1.0 CONTINUED HEALTH CARE BENEFIT
PROGRAM (CHCBP)
1.1 The CHCBP is a health care
program that allows certain groups of former Military Health System
(MHS) beneficiaries to continue receiving health care coverage when
they lose eligibility for military health care under the TRICARE
programs. This temporary health program is supported by premium
revenue collected from the participants in the program.
1.1.1 The Managed
Care Support Contractor (MCSC) for the East geographic area of responsibility
(herein referred to as the ‘CHCBP contractor’ unless otherwise specified)
shall provide all services necessary to support the CHCBP as outlined
in
32 CFR 199.20.
Other references describing the CHCBP that are to be used by the
CHCBP contractor in fulfilling its responsibilities are applicable
sections of this manual and the TRICARE Policy Manual (TPM), TRICARE
Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), and the
Federal
Register dated September 30, 1994 (pg. 49817ff), February
11, 1997 (pg. 6225ff), February 24, 1997 (pg. 8312), and September
16, 2011 (pg. 57637ff).
1.1.2 The CHCBP contractor shall
perform these functions for CHCBP beneficiaries on a worldwide basis, irrespective
of the geographic area in which the beneficiary resides or the area
in which health care services are received.
1.1.3 The CHCBP
contractor shall adhere to the following requirements for those
areas in which the CHCBP instructions and processing requirements
are different than TRICARE.
1.1.4 CHCBP
is not part of the TRICARE Program.
1.2 The legislative
basis for the program is Section 4408 of the National Defense Authorization
Act (NDAA) of 1993 (Public Law 102-484) which added Section 1078a
to Chapter 55 of 10 United States Code (USC).
1.2.1 Beneficiaries
who may be eligible to purchase the continued health program after
eligibility for coverage ends under a health benefits plan under
10 USC Chapter 55 or 10 USC § 1145(a) are described in 10 USC § 1078a.
1.2.2 For those
covered under premium-based TRICARE health benefits plans (e.g.,
TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), and
TRICARE Young Adult (TYA)) such coverage must have been purchased and
in place the day before the loss of eligibility.
2.0 VALIDATE
ELIGIBILITY FOR CHCBP
2.1 The CHCBP contractor shall
validate eligibility on the Defense Enrollment and Eligibility Reporting System
(DEERS) upon receipt DD Form 2837, CHCBP Application, from a prospective
beneficiary.
2.2 The CHCBP contractor shall
contact the applicant if additional documentation is required to
validate CHCBP eligibility.
2.3 The CHCBP
contractor shall request supporting documentation from the applicant
depending on the category of individual who is applying for enrollment:
2.3.1 Individual
Uniformed Service sponsor (herein referred to as “sponsor”) and
his or her family: a copy of the DD Form 214, Certificate of Release
or Discharge from Active Duty, or a copy of the sponsor’s active
duty orders.
2.3.2 Unremarried Former Spouse (URFS)
and stepchildren of the sponsor: a copy of the final divorce decree.
2.3.3 Child
who loses TRICARE coverage due to marriage: a copy of marriage certificate.
2.3.4 Child who loses TRICARE coverage
on his or her 21st birthday (age 23 if enrolled in a full-time course
of study at an approved institution of higher learning and dependent
on the uniformed service sponsor for more than half of his or her
financial support) a copy of the front and back of the Uniformed
Services identification (ID) card.
2.3.5 Child
who loses TRICARE coverage due to college graduation: a copy of
college transcript.
2.3.6 Child over the age of 21 and
before the age of 23 who loses TRICARE coverage when no longer enrolled in
a full-time course of study at an approved institution of higher
learning or no longer dependent on the uniformed service sponsor
for more than half of his or her financial support: a letter from
the institution of higher learning stating the student’s status
or a written statement from the dependent that he or she is no longer dependent
on the uniformed services sponsor for more than half of his or her
financial support.
2.3.7 Child
that was previously placed in sponsor’s legal custody and then loses
TRICARE coverage a copy of the court order.
Note: Children who lose TRICARE coverage
under
paragraphs 2.3.4 through
2.3.7 may
qualify to purchase TYA coverage until reaching the age of 26 (see
Chapter
25). If qualified to purchase TYA coverage, the child
cannot purchase CHCBP as an individual. If the child does not qualify
to purchase TYA because he or she qualifies for employer sponsored
coverage, he or she is ineligible to purchase CHCBP.
2.3.8 If TYA
coverage was terminated due to eligibility for employer-sponsored
health care coverage based on his or her own employment or failure
to pay TYA premiums, then the child is not eligible to purchase
CHCBP coverage (see
Chapter 25).
2.3.9 The CHCBP
contractor shall request information needed to verify eligibility
for any other situations in which an individual loses TRICARE coverage
and may potentially be eligible for CHCBP.
2.4 Family
Members Not Identified On DEERS
2.4.1 The CHCBP contractor shall
take the following action upon receipt of a CHCBP claim which includes
a family member not identified on DEERS as enrolled, but the sponsor
indicates CHCBP family coverage:
• If the claim includes a copy
of an appropriately marked CHCBP coverage card for the beneficiary,
the claim is to be processed.
• If the claim is for a beneficiary
who is less than 60 calendar days old, the claim is to be processed,
even if no copy of a CHCBP coverage card is attached as long as
at least one member of the sponsor’s family is currently enrolled
in CHCBP. In all other cases, the claim is to be denied.
2.4.2 In order
to be enrolled in the CHCBP, the beneficiary will be disenrolled
from any TRICARE programs in which enrolled. This will require no
action on the beneficiary’s part.
2.5 Disputes
Regarding Enrollment
2.5.1 The CHCBP contractor shall
confirm a person’s eligibility as a CHCBP beneficiary.
2.5.2 Disputed
questions of fact concerning a beneficiary’s eligibility will not
be considered an appealable issue, but must be resolved with the
appropriate Uniformed Service.
2.5.3 The CHCBP
contractor shall deny applications in writing within 10 business
days of the reason for the denial under the following circumstance:
if the contractor determines the applicant does not appear eligible
due to an ineligible response from DEERS (i.e., no history segments
or record of previous Department of Defense (DoD) entitlement) or
failure of the applicant to provide the documentation requested
to verify eligibility.
3.0 APPLICATION
PERIOD AND PREMIUMS
3.1 CHCBP Application Period
3.1.1 The CHCBP
contractor shall deny any applications received after a 60 calendar
day period, beginning the day following the end date of the beneficiary’s
eligibility for TRICARE coverage.
3.1.2 The CHCBP
contractor shall apply the following business rules when determining
the start of the 60-calendar day application period.
3.1.3 Members
and Former Members, Their Families, and Other Individuals Losing
TRICARE Coverage
3.1.3.1 The Government routinely notifies
beneficiaries prior to their loss of TRICARE coverage; Active Duty Service
Members (ADSMs) are notified of the CHCBP during out processing;
other beneficiaries who lose TRICARE coverage are notified by the
DMDC in writing of the availability of the CHCBP.
3.1.3.2 The CHCBP contractor shall
forward documentation to the Government Designated Authority (GDA) if
an eligible beneficiary advises the contractor that he or she was
not notified of this program and submits documentation to support
their position.
3.1.3.3 The GDA will provide direction
on the start date of the 60 calendar day application period.
3.1.4 URFSs
The CHCBP contractor shall
process all applications from URFS upon receipt as no formal mechanism
is established to promptly identify URFS that may qualify for this
program.
3.2 Coverage Categories
3.2.1 CHCBP
offers two coverage categories:
• Individual coverage is available
to the member or former member, an URFS, an adult child, a surviving
spouse, or other qualified individuals, and
• Family coverage is only available
to the member or former member and his or her dependents.
3.2.2 Dependents
cannot be covered under family coverage unless the member or former
member is also covered by family coverage.
3.3 CHCBP
Application
3.3.1 The CHCBP contractor shall
accept DD Form 2837, CHCBP application, as the application form
for CHCBP coverage.
3.3.2 The CHCBP contractor shall
use the latest version should DD Form 2837 be revised or renumbered
in the future.
3.4 Dates of Coverage & Premiums
3.4.1 Coverage
will begin the day following the beneficiary’s loss of TRICARE coverage
and will end the last day of premium coverage.
3.4.2 Due to
the documentation requirements for purchasing coverage, most coverage
will be retroactive; however, there may be some coverage that will
be prospective.
3.4.2.1 Prospective coverage must be
accompanied by a premium payment for one quarter.
3.4.2.2 Retroactive coverage must be
accompanied by full premium payment retroactive to the effective date
of coverage through the end coverage date in the quarter in which
the individual is applying.
3.4.3 Premiums
are as stated in
paragraph 3.5 of these instructions.
Examples of the premiums required
for retroactive and prospective coverage:
|
|
MILITARY Benefits End
|
APPLICATION RECEIVED
|
QUARTERS OF PREMIUM DUE
|
CHCBP COVERAGE
|
|
Example 1:
|
10/01/2020
|
11/15/2020
|
1 quarter
|
10/02/2020
|
|
Example 2:
|
09/15/2020
|
02/10/2021
|
2 quarters
|
09/16/2020
|
|
Example 3:
|
11/05/2020
|
10/01/2020
|
1 quarter
|
11/06/2020
|
|
Example 4:
|
03/01/2021
|
11/01/2020
|
1 quarter
|
03/02/2021
|
3.5 Premium
Rates
3.5.1 The amount of the CHCBP premiums
will be established by the Government and may be adjusted each fiscal
year.
3.5.2 The CHCBP contractor shall
begin charging the adjusted quarterly premiums on the date specified
in
Addendum A.
3.5.3 The CHCBP
contractor shall issue a written notice to the beneficiary of the
changes in premium amounts, to include the effective date of the
change upon receipt of adjusted rates from the Government.
3.5.4 This notification
should be done at least 30 calendar days prior to the effective
date directed by the Contracting Officer (CO).
3.5.5 The CHCBP
contractor shall issue a written notice to the beneficiary of changes
in the coverage category and premium amount, including the effective
date of the changes, within 10 business days of receiving such information.
3.5.6 When qualifying
events occur that change the sponsor from individual to family coverage
or vice-versa, coverage and premiums shall be changed effective
with the date of the qualifying event.
3.6 Forms
of Payment
3.6.1 The CHCBP contractor may propose
additional payment mechanisms to include electronic processes for
premium payments. Checks, money orders, or credit cards are allowable
forms of payment for CHCBP beneficiaries to use in paying their
premiums.
3.6.2 Proposed electronic processes
shall maintain the integrity and security of the application processes which
includes important documentation required to validate eligibility
for CHCBP.
3.6.3 The CHCPB contractor shall
accept VISA and MasterCard® for credit card payments, but is not
required to accept additional nationally recognized major credit
cards as a form of premium payment.
3.6.4 The CHCBP
contractor shall not accept premiums submitted by, or on behalf,
of a health care provider for any beneficiary other than: (1) the
provider him or herself, and (2) a member of the provider’s immediate
family.
3.6.4.1 The CHCBP contractor shall
return a provider submitted payment to the provider with a written notice
advising the provider that submission of premium payments by health
care providers is prohibited.
3.6.4.2 The CHCBP contractor shall
send a copy of the letter to the beneficiary.
3.6.4.3 The CHCBP contractor shall
submit documentation of this action to the Defense Health Agency
(DHA) Program Integrity (PI) Office to include the following:
• A copy of contractor’s notification
to the provider.
• Copy of front and back of premium
(money order or check).
• Originals of all documentation
submitted by the provider (to include mailing envelope).
• Documentation of all conversations
and communications the CHCBP contractor had with the provider on
the subject of paying premiums.
• Other information that the
CHCBP contractor has in its files or records concerning the provider
that might be of assistance in Government follow-up action on this
issue.
3.7 Insufficient
Funds
3.7.1 The CHCBP contractor shall,
in the case of insufficient funds, issue a written notice to the
applicant (for initial applications) or beneficiary (in the case
of renewal premiums) within three business days, advising the applicant
or beneficiary of the insufficient funds, the amount of the premium
due, and the date by which a valid premium must be received by the
CHCBP contractor.
3.7.1.1 For initial application requests,
the notice shall also advise the beneficiary that if premium payment
is not received in full by the due date (the last day of the 60-calendar
day application period), the applicant will not be covered in CHCBP.
3.7.1.2 For renewals, the notice shall
advise the beneficiary that if the CHCBP contractor does not receive valid
payment in full within 30 calendar days of the date of the contractor’s
letter, the coverage will be terminated. That notice shall also
provide the effective date of termination if payment is not received.
3.7.2 The CHCBP
contractor shall terminate the CHCBP coverage and issue a written
Termination Notice (TN) to the beneficiary confirming the termination
of coverage if the premium payment has not been received by the CHCBP
contractor within the specified time frame.
3.7.3 The CHCBP
contractor may assess the CHCBP applicant or purchaser a fee of
up to $20 US dollars ($20.00), which is retained by the CHCBP contractor,
in the event that there are insufficient funds to process a premium
payment.
3.8 Refunds
3.8.1 The CHCBP
contractor shall refund premiums if the applicant is no longer eligible
for CHCBP coverage, i.e., beneficiary regains TRICARE eligibility;
ex-spouse remarries; death of beneficiary; prospective member who
has prepaid premium but fails to provide required eligibility documentation;
and sponsor change in coverage from family to individual.
3.8.2 Voluntary
termination because the beneficiary obtained Other Health Insurance
(OHI) does not constitute grounds for a refund of unused premiums.
3.8.3 The CHCBP
contractor shall prorate refunds from the date of loss of eligibility
for program benefits through the last coverage date for which the
premium was paid when refunds are appropriate.
3.9 Limits
of CHCBP Coverage
The length
of a beneficiary’s CHCBP coverage varies according to the category
of individual. Coverage lengths and categories are listed in the
TPM,
Chapter 10, Section 4.1, Figure 10.4.1-1.
3.10 Processing
Applications
3.10.1 The CHCBP contractor shall
enter CHCBP enrollment into DEERS through the applicable on-line interface
once the CHCBP contractor has verified eligibility and approved
the application request.
3.10.1.1 As DEERS does not allow individuals
to be added to a sponsor’s record after the sponsor’s TRICARE coverage
ends, there will be a small number of CHCBP beneficiaries that the
contractor cannot complete the CHCBP enrollment in DEERS.
3.10.1.2 The majority will be newborns
whose birth occurred after the sponsor’s TRICARE coverage ends,
but there will occasionally be other beneficiaries as well.
3.10.1.3 The contractor should not rely
on DEERS as being the sole determinant of whether or not an individual
is eligible for CHCBP coverage as these individuals would not be
reflected on DEERS (refer to
paragraph 2.0).
3.10.2 The CHCBP contractor shall
ensure that its system can accurately accommodate these unique cases
in which the beneficiary is covered under CHCBP but not reflected
on DEERS to ensure these beneficiaries are provided with all required
CHCBP benefits and accurate processes (e.g., claims processing,
issuing authorizations, accessing services).
3.10.3 DEERS will not allow a CHCBP
enrollment to be entered if the sponsor or dependents are still
showing as eligible for TRICARE coverage. In these cases:
3.10.3.1 The CHCBP contractor shall
pend the application and advise the applicant in writing for the
sponsor to contact the nearest Uniformed Services ID card issuing
office (Real-Time Automated Personnel Identification System (RAPIDS))
to rectify the situation.
3.10.3.2 The CHCBP contractor shall
complete the processing of the application when DEERS has been updated
to reflect that the sponsor or dependents are no longer eligible
for services under TRICARE.
3.10.4 The CHCBP contractor shall
issue the beneficiaries a CHCBP coverage ID card within 10 business
days once the application has been fully processed. The card provides
the beneficiaries with (1) confirmation that the individual is covered
and the effective dates; and (2) documentation that the beneficiary
on how to access health care services.
3.10.4.1 The card shall contain sufficient
information to facilitate access to health care. Coverage dates
on the card shall be limited to those dates for which a valid quarterly
premium has been received by the contractor.
3.10.4.2 The CHCBP contractor shall
issue cards each quarter for all subsequent quarterly payments received by
the contractor.
3.10.4.3 The card shall reflect that
coverage is for the CHCBP and including but not limited to the contractor’s name,
address, toll-free telephone number, and claims center mailing address.
3.10.5 The CHCBP contractor shall
issue a letter to the applicant confirming CHCBP coverage (including
the dates of coverage) within 10 business days once an application
has been fully processed.
3.10.6 The letter shall advise the
beneficiary of the requirements that must be met for continued coverage
in the program, including information regarding future contractor
billings and premium payments that the beneficiary will be required
to make.
3.10.7 The CHCBP contractor shall
issue either a CHCBP coverage policy or such other sufficient written information
regarding the CHCBP for beneficiaries’ reference should they have
any questions regarding benefits and program requirements.
3.11 Coverage
And Renewals
3.11.1 The CHCBP contractor shall
mail initial premium renewal notices to beneficiaries no later than
30 calendar days before the expiration of the coverage.
3.11.2 The CHCBP contractor shall
not routinely query DEERS for renewal coverages and quarterly billings
as the beneficiary’s coverage in CHCBP is based on the documentation
that the applicant submits to verify eligibility.
3.11.3 The CHCBP contractor shall
assume that the individual continues to meet the requirements for
CHCBP absent information or evidence to the contrary.
3.11.3.1 The CHCBP contractor’s renewal
notices shall clearly specify the premium amount due, the date by which
the premium must be received, and the mailing address to which the
premium payment must be sent.
3.11.3.2 The CHCBP contractor’s renewal
notices shall specify that failure to submit the premium due will result
in denial of continued coverage and termination from the program.
3.11.4 The CHCBP contractor shall
provide a 30 calendar day grace period following the premium due
date in which the beneficiary may submit his or her premium and
continue benefits with no break in coverage.
3.11.5 The CHCBP contractor shall
issue a second renewal notice to the beneficiary within 10 business
days of the start of the grace period if the premium is not received
following the initial renewal notice to the beneficiary requesting
premium for the next quarter.
3.11.5.1 The CHCBP contractor’s second
renewal notice shall indicate that this is the second and final
billing notice and that if payment is not received by the due date
specified in the notice, that CHCBP coverage will be terminated
as of that date.
3.11.5.2 The CHCBP contractor’s notice
shall advise the beneficiary that if coverage is terminated due
to nonpayment of premium, he or she will be permanently locked-out
of CHCBP.
3.11.6 The CHCBP contractor shall
terminate the beneficiary’s coverage in CHCBP and send a TN to the beneficiary
confirming the termination within 10 business days, to include the
effective date and basis for the termination if the premium is not
received by the end of the grace period.
3.11.7 The CHCBP contractor shall
enter all CHCBP terminations into DEERS.
3.11.8 Beneficiaries who desire to
voluntarily withdraw from the CHCBP prior to the end of their paid
up period shall send a written request to the contractor. Beneficiaries
who voluntarily disenroll from the CHCBP are not permitted to re-enroll
until they gain and then once again lose TRICARE coverage. Refund
of unused premiums is only allowed for items covered in
paragraph 3.8.
3.11.9 The CHCBP contractor shall
issue a TN to the beneficiary following his or her termination from
the CHCBP within 10 business days from the termination date and
upon request up to 24 months after the termination date, unless
the beneficiary has re-established TRICARE coverage.
3.11.10 The CHCBP contractor shall
use the most current address on file or available when preparing
and mailing all written notices and correspondence to applicants
and beneficiaries.
3.12 CHCBP Coverage Data and Reports
3.12.1 The CHCBP contractor shall
maintain systems and databases to collect, track, and process applications.
3.12.2 The CHCBP contractor shall
have the capability to retroactively retrieve pertinent coverage
information on any individual who has been accepted or denied coverage
in the program, to include the basis for such denials.
6.0 FIDUCIARY
RESPONSIBILITIES AND REPORTING
6.1 The CHCBP contractor shall
act as a fiduciary for all funds acquired from CHCBP premium collections.
All funds acquired from CHCBP collections are retained by the Government.
6.1.1 The CHCBP
contractor shall develop strict funds control processes for its
collection, retention and transfer of CHCBP premiums to the Government.
6.1.2 The CHCBP
contractor shall follow the requirements in
Chapter
3.
6.2 The CHCBP contractor shall
maintain a system for tracking and reporting premiums and beneficiaries
and policy holders. The system is subject to Government review and
audit.
6.3 The CHCBP contractor shall
submit the following reports:
• Adjusted Premiums Report;
• Enrollment Premium Report;
• Enrollment Report;
• Premiums Summary Report;
• Workload Report; and
• Ad Hoc Reports.
For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
8.0 REPORTING
RESPONSIBILITIES
8.1 The CHCBP contractor shall
maintain the capability to produce CHCBP ad hoc reports on request
by the Government.
8.2 The data elements or information
for such reports would be limited to that information that the CHCBP contractor
has collected or should reasonably have collected in the performance
of CHCBP work.
8.3 Some manipulation and formatting
of the data and information may be required to meet the requirements
of the ad hoc reports.
8.4 The Government estimates that
the CHCBP contractor would not receive more than five such requests per
contract year and that the level of effort for the CHCBP contractor
to produce the ad hoc reports is not expected to be significant.
9.0 PATIENT
PROTECTION AND AFFORDABLE CARE ACT (ACA) OF 2010 INFORMATION REPORTING
9.1 When purchased,
CHCBP coverage is considered Minimum Essential Coverage (MEC) and
meets the individual coverage requirement of the ACA.
9.2 The CHCBP
contractor shall perform all Section 6055 information reporting
to the Internal Revenue Service (IRS) and provide statements to
individuals with CHCBP coverage during the reporting tax period
in the manner, time frames, and forms specified in Section 6055
of the Internal Revenue Code (IRC) and associated IRS regulations.
9.3 The CHCBP
contractor shall notify the Contracting Officer’s Representative
(COR) by email when completed each year.
9.4 The CHCBP
contractor shall use coverage data from the contractor’s enrollment
system to generate the required information reports and statements
because not all CHCBP enrollments are recorded in DEERS.
9.5 Only CHCBP
coverage information shall be reported to the IRS by the CHCBP contractor.