(a) General.
This section sets forth those
persons who, by the provisions of 10 U.S.C. chapter 55, and the
NATO Status of Forces Agreement, are eligible for CHAMPUS benefits.
A determination that a person is eligible does not automatically
entitle such a person to CHAMPUS payments. Before any CHAMPUS benefits
may be extended, additional requirements, as set forth in other
sections of this part, must be met. Additionally, the use of CHAMPUS
may be denied if a Uniformed Service medical treatment facility
capable of providing the needed care is available. CHAMPUS relies
primarily on the Defense Enrollment Eligibility Reporting System
(DEERS) for eligibility verification.
(b)
CHAMPUS eligibles--
(1) Retiree.
A member or former member of
a Uniformed Service who is entitled to retired, retainer, or equivalent
pay based on duty in a Uniformed Service.
(2) Dependent.
Individuals whose relationship
to the sponsor leads to entitlement to benefits. CHAMPUS eligible
dependents include the following:
(i) Spouse.
A lawful husband or wife of
a member or former member. The spouse of a deceased member or retiree
must not be remarried. A former spouse also may qualify for benefits
as a dependent spouse. A former spouse is a spouse who was married
to a military member, or former member, but whose marriage has been
terminated by a final decree of divorce, dissolution or annulment.
To be eligible for CHAMPUS benefits, a former spouse must meet the
criteria described in paragraphs (b)(2)(i)(A) through (b)(2)(i)(E)
of this section and must qualify under the group
defined in paragraph (b)(2)(i)(F)(1) or (b)(2)(i)(F)(2)
of this section.
(A) Must
be unremarried; and
(B) Must
not be covered by an employer-sponsored health plan; and
(C) Must have been
married to a member or former member who performed at least 20 years
of service which can be credited in determining the member’s or
former member’s eligibility for retired or retainer pay; and
(D) Must not be eligible
for Part A of Title XVIII of the Social Security Act (Medicare)
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii),
and (f)(3)(ix) of this section; and
(E) Must not be the
dependent of a NATO member; and
(F) Must meet the requirements
of paragraph (b)(2)(i)(F)(
1) or (b)(2)(i)(F)(
2)
of this section:
(1) The former spouse must have been married
to the same member or former member for at least 20 years, at least
20 of which were creditable in determining the member’s or former
member’s eligibility for retired or retainer pay. Eligibility continues
indefinitely unless affected by any of the conditions of paragraphs
(b)(2)(i)(A) through (b)(2)(i)(E) of this section.
(i) If the date
of the final decree of divorce, dissolution, or annulment was before
February 1, 1983, the former spouse is eligible for CHAMPUS coverage
of health care received on or after January 1, 1985.
(ii) If the date
of the final decree of the divorce, dissolution, or annulment was
on or after February 1, 1983, the former spouse is eligible for
CHAMPUS coverage of health care which is received on or after the
date of the divorce, dissolution, or annulment.
(2) The former
spouse must have been married to the same member or former member
for at least 20 years, and at least 15, but less than 20 of those
married years were creditable in determining the member’s or former
member’s eligibility for retired or retainer pay.
(i) If the date
of the final decree of divorce, dissolution, or annulment is before
April 1, 1985, the former spouse is eligible only for care received
on or after January 1, 1985, or the date of the divorce, dissolution,
or annulment, whichever is later. Eligibility continues indefinitely
unless affected by any of the conditions of paragraphs (b)(2)(i)(A)
through (b)(2)(i)(E) of this section.
(ii) If the date
of the final decree of divorce, dissolution or annulment is on or
after April 1, 1985, but before September 29, 1988, the former spouse
is eligible only for care received from the date of the decree of
divorce, dissolution, or annulment until December 31, 1988, or for
two years from the date of the divorce, dissolution, or annulment,
whichever is later.
(iii) If the date of the final decree of divorce,
dissolution, or annulment is on or after September 29, 1988, the
former spouse is eligible only for care received within the 365
days (366 days in the case of a leap year) immediately following
the date of the divorce, dissolution, or annulment.
(ii) Child.
A dependent child is an unmarried
child of a member or former member who has not reached his or her
twenty-first (21st) birthday, except an incapacitated adopted child
meeting the requirements of paragraph (b)(2)(ii)(H)(2)
of this section, and who bears one of the following relationships
to a member or former member of one of the Uniformed Services:
(A) A legitimate child;
or
(B) An adopted child
whose adoption has been legally completed on or before the child’s
twenty-first (21st) birthday; or
(C) A legitimate stepchild;
or
(D) An illegitimate
child of a member or former member whose paternity/maternity has
been determined judicially, and the member or former member
directed to support the child; or
(E) An illegitimate
child of a member or former member whose paternity/maternity
has not been determined judicially, who resides with or in the home
provided by the member or former member, and is or continues to
be dependent upon the member or former member for over one-half
of his or her support, or who was so dependent on the former member
at the time of the former member’s death; or
(F) An illegitimate
child of a spouse of a member who resides with
or in a home provided by the member and is, and continues to be
dependent upon the member for over one-half of his or her support;
or
(G) An illegitimate
child of a spouse of a former member who resides
with or in a home provided by a former member or the former member’s
spouse at the time of death of the former member, and is, or continues
to be, or was, dependent upon the former member for more than one-half
of his or her support at the time of death; or
(H) An individual who
falls into one of the following classes:
(1) A
student.
A child determined to be a
member of one of the classes in paragraphs (b)(2)(ii)(A) through
(b)(2)(ii)(G) of this section, who is not married, has passed his
or her 21st birthday but has not passed his or her 23rd birthday,
is dependent upon the member or former member for over 50 percent of
his or her support or was dependent upon the member or former member
for over 50 percent of his or her support on the date of the member’s
or former member’s death, and is pursuing a full-time course of
education in an institution of higher learning approved by the Secretary
of Defense or the Department of Education (as appropriate) or by
a state agency under 38 U.S.C. chapters 34 and 35.
Note: Courses of education offered
by institutions listed in the “Education Directory,” “Higher Education”
or “Accredited Higher Institutions” issued periodically by the Department
of Education meet the criteria approved by the Administering Secretary
or the Secretary of Education. For determination of approval of
courses offered by a foreign institution, by an institution not
listed in either of the above directories, or by an institution
not approved by a state agency pursuant to 38 U.S.C. chapters 34
and 35, a statement may be obtained from the Department of Education,
Washington, D.C. 20202.
(2) An
incapacitated child.
A child determined to be a
member of one of the classes in paragraphs (b)(2)(ii)(A) through
(b)(2)(ii)(G) of this section, who is not married and is incapable
of self-support because of a mental or physical disability that:
(i) Existed before
the child’s twenty-first (21st) birthday; or
(ii) Occurred
between the ages of 21 and 23 while the child was enrolled in a
full-time course of study in an institution of higher learning approved
by the Administering Secretary or the Department of Education (see
NOTE to paragraph (b)(2)(ii)(H)(2)(iii)
of this section), and is or was at the time of the member’s or former
member’s death dependent on the member or former member for over
one-half of his or her support; and
(iii) The incapacity
is continuous. (If the incapacity significantly improves or ceases
at any time, CHAMPUS eligibility cannot be reinstated on the basis
of the incapacity, unless the incapacity recurs and the beneficiary
is under age 21, or is under age 23 and is enrolled as a full-time
student under paragraph (b)(2)(ii)(H)(
2)(
ii)
of this section. If the child was not incapacitated after that date,
no CHAMPUS eligibility exists on the basis of the incapacity. However,
incapacitated children who marry and who subsequently become unmarried
through divorce, annulment, or death of spouse, may be reinstated
as long as they still meet all other requirements).
Note: An institution of higher learning
is a college, university, or similar institution, including a technical or
business school, offering post-secondary level academic instruction
that leads to an associate or higher degree, if the school is empowered
by the appropriate State education authority under State law to
grant an associate, or higher, degree. When there is no State law
to authorize the granting of a degree, the school may be recognized
as an institution of higher learning if it is accredited for degree programs
by a recognized accrediting agency. The term also shall include
a hospital offering educational programs at the post-secondary level
regardless of whether the hospital grants a post-secondary degree.
The term also shall include an educational institution that is not
located in a State, that offers a course leading to a standard college
degree, or the equivalent, and that is recognized as such by the
Secretary of Education (or comparable official) of the country,
or other jurisdiction, in which the institution is located (38 U.S.C.
chapter 34, section 1661, and chapter 35, section 1701.
Courses of education offered
by institutions listed in the “Education Directory,” “Higher Education”
or “Accredited Higher Institutions” issued periodically by the Department
of Education meet the criteria approved by the Administering Secretary
or the Secretary of Education. For determination of approval of
courses offered by a foreign institution, by an institution not
listed in either of the above directories, or by an institution
not approved by a state agency pursuant to chapters 34 and 35 of
38 U.S.C., a statement may be obtained from the Department of Education,
Washington, D.C. 20202.
(3) A
child of a deceased reservist.
A child, who is determined
to be a member of one of the classes in paragraphs (b)(2)(ii)(A)
through (b)(2)(ii)(G) of this section, of a reservist in a Uniformed
Service who incurs or aggravates an injury, illness, or disease,
during, or on the way to or from, active duty training for a period
of 30 days or less or inactive duty training, and the reservist
dies as a result of that specific injury, illness or disease.
(4) An
unmarried person.
An unmarried person placed
in the home of a member or former member prior to adoption. To be
a dependent child, the unmarried person must not have reached the
age of 21 (or otherwise meets the requirements of a student or incapacitated
child set out in paragraphs (b)(2)((ii)(H)(1) or (b)(2)(ii)(H)(2)
of this section) and has been placed in the home of the member or former
member by a recognized placement agency or by any other source authorized
by State or local law to provide adoption placement, in anticipation
of legal adoption by the member or former member.
(iii) Abused
dependents.--
(A) Categories of abused dependents.
An abused dependent may be
either a spouse or a child. Eligibility for either class of abused
dependent results from being either:
(1) The spouse
(including a former spouse) or child of a member who has received
a dishonorable or bad-conduct discharge, or dismissal from a Uniformed
Service as a result of a court-martial conviction for an offense
involving physical or emotional abuse of the spouse or child, or
was administratively discharged as a result of such an offense.
Until October 17, 1998, Medical benefits are limited to care related
to the physical or emotional abuse and for a period of 12 months
following the member’s separation from the Uniformed Service. On
or after October 17, 1998, medical benefits can include all under
the Basic Program and under the Extended Care Health Option for
the period that the spouse or child is in receipt of transitional
compensation under section 1059 of title 10 U.S.C.
(2) The spouse
(including a former spouse) or child of a member or former member
who while a member and as a result of misconduct involving abuse
of the spouse or child has eligibility to receive retired pay on
the basis of years of service terminated.
(B) Requirements
for categories of abused dependents--
(1) Abused spouse.
As long as the spouse is receiving
payments from the DoD Military Retirement Fund under court order,
the spouse is eligible for health care under the same conditions
as any spouse of a retired member. The abused spouse must:
(i) Under paragraph
(b)(2)(iii)(A)(1) of this section, be a lawful
husband or wife or a former spouse of the member; or
(ii) Under paragraph
(b)(2)(iii)(A)(
2) of this section, be a lawful
husband or wife or a former spouse of the member or former member,
and the spouse is receiving payments from the Department of Defense Military
Retirement Fund under 10 U.S.C. 1408(h) pursuant to a court order;
and
(A) Be a victim
of the abuse; and
(B) Have been married to the member or former
member at the time of the abuse; or
(C) Be the natural
or adoptive parent of a dependent child of the member or former
member who was the victim of the abuse.
(2) Abused
child.
The abused child must:
(i) Under paragraph
(b)(2)(iii)(A)(1) of this section, be a dependent
child of the member or former member.
(ii) Under paragraph
(b)(2)(iii)(A)(
2) of this section,
(A) Have been
a member of the household where the abuse occurred; and
(B) Be an unmarried
legitimate child, including an adopted child or stepchild of the
member or former member; and
(C) Be under
the age of 18; or
(D) Be incapable of self support because of
a mental or physical incapacity that existed before becoming 18
years of age and be dependent on the member or former member for
over one-half of his or her support; or
(E) If enrolled
in a full-time course of study in an institution of higher learning
recognized by the Secretary of Defense (for the purposed of 10 U.S.C.
1408(h)), be under 23 years of age and be dependent on the member
or former member for over one-half of his or her support.
(F) The dependent
child is eligible for health care, regardless of whether any court
order exists, under the same conditions as any dependent of a retired
member.
(3) TAMP eligibles.
A former member, including
his or her dependents, who is eligible under the provisions of the
Transitional Assistance Management Program as described in paragraph
(e) of this Sec. 199.3.
(iv) An unmarried person
who is placed in the legal custody of a member or former member
by a court of competent jurisdiction in the United States (or possession
of the United States) for a period of at least 12 consecutive months.
The unmarried person shall be considered a dependent of the member or
former member under this section provided he or she otherwise meets
the following qualifications:
(A) Has
not reached the age of 21 unless he or she otherwise meets the requirements
of a student set out in paragraph (b)(2)(ii)(H)(1) of this section
or the requirements for being incapacitated as set out in paragraph
(b)(2)(ii)(H)(2) of this section and the incapacitation occurred
while he or she was a dependent of the member or former member through
court ordered legal custody;
(B) Is dependent on
the member or former member for over one-half of the person’s support;
(C) Resides with the
member or former member unless separated by the necessity of military
service or to receive institutional care as a result of disability
or incapacitation or under such other authorized circumstances;
and,
(D) Is not a dependent
of a member or former member under any other provision of law or regulation.
(3) Eligibility
under TRICARE Senior Pharmacy Program.
Section
711 of the National Defense Authorization Act for Fiscal Year 2001
(Public Law 106-398, 114 Stat. 1654) established the TRICARE Senior
Pharmacy Program effective April 1, 2001. To be eligible for this
program, a person is required to be:
(i) Medicare eligible,
who is:
(A) 65 years of age
or older; and
(B) Entitled
to Medicare Part A; and
(C) Enrolled
in Medicare Part B, except for a person who attained age 65 prior
to April 1, 2001, is not required to enroll in Part B; and
(ii) Otherwise qualified
under one of the following categories:
(A) A retired uniformed
service member who is entitled to retired or retainer pay, or equivalent
pay including survivors who are annuitants; or
(B) A dependent of
a member of the uniformed services described in one of the following:
(1) A member
who is on active duty for a period of more than 30 days or died
while on such duty; or
(2) A member who died from an injury, illness,
or disease incurred or aggravated while the member was:
(i) On active
duty under a call or order to active duty of 30 days or less, on
active duty for training, or on inactive duty training; or
(ii) Traveling
to or from the place at which the member was to perform or had performed
such active duty, active duty for training, or inactive duty training.
Note to paragraph (b)(3)(ii)(B): Dependent
under Section 711 of the National Defense Authorization Act for
Fiscal Year 2001 includes spouse, unremarried widow/widower, child,
parent/parent-in-law, unremarried former spouse, and unmarried person
in the legal custody of a member or former member, as those terms
of dependency are defined and periods of eligibility are set forth
in 10 U.S.C. 1072(2).
(4) Medal
of Honor recipients.
(i) A
former member of the armed forces who is a Medal of Honor recipient
and who is not otherwise entitled to medical and dental benefits
has the same CHAMPUS eligibility as does a retiree.
(ii) Immediate
dependents.
CHAMPUS eligible dependents
of a Medal of Honor Recipient are those identified in paragraphs
(b)(2)(i) of this section (except for former spouses) and (b)(2)(ii)
of this section (except for a child placed in legal custody of a
Medal of Honor recipient under (b)(2)(ii)(H)(4) of this section).
(iii) Effective
date.
The CHAMPUS eligibility established
by paragraphs (b)(4)(i) and (ii) of this section is applicable to
health care services provided on or after October 30, 2000.
(5) Reserve
Component Members Issued Delayed-Effective-Date Orders.
(i) Member.
A member of a reserve component
of the armed forces who is ordered to active duty for a period of
more than 30 consecutive days in support of a contingency operation
under a provision of law referred to in section 101(a)(13)(B) of
Title 10, United States Code, that provides for active-duty service
to begin on a date after the date of the issuance of the order.
(ii) Dependents.
CHAMPUS eligible dependents
under this paragraph (b)(5) are those identified in paragraphs (b)(2)(i)
(except former spouses) and (b)(2)(ii) of this section.
(iii) Effective date.
The eligibility established
by paragraphs (b)(5)(i) and (ii) of this section shall begin on
or after November 6, 2003, and shall be effective on the later of
the date that is:
(A) The
date of issuance of the order referred to in paragraph (b)(5)(i)
of this section; or
(B) 180
days before the date on which the period of active duty is to begin.
(iv) Termination
date.
The eligibility established
by paragraphs (b)(5)(i) and (ii) of this section ends upon entry
of the member onto active duty (at which time CHAMPUS eligibility
for the dependents of the member is established under paragraph
(b)(2) of this section) or upon cancellation or amendment of the
orders referred to in paragraph (b)(5)(i) of this section such that
they no longer meet the requirements of that paragraph (b)(5)(i).
(c) Beginning
dates of eligibility.
(1) Beginning
dates of eligibility depend on the class to which the individual
belongs and the date the individual became a member of the class.
Those who join after the class became eligible attain individual
eligibility on the date they join.
(2) Beginning dates
of eligibility for each class of spouse
(excluding spouses
who are victims of abuse and eligible spouses of certain deceased
reservists) are as follows:
(i) A
spouse of a member for:
(A) Medical
benefits authorized by the Dependents’ Medical Care Act of 1956,
December 7, 1956;
(B) Outpatient
medical benefits under the Basic Program, October 1, 1966;
(C) Inpatient medical
benefits under the Basic Program and benefits under
the Extended Care Health Option, January 1, 1967;
(ii) A spouse of a
former member:
(A) For medical benefits
under the Basic Program, January 1, 1967.
(B) Ineligible for
benefits under the Extended Care Health Option.
(iii) A former spouse:
(A) For medical benefits
under the Basic Program, dates of beginning eligibility are as indicated
for each category of eligible former spouse identified within paragraph
(b)(2)(i) of this section.
(B) Ineligible
for benefits under the Extended Care Health Option.
(3) Beginning dates
of eligibility for spouses who are victims of abuse
(excluding
spouses who are victims of abuse of certain deceased reservists) are
as follows:
(i) An abused spouse
meeting the requirements of paragraph (b)(2)(iii)(A)(
1)
of this section, including an eligible former spouse:
(A) For medical and
dental care for problems associated with the physical or emotional
abuse under the Basic Program for a period of up to one year (12
months) following the person’s separation from the Uniformed Service,
November 14, 1986.
(B) For
all medical and dental benefits under the Basic Program for the
period that the spouse is in receipt of transitional compensation
under section 1059 of title 10 U.S.C., October 17, 1998.
(C) For medical and
dental care for problems associated with the physical or emotional
abuse under the Extended Care Health Option for a period up to one
year (12 months) following the person’s separation from the Uniformed
Service, November 14, 1986.
(D) For
all medical and dental benefits described in section 199.5 for the
period that the spouse is in receipt of transitional compensation
under section 1059 of title 10 U.S.C., October 17, 1998.
(ii) An abused spouse
meeting the requirements of paragraphs (b)(2)(iii)(A)(
2)
of this section, including an eligible former spouse:
(A) For all benefits
under the CHAMPUS Basic Program, October 23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(4) Beginning dates
of eligibility for spouses of certain deceased reservists,
including
spouses who are victims of abuse of certain deceased reservists,
are as follows:
(i) A spouse meeting
the requirements of paragraph (b)(2)(i) of this section, including
an eligible former spouse:
(A) For
benefits under the Basic Program, November 14, 1986.
(B) Ineligible for
benefits under the Extended Care Health Option.
(ii) An abused spouse
of certain deceased reservists, meeting the requirements of paragraphs (b)(2)(iii)
of this section, including an eligible former spouse,
for
the limited benefits and period of eligibility described
in paragraphs (b)(2)(iii) of this section:
(A) For benefits under
the Basic Program, November 14, 1986.
(B) For benefits under
the Extended Care Health Option, November 14, 1986.
(iii) An abused spouse
of certain deceased reservists, including an eligible former spouse,
meeting the requirements of paragraphs (b)(2)(iii) of this section:
(A) For benefits under
the Basic Program, October 23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(5)
Beginning
dates of eligibility for each class of dependent children,
(excluding
dependent children of certain deceased reservists, abused children
and incapacitated children whose incapacity occurred between the
ages of 21 and 23 while enrolled in a full-time course of study
in an institution of higher learning), are as follows:
(i) Legitimate child,
adopted child, or legitimate stepchild of a
member,
for:
(A) Medical benefits
authorized by the Dependents’ Medical Care Act of 1956, December
7, 1956;
(B) Outpatient
medical benefits under the Basic Program, October 1, 1966;
(C) Inpatient medical
benefits under the Basic Program and benefits under
the Extended Care Health Option, January 1, 1967;
(ii) Legitimate child,
adopted child or legitimate stepchild of
former members:
(A) For medical benefits
under the Basic Program, January 1, 1967.
(B) Ineligible for
benefits under the Extended Care Health Option.
(iii) Illegitimate
child of a male or female
member or former member whose
paternity/maternity has been determined judicially and the member
or former member has been directed to support the child, for:
(A) All benefits for
which otherwise entitled, August 31, 1972.
(B) Extended Care Health
Option benefits limited to dependent children of members only, August 31,
1972.
(iv) Illegitimate
child of:
(A) A male member or
former member whose paternity has not been determined
judicially:
(B) A
female member or former member who resides with, or in a home provided
by the member or former member, or who was residing in a home provided
by the member or former member at the time of the member’s or former
member’s death, and who is or continues to be dependent on the member for
over one-half of his or her support, or was so dependent on the
member or former member at the time of death;
(C) A spouse of a member
or former member who resides with or in a home provided by the member or
former member, or the parent who is the spouse of the member or
former member or was the spouse of a member or former member at
the time of death, and who is and continues to be dependent upon
the member or former member for over one-half of his or her support,
or was so dependent on the member or former member at the time of
death; for:
(1) All benefits
for which otherwise eligible, January 1, 1969.
(2) Extended
Care Health Option limited to dependent children of members only,
January 1, 1969.
(6) Beginning dates
of eligibility for children of certain deceased reservists who meet
the requirements of paragraph (b)(2)(ii)(H)(3) of this section,
excluding
incapacitated children who meet the requirements of paragraph (b)(2)(ii)(H)(
2)
of this section, for:
(i) Benefits
under the Basic program, November 14, 1986.
(ii) Not eligible for
benefits under the Extended Care Health Option.
(7) Beginning dates
of eligibility for children who are victims of abuse,
including
incapacitated children who meet the requirements of paragraph
(b)(2)(ii)(H)(
2) of this section are as follows:
(i) An abused child
meeting the requirements of paragraph (b)(2)(iii)(A)(
1)
of this section:
(A) Medical and dental
care for problems associated with the physical or emotional abuse
under the Basic Program for a period of up to one year (12 months)
following the person’s separation from the Uniformed Service, November
14, 1986.
(B) For
all medical and dental benefits under the Basic Program for the
period that the child is in receipt of transitional compensation
under section 1059 of title 10 U.S.C., October 17, 1998.
(C) Medical and dental
care for problems associated with the physical or emotional abuse
under the Extended Care Health Option for a period up to one year
(12 months) following the person’s separation from the Uniformed
Service, November 14, 1986.
(D) For
all medical and dental benefits described in section 199.5 for the
period that the child is in receipt of transitional compensation
under section 1059 of title 10 U.S.C., October 17, 1998.
(ii) An abused child
meeting the requirements of paragraphs (b)(2)(iii)(A)(
2)
of this section:
(A) For all benefits
under the CHAMPUS Basic Program, October 23, 1992.
(B) Ineligible for
benefits under the Extended Care Health Option.
(8) Beginning dates
of eligibility for incapacitated children who meet the requirements
of paragraph (b)(2)(ii)(H)(
2) of this section,
whose incapacity occurred between the ages of 21 and 23 while enrolled in
a full-time course of study in an institution of higher learning
approved by the Administering Secretary or the Department of Education,
and, are or were at the time of the member’s or former member’s
death, dependent on the member or former member for over one-half
of their support, for:
(i) All
benefits for which otherwise entitled, October 23, 1992.
(ii) Extended Care
Health Option benefits limited to children of members only,
October 23, 1992.
(9) Beginning
dates of eligibility for a child who meets the requirements of paragraph
(b)(2)(ii)(H)(
4) and:
(i) Has been placed
in custody by a court:
(A) All
benefits for which entitled, July 1, 1994.
(B) Extended Care Health
Option benefits limited to children of members only,
July 1, 1994.
(ii) Has
been placed in custody by a recognized adoption agency:
(A) All benefits for
which entitled, October 5, 1994.
(B) Extended Care Health
Option benefits limited to children of members only,
October 5, 1994.
(iii) Has
been placed in the home of a member by a placement agency or by
any other source authorized by State or local law to provide adoption
placement, in anticipation of the legal adoption of the member:
(A) All benefits for
which entitled, January 6, 2006.
(B) Extended Care Health
Option benefits limited to children of members only, January 6,
2006.
(10) Beginning
dates of eligibility for a retiree for:
(i) Medical benefits
under the Basic Program January 1, 1967.
(ii) Retirees and their
dependents are not eligible for benefits under the Extended Care
Health Option.
(d) Dual
eligibility.
Dual eligibility occurs when
a person is entitled to benefits from two sources. For example,
when an active duty member is also the dependent of another active
duty member, a retiree, or a deceased active duty member or retiree,
dual eligibility, that is, entitlement to direct care from the Uniformed
Services medical care system and CHAMPUS is the result. Since the
active duty status is primary, and it is the intent that all medical
care be provided an active duty member through the Uniformed Services
medical care system, CHAMPUS eligibility is terminated as of 12:01
a.m. on the day following the day the dual eligibility begins. However,
any dependent children in a marriage of two active duty persons
or of an active duty member and a retiree, are CHAMPUS eligible
in the same manner as dependent children of a marriage involving
only one CHAMPUS sponsor. Should a spouse or dependent who has dual
eligibility leave active duty status, that person’s CHAMPUS eligibility
is reinstated as of 12:01 a.m. of the day active duty ends, if he
or she otherwise is eligible as a dependent of a CHAMPUS sponsor.
Note: No CHAMPUS eligibility arises
as the result of the marriage of two active duty members.
(e) Eligibility under the Transitional Assistance
Management Program (TAMP).
(1) A
member of the armed forces is eligible for transitional health care
if the member is:
(i) A
member who is involuntarily separated from active duty.
(ii) A member of a
Reserve component who is separated from active duty to which called
or ordered in support of a contingency operation if the active duty
is active duty for a period of more than 30 consecutive days.
(iii) A member who
is separated from active duty for which the member is involuntarily
retained under 10 U.S.C. 12305 in support of a contingency operation;
or
(iv) A member who is
separated from active duty served pursuant to a voluntary agreement
of the member to remain on active duty for a period of less than
1 year in support of a contingency operation.
(v) A member who receives
a sole survivorship discharge (as defined in section 1174(i) of
this title).
(vi) A
member who is separated from Active Duty who agrees to become a
member of the Selected Reserve of the Ready Reserve of a reserve
component.
(2) A
spouse (as described in paragraph (b)(2)(i) of this section except
former spouses) and child (as described in paragraph (b)(2)(ii)
of this section) of a member described in paragraph (e)(1) of this section
is also eligible for TAMP benefits under TRICARE.
(3) TAMP benefits under
TRICARE begin on the day after the member is separated from active
duty, and, if such separation occurred on or after November 6, 2003,
end 180 days after such date. TRICARE benefits available to both
the member and eligible family members are generally those available
to family members of members of the uniformed services under this
Part. However, during TAMP eligibility, a member of a Reserve Component
as described in paragraph (e)(1)(ii) of this section, is entitled
to dental care to which a member of the uniformed services on active
duty for more than 30 days is entitled. Each branch of service will
determine eligibility for its members and eligible family members
and provide data to DEERS.
(f) Changes in status which result in termination
of CHAMPUS eligibility.
Changes in status which result
in a loss of CHAMPUS eligibility as of 12:01 a.m. of the day following
the day the event occurred, unless otherwise indicated, are as follows:
(1) Changes
in the status of a member.
(i) When
an active duty member’s period of active duty ends, excluding retirement
or death.
(ii) When
an active duty member is placed on desertion status (eligibility
is reinstated when the active duty member is removed from desertion
status and returned to military control).
Note: A member serving a sentence
of confinement in conjunction with a sentence of punitive discharge
is still considered on active duty until such time as the discharge
is executed.
(2) Changes
in the status of a retiree.
(i) When
a retiree ceases to be entitled to retired, retainer, or equivalent
pay for any reason, the retiree’s dependents lose their eligibility
unless the dependent is otherwise eligible (e.g., some former spouses,
some dependents who are victims of abuse and some incapacitated
children as outlined in paragraph (b)(2)(ii)(H)(2)
of this section).
(ii) A
retiree also loses eligibility when no longer entitled to retired,
retainer, or equivalent pay.
Note: A retiree who waives his or
her retired, retainer or equivalent pay is still considered a retiree
for the purposes of CHAMPUS eligibility.
(iii) Attainment of
entitlement to hospital insurance benefits (Part A) under Medicare
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii)
and (f)(3)(ix) of this section.
(3) Changes
in the status of a dependent.
(i) Divorce,
except for certain classes of former spouses as provided in paragraph
(b)(2)(i) of this section and the member or former member’s
own children
(i.e., legitimate, adopted, and judicially determined illegitimate
children).
Note: An unadopted
stepchild loses eligibility as of 12:01 a.m. of the day following
the day the divorce becomes final.
(ii) Annulment, except
for certain classes of former spouse as provided in paragraph (b)(2)(i)
of this section and the member or former member’s
own children
(i.e., legitimate, adopted, and judicially determined illegitimate
children).
Note: An unadopted
stepchild loses eligibility as of 12:01 a.m. of the day following
the day the annulment becomes final.
(iii) Adoption, except
for adoptions occurring after the death of a member or former member.
(iv) Marriage of a
child, except when the marriage is terminated by death, divorce,
or annulment before the child is 21 or 23 if an incapacitated child
as provided in paragraph (b)(2)(ii)(H)(2) of this section.
(v) Marriage of a widow
or widower, except for the child of the widow or widower who was
the stepchild of the deceased member or former member at the time
of death. The stepchild continues CHAMPUS eligibility as other classes
of dependent children.
(vi) Attainment
of entitlement to hospital insurance benefits (Part A) under Medicare
except as provided in paragraphs (b)(3), (f)(3)(vii), (f)(3)(viii),
and (f)(3)(ix) of this section. (This also applies to individuals
living outside the United States where Medicare benefits are not
available.)
(vii) Attainment
of age 65, except for dependents of active duty members, beneficiaries
not entitled to part A of Medicare, beneficiaries entitled to Part
A of Medicare who have enrolled in Part B of Medicare, and as provided
in paragraph (b)(3) of this section. For those who do not retain
CHAMPUS, CHAMPUS eligibility is lost at 12:01 a.m. on the first
day of the month in which the beneficiary becomes entitled to Medicare.
Note: If the person is not eligible
for Part A of Medicare, he or she must file a Social Security Administration,
“Notice of Disallowance” certifying to that fact with the Uniformed
Service responsible for the issuance of his or her identification
card so a new card showing CHAMPUS eligibility can be issued. Individuals
entitled only to supplementary medical insurance (Part B) of Medicare,
but not Part A, or Part A through the Premium HI provisions (provided
for under the 1972 Amendments to the Social Security Act) retain
eligibility under CHAMPUS (refer to Sec. 199.8 for additional information
when a double coverage situation is involved).
(viii) End stage renal
disease. All beneficiaries, except dependents of active duty members,
lose their CHAMPUS eligibility when Medicare coverage becomes available
to a person because of chronic renal disease unless the following
conditions have been met. CHAMPUS eligibility will continue if:
(A) The individual
is under 65 years old;
(B) The
individual became eligible for Medicare under the provisions of
42 U.S.C. 426-1(a);
(C) The
individual is enrolled in Part B of Medicare; and
(D) The individual
has applied and qualified for continued CHAMPUS eligibility through
the Defense Enrollment Eligibility Reporting System (DEERS).
(ix) Individuals with
certain disabilities. Each case relating to Medicare eligibility
resulting from being disabled requires individual investigation.
All beneficiaries except dependents of active duty members lose
their CHAMPUS eligibility when Medicare coverage becomes available
to a disabled person unless the following conditions have been met.
CHAMPUS eligibility will continue if:
(A) The
individual is under 65 years old;
(B) The individual
became eligible for Medicare under the provisions of 42 U.S.C. 426(b)(2);
(C) The individual
is enrolled in Part B of Medicare except that in the case of a retroactive determination
of entitlement to Medicare Part A hospital insurance benefits for
a person under 65 years of age there is no requirement to enroll
in Medicare Part B from the Medicare Part A entitlement date until
the issuance of such retroactive determination; and
(D) The individual
has applied and qualified for continued CHAMPUS eligibility through
the Defense Enrollment Eligibility Reporting System (DEERS).
(x) Disabled students,
that is children age 21 or 22, who are pursuing a full-time course
of higher education and who, either during the school year or between
semesters, suffer a disabling illness or injury with resultant inability
to resume attendance at the institution remain eligible for CHAMPUS medical
benefits for 6 months after the disability is removed or until the
student passes his or her 23rd birthday, whichever occurs first.
However, if recovery occurs before the 23rd birthday and there is resumption
of a full-time course of higher education, CHAMPUS benefits can
be continued until the 23rd birthday. The normal vacation periods
during an established school year do not change the eligibility
status of a dependent child 21 or 22 years old in a full time student
status. Unless an incapacitating condition existed before, and at
the time of, a dependent child’s 21st birthday, a dependent child
21 or 22 years old in student status does not have eligibility and may
not qualify for eligibility under the requirements related
to mental or physical incapacity as described in paragraph (b)(2)(ii)(H)(2)
of this section.
(g) Reinstatement
of CHAMPUS eligibility.
Circumstances which result
in reinstatement of CHAMPUS eligibility are as follows:
(1) End
Stage renal disease.
Unless CHAMPUS eligibility
has been continued under paragraph (f)(3)(viii) of the section,
when Medicare eligibility ceases for end-stage renal disease patients, CHAMPUS
eligibility resumes if the person is otherwise still eligible. He
or she is required to take action to be reinstated as a CHAMPUS
beneficiary and to obtain a new identification card.
(2) Disability.
Some disabilities are permanent,
others temporary. Each case must be reviewed individually. Unless
CHAMPUS eligibility has been continued under paragraph (f)(3)(ix)
of this section, when disability ends and Medicare eligibility ceases,
CHAMPUS eligibility resumes if the person is otherwise still eligible.
Again, he or she is required to take action to obtain a new CHAMPUS identification
card.
(3) Enrollment
in Medicare Part B.
For individuals whose CHAMPUS
eligibility has terminated pursuant to paragraph (f)(2)(iii) or
(f)(3)(vi) of this section due to beneficiary action to decline
Part B of Medicare, CHAMPUS eligibility resumes, effective on the
date Medicare Part B coverage begins, if the person subsequently
enrolls in Medicare Part B and the person is otherwise still eligible.
(h) Determination of eligibility status.
Determination of an individual’s
eligibility as a CHAMPUS beneficiary is the primary responsibility
of the Uniformed Service in which the member or former member is,
or was, a member, or in the case of dependents of a NATO military
member, the Service that sponsors the NATO member. For the purpose
of program integrity, the appropriate Uniformed Service shall, upon
request of the Director, OCHAMPUS, review the eligibility of a specific
person when there is reason to question the eligibility status.
In such cases, a report on the results of the review and any action
taken will be submitted to the Director, OCHAMPUS, or a designee.
(i) Procedures
for determination of eligibility.
Procedures
for the determination of eligibility are prescribed within the Department
of Defense Instruction 1000.13 available at local military facilities personnel
offices.
(j) CHAMPUS procedures for verification of eligibility.
(1) Eligibility for
CHAMPUS benefits will be verified through the Defense Enrollment
Eligibility Reporting System (DEERS) maintained by the Uniformed
Services, except for abused dependents as set forth in paragraph
(b)(2)(iii) of this section. It is the responsibility of the CHAMPUS
beneficiary, or parent, or legal representative, when appropriate, to
provide the necessary evidence required for entry into the DEERS
file to establish CHAMPUS eligibility and to ensure that all changes
in status that may affect eligibility be reported immediately to the
appropriate Uniformed Service for action.
(2) Ineligibility for
CHAMPUS benefits may be presumed in the absence of prescribed eligibility evidence
in the DEERS file.
(3) The
Director, OCHAMPUS, shall issue guidelines as necessary to implement
the provisions of this section.
[64 FR 46135, Aug 24, 1999,
as amended at 66 FR 9654, Feb 9, 2001; 66 FR 16400, Mar 26, 2001;
66 FR 40606, Aug 3, 2001; 67 FR 15725, Apr 3, 2002; 68 FR 23032,
Apr 30, 2003; 68 FR 32361, May 30, 2003; 69 FR 44947, Jul 28, 2004;
69 FR 51564, Aug 20, 2004; 69 FR 60554, Oct 12, 2004; 70 FR 12802,
Mar 16, 2005; 71 FR 31944, Jun 2, 2006; 72 FR 2447, Jan 19, 2007;
73 FR 30478, May 28, 2008; 75 FR 50883, Aug 18, 2010; 76 FR 81367,
Dec 28, 2011; 77 FR 38176, Jun 27, 2012; 80 FR 55254, Sep 15, 2015]