2.0 POLICY
2.1 Introduction
Section 1086(d) extends TRICARE
eligibility to persons who would otherwise have lost their TRICARE
eligibility due to attainment of entitlement to hospital insurance
benefits under Part A of Medicare. In order for these individuals to
retain their TRICARE eligibility, they must have Medicare Part B
(Supplementary Medical Insurance (SMI)). In general, when medical
care or, adjunctive dental care is provided to these individuals
and payment may be made under both Medicare and TRICARE, Medicare
is the primary payer and TRICARE will pay the patient liability
when the care received is a benefit of both the Medicare and TRICARE
Program.
2.2 Eligibility
The contractor shall determine
from the Defense Enrollment Eligibility Reporting System (DEERS)
if the individual is eligible for TFL. TFL claims are processed
in accordance with TOM,
Chapter 20.
2.3 TFL beneficiaries, in most
cases, are not eligible to enroll in TRICARE Prime (i.e., retirees
and their family members who are 65 years of age or older, and who
are entitled to Medicare Part A and who have Medicare Part B). See
the TOM,
Chapter 6, Section 1 for exceptions.
Note: Retirees, retiree family members,
and survivors (other than survivors of deceased members who died
on active duty) with any Medicare coverage at any age are not eligible
to enroll in TRICARE Select because they are excluded from the “Retired
Category” definition for TRICARE Select (10 USC 1075(b)(1)(B)).
2.4 Appeal rights are covered in
the TOM,
Chapter 12.
3.0 Other Dual Eligible Beneficiaries
In addition to TFL beneficiaries,
there are other categories of beneficiaries who have dual eligibility
under both TRICARE and Medicare:
3.1 TRICARE
beneficiaries who are age 65 or older and who are not entitled to
premium-free Medicare Part A on their own record or the record of
their current, former, or deceased spouse, but have Medicare Part
B, remain TRICARE eligible and are eligible to enroll in TRICARE
Prime or TRICARE Select.
3.2 Active
Duty Family Members (ADFMs) who are age 65 or older and who are
entitled to premium-free Medicare Part A only remain TRICARE eligible
and are eligible to enroll in TRICARE Prime or TRICARE Select.
3.3 TRICARE beneficiaries (retirees
and family members under age 65) who are entitled to premium-free Medicare
Part A and have Medicare Part B are eligible to enroll in TRICARE
Prime.
3.4 ADFMs under the age of 65 who
are entitled to premium-free Medicare Part A remain TRICARE eligible and
eligible to enroll in TRICARE Prime or TRICARE Select. (See Note
regarding special enrollment periods for certain ADFMs.)
3.5 TRICARE eligible individuals
who are entitled to premium-free Medicare Part A because of a disability
or End Stage Renal Disease (ESRD), where Social Security Disability
Insurance (SSDI) is awarded on appeal and there is a minimum six
month gap between Medicare Part A and Part B effective dates, remain
TRICARE eligible for the period where only Part A was effective.They
are not to be retroactively disenrolled from TRICARE Prime or TRICARE Select
for the period in which they have Medicare Part A only. If a beneficiary
declines Part B coverage, he or she will be ineligible for TRICARE
from the original effective date of Part B until Part B coverage
is established.
3.6 TRICARE
beneficiaries eligible for premium-free Medicare Part A generally
must have Medicare Part B to remain TRICARE eligible. If Part B
coverage is required, but the beneficiary does not have it, the
beneficiary is not eligible for any TRICARE benefits. If the beneficiary
refused or declined Part B coverage when they first became eligible
and subsequently enroll in Part B at a later date, TRICARE eligibility
is restored on the Part B effective date of coverage. In the following
circumstances, Part B is not required:
• Family members of Service members;
• Enrollment in the Uniformed
Services Family Health Plan (USFHP);
• Enrollment in the TRICARE Retired
Reserve (TRR); or
• Enrollment in TRICARE Reserve
Select (TRS).
Note: ADFMs entitled to Medicare
Part A are not required to have Part B to remain eligible for TRICARE
until the sponsor retires. They may enroll in Part B during a special
enrollment period. The special enrollment period is available anytime
the sponsor is on active duty or within the first eight months of
the sponsor’s retirement or loss of TRICARE coverage, whichever
occurs first. The Part B late enrollment premium surcharge is waived.
If the family member enrolls in Part B after the sponsor’s retirement
date, there will be a break in TRICARE coverage. This special enrollment
period does not apply to ADFMs whose Medicare entitlement is based
on ESRD. While ADFMs with ESRD and USFHP/TRS enrollees are not required
to have Medicare Part B, enrollment in Part B when the individual
is first eligible is encouraged. ESRD patients and USFHP/TRS enrollees
may be required to pay the 10% Medicare surcharge for each 12-month
period they were eligible to enroll in Part B, but did not. When
USFHP/TRS beneficiaries are no longer enrolled in these programs,
or when the sponsor of an ADFM with ESRD retires, they are not eligible
for other TRICARE coverage without Part B.