TRICARE Young Adult (TYA)

Army National Guard: State Active Duty

Benefit Fact Sheet

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Summary:

The TRICARE Young Adult (TYA) Program is a premium-based individual-only health care plan available for purchase by qualified adult Children of Service members who have aged out of regular TRICARE Family coverage. TYA offers Prime and Standard coverage levels worldwide. TYA includes medical and pharmacy benefits, but excludes dental coverage.

Beginning in January 2017, DFAS will provide IRS Form 1095-C to all U.S. military members, and IRS Form 1095-B to all Retirees, Annuitants, former Spouses and all other individuals having TRICARE coverage during all or any portion of tax year 2016. An IRS Form 1095 documents you (and your Family members, if applicable) have the minimum essential coverage. These forms will document the information that DFAS will provide to the IRS on yourself and your authorized Family members. The forms will be required to be reported with your 2016 federal tax return. DFAS will provide you with IRS Form 1095 series forms no later than 31 January 2017.

Eligibility:

You may generally purchase TYA coverage if you are all of the following:

  • A dependent of a TRICARE-enrolled eligible Service member.
  • Unmarried.
  • At least age 21 but not yet 26 years old
    • If enrolled in a full course of study at an approved institution of higher learning and your sponsor provides more than 50 percent of your financial support, your eligibility may not begin until age 23 or upon graduation, whichever comes first.
  • Not eligible to enroll in an employer-sponsored health plan based on your own employment.
  • Not otherwise eligible for TRICARE coverage

TYA Program and the Affordable Care Act: The Affordable Care Act, also known as the Health Care Reform Law, requires that individuals maintain health insurance or other coverage that meets the definition of "minimum essential coverage" beginning in 2014. If purchased, TYA is considered minimum essential coverage. However, adult-age dependents are encouraged to evaluate all healthcare coverage options after aging out of the Sponsor's TRICARE coverage. To assess other healthcare coverage options before purchasing TYA, visit https://www.healthcare.gov.

Benefit Highlights:

TYA Program Enrollment: TYA offers open enrollment and may be purchased at any time. After enrolling in TYA, the beneficiary and sponsor must visit a uniformed services identification (ID) card issuing facility to obtain an ID card. Two forms of ID are required - one must be an unexpired government-issued ID card with a picture. For more information on DOD ID card locations click here. 

NOTE: If the eligible adult Child is not already in the Defense Enrollment Eligibility Reporting System (DEERS), the sponsor must add him/her to the system before starting the application process.

There are four ways to enroll for the TYA Program:

  • Online
  • Call the Regional Contractor
  • Fax enrollment to Regional Contractor
  • Mail enrollment to Regional Contractor

Please click here to visit the TYA Program Enrollment Page for details and specific instructions.

TYA Program Options and Costs: TYA Program costs for adult Children of active-duty Service members are based on three things:

  • The option chosen (TYA-Prime or TYA-Standard).
  • Your Sponsor's duty location (CONUS or OCONUS). If you are applying for coverage overseas, you will need proof of command-sponsorship from your parent Service member.
  • Where you will get care (i.e., network vs. non-network).

NOTE: TYA-Prime members have the same priority for care at military hospitals and clinics as other TRICARE Prime members. TYA-Standard members may only be seen for care at military hospitals and clinics on a space available basis, in which case, the cost for care is usually $0.

TRICARE YOUNG ADULT -Prime:

Overview: Children of active duty sponsors in all U.S. locations and in all overseas areas (if command-sponsored) and Children of retired sponsors only in Prime service areas are eligible for TYA- Prime. The TRICARE Young Adult-Prime Option works the same as TRICARE Prime. You'll have an assigned primary care manager (PCM) who provides most of your care:

  • They will be a military or network provider Find a Provider
  • refers you to specialists for care he or she can't provide
  • works with your regional contractor for authorization and to find a specialist in the network
  • files claims for you

Premiums:

  • The 2016 monthly premium is $306 per month (through Dec 31, 2016).  The 2017 monthly premium is $319 per month (starting Jan 1, 2017).
  • When you first enroll, you will pay two months' premium payment by check, money order, cashier's check, or credit/debit card. After that, premiums are paid automatically by an electronic funds transfer (EFT) or recurring credit/debit card payment.

Deductibles/Cost Shares:

For Active Duty Sponsors

  • You pay nothing out-of-pocket
  • Unless you get care without a referral, then you will pay point-of-service charges.

TYA-Prime Table of Cost Shares for Prime Network Copayments for Active Duty Family Members

Services

Cost

Annual Deductible

$0 (unless using POS)

Ambulance Services

$20 per occurrence

Ambulatory Surgery (same-day)

$25

Mental Health (Inpatient)

$11 per day ($25 minimum charge)

Mental Health (Partial Hospitalization)

$12 per visit

Mental Health (Outpatient)

$12 per visit

Clinical Preventative Services

$0 for from a network provider

DME, Prosthetic Devices, Medical Supplies

20% of negotiated fee

Emergency Services

$30 per visit

Home Health Care

$0

Hospice Care

$0

Hospitalization (Inpatient Care)

$11 per day ($25 minimum charge)

Immunizations

$0 from a network provider

Laboratory/X-ray

Ancillary service: $0

Other Radiology services: $12 per visit

  • Ancillary services include:

 

  • Diagnostic radiology and ultrasound

 

  • Diagnostic nuclear medicine

 

  • Cardiovascular studies

 

  • Venipuncture

 

  • Collection of blood samples

 

  • Fetal monitoring

Maternity (office visits for delivery planned in a hospital inpatient setting)

$11 per day ($25 minimum charge)

Maternity (office visits for delivery planned in a TRICARE-authorized birthing center)

$25 per visit

Maternity (office visits for delivery planned at home or other setting)

$12 per visit

Newborn Care*

$11 per day ($25 minimum charge)

Outpatient Visit

$12 per visit

Skilled Nursing (Inpatient)

$11 per day ($25 minimum charge)

 

TYA-Standard:

Overview: All dependent adult Children who qualify for TRICARE Young Adult can select the Standard Option. The TRICARE Young Adult-Standard Option works just like TRICARE Standard and Extra:

  • Visit any TRICARE-Authorized Provider (An authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network) Find a Provider
  • If you see a network provider, you'll pay less out of pocket and the provider will file claims for you.
  • You do not need a referral for any type of care but some services may require prior authorization.

 Premiums:

  • The 2016 monthly premium is $228 per month (through Dec 31, 2016).  The 2017 monthly premium is $216 per month (starting Jan 1, 2017).
  • When you first enroll, you will pay two months' premium payment by check, money order, cashier's check, or credit/debit card. After that, premiums are paid automatically by an electronic funds transfer (EFT) or recurring credit/debit card payment.

Deductibles/ Cost Shares: To participate, you'll pay:

  • Monthly premiums
  • Annual Deductible
    • Sponsor rank E4 and below: $50 per person, but no more than $100 per Family
    • Sponsor rank E5 and above: $150 per person, but no more than $300 per Family
  • Cost Shares  
    • Cost sharing begins after you meet the annual deductible each fiscal year.

TYA-Standard Table of Cost Shares for Active Duty Family Members

Services

Cost Share: TYA-Standard (US and Territories)

Cost Share: TYA-Standard (Overseas)

Ambulance Services

Network: 15% of negotiated fee
Non-Network: 20% of allowable charge

20% of the covered costs

Ambulatory Surgery (same-day)

$25

$25

Mental Health (Inpatient)

$18.20 per day ($25 minimum charge)

$18.20 per day ($25 minimum charge)

Mental Health (Partial Hospitalization)

Network: 15% of negotiated fee
Non-Network: 20% of allowable charge

20% of allowable charge

Mental Health (Outpatient)

Network: 15% of negotiated fee
Non-Network: 20% of allowable charge

20% of allowable charge

Clinical Preventative Services

$0 for colorectal, breast, cervical & prostate cancer screenings. Immunizations and well-child care for children under age 6 (birth through age 5)
For all other preventative services: Network: 15% of negotiated fee
Non-Network: 20% of allowable charge

$0 for colorectal, breast, cervical & prostate cancer screenings. Immunizations and well-child care for children under age 6 (birth through age 5)
20% of allowable for all other preventative services

DME, Prosthetic Devices, Medical Supplies

Network: 15% of negotiated fee
Non-Network: 20% of allowable charge

20% of covered costs

Emergency Services

Network: 15% of negotiated fee
Non-Network: 20% of allowable charge

20% of covered costs

Home Health Care

$0

Not Available

Hospice Care

$0

Not Available

Hospitalization (Inpatient Care)

$18.20 per day ($25 minimum charge)

$18.20 per day ($25 minimum charge)

Immunizations

$0

$0

Laboratory/X-ray

Network: 15% of negotiated fee Non-Network: 20% of allowable charge

20% of covered costs

Maternity (office visits for delivery planned in a hospital inpatient setting)

$18.20 per day ($25 minimum charge)

$18.20 per day ($25 minimum charge)

Maternity (office visits for delivery planned in a TRICARE-authorized birthing center)

$25

Not Available

Maternity (office visits for delivery planned at home or other setting)

Network: 15% of negotiated fee Non-Network: 20% of allowable charge

20% of covered costs

Newborn Care*

The lower of the number of hospital days minus three multiplied by $18.20, or 25% of billed charges.

The lower of the number of hospital days minus three multiplied by $18.20, or 25% of billed charges.

Outpatient Visit

Network: 15% of negotiated fee
Non-Network: 20% of allowable charge

20% of covered costs

Skilled Nursing (Inpatient)

$18.20 per day ($25 minimum charge)

Not Available

*NOTE: Newborn care is not covered unless the father of the Child is a uniformed Service Member.

Disenrollment: Members may choose to end TYA coverage at any time by completing the fields related to terminating coverage on the TRICARE Young Adult Application and submitting it to their regional contractor (North, South, West, Overseas). If the member decides to end TYA coverage, he or she will be locked out for one year following the date of termination. There will be no lockout if the coverage is terminated because of employer-sponsored coverage.

Coverage is also terminated because of nonpayment or a change in status. Nonpayment results in a 12-month TYA purchase lockout. TYA coverage ends when any of the following occurs:

  • Member reaches age 26
  • Member is married
  • Member becomes eligible for an employer-sponsored health plan
  • Member gains other TRICARE coverage
  • Member's sponsor ends TRICARE coverage or loses eligibility for TRICARE

Additional Information:

For more information, visit the TRICARE Young Adult web site:
http://www.tricare.mil/Costs/HealthPlanCosts/TYA.aspx

To view and download the TYA Program Fact Sheet:
www.tricare.mil/~/media/Files/TRICARE/Publications/FactSheets/TYA_FS.pdf 

TRICARE Young Adult- Standard Cost Shares
http://www.tricare.mil/Costs/HealthPlanCosts/TYA/StandardOption.aspx

To visit the TRICARE Homepage and Regions, visit the following pages:

TRICARE Homepage: http://www.tricare.mil/

TRICARE North Region:
https://www.hnfs.com/content/hnfs/home/tn/common/app_help_pages/provider_directory.html/pp/content/hnfs/home/tn/bene

TRICARE South Region:
https://www.humanamilitary.com/provider-locator

TRICARE West Region:
https://www.uhcmilitarywest.com/FindAProvider/

Document Review Date: 18 November 2016