[Federal Register Volume 76, Number 81 (Wednesday, April 27, 2011)]
[Rules and Regulations]
[Pages 23479-23485]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-10241]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[Docket ID: DOD-2011-HA-0029; RIN 0720-AB48]
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); TRICARE Young Adult
AGENCY: Office of the Secretary, DoD.
ACTION: Interim final rule with comment period.
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SUMMARY: This interim final rule implements Section 702 of the Ike
Skelton National Defense Authorization Act for Fiscal Year 2011 (NDAA
for FY11). It establishes the TRICARE Young Adult (TYA) program to
provide an extended medical coverage opportunity to most unmarried
children under the age of 26 of uniformed services sponsors. The
TRICARE Young
[[Page 23480]]
Adult program is a premium-based program.
DATES: This interim final rule is effective April 27, 2011. Written
comments received at the address indicated below by June 27, 2011 will
be considered and addressed in the final rule.
ADDRESSES: You may submit comments, identified by docket number and or
RIN number and title, by any of the following methods: Federal
eRulemaking Portal: http://www.regulations.gov. Follow the instructions
for submitting comments. Mail: Federal Docket Management System Office,
1160 Defense Pentagon, Washington, DC 20301-1160. Instructions: All
submissions received must include the agency name and docket number or
Regulatory Information Number (RIN) for this Federal Register document.
The general policy for comments and other submissions from dependents
of the public is to make these submissions available for public viewing
on the Internet at http://regulations.gov as they are received without
change, including any personal identifiers or contact information.
FOR FURTHER INFORMATION CONTACT: Mark Ellis, TRICARE Management
Activity, TRICARE Policy and Operations Directorate, telephone (703)
681-0039. Questions regarding payment of specific claims under the
TRICARE allowable charge method should be addressed to the appropriate
TRICARE contractor.
SUPPLEMENTARY INFORMATION:
I. Introduction and Background
The purpose of this interim final rule is to establish the TRICARE
Young Adult program implementing Section 702 of the Ike Skelton NDAA
for FY 2011 (Pub. L. 111-383) to provide medical coverage to unmarried
children under the age of 26 who no longer meet the age requirements
for TRICARE eligibility (age 21, or 23 if enrolled in a full-time
course of study at an institution of higher learning approved by the
Secretary of Defense), and who are not eligible for medical coverage
from an eligible employer-sponsored plan (as defined in section
5000A(f)(2) of the Internal Revenue Code of 1986). If qualified, they
can purchase TRICARE Standard/Extra or TRICARE Prime benefits coverage.
The particular TRICARE plan available depends on the military sponsor's
eligibility and the availability of the TRICARE plan in the dependent's
geographic location.
II. Provisions of the Rule Regarding the TRICARE Young Adult Program
A. Establishment of the TRICARE Young Adult Program (paragraph
199.26(a)). This paragraph describes the nature, purpose, statutory
basis, scope, and major features of TRICARE Young Adult, a full cost,
premium-based medical coverage program made available for purchase
worldwide. TYA is similar to young adult coverage under the Patient
Protection and Affordable Care Act, but reflects a number of
differences between TRICARE and typical civilian health care plans.
Among these is that TYA is a full cost premium based program; it is
limited to unmarried dependent children; and the dependent child must
not be eligible for medical coverage from an eligible employer-
sponsored plan (an exclusion that does not expire on January 1, 2014,
but is permanent). TRICARE Young Adult is codified in Title 10, United
States Code, Section 1110b.
The major features of the program include making coverage available
for purchase at a premium which will represent the full cost, including
reasonable administrative costs, as determined on an appropriate
actuarial basis for coverage. There will be various premiums depending
on whether the dependent's sponsor is active duty, retired or eligible
under another plan such as TRICARE Reserve Select or TRICARE Retired
Reserve, and the adult dependent's health coverage--TRICARE Standard
or, for those eligible and where available, TRICARE Prime. The rules
and procedures otherwise outlined in Part 199 of 32 CFR relating to the
operation and administration of the TRICARE program based on the
sponsor's status and health coverage plan will apply for cost-shares,
deductibles, and catastrophic caps upon purchasing TRICARE Young Adult
coverage. Young adult dependents of members on active duty for more
than 30 days are eligible for benefits under the TRICARE ECHO program
under section 199.5 of this Part.
The TRICARE Dental Program (Sec. 199.13 of this Part) and the
TRICARE Retiree Dental Program (Sec. 199.22 of this Part) are not
included as part of TYA.
Under TRICARE Young Adult, qualified young adult dependents may
purchase individual TRICARE coverage by submitting a completed request
in the appropriate format along with an initial payment of the
applicable premium at the time of enrollment. When coverage becomes
effective, a TRICARE Young Adult purchaser receives the TRICARE
benefits according to the rules governing the TRICARE program that the
enrollee qualified for and selected based on the uniformed services
sponsor's status (active duty, retired, Selected Reserve, or Retired
Reserve) and the availability of a desired plan in his or her
geographic location. The rules and procedures otherwise outlined in the
TRICARE Regulation (Part 199) relating to the operation and
administration of the TRICARE programs will apply for cost-shares,
deductibles, and catastrophic caps upon purchasing TRICARE Young Adult
coverage. The young adult dependent's cost-shares, deductibles, and
catastrophic caps will be based on the sponsor's status (active duty,
retired, Selected Reserve, or Retired Reserve) and whether the
dependent has purchased TRICARE Standard/Extra or Prime coverage.
TRICARE Young Adult dependents are provided access priority for care in
military treatment facilities based on their uniformed services
sponsor's status and the selection of health plan.
The Continued Health Care Benefits Program (see Sec. 199.20) shall
be made available to all young adult dependents after aging out of the
TRICARE Young Adult program or who otherwise lose their eligibility for
the TRICARE Young Adult program.
B. Qualifications for TYA coverage (paragraph 199.26(b)). This
paragraph defines the statutory conditions under which unmarried
children qualify as young adult dependents under the TRICARE Young
Adult program. To qualify as a young adult dependent, the dependent
must be under the age of 26, not be otherwise eligible for another
TRICARE program, and not be eligible for medical coverage from an
eligible employer-sponsored plan (as defined in section 5000A(f)(2) of
the Internal Revenue Code of 1986). The dependents' sponsor is
responsible for keeping the Defense Enrollment Eligibility Reporting
System (DEERS) current with eligibility data through the sponsor's
Service personnel office. Using information from the DEERS, the managed
care support contractors have the responsibility to validate a
dependent's qualifications to purchase TRICARE Young Adult coverage.
C. TRICARE Young Adult premiums (paragraph 199.26(c)). Qualified
young adult dependents are charged premiums for coverage under TRICARE
Young Adult that represent the full cost of providing TRICARE benefits
under this program, including the reasonable costs of administration of
the program. The total annual premium amounts shall be determined by
the Assistant Secretary of Defense for Health Affairs (ASD(HA)) using
an appropriate actuarial basis and
[[Page 23481]]
are established and updated annually, on a calendar year basis, by the
ASD(HA) for qualified young adult dependents.
TRICARE Young Adult Premiums--Calendar Year 2011
------------------------------------------------------------------------
Monthly
TRICARE program premium
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TRICARE Standard/Extra Plans............................... $186
TRICARE Prime Plans........................................ 213
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A premium shall be charged for each individual qualified young
adult dependent regardless of whether a sponsoring member has more than
one young adult dependent child who qualifies or purchases coverage
under the TRICARE Young Adult program. The cost shares for TRICARE
Standard/Extra or Prime programs in which the adult child is enrolled
shall be based on the status of the dependent's sponsor. Because of the
differences in cost-shares among the programs and status of the
sponsor, there will be a different premium for TRICARE Standard and
TRICARE Prime. Premiums are to be paid monthly. The monthly rate for
each month of a calendar year is one-twelfth of the annual rate for
that calendar year.
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 Young Adult as determined by the ASD(HA). TRICARE Young Adult
premiums shall be based on the actual costs of providing benefits to
TRICARE Young Adult dependents during the preceding years if the
population of Young Adult dependents enrolled in TRICARE Young Adult is
large enough during those preceding years to be considered actuarially
appropriate. Until such time that actual costs from those preceding
years become available, TRICARE Young Adult premiums shall be based on
the actual costs during the preceding calendar years for providing
benefits to the population of dependents over the age 21 up to age of
26 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. Additionally, premium adjustments may be
made to cover the prospective costs of any significant program changes.
D. Procedures (paragraph 199.26(d)). The Director, TRICARE
Management Activity (TMA) will establish procedures for administration
of TYA. These will include procedures to purchase individual coverage,
such as a request in an approved format, along with an initial payment
of the applicable premium. Applicants must also certify that they meet
the statutory qualifications to purchase coverage under this program.
Additional procedures will be established for a qualified young adult
dependent to purchase TRICARE Young Adult coverage with an effective
date immediately following the last effective date of coverage under
which they previously qualified in another TRICARE program.
There will be open enrollment so that a qualified young adult
dependent may purchase TRICARE Young Adult coverage at any time. The
effective date of coverage for TRICARE Standard will coincide with the
first day of a month after the date the application and required
payment is received. The effective date of coverage for TRICARE Prime
will be first day of the second month after the month in which
application and required payment is received. There will be a limited
period for retroactive coverage. A qualified young adult dependent may
elect to start coverage under the TRICARE Standard plan effective with
the statutory start date of January 1, 2011, if the dependent was
eligible as of that date. If retroactive coverage is elected then
retroactive premiums must be paid back to the statutory start date of
January 1, 2011. If no retroactive coverage is elected or the
retroactive premiums are not paid within the time prescribed, then
coverage will not be retroactive and coverage will apply only
prospectively beginning on the first day of the month after the date of
the application. There shall be no retroactive coverage offered under
any TRICARE Prime plan. No purchase of retroactive coverage may take
place after September 30, 2011.
With respect to termination of coverage, a loss of eligibility or
entitlement for medical benefits of the sponsor will result in
termination of coverage for the dependent's TRICARE Young Adult
coverage on the same date as the sponsor, unless otherwise authorized.
Upon the death of an active duty sponsor, young adult age dependents
may purchase TYA coverage up to the age of 26. If a Selected Reserve
(Sel Res) or Retired Reserve member ends TRICARE Reserve Select (TRS)
or TRICARE Retired Reserve (TRR) coverage, respectively, eligibility
for the young adult dependent to purchase coverage under TRICARE Young
Adult also ends. If a Sel Res sponsor dies while enrolled in TRS, the
otherwise eligible adult age dependent can purchase TYA coverage up to
6 months after the death of the sponsor. If a Retired Reserve sponsor
dies while enrolled in TRR, the otherwise eligible young adult
dependent may continue to purchase TYA coverage until the date on which
the deceased sponsor would have turned age 60. If the Retired Reserve
sponsor was not enrolled in TRR at the time of death, there is no
eligibility to purchase TYA coverage until the sponsor would have
turned age 60. At that point, the young adult dependent qualifies as a
dependent of a deceased retired sponsor and can purchase coverage up to
the age of 26.
Coverage will terminate whenever a dependent ceases to meet the
qualifications for the program. Claims will be denied effective with
the termination date. In addition, covered dependents may terminate
coverage at any time by submitting a completed request in the
appropriate format. Dependents whose coverage under TRICARE Young Adult
terminates for failure to pay premiums in accordance with program
requirements will not be allowed to purchase coverage again under
TRICARE Young Adult for a period of one year following the date of
their coverage termination. This ineligibility period shall be known as
a ``lockout'' period. A request for a waiver of the ``lockout'' period
may be granted by the Director, TRICARE Management Activity, based on
extraordinary circumstances beyond the control of the adult dependent
which resulted in inability to make payments in accordance with program
requirements. The Director may allow a 90-day grace period for payment
to be made. However, if payment is not made by the 90th day, then
coverage will be deemed to have terminated as of the last day of the
month in which an appropriate payment was made and no claims may be
paid for care rendered after the date of termination. Upon termination
of eligibility to purchase TYA coverage, qualified dependents may
purchase coverage under the Continued Health Care Benefit Program for
up to 36 months except if locked out of TYA. Upon application and
payment of appropriate premiums, a young adult dependent who has
already purchased coverage under any of the plans offered under TYA may
change to another TRICARE program for which the dependent is eligible.
Eligibility is based on the sponsor's status and the dependent's
geographic location.
E. Preemption of State laws (paragraph 199.26(e)). This paragraph
provides that the preemptions of State and local laws established for
the TRICARE program also apply to
[[Page 23482]]
TRICARE Young Adult. 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 Young Adult.
F. Administration (paragraph 199.26(f)). This paragraph provides
that the Director, TRICARE Management Activity, may establish other
administrative processes and procedures necessary for the effective
administration of TRICARE Young Adult.
III. Regulatory Procedures
Executive Order 12866 requires certain regulatory assessments for
any significant regulatory action that would result in an annual effect
on the economy of $100 million or more, or have other substantial
impacts. The Congressional Review Act establishes certain procedures
for major rules, defined as those with similar major impacts. The
Regulatory Flexibility Act (RFA) requires that each Federal agency
prepare, and make available for public comment, a regulatory
flexibility analysis when the agency issues a regulation that would
have significant impact on a substantial number of small entities. This
interim final rule will not have an impact on the economy greater than
$100 million annually. Further, it will not have a major impact as that
term is used under the Congressional Review Act nor will have a
significant impact on a substantial number of small entities. This
rule, however, does address novel policy issues relating to
implementation of a new medical benefits program for certain dependents
of the uniformed services. Thus, this rule has been reviewed by the
Office of Management and Budget under E.O. 12866.
Paperwork Reduction Act of 1995
Section III of this interim final rule contains information
collection requirements. DoD has submitted the following proposal to
OMB under the provisions of the Paperwork Reduction Act (44 U.S.C.
Chapter 35). Comments are invited on: (a) Whether the proposed
collection of information is necessary for the proper performance of
the functions of DoD, including whether the information will have
practical utility; (b) the accuracy of the estimate of the burden of
the proposed information collection; (c) ways to enhance the quality,
utility, and clarity of the information to be collected; and (d) ways
to minimize the burden of the information collection on respondents,
including the use of automated collection techniques or other forms of
information technology.
Title: TRICARE Young Adult Application.
Type of Request: Revision.
Number of Respondents: 60,000.
Responses per Respondent: Estimated responses are on average two
per respondent during the term of their TRICARE Young Adult coverage.
Respondents will complete the application upon applying for, changing,
or terminating their TRICARE Young Adult coverage. Not all respondents
will change their coverage, and others may choose to let their coverage
lapse or stop paying premiums instead of submitting a termination
request.
Annual Responses: 120,000.
Average Burden Per Response: The public reporting burden for this
collection of information is estimated to average 15 minutes per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
Annual Burden Hours: 30,000 hours.
Needs and Uses: To evaluate eligibility of young adult dependents
applying for extended dependent coverage under the TRICARE Young Adult
program (10 U.S.C. 1110b).
Affected Public: Young adult dependents applying for, changing, or
terminating their extended medical coverage under the TRICARE Young
Adult program.
Frequency: Whenever the respondent wishes to apply for extended
dependent coverage under the TRICARE Young Adult program, when the
respondent wishes to change their coverage under the TRICARE Young
Adult program, or when the respondent wishes to terminate their
coverage under the TRICARE Young Adult program.
Respondent's Obligation: Required to obtain or retain benefits.
Young adult dependents wishing to purchase extended dependent coverage
will complete the application to apply for, change, or terminate
medical coverage under the TRICARE Young Adult program. Respondents
will complete the requested information. Disclosure is voluntary;
however, failure to provide the information will result in the denial
of the application.
OMB Desk Officer
Written comments and recommendations on the proposed information
collection should be sent to Ms. Jasmeet Seehra at the Office of
Management and Budget, DoD Desk Officer, Room 10102, New Executive
Office Building, Washington, DC 20503, with a copy to the TRICARE
Management Activity, 5111 Leesburg Pike, Suite 810A, Falls, Church, VA
22041. Comments can be received from 30 to 60 days after the date of
this notice, but comments to OMB will be most useful if received by OMB
within 30 days after the date of this notice.
You may also submit comments, identified by docket number and
title, by the following method:
Federal eRulemaking Portal: http://www.regulations.gov.
Follow the instructions for submitting comments.
Instructions: All submissions received must include the agency
name, docket number and title for this Federal Register document. The
general policy for comments and other submissions from members of the
public is to make these submissions available for public viewing on the
Internet at http://www.regulations.gov as they are received without
change, including any personal identifiers or contact information.
To request more information on this proposed information collection
or to obtain a copy of the proposal and associated collection
instruments, please write to TRICARE Management Activity, 5111 Leesburg
Pike, Suite 810A, Falls Church, VA 22041, Mark Ellis, (703) 681-0039.
Additional Regulatory Procedures
We have examined the impact(s) of the interim final rule under
Executive Order 13132 and it does not have policies that have
federalism implications that would have substantial direct effects on
the States, on the relationship between the national government and the
States, or on the distribution of power and responsibilities among the
various levels of government. The preemption provisions in the rule
conform to law and long-established TRICARE policy. Therefore,
consultation with State and local officials is not required.
This rule is being published as an interim final rule with comment
period as an exception to our standard practice of first soliciting
public comment under a proposed rule, in order to comply with the
requirements of the Ike Skelton National Defense Authorization Act for
Fiscal Year 2011, Public Law 111-383, Section 702, which was enacted on
January 7, 2011. This section provides ``the amendments by this section
shall take effect on January 1, 2011. The Secretary of Defense shall
prescribe an interim final rule with respect to such amendments,
effective not later than January 1, 2011.'' In order to provide
coverage as soon as possible consistent
[[Page 23483]]
with statutory requirement, and as proscribed by the provision, the
ASD(HA) has determined that following the standard practice is
unnecessary, impractical, and contrary to the public interest. Public
comments are welcome and will be considered before publication of the
final rule.
List of Subjects in 32 CFR Part 199
Claims, Handicapped, Health insurance, and Military personnel.
Accordingly, 32 CFR part 199 is amended as follows:
PART 199--[AMENDED]
0
1. The authority citation for part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
0
2. Section 199.2(b) is amended by adding in alphabetical order the
definition of ``TRICARE Young Adult'' to read as follows:
Sec. 199.2 Definitions.
* * * * *
(b) * * *
TRICARE Young Adult. The program authorized by and described in
Sec. 199.26 of this part.
* * * * *
0
3. Section 199.26 is added to read as follows:
Sec. 199.26 TRICARE Young Adult.
(a) Establishment. The TRICARE Young Adult (TYA) program offers the
medical benefits provided under the TRICARE programs to qualified
unmarried adult children who do not otherwise have eligibility for
medical coverage under a TRICARE program at age 21 (23 if enrolled in a
full-time course of study at an institution of higher learning approved
by the Secretary of Defense) and are under age 26.
(1) Purpose. As specified in paragraph (c) of this section, TRICARE
Young Adult is a premium-based health plan that is available for
purchase by any qualified adult child as that term is defined in
paragraph (b) of this section. The TRICARE Young Adult program allows a
qualified adult child to purchase TRICARE coverage.
(2) Statutory authority. TRICARE Young Adult is authorized by 10
U.S.C. 1110b.
(3) Scope of the program. TRICARE Young Adult is geographically
applicable to the same extent as specified in section 199.1(b)(1) of
this part.
(4) Major features of TRICARE Young Adult. (i) TRICARE rules
applicable.
(A) Unless specified in this section or otherwise prescribed by the
ASD (HA), provisions of this Part apply to TRICARE Young Adult.
(B) The TRICARE Dental Program (Sec. 199.13 of this part) and the
TRICARE Retiree Dental Program (Sec. 199.22 of this part) are not
covered under TRICARE Young Adult.
(C) TRICARE Standard is available to all TYA-eligible young adult
dependents. TYA enrollees in TRICARE Standard may use TRICARE Extra
(under Sec. 199.17(e) of this Part).
(D) TRICARE Prime is available to TYA-eligible young adult
dependents of sponsors to the same extent it is available to those
sponsors' dependents who do not exceed the age requirements of Sec.
199.3 of this part, provided that TRICARE Prime is available in the
geographic location where the TYA enrollee resides. This applies to
TYA-eligible:
(1) Dependents of sponsors on active duty for more than 30 days or
covered by TAMP (under Sec. 199.3(e));
(2) Dependents of sponsors who are retired members eligible for
TRICARE Prime; and
(3) Survivors of members who died while on active duty for more
than 30 days or while receiving retired or retainer pay.
(ii) Premiums. TRICARE Young Adult coverage is a premium based
program that an eligible young adult dependent may purchase. There is
only individual coverage, and a premium shall be charged for each
dependent even if there is more than one qualified dependent in the
military sponsor's family that qualifies for TRICARE Young Adult
coverage. Dependents qualifying for TRICARE Young Adult status can
purchase individual TRICARE Standard or Prime coverage (as applicable)
according to the rules governing the TRICARE program for which they are
qualified on the basis of their military sponsor's status (active duty,
retired, Selected Reserve, or Retired Reserve) and the availability of
a desired plan in their geographic location. Premiums shall be
determined in accordance with paragraph (c) of this section.
(iii) Procedures. Under TRICARE Young Adult, qualified dependents
under paragraph (b) of this section may purchase individual TRICARE
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
paragraph (d) of this section.
(iv) Benefits. When their TRICARE coverage becomes effective,
qualified beneficiaries receive the benefit of the TRICARE program that
they selected, including, if applicable, access to military treatment
facilities and pharmacies. TRICARE Young Adult coverage features the
per service cost share, deductible and catastrophic cap provisions
based on program selected, i.e., the TRICARE Standard/Extra program or
the TRICARE Prime program, as well as the status of their military
sponsor. Access to military treatment facilities under the system of
access priorities in section 199.17(d)(1) of this Part is also based on
the program selected as well as the status of the military sponsor.
Premiums are not credited to deductibles or catastrophic caps.
(v) Transition period. During fiscal year 2011, the TYA program
will include only TRICARE Standard program coverage.
(b) Eligibility for TRICARE Young Adult coverage.--(1) Young adult
dependent. A young adult dependent qualifies to purchase TRICARE Young
Adult coverage if the dependent meets the following criteria:
(i) Would be a dependent child under section 199.3 of this Part but
for exceeding the age limit under that section; and
(ii) Is a dependent under the age of 26; and
(iii) Is not enrolled, or eligible to enroll, for medical coverage
in an eligible employer-sponsored health plan as defined in section
5000A(f)(2) of the Internal Revenue Code of 1986; and
(iv) Is not otherwise eligible under section 199.3 of this Part;
and
(v) Is not a member of the uniformed services.
(2) The dependents' sponsor is responsible for keeping the Defense
Enrollment Eligibility Reporting System (DEERS) current with
eligibility data through the sponsor's Service personnel office. Using
information from the DEERS, the managed care support contractors have
the responsibility to validate a dependent's qualifications to purchase
TRICARE Young Adult coverage.
(c) TRICARE Young Adult premiums. Qualified young adult dependents
are charged premiums for coverage under TRICARE Young Adult that
represent the full cost of the program, including reasonable
administrative costs, as determined by the ASD(HA) utilizing an
appropriate actuarial basis for the provision of TRICARE benefits for
the TYA-eligible beneficiary population. Separate premiums shall be
established for TRICARE Standard and Prime plans.
[[Page 23484]]
There may also be separate premiums based on the uniformed services
sponsor's status. Premiums are to be paid monthly. 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 Young Adult
monthly premium rates shall be established and updated annually on a
calendar year basis by the ASD(HA) for TRICARE Young Adult individual
coverage.
(ii) The appropriate actuarial basis used for calculating premium
rates shall be one that most closely approximates the actual cost of
providing care to a similar demographic population (based on age and
health plans) as those enrolled in TRICARE Young Adult, as determined
by the ASD(HA). TRICARE Young Adult premiums shall be based on the
actual costs of providing benefits to TYA dependents during the
preceding years if the population of TYA enrollees is large enough
during those preceding years to be considered actuarially appropriate.
Until such time that actual costs from those preceding years become
available, TRICARE Young Adult premiums shall be based on the actual
costs during the preceding calendar years for providing benefits to the
population of similarly aged dependents to make the underlying group
actuarially appropriate. An adjustment may be applied to cover overhead
costs for administration of the program.
(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 mandated by legislative enactment, including but not
limited to significant new programs or benefits.
(d) Procedures. The Director, TRICARE Management Activity (TMA),
may establish procedures for the following.
(1) Purchasing coverage. Procedures may be established for a
qualified dependent to purchase individual coverage. To purchase
TRICARE Young Adult coverage for effective dates of coverage described
below, qualified dependents 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 by the
Director, TRICARE Management Activity for a qualified dependent to
purchase TRICARE Young Adult coverage with an effective date
immediately following the date of termination of coverage under another
TRICARE program. Application for continuation coverage must be made
within 30 days of the date of termination of coverage under another
TRICARE program.
(ii) Open enrollment. Procedures may be established for a qualified
dependent to purchase TRICARE Young Adult coverage at any time. The
effective date of coverage will coincide with the first day of a month.
(iii) Retroactive coverage. A qualified young adult dependent may
elect retroactive TRICARE Standard coverage effective as of January 1,
2011 if dependent was eligible as of that date. In the case of a young
adult dependent who was not eligible as of January 1, 2011, but became
eligible after that date but prior to the date of enrollment, the young
adult dependent may elect retroactive TRICARE Standard coverage
effective as of the date of eligibility. If retroactive coverage is
elected, retroactive premiums must be paid for the time period between
initial eligibility and the date of the election. If no retroactive
coverage is elected or the retroactive premiums are not paid within the
time prescribed, coverage will not be retroactive and coverage will
apply only prospectively under the procedures set forth for open
enrollment. No purchase of retroactive coverage may take place after
September 30, 2011. Coverage under TRICARE Prime may not be made
retroactively.
(2) Termination of coverage. (i) Loss of eligibility or entitlement
for coverage by the sponsor will result in termination of the
dependent's TRICARE Young Adult coverage unless otherwise specified.
The effective date of the sponsor's loss of eligibility for care will
also be the effective date of termination of benefits under the TYA
program unless specified otherwise.
(A) Active Duty Military Sponsor. TYA coverage ends effective the
date of military sponsor's separation from military service. Upon the
death of an active duty sponsor, dependents eligible for Transitional
Survivor coverage may purchase TYA coverage up to the age of 26.
(B) Selected Reserve (Sel Res) Sponsor. Sel Res sponsors must be
currently enrolled in TRICARE Reserve Select (TRS) before a young adult
dependent is eligible to purchase TYA. If TRS coverage is terminated by
the sponsor, TYA coverage ends effective the same termination date as
the sponsor. If the Sel Res sponsor dies while enrolled in TRS, the
young adult dependent is eligible to purchase TYA coverage for six
months after the date of death of the Sel Res sponsor, if otherwise
eligible.
(C) Retired Reserve Sponsor. Retired Reserve members not yet
eligible for retired or retainer pay must be enrolled in TRICARE
Retired Reserve (TRR) to establish TYA eligibility for their young
adult dependents. If TRR coverage is terminated by the sponsor, the TYA
coverage for the young adult dependent ends effective the same date as
the sponsor's termination of coverage under TRR. If the retired reserve
sponsor dies while enrolled in TRR, the young adult dependent may
continue to purchase TYA coverage until the date on which the deceased
member would have attained age 60, as long as otherwise eligible. If
the Retired Reserve member dies and is not enrolled in TRR, there is no
eligibility for TYA coverage until the sponsor would have reached age
60. On the date the military sponsor would have reached 60, a young
adult dependent who otherwise qualifies for TYA qualifies as a
dependent of a deceased retired sponsor and can purchase TYA coverage.
(ii) Failure of a young adult dependent to maintain the eligibility
qualifications in paragraph (b) of this section shall result in the
termination of coverage under the TYA program. The effective date of
termination shall be the date upon which the adult young dependent
failed to meet any of the perquisite qualifications. If a subsequent
change in circumstances re-establishes eligibility (such as losing
eligibility for an eligible employer-sponsored plan), the young adult
dependent may re-enroll for coverage under the TYA program.
(iii) Termination of coverage results in denial of claims for
services with a date of service after the effective date of
termination.
(iv) Covered dependents may request termination of coverage at any
time by submitting a completed request in the appropriate format in
accordance with established procedures.
(3) Lockout. Dependents whose coverage under TRICARE Young Adult
terminates for failure to pay premiums will not be allowed to purchase
coverage again under TYA for a period of one year following the
effective date of termination. Dependents who are terminated for
failure to pay may request a waiver of the lockout from the Director,
TRICARE Management Activity if extraordinary circumstances, as
determined by the Director, prevented the dependent from being able to
pay the premium. The Director may also provide a grace period not to
exceed 90 days after the end of the month during which the last full
[[Page 23485]]
premium was paid, during which a young adult dependent who would
otherwise be subject to a lockout may be reinstated by the payment of
all unpaid premiums. After 90 days, any waiver of a lockout by the
Director shall allow the young adult dependent to re-enroll but not to
receive retroactive coverage.
(4) Eligibility for the Continued Health Care Benefit Program. Upon
termination of eligibility to purchase TYA coverage, dependents may
purchase coverage for up to 36 months through the Continued Health Care
Benefit Program under section 199.20 of this Part unless locked out of
TYA.
(5) Changing Coverage. Upon application and payment of appropriate
premiums, qualified dependents already enrolled in and who are current
in their premium payments may elect to change to another TRICARE
program for which the qualified dependent is eligible based on the
sponsor's eligibility and the geographic location of the qualified
young adult dependent. The Director, TMA shall establish administrative
processes for this change in program enrollment; however, no change
shall be effective until the applicable premium has been paid.
(e) Preemption of State Laws.--The preemption provisions of Sec.
199.17(a)(7) of this part are applicable to the TYA program.
(f) Administration. The Director, TRICARE Management Activity, may
establish other processes, policies and procedures for the effective
administration of TRICARE Young Adult and may authorize exceptions to
requirements of this section, if permitted by law, based on
extraordinary circumstances.
Dated: April 22, 2011.
Patricia L. Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2011-10241 Filed 4-25-11; 11:15 am]
BILLING CODE 5001-06-P