Background
My name is Brian Smith and I am the Program Manager at the Defense Health Agency (DHA), for Reserve Component (RC) health plans and benefits. After receiving recent Congressional inquiries involving RC members, our office has become aware of some significant matters regarding personnel statuses and TRICARE eligibility; where statuses were either changed retroactively due to late or erroneous reporting, incorrect orders being issued, or incorrect status terminations processed. These in turn, have had a major impact involving prior TRICARE eligibility being reversed and subsequently removed; thus rendering members as ineligible and leaving them with extreme, financial difficulties.
TRICARE Reserve Select (TRS)
In order to qualify to purchase TRICARE Reserve Select (TRS) coverage, RC members must be in the Selected Reserve (SELRES) and not eligible for, or enrolled in, a Federal Employee Health Benefit program. RC members in the IRR do NOT qualify for TRS eligibility. That said, here is one specific example of an inquiry regarding TRS:
- Member was loaded in the Reserve Components Common Personnel Data System (RCCPDS) as a member in the SELRES. The member purchases TRS coverage for themselves and their family members, and received care that TRICARE made payments on to providers over the course of a couple of years. An audit is done by the RC and determines this member's status in the SELRES was loaded in the RCCPDS erroneously (was always in the IRR) and cancels the SELRES status in its entirety, retroactively. This results in TRICARE having to recoup all payments made to providers, as by law, TRICARE cannot pay on claims for beneficiaries who are ineligible. Providers then sought payments from the member at 100% of the billed charges. The regional contractor then received an unsolicited personal notification transaction (PNT) as a result of the status change made in the RCCPDS and subsequently DEERS, and refunded all premium payments paid back to the member. NOTE: TRICARE/DHA has no jurisdiction or authority with regards to establishing medical eligibility under TRICARE.
Reservists Retired Awaiting Receipt of Retirement Pay (RET-2)
Another issue involves that of non-regular, retired Reservists under the age of 60 (better known as grey-area retirees or RET-2) who may draw early retirement pay, granted by the NDAA 2008, Section 647 and Title 10 USC Section 12731. There is a false impression that once a retired Reservist draws early retirement pay, they are then eligible for Uniformed Services Health Benefits Program (USHBP), or better known as premium-free TRICARE health coverage under Prime or Standard; even if under age 60. This could not be further from the truth. The only TRICARE eligibility that these particular members may qualify for would be TRICARE Retired Reserve (TRR). Any orders issued for these particular members should never state being eligible for USHBP. Personnel offices should be aware that these particular members may only qualify to purchase TRR. Once these members turn age 60, then and only then, would they become considered regular retired (if served 20 or more years of active service) and eligible for premium-free TRICARE programs. Here is one specific example of an inquiry regarding this particular issue:
- Grey-area retired Reservist who received early retirement pay was issued retirement orders stating they were eligible for medical care under the USHBP and how to obtain new ID cards. When going to a DEERS/RAPIDS ID card issuing facility, the person who assisted the member with issuing the ID cards saw the orders and thus, processed his update in DEERS as a regular retiree with full medical eligibility. This too, ended up with the error being discovered and previous TRICARE eligibility being removed; resulting in TRICARE denying claims payment and leaving the member with the financial responsibility of paying the providers.
Mobilization Early Identification Eligibility
Lastly, when RC members are notified of a pre-alert for mobilization and issued delayed-effective date active service orders for more than 30 days in support of a contingency operation, they are entitled to early TRICARE eligibility (Early Eligibility or E-ID) as an Active Duty Service Member (ADSM) (as well as their family members as Active Duty Family Members (ADFM)). It is important to note that if a member's Service removes them from the deployment (i.e. deems them not fit for duty or shortens the required amount of members necessary to deploy), the Service personnel office should NOT "CANCEL" the order in its entirety, but instead "TERMINATE" the activation in RCCPDS and DEERS on the date the deployment termination was issued; leaving initial and prior to termination, TRICARE eligibility. Case in point:
- Member received delayed-effective date active service orders resulting in E-ID. Member and family members sought care under premium-free ADSM and ADFM TRICARE benefits. Service cancels member's orders retroactively, removing all previous E-ID coverage; resulting in TRICARE having to recoup all payments made to providers. Providers then seek payments from the member at 100% of the billed charges.
SPO Responsibility
Members rely on their Servicing Personnel Offices to properly and in a timely manner, load their status accordingly in Direct Access, which feeds the RCCPDS and DEERS systems. While these offices also experience challenges from their Service commands, nonetheless please ensure this information is shared with all offices and personnel who deal with policy and benefits, and personnel activities, to make certain they are properly trained and informed on what RC members are and are not eligible for with TRICARE coverage and how their actions can greatly impact RC members' lives.
While unaware of any issues in our office, I'd like to close with one last matter involving the RC. NDAA 2013 provided certain SELRES members involuntarily separated under other than adverse conditions AND had TRS coverage prior to their separation date, an extended 180 days of TRS coverage. NOTE: Personnel offices must load the proper loss-codes in RCCPDS, in order to provide this extension.
Brian D. Smith, MHSA
Program Manager/Reserve Component Health Plans and Benefit Programs
Reserve and Service Member Support Office
Defense Health Agency