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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Young Adult (TYA)
Chapter 25
Section 1
TRICARE Young Adult (TYA)
Revision:  C-4, May 8, 2024
1.0  General
TYA is premium-based TRICARE coverage available for purchase by qualified young adult dependents (referred to as “family members” from here on) under the age of 26 who are no longer eligible for TRICARE at age 21 (age 23 if enrolled in a full-time course of study at an institution of higher learning approved by the Secretary of Defense and more than 50% dependent family member on the Uniformed Service sponsor for financial support). Section 702 of the Ike Skelton National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2011 (Public Law 111-383) established the authority for the TYA program and created Section 1110b, Chapter 55, 10 United States Code (USC). The effective date of coverage for TYA Standard coverage was January 1, 2011; the effective date for TYA Prime coverage was January 1, 2012.
1.1  Benefits And Scope Of Care
Qualified beneficiaries receive the benefits of the TRICARE program purchased, including access to Markets/Military Medical Treatment Facilities (MTFs) and pharmacies. TYA coverage features the per service cost-share, deductible, and catastrophic cap provisions of the TRICARE plan purchased based on the status of the Uniformed Service sponsor and the geographical location of the young adult dependent family member. Premiums are not credited to deductibles or catastrophic caps. The provisions of 32 CFR 199.16(a)(3) concerning the Supplemental Health Care Program (SHCP) for dependents family members under the care of the Market/MTF apply to TYA.
1.2  Specific programs not available under TYA include those listed below:
•  TRICARE Dental Program (TDP) and the retiree dental program with FEDVIP are not part of the medical programs under Chapter 55, 10 USC and, therefore, not covered under TYA. Eligibility for these dental programs end when the dependent family member turns age 21 (age 23 if enrolled in a full-time course of study at an institution of higher learning approved by the Secretary of Defense) or as otherwise indicated in the implementing regulations for those programs.
•  Continued Health Care Benefit Program (CHCBP).
•  TRICARE Reserve Select (TRS) if the young adult dependent family member is a Selected Reserve member in his or her own right.
2.0  TYA COVERAGE
2.1  TYA offers individual coverage only with an individual fee “paid-through date” for each TYA purchaser. A separate monthly premium will be is charged for each young adult dependent family member even if there is more than one qualified dependent family member in the Uniformed Service sponsor’s family who purchases TYA coverage.
2.1.1  DependentsFamily members qualifying for TYA coverage may purchase individual coverage according to the rules governing the TRICARE programs for which they are qualified on the basis of their Uniformed Service sponsor’s status (active duty, retired, Selected Reserve, or TRR).
2.1.2  Young adult dependents under the care family members may purchase TRICARE coverage plans that are offered in their geographic area, i.e., TRICARE Select and TRICARE Prime. Refer to TRICARE Reimbursement Manual (TRM), Chapter 2.
2.2  Each year the Government will determine the monthly premium rates payable by young adult dependents under the care family members for TYA coverage.
2.2.1  The Government will provide the premium rates to the contractor no later than 60 calendar days prior to the effective date.
2.2.2  The contractor shall send enrollees a written notification of any premium changes at least 30 calendar days prior to the effective date.
2.2.3  Unless otherwise specified or directed, the premium rate will be is in effect for a full calendar year on the date specified in Addendum A.
3.0  QUALIFYING TO PURCHASE TYA COVERAGE
3.1  In order to purchase TYA coverage, young adult dependents under the care family members who meet the qualifications listed in paragraph 3.4 and must also be listed in the Defense Enrollment Eligibility Reporting System (DEERS) database. DMDC will ensure that dependents under the care family members meeting the qualifications will be are reflected as eligible to purchase or continue TYA coverage if the Uniformed Service sponsor is eligible for health care under Chapter 55, 10 USC or Chapter 58, 10 USC Section 1145(a), Transitional Assistance Management Program (TAMP).
3.2  The contractor shall rely solely upon DEERS to identify young adult dependents under the care family members qualified to purchase TYA coverage.
3.3  The contractor shall refer young adult dependents under the care family members and Uniformed Service sponsors to the Real-Time Automated Personnel Identification System (RAPIDS) site if the dependent family member is not found in DEERS.
3.4  DependentFamily Member Qualifications For Purchase Of TYA Coverage
A young adult dependent family member qualifies to purchase TYA coverage if the dependent family member meets the following criteria:
3.4.1  Would be a dependent family member child under Chapter 55, 10 USC Section 1072(2) but for exceeding the age limit under that section,
3.4.2  Is a dependent family member under the age of 26,
3.4.3  Is not eligible for medical coverage from an eligible employer-sponsored health plan from the young adult dependent’s family member’s employer as defined in Section 5000A(f)(2) of the Internal Revenue Code of 1986,
•  Is not married,
•  Is not otherwise eligible for care under Chapter 55, 10 USC or Chapter 58, 10 USC Section 1145(a), TAMP,
•  Is not a member of the Uniformed Services.
3.5  Eligibility Of Uniformed Service Sponsor
3.5.1  Eligibility for TYA is only determined by a proper eligibility response in DEERS. Based on the status of the Uniformed Service sponsor, the ability to purchase may be limited or not allowed based on the Uniformed Service sponsor’s status and eligibility for medical care under Chapter 55, 10 USC or Chapter 58, 10 USC Section 1145(a). In addition, young adult dependents under the care family members must meet all other qualifications shown in paragraph 3.4
3.5.2  Young adult dependents under the care family members of active duty members (including those called to active duty for more than 30 calendar days) may qualify to purchase TYA coverage until the active duty sponsor’s date of separation or until the young adult dependent family member reaches the age of 26, whichever comes first.
3.5.3  Upon the death of an active duty sponsor, former young adult dependents under the care family members already aged out of TRICARE are classified as Survivors and may qualify to purchase TYA coverage up to the age of 26 but with Survivor (retiree) cost-shares.
3.5.4  Young adult dependents under the care family members of retired Uniformed Service sponsors may qualify to purchase TYA coverage until they reach the age of 26.
3.5.5  Young adult dependents under the care family members of Uniformed Service sponsors eligible to purchase TRS or TRICARE Retired Reserve (TRR) may qualify to purchase TYA coverage only if the sponsor is enrolled in TRS or TRR and until the young adult dependent family member reaches age 26.
3.5.6  Failure of the Uniformed Service sponsor to enroll in and maintain enrollment in TRS or TRR or failure to pay TRS or TRR premiums will result in the young adult dependent family member not being eligible to purchase TYA coverage as of the date of the sponsor’s loss of enrollment in TRS or TRR.
3.5.7  If the Selected Reserve sponsor dies while enrolled in TRS, the young adult dependent family member may qualify to purchase TYA coverage for up to six months after the date of death of the Selected Reserve sponsor, or until the young adult dependent family member reaches the age of 26, whichever comes first, but with Survivor (retiree) cost-shares.
3.5.8  Young adult dependents under the care family members of a member of the TRR, who dies while in a period of TRR coverage, may qualify to purchase new or continue existing TYA coverage until the young adult dependent family member reaches the age of 26.
3.5.9  If a member of the TRR is not covered by TRR on the date of his or her death, his or her surviving dependents under the care family members do not qualify for TYA coverage until the date on which the deceased member of the TRR would have attained age 60, at which time they may qualify to purchase TYA coverage until reaching the age of 26.
3.5.10  Young adult dependents under the care family members of a member eligible for TAMP coverage may qualify to purchase TYA coverage until the TAMP coverage ends or the young adult dependent family member reaches age 26, whichever comes first.
3.5.11  If the member dies while covered under TAMP, the young adult dependent family member may qualify to purchase TYA coverage to the end of the TAMP coverage period or until the young adult dependent family member reaches age 26, whichever comes first, with Active Duty Family Member (ADFM) cost-shares.
4.0  COVERAGE-RELATED PROCEDURES
The TRICARE Overseas Program (TOP) contractor shall perform these services for young adult dependents under the care family members residing outside of the 50 United States (US) or the District of Columbia.
4.1  Coverage Requests
4.1.1  The contractor shall accept completed TYA enrollment requests presented from the Government-furnished web-based self-service enrollment system/application as well as those presented by phone, by mail, TRICARE Service Centers (TSCs) operated by the TOP contractor, and other means determined by the contractor.
4.1.2  To purchase, change or terminate TYA coverage, qualified young adult dependents under the care family members must present a complete request within deadlines specified in the following paragraphs.
4.1.3  The contractor shall reject and return incomplete requests along with any incorrect premium payments to the applicant, within 10 business days, with an explanation of what is needed for the contractor to accept the application for processing.
4.1.3.1  If a qualified young adult dependent family member would like to change coverage from TYA Select to TYA Prime, they must submit a separate application must be submitted.
4.1.3.2  The contractor shall accept and process requests up to 90 calendar days before the end of the 12-month lockout period if an enrollment lockout is in place (refer to paragraph 4.1.4.3). The procedures for determining the effective date of coverage are specified in the following paragraphs.
4.1.4  The contractor shall meet the following requirements in order for a request to be complete.:
4.1.4.1  Collect an initial payment equal to two months of premium applicable for the type of coverage requested. The contractor shall accept initial payment may be made with a personal check, cashier’s check, money order, credit or debit card (i.e., Visa or MasterCard).
4.1.4.2  Ensure that the request contains account information for collection of ongoing monthly premium payments by either a Recurring Credit Card or Debit Card (RCC) (i.e., Visa or MasterCard) payment or an Electronic Funds Transfer (EFT). The contractor is not required to validate the account information at the time of receipt.
4.1.4.3  Accept completed requests for new coverage when a lockout is in effect for up to 90 calendar days before the end of the 12 month lockout period. The new coverage is to begins after the 12-month lock period ends.
4.1.4.4  Ensure requests generated from the web application and presented (by mail or in-person) as hard copy shall contain an original signature.
4.1.4.5  Ensure requests generated from the web application and presented electronically shall be are signed electronically.
4.1.4.6  Review all information in the signature block on the applicable form with the requestor for requests presented verbally on the phone.
4.1.4.6.1  The contractor shall ask if the requestor agrees to the terms and conditions presented to them.
4.1.4.6.2  The contractor shall reject the request and document in the contractor’s call notes accordingly if the requestor does not agree.
4.1.4.6.3  The contractor shall document agreement in the contractor’s call notes accordingly and continue with processing the request if the requestor agrees.
4.2  Continuous Open Enrollment
A qualified young adult dependent family member may purchase TYA coverage throughout the year unless locked out from TYA coverage.
4.2.1  TYA Select
The effective date of TYA Select coverage shall be is the date the completed request (refer to paragraph 4.1) is received by the contractor or a date up to 90 calendar days in the future as specified by the requestor.
4.2.2  TYA Prime Plans
4.2.2.1  The effective date of TYA Prime coverage shall be 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.
4.2.2.2  Young adult dependents under the care family members may qualify to purchase TOP Prime or TOP Prime Remote plan coverage (refer to Chapter 24, Section 5).
4.2.2.3  Young adult dependents under the care family members may request cross-geographical area of responsibility enrollment (refer to Chapter 6, Section 1) but apply using the TYA Application (DD Form 2947) in accordance with paragraph 4.5.
4.2.2.4  The contractor shall notify TYA Prime enrollees who no longer meet TRICARE Prime enrollment requirements (refer to Chapter 6, Section 1) that their TYA coverage will be terminated on the first of the month following 30 calendar days from the initial notification date and the option of applying for TYA Select coverage refer to (paragraphs 4.1 and 4.4). No lockout shall be applied.
4.3  Continuation Coverage
4.3.1  A qualified young adult dependent family member may purchase TYA coverage with an effective date immediately following the termination of coverage under another TRICARE program, including the CHCBP.
4.3.2  The completed TYA request required by paragraph 4.1 must either be received by the contractor or TOP contractor by phone, entered into the Government-furnished web-based self-service enrollment system/application, or postmarked no later than 90 calendar days following termination of coverage.
4.3.3  The contractor shall process the application as a new request if the young adult dependent family member does not meet the requirement for continuation coverage.
4.3.4  The contractor shall process the application as an open enrollment request if the young adult dependent family member does not meet the requirement for continuation coverage. (See the TRICARE Policy Manual (TPM), Chapter 10, Section 4.1, for information regarding the CHCBP).
4.4  Changing Coverage Within The Same Contractor
4.4.1  Upon receipt of a completed request (refer to paragraph 4.1), qualified dependents under the care family members already enrolled in a TYA plan and who are current in their premium payments may elect to change to another TYA plan for which the qualified dependent family member is eligible based on the sponsor’s eligibility and the geographic location of the qualified young adult dependent family member. Changes in coverage are effective following the application processing time frames listed in paragraph 4.6.
4.4.2  The contractor shall, if the premium amount changes, adjust future premiums by applying any overages to future TYA premium payments and adjusting the (EFT or RCC) payments so the young adult dependent family member is not over or undercharged for the coverage requested.
4.5  Transfer of Coverage to Another Contractor
4.5.1  The gaining contractor shall process valid transfer requests within 10 calendar days. Changes in coverage are effective following the request processing time frames listed in paragraph 4.6.
4.5.1.1  Young adult dependents under the care family members desiring to transfer TYA coverage to another contractor must submit a completed request (refer to paragraph 4.1) to the desired contractor.
4.5.1.2  Transfer of TYA coverage to another contractor is only permitted if the young adult dependent family member is current with his or her premiums.
4.5.2  The contractor shall, if the premium amount changes, adjust future premiums by applying any overages to future TYA premium payments, and adjusting the EFT or RCC payments so the young adult dependent family member is not over or undercharged for the coverage requested.
4.6  Processing
4.6.1  The contractor shall process all TYA transactions through the Government-furnished web-based system/application for young adult dependents under the care family members with a residential address as indicated by the TYA requestor on the TYA application in the contractor’s jurisdiction.
4.6.2  PremiumThe contractor shall report premium-related transactions shall be reported through the enrollment fee payment interface or Catastrophic Cap and Deductible (CC&D) Fee website (refer to the TRICARE Systems Manual (TSM), Chapter 3, Section 4.2).
4.6.3  The contractor shall process TYA completed requests (refer to paragraph 4.1) no later than 10 calendar days after receipt.
4.6.4  The contractor shall assign Primary Care Managers (PCMs) to purchasers of TYA Prime coverage per Chapter 6.
4.6.5  The contractor shall notify the young adult within 10 calendar days of receipt of the request if the contractor is unable to enroll the young adult dependent family member in the Government-furnished web-based system/application due to:
•  A 90-day future enrollment limitation;
•  DEERS not reflecting eligibility; or
•  Any other Government-furnished web-based system/application limitation.
4.6.6  The contractor shall, in the notification described in paragraph 4.6.5, offer to return any premium payments collected to the member. The notice shall explain what is needed for the contractor to accept the request for processing.
Note:  See the TSM, Chapter 2, Addendum L, for a full list of TRS Health Care Delivery Plan (HCDP) coverage code values.
4.7  Termination Of TYA Coverage
4.7.1  The contractor shall initiate return of any excess premium amounts paid prorated to the day as indicated no later than 10 calendar days after the effective date of the termination or after receipt of a Government-furnished policy notification of a termination, whichever is later.
4.7.2  PremiumThe contractor shall send premium refunds, to include an explanation of the premium refund, will be sent to the young adult dependent’s family member’s residential address unless the sponsor/young adult family member provides an alternate mailing address has been provided.
4.7.3  The contractor shall update DEERS with any premium amount refunded within 30 calendar days.
4.7.4  The contractor shall apply a lockout on the occasion of termination of TYA coverage as specified in the following paragraphs. When applied, a lockout shall remain in effect for 12 months after the last paid-through date.
4.8  Loss Of TYA Qualification
4.8.1  No lockout will be is applied for loss of qualification.
4.8.2  At any time a young adult dependent family member ceases to meet all eligibility qualifications, coverage under the TYA program shall terminate.
4.8.3  DEERS will automatically enroll or change the enrollment of certain beneficiaries as described in Chapter 6, Section 1.
4.8.3.1  The contractor will receive a Government-furnished policy notification advising it of all changes.
4.8.3.2  The effective date of termination shall be the date upon which the young adult dependent family member ceased to meet any of the prerequisite qualifications.
4.8.4  If a subsequent change in circumstances occurs such as losing eligibility for an eligible employer-sponsored plan, the young adult dependent family member may qualify again to purchase coverage under the TYA program.
4.8.5  Young adult dependents under the care family members who age out of TYA at age 26 may be eligible to purchase CHCBP coverage (see TPM, Chapter 10, Section 4.1).
4.8.6  Upon termination of coverage, DMDC will send a notification to the young adult dependent family member.
4.9  Change in Sponsor Status
A change in sponsor status (e.g., active to retired; active duty to the Reserve Component (RC)), may require the young adult dependent’s family member’s coverage to be transferred to another TYA coverage plan or cause TYA coverage to be terminated.
4.10  TYA Select Coverage
4.10.1  DEERS will automatically enroll or change the enrollment of certain beneficiaries as described in Chapter 6, Section 1.
4.10.2  The contractor will receive a Government-furnished policy notification advising it of all changes.
4.10.3  When a sponsor’s status changes, coverage under a TYA Select coverage may be transferred in DEERS by DMDC to an appropriate TYA Select plan consistent with the new sponsor status unless the Uniformed Service sponsor is not eligible for TRICARE coverage or the RC Uniformed Service sponsor is not enrolled in TRR or TRS.
4.10.3.1  DEERS will send the contractor with which the young adult dependent family member is enrolled an unsolicited Government-furnished policy notification advising the contractor of the transferred coverage.
4.10.3.2  When a sponsor status changes and the coverage cannot be transferred, DEERS will terminate the coverage.
4.10.3.3  If the termination date is different from the anticipated end date, DEERS will notify the contractor with an unsolicited Government-furnished policy notification that the coverage is terminated. DMDC will send a notification to the young adult dependent family member.
4.10.4  The contractor shall update its fee system as appropriate.
4.10.5  The contractor shall, upon receipt of an unsolicited Government-furnished policy notification with an updated enrollment end reason code and an enrollment extension end reason code indicating a TYA individual is again eligible for TYA coverage after termination due to a change in sponsor status, contact the TYA individual family member within 10 calendar days to offer enrollment assistance if TYA coverage has not already been re-established.
4.11  TYA Prime Coverage
4.11.1  The contractor shall update the fee system based on the terminated coverage for the young adult dependent family member as appropriate.
4.11.2  When a sponsor’s status changes, DMDC will terminate coverage under TYA Prime plans is terminated in DEERS by DMDC.
4.11.3  If termination is at a date other than the anticipated end date, DEERS will send the contractor with whom the young adult dependent family member is enrolled (and if Market/MTF enrollee) an unsolicited notification advising of the terminated coverage.
4.11.4  DMDC will send a termination notice (TN) to the young adult dependent family member advising them of the termination of coverage.
4.11.5  The contractor shall contact the young adult dependent family member within 10 calendar days to offer enrollment assistance if TYA coverage has not already been re-established upon receipt of an unsolicited Government-furnished policy notification with an updated enrollment end reason code and an enrollment extension end reason code indicating a young adult dependent family member is again eligible for TYA coverage after termination due to a change in sponsor status.
4.11.6  If TYA eligibility is re-established subsequent to a termination due to a sponsor status change, DMDC will send an unsolicited Government-furnished policy notification with an updated enrollment end reason code and an enrollment extension end reason code.
4.12  Sponsor Loss of Eligibility
4.12.1  No lockout shall be applied for sponsor loss of eligibility. When a sponsor‘s eligibility is terminated, coverage under TYA is also terminated.
4.12.2  The contractor shall update the fee system based on the terminated coverage for the young adult dependent family member as appropriate if advised by DEERS of terminated coverage through an unsolicited Government-furnished policy notification. This occurs if a young adult dependent’s family member’s enrollment is terminated at a date other than the anticipated end date.
4.12.3  The contractor shall terminate coverage for the young adult dependent family member as appropriate (refer to paragraph 4.7) when eligibility is terminated at the anticipated end date. In this case, DEERS will not send the contractor an unsolicited Government-furnished policy notification advising the contractor of the terminated coverage. Upon termination of coverage, DMDC will send a notification to the young adult dependent family member.
4.13  Young Adult Dependent Family Member Loss Of Eligibility
4.13.1  No lockout will be is applied for young adult dependent family member loss of eligibility.
4.13.1.1  If a young adult dependent’s family member’s coverage is terminated at a date other than the anticipated end date, DEERS will send the contractor with whom the young adult dependent family member is enrolled an unsolicited Government-furnished policy notification advising the contractor of the terminated coverage.
4.13.1.2  If a young adult dependent’s family member’s coverage is terminated at the anticipated end date, DEERS will not send the contractor with whom the young adult dependent family member is enrolled an unsolicited Government-furnished policy notification advising the contractor of the terminated coverage.
4.13.2  The contractor shall terminate coverage for the young adult dependent family member as appropriate (refer to paragraph 4.7).
4.13.3  The contractor shall update the fee system based on the terminated coverage for the young adult dependent family member as appropriate. DMDC will send a TN to the young adult dependent family member. Upon termination of coverage, DMDC will send a notification to the young adult dependent family member.
4.14  Young Adult Dependent Family Member Gains Other TRICARE Coverage
No lockout shall be applied for terminated coverage due to the gain of other TRICARE coverage.
4.15  Young Adult Dependent Family Member Gains Own Eligible Employer-Sponsored Coverage
No lockout shall be applied for termination due to eligibility for medical coverage offered from an eligible employer-sponsored plan. The young adult dependent family member must notify the contractor with a written request, on the Government-furnished web-based self-service enrollment system/application, or with a telephone request (which is to be the contractor shall documented in the contractor’s call notes) to terminate TYA coverage within 30 calendar days of when he or she becomes eligible for an employer-sponsored health plan offered by his or her employer.
4.15.1  If a young adult dependent family member becomes eligible under an eligible employer-sponsored health plan based on the young adult dependent’s family member’s employment for a period of 30 calendar days or less, TYA coverage will continue unchanged.
4.15.2  The contractor shall terminate the TYA coverage using the Government-furnished web-based system/application without applying a lockout upon notification from a young adult dependent family member that he or she is eligible for medical coverage from an eligible employer-sponsored health plan for a period of more than 30 calendar days.
4.16  Young Adult Dependent Family Member Loses Eligibility Due To Non-Payment Of TRS Or TRR Premiums By Their Sponsor
No lockout shall be applied for young adult dependents under the care family members of a TRS or TRR sponsor that was disenrolled and locked out for failure to pay TRS or TRR premiums. However, until the TRS or TRR-eligible sponsor restores TRS or TRR coverage, the young adult dependent family member does not qualify to purchase TYA coverage.
4.17  Failure To Make Payment
4.17.1  Failure or refusal to pay monthly premiums or any outstanding insufficient funds fees in accordance with the procedures in this chapter shall result in termination of coverage and a lockout as specified in paragraph 4.7. The effective date of termination is the first day following the paid-through date.
4.17.2  The contractor shall terminate coverage of the young adult dependent family member if the monthly premium payment is not received by the last day of the month following the due date for the monthly premium payment.
4.17.3  The contractor shall terminate coverage with a termination effective date retroactive to the last paid-through date after the last day of the month.
4.17.4  Failure to provide information to establish or maintain a recurring EFT or a RCC for monthly premium payment will result in coverage being terminated for failure to comply with paragraph 5.3 and subordinate paragraphs.
4.17.5  DMDC sends written notification of the termination and the lockout from the last paid-through date to the young adult dependent family member.
4.17.6  The contractor shall pend any claims received for health care furnished to the young adult dependent family member 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 young adult dependent family member will be responsible for the cost of any health care received after the termination effective date following retroactive termination of coverage.
4.17.7  The contractor shall initiate recoupment of health care costs following the procedures in Chapter 10, Section 3 if claims are not pended.
4.18  Requests For Voluntary Termination
The contractor shall apply a lockout as specified in paragraph 4.7 for voluntary termination requested by the young adult dependent family member unless the young adult dependent family member is eligible for an employer-sponsored health plan. DMDC sends written notification of the termination and the lockout from the last paid-through date.
4.18.1  The contractor shall accept requests for termination of coverage from young adult dependents under the care family members at any time. Termination of coverage requests includes those with:
•  An original signature;
•  A validated electronic signature offered by and collected by the contractor;
•  A verbal consent provided by telephone and documented in the contractor’s call notes;
•  A self-attestation by the beneficiary when using the Government-furnished web-based self-service enrollment system/application system.
4.18.2  The effective date of termination is either:
•  The last day of the month in which the request was received by the contractor;
•  The last day of a future month as specified in the request given that the request was received by the contractor in the month preceding the requested month of termination;
•  As directed by the waiver approval authority for waiver cases.
4.19  Canceled Eligibility And Enrollment
4.19.1  No lockout shall be applied for a canceled enrollment.
4.19.2  The contractor shall notify the young adult dependent family member of the cancellation and refund any unused portion of the premium payment; including an explanation for the premium refund when the contractor receives a Government-furnished policy notification for a canceled enrollment.
4.19.3  The contractor shall update DEERS with any premium amount refunded within 30 calendar days. No lockout shall be applied for a canceled enrollment.
4.19.4  The contractor shall recoup claims for the canceled enrollment period.
4.20  Reinstatement
4.20.1  The contractor shall accept and honor a request from an otherwise qualified young adult family member to reinstate TYA coverage retroactive to the last paid-through date with no justification needed when a lockout is in effect if the request meets all of the following conditions:
4.20.1.1  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.
4.20.1.2  Payment of all premiums from the last paid-through date through the current month, plus the amount for the following two months is included (to include any administrative fees)
4.20.2  Information is provided to establish recurring electronic premium payments as specified in paragraph 4.1.4.2.
4.20.3  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.
5.0  PREMIUM COLLECTION
5.1  The contractor shall perform all premium functions required for TYA.
5.1.1  Young adult dependents under the care family members are responsible for all premium payments for the individual coverage being purchased.
5.1.2  At least an initial payment (see paragraph 4.1) of premiums are required, then only monthly premium payments are permitted.
5.1.3  The contractor shall report premium-related transactions through the enrollment fee payment interface or CC&D Fee Website (see TSM, Chapter 3, Section 4.2).
5.2  Jurisdiction For Premium Billing And Collection
5.2.1  The contractor shall perform premium functions for the young adult dependent family member if servicing the residential address for the young adult dependent family member.
5.2.2  The servicing contractor is defined by the young adult’s residential, not alternate, mailing address. A young adult dependent family member may elect to provide an alternate mailing address and may also transfer of geographical area of responsibility at any time. No maximum exists for The contractor shall not limit the number of transfers allowed from one geographical area of responsibility to another each year.
5.2.2.1  The outgoing contractor shall notify the young adult dependent family member within 10 calendar days that he or she need to contact a servicing contractor in his or her new area to transfer coverage to the new area any time the servicing contractor notices that a new residential address is in the servicing area of another contractor.
5.2.2.2  The gaining contractor shall perform the premium collections for future payments.
5.2.3  All unsolicited Government-furnished policy notifications for young adult dependents under the care will be family members are evaluated to determine if residential address changes require a notification to the young adult dependent family member (refer to paragraphs 5.2.2 through 5.2.2.2).
5.3  Premium Collection Processes
5.3.1  The contractor shall credit the young adult dependent’s family member’s account for premium payments received.
5.3.1.1  Premium payments are due for receipt by the contractor no later than the last calendar day of the current month for the following month of coverage.
5.3.1.2  In the case of a start date of coverage at any time other than the first of a month (refer to paragraph 4.6 or as directed by the waiver approval authority), the contractor shall calculate the first payment collected shall to include the prorated amount on a daily basis necessary to synchronize the paid-through date to the last day of the month.
5.3.1.3  The daily prorated amount is equal to 1/30th of the appropriate premium (rounded to the penny) regardless of how many days are actually in the month.
5.3.2  The contractor shall collect monthly premium payments from TYA purchasers as appropriate and report to DEERS the premium amount paid for those payments, including any overpayments that are not refunded to the purchaser (refer to the TSM, Chapter 3).
5.3.3  The contractor may, in the event that there are insufficient funds to process a premium payment, assess the account holder a fee of up to $20 US dollars ($20.00) which is retained by the contractor.
5.3.4  The contractor shall provide commercial payment methods for TYA premiums that best meet the needs of beneficiaries while conforming toparagraphs 5.3.5 through 5.3.10.
5.3.5  The contractor shall process an EFT or RCC payment within the first five business days of the month of coverage.
5.3.5.1  The contractors shall ensure recurring monthly premiums are paid by an automated, electronic payment through an EFTs or a RCC from a designated financial institution. These are the only acceptable payment methods for the recurring monthly premiums.
5.3.5.2  The contractor shall contact the applicant to make arrangements for payment by EFT or RCC from a designated financial institution if an application is received requesting TYA premium payments via monthly allotment from military retired pay.
5.3.5.3  RecurringThe contractor shall process recurring payments via EFT/RCC shall be processed within the first five business days of the month of coverage.
5.3.6  The contractor shall ensure the first initial payment (as specified in paragraph 4.6) is paid by the purchaser at the time the TYA application is submitted to allow time to establish the EFT/RCC recurring payment.
5.3.6.1  The contractor shall accept payment of the first installment by personal check, cashier’s check, traveler’s check, money order, or credit card (i.e., Visa or MasterCard).
5.3.6.2  The contractor shall initiate recurring monthly EFT/RCC payments and shall obtain and verify the information necessary to do so.
5.3.7  The contractor shall initiate action to modify EFT/RCC recurring payment amounts to support premium changes.
5.3.8  The contractor shall direct bill the young adult dependent family member only when a problem occurs in setting up or maintaining the EFT/RCC recurring payment.
5.3.9  The contractor shall send bills to the residential or mailing address designated by the young adult dependent family member.
5.3.10  The contractor shall grant the TYA purchaser 30 calendar days after the paid-through date to provide information for a new automated monthly payment method when an administrative issue arises that stops or prevents an EFT/RCC recurring monthly payment from being received by the contractor (e.g., incorrect or transposed number provided by the beneficiary, credit card expired, or bank account closed).
5.3.11  The contractor shall accept payment in accordance with paragraph 5.3.6 during this 30 day period in order to preserve the beneficiary’s TYA enrollment status.
5.4  Annual Premium Adjustment
5.4.1  ContractorsThe contractor shall notify current TYA purchasers in writing of any annual premium adjustments no later than 30 calendar days after the contractors receive notification of the updated premiums.
5.4.2  The contractor’s notification shall include the new amount for TYA coverage (refer to Addendum A) and shall include the following statement:
“You must notify us if you:
•  Become eligible for employer-sponsored medical coverage based upon your own employment as defined in section 5000A(f)(2) of the Internal Revenue Code of 1986;
•  Marry;
•  Are a Uniformed Services member on active duty greater than 30 calendar days;
•  Are a Uniformed Services member of the Selected Reserves;
•  If any of the above occurs, you shall notify us by submitting a request to terminate TYA coverage to preclude recoupment actions and to request a refund of any overpaid premiums, as applicable.”
6.0  CLAIMS PROCESSING
6.1  The contractor shall process TYA claims using established TRICARE cost-sharing rules and guidance based on the sponsor‘s status and the TYA plan purchased.
6.2  Claims jurisdiction rules apply (refer to Chapter 8, Section 2). TRICARE Other Health Insurance (OHI) processing rules apply to TYA except for claims from eligible employer-sponsored health plans (refer to paragraph 6.6).
6.3  The contractor shall not recalculate the individual cost-shares, contributions to the individual and family deductibles, and contributions to the family catastrophic if a young adult dependent family member purchases TYA coverage during the same calendar year that he or she had another TRICARE health plan in effect.
6.4  Medicare is the primary payer for TRICARE beneficiaries who are eligible for Medicare. Claims under the TRICARE Medicare Eligible Program (TMEP) will be are adjudicated under the rules set forth in the TRM, Chapter 4, Section 4.
6.4.1  The contractor shall follow procedures established in Chapter 8, Section 2 regarding claims jurisdiction for dual eligibles.
6.4.2  Payment of Medicare Part B premiums does not provide a basis to waive TYA premiums.
6.5  The contractor shall initiate recoupment of claims paid if appropriate as specified in Chapter 10 when the contractor receives a Government-furnished policy notification of a retroactive TYA disenrollment.
6.6  The contractor shall report the discovery to the appropriate waiver approval authority no later than one business day after discovery if at any time the contractor discovers that the young adult dependent family member may be eligible or is enrolled in an eligible employer-sponsored health plan from his or her employer.
6.6.1  The contractor may pend claims until a final decision is reached.
6.6.2  The contractor shall follow paragraph 4.7 and its subordinate paragraphs for loss of TYA eligibility, if applicable.
7.0  COMMUNICATIONS AND CUSTOMER SERVICE (C&CS)
7.1  The contractor shall perform C&CS functions to the same extent as it does for other TRICARE plans in addition to C&CS functions specified throughout this Chapter.
7.2  The contractor shall send fulfillment materials only upon request.
7.3  Upon start of coverage under TYA, the DMDC-generated enrollment notification will include information on how purchasers can obtain TYA and other TRICARE plan materials over the Internet or how to request fulfillment materials from the contractor.
7.4  Customer Education
7.4.1  The contractor shall distribute all informational materials associated with the TYA program to the same extent and through the same means as other TRICARE materials are distributed.
7.4.2  Materials (e.g., public notices, flyers, informational brochures, website) will be are developed and distributed centrally by Department of Defense (DoD), Defense Health Agency (DHA) Communications.
7.4.3  CopiesThe contractor may obtain copies of TYA informational materials may be obtained through DHA Communications.
7.5  Customer Service
The contractor shall provide all customer service support to young adult dependents under the care family members in a manner equivalent to that provided to other TRICARE beneficiaries.
8.0  ANALYSIS AND REPORTING
TYA workload shall be includedThe contractor shall include, but not separately identified identify, TYA workload in all beneficiary-related reports required by the Government Designated Authority (GDA).
9.0  PAYMENTS FOR CONTRACTOR SERVICES RENDERED
9.1  Claims Reporting
The contractor shall report TYA program claims according to Chapter 3 and process payments on a non-underwritten basis for the health care costs incurred for each TYA claim processed to completion according to the provisions of Chapter 3.
9.2  Fiduciary Responsibilities
9.2.1  The contractor shall act as a fiduciary for all funds acquired from TYA premium collections, which are retained by the Government.
9.2.2  The contractor shall develop strict funds control processes for its collection, retention and transfer of premium funds to the Government.
9.2.3  The contractor shall maintain all premium collections received in accordance with these procedures.
9.2.4  The contractor shall deposit TYA premium collections to a non-interest bearing account established to collect and disburse TYA premiums within one business day of receipt.
9.2.5  A separate bank account is not required; however, individual line item reporting for the TYA program is required.
9.2.6  The contractor shall wire-transfer the premium collections, and net of refund payments, monthly to a specified Government account as directed by the DHA Contract Resource Management (CRM) Finance and Accounting Office (F&AO).
9.2.6.1  The Government will provide the contractor with information for this Government account.
9.2.6.2  The contractor shall notify the DHA CRM F&AO, by email, within one business day of the deposit, specifying the date and amount of the deposit as well as its purpose (i.e., TYA premiums).
9.2.6.3  The contractor shall maintain a system for tracking and reporting premium billings, collections, and starts of coverage.
9.2.6.4  The system is subject to Government review and audit.
9.2.7  The contractor shall electronically submit monthly reports of premium activity supporting the wire transfers of dollars. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
10.0  CODING OF TRICARE ENCOUNTER DATA (TED) RECORDS
10.1  The contractor shall submit TED records in accordance with the TSM.
10.2  The contractor shall submit the primary TYA HCDP Coverage Code and Special Processing Codes PF or AU as appropriate on the TED record when the secondary HCDP Coverage Code is 400 (Extended Care Health Option (ECHO)) and the TYA beneficiary is receiving care considered an ECHO benefit.
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