1.0 DESCRIPTION
1.1 Eligible
surviving family members whose sponsor died while on active duty
for a period of more than 30 calendar days (to include those who
die while on delayed-effective-date active duty orders) may continue
their TRICARE eligibility and their status is reflected as either
Transitional Survivor or Survivor.
1.2 Transitional
Survivor and Survivor are terms used to reflect the status of certain
otherwise eligible TRICARE beneficiaries. The status determines
the appropriate payment rate and benefit level used in claims processing.
Transitional Survivor status reflects Active Duty Family Member
(ADFM) payment rates and provisions. Survivor status reflects retiree
payment rates.
1.3 TRICARE Eligibility rules have
priority over the rules that apply to those in Transitional Survivor
or Survivor status.
2.0 BACKGROUND
2.1 Family
members of Active Duty Service Members (ADSMs) who died while on
active duty have always been eligible for TRICARE; however, their
payment rates/cost-sharing provisions have changed over time. Initially, their
cost-sharing provisions were at the retiree payment rate for all
care received.
2.2 Section 707(c) of the National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 1995, Public
Law 103-337 provided for two changes.
2.2.1 For dependents
of active duty members who died while on active duty between January
1, 1993 and October 1, 1993, only care for pre-existing conditions
was cost-shared at the active duty dependent payment rate.
2.2.2 Effective October 1, 1993,
active duty dependent payment rate was limited to a one-year period.
2.3 Section 704 of the Floyd D.
Spence NDAA FY 2001 created a three year period, beginning with
the date of death, for health care to be cost-shared at the active
duty dependent payment rate. After three years, survivors remained
eligible for TRICARE, but at the retiree payment rate. This provision
was effective October 30, 2000.
2.4 Section
715 of the NDAA for FY 2006, as codified in 10 United States Code
(USC) 1079(g)(2), extended the transitional survivor status for
the dependent children as outlined in
paragraph 3.0. It made this
benefit retroactive to October 7, 2001.
2.5 Section 701 of the NDAA for
FY 2017, changed how enrollment fees are calculated for Chapter
61 retirees that are medically retired after December 31, 2017 and
their family members, and ADSM survivors whose sponsor died after
December 31, 2017. Enrollment fees for this group may be adjusted
each year based on Cost-of-Living Adjustments (COLA) to pay.
2.6 Section 702 of the NDAA for
FY 2018 states that pharmaceutical agents for survivors shall be
equal to the cost-sharing amount for 2017.
3.0
POLICY
3.1 Effective
with respect to deaths occurring on or after October 7, 2001, Section
715 of the NDAA FY 2006, Public Law 109-163, extended the time frame
that certain eligible dependents (children and unmarried persons) remain
in Transitional Survivor status. See
paragraph 3.2.
3.2 Time
Frames for Transitional Survivor Status.
3.2.1 Spouse.
Transitional Survivor status is retained for three years from the
date of death of the sponsor. After three years, the surviving spouse
converts to Survivor status and TRICARE benefits may continue at
retiree payment rates and rules.
3.2.2 Children
and unmarried persons (those defined in 10 USC 1072(2)(D) or (I))
whose sponsor died on or after October 7, 2001. Transitional survivor
status ends at age 21 or 23 if enrolled in a full-time course of
study in a secondary school or in a full-time course of study in
an institution of higher education (subject to the eligibility limitations
as described in the Note).
3.2.3 Incapacitated
Children and Incapacitated Unmarried Persons (those defined in 10
USC 1072(2)(D) or (I)) whose sponsor died on or after October 7,
2001. Transitional Survivor status (subject to the eligibility limitations
as described in the Note) is the greater of:
• Three years from the sponsor’s
date of death; OR
• The date on which such dependent
attains 21 years of age; OR
• The date on which the dependent
attains 23 years of age if enrolled in a full-time course of study
in a secondary school or in a full-time course of study in an institution
of higher education.
Note: A
status of Transitional Survivor or Survivor status does not impact
eligibility rules. Loss of eligibility as a result of any condition
which routinely results in loss of TRICARE eligibility such as reaching
age limits, marriage, remarriage, etc. also results in loss of Transitional
Survivor/Survivor status. Individuals are considered to be eligible for
TRICARE if they are shown as eligible on the Defense Enrollment
Eligibility Reporting System (DEERS). The DEERS record will indicate
the dates of eligibility and the status.
Note: Transitional survivors who
are entitled to Medicare should sign up for Medicare Part B within
eight months of the sponsor’s death to avoid paying higher Part
B premiums for late enrollment.
3.3 Actions necessary due to retroactive
implementation of 10 USC 1079(g)(2).
3.3.1 Status
Conversion. Dependent children whose sponsor’s death occurred on
or after October 7, 2001, and who, upon implementation of this policy
are:
3.3.1.1 In Transitional Survivor status
shall remain in Transitional Survivor status in accordance with
time frames found in
paragraph 3.2. The Transitional Survivor’s
Health Care Plan (HCP) (e.g., Prime, Standard) shall continue until
such time it is changed by the beneficiary.
3.3.1.2 In
Survivor status shall have their Transitional Survivor status reinstated
and shall remain in Transitional Survivor status in accordance with
paragraph 3.2.
The HCP (e.g., TRICARE Prime, TRICARE Standard) that the beneficiary
was in as a Survivor shall continue to apply and will be carried
over when the status is changed to Transitional Survivor until such
time the beneficiary elects to choose another plan.
3.3.1.3 In
Survivor status and who have since lost TRICARE eligibility shall
have their Transitional Survivor status end date changed to the
date they lost eligibility for TRICARE. The HCP (e.g., TRICARE Prime,
TRICARE Standard) that the beneficiary was in as a Survivor shall
also be applied to the period of Transitional Survivor status.
3.3.2 Refunds - General
3.3.2.1 The contractor shall process
refunds of enrollment fees proactively.
3.3.2.2 The contractor shall reprocess
claims either based on proactive contact with the beneficiary, upon the
beneficiary’s request, or when contacted by a beneficiary’s parent
or legal guardian.
3.3.2.3 The contractor shall confirm
the beneficiary’s mailing address before mailing any refunds.
3.3.2.4 The contractor shall send a
letter to beneficiaries affected by changes found in Section 715,
NDAA FY 2006. The letter will advise them of the extended Transitional
Survivor time frames and will direct them to contact the contractor
for further information.
3.3.2.5 The contractor shall assist
the beneficiary with actions necessary in order to correctly reprocess claims
in accordance with this policy, once contacted by the beneficiary
or beneficiary’s parent or legal guardian.
3.3.3 Refunds - Enrollment Fees
3.3.3.1 The contractor shall issue
an enrollment fee refund for all individuals described in
paragraphs 3.3.1.2 and
3.3.1.3 upon
contact by a beneficiary, beneficiary’s parent, or legal guardian
or when the contractor initiates contact with those due a refund
of enrollment fees.
3.3.3.2 Since the TRICARE Prime Health
Care Delivery Program (HCDP) that the beneficiary was in during
the Survivor status shall be carried over and applied during the
Transitional Survivor status, refunds are necessary. Refunds shall
be:
3.3.3.2.1 The difference between TRICARE
Prime enrollment fee for family versus Prime enrollment fee for individual
(if a spouse was enrolled); or
3.3.3.2.2 Refund of all applicable enrollment
fees (if a spouse was not enrolled).
3.3.3.3 The contractor shall include
a written explanation, with any applicable refund of enrollment
fees.
3.3.4 Refunds - Claims
3.3.4.1 The contractor shall reprocess
claims and issue refunds to the family for those individuals described in
paragraphs 3.3.1.2 and
3.3.1.3.
Since the HCDP (e.g., TRICARE Prime, TRICARE Standard.) that the
beneficiary was in as a Survivor shall be carried over and applied
during the Transitional Survivor status, refunds shall be the difference
between any retiree payment rates the beneficiary may have paid
and the active duty payment rates that now apply. For example, those
Survivors who were in TRICARE Standard and had paid retiree cost-shares
for covered care may now be entitled to refunds of the difference
between Standard retiree cost-shares and active duty dependent cost-shares.
3.3.4.2 Waiver of timely filing.
32 CFR 199.7(d)(2)(i)(A) permits an exception
for the timely filing waiver of claims in the event of retroactive
eligibility. Consequently, timely filing waivers apply to those
whose status is changed from Survivor to Transitional Survivor.
3.3.5 Refunds - PFPWD/ECHO
3.3.5.1 The
contractor shall reprocess Survivor Basic Program claims that otherwise
would have been processed as Program For Persons With Disabilities
(PFPWD) claims had Transitional Survivor status been in effect at the
time the benefit was received and will issue appropriate refunds,
and will waive the requirement for prior authorization of a PFPWD
benefit and the requirement for the “Public Facility Use Certification.”
3.3.5.2 The
contractor shall reprocess denied Survivor
Basic Program claims that otherwise would have been processed as
PFPWD claims had Transitional Survivor status been in effect at
the time the benefit was received and will issue appropriate refunds,
and will waive the requirement for prior authorization of a PFPWD
benefit and the requirement for the “Public Facility Use Certification.”
3.3.5.3 The
contractor shall assist those Transitional Survivors who are otherwise
eligible for the Extended Care Health Option (ECHO) to register
in ECHO and will waive the ECHO requirement that the beneficiary demonstrate
enrollment in the Exceptional Family Member Program (EFMP).
3.3.5.4 The contractor shall reprocess
claims for services or items that were previously denied and claims
for services or items that were not previously submitted because
the beneficiary was not eligible for ECHO due to his or her Survivor
status at the time such services or items were received by the beneficiary.
3.3.5.5 The contractor shall process
claims under
paragraphs 3.3.5.1,
3.3.5.2, and
3.3.5.3,
in accordance with the claims adjustment policies in effect at the
time the claim was originally processed. In no case will reprocessing result
in a greater cost-share to the sponsor/beneficiary than what was
determined when the claims were originally processed.
3.4 TRICARE Prime And TRICARE Prime
Select Enrollment
3.4.1 Transitional Survivors shall
retain eligibility to enroll in TRICARE Prime, TRICARE Prime Remote
Active Duty Family Member (TPRADFM), TRICARE Overseas Program (TOP)
Prime and TOP TPRADFM (if available), and TRICARE Select at the
ADFM payment rate and shall receive the ADFM health care benefit.
For Overseas enrollments, see the TRICARE Operations Manual (TOM),
Chapter 24, Section 5.
3.4.2 Survivors are eligible to enroll
in TRICARE Prime (if available), TRICARE Select at retiree payment
rates, or TFL if entitled to Medicare Parts A and B. (See TRICARE
Reimbursement Manual (TRM),
Chapter 2, Section 1 and
2). TPRADFM and TOP Prime are notavailable
to Survivors and Survivors are covered by TRICARE Standard (effective January
1, 2018, replaced by TRICARE Select if the survivor chooses to enroll).
3.5 Benefits
3.5.1 Transitional
Survivors receive the same TRICARE benefits that are available to
ADFMs subject to any exclusions. This includes those TRICARE benefits
that are restricted to ADFMs such as, but not limited to, hearing aids
and eye examinations.
3.5.2 Survivors
receive the same TRICARE benefits that are available to retirees.
3.6 ECHO
3.6.1 Transitional
Survivors may register in the ECHO program subject to all ECHO rules
and policies. See
Chapter 9, Section 2.1 for further information
on ECHO eligibility.
3.6.2 Survivors
are excluded from the ECHO registration. This is because the ECHO
is not available to retirees and Survivors are treated as retirees.
3.7 Payment Rates (e.g., Catastrophic
Cap, Cost-Shares, Copayments, Deductibles)
3.7.1 Transitional
Survivors. Payment rates are the same as ADFM payment rates for
their respective TRICARE health plan. See the TRM,
Chapter 2, Sections 2 and
4.
3.7.2 Survivors.
Payment rates are the same as retiree payment rates for their respective
TRICARE health plan. See the TRM,
Chapter 2, Sections 2 and
4.