DD Form 2837 Continued Health Care Benefit Program (CHCBP) Applicatio

OMB No. 0704-0364
OMB Approval Expires
Nov 30, 2008

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP)
APPLICATION

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, Executive Services Directorate (0704-0364). 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 APPLICATION TO THE ABOVE ORGANIZATION. RETURN COMPLETED APPLICATION WITH PREMIUM
PAYMENT TO: Humana Military Healthcare Services, Inc., Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1086 and E.O. 9397.
PRINCIPAL PURPOSE(S): This form is used by certain former military health care beneficiaries to apply for coverage under the Continued Health
Care Benefit Program (CHCBP). Please see 32 C.F.R. 199.20(d) for a list of the eligible beneficiaries.
ROUTINE USE(S): Disclosure may be made to Federal, state, local, foreign government agencies, private business entities and individual providers
of care on matters relating to entitlement, fraud, program abuse, program integrity, or civil and criminal litigation related to the operation of the
Continued Health Care Benefit Program.
DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in the applicant not being enrolled in the Continued Health
Care Benefit Program.
1. APPLICANT NAME (Last, First, Middle Initial)

2. TELEPHONE NO. (Include Area Code)
a. HOME

3. RESIDENCE ADDRESS (Street, Apartment No., City, State, ZIP Code)

b. WORK

4. MAILING ADDRESS (If different from Residence Address)

5. SERVICE MEMBER SPONSOR THROUGH WHOM YOU QUALIFY (If different from Applicant)
a. NAME (Last, First, Middle Initial)

b. SPONSOR'S SOCIAL SECURITY NUMBER

6. PERSON(S) TO BE ENROLLED IN CHCBP (Including Applicant)
a. NAME
(Last, First, Middle Initial)

b. SSN
OF INDIVIDUAL

c. DATE OF BIRTH
(YYYYMMDD)

d. SEX
(M/F)

(1) SPONSOR (Submit copy of DD214 Member 4 Copy)
(2) DEPENDENTS
(Submit copy of DD214 Member 4 Copy)
(Sponsor must enroll for dependents
to be enrolled. List all family
members. Use a separate sheet
of paper if more space
is needed.)

(3) UNREMARRIED FORMER SPOUSE
(Submit copy of final divorce decree.)
(4) CHILD LOSING MILITARY BENEFITS
DUE TO AGE*
(Submit copy of Military ID Card)
(5) CHILD LOSING MILITARY BENEFITS
FOR ANY OTHER REASON*
(Submit copy of proof of event that
resulted in loss of benefits.)

*Children age 21 (23 if a full-time student) losing military coverage must apply separately for their own individual policy.
If more than three children, use separate sheet of paper.
7. TOTAL THREE-MONTH PREMIUM ENCLOSED: (Individual three-month premium is $933.00. Family three-month premium is $1,996.00.)

$
PAID BY:

PREMIUM PAID IS FOR:
CHECK

MONEY ORDER

INDIVIDUAL COVERAGE

FAMILY COVERAGE

(Check/money order payable to the United States Treasury)

8. APPLICANT'S SIGNATURE AND DATE
By signing this form, the applicant is certifying that the information provided on this form 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 imprisonment under
applicable Federal law.
a. SIGNATURE

DD FORM 2837, SEP 2006

b. DATE SIGNED (YYYYMMDD)

PREVIOUS EDITION IS OBSOLETE.

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CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP)
SUMMARY
WHAT IS THE CHCBP?
The Continued Health Care Benefit Program
(CHCBP) is a program of temporary health benefit
coverage for certain eligible individuals who lose
military health benefits. The CHCBP is premium
based, with the medical benefits under this program
mirroring the benefits offered in the TRICARE
Standard Program and functioning under most of the
rules and procedures of TRICARE Standard.

HOW DOES ONE ENROLL IN THE CHCBP?
In order to enroll in the CHCBP, an eligible individual
must submit a completed enrollment application form,
proof of eligibility, and payment in full for the first 90 days
of coverage (check or money order made payable to the
United States Treasury). The enrollment form may be
requested from Humana Military Healthcare Services,
Inc., by writing or calling them. The enrollment form can
also be found on the Web at www.tricare.osd.mil or
www.humana-military.com.

ARE THERE SPECIFIC ENROLLMENT
REQUIREMENTS?
Yes. Beneficiaries must elect coverage in the
CHCBP within 60 days following: (1) loss of
entitlement to the Military Health System; or
(2) being notified of the CHCBP. Beneficiaries may
not select the effective date of their CHCBP policy; the
period of coverage must begin on the day after loss of
military entitlement.

PROOF OF ELIGIBILITY:
Proof of eligibility must be submitted with the
completed enrollment application and payment. The
documentation that is required is shown in Sections 6(1)
through 6(5) of the enrollment application, depending on
the category of the individual applying. Additional
information and documentation may be requested to
confirm the applicant's eligibility.

WHO IS ELIGIBLE?
(1) The sponsor; (2) certain unremarried former
spouses; (3) a child who loses military benefits due to
his or her age; and (4) a child placed in the legal
custody of the sponsor.
WHAT ARE THE ENROLLMENT CATEGORIES?
CHCBP provides two types of coverage plans:
individual and family. Individual coverage is available
to the sponsor, an unremarried former spouse, and a
child losing military benefits due to age. Family
coverage is only available to the separating service
member and his or her family members. Once the
election is made, the sponsor's enrollment category
can be changed from individual to family coverage
under the following conditions: (1) birth of a child; (2)
marriage of the sponsor; (3) legal adoption of a child
by the sponsor; or (4) placement by a court of a child
as a legal ward in the home of the sponsor. If one of
the above events has occurred, the former member
can change his or her enrollment from individual to
family coverage, effective as of the date of the
qualifying event. The sponsor must send a written
request to Humana Military Healthcare Services, Inc.,
Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201,
no later than 60 days from the qualifying event and
must include sufficient documentation to support the
change in enrollment categories.

DD FORM 2837 INSTRUCTIONS, SEP 2006

HOW LONG IS COVERAGE OFFERED?
CHCBP coverage ranges from a period of 18 to 36
months, depending on the category of the beneficiary.
Former active duty members and their family members
are entitled to purchase up to 18 months of coverage.
All other eligible beneficiaries are entitled to 36 months
of coverage. Certain former spouses may be eligible for
coverage beyond 36 months. All former spouses should
review the criteria for extended coverage before
enrolling in CHCBP to determine their eligibility for
continued coverage beyond 36 months. CHCBP
coverage is offered in increments of 90 days, renewable
up to the total number of months referenced above.
WHAT DOES CHCBP COVERAGE COST?
The cost of CHCBP coverage depends on the
category of enrollment, either individual or family. The
premium for individual coverage is $933.00 per quarter
and the premium for family coverage is $1,996.00 per
quarter.
HOW IS COVERAGE RENEWED?
At least thirty days prior to the expiration of the
current coverage period, a renewal notice will be sent to
the enrollee. The enrollee must return the renewal
notice and payment in full, by check, money order or
major credit card, no later than 30 days after the end of
the current coverage period. Failure to renew within the
required time will result in the permanent loss of
entitlement to purchase any additional CHCBP
coverage.

CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP)
SUMMARY (Continued)
ARE PREMIUMS REFUNDABLE?
Refunds of premiums paid for CHCBP coverage are not
refundable other than in extraordinary circumstances, e.g.,
if the enrollee is no longer eligible for CHCBP coverage.
WHAT BENEFITS ARE OFFERED?
Health care coverage under the CHCBP mirrors the
coverage of the TRICARE Standard benefit, which covers
a majority of medical conditions. However, for some types
of treatment, coverage can be limited. Prior to enrolling in
the CHCBP, interested beneficiaries are encouraged to
contact a TRICARE Service Center to ask specific
questions regarding TRICARE Standard coverage.
WHAT ADDITIONAL COSTS ARE THERE?
When medical care is received, the beneficiary will be
responsible for payment of certain deductible and
cost-sharing amounts in connection with otherwise covered
services and supplies. For detailed information concerning
the amounts of cost-shares and deductibles, beneficiaries
are encouraged to contact a TRICARE Service Center
nearest their home.
HOW TO FILE A CLAIM:
Enrollees may request the provider to file medical
claims on their behalf. If the provider does not file the
claim, the enrollee will have to do so. It is helpful to attach
a copy of the CHCBP enrollment card to the claim.
Information regarding where to submit a claim can be
found at the TRICARE Web Site www.tricare.osd.mil or by
contacting either Humana Military Healthcare Services,
Inc., or a TRICARE Service Center nearest the enrollee's
residence.
If there are any problems with the processing of a CHCBP
claim, the enrollee should contact the claims processor. If
that is not successful, the enrollee may then write to the
TRICARE Management Activity at the following address:
Beneficiary and Provider Services
TRICARE Management Activity
16401 East Centretech Parkway
Aurora, CO 80011-9066

DD FORM 2837 INSTRUCTIONS (BACK), SEP 2006

HOW CAN PROVIDERS VERIFY CHCBP
ELIGIBILITY?
Providers may call 1-800-444-5445 to verify
the eligibility of the beneficiary or to obtain basic
CHCBP information.
WHAT STEPS SHOULD ACTIVE DUTY
MEMBERS TAKE WHEN SEPARATING FROM
THE MILITARY?
Current active duty members anticipating
separation from the military should ensure they
participate in pre-separation counseling, which
will provide information regarding various
benefits available to members after leaving the
military. Former members must also ensure that
their correct status is recorded in DEERS upon
separation.
HOW TO OBTAIN INFORMATION ABOUT
CHCBP:
Humana Military Healthcare Services, Inc.,
provides administrative and educational support
for the CHCBP. As part of this effort, they
operate a toll-free line 24 hours a day.
Beneficiary Service Representatives are
available Monday through Friday 8:00 a.m. to
7:00 p.m. Eastern Time (except holidays).
ADDITIONAL INFORMATION:
Write or call:
Humana Military Healthcare Services, Inc.
Attn: CHCBP
P.O. Box 740072
Louisville, KY 40201
1-800-444-5445
or visit their Web Site at:
www.humana-military.com