[Code of Federal Regulations]
[Title 32, Volume 2]
[Revised as of July 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 32CFR199.3]

[Page 92-102]
 
                       TITLE 32--NATIONAL DEFENSE
 
        CHAPTER I--OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED)
 
PART 199_CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES 
 
Sec. 199.3  Eligibility.

    (a) General. This section sets forth those persons who, by the 
provisions of 10 U.S.C. chapter 55, and the NATO Status of Forces 
Agreement, are eligible for CHAMPUS benefits. A determination that a 
person is eligible does not automatically entitle such a person to 
CHAMPUS payments. Before any CHAMPUS benefits may be extended, 
additional requirements, as set forth in other sections of this part, 
must be met. Additionally, the use of CHAMPUS may be denied if a 
Uniformed Service medical treatment facility capable of providing the 
needed care is available. CHAMPUS relies primarily on the Defense 
Enrollment Eligibility Reporting System (DEERS) for eligibility 
verification.
    (b) CHAMPUS eligibles--(1) Retiree. A member or former member of a 
Uniformed Service who is entitled to retired, retainer, or equivalent 
pay based on duty in a Uniformed Service.
    (2) Dependent. Individuals whose relationship to the sponsor leads 
to entitlement to benefits. CHAMPUS eligible dependents include the 
following:
    (i) Spouse. A lawful husband or wife of a member or former member. 
The spouse of a deceased member or retiree must not be remarried. A 
former spouse also may qualify for benefits as a dependent spouse. A 
former spouse is a spouse who was married to a military member, or 
former member, but whose marriage has been terminated by a final decree 
of divorce, dissolution or annulment. To be eligible for CHAMPUS 
benefits, a former spouse must meet the criteria described in paragraphs 
(b)(2)(i)(A) through (b)(2)(i)(E) of this section and must qualify under 
the group defined in paragraph (b)(2)(i)(F)(1) or (b)(2)(i)(F)(2) of 
this section.
    (A) Must be unremarried; and
    (B) Must not be covered by an employer-sponsored health plan; and
    (C) Must have been married to a member or former member who 
performed at least 20 years of service which can be credited in 
determining the member's or former member's eligibility for retired or 
retainer pay; and
    (D) Must not be eligible for Part A of Title XVIII of the Social 
Security Act (Medicare) except as provided in paragraphs (b)(3), 
(f)(3)(vii), (f)(3)(viii), and (f)(3)(ix) of this section; and
    (E) Must not be the dependent of a NATO member; and
    (F) Must meet the requirements of paragraph (b)(2)(i)(F)(1) or 
(b)(2)(i)(F)(2) of this section:
    (1) The former spouse must have been married to the same member or 
former member for at least 20 years, at least 20 of which were 
creditable in determining the member's or former member's eligibility 
for retired or retainer pay. Eligibility continues indefinitely unless 
affected by any of the conditions of paragraphs (b)(2)(i)(A) through 
(b)(2)(i)(E) of this section.
    (i) If the date of the final decree of divorce, dissolution, or 
annulment was before February 1, 1983, the former

[[Page 93]]

spouse is eligible for CHAMPUS coverage of health care received on or 
after January 1, 1985.
    (ii) If the date of the final decree of the divorce, dissolution, or 
annulment was on or after February 1, 1983, the former spouse is 
eligible for CHAMPUS coverage of health care which is received on or 
after the date of the divorce, dissolution, or annulment.
    (2) The former spouse must have been married to the same member or 
former member for at least 20 years, and at least 15, but less than 20 
of those married years were creditable in determining the member's or 
former member's eligibility for retired or retainer pay.
    (i) If the date of the final decree of divorce, dissolution, or 
annulment is before April 1, 1985, the former spouse is eligible only 
for care received on or after January 1, 1985, or the date of the 
divorce, dissolution, or annulment, whichever is later. Eligibility 
continues indefinitely unless affected by any of the conditions of 
paragraphs (b)(2)(i)(A) through (b)(2)(i)(E) of this section.
    (ii) If the date of the final decree of divorce, dissolution or 
annulment is on or after April 1, 1985, but before September 29, 1988, 
the former spouse is eligible only for care received from the date of 
the decree of divorce, dissolution, or annulment until December 31, 
1988, or for two years from the date of the divorce, dissolution, or 
annulment, whichever is later.
    (iii) If the date of the final decree of divorce, dissolution, or 
annulment is on or after September 29, 1988, the former spouse is 
eligible only for care received within the 365 days (366 days in the 
case of a leap year) immediately following the date of the divorce, 
dissolution, or annulment.
    (ii) Child. A dependent child is an unmarried child of a member or 
former member who has not reached his or her twenty-first (21st) 
birthday, except an incapacitated adopted child meeting the requirements 
of paragraph (b)(2)(ii)(H)(2) of this section, and who bears one of the 
following relationships to a member or former member of one of the 
Uniformed Services:
    (A) A legitimate child; or
    (B) An adopted child whose adoption has been legally completed on or 
before the child's twenty-first (21st) birthday; or
    (C) A legitimate stepchild; or
    (D) An illegitimate child of a member or former member whose 
paternity/maternity has been determined judicially, and the member or 
former member directed to support the child; or
    (E) An illegitimate child of a member or former member whose 
paternity/maternity has not been determined judicially, who resides with 
or in the home provided by the member or former member, and is or 
continues to be dependent upon the member or former member for over one-
half of his or her support, or who was so dependent on the former member 
at the time of the former member's death; or
    (F) An illegitimate child of a spouse of a member who resides with 
or in a home provided by the member and is, and continues to be 
dependent upon the member for over one-half of his or her support; or
    (G) An illegitimate child of a spouse of a former member who resides 
with or in a home provided by a former member or the former member's 
spouse at the time of death of the former member, and is, or continues 
to be, or was, dependent upon the former member for more than one-half 
of his or her support at the time of death; or
    (H) An individual who falls into one of the following classes:
    (1) A student. A child determined to be a member of one of the 
classes in paragraphs (b)(2)(ii)(A) through (b)(2)(ii)(G) of this 
section, who is not married, has passed his or her 21st birthday but has 
not passed his or her 23rd birthday, is dependent upon the member or 
former member for over 50 percent of his or her support or was dependent 
upon the member or former member for over 50 percent of his or her 
support on the date of the member's or former member's death, and is 
pursuing a full-time course of education in an institution of higher 
learning approved by the Secretary of Defense or the Department of 
Education (as appropriate) or by a state agency under 38 U.S.C. chapters 
34 and 35.


[[Page 94]]


    Note: Courses of education offered by institutions listed in the 
``Education Directory,'' ``Higher Education'' or ``Accredited Higher 
Institutions'' issued periodically by the Department of Education meet 
the criteria approved by the Administering Secretary or the Secretary of 
Education. For determination of approval of courses offered by a foreign 
institution, by an institution not listed in either of the above 
directories, or by an institution not approved by a state agency 
pursuant to 38 U.S.C. chapters 34 and 35, a statement may be obtained 
from the Department of Education, Washington, D.C. 20202.

    (2) An incapacitated child. A child determined to be a member of one 
of the classes in paragraphs (b)(2)(ii)(A) through (b)(2)(ii)(G) of this 
section, who is not married and is incapable of self-support because of 
a mental or physical disability that:
    (i) Existed before the child's twenty-first (21st) birthday; or
    (ii) Occurred between the ages of 21 and 23 while the child was 
enrolled in a full-time course of study in an institution of higher 
learning approved by the Administering Secretary or the Department of 
Education (see NOTE to paragraph (b)(2)(ii)(H)(2)(iii) of this section), 
and is or was at the time of the member's or former member's death 
dependent on the member or former member for over one-half of his or her 
support; and
    (iii) The incapacity is continuous. (If the incapacity significantly 
improves or ceases at any time, CHAMPUS eligibility cannot be reinstated 
on the basis of the incapacity, unless the incapacity recurs and the 
beneficiary is under age 21, or is under age 23 and is enrolled as a 
full-time student under paragraph (b)(2)(ii)(H)(2)(ii) of this section. 
If the child was not incapacitated after that date, no CHAMPUS 
eligibility exists on the basis of the incapacity. However, 
incapacitated children who marry and who subsequently become unmarried 
through divorce, annulment, or death of spouse, may be reinstated as 
long as they still meet all other requirements).

    Note: An institution of higher learning is a college, university, or 
similar institution, including a technical or business school, offering 
post-secondary level academic instruction that leads to an associate or 
higher degree, if the school is empowered by the appropriate State 
education authority under State law to grant an associate, or higher, 
degree. When there is no State law to authorize the granting of a 
degree, the school may be recognized as an institution of higher 
learning if it is accredited for degree programs by a recognized 
accrediting agency. The term also shall include a hospital offering 
educational programs at the post-secondary level regardless of whether 
the hospital grants a post-secondary degree. The term also shall include 
an educational institution that is not located in a State, that offers a 
course leading to a standard college degree, or the equivalent, and that 
is recognized as such by the Secretary of Education (or comparable 
official) of the country, or other jurisdiction, in which the 
institution is located (38 U.S.C. chapter 34, section 1661, and chapter 
35, section 1701.
    Courses of education offered by institutions listed in the 
``Education Directory,'' ``Higher Education'' or ``Accredited Higher 
Institutions'' issued periodically by the Department of Education meet 
the criteria approved by the Administering Secretary or the Secretary of 
Education. For determination of approval of courses offered by a foreign 
institution, by an institution not listed in either of the above 
directories, or by an institution not approved by a state agency 
pursuant to chapters 34 and 35 of 38 U.S.C., a statement may be obtained 
from the Department of Education, Washington, D.C. 20202.

    (3) A child of a deceased reservist. A child, who is determined to 
be a member of one of the classes in paragraphs (b)(2)(ii)(A) through 
(b)(2)(ii)(G) of this section, of a reservist in a Uniformed Service who 
incurs or aggravates an injury, illness, or disease, during, or on the 
way to or from, active duty training for a period of 30 days or less or 
inactive duty training, and the reservist dies as a result of that 
specific injury, illness or disease.
    (4) An unmarried person. An unmarried person placed in the home of a 
member or former member prior to adoption. To be a dependent child, the 
unmarried person must not have reached the age of 21 (or otherwise meets 
the requirements of a student or incapacitated child set out in 
paragraphs (b)(2)((ii)(H)(1) or (b)(2)(ii)(H)(2) of this section) and 
has been placed in the home of the member or former member by a 
recognized placement agency or by any other source authorized by State 
or local law to provide adoption placement, in anticipation of legal 
adoption by the member or former member.

[[Page 95]]

    (iii) Abused dependents--(A) Categories of abused dependents. An 
abused dependent may be either a spouse or a child. Eligibility for 
either class of abused dependent results from being either:
    (1) The spouse (including a former spouse) or child of a member who 
has received a dishonorable or bad-conduct discharge, or dismissal from 
a Uniformed Service as a result of a court-martial conviction for an 
offense involving physical or emotional abuse of the spouse or child, or 
was administratively discharged as a result of such an offense. Until 
October 17, 1998, Medical benefits are limited to care related to the 
physical or emotional abuse and for a period of 12 months following the 
member's separation from the Uniformed Service. On or after October 17, 
1998, medical benefits can include all under the Basic Program and under 
the Extended Care Health Option for the period that the spouse or child 
is in receipt of transitional compensation under section 1059 of title 
10 U.S.C.
    (2) The spouse (including a former spouse) or child of a member or 
former member who while a member and as a result of misconduct involving 
abuse of the spouse or child has eligibility to receive retired pay on 
the basis of years of service terminated.
    (B) Requirements for categories of abused dependents--(1) Abused 
spouse. As long as the spouse is receiving payments from the DoD 
Military Retirement Fund under court order, the spouse is eligible for 
health care under the same conditions as any spouse of a retired member. 
The abused spouse must:
    (i) Under paragraph (b)(2)(iii)(A)(1) of this section, be a lawful 
husband or wife or a former spouse of the member; or
    (ii) Under paragraph (b)(2)(iii)(A)(2) of this section, be a lawful 
husband or wife or a former spouse of the member or former member, and 
the spouse is receiving payments from the Department of Defense Military 
Retirement Fund under 10 U.S.C. 1408(h) pursuant to a court order; and
    (A) Be a victim of the abuse; and
    (B) Have been married to the member or former member at the time of 
the abuse; or
    (C) Be the natural or adoptive parent of a dependent child of the 
member or former member who was the victim of the abuse.
    (2) Abused child. The abused child must:
    (i) Under paragraph (b)(2)(iii)(A)(1) of this section, be a 
dependent child of the member or former member.
    (ii) Under paragraph (b)(2)(iii)(A)(2) of this section,
    (A) Have been a member of the household where the abuse occurred; 
and
    (B) Be an unmarried legitimate child, including an adopted child or 
stepchild of the member or former member; and
    (C) Be under the age of 18; or
    (D) Be incapable of self support because of a mental or physical 
incapacity that existed before becoming 18 years of age and be dependent 
on the member or former member for over one-half of his or her support; 
or
    (E) If enrolled in a full-time course of study in an institution of 
higher learning recognized by the Secretary of Defense (for the purposed 
of 10 U.S.C. 1408(h)), be under 23 years of age and be dependent on the 
member or former member for over one-half of his or her support.
    (F) The dependent child is eligible for health care, regardless of 
whether any court order exists, under the same conditions as any 
dependent of a retired member.
    (3) TAMP eligibles. A former member, including his or her 
dependents, who is eligible under the provisions of the Transitional 
Assistance Management Program as described in paragraph (e) of this 
Sec. 199.3.
    (iv) An unmarried person who is placed in the legal custody of a 
member or former member by a court of competent jurisdiction in the 
United States (or possession of the United States) for a period of at 
least 12 consecutive months. The unmarried person shall be considered a 
dependent of the member or former member under this section provided he 
or she otherwise meets the following qualifications:
    (A) Has not reached the age of 21 unless he or she otherwise meets 
the requirements of a student set out in paragraph (b)(2)(ii)(H)(1) of 
this section or the requirements for being incapacitated as set out in 
paragraph

[[Page 96]]

(b)(2)(ii)(H)(2) of this section and the incapacitation occurred while 
he or she was a dependent of the member or former member through court 
ordered legal custody;
    (B) Is dependent on the member or former member for over one-half of 
the person's support;
    (C) Resides with the member or former member unless separated by the 
necessity of military service or to receive institutional care as a 
result of disability or incapacitation or under such other authorized 
circumstances; and,
    (D) Is not a dependent of a member or former member under any other 
provision of law or regulation.
    (3) Eligibility under TRICARE Senior Pharmacy Program. Section 711 
of the National Defense Authorization Act for Fiscal Year 2001 (Public 
Law 106-398, 114 Stat. 1654) established the TRICARE Senior Pharmacy 
Program effective April 1, 2001. To be eligible for this program, a 
person is required to be:
    (i) Medicare eligible, who is:
    (A) 65 years of age or older; and
    (B) Entitled to Medicare Part A; and
    (C) Enrolled in Medicare Part B, except for a person who attained 
age 65 prior to April 1, 2001, is not required to enroll in Part B; and
    (ii) Otherwise qualified under one of the following categories:
    (A) A retired uniformed service member who is entitled to retired or 
retainer pay, or equivalent pay including survivors who are annuitants; 
or
    (B) A dependent of a member of the uniformed services described in 
one of the following:
    (1) A member who is on active duty for a period of more than 30 days 
or died while on such duty; or
    (2) A member who died from an injury, illness, or disease incurred 
or aggravated while the member was:
    (i) On active duty under a call or order to active duty of 30 days 
or less, on active duty for training, or on inactive duty training; or
    (ii) Traveling to or from the place at which the member was to 
perform or had performed such active duty, active duty for training, or 
inactive duty training.

    Note to paragraph (b)(3)(ii)(B): Dependent under Section 711 of the 
National Defense Authorization Act for Fiscal Year 2001 includes spouse, 
unremarried widow/widower, child, parent/parent-in-law, unremarried 
former spouse, and unmarried person in the legal custody of a member or 
former member, as those terms of dependency are defined and periods of 
eligibility are set forth in 10 U.S.C. 1072(2).

    (4) Medal of Honor recipients. (i) A former member of the armed 
forces who is a Medal of Honor recipient and who is not otherwise 
entitled to medical and dental benefits has the same CHAMPUS eligibility 
as does a retiree.
    (ii) Immediate dependents. CHAMPUS eligible dependents of a Medal of 
Honor Recipient are those identified in paragraphs (b)(2)(i) of this 
section (except for former spouses) and (b)(2)(ii) of this section 
(except for a child placed in legal custody of a Medal of Honor 
recipient under (b)(2)(ii)(H)(4) of this section).
    (iii) Effective date. The CHAMPUS eligibility established by 
paragraphs (b)(4)(i) and (ii) of this section is applicable to health 
care services provided on or after October 30, 2000.
    (5) Reserve Component Members issued delayed-effective-date orders--
(i) Member. A member of a reserve component of the armed forces who is 
ordered to active duty for a period of more than 30 consecutive days in 
support of a contingency operation under a provision of law referred to 
in section 101(a)(13)(B) of Title 10, United States Code, that provides 
for active-duty service to begin on a date after the date of the 
issuance of the order.
    (ii) Dependents. CHAMPUS eligible dependents under this paragraph 
(b)(5) are those identified in paragraphs (b)(2)(i) (except former 
spouses) and (b)(2)(ii) of this section.
    (iii) Effective date. The eligibility established by paragraphs 
(b)(5)(i) and (ii) of this section shall begin on or after November 6, 
2003, and shall be effective on the later of the date that is:
    (A) The date of issuance of the order referred to in paragraph 
(b)(5)(i) of this section; or
    (B) 90 days before the date on which the period of active duty is to 
begin.
    (iv) Termination date. The eligibility established by paragraphs 
(b)(5)(i) and (ii) of this section ends upon entry of

[[Page 97]]

the member onto active duty (at which time CHAMPUS eligibility for the 
dependents of the member is established under paragraph (b)(2) of this 
section) or upon cancellation or amendment of the orders referred to in 
paragraph (b)(5)(i) of this section such that they no longer meet the 
requirements of that paragraph (b)(5)(i).
    (c) Beginning dates of eligibility. (1) Beginning dates of 
eligibility depend on the class to which the individual belongs and the 
date the individual became a member of the class. Those who join after 
the class became eligible attain individual eligibility on the date they 
join.
    (2) Beginning dates of eligibility for each class of spouse 
(excluding spouses who are victims of abuse and eligible spouses of 
certain deceased reservists) are as follows:
    (i) A spouse of a member for:
    (A) Medical benefits authorized by the Dependents' Medical Care Act 
of 1956, December 7, 1956;
    (B) Outpatient medical benefits under the Basic Program, October 1, 
1966;
    (C) Inpatient medical benefits under the Basic Program and benefits 
under the Extended Care Health Option, January 1, 1967;
    (ii) A spouse of a former member:
    (A) For medical benefits under the Basic Program, January 1, 1967.
    (B) Ineligible for benefits under the Extended Care Health Option.
    (iii) A former spouse:
    (A) For medical benefits under the Basic Program, dates of beginning 
eligibility are as indicated for each category of eligible former spouse 
identified within paragraph (b)(2)(i) of this section.
    (B) Ineligible for benefits under the Extended Care Health Option.
    (3) Beginning dates of eligibility for spouses who are victims of 
abuse (excluding spouses who are victims of abuse of certain deceased 
reservists) are as follows:
    (i) An abused spouse meeting the requirements of paragraph 
(b)(2)(iii)(A)(1) of this section, including an eligible former spouse:
    (A) For medical and dental care for problems associated with the 
physical or emotional abuse under the Basic Program for a period of up 
to one year (12 months) following the person's separation from the 
Uniformed Service, November 14, 1986.
    (B) For all medical and dental benefits under the Basic Program for 
the period that the spouse is in receipt of transitional compensation 
under section 1059 of title 10 U.S.C., October 17, 1998.
    (C) For medical and dental care for problems associated with the 
physical or emotional abuse under the Extended Care Health Option for a 
period up to one year (12 months) following the person's separation from 
the Uniformed Service, November 14, 1986.
    (D) For all medical and dental benefits described in section 199.5 
for the period that the spouse is in receipt of transitional 
compensation under section 1059 of title 10 U.S.C., October 17, 1998.
    (ii) An abused spouse meeting the requirements of paragraphs 
(b)(2)(iii)(A)(2) of this section, including an eligible former spouse:
    (A) For all benefits under the CHAMPUS Basic Program, October 23, 
1992.
    (B) Ineligible for benefits under the Extended Care Health Option.
    (4) Beginning dates of eligibility for spouses of certain deceased 
reservists, including spouses who are victims of abuse of certain 
deceased reservists, are as follows:
    (i) A spouse meeting the requirements of paragraph (b)(2)(i) of this 
section, including an eligible former spouse:
    (A) For benefits under the Basic Program, November 14, 1986.
    (B) Ineligible for benefits under the Extended Care Health Option.
    (ii) An abused spouse of certain deceased reservists, meeting the 
requirements of paragraphs (b)(2)(iii) of this section, including an 
eligible former spouse, for the limited benefits and period of 
eligibility described in paragraphs (b)(2)(iii) of this section:
    (A) For benefits under the Basic Program, November 14, 1986.
    (B) For benefits under the Extended Care Health Option, November 14, 
1986.
    (iii) An abused spouse of certain deceased reservists, including an 
eligible

[[Page 98]]

former spouse, meeting the requirements of paragraphs (b)(2)(iii) of 
this section:
    (A) For benefits under the Basic Program, October 23, 1992.
    (B) Ineligible for benefits under the Extended Care Health Option.
    (5) Beginning dates of eligibility for each class of dependent 
children, (excluding dependent children of certain deceased reservists, 
abused children and incapacitated children whose incapacity occurred 
between the ages of 21 and 23 while enrolled in a full-time course of 
study in an institution of higher learning), are as follows:
    (i) Legitimate child, adopted child, or legitimate stepchild of a 
member, for:
    (A) Medical benefits authorized by the Dependents' Medical Care Act 
of 1956, December 7, 1956;
    (B) Outpatient medical benefits under the Basic Program, October 1, 
1966;
    (C) Inpatient medical benefits under the Basic Program and benefits 
under the Extended Care Health Option, January 1, 1967;
    (ii) Legitimate child, adopted child or legitimate stepchild of 
former members:
    (A) For medical benefits under the Basic Program, January 1, 1967.
    (B) Ineligible for benefits under the Extended Care Health Option.
    (iii) Illegitimate child of a male or female member or former member 
whose paternity/maternity has been determined judicially and the member 
or former member has been directed to support the child, for:
    (A) All benefits for which otherwise entitled, August 31, 1972.
    (B) Extended Care Health Option benefits limited to dependent 
children of members only, August 31, 1972.
    (iv) Illegitimate child of:
    (A) A male member or former member whose paternity has not been 
determined judicially:
    (B) A female member or former member who resides with, or in a home 
provided by the member or former member, or who was residing in a home 
provided by the member or former member at the time of the member's or 
former member's death, and who is or continues to be dependent on the 
member for over one-half of his or her support, or was so dependent on 
the member or former member at the time of death;
    (C) A spouse of a member or former member who resides with or in a 
home provided by the member or former member, or the parent who is the 
spouse of the member or former member or was the spouse of a member or 
former member at the time of death, and who is and continues to be 
dependent upon the member or former member for over one-half of his or 
her support, or was so dependent on the member or former member at the 
time of death; for:
    (1) All benefits for which otherwise eligible, January 1, 1969.
    (2) Extended Care Health Option limited to dependent children of 
members only, January 1, 1969.
    (6) Beginning dates of eligibility for children of certain deceased 
reservists who meet the requirements of paragraph (b)(2)(ii)(H)(3) of 
this section, excluding incapacitated children who meet the requirements 
of paragraph (b)(2)(ii)(H)(2) of this section, for:
    (i) Benefits under the Basic program, November 14, 1986.
    (ii) Not eligible for benefits under the Extended Care Health 
Option.
    (7) Beginning dates of eligibility for children who are victims of 
abuse, including incapacitated children who meet the requirements of 
paragraph (b)(2)(ii)(H)(2) of this section are as follows:
    (i) An abused child meeting the requirements of paragraph 
(b)(2)(iii)(A)(1) of this section:
    (A) Medical and dental care for problems associated with the 
physical or emotional abuse under the Basic Program for a period of up 
to one year (12 months) following the person's separation from the 
Uniformed Service, November 14, 1986.
    (B) For all medical and dental benefits under the Basic Program for 
the period that the child is in receipt of transitional compensation 
under section 1059 of title 10 U.S.C., October 17, 1998.
    (C) Medical and dental care for problems associated with the 
physical or emotional abuse under the Extended Care Health Option for a 
period up to

[[Page 99]]

one year (12 months) following the person's separation from the 
Uniformed Service, November 14, 1986.
    (D) For all medical and dental benefits described in section 199.5 
for the period that the child is in receipt of transitional compensation 
under section 1059 of title 10 U.S.C., October 17, 1998.
    (ii) An abused child meeting the requirements of paragraphs 
(b)(2)(iii)(A)(2) of this section:
    (A) For all benefits under the CHAMPUS Basic Program, October 23, 
1992.
    (B) Ineligible for benefits under the Extended Care Health Option.
    (8) Beginning dates of eligibility for incapacitated children who 
meet the requirements of paragraph (b)(2)(ii)(H)(2) of this section, 
whose incapacity occurred between the ages of 21 and 23 while enrolled 
in a full-time course of study in an institution of higher learning 
approved by the Administering Secretary or the Department of Education, 
and, are or were at the time of the member's or former member's death, 
dependent on the member or former member for over one-half of their 
support, for:
    (i) All benefits for which otherwise entitled, October 23, 1992.
    (ii) Extended Care Health Option benefits limited to children of 
members only, October 23, 1992.
    (9) Beginning dates of eligibility for a child who meets the 
requirements of paragraph (b)(2)(ii)(H)(4) and:
    (i) Has been placed in custody by a court:
    (A) All benefits for which entitled, July 1, 1994.
    (B) Extended Care Health Option benefits limited to children of 
members only, July 1, 1994.
    (ii) Has been placed in custody by a recognized adoption agency:
    (A) All benefits for which entitled, October 5, 1994.
    (B) Extended Care Health Option benefits limited to children of 
members only, October 5, 1994.
    (iii) Has been placed in the home of a member by a placement agency 
or by any other source authorized by State or local law to provide 
adoption placement, in anticipation of the legal adoption of the member:
    (A) All benefits for which entitled, January 6, 2006.
    (B) Extended Care Health Option benefits limited to children of 
members only, January 6, 2006.
    (10) Beginning dates of eligibility for a retiree for:
    (i) Medical benefits under the Basic Program January 1, 1967.
    (ii) Retirees and their dependents are not eligible for benefits 
under the Extended Care Health Option.
    (d) Dual eligibility. Dual eligibility occurs when a person is 
entitled to benefits from two sources. For example, when an active duty 
member is also the dependent of another active duty member, a retiree, 
or a deceased active duty member or retiree, dual eligibility, that is, 
entitlement to direct care from the Uniformed Services medical care 
system and CHAMPUS is the result. Since the active duty status is 
primary, and it is the intent that all medical care be provided an 
active duty member through the Uniformed Services medical care system, 
CHAMPUS eligibility is terminated as of 12:01 a.m. on the day following 
the day the dual eligibility begins. However, any dependent children in 
a marriage of two active duty persons or of an active duty member and a 
retiree, are CHAMPUS eligible in the same manner as dependent children 
of a marriage involving only one CHAMPUS sponsor. Should a spouse or 
dependent who has dual eligibility leave active duty status, that 
person's CHAMPUS eligibility is reinstated as of 12:01 a.m. of the day 
active duty ends, if he or she otherwise is eligible as a dependent of a 
CHAMPUS sponsor.

    Note: No CHAMPUS eligibility arises as the result of the marriage of 
two active duty members.

    (e) Eligibility under the Transitional Assistance Management Program 
(TAMP). (1) A member of the armed forces is eligible for transitional 
health care if the member is:
    (i) A member who is involuntarily separated from active duty.
    (ii) A member of a Reserve component who is separated from active 
duty to which called or ordered in support of a contingency operation if 
the active duty is active duty for a period of more than 30 consecutive 
days.

[[Page 100]]

    (iii) A member who is separated from active duty for which the 
member is involuntarily retained under 10 U.S.C. 12305 in support of a 
contingency operation; or
    (iv) A member who is separated from active duty served pursuant to a 
voluntary agreement of the member to remain on active duty for a period 
of less than 1 year in support of a contingency operation.
    (2) A spouse (as described in paragraph (b)(2)(i) of this section 
except former spouses) and child (as described in paragraph (b)(2)(ii) 
of this section) of a member described in paragraph (e)(1) of this 
section is also eligible for TAMP benefits under TRICARE.
    (3) TAMP benefits under TRICARE begin on the day after the member is 
separated from active duty, and, if such separation occurred on or after 
November 6, 2003, and end 180 days after such date. TRICARE benefits 
available to both the member and eligible family members are generally 
those available to family members of members of the uniformed services 
under this Part. Each branch of service will determine eligibility for 
its members and eligible family members and provide data to DEERS.
    (f) Changes in status which result in termination of CHAMPUS 
eligibility. Changes in status which result in a loss of CHAMPUS 
eligibility as of 12:01 a.m. of the day following the day the event 
occurred, unless otherwise indicated, are as follows:
    (1) Changes in the status of a member. (i) When an active duty 
member's period of active duty ends, excluding retirement or death.
    (ii) When an active duty member is placed on desertion status 
(eligibility is reinstated when the active duty member is removed from 
desertion status and returned to military control).

    Note: A member serving a sentence of confinement in conjunction with 
a sentence of punitive discharge is still considered on active duty 
until such time as the discharge is executed.

    (2) Changes in the status of a retiree. (i) When a retiree ceases to 
be entitled to retired, retainer, or equivalent pay for any reason, the 
retiree's dependents lose their eligibility unless the dependent is 
otherwise eligible (e.g., some former spouses, some dependents who are 
victims of abuse and some incapacitated children as outlined in 
paragraph (b)(2)(ii)(H)(2) of this section).
    (ii) A retiree also loses eligibility when no longer entitled to 
retired, retainer, or equivalent pay.

    Note: A retiree who waives his or her retired, retainer or 
equivalent pay is still considered a retiree for the purposes of CHAMPUS 
eligibility.

    (3) Changes in the status of a dependent. (i) Divorce, except for 
certain classes of former spouses as provided in paragraph (b)(2)(i) of 
this section and the member or former member's own children (i.e., 
legitimate, adopted, and judicially determined illegitimate children).

    Note: An unadopted stepchild loses eligibility as of 12:01 a.m. of 
the day following the day the divorce becomes final.

    (ii) Annulment, except for certain classes of former spouse as 
provided in paragraph (b)(2)(i) of this section and the member or former 
member's own children (i.e., legitimate, adopted, and judicially 
determined illegitimate children).

    Note: An unadopted stepchild loses eligibility as of 12:01 a.m. of 
the day following the day the annulment becomes final.

    (iii) Adoption, except for adoptions occurring after the death of a 
member or former member.
    (iv) Marriage of a child, except when the marriage is terminated by 
death, divorce, or annulment before the child is 21 or 23 if an 
incapacitated child as provided in paragraph (b)(2)(ii)(H)(2) of this 
section.
    (v) Marriage of a widow or widower, except for the child of the 
widow or widower who was the stepchild of the deceased member or former 
member at the time of death. The stepchild continues CHAMPUS eligibility 
as other classes of dependent children.
    (vi) Attainment of entitlement to hospital insurance benefits (Part 
A) under Medicare except as provided in paragraphs (b)(3), (f)(3)(vii), 
(f)(3)(viii), and (f)(3)(ix) of this section. (This also applies to 
individuals living outside the United States where Medicare benefits are 
not available.)

[[Page 101]]

    (vii) Attainment of age 65, except for dependents of active duty 
members, beneficiaries not entitled to part A of Medicare, beneficiaries 
entitled to Part A of Medicare who have enrolled in Part B of Medicare, 
and as provided in paragraph (b)(3) of this section. For those who do 
not retain CHAMPUS, CHAMPUS eligibility is lost at 12:01 a.m. on the 
first day of the month in which the beneficiary becomes entitled to 
Medicare.

    Note: If the person is not eligible for Part A of Medicare, he or 
she must file a Social Security Administration, ``Notice of 
Disallowance'' certifying to that fact with the Uniformed Service 
responsible for the issuance of his or her identification card so a new 
card showing CHAMPUS eligibility can be issued. Individuals entitled 
only to supplementary medical insurance (Part B) of Medicare, but not 
Part A, or Part A through the Premium HI provisions (provided for under 
the 1972 Amendments to the Social Security Act) retain eligibility under 
CHAMPUS (refer to Sec. 199.8 for additional information when a double 
coverage situation is involved).
    (viii) End stage renal disease. All beneficiaries, except dependents 
of active duty members, lose their CHAMPUS eligibility when Medicare 
coverage becomes available to a person because of chronic renal disease 
unless the following conditions have been met. CHAMPUS eligibility will 
continue if:
    (A) The individual is under 65 years old;
    (B) The individual became eligible for Medicare under the provisions 
of 42 U.S.C. 426-1(a);
    (C) The individual is enrolled in Part B of Medicare; and
    (D) The individual has applied and qualified for continued CHAMPUS 
eligibility through the Defense Enrollment Eligibility Reporting System 
(DEERS).
    (ix) Individuals with certain disabilities. Each case relating to 
Medicare eligibility resulting from being disabled requires individual 
investigation. All beneficiaries except dependents of active duty 
members lose their CHAMPUS eligibility when Medicare coverage becomes 
available to a disabled person unless the following conditions have been 
met. CHAMPUS eligibility will continue if:
    (A) The individual is under 65 years old;
    (B) The individual became eligible for Medicare under the provisions 
of 42 U.S.C. 426(b)(2);
    (C) The individual is enrolled in Part B of Medicare; and
    (D) The individual has applied and qualified for continued CHAMPUS 
eligibility through the Defense Enrollment Eligibility Reporting System 
(DEERS).
    (x) Disabled students, that is children age 21 or 22, who are 
pursuing a full-time course of higher education and who, either during 
the school year or between semesters, suffer a disabling illness or 
injury with resultant inability to resume attendance at the institution 
remain eligible for CHAMPUS medical benefits for 6 months after the 
disability is removed or until the student passes his or her 23rd 
birthday, whichever occurs first. However, if recovery occurs before the 
23rd birthday and there is resumption of a full-time course of higher 
education, CHAMPUS benefits can be continued until the 23rd birthday. 
The normal vacation periods during an established school year do not 
change the eligibility status of a dependent child 21 or 22 years old in 
a full time student status. Unless an incapacitating condition existed 
before, and at the time of, a dependent child's 21st birthday, a 
dependent child 21 or 22 years old in student status does not have 
eligibility and may not qualify for eligibility under the requirements 
related to mental or physical incapacity as described in paragraph 
(b)(2)(ii)(H)(2) of this section.
    (g) Reinstatement of CHAMPUS eligibility. Circumstances which result 
in reinstatement of CHAMPUS eligibility are as follows:
    (1) End Stage renal disease. Unless CHAMPUS eligibility has been 
continued under paragraph (f)(3)(viii) of the section, when Medicare 
eligibility ceases for end-stage renal disease patients, CHAMPUS 
eligibility resumes if the person is otherwise still eligible. He or she 
is required to take action to be reinstated as a CHAMPUS beneficiary and 
to obtain a new identification card.
    (2) Disability. Some disabilities are permanent, others temporary. 
Each

[[Page 102]]

case must be reviewed individually. Unless CHAMPUS eligibility has been 
continued under paragraph (f)(3)(ix) of this section, when disability 
ends and Medicare eligibility ceases, CHAMPUS eligibility resumes if the 
person is otherwise still eligible. Again, he or she is required to take 
action to obtain a new CHAMPUS identification card.
    (h) Determination of eligibility status. Determination of an 
individual's eligibility as a CHAMPUS beneficiary is the primary 
responsibility of the Uniformed Service in which the member or former 
member is, or was, a member, or in the case of dependents of a NATO 
military member, the Service that sponsors the NATO member. For the 
purpose of program integrity, the appropriate Uniformed Service shall, 
upon request of the Director, OCHAMPUS, review the eligibility of a 
specific person when there is reason to question the eligibility status. 
In such cases, a report on the results of the review and any action 
taken will be submitted to the Director, OCHAMPUS, or a designee.
    (i) Procedures for determination of eligibility. Procedures for the 
determination of eligibility are prescribed within the Department of 
Defense Instruction 1000.13 available at local military facilities 
personnel offices.
    (j) CHAMPUS procedures for verification of eligibility. (1) 
Eligibility for CHAMPUS benefits will be verified through the Defense 
Enrollment Eligibility Reporting System (DEERS) maintained by the 
Uniformed Services, except for abused dependents as set forth in 
paragraph (b)(2)(iii) of this section. It is the responsibility of the 
CHAMPUS beneficiary, or parent, or legal representative, when 
appropriate, to provide the necessary evidence required for entry into 
the DEERS file to establish CHAMPUS eligibility and to ensure that all 
changes in status that may affect eligibility be reported immediately to 
the appropriate Uniformed Service for action.
    (2) Ineligibility for CHAMPUS benefits may be presumed in the 
absence of prescribed eligibility evidence in the DEERS file.
    (3) The Director, OCHAMPUS, shall issue guidelines as necessary to 
implement the provisions of this section.

[64 FR 46135, Aug. 24, 1999, as amended at 66 FR 9654, Feb. 9, 2001; 66 
FR 16400, Mar. 26, 2001; 66 FR 40606, Aug. 3, 2001; 67 FR 15725, Apr. 3, 
2002; 68 FR 23032, Apr. 30, 2003; 68 FR 32361, May 30, 2003; 69 FR 
51564, Aug. 20, 2004; 69 FR 60554, Oct. 12, 2004; 70 FR 12802, Mar. 16, 
2005; 72 FR 2447, Jan. 19, 2007]