1.0 General
The TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC) encompasses the processing of all
TRICARE claims for services rendered within the 50 United States
(U.S.) and the District of Columbia, as well as Puerto Rico, Guam,
the U.S. Virgin Islands, American Samoa, and the Northern Mariana
Islands, to individuals who have dual eligibility under both TRICARE
and Medicare.
2.0 Dual Eligibles
There
are six general categories of beneficiaries who have dual eligibility
under both TRICARE and Medicare and whose claims will be processed
under TDEFIC:
2.1 TRICARE beneficiaries, who
are 65 or older and who are entitled to premium-free Medicare Part A
and who have Medicare Part B;
2.2 TRICARE
beneficiaries who are 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;
2.3 Active Duty Family Members
(ADFMs) who are 65 or older and who are entitled to premium-free
Medicare Part A only;
2.4 TRICARE
beneficiaries who are entitled to premium-free Medicare Part A because
of a disability or End Stage Renal Disease (ESRD) and who have Medicare
Part B;
2.5 ADFMs
who have a disability or ESRD and are entitled to premium-free Medicare
Part A only (While those with Medicare based on disability get a
special enrollment period and therefore are not subject to the Part
B premium surcharge, the special enrollment period does not apply
to those with ESRD. ESRD patients who do not keep Medicare Part
B when first eligible may have to pay a surcharge of 10% for each
12 month period that they could have enrolled in Part B but did
not.); and
2.6 TRICARE
beneficiaries, who are entitled to premium-free Medicare Part A
because of a disability, where Social Security Disability Insurance
(SSDI) is awarded on appeal. These beneficiaries will have a Medicare
Part B effective date of October 1, 2009, or later and a six-month
minimum gap between their Medicare Part A and Medicare Part B effective
dates and will 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 Part B effective
date until Part B coverage is established.
3.0 Applicability Of TRICARE Requirements
Unless specifically waived
or superseded by the provisions of this chapter, all normal TRICARE requirements
set forth in the TRICARE Operations Manual (TOM), TRICARE Policy
Manual (TPM), TRICARE Reimbursement Manual (TRM), and TRICARE Systems
Manual (TSM) apply to claims processed under TDEFIC.