TRICARE Young Adult Application - US Family Health Plan

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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0720-0049). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE DESIRED SERVICING CONTRACTOR SHOWN BELOW.

PRIVACY ACT STATEMENT

This statement informs you of the purpose for collecting personal information required by the TRICARE Young Adult Program and how it will be used.
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care, 32 CFR Part 199, Civilian Health and Medical Program of the Uniformed Serivces (CHAMPUS); DoD Instruction 1341.2, Defense Enrollment Eligibility Reporting System (DEERS) Procedures; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To collect the information necessary to process your request for coverage, to terminate coverage, or to change your provider.
ROUTINE USE(S): Any protected health information governed by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD by DoD 6025.18-R, may disclosed as permitted under those provisions, which includes for treatment, payment, and healthcare operations. In addition, your records may be disclosed to the Department of Health and Human Services for use in reports and Medicare determinations. Your records may be disclosed to Federal agencies, and state, local and territorial governments, in order to collect debts and overpayments, to determine whether beneficiaries are eligible for, or enrolled in, other government or private health insurance plans, and to stop fraud, waste and abuse. Your records may be disclosed outside of DoD to support research concerning the health and wellbeing of TRICARE beneficiaries. Your records may also be used and disclosed in accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD "Blanket Routine Uses" published at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html.
DISCLOSURE: Voluntary. However, failure to provide all requested information may result in denial of your request to enroll in or change your TRICARE Young Adult health plan coverage.

TRICARE YOUNG ADULT PROGRAM

The TRICARE Young Adult Program extends dependent medical coverage via a premium-based program that allows former dependents to purchase TRICARE health care plan coverage if qualified. Coverage is extended from age 21 (age 23 if previously enrolled in a full-time course of study at an institution of higher learning) until reaching age 26 for unmarried dependents that are not eligible for medical coverage from employer-sponsored medical coverage as a result of their employment.

General eligibility requirements are shown below.

Sponsor Status

TRICARE Prime (1)

TRICARE Prime Remote (1)

TRICARE Standard

Uniformed Services Family Health Plan (1)

TRICARE Overseas Prime (1)

TRICARE Overseas Prime Remote (1)

TRICARE Overseas Standard

Active Duty

Yes

Retired

Yes

No

Yes

No

Yes

Selected Reserve (2)

No

Yes

No

Yes

Retired Reserve (2)

No

Yes

No

Yes

(1) To purchase this coverage, it must be offered in your geographic area and you must meet all other eligibility criteria.

(2) If you are an adult child of a non-activated member of the Selected Reserve of the Ready Reserve or of the Retired Reserve, your sponsor must be enrolled in TRICARE Reserve Select or TRICARE Retired Reserve as applicable for you to be eligible to purchase TYA coverage.
For specific information on eligibility, coverage, costs, claims submission, go to: www.tricare.mil/tya.

APPLICATION OPTIONS

ONLINE:
You may electronically complete, submit and print a copy of your enrollment, disenrollment, transfer to another TYA plan, or request a change in an assigned Primary Care Manager (PCM) by logging into the Beneficiary Web Enrollment (BWE) website at www.tricare.mil/bwe/. The BWE website is not available to beneficiaries in overseas areas.

MAILING THE FORM:
For manual enrollment, disenrollment, or PCM changes in a TRICARE Young Adult plan, complete and submit the form to the address below.

1. Forms may be mailed to the contractor identified below or, with the exception of USFHP applications, taken to a TRICARE Service Center (TSC). Call your Contractor to determine when your new or transferred enrollment will begin.

2. For enrollment assistance, please call US FAMILY HEALTH PLAN 1(800) 241-4848

3. For additional information on TRICARE, visit the TRICARE website at www.tricare.mil, the Contractor's website at www.hnfs.com or your local TRICARE Service Center (TSC).

(TMA BE&SDs/Contractors will add servicing contractor information. Include name, mailing address and web address of contractor, and enrollment fees.)
US FAMILY HEALTH PLAN
5 PENN PLAZA 9TH FLOOR
NEW YORK, N.Y. 10001
Fax: 212-356-4849
https://www.usfhp.net

Uniformed Services Family Health Plan (USFHP) (Include locations, addresses and telephone numbers.)

ME and NH

MD, DE, DC, PA, VA, and WV

MA and RI

NY, NJ, PA, and CT

US Family Health Plan at

Martin's Point Health Care
P.O. Box 9746

Johns Hopkins
P.O. Box 815

Brighton Marine
P.O. Box 9195

St. Vincent at NYC
5 Penn Plaza 9th Floor

Portland, ME 04104-5040

Glen Burnie, MD 21060

Watertown, MA 02471-9900

New York, NY 10001-2646

TRICARE YOUNG ADULT OPTION DESIRED:

TRICARE Standard: Includes dependents of sponsors enrolled in the TRICARE Reserve Select and TRICARE Retired Reserve health plans.
TRICARE Prime: Where available. Enrollment is not automatic. If eligible, active duty family members may be enrolled in TRICARE Prime Remote for Active Duty Family Members (TPRADFM).
TRICARE Overseas Program Prime: For active duty family members only. Must meet specific overseas enrollment criteria. If eligible, may be enrolled in TRICARE Overseas Prime Remote.
Uniformed Services Family Health Plan (USFHP): Available in six locations. Submit the completed Enrollment Application to the USFHP address listed on Page 1. For the service area descriptions and telephone numbers for questions, please visit the TRICARE website at www.tricare.mil/usfhp.

SECTION I - SPONSOR INFORMATION

1. SPONSOR'S NAME*

(Must match DEERS)

First Middle Initial Last

2. SPONSOR'S SOCIAL SECURITY NUMBER (SSN) or DoD BENEFITS NUMBER (DBN)*

SPONSOR'S SOCIAL SECURITY NUMBER (SSN)*

DoD BENEFITS NUMBER (DBN)*

3. SPONSOR IS:*

4. SPONSOR'S TELEPHONE NUMBER

a. WORK:

b. RESIDENTIAL:

5. SPONSOR'S E-MAIL ADDRESS*

Check to receive TRICARE e-mails

6. SPONSOR'S RESIDENCE ADDRESS

(Street, Apartment No., City, State, ZIP Code, Country)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

7. SPONSOR'S MAILING ADDRESS

Same as residence
New

(Provide APO or FPO if stationed overseas)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

8. SPONSOR'S MILITARY ASSIGNMENT

a. UNIT

b. UNIT IDENTIFICATION CODE (UIC)

(If known)

c. STATE, ZIP CODE AND COUNTRY OF WORK ADDRESS

State / Province / Region ZIP / Postal Code Country

SECTION II - ENROLLING TRICARE YOUNG ADULT FAMILY MEMBER INFORMATION OR PCM CHANGE

9. FAMILY MEMBER NAME*

(Must match DEERS)

First Middle Initial Last

10. DATE OF BIRTH*

11. REQUESTED ACTION:*

Enroll
Transfer Enrollment
PCM Change
Disenroll

Effective Date:*

12. RESIDENCE ADDRESS*

Same as Sponsor
New

(Provide address, with ZIP Code and Country, if different from Sponsor)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

13. MAILING ADDRESS*

Same as Residence
New

(Provide address, with ZIP Code and Country, if different from Sponsor

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

14. TELEPHONE NUMBER

a. WORK:

b. RESIDENTIAL:

15. E-MAIL ADDRESS

Check to receive TRICARE e-mails

16. PRIMARY CARE MANAGER (PCM) PREFERENCE (Complete only if selecting a Prime or USFHP plan, or requesting a PCM change. Please list your first and second choices below. Honoring your preference depends upon availability and local Military Treatment Facility (MTF) policy. Contact your TRICARE Service Center, preferred MTF, or US Family Health Plan Member Services for availability of PCMs. If no PCM preference is indicated, one will be assigned.)

a. 1st CHOICE

MTF
Civilian
Same as Sponsor

FULL NAME or MTF/CLINIC

b. 2nd CHOICE

MTF
Civilian
Same as Sponsor

FULL NAME or MTF/CLINIC

c. PCM SPECIALTY

d. PREFERRED PCM GENDER

No Preference
Male
Female

17. REASON FOR DISENROLLMENT OR PCM CHANGE

SPONSOR'S SSN/DBN:*

SOCIAL SECURITY NUMBER (SSN)*

DoD BENEFITS NUMBER (DBN)*

SECTION III - OTHER HEALTH INSURANCE

18. PLEASE IDENTIFY IF YOU ARE CURRENTLY COVERED BY OTHER HEALTH INSURANCE.

TRICARE Supplement
Medical Insurance:
Dental Insurance:
Vision Insurance:
Prescription Insurance:

Medical Insurance:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

Policy Effective Date:

Dental Insurance:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

Policy Effective Date:

Vision Insurance:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

Policy Effective Date:

Prescription Insurance:

Person(s) Covered:

Policy Holder Name:

Carrier Name:

Policy Number:

Policy Effective Date:

SECTION IV - ACCESS WAIVER, ATTESTATIONS, AND SIGNATURE

I understand that if I selected a Primary Care Manager (PCM) by name, team, or location (MTF or civilian), the TRICARE program will enroll me with that PCM if capacity exists. If my selected or assigned PCM is greater than a 30 minute drive-time from my residence, or if I reside outside the Prime Service Area, I understand that: (1) I must also waive the specialty care access standard of one hour drive-time from my residence, and (2) this application constitutes my agreement to waive both the primary care access standard and specialty care access standard as applicable.

I understand recurring monthly premium payments may be adjusted as necessary based on a desired change in TYA coverage or due to changes in monthly premium amounts required by law.

I understand that it is my responsibility to comply with all TRICARE Young Adult policies and procedures. By signing this form, I certify the information provided is true, accurate, and complete. Federal funds are involved in this program and any false claims, statements, comments, or concealment of a material fact may be subject to fine and/or imprisonment under applicable Federal law.

COMPLETION IS MANDATORY - CHECK YES OR NO FOR EACH STATEMENT

I am eligible to enroll in an employer-sponsored health plan offered through my employer.*

Yes
No

I am married.*

Yes
No

19. NAME OF YOUNG ADULT DEPENDENT APPLICANT*

First Last

20. DATE SIGNED

ENROLLMENT NOTE: Initial enrollment effective date for TRICARE Standard coverage is the 1st of the month following the month the application is received, or the 1st of the month requested up to 90 days in the future. Effective dates for TRICARE Prime coverage are based primarily on the 20th of the month rule (applications received by the 20th of the month are effective the first day of the next month). If a TYA application is received by the contractor or postmarked within 30 days after termination of previous TRICARE coverage, you can request an effective coverage date immediately following termination of your previous TRICARE coverage. You should confirm enrollment (and PCM assignment for Prime plans) before obtaining routine medical care by calling your contractor.

DISENROLLMENT NOTE: You may incur a 12 month lock-out from TRICARE Young Adult coverage for failure to pay premiums or for voluntary termination not associated with gaining employer-sponsored health plan coverage. You may not be allowed to re-enroll in TRICARE Young Adult for 12 months from the date of the disenrollment.

PAYMENT OPTIONS: See Section V.

SPONSOR'S SSN/DBN:*

SOCIAL SECURITY NUMBER (SSN)*

DoD BENEFITS NUMBER (DBN)*

SECTION V - PAYMENT OF TRICARE YOUNG ADULT PREMIUMS

21. PREMIUM PAYMENT METHOD (complete as applicable.) (See www.tricare.mil/costs for current rates.) Failure to complete both parts a. and b. of this section when requesting new and/or recurring TYA coverage will result in your application being returned without action.

a. INITIAL PREMIUMS*

(Two months of initial premiums are required.)

Check/Money Order/Cashier's Check
Visa/MasterCard Credit or Debit Card

PAYMENT AMOUNT:*

(Enclose applicable premium payable to contractor on first page.)

CARD NUMBER:*

EXPIRATION DATE:*

(MM/YYYY)

NAME OF CARDHOLDER:*

First Middle Initial Last

CARDHOLDER BILLING ADDRESS:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

b. RECURRING AUTOMATED MONTHLY PREMIUMS*

(Recurring monthly premiums must be paid via a Recurring Credit Charge on a Visa/MasterCard credit or debit card or an Electronic Funds Transfer from a checking or savings account; either option is initiated and maintained by your servicing contractor. Failure to ensure premiums can be paid monthly via automated means will result in termination of TYA coverage.)

Use same Visa/MasterCard Credit or Debit Card information used for initial payment of premiums.
Other Visa/MasterCard Credit or Debit Card:
Electronic Funds Transfer (EFT).

CARD NUMBER:*

EXPIRATION DATE:*

(MM/YYYY)

NAME OF CARDHOLDER:*

First Middle Initial Last

CARDHOLDER BILLING ADDRESS:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

From:*

Checking (Optional - attach voided check)
Savings

Attach Photocopy of Voided Check*

NAME OF FINANCIAL INSTITUTION*

ADDRESS OF FINANCIAL INSTITUTION*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

NAME ON ACCOUNT*

First Last

TELEPHONE NUMBER OF FINANCIAL INSTITUTION*

ACCOUNT NUMBER*

BANK OR ABA ROUTING NUMBER*

Name

This field is for validation purposes and should be left unchanged.