(a) Establishment.
TRICARE Reserve Select offers
the TRICARE Select self managed, preferred-provider network option
under Sec. 199.17 to qualified members of the Selected Reserve,
their immediate family members, and qualified survivors under this
section.
(1) Purpose.
TRICARE Reserve Select is a
premium-based health plan that is available for purchase by members
of the Selected Reserve and certain survivors of Selected Reserve
members as specified in paragraph (c) of this section.
(2) Statutory
Authority.
TRICARE Reserve Select is authorized
by 10 U.S.C. 1076d.
(3) Scope
of the Program.
TRICARE Reserve Select is applicable
in the 50 United States, the District of Columbia, Puerto Rico,
and, to the extent practicable, other areas where members of the
Selected Reserve serve. In locations other than the 50 states of
the United States and the District of Columbia, the Assistant Secretary
of Defense (Health Affairs) may authorize modifications to the program
rules and procedures as may be appropriate to the area involved.
(4) Major Features of TRICARE Reserve Select.
The major features of the program
include the following:
(i) TRICARE
Select rules applicable.
(A) Unless
specified in this section or otherwise prescribed by the Director,
provisions of TRICARE Select under Sec. 199.17 apply to TRICARE
Reserve Select.
(B) Certain
special programs established in 32 CFR part 199 are not available
to members covered under TRICARE Reserve Select. These include the
Extended Care Health Option (Sec. 199.5), the Special Supplemental
Food Program (see Sec. 199.23), and the Supplemental Health Care
Program (Sec. 199.16), except when referred by a Military Treatment
Facility (MTF) provider for incidental consults and the MTF provider
maintains clinical control over the episode of care. The TRICARE
Dental Program (Sec. 199.13) is independent of this program and
is otherwise available to all members of the Selected Reserve and
their eligible family members whether or not they purchase TRICARE
Reserve Select coverage. The Continued Health Care Benefits Program
(Sec. 199.20) is also independent of this program and is otherwise
available to all members who qualify.
(ii) Premiums.
TRICARE Reserve Select coverage
is available for purchase by any Selected Reserve member if the
member fulfills all of the statutory qualifications. A member of
the Selected Reserve covered under TRICARE Reserve Select shall
pay 28 percent of the total amount that the ASD(HA) determines on
an appropriate actuarial basis as being appropriate for that coverage.
There is one premium rate for member-only coverage and one premium
rate for member and family coverage.
(iii) Procedures.
Under TRICARE Reserve Select,
Reserve Component members who fulfilled all of the statutory qualifications
may purchase either the member-only type of coverage or the member-and-family
type of coverage by submitting a completed request in the appropriate
format along with an initial payment of the applicable premium.
Rules and procedures for purchasing coverage and paying applicable
premiums are prescribed in this section.
(iv) Benefits.
When their coverage becomes
effective, TRICARE Reserve Select beneficiaries receive the TRICARE
Select benefit including access to military treatment facility services
and pharmacies, as described in Secs. 199.17 and 199.21. TRICARE
Reserve Select coverage features the deductible, catastrophic cap
and cost share provisions of the TRICARE Select plan applicable
to Group B active duty family members under Sec. 199.17(l)(2)(ii)
for both the member and the member’s covered family members; however,
the TRICARE Reserve Select premium under paragraph (c) of this section
applies instead of any TRICARE Select plan enrollment fee under
Sec. 199.17. Both the member and the member’s covered family members
are provided access priority for care in military treatment facilities on
the same basis as active duty service members’ dependents who are
not enrolled in TRICARE Prime as described in Sec. 199.17(d)(1)(i)(D).
(b) Qualifications
for TRICARE Reserve Select coverage--
(1) Ready
Reserve member. A Ready Reserve
member qualifies to purchase TRICARE Reserve Select coverage prior
to January 1, 2030, if the Service member meets the criteria listed
in both paragraphs (b)(1)(i) and (ii) of this section. Beginning January
1, 2030, only the criteria in paragraph (b)(1)(i) of this section
is necessary for qualification.
(i) Is a member of
the Selected Reserve of the Ready Reserve of the Armed Forces, or
a member of the Individual Ready Reserve of the Armed Forces who
has volunteered to be ordered to active duty pursuant to the provisions
of 10 U.S.C. 12304 in accordance with section 10 U.S.C. 10144(b);
and
(ii) Is not enrolled
in, or eligible to enroll in, a health benefits plan under 5 U.S.C.
chapter 89. That statute has been implemented under 5 CFR part 890
as the Federal Employees Health Benefits (FEHB) program. For purposes
of the FEHB program, the terms “enrolled,” “enroll” and “enrollee”
are defined in 5 CFR 890.101. Further, the member (or certain former
member involuntarily separated) no longer qualifies for TRICARE
Reserve Select when the member (or former member) has been eligible
for coverage to be effective in a health benefits plan under the
FEHB program for more than 60 days.
(2) TRICARE
Reserve Select survivor.
If a qualified Service member
dies while in a period of TRICARE Reserve Select coverage, the immediate
family member(s) of such member is qualified to purchase new or
continue existing TRICARE Reserve Select coverage for up to six
months beyond the date of the member’s death as long as they meet
the definition of immediate family members as specified in paragraph
(g)(2) of this section. This applies regardless of type of coverage
in effect on the day of the TRICARE Reserve Select member’s death.
(c) TRICARE Reserve Select premiums.
Members are charge premiums
for coverage under TRICARE Reserve Select that represent 28 percent
of the total annual premium amount that the Director determines
on an appropriate actuarial basis as being appropriate for coverage
under the TRICARE Select benefit for the TRICARE Reserve Select
eligible population. Premiums are to be paid monthly, except as
otherwise provided through administrative implementation, pursuant
to procedures established by the Director. The monthly rate for
each month of a calendar year is one-twelfth of the annual rate
for that calendar year.
(1) Annual
establishment of rates.
TRICARE
Reserve Select monthly premium rates shall be established and updated
annually on a calendar year basis for each of the two types of coverage, member-only
and member- and-family as described in paragraph (d)(1) of this
section. Starting with calendar year 2009, the appropriate actuarial
basis for purposes of this paragraph (c) shall be determined for
each calendar year by utilizing the actual reported cost of providing
benefits under this section to members and their dependents during
the calendar years preceding such calendar year. Reported actual
TRS cost data from calendar years 2006 and 2007 was used to determine
premium rates for calendar year 2009. This established pattern will
be followed to determine premium rates for all calendar years subsequent
to 2009.
(2) Premium
adjustments.
In addition to the determinations
described in paragraph (c)(1) of this section, premium adjustments
may be made prospectively for any calendar year to reflect any significant
program changes or any actual experience in the costs of administering
TRICARE Reserve Select.
(3) Survivor
premiums.
A surviving family member of
a Reserve Component service member who qualified for TRICARE Reserve
Select coverage as described in paragraph (b)(2) of this section
will pay premium rates as follows. The premium amount shall be at
the member-only rate if there is only one surviving family member
to be covered by TRICARE Reserve Select and at the member and family
rate if there are two or more survivors to be covered.
(d) Procedures.
The Director may establish
procedures for the following.
(1) Purchasing
coverage.
Procedures may be established
for a qualified member to purchase one of two types of coverage:
Member-only coverage or member and family coverage. Immediate family members
of a qualified member as specified in paragraph (g)(2) of this section
may be included in such family coverage. To purchase either type
of TRICARE Reserve Select coverage for effective dates of coverage
described below, members and survivors qualified under either paragraph
(b)(1) or (2) of this section must submit a request in the appropriate
format, along with an initial payment of the applicable premium
required by paragraph (c) of this section in accordance with established procedures.
(i) Continuation
coverage.
Procedures may be established
for a qualified member or qualified survivor to purchase TRICARE
Reserve Select coverage with an effective date immediately following
the date of termination of coverage under another TRICARE program.
(ii) Qualifying event.
Procedures for qualifying events
in TRICARE Select plans under Sec. 199.17(o) shall apply to TRICARE
Reserve Select coverage. Additionally, the Director may identify
other events unique to needs of the Reserve Components as qualifying
events.
(iii) Enrollment.
Procedures for enrollment in
TRICARE Select plans under Sec. 199.17(o) shall apply to TRICARE
Reserve Select enrollment. Generally, the effective date of coverage
will coincide with the first day of a month unless enrollment is
due to a qualifying event and a different date on or after the qualifying
event is required to prevent a lapse in health care coverage.
(iv) Survivor coverage
under TRICARE Reserve Select.
Procedures
may be established for a surviving family member of a Reserve Component
service member who qualified for TRICARE Reserve Select coverage
as described in paragraph (b)(2) of this section to purchase new
TRICARE Reserve Select coverage or continue existing TRICARE Reserve
Select coverage for up to six months beyond the date of the member’s
death. The effective date of coverage will be the day following
the date of the member’s death.
(2) Termination.
Termination
of coverage for the TRS member/survivor will result in termination
of coverage for the member’s/survivor’s family members in TRICARE
Reserve Select. Procedures may be established for coverage to be
terminated as follows.
(i) Coverage shall
terminate when members or survivors no longer qualify for TRICARE
Reserve Select as specified in paragraph (b) of this section, with
one exception. If a member is involuntarily separated from the Selected
Reserve under other than adverse conditions, as characterized by
the Secretary concerned, and is covered by TRICARE Reserve Select
on the last day of his or her membership in the Selected Reserve,
then TRICARE Reserve Select coverage may terminate up to 180 days
after the date on which the member was separated from the Selected
Reserve. This applies regardless of type of coverage. This exception
expires December 31, 2018.
(ii) Coverage may terminate
for members, former members, and survivors who gain coverage under another
TRICARE program.
(iii) In accordance
with the provisions of Sec. 199.17(o)(2) coverage terminates for
members/survivors who fail to make premium payments in accordance
with established procedures.
(iv) Coverage may be
terminated for members/survivors upon request at any time by submitting
a completed request in the appropriate format in accordance with
established procedures.
(3) Re-enrollment
following termination.
Absent a new qualifying event,
members/survivors (subject to paragraph (d)(1)(iv) of this section)
are not eligible to re-enroll in TRICARE Reserve Select until the next
annual open season.
(4) Processing.
Upon receipt of a completed
request in the appropriate format, enrollment actions will be processed
into DEERS in accordance with established procedures.
(5) Periodic revision.
Periodically,
certain features, rules or procedures of TRICARE Reserve Select
may be revised. If such revisions will have a significant effect
on members’ or survivors’ costs or access to care, members or survivors
may be given the opportunity to change their type of coverage or terminate
coverage coincident with the revisions.
(e) Preemption of State laws.
(1) Pursuant to 10
U.S.C. 1103, the Department of Defense has determined that in the
administration of chapter 55 of title 10, U.S. Code, preemption
of State and local laws relating to health insurance, prepaid health
plans, or other health care delivery or financing methods is necessary
to achieve important Federal interests, including but not limited
to the assurance of uniform national health programs for military
families and the operation of such programs, at the lowest possible
cost to the Department of Defense, that have a direct and substantial
effect on the conduct of military affairs and national security
policy of the United States. This determination is applicable to
contracts that implement this section.
(2) Based on the determination
set forth in paragraph (f)(1) of this section, any State or local
law or regulation pertaining to health insurance, prepaid health
plans, or other health care delivery, administration, and financing
methods is preempted and does not apply in connection with TRICARE Reserve
Select. Any such law, or regulation pursuant to such law, is without
any force or effect, and State or local governments have no legal
authority to enforce them in relation to TRICARE Reserve Select.
(However, the Department of Defense may, by contract, establish
legal obligations on the part of DoD contractors to conform with
requirements similar to or identical to requirements of State or local
laws or regulations with respect to TRICARE Reserve Select.)
(3) The preemption
of State and local laws set forth in paragraph (f)(2) of this section
includes State and local laws imposing premium taxes on health insurance
carriers or underwriters or other plan managers, or similar taxes
on such entities. Such laws are laws relating to health insurance,
prepaid health plans, or other health care delivery or financing
methods, within the meaning of 10 U.S.C. 1103. Preemption, however,
does not apply to taxes, fees, or other payments on net income or
profit realized by such entities in the conduct of business relating
to DoD health services contracts, if those taxes, fees or other
payments are applicable to a broad range of business activity. For
the purposes of assessing the effect of Federal preemption of State
and local taxes and fees in connection with DoD health services
contracts, interpretations shall be consistent with those applicable
to the Federal Employees Health Benefits Program under 5 U.S.C.
8909(f).
(f) Administration.
The Director may establish
other rules and procedures for the effective administration of TRICARE
Reserve Select, and may authorize exceptions to requirements of
thissection, if permitted by law.
(g) Terminology.
The following terms are applicable
to the TRICARE Reserve Select program.
(1) Coverage.
This term means the medical
benefits covered under the TRICARE Select program as further outlined
in § 199.17 whether delivered in military treatment facilities or
purchased from civilian sources.
(2) Immediate
family member.
This term means spouse (except
former spouses) as defined in Sec. 199.3(b)(2)(i), or child as defined
in Sec. 199.3(b)(2)(ii).
(3) Qualified
member.
This term means a member who
has satisfied all the criteria that must be met before the member
is authorized for TRS coverage.
(4) Qualified
survivor.
This term means an immediate
family member who has satisfied all the criteria that must be met
before the survivor is authorized for TRS coverage.
[70 FR 12802, Mar 16, 2005;
71 FR 31944; Jun 2, 2006; 71 FR 35532, Jun 21, 2006; 72 FR 46383,
Aug 20, 2007; 76 FR 57641, Sep 16, 2011; 80 FR 55254; Sep 15, 2015;
82 FR 45458, Sep 29, 2017; 86 FR 67862, Nov 30, 2021]