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.