(a) Establishment.
The TRICARE Young
Adult (TYA) program offers options of medical benefits provided
under the TRICARE program to qualified unmarried adult children
of TRICARE-eligible uniformed service sponsors who do not otherwise
have eligibility for medical coverage under a TRICARE program at
age 21 (23 if enrolled in a full-time course of study at an approved
institution of higher learning, and the sponsor provides over 50
percent of the student’s financial support), and are under age 26.
(1) Purpose.
As specified in paragraph (c)
of this section, TYA is a premium-based health option that is available
for purchase by any qualified adult child as that term is defined
in paragraph (b) of this section. The TYA program allows a qualified
adult child to purchase TRICARE coverage.
(2) Statutory
authority.
TYA is authorized by 10 U.S.C.
1110b.
(3) Scope
of the program.
TYA is geographically applicable
to the same extent as specified in Sec. 199.1(b)(1).
(4) Major features of TYA.
(i) TRICARE
rules applicable.
(A) Unless
specified in this section or otherwise prescribed by the Assistant
Secretary of Defense (Health Affairs) (ASD (HA)), provisions of
this part apply to TYA.
(B) The
TRICARE Dental Program (Sec. 199.13) and the TRICARE Retiree Dental
Program (Sec. 199.22) are not covered under TYA.
(C) TRICARE
Select is available to all TYA-eligible young adult dependents.
(D)
TRICARE
Prime is available to TYA-eligible young adult dependents, provided
that TRICARE Prime (including the Uniformed Services Family Health
Plan) is available in the geographic location where the TYA enrollee
resides. TYA-eligible young adults are:(1) Dependents
of sponsors on active duty orders written, or otherwise continuously,
for more than 30 days or covered by TAMP (under Sec. 199.3(e));
(2) Dependents
of sponsors who are retired members other than retired members of
the Retired Reserve; and
(3) Survivors of members who died while on
active duty for more than 30 days or while receiving retired or
retainer pay.
(ii) Premiums.
TYA coverage
is a premium based program that an eligible young adult dependent may
purchase. There is only individual coverage, and a premium shall
be charged for each dependent even if there is more than one qualified
dependent in the uniformed service sponsor’s family that qualifies
for TYA coverage. Dependents qualifying for TYA status can purchase
individual TRICARE Select or TRICARE Prime coverage (as applicable)
according to the rules governing the TRICARE option for which they
are qualified on the basis of their uniformed service sponsor’s
TRICARE-eligible status (active duty, retired, Selected Reserve,
or Retired Reserve) and the availability of a desired option in their
geographic location. Premiums shall be determined in accordance
with paragraph (c) of this section.
(iii) Procedures.
Under TYA, qualified dependents
under paragraph (b) of this section may purchase individual TYA
coverage by submitting a completed request in the appropriate format
along with an initial payment of the applicable premium. Procedures
for purchasing coverage and paying applicable premiums are prescribed
in paragraph (d) of this section.
(iv) Benefits.
When their TYA
coverage becomes effective, qualified beneficiaries receive the
benefit of the TRICARE option that they selected, including, if
applicable, access to military treatment facilities and pharmacies.
TYA coverage features the cost share, deductible and catastrophic
cap provisions applicable to Group B beneficiaries based on the
program selected, i.e., the TRICARE Select program under Sec. 199.17(l)(2)(ii)
or the TRICARE Prime program under Sec. 199.17(l)(ii), as well as
the status of their military sponsor. Access to military treatment
facilities under the system of access priorities in Sec. 199.17(d)(1)
is also based on the program selected as well as the status of the
military sponsor. Premiums are not credited to deductibles or catastrophic
caps; however, TYA premiums shall apply instead of any applicable
TRICARE Prime or Select enrollment fee.
(b) Eligibility
for TRICARE Young Adult coverage.--
(1) Young
Adult Dependent.
A young adult dependent qualifies
to purchase TYA coverage if the dependent meets the following criteria:
(i) Would be a dependent
child under 10 U.S.C. 1072, but for exceeding the age limit under
that section (abused dependents and NATO dependents are not eligible
for TYA coverage); and
(ii) Is
a dependent under the age of 26; and
(iii) Is not enrolled,
or eligible to enroll, for medical coverage in an eligible employer-sponsored health
plan as defined in section 5000A(f)(2) of the Internal Revenue Code
of 1986; and
(iv) Is
not otherwise eligible under Sec. 199.3; and
(v) Is not a member
of the uniformed services.
(2) The
dependents’ sponsor is responsible for keeping the Defense Enrollment
Eligibility Reporting System (DEERS) current with eligibility data
through the sponsor’s Service personnel office. Using information
from the DEERS, the TRICARE regional contractors have the responsibility
to validate a dependent’s qualifications to purchase TYA coverage.
(c) TRICARE Young Adult premiums.
Qualified young
adult dependents are charged premiums for coverage under TYA that
represent the full cost of the program, including reasonable administrative costs,
as determined by the Director utilizing an appropriate actuarial
basis for the provision of TRICARE benefits for the TYA-eligible
beneficiary population. Separate premiums shall be established for TRICARE
Select and Prime plans. There may also be separate premiums based
on the uniformed services sponsor’s status. 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.--
(i) Monthly premium
rates shall be established and updated annually on a calendar year
basis by the ASD(HA) for TYA individual coverage.
(ii) The appropriate
actuarial basis used for calculating premium rates shall be one
that most closely approximates the actual cost of providing care
to a similar demographic population (based on age and health plans)
as those enrolled in TYA, as determined by the ASD(HA). TYA premiums
shall be based on the actual costs of providing benefits to TYA
dependents during the preceding years if the population of TYA enrollees
is large enough during those preceding years to be considered actuarially
appropriate. Until such time that actual costs from those preceding
years become available, TYA premiums shall be based on the actual
costs during the preceding calendar years for providing benefits
to the population of similarly aged dependents to make the underlying
group actuarially appropriate. An adjustment may be applied to cover
overhead costs for administration of the program.
(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 mandated by legislative enactment, including but
not limited to significant new programs or benefits.
(d) Procedures.
The Director
may establish procedures for the following.
(1) Purchasing coverage.
Procedures
may be established for a qualified dependent to purchase individual
coverage. To purchase TYA coverage for effective dates of coverage
described below, qualified dependents 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 dependent to purchase TYA coverage with an effective
date immediately following the date of termination of coverage under another
TRICARE program. Application for continuation coverage must be made
within 30 days of the date of termination of coverage under another
TRICARE program.
(ii) Enrollment. Procedures for
enrollment in TRICARE plans under Sec. 199.17(o) shall apply to
a qualified dependent purchasing TYA coverage. 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.
(2) Termination. Procedures may
be established for TYA coverage to be terminated as follows.
(i) Loss of eligibility
or entitlement for coverage by the sponsor will result in termination
of the dependent’s TYA coverage unless otherwise specified. The
effective date of the sponsor’s loss of eligibility for care will
also be the effective date of termination of benefits under the
TYA program unless specified otherwise.
(A) Active
duty military sponsor.
TYA coverage ends effective
the date of military sponsor’s separation from military service,
unless the dependent would be eligible under section 199.3(e) of
this Part but for the dependent’s age, for the duration of the Transitional
Assistance Management Program (TAMP) eligibility or until reaching
age 26, whichever comes first. Upon the death of an active duty
sponsor, dependents eligible for Transitional Survivor coverage
may purchase TYA coverage if otherwise qualified.
(B) Selected
Reserve (Sel Res) Sponsor.
Sel Res sponsors must be currently
enrolled in TRICARE Reserve Select (TRS) before a young adult dependent
is eligible to purchase TYA. If TRS coverage is terminated by the
sponsor, TYA coverage ends effective the same termination date as
the sponsor. If the Sel Res sponsor dies while enrolled in TRS,
the young adult dependent is eligible to purchase TYA coverage for
six months after the date of death of the Sel Res sponsor, if otherwise
qualified.
(C) Retired
Reserve Sponsor.
Retired Reserve members not
yet eligible for retired or retainer pay must be enrolled in TRICARE
Retired Reserve (TRR) to establish TYA eligibility for their young
adult dependents. If TRR coverage is terminated by the sponsor,
the TYA coverage for the young adult dependent ends effective the
same date as the sponsor’s termination of coverage under TRR. If
the retired reserve sponsor dies while enrolled in TRR, the young
adult dependent may continue to purchase TYA coverage until the
date on which the deceased member would have attained age 60, if otherwise
qualified. If the Retired Reserve member dies and is not enrolled
in TRR, there is no eligibility for TYA coverage until the sponsor
would have reached age 60. On the date the Retired Reserve member
would have reached 60, a young adult dependent who otherwise qualifies
for TYA qualifies as a dependent of a deceased retired sponsor and
can purchase TYA coverage.
(ii) Failure of a young
adult dependent to maintain the eligibility qualifications in paragraph
(b) of this section shall result in the termination of coverage
under the TYA program. The effective date of termination shall be
the date upon which the adult young dependent failed to meet any
of the prerequisite qualifications. If a subsequent change in circumstances
re-establishes eligibility (such as losing eligibility for an eligible
employer-sponsored plan), the young adult dependent may re-enroll
for coverage under the TYA program.
(iii) Coverage may
also be terminated due to a change in the sponsor’s status, and
the young adult dependent must re-qualify and reapply for TYA coverage
within 30 days of termination to preclude a gap in coverage.
(iv) Termination of
coverage results in denial of claims for services with a date of
service after the effective date of termination.
(v) Coverage
may be terminated for young adult dependents upon request at any
time by submitting a completed request in the appropriate format
in accordance with established procedures.
(vi) In
accordance with the provisions of Sec. 199.17(o)(2), coverage terminates
for young adult dependents who fail to make premium payments in
accordance with established procedures.
(vii) Absent
a new qualifying event, young adults are not eligible to re-enroll
in TYA until the next annual open season.
(3) Eligibility
for the Continued Health Care Benefit Program.
Upon termination
of eligibility to purchase TYA coverage, dependents may purchase
coverage for up to 36 months through the Continued Health Care Benefit
Program under Sec. 199.20 unless locked out of TYA.
(4) Changing coverage.
Upon
application and payment of appropriate premiums, qualified dependents
already enrolled in and who are current in their premium payments
may elect to change to another TRICARE program for which the qualified
dependent is eligible based on the sponsor’s eligibility and the
geographic location of the qualified young adult dependent. Upon
change in sponsor status (for example, active duty to retired status),
TYA coverage may be automatically transferred to the appropriate
TRICARE option consistent with the sponsor’s new status. Recurring
TYA premiums may be adjusted accordingly. Administrative processes
may be established for changes in program enrollment; however, no
change shall be effective until the applicable premium has been paid.
(e) Preemption
of State laws.--
The preemption
provisions of Sec. 199.17(a)(7) are applicable to the TYA program.
(f) Administration.
The Director
may establish other processes, policies and procedures for the effective
administration of the TYA Program and may authorize exceptions to
requirements of this section, if permitted.
[76 FR 23483, Apr 27, 2011;
78 FR 32119, May 29, 2013; 82 FR 45460, Sep 29, 2017]