7.0 SURVIVOR QUALIFICATIONS FOR
PURCHASE OF TRR AND TRS COVERAGE
7.1 If a member of the SelRes dies
while in a period of TRS coverage, the eligible surviving family
member(s) may purchase new or continue existing TRS coverage for
up to six months from the date of the member’s death.
7.2 If a member
of the SelRes is not covered by TRS on the date of the member’s
death, his or her surviving dependents do not qualify for TRS survivor
coverage at any time.
7.3 If a Retired Reserve member
dies while in a period of TRR coverage, the eligible surviving family member(s)
may purchase new or continue existing TRR coverage until the date
on which the deceased Retired Reserve member would have attained
age 60.
7.4 If a member of the Retired
Reserve is not covered by TRR on the date of his or her death, his
or her surviving dependents do not qualify for TRR survivor coverage
at any time.
7.5 For both TRS and TRR survivor
qualification, exclusionary criterion involving FEHB under 5 USC
Chapter 89 does not exist.
8.0 COVERAGE REQUESTS
8.1 The TOP
contractor shall perform these services for TRS and TRR members
and survivors, residing outside of the 50 United States (US) or
the District of Columbia.
8.2 The contractor shall only accept
TRS and TRR requests presented from the Government-furnished web-based
self-service enrollment system/application, by phone, by mail, fax,
or at TRICARE Service Centers (TSCs) operated by the TOP contractor.
8.3 To purchase,
change or terminate TRS or TRR coverage, qualified SelRes and Retired
Reserve members, and survivors, must present a completed request
within the following deadlines:
8.3.1 The contractor shall reject
and return incomplete TRS and TRR requests, along with any incorrect premium
payments, to the member or survivor within 10 business days explaining
what is needed for the contractor to accept the request for processing.
8.3.2 If a lockout
is in place, the contractor may accept and process TRS and TRR requests
up to 90 calendar days before the end of the 12-month lockout period
for new coverage to begin after the 12-month lockout period ends.
8.4 The contractor
shall ensure that each of the following requirements are met in
order for a TRS and TRR request to be complete:
8.4.1 The contractor
shall collect a payment equal to two months of monthly premium applicable
for the type of coverage requested for SelRes and Retired Reserve
members purchasing initial TRS or TRR coverage.
8.4.2 The initial
payment may be made with a personal check, cashier’s check, money
order, credit, or debit card (i.e., Visa or MasterCard).
8.4.3 The contractor
shall collect a payment up to three months of premium applicable
for the type of coverage requested for SelRes and Retired Reserve
members purchasing continuous coverage; contingent on the method
and date the request is submitted.
8.4.4 The contractor
shall ensure the request contains account information for collection
of ongoing monthly premium payments by either a Recurring Credit
or Debit Card (RCC) (i.e., Visa or MasterCard) payment or an Electronic
Funds Transfer (EFT).
8.4.5 The contractor is not required
to validate the account information at the time of receipt.
8.5 The contractor
shall accept completed requests for new coverage up to 90 calendar
days before the end of the 12 month lockout period to begin after
the 12 month lock period ends, when a lockout is in effect as specified
in
paragraph 8.15 and its subordinate paragraphs.
8.5.1 Requests
generated from the web application and presented (by mail or in-person)
as a hard copy shall contain an original signature.
8.5.2 Requests
generated from the web application and presented electronically
shall be signed using a validated electronic signature.
8.6 The contractor
shall review all information in the signature block on the applicable
form with the requestor for requests presented verbally on the phone.
(Contact the Contracting Officer (CO) or Contracting Officer Representative
(COR) for a copy of the applicable form.).
8.6.1 The contractor
shall not process the request if the requestor does not agree to
the terms and conditions.
8.6.2 If the
request is for survivor coverage, the statements about “a health
coverage plan under 5 USC 89, specifically Federal Employee Health
Benefit Program (FEHBP)” do not apply.
8.6.3 The contractor
shall document that the requestor agrees or disagrees to the terms
and conditions.
8.6.4 The contractor shall not process
the request if the requestor does not agree to the terms and conditions.
8.7 Open Enrollment
8.7.1 A qualified
member or survivor may purchase TRS or TRR coverage throughout the
year unless locked out from coverage.
8.7.2 The effective
date of coverage is the date the completed request is received by
the contractor or a date up to 90 calendar days in the future as
specified by the requestor as indicated on the TRS and TRR request.
8.8 Continuation Coverage
8.8.1 A qualified
member or survivor may purchase TRS or TRR coverage with an effective
date immediately following the termination of coverage under another
TRICARE program.
8.8.2 The completed TRS and TRR request
required by
paragraph 8.0 must be received by the contractor
by phone, entered into the Government-furnished web-based self-service
enrollment system/application or postmarked no later than 90 calendar
days after the termination of other TRICARE coverage.
8.8.3 If the
qualified member or survivor does not meet the requirement for continuation
coverage, the request will be processed as a new request.
8.8.4 See the
TPM,
Chapter 10, Section 4.1, for information regarding
the Continued Health Care Benefits Program (CHCBP).
8.9 Qualifying Life Events (QLEs)
A qualified SelRes or non-regular
Retired Reserve member may purchase TRS or TRR coverage in connection
with a QLE.
8.9.1 First, qualified SelRes or
non-regular Retire Reserve members are responsible to report all
changes in family composition to military personnel officials who
update DEERS.
8.9.2 Second, the request identifying
the QLE must be received by the contractor or postmarked within
90 calendar days from the date of the QLE. See TPM,
Chapter 10, Section 2.1 for a list of QLEs.
8.10 Survivor
Coverage Under TRS
8.10.1 If a SelRes member dies while
in a period of TRS coverage, the surviving eligible family members
may purchase (or continue) TRS coverage for up to six months from
the date of the member’s death. Except for automatic transfers,
effective dates and deadlines specified in
paragraphs 8.7,
8.8,
and
8.9 apply. The effective date of TRS survivor
coverage is the day after the date of death. Applicable premium
rates are specified in
paragraph 4.0.
8.10.2 If TRS member and family coverage
was in effect on the date of the SelRes member’s death, DEERS will automatically
transfer covered family members to TRS survivor coverage with an
effective date of the day after the date of death and establish
an end eligibility date in DEERS six months from the date of the
SelRes member’s death.
8.10.3 DMDC will notify covered family
members of their continued coverage and their option to terminate coverage,
if so desired, by presenting a completed TRS request as specified
in
paragraph 8.0.
8.10.4 If TRS member-only coverage
was in effect on the date of the SelRes member’s death, DEERS will terminate
coverage with an effective date coinciding with the date of death.
8.10.5 Eligible family members may
purchase coverage by presenting a completed TRS request as specified
in
paragraph 8.0. The TRS request required by
paragraph 8.0 must
be either received by the contractor or postmarked no later than
90 calendar days after the date of death of the SelRes member. DMDC
will notify to survivors of the option to purchase coverage.
8.11 Survivor
Coverage Under TRR
8.11.1 If a Retired Reserve member
dies while in a period of TRR coverage, the surviving family members
may purchase (or continue) TRR coverage until the date on which
the deceased Retired Reserve member would have attained age 60.
Except for automatic transfers specified in
paragraph 8.11.2, effective
dates and deadlines specified in
paragraph 8.7,
8.8,
and
8.9 apply. The effective date of TRR survivor
coverage is the day after the date of death. Applicable premium
rates are specified in
paragraph 4.0.
8.11.2 If TRR member-and-family coverage
was in effect on the date of the Retired Reserve member’s death, DEERS
will automatically transfer covered family members to TRR survivor
coverage with an effective date of the day after the date of death
and establish an end-eligibility date in DEERS that is the date
on which the deceased Retired Reserve member would have attained
age 60.
8.11.3 DMDC will notify survivors
of their continued coverage and their option to terminate coverage,
if so desired, by presenting a completed TRR request as specified
in
paragraph 8.0.
8.11.4 If TRR member-only coverage
was in effect on the date of the Retired Reserve member’s death,
DEERS will terminate coverage with an effective date coinciding
with the date of death. Eligible family members may purchase coverage
by presenting a completed TRR request as specified in
paragraph 8.0.
The TRR request required by
paragraph 8.0 must be either received by the
contractor or postmarked no later than 90 calendar days after the date
of death of the Retired Reservist.
8.11.5 DMDC will notify survivors
advising them of the option to purchase coverage.
8.12 Changes
in TRS And TRR Coverage
Once TRS
or TRR coverage is in effect, members and survivors may request
the following types of changes.
8.12.1 Type
of Coverage Changes
The contractor
shall follow procedures specified in this section for premium adjustments
resulting from changes in coverage. A TRS or TRR member or survivor
may change TRS or TRR type of coverage following procedures for
a QLE stated in
paragraph 8.9.
8.12.2 Addition
Of Family Members to TRS And TRR Coverage
The contractor shall process
additional requests either received or postmarked no later than
90 calendar days after the effective date of coverage for the added
family member(s), pursuant to procedures specified in this section.
8.12.2.1 TRS and TRR members or survivors
may request to add eligible family members to existing TRS or TRR coverage,
once eligibility for the family member is established in DEERS.
8.12.2.2 Eligibility is established
in DEERS by going to a military personnel office and RAPIDS ID card
office who update DEERS.
8.12.3 TRS
And TRR Newborn Or Adopted Child Coverage
8.12.3.1 For newborns or adopted children
added to existing TRS and TRR Member Only coverage, a request to
enroll the newborn or adopted child must be submitted as specified
in
paragraph 8.9; as well as a required monthly
premium payment that equals Member and Family coverage from the
newborn’s or adopted child’s date of birth or adoption.
8.12.3.1.1 The contractor shall pend claims
for the newborn or adopted child prior to receiving the request.
8.12.3.1.2 The contractor shall deny claims
and process the coverage date effective the date the request is received
or postmarked if the request and required monthly premium payment
are not submitted by the 90th calendar day (120 calendar days if
overseas) of the birth or adoption.
8.12.3.2 For newborns or adopted children
added to existing TRS and TRR Member and Family coverage, a request
to enroll the newborn or adopted child must be submitted as specified
in
paragraph 8.9.
8.12.3.2.1 The contractor shall pend claims
for the newborn or adopted child under TRS and TRR Member and Family
coverage.
8.12.3.2.2 The contractor shall deny claims
and process the coverage date effective the date the request is received
or postmarked if the request is not submitted by the 90th calendar
day (120 calendar days if overseas).
8.13 Automatic
Eligibility Updates
DEERS
will automatically update start and end dates of coverage when a
beneficiary’s eligibility is updated by the military services (e.g.,
an adjustment to the effective date of active duty, retirement date
changes, and divorces). The contractor will receive a Government-furnished
policy notification for all changes.
8.14 Processing
8.14.1 The contractor shall process
all TRS and TRR transactions through the Government-furnished web-based
system/application for members or survivors with a residential address
as indicated by the requestor on the TRS and TRR request in the
contractor’s geographic area of responsibility.
8.14.2 The contract shall report premium-related
transactions through the enrollment fee payment interface or Catastrophic
Cap and Deductible (CC&D) Fee Website (see TRICARE Systems Manual
(TSM),
Chapter 3, Section 4.2).
8.14.3 The contractor shall process
completed TRS and TRR requests (see
paragraph 8.0) no later than
10 calendar days after receipt.
8.14.4 The contractor shall process
all TRS and TRR transactions using the Government-furnished web-based system/application
due to one of the following:
• A 90 calendar day future enrollment
limitation;
• DEERS not reflecting eligibility;
or
• Any other Government-furnished
web-based system/application limitation.
8.14.5 The contractor shall notify
the requestor of incomplete requests within 10 business days and
offer to return any premium payments collected to the member, with
an explanation of what is needed for the contractor to accept the
request for processing.
8.14.6 See the TSM,
Chapter 2, Addendum L, for a full list of
TRS and TRR Health Care Delivery Plan (HCDP) coverage code values.
8.15 Termination of TRS And TRR
Coverage
8.15.1 The contractor shall initiate
return of any excess premium amounts paid prorated to the day as indicated
no later than 10 business days after the effective date of the termination
or after receipt of a Government-furnished policy notification of
a termination, whichever is later. Premium refunds, to include an
explanation of the premium refund, will be sent to member’s or survivors
residential address unless an alternate mailing address has been
provided.
8.15.2 The contractor shall also update
DEERS with any premium amount refunded within 30 calendar days and
include an explanation for the premium refund. The following paragraphs
specify if and when a lockout must be applied at the termination
of TRS or TRR coverage. When applied, a lockout shall remain in
effect for 12 months after the last paid-through date.
8.16 Loss
of TRS And TRR Qualification
8.16.1 No lockout shall be applied
for the loss of qualification. At any time a member or survivor
ceases to meet all eligibility qualifications, coverage under TRS
and TRR shall terminate. The effective date of termination for a
member or survivor covered under TRS or TRR coverage shall be the
effective date of the loss of his or her qualification.
8.16.2 If a subsequent change in circumstances
occurs, such as losing eligibility for FEHB, the member may qualify
again to purchase TRS or TRR coverage. Members or survivors may
be eligible to purchase CHCBP coverage (see TPM,
Chapter 10, Section 4.1).
8.16.3 Upon termination of coverage,
DMDC will send a notification to the member or survivor.
8.17 Sponsor Loss of Eligibility
8.17.1 No lockout shall be applied
for sponsor loss of eligibility. When a sponsor’s eligibility is
terminated, coverage under TRS or TRR is also terminated. If a sponsor’s
eligibility is terminated at a date other than the anticipated end
date, DEERS will send the contractor an unsolicited Government-furnished
policy notification advising the contractor of the terminated coverage.
8.17.2 If a sponsor’s eligibility
is restored within 90 calendar days from loss of eligibility, DEERS
will automatically reinstate the TRS or TRR coverage previously
in effect and send the unsolicited Government-furnished policy notification
to the appropriate contractor notifying the reinstated TRS or TRR
coverage.
8.17.3 The contractor shall contact
the sponsor within 10 business days from receipt of an unsolicited Government-furnished
policy notification of reinstated TRS or TRR coverage and collect
all required premiums owed through the current month as outlined
in this section.
8.17.4 The contractor shall terminate
coverage for the sponsor or survivor as appropriate when a sponsor’s eligibility
is terminated at the anticipated end date. Upon termination of coverage,
DMDC will send a notification to the member. DEERS will not send
the contractor an unsolicited Government-furnished policy notification
advising the contractor of the terminated coverage.
8.18 Individual
Family Member or Survivor Loss of Eligibility
8.18.1 No lockout shall be applied
for individual family member or survivor loss of eligibility. If
a family member’s or survivor’s eligibility is terminated at a date
other than an anticipated end date, DEERS will send the contractor
an unsolicited Government-furnished policy notification advising
the contractor of the terminated coverage. When an individual family
member’s or survivor’s eligibility is terminated at the anticipated
end date, DEERS will not send the contractor an unsolicited Government-furnished
policy notification advising the contractor of the terminated coverage.
8.18.2 The contractor shall terminate
coverage for the family member(s) or survivor(s) as described in
this section.
8.18.3 The contractor shall update
the fee system based on the terminated coverage for the family member(s) or
survivor(s) as appropriate. Upon termination of coverage, DMDC will
send a notification to the family member(s) or survivor(s).
8.19 Member
or Survivor Gains Other TRICARE Coverage
8.19.1 No lockout shall be applied
for terminated coverage due to the gain of other TRICARE coverage.
8.19.2 If a TRS or TRR member or survivor
gains other TRICARE coverage for a period of 30 calendar days or less,
TRS or TRR coverage will continue unchanged.
8.19.3 If a TRS or TRR member or survivor
gains other TRICARE coverage for a period of more than 30 calendar days,
DEERS will terminate TRS or TRR coverage in accordance with
paragraph 8.17.
The contractor must be aware of the fact that DEERS may reflect
ADSM and ADFM TRICARE coverage before the member actually reports
for active duty.
8.19.4 If a TRS or TRR member or survivor
gains other TRICARE coverage via a family member, the member and family
members may terminate coverage under TRS or TRR without incurring
a lockout.
8.19.5 Failure to Make A Payment
8.19.5.1 The contractor shall automatically
terminate TRS or TRR coverage of the member or survivor, and all covered
family members and survivors, if the monthly premium payment is
not received by the last day of the month following the due date
for the monthly premium payment by the last day of the month the
monthly premium payment is due.
8.19.5.2 Termination of TRS or TRR coverage
is to occur the next day from the last day of the immediate, previous
month, with a termination effective date retroactive to the last
paid-through-date. Failure or refusal to pay monthly premiums or
any outstanding insufficient funds fees in accordance with the procedures
in this section shall result in termination of coverage and a lockout
shall be applied as specified in this section.
8.19.5.3 Failure to provide information
to establish or maintain a recurring EFT or RCC for monthly premium payments
will result in coverage being terminated for failure to comply with
requirements in this section.
8.19.5.4 DMDC will send a written notification
of the termination, the effective date, the reason, and the lockout
from the last paid-through date to the TRS or TRR member or survivor.
8.19.5.5 The contractor shall pend any
claims received for health care furnished to the TRS or TRR member, family
members, or survivors during the period for which premiums have
yet to be paid, until the termination action is processed, to avoid
creating recoupment of health care costs for ineligible beneficiaries.
The TRS or TRR member, family members, or survivors will be responsible
for the cost of any health care received after the termination effective
date.
8.19.5.6 The contractor shall initiate
recoupment of health care costs following the procedures in
Chapter 10, Section 2 if claims are not pended.
8.19.6 Request
for Voluntary Termination
8.19.6.1 The contractor shall apply
a lockout as specified in this section for voluntary termination
requested by the member or survivor. DMDC sends written notification
of the termination, the effective date, the reason, and the lockout
period from the last paid-through date.
8.19.6.2 The contractor shall accept
requests for termination of coverage from members, survivors, or individual
family members at any time. Termination of coverage requests includes
those with:
• An original signature;
• An electronic signature offered
by and collected by the contractor;
• A verbal consent provided via
telephone and documented in the contractor’s call notes; or
• A self-attestation by the beneficiary
when using the Government-furnished web-based self-service enrollment/application
system.
8.19.6.3 The effective date of termination
is either the last day of the month in which the request was postmarked
or received by the contractor or the last day of a future month
as specified in the request, if the request was postmarked or received
by the contractor in the month preceding the requested month of
termination.
8.19.7 Canceled Eligibility and Enrollment
8.19.7.1 No lockout shall be applied
for a canceled enrollment.
8.19.7.2 The contractor shall notify
the covered member or survivor of the cancellation and refund any unused
portion of the premium payment when the contractor receives a Government-furnished
policy notification for a canceled enrollment.
8.19.7.3 The contractor shall update
DEERS with any premium amount refunded within 30 calendar days.
8.19.7.4 The contractor shall recoup
claims for the canceled enrollment period.
8.19.8 TRS
And TRR Survivor Coverage Termination
8.19.8.1 If TRS or TRR coverage is continued
as described in
paragraphs 8.10.2 and
8.10.3 and
the survivors do not wish to keep the coverage, the survivors must
submit a request, in accordance with procedures described in
paragraphs 8.10.2 and
8.10.3,
to be received by the contractor no later than 90 calendar days
after the date of death in order to terminate coverage retroactive
to the day after the member’s death. Otherwise, DEERS will terminate TRS
survivor coverage six months after the date of the SelRes member’s
death and terminate TRR survivor coverage on the date the Retired
Reserve member would have attained age 60.
8.19.8.2 The contractor shall process
refunds of premiums as specified in this section.
8.19.9 Exceptions
8.19.9.1 Administrative
Issues
The GDA
or his or her designee will notify the contractor when the Government
determines that an administrative situation (i.e., delay in RC personnel
transaction) occurred that prevented a SelRes or Retired Reserve
member’s or survivor’s request to enroll from being accepted for
processing according to submission deadlines specified in this section.
8.19.9.2 Reinstatement
of Terminated TRS And TRR Coverage (Retroactive Coverage)
8.19.9.3 The contractor shall accept
the request from a qualified member or survivor to reinstate terminated TRS
or TRR coverage retroactive to the last paid-through date with no
justification needed if the request meets all of the following conditions:
• The request is received by
the contractor or postmarked no later than the first business day
of the fourth month after the paid-through date;
• Payment of all premiums from
the last paid-through date through the current month, plus the amount
required from the contractor to reestablish EFT or RCC monthly premium
payments is included (to include any administrative fees); and
• Information is provided to
establish recurring electronic premium payments as specified in
this section.
Note: If the member or survivor contacts
the contractor via telephone for reinstatement of previous coverage, up
to three months of additional premiums are required as determined
by the contractor to reestablish EFT or RCC monthly premium payments
(plus any administrative fees).
8.19.9.4 The contractor shall reject
the request to reinstate coverage retroactively if any of the conditions above
are not met and inform the member or survivor of his or her option
to purchase new coverage after the 12-month lockout period.
9.0 PREMIUM COLLECTION
The contractor shall perform
all premium collection functions required for TRS and TRR. SelRes
members, Retired Reserve members or survivors are responsible for
all premium payments for the type of coverage elected (i.e., TRS or
TRR member-only or TRS or TRR member and family). After enrollment,
only monthly, automated premium payments of an RCC or EFT are permitted.
Premium related transactions shall be reported through the enrollment fee
payment interface or CC&D Fee Web (see TSM,
Chapter
3).
9.1 Jurisdiction
for Premium Collection
9.1.1 The contractor shall perform
premium collection functions for the TRS or TRR member or survivor
if servicing the residential address for the TRS or TRR member or
survivor.
9.1.2 The contractor shall identify
the financially responsible individual for survivor plans from the
survivors actually covered by TRS or TRR in descending order of
precedence:
• Spouse;
• Oldest enrolled child; or
• Legal guardian, as applicable.
9.1.3 The contractor
shall upon noticing that a new residential address is in another
TRICARE contractor’s geographical area of responsibility, notify
the TRS or TRR members or survivor within 10 calendar days they
need to contact the contractor in their new residence to transfer
coverage and automated, monthly premium payment method to the new
geographical area of responsibility.
9.1.3.1 A TRS and TRR member or survivor
may elect to provide an alternate mailing address, but the servicing
contractor shall be based on the TRS or TRR members or financially
responsible survivor’s residential, not alternate mailing address.
Any TRS or TRR member or financially responsible survivor may transfer
responsibility at any time.
9.1.3.2 The gaining contractor shall
perform the premium collections for future payments.
9.1.4 The contractor
shall review all unsolicited Policy Notification Transactions (PNTs)
for TRS and TRR members or survivors to determine if residential
address changes require a notification to the TRS or TRR member or
survivor (see
paragraphs 9.1.3.1 and
9.1.3.2).
9.2 Premium Collection Processes
The contractor shall credit
the TRS or TRR member or survivor for premium payments received.
9.2.1 The contractor
shall include, in the first payment collected, the prorated amount
on a daily basis necessary to synchronize billing to the last day
of the month when a coverage start date is other than the first
of the month. The daily prorated amount shall be equal to 1/30th
of the appropriate premium (rounded to the penny) regardless of
how many days are actually in the month. DEERS will automatically
prorate the premium due for mid-month enrollments from the effective
date of coverage to the end of that first enrollment month, e.g.,
from the 18th of the month to the 31st.
9.2.2 The contractor
shall collect monthly premium payments from TRS and TRR members
or survivors as appropriate and report the premium amount paid for
those payments to DEERS (see TSM,
Chapter
3), including any overpayments that are not refunded to
the TRS or TRR member or survivor.
9.2.3 In the
event that there are insufficient funds to process a premium payment,
the contractor may assess the account holder a fee of up to $20
US dollars, which is retained by the contractor.
9.2.4 The contractor
shall provide commercial payment methods for TRS and TRR monthly
premiums that best meet the needs of beneficiaries while conforming
to
paragraphs 9.2.5 through
9.2.11.2.
9.2.5 The contractor shall advise
TRS and TRR members or survivors at the time of EFT or RCC election
that an insufficient funds fee of up to $20 US dollars may be assessed
if sufficient funds are not available.
9.2.5.1 Monthly premiums must be paid
through an automated, recurring electronic payment through EFT or
RCC (i.e., Visa or MasterCard) from a designated financial institution.
These are the only acceptable payment methods for the recurring
monthly premiums.
9.2.5.2 The contractor shall process
an EFT or RCC payment within the first five business days of the
month of coverage.
9.2.6 TRS and
TRR members or survivors must make the required initial payment
(as specified in
paragraphs 9.2.7 through
9.2.11.2)
at the time the TRS or TRR request is submitted to allow time for
the EFT or RCC to be established for subsequent monthly premium
payments.
9.2.7 The contractor
shall establish recurring monthly EFTs or RCCs and is responsible
for obtaining and verifying the information necessary to do so.
9.2.8 The contractor
shall initiate action to modify EFT or RCC payment amounts to support
premium changes.
9.2.9 The contractor shall grant
the TRS or TRR member or survivor 90 calendar days after the paid-through date,
to provide information for a new automated monthly premium payment
method when an administrative issue arises that stops or prevents
an automated monthly premium payment from being received by the
contractor (e.g., incorrect or transposed number provided by the
beneficiary, credit card expired, or bank account closed).
9.2.10 The contractor may accept payment
in accordance with
paragraph 8.0 during this 90 calendar day period
in order to preserve the TRS or TRR member’s or survivor’s enrollment
status.
9.2.11 The contractor shall directly
bill the TRS or TRR member or survivor only when a problem occurs
in setting up or maintaining the EFT or RCC payment; to include
a fee of up to $20 US dollars due to insufficient funds.
9.2.11.1 The contractor may send bills
to the residential or alternate mailing address designated by the
TRS or TRR member or survivor. All bills shall specify the premium
payment is due for receipt by the contractor no later than the last
business day of the month. Premium payments shall be made payable
to the contractor servicing the member’s or survivor’s coverage
as specified in
paragraph 9.1.
9.2.11.2 The contractor shall terminate
billing once the problem with EFT or RCC payment is resolved.
9.3 Annual
Premium Adjustment
9.3.1 The contractor shall notify
current TRS and TRR members or survivors in writing of any annual
premium adjustments no later than 30 calendar days after the contractors
receive notification of the updated premiums.
9.3.2 The Government
will provide instructions to the contractors regarding notification
of TRS and TRR members or survivors for premium adjustments that
go into effect at any time other than January the first.
9.4 Premium
Adjustments from Changes Associated with QLEs
9.4.1 When a
QLE is processed that changes the premium, the effective date of
the premium change shall be the date of the QLE.
9.4.2 The contractor
shall notify the TRS or TRR member or survivor of the increase and
adjust the next premium amount due if the change from a QLE results
in any monthly premium increase and adjust the next monthly premium
amount due. This notification shall include any underpaid amount
(prorated to the day as specified in
paragraph 9.2) to the effective
date of the change.
9.4.3 The contractor shall retain
any overpaid monthly premium amount and apply it to subsequent monthly,
electronic premium payments until all of the overpayment is exhausted
if the change from a QLE results in a decrease in the premium.
9.5 Terminations
The contractor shall initiate
the process to refund any premium amounts applied for coverage after
the date of termination as specified in
paragraph 8.15.
9.6 Online
Transactions
In addition
to requirements specified in
paragraph 9.0 and its subordinate paragraphs,
the contractor may provide on-line capability for TRS and TRR members
or survivors to conduct business related to monthly premium collection
and other applicable administrative services through secure access
to the contractor’s website.
10.0 CLAIMS PROCESSING
10.1 The contractor
shall process TRS and TRR claims under established TRICARE Select
cost-sharing rules and guidance. Normal TRICARE Other Health Insurance
(OHI) processing rules apply to TRS and TRR.
10.2 The contractor
shall pend all claims for health care provided to a newborn or adopted
child of a TRS or TRR member or survivor until the member or survivor
completes the process specified in the TPM,
Chapter
10.
10.2.1 For Member Only coverage at
time of claims received, and a request to enroll a newborn or adopted child
and required premium payment that equals Member and Family coverage
are not submitted within 90 calendar days from date of birth or
adoption.
10.2.2 The contractor shall deny all
claims and process any subsequent claims from the date a request
and premium payment are received or postmarked.
10.2.3 For Member and Family coverage
at time of claims received, and a request to enroll a newborn or adopted
child is not submitted within the 90 calendar days from date of
birth or adoption. The contractor shall deny all claims and process
any subsequent claims from the date a request is received or postmarked.
10.3 The contractor
shall notify the TRS or TRR member or survivor of the requirement
to register the newborn or adopted child in DEERS and submit a TRS
or TRR request for the newborn or adopted child no later than 90 calendar
days (120 calendar days if overseas) after birth or custody if the
contractor becomes aware that a TRS or TRR member or survivor has
an unregistered newborn or new child.
10.4 Monthly
premium payments made for TRS and TRR coverage shall not be applied
to the calendar year deductible or catastrophic cap limit.
10.5 The contractor
shall follow procedures established in
Chapter 8, Section 2,
regarding claims jurisdiction for dual eligible, in regards to Medicare
coverage. Medicare is the primary payer for TRICARE beneficiaries
who are eligible for Medicare. Claims under the TRICARE Medicare
Eligible Program (TMEP) will be adjudicated under the rules set
forth in the TRM,
Chapter 4, Section 4. Payment of Medicare
Part B premiums does not provide a basis to waive TRS and TRR monthly
premiums.
10.6 The contractor shall initiate
recoupment of claims paid, if appropriate, as specified in
Chapter
10, if the contractor receives a Government-furnished
policy notification of a retroactive TRS or TRR disenrollment.
10.7 The contractor
shall report any discovery that a SelRes or Retired Reserve member
may be eligible for or enrolled in the FEHBP to the appropriate
GDA or his or her designee no later than three business days after discovery.
Discovery may be through self-attestation from a TRS/TRR sponsor
or via receipt of an OHI claim form where the TRS/TRR sponsor is
listed as the Primary on a FEHBP. As applicable, loss of TRS and
TRR qualification procedures should be followed pursuant this section
as directed by the GDA.