3.0 QUALIFYING
TO PURCHASE TYA COVERAGE
3.1 In order to purchase TYA coverage,
young adult family members who meet the qualifications listed in
paragraph 3.4 must
also be listed in the Defense Enrollment Eligibility Reporting System
(DEERS) database. DMDC will ensure that family members meeting the
qualifications 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 family members qualified
to purchase TYA coverage.
3.3 The contractor shall refer
young adult family members and Uniformed Service sponsors to the
Real-Time Automated Personnel Identification System (RAPIDS) site
if the family member is not found in DEERS.
3.4 Family Member Qualifications
For Purchase Of TYA Coverage
A young adult family member qualifies
to purchase TYA coverage if the family member meets the following
criteria:
3.4.1 Would be a 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 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 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
family members must meet all other qualifications shown in
paragraph 3.4
3.5.2 Young
adult 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 family member reaches the age of 26, whichever
comes first.
3.5.3 Upon the death of an active
duty sponsor, former young adult 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 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
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 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 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 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 family member reaches the age of 26, whichever comes
first, but with Survivor (retiree) cost-shares.
3.5.8 Young
adult 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 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 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 family members of
a member eligible for TAMP coverage may qualify to purchase TYA coverage
until the TAMP coverage ends or the young adult family member reaches
age 26, whichever comes first.
3.5.11 If the member dies while covered
under TAMP, the young adult family member may qualify to purchase TYA
coverage to the end of the TAMP coverage period or until the young
adult 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 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 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 family
member would like to change coverage from TYA Select to TYA Prime, they
must submit a separate application.
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 CollectThe
contractor shall collect an initial payment equal to
two months of premium applicable for the type of coverage requested.
The contractor shall accept initial payment made with a personal
check, cashier’s check, money order, credit or debit card (i.e.,
Visa or MasterCard).
4.1.4.2 EnsureThe
contractor shall 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 AcceptThe
contractor shall 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 begins after
the 12-month lock period ends.
4.1.4.4 EnsureThe
contractor shall ensure requests generated from the
web application and presented (by mail or in-person) as hard copy
contain an original signature.
4.1.4.5 EnsureThe
contractor shall ensure requests generated from the
web application and presented electronically are signed electronically.
4.1.4.6 ReviewThe
contractor shall 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 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 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 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 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 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 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 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 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
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 family member is eligible based on the sponsor’s
eligibility and the geographic location of the qualified young adult
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 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 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 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 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 family members with
a residential address as indicated by the TYA requestor on the TYA
application in the contractor’s jurisdiction.
4.6.2 The contractor
shall report premium-related transactions 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 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 The contractor
shall send premium refunds, to include an explanation of the premium
refund, to the young adult family member’s residential address unless the
sponsor/young adult family member provides an alternate mailing
address.
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 is applied
for loss of qualification.
4.8.2 At any
time a young adult 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 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 family member may
qualify again to purchase coverage under the TYA program.
4.8.5 Young
adult 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 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 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 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 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 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 family
member as appropriate.
4.11.2 When a sponsor’s status changes, DMDC
will terminate coverage under TYA Prime plans in DEERS.
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 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 family member advising them of the termination
of coverage.
4.11.5 The contractor shall contact
the young adult 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 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 family
member as appropriate if advised by DEERS of terminated coverage
through an unsolicited Government-furnished policy notification.
This occurs if a young adult 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 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 family member.
4.13 Young
Adult Family Member Loss Of Eligibility
4.13.1 No lockout is applied for young
adult family member loss of eligibility.
4.13.1.1 If a young adult 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 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 family member’s coverage
is terminated at the anticipated end date, DEERS will not send the
contractor with whom the young adult 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 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 family
member as appropriate. DMDC will send a TN to the young adult family
member. Upon termination of coverage, DMDC will send a notification
to the young adult family member.
4.14 Young
Adult 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 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 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 the contractor shall document 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 their employer.
4.15.1 If a young adult family member becomes
eligible under an eligible employer-sponsored health plan based
on the young adult 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 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 Family Member Loses
Eligibility Due To Non-Payment Of TRS Or TRR Premiums By Their Sponsor
No lockout shall be applied
for young adult 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 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 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 family member.
4.17.6 The contractor shall pend any
claims received for health care furnished to the young adult 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 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 family member unless the
young adult 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 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 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 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 family member if servicing
the residential address for the young adult family member.
5.2.2 The servicing contractor is defined
by the young adult’s residential, not alternate, mailing address.
A young adult family member may elect to provide an alternate mailing
address and may also transfer of geographical area of responsibility
at any time. 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 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 family
members are evaluated to determine if residential address changes
require a notification to the young adult 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 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 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 to
paragraphs 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 The contractor shall process
recurring payments via EFT/RCC 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 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 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 The 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 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) 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 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) are developed
and distributed centrally by Defense Health Agency (DHA) Communications.
7.4.3 The contractor
may obtain copies of TYA informational materials through DHA Communications.
7.5 Customer
Service
The contractor
shall provide all customer service support to young adult family
members in a manner equivalent to that provided to other TRICARE
beneficiaries.