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TRICARE Operations Manual 6010.62-M, April 2021
Reserve Component (RC) Health Coverage Plans
Chapter 22
Section 1
TRICARE Reserve Select (TRS) And TRICARE Retired Reserve (TRR)
Revision:  
1.0  GENERAL
1.1  TRS is a premium-based TRICARE health plan available for purchase by qualified members of the Selected Reserve (SelRes) of the Ready Reserve and qualified survivors that offers health coverage for Reserve Component (RC) members and their eligible family members.
1.2  TRR is a premium-based TRICARE health plan available for purchase by qualified non-regular Retired Reserve members and qualified survivors that offers health coverage for Retired Reserve members and their eligible family members.
1.3  The RCs will validate members’ and survivors’ qualifications to purchase TRS or TRR coverage and will identify qualified members or survivors in the Defense Enrollment Eligibility Reporting System (DEERS).
1.4  SelRes and non-regular Retired Reservists do not qualify to purchase TRS or TRR if they are eligible for, or enrolled in a Federal Employees Health Benefit Program (FEHB).
1.5  The term “contractor” in this Section refers to the Managed Care Support Contractors (MCSCs) and the TRICARE Overseas Program (TOP) contractor.
2.0  BENEFITS AND SCOPE OF CARE
2.1  TRS and TRR health plans deliver the TRICARE Select benefit to all covered individuals; including access to Markets/Military Medical Treatment Facilities (MTFs) and pharmacies with the same Market/MTF access priority as Active Duty Family Members (ADFMs) not enrolled in TRICARE Prime on a space-available basis.
2.2  TRS and TRR features TRICARE Select cost-shares, deductibles and catastrophic caps applicable to ADFMs for all TRS- and TRR-covered individuals (including SelRes and non-regular Retired Reserve members themselves).
2.3  TRS and TRR premiums are not credited to deductibles or catastrophic caps.
2.4  The provisions of 32 CFR 199.16(a)(3) concerning the Supplemental Health Care Program (SHCP) for dependents under the care of the Market/MTF apply to TRS.
2.5  The contractor shall review and propose revisions to Market/MTF Memoranda of Understanding (MOU)/Statement of Responsibilities (SOR) as necessary to reflect Market/MTF requirements for accommodating and ensuring that TRS or TRR members, family members and survivors are provided the same level of service as ADFMs or retired family members under TRICARE Select.
3.0  SPECIFIC PROGRAMS NOT AVAILABLE UNDER TRS AND TRR
Specific programs not available under TRS and TRR include those listed below the following:
3.1  TRICARE Dental Program (TDP) under 10 United States Code (USC) Chapter 55; to include dental coverage under FEDVIP.
3.2  TRICARE Reserve and National Guard Family Member Benefits program as specified in TRICARE Policy Manual (TPM), Chapter 10, Section 8.1.
3.3  Extended Care Health Option (ECHO).
3.4  TRICARE Prime Programs including the Uniformed Services Family Health Plan (USFHP).
3.5  SHCP funds, except for civilian care referred by Military Health System (MHS) facilities as specified in Chapter 17 to the same extent that SHCP covers civilian care for MHS beneficiaries who are not Active Duty Service Members (ADSMs).
3.6  Special Supplemental Food Program.
4.0  TRS AND TRR COVERAGE AND PREMIUMS
4.1  TRS and TRR offer two types of coverage: member-only and member and family.
4.2  Each year the Government will determine premium rates payable monthly by the member/survivor for each type of coverage.
4.2.1  The Government will provide the premium rates to the contractor no later than 60 calendar days prior to the effective date.
4.2.2  TRS premium rates are specified in Addendum A, Figure 22.A-1.
4.2.3  TRR premium rates are specified in Addendum A, Figure 22.A-2.
4.2.4  Unless otherwise specified, the premium rates will be in effect for a full calendar year effective the first day in January.
4.2.5  A surviving family member who qualifies to purchase (or continue) TRS or TRR coverage as described in paragraph 7.0, shall pay the member-only rate if there is only one covered survivor and the member and family rate if there are two or more survivors to be covered.
5.0  QUALIFYING TO PURCHASE TRS AND TRR COVERAGE
5.1  The contractor shall use DEERS to identify members and survivors who are qualified to purchase TRS or TRR coverage.
5.2  The contractor shall refer RC members and survivors to their respective RC for issues concerning incorrect DEERS data, or TRS/TRR eligibility.
5.3  The RCs will validate members’ and survivors’ qualifications to purchase TRS or TRR coverage and will identify qualified members or survivors in DEERS.
6.0  MEMBER QUALIFICATIONS FOR PURCHASE OF TRS AND TRR COVERAGE
6.1  A member of the RC of the Armed Forces qualifies to purchase TRS coverage if the member meets both of the following conditions:
•  Member of the SelRes of the Ready Reserve; and
•  Not enrolled in, or eligible to enroll in, a health benefits plan under 5 USC Chapter 89, specifically the FEHB.
6.2  A Retired Reserve member qualifies to purchase TRR coverage if the member meets both of the following conditions:
•  Member of the Retired Reserve of a RC of the armed forces who is qualified for a non-regular retirement under 10 USC Chapter 1223, but is not age 60; and
•  Not enrolled, or eligible to enroll, in a health benefits plan under 5 USC Chapter 89, specifically FEHB.
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.
11.0  COMMUNICATIONS AND CUSTOMER SERVICE (C&CS)
The contractor shall perform C&CS functions to the same extent as they do for TRICARE Select, in addition to C&CS functions specified throughout this chapter.
11.1  Customer Education
The contractor shall distribute information materials relevant to TRS and TRR as specified in Chapter 2, Section 5 and Chapter 11, Section 1 for TRICARE Select. Upon start of coverage under TRS or TRR, the DMDC-generated enrollment notification will include information on how purchasers can obtain TRS and TRR-specific and other TRICARE health plan information.
11.2  Customer Service
11.2.1  The contractor shall provide all customer service support in a manner equivalent to that provided TRICARE Select enrollees.
11.2.2  The contractor shall refer the individual to the SelRes or Retired Reserve member’s personnel office when the contractor receives an inquiry involving TRS and TRR qualifications.
12.0  PAYMENTS FOR CONTRACTOR SERVICES RENDERED
12.1  Claims Reporting
12.1.1  The contractor shall report TRS and TRR claims according to Chapter 3. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
12.1.2  The contractor shall process payments on a non-underwritten basis for the health care costs incurred for each TRS and TRR claim processed to completion according to the provisions of Chapter 3.
12.2  Fiduciary Responsibilities
12.2.1  The contractor shall act as a fiduciary for all funds acquired from TRS and TRR monthly premium collections, which are Government property.
12.2.1.1  The contractor shall develop strict funds control processes for its collection, retention and transfer of TRS and TRR monthly premium funds to the Government.
12.2.1.2  The contractor shall maintain all TRS and TRR monthly premium collections received in accordance with these procedures.
12.2.2  The contractor shall deposit all TRS and TRR monthly premium collections to the established account within one business day of receipt. An established account is a separate non-interest bearing account for the collection and disbursement of TRS and TRR monthly premiums.
12.2.3  The contractor shall wire-transfer all TRS and TRR monthly premium collections and net of refund payments monthly to a specified Government account as directed by the Defense Health Agency (DHA) Contract Resource Management (CRM) Office. The Government will provide the contractor with information for this Government account.
12.2.4  The contractor shall notify the DHA CRM by email within one business day of the deposit specifying, the date and amount of the deposit, as well as its purpose (i.e., TRS premiums).
12.2.4.1  Monthly premiums for TRS and TRR, when established, may be sent as a single wire as long as CRM is notified of the amounts of each type of monthly premium. Collections for delinquency cases that have been transferred to DHA Office of General Counsel (OGC) shall be wire-transferred separately.
12.2.4.2  The contractor shall notify DHA CRM Finance & Accounting Office (F&AO) and DHA OGC by email within one business day of the day of deposit, specifying the sponsor name, the last four digits of the sponsor’s Social Security Number (SSN), payment amount, payment date, date case was transferred to DHA OGC and the date and amount of the deposit.
12.2.5  The contractor shall maintain a system for tracking and reporting TRS and TRR monthly premium billings, collections, and starts of coverage. The system is subject to Government review and audit.
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