(a) Establishment.
TRICARE Retired
Reserve offers the TRICARE Select self managed, preferred-provider network
option under Sec. 199.17 to qualified members of the Retired Reserve,
their immediate family members, and qualified survivors under this
section.
(1) Purpose.
As specified in paragraph (c)
of this section, TRICARE Retired Reserve is a premium-based health plan
that is available for purchase by any Retired Reserve member who
is qualified for non-regular retirement, but is not yet 60 years
of age, unless that member is either enrolled in, or eligible to
enroll in, a health benefit plan under Chapter 89 of Title 5, United
States Code, as well as certain survivors of Retired Reserve members.
(2) Statutory
Authority.
TRICARE Retired Reserve is
authorized by 10 U.S.C. 1076e.
(3) Scope
of the Program.
TRICARE Retired Reserve is
geographically applicable to the same extent as specified in 32
CFR 199.1(b)(1).
(4) Major
Features of TRICARE Retired Reserve.
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 ASD(HA), provisions
of TRICARE Select under Sec. 199.17 apply to TRICARE Retired Reserve.
(B) Certain special
programs established in 32 CFR part 199 are not available to members
covered under TRICARE Retired Reserve. The Extended Health Care
Option (ECHO) program (sec. 199.5) is not included. The Supplemental Health
Care Program (sec. 199.16) is not included, except when a TRICARE
Retired Reserve covered beneficiary is 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
Retiree Dental Program (sec. 199.13) is independent of this program
and is otherwise available to all members who qualify for the TRICARE
Retiree Dental Program whether or not they purchase TRICARE Retired
Reserve coverage. The Continued Health Care Benefits Program (sec.
199.13) is also independent of this program and is otherwise available
to all members who qualify for the Continued Health Care Benefits
Program.
(ii) Premiums.
TRICARE Retired Reserve coverage
is available for purchase by any Retired Reserve member if the member
fulfills all of the statutory qualifications as well as certain
survivors. A member of the Retired Reserve or qualified survivor
covered under TRICARE Retired Reserve shall pay the amount equal
to 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 Retired Reserve,
Retired Reserve members (or their survivors) 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. Procedures for purchasing coverage
and paying applicable premiums are prescribed in this section.
(iv) Benefits.
When their coverage
becomes effective, TRICARE Retired Reserve beneficiaries receive
the TRICARE Select benefit including access to military treatment
facilities on a space available basis and pharmacies, as described
in Sec. 199.17. TRICARE Retired Reserve coverage features the deductible,
cost sharing, and catastrophic cap provisions of the TRICARE Select
plan applicable to Group B retired members and dependents of retired members
under Sec. 199.17(l)(2)(ii); 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 retired
members and their dependents who are not enrolled in TRICARE Prime
as described in Sec. 199.17(d)(1)(i)(E).
(b) Qualifications
for TRICARE Retired Reserve coverage--
(1) Retired
Reserve Member.
A Retired Reserve member qualifies
to purchase TRICARE Retired Reserve coverage if the member meets
both the following criteria:
(i) Is a member of
a Reserve component of the armed forces who is qualified for a non-regular
retirement at age 60 under chapter 1223 of title 10, U.S.C., but
who is not yet age 60 and
(ii) Is
not enrolled in, or eligible to enroll in, a health benefits plan
under chapter 89 of title 5, U.S.C. That statute has been implemented
under part 890 of title 5, CFR as the Federal Employee Health Benefits
(FEHB) program. For purposes of the FEHB program, the terms “enrolled”,
“enroll” and “enrollee” are defined in Sec. 890.101 of title 5, CFR.
(2) Retired
Reserve Survivor.
If a qualified member of the
Retired Reserves dies while in a period of TRICARE Retired Reserve
coverage, the immediate family member(s) of such member shall remain
qualified to purchase new or continue existing TRICARE Retired Reserve
coverage until the date on which the deceased member of the Retired
Reserve would have attained age 60 as long as they meet the definition
of immediate family members specified in paragraph (g)(2) of this
section. This applies regardless whether either member-only coverage
or member and family coverage was in effect on the day of the TRICARE
Retired Reserve member’s death.
(c) TRICARE
Retired Reserve premiums.
Members are charged
for coverage under TRICARE Retired Reserve that represent the full
cost of the program as determined by the Director utilizing an appropriate
actuarial basis for the provision of the benefits provided under
the TRICARE Select program for the TRICARE Retired Reserve eligible beneficiary
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.--
(i) TRICARE
Retired Reserve monthly premium rates shall be established and updated
annually on a calendar year basis by the ASD(HA) for each of the
two types of coverage, member-only coverage and member-and-family
coverage as described in paragraph (d)(1) of this section.
(ii) The appropriate
actuarial basis used for calculating premium rates shall be one
that most closely approximates the actual cost of providing care
to the same demographic population as those enrolled in TRICARE Retired
Reserve as determined by the ASD(HA). TRICARE Retired Reserve premiums
shall be based on the actual costs of providing benefits to TRICARE
Retired Reserve members and their dependents during the preceding
years if the population of Retired Reserve members enrolled in TRICARE
Retired Reserve is large enough during those preceding years to
be considered actuarially appropriate. Until such time that actual
costs from those preceding years becomes available, TRICARE Retired
Reserve premiums shall be based on the actual costs during the preceding
calendar years for providing benefits to the population of retired
members and their dependents in the same age categories as the retired
reserve population in order to make the underlying group actuarially appropriate.
An adjustment may be applied to cover overhead costs for administration
of the program by the government.
(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
the TRICARE Retired Reserve Program.
(3) Survivor
Premiums.
A surviving family member of
a Retired Reserve member who qualified for TRICARE Retired Reserve
coverage as described herein will pay premium rates at the member-only
rate if there is only one surviving family member to be covered
by TRICARE Retired Reserve 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 the Retired Reserve member as specified in paragraph
(g)(2) of this section may be included in such family coverage.
To purchase either type of TRICARE Retired Reserve coverage for
effective dates of coverage described below, Retired Reserve members
and survivors qualified under either paragraph (b)(1) or (b)(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
Retired Reserve 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 Retired Reserve coverage.
(iii) Enrollment. Procedures for
enrollment in TRICARE Select plans under Sec. 199.17(o) shall apply
to TRICARE Retired Reserve 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 Retired Reserve.
Procedures
may be established for a surviving family member of a qualified
Retired Reserve member who qualified for TRICARE Retired Reserve
coverage as described in paragraph (b)(2) of this section to purchase
new TRICARE Retired Reserve coverage or continue existing TRICARE Retired
Reserve coverage. Procedures similar to those for qualifying life
events may be established for a qualified surviving family member
to purchase new or continuing coverage with an effective date coinciding
with the day of the member’s death. Procedures similar to those
for open enrollment may be established for a qualified surviving family
member to purchase new coverage at any time with an effective date
coinciding with the first day of a month.
(2) Termination. Termination of
coverage for the TRR member/survivor will result in termination
of coverage for the member’s/survivor’s family members in TRICARE
Retired Reserve. Procedures may be established for coverage to be
terminated as follows.
(i) Coverage shall terminate
when members or survivors no longer qualify for TRICARE Retired
Reserve as specified in paragraph (c) of this section. For purposes
of this section, the member or their survivor no longer qualifies
for TRICARE Retired Reserve when the member has been eligible for
coverage in a health benefits plan under Chapter 89 of Title 5,
U.S.C. for more than 60 days. Further, coverage shall terminate
when the Retired Reserve member attains the age of 60 or, if survivor
coverage is in effect, when the deceased Retired Reserve member
would have attained the age of 60.
(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 are not eligible to re-enroll
in TRICARE Retired Reserve 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 Retired Reserve 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 Retired
Reserve. 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 Retired Reserve.
(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 Retired Reserve).
(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 of 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 Retired Reserve, and may authorize exceptions to requirements
of this section, if permitted by law.
(g) Terminology.
The following terms are applicable
to the TRICARE Retired Reserve program.
(1) Coverage.
This term means
the medical benefits covered under the TRICARE Select program as
further outlined in Sec. 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 paragraph 199.3(b)(2)(i) of this part,
or child as defined in paragraph 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 TRR 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 TRR coverage.