shall limit coverage dates on the card to
those dates for which the contractor has received a
valid quarterly premium. The
contractor shall issue cards each
quarter for all subsequent quarterly payments received by the contractor.
The contractor shall ensure the card reflects coverage for
the CHCBP and provides the contractor’s
name, address, toll-free telephone number, and claims center mailing
address at a minimum.
3.10.4 Once an application has been
fully processed, the contractor shall issue a letter to the applicant
confirming CHCBP coverage (including the dates of coverage) within
10 business days. The
contractor shall ensure the letter
:
• Includes requirements for
continued coverage;
• Includes information
regarding future bills and premium
payments;
• Includes a
CHCBP coverage policy, or such other
sufficient written information regarding the CHCBP for beneficiaries to reference for benefits
and program requirements questions.
3.11 Coverage and Renewals
3.11.1 The contractor shall mail initial
premium renewal notices to beneficiaries no later than 30 days before
the expiration of the coverage. The beneficiary’s coverage in CHCBP
is based on the documentation that the applicant submits to verify
eligibility, therefore, the contractor shall not routinely query
DEERS for renewal coverages and quarterly billings. Absent information
or evidence to the contrary, the contractor shall assume that the
individual continues to meet the requirements for CHCBP. The
contractor shall ensure renewal notices clearly
specify the premium amount due, the date by which the premium must
be received, and the mailing address to send the
premium payment. The contractor
shall ensure renewal notices specify
that failure to submit the premium due will result in denial of
continued coverage and termination from the program.
3.11.2 The contractor shall provide
a 30 day grace period following the
premium due date in which the beneficiary may submit their premium
and continue benefits with no break in coverage. If the premium
is not received following the initial renewal notice to the beneficiary
requesting premium payment for the
next quarter, the contractor shall issue a second renewal notice
to the beneficiary within 10 business days of the start of the grace
period. The contractor shall ensure the second
renewal notice indicates
it is the second and final billing notice and that
if the contractor does not receive payment by
the due date specified in the notice, that CHCBP coverage will be
terminated as of that date. The contractor shall ensure
the notice advises the
beneficiary that if coverage is terminated due to nonpayment of
premium, that the beneficiary will
be permanently locked-out of CHCBP.
3.11.3 If the premium is not received
by the end of the grace period, the contractor shall terminate the
beneficiary’s coverage in CHCBP and send a TN to the beneficiary
confirming the termination within 10 business days, to include the
effective date and basis for the termination. The contractor shall enter
all CHCBP terminations into DEERS.
3.11.4 Beneficiaries who desire to
voluntarily withdraw from the CHCBP prior to the end of their paid
up period
must send a written request
to the contractor.
The contractor shall not permit beneficiaries
who voluntarily disenroll from the CHCBP
to
re-enroll until they gain and then once again lose TRICARE coverage.
The
contractor shall refund
unused
premiums
for items covered in
paragraph 3.8.
3.11.5 Following a beneficiary’s termination
from the CHCBP, except for those who have re-established TRICARE
coverage, the contractor shall issue a TN to the beneficiary within
10 business days from the termination date and upon request up to
24 months after the termination date.
3.11.6 In preparing and mailing all
written notices and correspondence to applicants and beneficiaries,
the contractor shall use the most current address on file or available.
3.12 CHCBP Coverage Data and Report
The
contractor shall maintain systems and databases to collect, track
and process applications. The contractor shall have the capability
to retroactively retrieve pertinent coverage information on any individual
who has been accepted or denied coverage in the program, to include
the basis for such denials.
6.0 Fiduciary Responsibilities
6.1 The contractor shall act as
a fiduciary for all funds acquired from CHCBP premium collections, which
are Government property. The contractor shall develop strict funds
control processes for its collection, retention and transfer of
CHCBP premiums to the Government. The contractor shall follow the
requirements in
Chapter 3.
6.2 The
contractor shall maintain a system for tracking and reporting premiums
and beneficiaries/policy holders. The system is subject to Government
review and approval.
6.3 The
contractor shall submit reports as identified by the DD Form 1423,
Contract Data Requirements List (CDRL), located in Section J of
the applicable contract.
9.0 Patient Protection And Affordable
Care Act (ACA) Of 2010 Information Reporting
9.1 When purchased, CHCBP coverage
is Minimum Essential Coverage (MEC) and meets the individual coverage
requirement of the ACA.
9.2 The
CHCBP contractor shall perform all Section 6055 information reporting
to the Internal Revenue Service (IRS) and provide statements to
individuals with CHCBP coverage during the reporting tax period
in the manner, time frames, and forms specified in Section 6055
of the Internal Revenue Code (IRC) and associated IRS regulations.
The CHCBP contractor shall notify the Contracting Officer’s Representative
(COR) when completed each year.
9.3 Because
not all CHCBP enrollments are recorded in DEERS, the CHCBP contractor
shall use coverage data from the contractor’s enrollment system
to generate the required information reports and statements. The
CHCBP contractor shall report CHCBP coverage information to
the IRS.