1.0 General
TMEP 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 the contractor
shall process under TMEP:
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 too 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 who 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 will remain TRICARE eligible for the period where only Part
A was effective. If a beneficiary declines Part B coverage, they
will be ineligible for TRICARE from the original Part B effective
date until Part B coverage is established.