Managed Care Support Contractors,
Uniformed Services Family Health Plan (USFHP) Designated Provider
(DP), and TRICARE Overseas Program (TOP) contractors shall record
all enrollments on Defense Enrollment Eligibility Reporting System
(DEERS), as specified in the TRICARE Systems Manual (TSM),
Chapter 3. The word “contractor” refers to
all three contractors (listed above) for this section unless otherwise
noted.
1.0
Enrollment
Processing
1.1 For paper enrollment requests, contractors
shall use the TRICARE Prime Enrollment, Disenrollment, and Primary
Care Manager (PCM) Change Form (one combined form), Department of Defense
(DD) Form 2876. For TRICARE Select enrollments, the contractor shall
use the TRICARE Select Enrollment, Disenrollment, and Change Form,
DD Form 3043. Contractors shall ensure the aforementioned form is
readily available to potential enrollees. Contractors shall implement
enrollment processes (which do not duplicate Government systems)
that ensure success and assistance to all beneficiaries. Contractors
shall collect enrollment forms at a site(s) mutually agreed to by
the contractor, TROs, and Military Treatment Facility (MTF) Commanders/eMSM
Managers, by mail, fax, or by other methods proposed by the contractor
and accepted by the Government. Contractors shall encourage the
beneficiaries to use the Government furnished web-based self-service
enrollment system/application to enroll. The overseas contractor
shall also collect applications at TRICARE Service Centers (TSCs).
1.2 Enrollment
requests must be initiated by the sponsor, spouse, other legal guardian
of the beneficiary, or an eligible beneficiary age 18 or older.
An official enrollment request includes those with (1) an original
signature, (2) an electronic signature offered by and collected
by the contractor, (3) a verbal consent provided via telephone and
documented in the contractor’s call notes, or (4) a self-attestation
by the beneficiary when using the Government furnished web-based
self-service enrollment system/application. A signature from a Service
member is never required to complete Prime enrollment as enrollment
in Prime is mandatory per the TRICARE Policy Manual (TPM),
Chapter 10, Section 2.1.
1.3 The contractor shall provide beneficiaries
who enroll full and fair disclosure of any restrictions on freedom
of choice that apply to enrollees, including the Point of Service
(POS) option for TRICARE Prime enrollees and the consequences of
possibly having direct care only coverage on a space available basis
for failure to pay enrollment fees on time, choosing to not enroll,
or disenroll from either TRICARE Prime or TRICARE Select.
1.4 Enrollment shall be on an individual or family
basis. For newborns and adoptees, see the TPM,
Chapter 10, Section 3.1.
1.5 For TRICARE Prime enrollments, the contractor
shall follow the specifications recorded in each MTF/eMSM’s Memorandum
of Understanding (MOU)/Statement of Responsibility (SOR).
1.6 Contractors shall record all enrollments using
the Government furnished web-based enrollment system/application,
within 10 working days of receipt. The equipment needed to run the DEERS
desktop enrollment application shall be furnished by the contractor
and shall meet technical specifications in the TSM,
Chapter 3.
1.6.1 Contractors shall resend TRICARE Prime/TRICARE
Plus PCM Information Transfers (PITs) to MTF/eMSMs when requested.
1.6.2 Contractors shall submit required changes to
the DEERS Support Office (DSO) as required.
1.7 At the time of enrollment processing, the contractor
shall access DEERS to verify beneficiary eligibility and shall update
the residential, mailing, and e-mail addresses and any other fields
that they can update on DEERS.
1.7.1 If the enrollment request (see
paragraph 1.2)
contains neither a residential address nor a mailing address, the
contractor shall develop for a residential or mailing address.
1.7.2 Enrollees or the Government may provide the
contractor a temporary address (i.e., Post Office Box, Unit address,
etc.), until a permanent address is established. Temporary addresses
shall be updated with the permanent address when provided to the
contractor by the enrollee in accordance with the TSM,
Chapter 3, Section 4.2. The contractor shall
not input temporary addresses unless provided by the enrollee or
the Government.
1.7.3 If the
DEERS record does not contain an address, or if the enrollment request
contains information different from that contained on DEERS in fields
for which the contractor does not have update capability, the contractor
shall contact the beneficiary by telephone within five calendar
days, outline the discrepant information and request the beneficiary
contact their military personnel office.
1.8 Defense Manpower Data Center (DMDC)/DEERS shall
notify the beneficiary of the TRICARE wallet card at MilConnect.
DMDC will also provide notification of PCM assignments for new TRICARE Prime
enrollments, disenrollments, enrollment transfers, and PCM changes.
(See TSM,
Chapter 3, Section 4.2.) The return address
on any correspondence mailed by DMDC will be that of the appropriate contractor.
In the case of receiving returned mail, the contractors shall develop
a process to fulfill the delivery if the correspondence is returned
to the contractor by the United States Post Office (USPS).
2.0
Automatic
Enrollment Management
2.1 Automatic
Eligibility Updates
DEERS will automatically
update start and/or end dates of coverage when a beneficiary’s eligibility
is updated by the Uniformed Services. The contractor will receive
a Policy Notification Transaction (PNT) advising them of all changes,
and will take action accordingly.
2.2 Automatic Enrollment of Active
Duty Service Members (ADSMs)
DEERS
will automatically enroll all new active duty service member accessions,
to include Reserve Component members on active duty
for more than 30 days, into Health Care Delivery
Plan 001 (TRICARE Prime for Active Duty Sponsors, No PCM Assigned).
2.3
Automatic
Enrollment of Newly Eligible Active Duty Family Members (ADFMs)
Note: Automatic enrollment
of ADFMs does not apply to USFHP contractors.
Contractors shall upon request from a beneficiary
or sponsor, who was auto-enrolled, adjust any claims in question
to apply Prime plan benefits, and waive POS cost-sharing provisions.
Contractors shall educate the beneficiary or sponsor of this one-time
correction and provide instruction to the beneficiary regarding
their PCM assignment and the requirement to have referrals for all
future specialty care. If received over the phone, the conversation
shall be documented in the Contractor’s call notes. The contractor
need not identify these claims; however, the claims shall be adjusted
as they are brought to their attention by beneficiaries.
3.0
Dual
Eligibles (Entitlement Under Both Medicare And TRICARE)
3.1 Dual eligibles, (retired and retired family
members, under age 65) are eligible to enroll in TRICARE Prime provided
they maintain Medicare Part A and Part B. Dual eligible ADFMs, regardless
of age, are eligible to enroll in TRICARE Prime or TRICARE Select. Dual
eligible retirees and family members age 65 and over are not eligible
to enroll in TRICARE Prime or TRICARE Select. Exception: Those not entitled
to premium free Medicare part A on their own or the record of their
current, former, deceased spouse may enroll in TRICARE Prime or TRICARE Select. Medicare
is primary payor for all dual eligibles regardless of their sponsor’s
status. (See the TPM,
Chapter 10, Section 2.1 for additional dual
eligible information.)
3.2 TRICARE Prime-enrolled dual eligibles, to the
extent practicable, should follow all TRICARE Prime requirements
for PCM assignment, referrals and authorizations. However, they
are not subject to POS cost-sharing. Enrollment fees are waived
for dual eligibles. (See
paragraph 5.0.)
4.0 Assignment
Of PCM For TRICARE Prime Enrollees
The contractor
shall assign all TRICARE Prime enrollees a PCM by name (PCMBN) on
the Government furnished web-based enrollment system/application
at the time of TRICARE Prime enrollment. This applies to beneficiaries
assigned to the Direct Care (DC) system as well as civilian network
PCMs.
4.1 The contractor shall comply
with the MTF Commander’s/eMSM Manager’s specifications in the MTF/eMSM
MOU/SOR for which enrollees or categories of enrollees shall be
assigned a DC PCM or offered a choice of civilian network PCMs.
4.1.1 The contractor shall enroll TRICARE Prime beneficiaries
to the MTF/eMSM until the capacity is optimized in accordance with
the MTF Commander’s/eMSM Manager’s determinations. TRICARE Prime
beneficiaries who cannot be enrolled to the MTF/eMSM will be enrolled
to the contractor’s network.
4.1.2 All active duty personnel not meeting the requirements
for TRICARE Prime Remote (TPR) shall be enrolled to an MTF/eMSM,
not the contractor’s network, regardless of capacities.
4.1.3 When a family member of an active duty E-1
through E-4 sponsor requests a PCM in an MTF/eMSM that offers TRICARE
Prime for any beneficiary category other than active duty, that beneficiary
must be assigned an MTF/eMSM PCM unless capacity has been reached.
If overall MTF/eMSM capacity has not been reached, the contractor
shall request the MTF/eMSM to shift capacity in the Government furnished
web-based enrollment system/application to the ADFM beneficiary category
from another category if necessary to accommodate an E-1 through
E-4 ADFM beneficiary’s PCM assignment request.
4.2 The contractor shall provide guidance to the
enrollee in selecting a primary care location or PCM, as appropriate
given MTF/eMSM guidance in the MOU. Upon receipt of an inquiry from
a DC enrollee in regards to the person’s assigned PCM, the contractor
shall refer the beneficiary to the MTF/eMSM where the beneficiary
is enrolled.
4.3 At the time of enrollment,
the contractor shall determine the appropriate enrollment Defense Medical
Information System Identification (DMIS-ID) based on the regional
and MTF/eMSM MOUs, access standards and/or other specific Government
guidance. The contractor shall assign each enrollee a PCMBN at the
time of enrollment based on those PCMs available within the Government
furnished web-based enrollment system/application.
4.3.1 The contractor shall attempt to assign the
beneficiary to the PCM requested by the beneficiary (see
paragraph 1.2)
if capacity is available. If the preferred PCM is not available,
the contractor shall use the default PCM for that DMIS.
4.3.2 If the enrollment request (see
paragraph 1.2)
identifies a gender or specialty preference, the contractor shall assign
an appropriate PCM. If the gender or specialty is not available,
the beneficiary will be enrolled to the default PCM for that DMIS.
4.3.3 If no PCM preference is stated on the enrollment
request (see
paragraph 1.2), the contractor shall use the
default PCM for that DMIS.
4.3.4 If there is no DC PCM available in the appropriate
DMIS/MTF/eMSM, nonactive duty beneficiaries may be enrolled to a
civilian PCM, by following the procedures specified in the MTF/eMSM MOU.
4.3.5 If there is no PCM capacity in the MTF/eMSM
for a Service member, then the contractor shall contact the MTF/eMSM
for instructions.
4.4 The Government furnished web-based enrollment
system/application reflects only those DC PCMs that the MTF/eMSM
has loaded onto the DEERS PCM Repository. Further, the Government furnished
web-based enrollment system/application will only display PCMs with
available capacity for the specific beneficiary’s category and age.
The contractor shall not add, delete, or modify DC PCMs on the repository.
4.5 The contractor shall complete all panel PCM
reassignments (batch) using a Government-provided systems application,
PCM Reassignment System (PCMRS). Panel reassignments may be specified
by the appropriate MTF Commander/eMSM Manager for a variety of reasons,
including the rotation or deployment of DC PCMs. The contractor
should expect at least one-half of DC PCM assignments to change
each year. These moves may be based on various factors of either
the enrollment or the individual beneficiary, including:
• DMIS
ID to DMIS ID
• PCM
ID to PCM ID
• Health
Care Delivery Program (HCDP)
• Sex of beneficiary
• Unit Identification
Code (UIC) (active duty only)
• Age of beneficiary
• Sponsor Social
Security Number (SSN) and DoD Benefits Number (DBN)
• Name of beneficiary
4.6 MTFs/eMSMs may request PCM reassignment, including
panel reassignments, in several ways, including telephone, e-mail
or other electronic submissions. The preferred method for panel reassignments
is the batch staging application within PCMRS. Regardless of the
submission method, the MTF/eMSM must provide sufficient information
identifying both the PCMs and beneficiaries involved in a move to
allow the contractor to reasonably accomplish the move. Thereafter,
the contractor shall complete each DC PCM reassignment, both individual
and panel reassignment, within three working days of receiving all
necessary information from the MTF/eMSM.
4.7 PCM change requests submitted by beneficiaries
enrolled to a civilian network PCM via any means other than the
Government furnished web-based self-service enrollment system/application shall be
processed by the contractor within three working days of receipt,
with an effective date no later than the third working day.
4.8 PCM change requests submitted to the contractor
via the Government furnished web-based self-service enrollment system/application
shall be processed within six calendar days of receiving the request.
The contractor shall modify the effective date to be no later than
the third working day, or the date requested by the beneficiary
up to 90 days in the future. Effective January 1, 2018, the contractor shall
modify the effective date to be the date the contractor received
the request.
5.0
Enrollment
Period
5.1 Through December 31, 2017, the contractor shall
support continuous open enrollment for all beneficiaries. Enrollment
may occur any time during the contract period; however, all new
enrollment periods will be aligned with the fiscal year. Therefore,
the initial enrollment period may be shorter than a 12 month period.
Note: The enrollment
period for fiscal year 2017 includes the period between October
1, 2017 and December 31, 2017.
5.2
Starting
January 1, 2018
5.2.1 The contractor shall support
one annual open enrollment period per calendar year for all Non-Active
Duty Service Member (NADSM) beneficiaries. Enrollments, with the
appropriate application and any required enrollment fee, will be
effective on January 1 of the following year. Beneficiaries will be
automatically re-enrolled each year unless they elect a different
option or disenroll during the open enrollment period. See TPM,
Chapter 10, Section 2.1.
5.2.2 A one-time transition period will be in effect
for the enrollment period beginning January 1, 2018 and ending December
31, 2018. Beneficiaries may elect to enroll in or change their TRICARE Prime
or Select coverage at any time during the calendar year 2018 enrollment
period.
5.3
Effective
Date of Enrollment (Prior to January 1, 2018)
The
contractor shall support continuous open enrollment for all beneficiaries.
Enrollment may occur any time during the contract period; however,
all new enrollment periods will be aligned with the fiscal year.
Therefore, the initial enrollment period may be shorter than a 12
month period.
5.3.1 The effective date of enrollment
for Service members shall be the date the contractor receives the
enrollment application. For enrollment requests received via the
Government furnished web-based self-service enrollment system/application,
the contractor shall modify the effective date to be the date the
enrollment was submitted.
5.3.2 For
all other beneficiary categories, enrollment periods shall begin
on the first day of the month following the month in which the enrollment
application and any required enrollment fee payment is received
by the contractor. If an application and fee are received after
the 20th day of the month, enrollment will be on the first day of
the second month after the month in which the contractor received
the application. (This recurring principle is referred to as the
“20th of the month” rule.)
5.3.3 Enrollees who transfer enrollment continue
with the same enrollment period. The enrollment transfer, however,
is effective the date the gaining contractor receives a signed enrollment application
or transfer application. For enrollment transfers received via the
Government furnished web-based self-service enrollment system/application,
the contractor shall modify the effective date to be the date the
enrollment was submitted. See TPM,
Chapter 10, Sections 2.1 and
5.1 for information on Transitional Assistance
Management Program (TAMP) and other changes in status.
5.3.4 Effective
Date of Enrollment (On or After January 1, 2018)
5.3.4.1 TRICARE Prime and TRICARE Select enrollments
will be effective the date of the Qualifying Life Event (QLE) or
on January 1 of the following year for open enrollment period enrollments
(see TPM,
Chapter 10, Section 2.1). Enrollment requests
will no longer be pended for six days.
5.3.4.2 Requests for enrollment based on a QLE may
be received up to 90 days before and no later than 90 days after
the date of the QLE. For online requests for an enrollment date
less than 90 days or more than 90 days from the date of the QLE,
the web- based self-service enrollment system/application will display
a message to contact the contractor.
5.4 Enrollment
Expiration (Before January 1, 2018)
5.4.1 Due to the extended enrollment period in 2017,
the contractor shall not send renewal notices to TRICARE Prime enrollees
on October 1, 2017 as in previous years. See
paragraph 5.5.1.
5.4.2 The contractor shall automatically renew enrollments,
including those for Service members, upon expiration unless the
enrollee declines renewal, is no longer eligible for Prime enrollment,
or fails to pay any required re-enrollment fee on a timely basis,
including a 30 calendar day grace period beginning the first day
following the last day of the enrollment period. See
paragraph 11.5.1,
for actions required if a beneficiary is identified as being ineligible
for continued Prime, TPR or TPRADFM enrollment.
5.4.3 If the enrollee requests disenrollment during
this grace period, the contractor shall disenroll the beneficiary
effective retroactive to the enrollment period expiration date (last
paid-through date).
5.4.4 If an enrollee does not respond to the notification
and fails to make an enrollment fee payment by the end of the grace
period, the contractor shall assume that the enrollee has declined continued enrollment.
The contractor shall disenroll the beneficiary retroactive to the
enrollment expiration date (last paid-through date).
5.4.5 Service
members may not decline continued enrollment nor request disenrollment.
5.4.6 DMDC sends written notification to the beneficiary
of the disenrollment and the reason for the disenrollment within
five business days of the disenrollment transaction.
5.5 Enrollment
Expiration (Starting January 1, 2018)
5.5.1 The
contractor shall not send renewal notices to enrollees. Exception:
Thirty (30) days before the expiration date of enrollment for beneficiaries
paying enrollment fees quarterly or annually, the contractor shall
send the appropriate individual (sponsor, custodial parent, retiree,
retiree family member, survivor or eligible former spouse, etc.)
a written notification of the pending enrollment expiration that
includes a bill for the re-enrollment fee. The notification will
alert the beneficiary that he/she will only be eligible for MTF
space-available care only should payment not be received. If appropriate,
the notification will include any rate change information. The bill
shall offer all available payment options and methods. The contractor
shall issue a delinquency notice to the appropriate individual 15
calendar days after the expiration date of the enrollment if a renewal
payment is not received.
5.5.2 For beneficiaries that pay enrollment fees
on a monthly basis: contractors shall send the appropriate individual
(sponsor, custodial parent, retiree, retiree family member, survivor
or eligible former spouse, etc.) a written notification alerting
the beneficiary of any fee changes at least 30 days prior to the
implementation of any fee changes.
5.5.3 The contractor shall automatically renew enrollments,
including those for Service members, each calendar year unless the
enrollee declines renewal, is no longer eligible for enrollment, or
fails to pay any required enrollment fee on a timely basis. See
TPM,
Chapter 10, Section 2.1 for actions required
if a beneficiary is identified as being ineligible for continued
enrollment. Contractors may reinstate coverage if the request is
received with appropriate payment of fees within 90 days from the last
paid-through date.
5.5.4 Active Duty Service Members
(ADSMs) may not decline reenrollment nor request disenrollment.
5.5.5 DMDC shall notify the beneficiary of the disenrollment
within five business days of the disenrollment transaction.
5.6
Disenrollment
5.6.1 Disenrollment
requests must be initiated by the sponsor, spouse, other legal guardian
of the beneficiary, or an eligible beneficiary 18 or older. An official
disenrollment request includes those with:
• An original signature;
• An electronic signature
offered by and collected by the contractor;
• A verbal consent provided
vial telephone and documented in the contractor’s call notes; or
• A self-attestation
by the beneficiary when using the Government furnished web-based self-service
enrollment system/application. (A Service member cannot request disenrollment.)
5.6.2 The
contractor shall automatically disenroll beneficiaries when the
appropriate enrollment fee payment is not received by the 30th calendar
day following the last paid-through date. The contractor shall set
the disenrollment effective date retroactive to the last paid-through
date. An enrollment fee payment includes the correct amount for
the period the fee is intended to cover (i.e., monthly, quarterly,
or annually).
5.6.3 Prior to processing a disenrollment
for “non-payment of fees,” the contractor shall reconcile their
fee payment system against the fee totals in DEERS. Once the contractor
confirms that the payment amounts match, the disenrollment may be
entered in the Government furnished web-based enrollment system/application.
5.6.4 Prior
to January 1, 2018
5.6.4.1 The disenrolled
beneficiary is responsible for the deductible and cost-shares applicable under
TRICARE Extra or Standard for any health care received during the
30 day grace period. In addition, the beneficiary is responsible
for the cost of any services received during the 30 day grace period
that may have been covered under TRICARE Prime but are not a benefit
under TRICARE Extra or Standard.
5.6.4.2 The contractor may suspend claims processing
during the grace period to avoid the need to recoup overpayments.
5.6.5 Effective
January 1, 2018
The contractor shall pend
claims received during the grace period to avoid the need to recoup
overpayments. See the TPM,
Chapter 10, Sections 2.1 and
3.1 for additional information on disenrollment.
5.7 Enrollment
Lockout (Prior to January 1, 2018)
5.7.1 The contractor shall “lockout” or deny re-enrollment effective the date
of disenrollment for the following beneficiaries:
• Retirees and/or their
family members who voluntarily disenroll prior to their annual enrollment
renewal date;
• ADFMs
(E-5 and above) who change their enrollment status (i.e., from enrolled
to disenrolled twice in a given year) for any reason during the
enrollment year (October 1 to September 30) (refer to this chapter
and TPM,
Chapter 10, Sections 2.1 and
3.1; and
• Any beneficiary disenrolled
for failure to pay required enrollment fees during a period of enrollment.
Note: The 12 month lockout provision is not applicable
to ADFMs whose sponsor’s pay grade is E-1 through E-4.
5.7.2 Beneficiaries who are disenrolled for the above
reasons prior to December 31, 2018 are eligible to re-enroll any
time during calendar year 2018. Beginning January 1, 2019, the 2018 enrollment
grace period ends and only the annual open enrollment season and
QLE rules fully apply. See TPM,
Chapter 10, Section 2.1.
5.8 Enrollment
Lockout (Starting January 1, 2018)
5.8.1 Enrollment lockouts are no
longer necessary for TRICARE Prime and TRICARE Select as enrollments
are only allowed during the annual open enrollment period or due
to a QLE.
5.8.2 The contractor shall reinstate
(restore) the enrollment if the beneficiary requests reinstatement
within 90 days of their disenrollment date (last paid-through date)
and pays all past due fees if applicable. Otherwise, requests for
reinstatement due to failure to pay fees received after 90 days past
the last paid-through date shall be denied by the contractor.
5.8.3 Exception
In the event the “failure to pay” disenrollment
was directly caused by contractor or Government error, for
example, the contractor failed to submit the correct allotment amount
to the Defense Finance and Account Service (DFAS), upon request
of the beneficiary via the contractor, the TROs/TRICARE Area Offices/USFHP
program office may direct reinstatement of the coverage greater than
90 days past the last paid-through date if all past fees are paid
if applicable. In no instance shall a new enrollment period be started
in lieu of reinstatement from the last paid-through date.
6.0 Enrollment Fees
6.1 General
The contractor shall collect enrollment fee
payments from TRICARE Prime and TRICARE Select enrollees as appropriate
and report those fees, including any overpayments that are not refunded
to the enrollee, to DEERS.
• The
contractor shall report refunds to DEERS: (1) all refunds of any
enrollment fees collected, and (2) fee amounts forfeited by enrollees prior
to January 1, 2018 who voluntarily disenroll and are not due a refund.
The forfeited fee amounts, unless they can be credited to the enrollment
of another family member(s), shall not be retained as a credit. For
forfeited fees, the contractor shall adjust the fees paid on the
enrollment policy to match with the voluntary termination date (“zero”
the fees paid). (See the TSM,
Chapter 3.) For
enrollment fee refund policies as of January 1, 2018, see
paragraph 9.0.
• To permit the transition
from a fiscal to a calendar enrollment year, fiscal year 2017 is defined
as the period from October 1, 2016 through December 31, 2017. For
FY 2017, prorated TRICARE Prime enrollment fees are required for
the additional period of October 1, 2017 through December 31, 2017.
• TRICARE Prime and TRICARE Select enrollees may
select one of the following three payment fee options (i.e., annual,
quarterly, or monthly).
• When
enrollment fee or premium payments are permitted by credit or debit
cards, beneficiaries in overseas locations must utilize a credit
or debit card issues by a U.S. banking institution or other U.S.
financial institution.
• In
the event that there are insufficient funds to process an enrollment
fee or premium payment, the contractor may assess the account holder
a fee of up to 20 U.S. dollars ($20.00), which is retained by the
contractor. The contractor shall provide commercial payment methods
for enrollment fees and premiums that best meet the needs of beneficiaries
while conforming to
paragraphs 6.1.2 through
6.7.
6.1.1 Fiduciary
Responsibilities
6.1.1.1 The contractor
shall act as a fiduciary for all funds acquired from TRICARE Prime and
Select enrollment fees, which are Government property. The contractor
shall develop strict funds control processes for its collection,
retention and transfer of enrollment fees to the Government. All
enrollment fees received by the contractor shall be maintained in
accordance with these procedures.
6.1.1.2 A separate non-interest bearing account shall
be established for the collection and disbursement of enrollment
fees. The contractor shall deposit enrollment fees into the established account
within one business day of receipt.
6.1.1.3 The contractor shall wire-transfer the enrollment
fees minus any refund payments twice monthly, on the first (business
day) and the 15th to a specified Government account as directed
by the Defense Health Agency (DHA) Contract Resource Management
(CRM) Office, refer to Section J of the contract. The Government
will provide the contractor with information for this Government
account. The contractor shall notify the DHA CRM, by e-mail, within
one business day of the deposit stating the date and amount of the
deposit.
6.1.1.4 The contractor
shall maintain a clear, auditable record of all enrollment fees
received, the date received and the date transferred to the Government.
The contractor’s record shall also document all refunds issued,
to whom the refund was issued, the amount of the refund, and the
date reported to the Government.
6.1.2
Annual
Payment Fee Option
An annual installment
is collected in one lump sum. For initial enrollments, the contractor shall
prorate the fee from the enrollment date to December 31. The contractor
shall accept payment of the annual enrollment fee only by debit/credit
card (e.g., Visa/MasterCard). See
paragraph 5.6 for disenrollment information
if the appropriate enrollment fee payment is not received.
6.1.3 Quarterly
Payment Fee Option
Quarterly installments
are equal to one-fourth (1/4) of the total annual fee amount. For initial
enrollments, the contractor shall prorate the quarterly fee to cover
the period until the next quarter. Quarters begin on January 1,
April 1, July 1, and October 1. The contractor shall collect quarterly
fees thereafter. The contractor shall accept payment of the quarterly
enrollment fee by debit/credit card (e.g., Visa/MasterCard) and
optionally may elect to receive quarterly payments via recurring debit/credit
card or Electronic Funds Transfer (EFT) transactions. See
paragraph 5.6 for
disenrollment information if the appropriate enrollment fee payment
is not received.
6.1.4 Monthly
Payment Fee Option
Monthly installments are
equal to one-twelfth (1/12) of the total annual fee amount rounded
down if not divisible by 12. Monthly enrollment fees must be paid-through
an automated, recurring electronic payment either in the form of
an allotment from retirement pay or through EFTs from the enrollee’s
designated financial institution (which may include a recurring
credit or debit card charge). These are the only acceptable payment
methods for the monthly payment option.
6.1.4.1 Enrollees who elect the monthly fee payment
option must pay one to three months of fees (contractor determined),
at the time the enrollment request is submitted to allow time for
the allotment or EFT to be established. The contractor shall explain
the deposit amount required and accept payment by personal check,
cashier’s check, traveler’s check, money order, or debit/credit
card (e.g., Visa/MasterCard).
6.1.4.2 Contractors shall obtain and verify the information
needed to initiate monthly allotments and EFTs.
6.1.4.3 Contractors shall direct bill the beneficiary
only when a problem occurs.
6.1.4.4 When an administrative issue arises that stops
or prevents an automated monthly payment from being received by
the contractor (e.g., incorrect or transposed number provided by
the beneficiary, credit card expired, bank account closed, etc.),
the contractor shall grant the enrollee 30 days from the paid-through
date to provide information for a new automated monthly payment method
or the option to pay quarterly or annually. Contractors may accept
payment by check during this 30 day period in order to preserve
the beneficiary’s TRICARE Prime or Select enrollment status.
6.1.4.5 Allotments from retired pay will be coordinated by the
contractor with the DFAS, U.S. Coast Guard (USCG), or Public Health
Service (PHS), as appropriate (see the TSM,
Chapter 1, Section 1.1, paragraph 7.10 for
Payroll Allotment Interface Requirements).
6.1.4.6 Contractors shall also research and resolve
all requests that have been rejected or not processed by DFAS, USCG,
or PHS. If the contractor’s research results in the positive application
of the allotment action, the contractor shall resubmit the allotment
request.
6.1.4.7 Within
five business days, the contractor shall notify the beneficiary
of rejected allotment requests and issue an invoice to the beneficiary
for any outstanding enrollment fees due. Contractors shall respond
to all beneficiary inquiries regarding allotments.
6.2 Member
Category
The sponsor’s member category on
the effective date of the initial enrollment, as displayed in the
Government furnished web-based enrollment system/application, shall
determine the requirement for an enrollment fee.
6.3 Unremarried
Former Spouses (URFSs) and Children Residing with Them
6.3.1 URFSs became sponsors in their own right as
of October 1, 2003. As such, they are enrolled under their own SSNs
and pay an individual enrollment fee. URFS may not “sponsor” other
family members and their fees may not be factored into any family
fees associated with the former spouse/sponsor.
6.3.2 Children residing with URFS, whose eligibility
for benefits is based on the ex-spouse/former sponsor, are identified
and enrolled under the ex- spouse/former sponsor’s SSN on DEERS,
and fees for these children shall be combined with other fees paid
under the ex-spouse/former sponsor.
Example: A
contractor shall collect the individual enrollment fee for an URFS’s
enrollment under the URFS’s own SSN. The contractor shall also collect
a family enrollment fee for any two or more eligible family members
enrolled under the SSN of the ex-spouse/former sponsor. These enrollees
might include the sponsor, any current spouse, and all eligible children,
including those living with the URFS.
6.4 TRICARE
Prime Fee Waiver
Each TRICARE Prime enrolled
beneficiary, who is required to pay enrollment fees, regardless
of age, who maintains enrollment in Medicare Part B, is entitled
to a waiver of an amount equivalent to the individual TRICARE Prime
enrollment fee. Hence, individual enrollments for such beneficiaries
will have the enrollment fee waived. A family enrollment in TRICARE
Prime, where one family member maintains enrollment in Medicare
Part B, shall have one-half of the family enrollment fee waived;
the remaining half must be paid. For a family enrollment where two
or more family members maintain enrollment in Medicare Part B, the
family enrollment fee is waived regardless of the number of family members
who are enrolled in addition to those entitled to Medicare Part
B.
6.5 Survivors of Active Duty Deceased
Sponsors and Medically Retired Uniformed Services Members and their
Dependents
6.5.1 Beneficiaries
Whose Sponsor Has An Initial Service Date Before January 1, 2018
Effective Fiscal Year (FY) 2012, TRICARE Prime beneficiaries
who are (1) survivors of active duty deceased sponsors, or (2) medically
retired Uniformed Services members and their dependents, shall have
their Prime enrollment fees frozen at the rate in effect when classified
and enrolled in a fee paying Prime plan. (This does not include
TRICARE Young Adult (TYA) plans). Beneficiaries in these two categories
who were enrolled in FY 2011 will continue paying the FY 2011 rate.
The beneficiaries who become eligible in either category and enrolled
during FY 2012, or in any future fiscal year, shall have their fee
frozen at the rate in effect at the time of enrollment in Prime.
The fees for these beneficiaries shall remain frozen as long as
at least one family member remains enrolled in Prime. The fee for
the dependent(s) of a medically retired Uniformed Services member
will not change if the dependent(s) is later re-classified a survivor. These
two categories of beneficiaries who choose to enroll in TRICARE Select
do not pay enrollment fees.
6.5.2 Beneficiaries
Whose Sponsor Has An Initial Service Date On Or After January 1,
2018
There is no TRICARE Prime enrollment
fee freeze for these retirees and family members; they pay the established
annual TRICARE Prime enrollment fee amount. Medically retired members
and their family members who choose to enroll in TRICARE Select
pay the established annual TRICARE Select
enrollment fee.
6.6 Mid-Month
Enrollees
6.6.1 The
contractor shall collect any applicable enrollment fee from mid-month
enrollees at the time of enrollment. However, there will be no enrollment
fee collected for the days between the effective enrollment date
and the determined enrollment date.
6.6.2 The
determined enrollment date shall be established using the “20th
of the month rule,” as it is for initial enrollments.
Example: If
the retirement date is May 27, the effective enrollment date will
be May 27 and the determined enrollment date will be July 1. Fees
will be charged for the period from July 1 forward; no fees will
be assessed for the period from May 27 through June 30. DEERS will
calculate the paid-through dates based on DEERS data and the enrollment
fee amount collected and entered into DEERS by the contractor.
6.6.3 Effective January 1, 2018,
paragraphs 6.6.1 through
6.6.2 no
longer apply. Fee amounts shall be pro-rated based on 1/30th of
the TRICARE Prime or TRICARE Select fee, as applicable, calculated from
the date of enrollment (initial eligibility or QLE date) to the
end of the month.
6.7
Overpayment
Of Enrollment Fees
6.7.1 Contractors shall update DEERS
with the enrollment fee amount collected and DEERS will calculate
the paid-through date and notify the contractor. DEERS will only
extend the paid-through date to cover the current enrollment year,
plus two future fiscal years (prior to January 1, 2018) or calendar
years (starting January 1, 2018). DEERS will store amounts that
cannot cover one month’s fees or amounts that extend the paid-through
date beyond
two years in the future
as a credit. Funds applied that would move the paid-through date
beyond the policy end date are stored as a credit. (The exception
is when Prime policies, prior to January 1, 2018, end mid-month;
DEERS will set a paid-through date to the end of that month.) Also,
if there is a 100% fee waiver with an end date that exceeds more
than two
fiscal years beyond the current
enrollment year, the paid period can extend beyond the
two fiscal
years and any fee amounts sent to DEERS will be applied as a credit.
The contractor shall refund any credit of $1 or more on a current
enrollment that extends beyond
two fiscal years.
The contractor shall update DEERS with any fee amount refunded within
30 calendar days. The contractor shall include an explanation for
the premium refund. See also
paragraph 8.0.
6.7.2 The following reports will be provided to the
contractor by DEERS on a monthly basis to assist with identifying
and correcting enrollment fee discrepancies. The contractor responsible
for a beneficiary’s current enrollment shall resolve any over/under
payments. For split enrollments, the reports will use the billing
hierarchy to determine the responsible contractor.
• Current policies that
are two months past due (paid period end date more than two months
in the past).
• Any
policies where the paid period end date exceeds the policy end date.
• Policies where the
paid period end date meets the policy end date but a credit exists.
• Terminated policies
where the paid period end date does not meet the policy end date.
6.7.3 Contractors shall analyze and correct all report
accounts within 30 days of the report’s availability. Contractors
shall correct any data inaccuracies in the enrollment fee reporting
system to include the refunding of enrollment fees in excess of
what is due, if necessary. Contractors shall update DEERS with any
enrollment fee amounts refunded within 30 calendar days and notify
DHA as specified above.
7.0
Enrollment
Of Family Members Of E-1 Through E-4
7.1 When
family members of E-1 through E-4 reside within a 30 minute drive
time of an MTF/eMSM offering TRICARE Prime, the family members will
be encouraged to enroll in TRICARE Prime by the enrolling entity
(Government or contractor). Upon enrollment, they will choose or
be assigned a PCM located in the MTF/eMSM. The choice of whether
to enroll or to decline enrollment in TRICARE Prime is completely
voluntary. Family members of E-1 through E-4 who decline enrollment
or who enroll in Prime and subsequently disenroll may not re-enroll until
the next open period or they experience a QLE.
7.2 Enrollment processing and allowance of civilian
PCM assignments shall be in accordance with the Memorandum of Understanding
between the contractor and the MTF/eMSM.
7.3 The primary means of identification and subsequent
referral for enrollment shall occur during in-processing to the
installation. Non-enrolled E-4 and below families may also be referred
to the contractor’s call center, by Commanders, First Sergeants/Sergeants
Major, Supervisors, Family Support Centers, and others. Beneficiaries
at overseas locations may also be referred to their local TRICARE Service
Center (TSC).
7.4 Contractor call center representatives
and those giving beneficiary education briefings shall provide enrollment
information and support the family member in managing their enrollment
options. The education of such potential enrollees shall specifically
address the advantages of TRICARE Prime enrollment, including guaranteed
access, the support of a PCM, etc. The contractor shall reinforce
that enrollment is at no cost for family members of E-1 through
E-4 and will give them the opportunity to select or be assigned
an MTF/eMSM PCM, to select a civilian PCM if permitted by applicable
MOU or with USFHP, if available, or to decline enrollment in TRICARE
Prime.
7.5 The contractor shall discuss
the potential effective date of the enrollment.
7.6 Enrollment may be terminated at any time upon
request of the enrollee, sponsor or other party as appropriate under
existing enrollment/disenrollment procedures. Prior to January 1,
2018, beneficiaries may re-enroll at any time without restriction
or penalty. See
paragraph 5.2 for enrollment rules as of January
1, 2018.
7.7 Contractors shall not screen
TRICARE claims to determine whether it may be for treatment of a non-enrolled
ADFM of E-1 through E-4 living in a PSA. Rather, they are to support
the prompt and informed enrollment of such individuals when they
have been identified by DoD in the course of such a person’s interaction
with the military health care system or personnel community and
have been referred to the contractor for enrollment.
7.8 Effective January 1, 2018, DMDC will automate
the enrollment of newly eligible ADFMs into TRICARE Prime or TRICARE
Select, if overseas into TOP Select. See
paragraph 2.3.
8.0
TRICARE
Eligibility Changes/Refunds Of Fees
See
paragraph 9.0 for
additional requirement starting January 1, 2018.
8.2 The contractor shall allow a TRICARE-eligible
beneficiary who has less than 12 months of eligibility remaining
to enroll in TRICARE Prime or TRICARE Select until
such time as the enrollee loses his/her TRICARE eligibility. The
beneficiary shall have the choice of paying the entire enrollment
fee or paying the fees on a more frequent basis (e.g., monthly or
quarterly). If the enrollee chooses to pay by installments, the
contractor shall collect only those installments required to cover
the period of eligibility. DEERS will calculate the paid-through
date based on the enrollment fee amount collected and entered into
DEERS by the contractor, which in this circumstance, should cover
the period of the beneficiary’s eligibility. The contractor shall
refund any overpayment of $1 or more that DEERS does not use to
extend the paid-through date to the policy end date (or the last
day of the month in which a TRICARE Prime or
TRICARE Select policy ends). The contractor shall
include an explanation to the beneficiary for the fee refund. The
contractor shall update DEERS with any fee amount refunded within 30
calendar days.
8.3 Contractors shall refund the
unused portion of TRICARE Prime
or TRICARE Select enrollment fee
s to
retired enrollees whose sponsor
is recalled
to active duty. The contractor shall include an explanation to the
beneficiary for the fee refund. Contractors shall calculate the
refund using monthly prorating, and shall report such refunds to
DEERS within 30 calendar days.
Upon activation of
the member, the family members will be automatically enrolled as
ADFMs (see TPM, Chapter 10, Section 2.1). If
the reactivated member’s family chooses continued enrollment in
TRICARE Prime
or TRICARE Select, the
family shall begin a new enrollment period and shall be offered
the opportunity to keep their PCM
(TRICARE Prime only),
if possible.
8.4 Any catastrophic cap
accumulations shall be applied to the new enrollment period.
8.5 Contractors shall refund enrollment fees for
deceased enrollees upon receiving a written request, along with
a copy of the death certificate, from the remaining enrollee or
the executor of the decedent’s estate. The contractor shall include
an explanation for the fee refund to the beneficiary. Refunds shall
be prorated on a monthly basis and apply both to individual plans
where the sole enrollee is deceased and to the conversion of a family
enrollment to an individual plan upon the death of one or more family
members. For individual enrollments, the contractor shall refund
remaining enrollment fees to the executor of the estate. For family
enrollments that convert to individual plans, the contractor shall
either credit the excess fees to the individual plan or refund them
either to the remaining enrollee or to the executor of the decedent’s
estate, as appropriate. Enrollment fees for family enrollments of
three or more members are not affected by the death of only one
enrollee and no refunds shall be issued. Contractors shall update
DEERS with any amount refunded within 30 calendar days.
8.6 Contractors shall refund the unused portion
of TRICARE Prime
or TRICARE Select enrollment fee
s to
enrollees who become eligible for Medicare Part A based upon disability,
End Stage Renal Disease (ESRD) or upon attaining age 65, provided
the beneficiary has Medicare Part B coverage.
8.6.1 The contractor shall issue refunds to these
beneficiaries upon receiving (1) a written request from the beneficiary
(that includes a copy of their Medicare card) and either confirming
their Part B enrollment in DEERS or in a previous Government furnished
policy notification, or (2) upon receipt of an unsolicited Government
furnished policy notification noting a beneficiary’s fee waiver update
based on the Part B enrollment. DEERS generates a Government furnished
policy notification when the Centers for Medicare and Medicaid Services
(CMS) sends DEERS data indicating a Part B enrollment or disenrollment.
Refunds are required for all payments that extend beyond the date
the enrollee has Medicare Part B coverage, as calculated by DEERS.
The contractor shall update DEERS with any amount refunded within
30 calendar days. The contractor shall include an explanation to
the beneficiary for the fee refund. If the fee waiver is a 100%
waiver of the TRICARE Prime enrollment
fee, the contractor shall send a refund to the beneficiary. If the
fee waiver is a 50% waiver of the TRICARE Prime
enrollment fee, DEERS will automatically calculate the overpayment
and extend the paid-through date for the policy. A refund may not
be required unless a credit remains when the policy is paid in full.
8.6.2 For TRICARE Prime
enrollees who become Medicare eligible and who maintain Medicare Part
B coverage and TRICARE Select enrollees who become
Medicare eligible, refunds are required for overpayments
occurring on and after the start of health care delivery. The contractor
shall utilize the Government furnished policy notifications received
indicating a fee waiver based on Medicare to substantiate any claim
of overpayment. The contractor shall update DEERS with any amount
refunded within 30 calendar days and include an explanation to the
beneficiary for the fee refund.
8.6.3 Medicare eligible ADFMs age 65 and over are
not required to have Medicare Part B to remain enrolled in TRICARE
Prime or TRICARE Select. To maintain
TRICARE coverage upon the sponsor’s retirement, they must enroll
in Medicare Part B during Medicare’s Special Enrollment Period prior
to their sponsor’s retirement date. (The Special Enrollment Period
is available anytime the sponsor is on active duty or within the
first eight months of the sponsor’s retirement. If they enroll in
Part B after their sponsor’s retirement date, they will have a break
in TRICARE coverage.)
8.6.4 Medicare
eligibles age 65 and over who are not entitled to premium-free Medicare
Part A are not required to have Medicare Part B to remain enrolled
in TRICARE Prime and TRICARE Select. Because
they may become eligible for premium-free Medicare Part A at a later
date, under their or their spouse’s SSN, they should enroll in Medicare
Part B when first eligible at age 65 to avoid the Medicare surcharge
for late enrollment.
8.7 Refunds shall be drawn from the contractor’s
enrollment fee account and reported to the Government in accordance
with the requirements specified above.
8.8 The contractor shall include full and complete
information about the effects of changes in eligibility and rank
in beneficiary education materials and briefings.
9.0 TRICARE Eligibility Changes/Refund
of Fees
9.1 Criteria and documentation required for the
specific TRICARE eligibility changes as listed in
paragraph 7.0 still
apply; however, whenever any overpaid fee situation is identified,
the contractor will:
9.1.1 Apply overpaid fees to another
enrolled family member under the same Uniformed Service sponsor
if within the maximum two calendar years.
Overpaid fees for URFSs can only be applied to their enrollment
records.
9.1.2 Automatically refund prorated
enrollment fees in excess of two calendar years.
9.1.3 Upon request from sponsor or responsible individual,
apply overpaid fees as directed up to the maximum two calendar years
and/or refund overpaid fees as requested.
9.1.4 Refunds must be $1 or more.
9.1.5 Refunds will be issued within 30 days to a
Uniformed Service sponsor, eligible spouse, and then oldest child
in that order. Refunds for URFS enrollment fees shall only be refunded
to the URFS.
9.1.6 Update DEERS within 30 calendar
days with any refund amount.
10.0
Wounded,
Ill, And Injured (WII) Enrollment Classification
The
WII Program provides a continuum of integrated care from the point
of injury to the return to duty or transition to active citizenship
for the Active Component (AC) or the Reserve Component (RC) Service
members who have been activated for more than 30 days. These AC/RC
Service members, referred to as Service members, have been injured
or became ill while on active duty and will remain in an active
duty status while receiving medical care or undergoing physical
disability processing. WII Programs vary in name according to Service.
The Service shall determine member eligibility for enrollment into
a WII Program, as well as whether or not to utilize these enrollments.
To better manage this population, a secondary
enrollment classification of HCDP Plan Coverage Codes, WII 415 and
WII 416 were developed. The primary rules apply to the WII HCDP
codes:
• Service members must
be enrolled to TRICARE Prime prior to, or at the same time, as being enrolled
into a WII 415 or WII 416 Program.
• A member cannot be
enrolled in WII 415 and WII 416 Programs at the same time.
• WII 415 and WII 416
enrollments will terminate at the end of the member’s active duty eligibility,
when members transfer enrollment to another MTF/eMSM, change of
a plan code, or at the direction of the Service-specific WII entity.
• Any claims processed
for WII 415/416 enrollees shall follow the rules associated with
the primary HCDP Plan Coverage Code, such as TRICARE Prime, TPR,
TOP Prime, or TOP Prime Remote. All claims will process and pay
under Supplemental Health Care Program (SHCP) rules. DEERS will
not produce specific enrollment cards or letters for WII 415/416 enrollment.
WII 415/416 TRICARE Encounter Data (TED) records
shall be coded with the WII 415/416 HCDP Plan Coverage Code; however,
the Enrollment/Health Plan Code data element on the TED record shall reflect
the appropriate value for the primary HCDP Plan Coverage Code. For
example, a TED record for a WII 416 enrollee with primary enrollment
to TPR would reflect the HCDP Plan Coverage Code of “416” but the
Enrollment/Health Plan Code would be coded “W TPR Active
Duty Service Member”.
10.1 WII
415 - Wounded, Ill, And Injured (e.g., Warrior Transition/MEDHOLD
Unit (WTU))
10.1.1 Service
defined eligible Service members assigned to a WII 415 Program such
as a MEDHOLD or WTU shall be enrolled to TRICARE Prime or TOP Prime
prior to, or at the same time, as being enrolled into the WII 415.
Members cannot be enrolled to the WII 415 without a concurrent TRICARE
Prime or TOP Prime enrollment. Service appointed WII case managers
will coordinate with the MTF/eMSM to facilitate TRICARE Prime PCM
assignments for WII 415 members. The contractor shall assign a PCM
in accordance with the MTF/eMSM MOU and in coordination with the
WII case manager. WII 415 enrollment will not run in conjunction
with TAMP and members enrolled in TPR, or TOP Prime Remote are not
eligible to enroll in the WII 415.
10.1.2 The Service-specific WII entity will stamp
the front page of the DD Form 2876, enrollment application form,
with WII 415. The enrollment form will then be sent to the appropriate
contractor who shall perform the enrollment in the Government furnished
web-based enrollment system/application and include the following
information:
• WII
415 HCDP Plan Coverage Code
• WII 415 Enrollment
Start Date (Contractors may change the Government furnished web-based
enrollment system/application defaulted start date, which may or
may not coincide with the Prime Enrollment Start Date. The start
date may be changed up to 289 days in the past or 90 days into the
future.)
10.1.3 WII 415 enrollments shall be in conjunction
with an MTF/eMSM enrollment only, not to civilian network PCMs under
TPR enrollment rules. DEERS shall end WII 415 enrollments upon loss
of member’s active duty eligibility. WII 415 program enrollments
shall not be portable across programs or regions. The TOP contractor
shall enter WII 415 enrollments through the Government furnished
web-based enrollment system/application for outside the 50 United
States (U.S.) and the District of Columbia.
10.1.4 The contractor shall accomplish the following
functions based on receipt of notification from the Service-specific
WII Program entities:
• Enrollment.
• Disenrollment.
• Cancel enrollment.
• Cancel disenrollment.
• Address update.
• Contractors can
request unsolicited Government furnished policy notifications resend.
• Modify begin date.
• Modify end date.
10.2 WII
416 - Wounded, Ill, And Injured - Community Care Units (CCUs)
10.2.1 Service defined eligible Service members may
be assigned to a WII 416 Program such as the Army’s CCU and receive
required medical care near the member’s home. The Service member
shall be enrolled to TRICARE Prime, TPR, TOP Prime, or TOP Prime
Remote prior to or at the same time as being enrolled into WII 416.
Members cannot be enrolled to the WII 416 program without a concurrent
Prime, TPR, TOP Prime, or TOP Prime Remote enrollment. Service appointed
case managers will coordinate with the contractor or MTF/eMSM to
facilitate TRICARE Prime or TPR PCM assignments for eligible beneficiaries.
The contractor shall assign a PCM based on the MTF/eMSM MOU and
in coordination with the WII entity (e.g., CCU). WII 416 enrollments
will not run in conjunction with TAMP.
10.2.2 The Service-specific WII Program will stamp
the front page of the DD Form 2876, enrollment application form,
with WII 416 for all new enrollments. The begin date will be the
date the contractor receives the signed enrollment form. A signed
enrollment application includes those with an original signature,
or an electronic signature offered by and collected by the contractor.
The enrollment form will then be sent to the appropriate contractor
who shall perform the enrollment in the Government furnished web-based
enrollment system/application and include the following information:
• WII
416 HCDP Plan Coverage Code.
• WII 416 Enrollment
Start Date. (Date received by the contractor or the date indicated
by the Service-specific WII Program which may be up to 289 days
in the past, or 90 days in the future.)
10.2.3 WII 416 enrollments must be in conjunction
with an MTF/eMSM, TPR, TOP Prime, or TOP Prime Remote enrollment.
DEERS will end WII 416 enrollments upon loss of member’s active
duty eligibility. WII 416 program enrollments are not portable across
programs or regions.
10.2.4 The contractor shall accomplish the following
functions based on receipt of notification from Service-specific
WII program entities:
• Enrollment.
• Disenrollment.
• Cancel enrollment.
• Cancel disenrollment.
• Address update.
• Contractors can
request Government furnished policy notification resend.
• Modify begin date.
• Modify end date.
11.0 TRICARE POLICY For Access
To Care (ATC) And Prime Service Area (PSA) Standards
11.1 Non-active
duty beneficiaries in the Continental United States (CONUS) and
Hawaii who reside more than 30 minutes travel time from their desired
PCM but less than 100 miles must waive primary and specialty drive-time
ATC standards if they wish to enroll in TRICARE Prime. (Due to the
unique health care delivery challenges in Alaska, the requirement
to request a waiver for the drive-time access standard does not
apply to beneficiaries in Alaska.) Before effecting an enrollment
or portability transfer request, contractors shall ensure that a
beneficiary has waived travel time ATC standards either by checking
the Drive Time Waiver box in Section V of the DD Form 2876 enrollment
application (this includes an electronic signature offered by and
collected by the contractor), by providing verbal consent via telephone
communication (which shall be documented in the contractor call
notes), or by requesting enrollment through the Government furnished
web-based self-service enrollment system/application (for both civilian
and MTF/eMSM PCMs). An approved waiver for a beneficiary residing
less than 100 miles but more than 30 minutes from their PCM will
remain in effect until the beneficiary changes residence.
11.2 The contractor must estimate the travel time
or distance between a beneficiary’s residence to a PCM (either a
civilian PCM or an MTF/eMSM) using at least one web-based mapping
program. The choice of the mapping program(s) is at the discretion
of the contractor, but the contractor must use a consistent process
to determine the driving distance for each enrollee applicant who
may reside more than 30 minutes travel time from their PCM. The
time or distance shall be computed between the enrollee’s residence
and the physical location of the PCM (including MTFs/eMSMs). It
is not acceptable to use a geographic substitute, such as a geographic
centroid.
11.3 The contractor (in conjunction
with MTFs/eMSMs for MTF/eMSM enrollees) shall provide beneficiary
drive-time waiver education and ensure that beneficiaries who choose
to waive these standards have a complete understanding of the rules
associated with their enrollment and the travel time standards they
are forfeiting. This includes educating beneficiaries, who waive
their ATC travel standards, of the following:
• They should expect
to travel more than 30 minutes for access to primary care (including urgent
care) and possibly more than one hour for access to specialty care
services.
• They
will be held responsible for POS charges for care they seek that
has not been referred by their PCM (or for MTF/eMSM enrollees, by
another MTF/eMSM provider).
• They should consider
whether any delay in accessing their enrollment site might aggravate their
health status or delay receiving timely medical treatment.
11.4
Cross-Region TRICARE
Prime Enrollment
Beneficiaries shall enroll
to the Region where the desired PCM is located; however, all TRICARE Prime
enrollment policies still apply, i.e., PCM selection and utilization,
referrals, drive times and distance standards to the desired PCM.
An access to care drive-time waiver is required (see
paragraph 11.1).
All claims are processed by the Region of enrollment. Cross-region
enrollment must be requested by either submitting an enrollment
form (DD Form 2876) or by calling the regional contractor servicing the
desired PCM. The enrolling contractor shall ensure a beneficiary
is not approved for cross-region enrollment if they live within
30-minutes of an MTF/eMSM, unless the MTF’s/eMSM’s servicing contractor
approves the enrollment. The beneficiary shall be enrolled to the
MTF/eMSM if a PCM is available.
11.5 Discrepant
Addresses
11.5.1 If
at any point during the enrollment period the contractor determines
or is advised that a beneficiary is no longer eligible for continued
TRICARE Prime enrollment due to their address, the contractor shall
inform the beneficiary of the discrepant address situation. For
example, their residential address is 100 miles or more from the
PCM or MTF/eMSM (with no 100 mile waiver) to which they are enrolled
or their residential address is 100 miles or more from their assigned
network PCM. This notification (letter, telephone call, or e-mail)
shall occur when the discrepant information is first known by the
contractor. If the beneficiary confirms the DEERS-recorded address
is incorrect, and the beneficiary updates DEERS with correct information
(contractor to assist as appropriate), the beneficiary will remain
enrolled in TRICARE Prime if all enrollment requirements are met.
11.5.2 If the contractor confirms the beneficiary
is ineligible for enrollment due to their address, the contractor
shall notify the beneficiary they are being disenrolled. Their disenrollment
from TRICARE Prime will be effective the first of the month following
30 days from the initial notification date. The contractor shall
provide the beneficiary information about TRICARE Standard and Extra,
prior to January 1, 2018 or TRICARE Select starting January 1, 2018.
If the beneficiary chooses to not enroll in TRICARE Select, or USFHP
where available, the contractor shall inform the beneficiary about
limiting their military medical benefits to direct care access to
MTFs on a space available basis only. Beneficiaries have 90 days
after the disenrollment date to correct their disenrollment.
11.6
MTF/eMSM TRICARE
Prime Enrollees
11.6.1 Non-active
duty beneficiaries must reside within 30 minutes travel time from
an MTF/eMSM to which they desire to enroll. If a beneficiary desiring
enrollment resides more than 30 minutes (but less than 100 miles)
from the MTF/eMSM, they may be enrolled so long as they waive primary
and specialty ATC standards and the MTF Commander/eMSM Manager,
or designee, approves the enrollment. (If the MOU includes zip codes
or drive-time distances for which the MTF/eMSM is willing to accept
enrollments that are beyond a 30 minute drive, this constitutes
approval. See
32 CFR 199.17 for information
on access standards. If not addressed in the MOU, the contractor
shall submit each request to the MTF Commander/eMSM Manager, or
designee, in a method that is outlined in the MOU.) The Director,
TROs may approve waiver requests from beneficiaries who desire to
enroll to an MTF/eMSM and who reside 100 miles or more from the
MTF/eMSM. In these cases, the MTF Commander/eMSM Manager must also
be agreeable to the enrollment and have sufficient capacity and
capability.
11.6.2 If the
contractor determines that the beneficiary resides 100 miles or
more from the MTF/eMSM to which they are enrolled, and there is
no 100 mile waiver on file, the contractor shall inform the beneficiary
that they are no longer eligible for Prime enrollment to the MTF/eMSM.
Any notice shall include information on any alternative options
for enrollment. The notice shall also advise the beneficiary of
the option to use TRICARE Standard/Extra (before January 1, 2018), enroll
in TRICARE Select (on or after January 1, 2018) as a QLE, or enroll
with a USFHP where available. If the beneficiary chooses to not
enroll in TRICARE Select, or USFHP where available, the contractor
shall inform the beneficiary about limiting their military medical
benefits to direct care access to MTFs/eMSM on a space available
basis only.
11.6.3 The contractor shall process all requests for
enrollment to an MTF/eMSM in accordance with the MOU between the
MTF/eMSM and the contractor. See
paragraph 11.4 regarding cross-region enrollments.
Enrollment guidelines in MOUs may include:
11.6.3.1 Zip codes and/or distances for which the MTF
Commander/eMSM Manager is mandating enrollment to the MTF/eMSM.
These mandatory MTF/eMSM enrollment areas must be within access standards
(i.e., a 30 minute drive-time of the MTF/eMSM) and may apply to
all eligible beneficiaries or may be based on beneficiary category
priorities for MTF/eMSM access.
Note: Non-active duty
TRICARE Prime applicants who reside more than 30 minutes travel
time from an MTF/eMSM must be afforded the opportunity to enroll
with a civilian PCM.
11.6.3.2 There may be zip codes and/or distances for
which the MTF Commander/eMSM Manager is willing to accept enrollment.
This can include both areas within a 30 minute or less drive-time
and over a 30 minute drive but within 100 miles. Any enrollment
for a beneficiary with a drive of more than 30 minutes requires
a signed waiver of access standards. If an enrollee applicant resides
within a zip code previously determined to lie entirely within 30
minutes travel time from the MTF/eMSM, the contractor need not compute
the travel time for that applicant.
11.6.3.3 In determining whether or not the MTF Commander/eMSM
Manager will consider a request for TRICARE Prime enrollment beyond
100 miles, the MTF Commander/eMSM Manager may use zip codes to designate
those areas where he/she will consider requests or will not consider requests.
11.6.4 The contractor shall notify the MTF Commander/eMSM
Manager (or designee) when a beneficiary residing 100 miles or more
from the MTF/eMSM, but in the same Region, requests a new enrollment
or portability transfer to the MTF/eMSM. Such notification is not
necessary if the MOU has already established that the MTF Commander/eMSM
Manager will not accept enrollment of beneficiaries who reside 100
miles or more from the MTF/eMSM. The contractor shall make this notification
by any mutually agreeable method specified in the MOU. The contractor
shall not make the MTF/eMSM enrollment effective unless notified
by the MTF/eMSM to do so.
11.6.4.1 The MTF
Commander/eMSM Manager will notify the Director, TROs of their desire
to enroll a beneficiary who resides 100 miles or greater from the
MTF/eMSM and request approval for the TRICARE Prime enrollment.
The Director, TROs will make a determination on whether or not to
approve or deny the request and notify the MTF Commander/eMSM Manager
of his decision by a mutually agreeable method. The MTF Commander/eMSM
Manager is responsible for notifying the contractor of all approved
enrollment requests for beneficiaries who reside 100 miles or greater
from the MTF/eMSM. The contractor shall notify the beneficiary of
the final decision.
11.6.4.2 Approved waivers for beneficiaries residing
100 miles or more from the MTF/eMSM shall remain in effect until
the beneficiary changes residence or unless the MTF Commander/eMSM
Manager determines that they will no longer allow these enrollments.
Even if a beneficiary has previously waived travel time standards,
any MTF Commander/eMSM Manager may revise the MOU (following the
MOU revision process) to state that enrollment of some or all current
enrollees who reside 100 or more miles from the MTF/eMSM are not
to be renewed at the end of the enrollment period. The contractor
shall inform such beneficiaries no later than two months prior to
expiration of the current enrollment period that they are no longer
qualified for renewal of enrollment to the MTF/eMSM. Prior to notification,
the contractor shall obtain the rationale for the change from the
MTF/eMSM to include in the notice to the beneficiary. The proposed
notice shall be reviewed and concurred on by the Director, TROs
prior to being sent to the impacted beneficiaries. (The TRO will
coordinate notices with the DHA Communications prior to approval.)
11.6.5 At any time during the enrollment period, if
the contractor determines there is no signed travel time waiver
on file for a current MTF/eMSM enrollee who resides more than 30
minutes from the MTF/eMSM, the contractor shall, require the beneficiary
to waive the primary and specialty care travel standards to continue
their TRICARE Prime enrolled status. (This includes monitoring address
changes received by the contractor from all sources.) The contractor
shall notify the beneficiary of this waiver requirement within 30
days of determining a need for waiver. The language for all beneficiary
notices shall be reviewed and concurred on by the TRO prior to being
sent to beneficiaries. (The TRO will coordinate notices with the
DHA Communications prior to approval.)
• Any notice to a beneficiary
that is requesting they sign a waiver of access standards, denying
their enrollment, or advising them they are not eligible for re-enrollment
to an MTF/eMSM, shall include information on any available TRICARE
plan options.
11.6.6 For each approved enrollment to an MTF/eMSM
where the beneficiary has waived access standards, the contractor
shall retain the enrollment request in a searchable electronic file
until 24 months after the beneficiary is no longer enrolled to the
MTF/eMSM. The contractor shall provide the retained file to a successor
contractor at the end of the final option period.
11.6.7 When an enrollment request requires MTF Commander/eMSM
Manager or Director, TROs approval, any contractual requirements
relating to processing timeliness for enrollment requests will begin
when the contractor has obtained direction from the MTF Commander/eMSM
Manager or Director, TROs regarding waiver approval or disapproval.
11.7 Civilian TRICARE
Prime PCMs
11.7.1 Within
a PSA, the contractors’ civilian network shall have the capability
and capacity to allow beneficiaries who reside in the PSA to enroll
to a PCM within access standards. If a beneficiary who resides in
the PSA requests enrollment to a specific PCM who is located more
than a 30 minute drive from the beneficiary’s residence, the contractor
may allow the enrollment if beneficiary waives travel time access
standards. (Also, see
Chapter 5, Section 1.)
11.7.2 Outside a PSA, for new enrollments (including
portability transfers), the contractor is not required to establish
a network with the capability and capacity to grant TRICARE Prime enrollment
to beneficiaries who reside outside a PSA. Requests for new enrollments
to the civilian network from beneficiaries residing outside a PSA
will be granted provided there is sufficient unused network capacity
and capability to accommodate the enrollment and that the PSA civilian
network PCM to be assigned is located less than 100 miles from the
beneficiary’s residence. Beneficiaries who reside outside the PSA
and enroll in TRICARE Prime must waive their primary and specialty
care travel time access standards.
11.7.2.1 ADFMs
(Including ADFM TYA Prime Enrollees) Residing Outside A PSA
ADFMs (including ADFM TYA Prime enrollees)
enrolled in TRICARE Prime and who reside outside of a T-3 PSA on
September 30, 2013, will be grandfathered in TRICARE Prime starting
October 1, 2013. They will remain enrolled in TRICARE Prime as long
as they reside within 40 miles of the residence where they were
originally granted grandfathered status and maintain eligibility
as ADFMs. The contractors must continue to have a PCM available
for these beneficiaries and ensure all claims and benefits are administered
as TRICARE Prime. ADFMs shall remain enrolled in TPRADFM, as appropriate. The
contractors will manage the grandfathered ADFMs as stated in this
chapter.
11.7.2.2 Terms Of Grandfathered Prime
- Status
The ADFM must maintain a residence
within 40 miles of the residence where they were originally granted
grandfathered status in order to retain grandfathered status. Grandfathered
ADFMs must be assigned a PCM. Grandfathered ADFMs may add or terminate
enrollment of dependents like any other ADFM (marriage, birth, adoption,
divorce, etc.). Dependents may live in a separate residence outside
a T-3 PSA and still be grandfathered.
11.7.2.3 Grandfathered
ADFMs lose their grandfathered status when they are:
• No longer TRICARE
eligible;
• No
longer residing within 40 miles of the residence where they were
originally granted grandfathered status; or
• Change to retired
status.
11.7.3 Beneficiaries who reside outside the PSA and
are 100 miles or greater from an available civilian network PCM
in the PSA shall not be allowed to enroll in TRICARE Prime.
12.0 Reports
The
contractor shall provide monthly Service member enrollment and beneficiary
services reports according to the Contract Data Requirements List
(CDRL).