Source: http://thefederalregister.com/2011/04/27/2011-10241.html
Timestamp: 2018-10-21 05:28:24
Document Index: 386575258

Matched Legal Cases: ['§ 199', '§ 199', '§ 199', 'ART 199', 'art 199', '§ 199', '§ 199', '§ 199', '§ 199', '§ 199', '§ 199', '§ 199']

Federal Register | Civilian Health and Medical Program of the Uniformed Services
[Docket ID: DOD-2011-HA-0029; RIN 0720-AB48]
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 YoungAdult 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 thisFederal Registerdocument. 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 athttp://regulations.govas 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.
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 TRICARE Dental Program (§ 199.13 of this Part) and the TRICARE Retiree Dental Program (§ 199.22 of this Part) are not included as part of TYA.
The Continued Health Care Benefits Program (see § 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 andare 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 TRICARE program Monthly
TRICARE Standard/Extra Plans $186 TRICARE Prime Plans 213
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.
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 toTRICARE 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.
Title:TRICARE Young Adult Application.
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.
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 consistentwith 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.
Claims, Handicapped, Health insurance, and Military personnel.
PART 199—[AMENDED] 1. The authority citation for part 199 continues to read as follows: Authority:
TRICARE Young Adult.The program authorized by and described in § 199.26 of this part.
(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.
(B) The TRICARE Dental Program (§ 199.13 of this part) and the TRICARE Retiree Dental Program (§ 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 § 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 § 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 § 199.3(e));
(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:
(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.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.
(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.
(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 fullpremium 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 § 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.