TRICARE is the U.S. military's health care program. It is under the Department of Defense (DoD). It provides health care for active or retired members of the Armed Services and their dependents, and for dependents of deceased members of the Armed Services.

Until 1991 (see HI 00805.731 A.), TRICARE entitlement terminated when any individual became eligible for hospital insurance (HI) under Medicare on a non-premium basis. Since 1991, TRICARE does not terminate for beneficiaries entitled to Medicare on the basis of disability (but not ESRD) if they enroll in SMI. (TRICARE then becomes secondary payer for the disabled and also pays for prescription drugs.)

Since dates of birth are on TRICARE records, those who are approaching age 65 are notified by TRICARE to file for HI and SMI because TRICARE will end at age 65. They then obtain HI and SMI, if eligible.

If not eligible for premium-free HI, they receive a disallowance letter from SSA which, when submitted to TRICARE, permits continued TRICARE entitlement.

TRICARE does not have a reliable way of pinpointing which of its beneficiaries under age 65 are disabled or have ESRD. Some of the TRICARE advisors have incorrectly counseled beneficiaries about their eligibility. As a result of these problems, some disabled people have been continued on TRICARE erroneously.

In addition, some aged or ESRD beneficiaries, while properly identified, have been given erroneous information by TRICARE advisors about the effect of Medicare on TRICARE eligibility and have been erroneously continued on the TRICARE rolls.

When the erroneous entitlements are discovered, and if DoD records show that the cause is Federal Government error, the individuals receive a letter from DoD's Defense Enrollment Eligibility Reporting System (DEERS) admitting fault and referring the individuals to SSA for enrollment in SMI under equitable relief.

Use the Form CMS-40B or any signed statement to the effect that the individual wants to be enrolled in SMI and the date they want SMI (currently or fully retroactive).

Include in the material being sent to ODO (or a PSC) a copy of the DEERS letter, and a cover Report of Contact that says in red: “Process this SMI enrollment in accordance with HI 00805.236.”

If an individual alleges that they were unaware that Medicare eligibility affected TRICARE entitlement, but does not have the letter from DEERS, direct the individual to one of the following numbers to discuss the situation and to obtain the above-mentioned letter from DEERS, if there was Federal Government fault.

In California — 1-800-334-4162

In Alaska and Hawaii — 1-800-527-5602

All other areas — 1-800-538-9552

If an individual is unable to obtain the letter from DEERS:

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  do not process an enrollment under the equitable relief rules; and

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  advise the individual about the regular GEP and premium surcharge provisions, as applicable.