2.3 Enrollment
Procedures
2.3.1 No non-active duty beneficiary
shall be enrolled unless he/she is shown as eligible on the DEERS.
All enrollments and re-enrollments shall be recorded on the DEERS.
2.3.2 Enrollment will be done during an open season enrollment
period prior to the beginning of each plan year, which operates
with the calendar year. An enrollment choice will be effective for
the plan year. Beneficiaries may choose to enroll, change, or terminate
TRICARE Prime or Select coverage from the Monday of the second full
week in November to the Monday of the second full week in December
of each calendar year. There is a limited grace period exception
to this enrollment requirement for calendar year 2018, as provided
in National Defense Authorization Act (NDAA) FY 2017, Section 701(d)(3),
to give TRICARE Prime or TRICARE Select eligible beneficiaries another
chance to adjust to this new requirement for annual enrollment ending
on December 31, 2018. See TOM,
Chapter 6, Section 1.
2.3.2.1 If electing to change their TRICARE coverage
during the open season, the newly elected coverage will begin on
January 1 of the following year and will continue in effect until
they lose eligibility or request to change their coverage when authorized.
2.3.2.2 If a beneficiary chooses to not elect to change
their TRICARE coverage during the open enrollment period,
the coverage will be continued until the end of the next calendar
year unless otherwise terminated.
2.3.3 Qualifying Life Events (QLEs)
As an exception to the open enrollment
period rule,
enrollment changes can be made during the plan year for certain
QLEs, including:
• Marriage,
divorce, or annulment;
• Birth
or adoption of a child;
• Placement
of a child by a court in a member’s home;
• Change
in sponsor status that results in ineligibility to continue existing
TRICARE coverage);
• Gain or loss of command
sponsorship (overseas only);
• Loss
of sponsor or family member eligibility (age, Medicare, etc.);
• Relocation
to a new country, and/or city (OCONUS), region or zip +4 code (date received
or date specified by the beneficiary in the future) (self-attestation);
• Loss
of Other Health Insurance (OHI) (self-attestation);
• Death
of a sponsor, spouse or child;
• Change
in eligibility status of any single family member in another family
(e.g., joint service member);
• Change
in family composition (gaining family only): Beneficiaries with
multiple sponsors whose eligibility to enroll is established from
one sponsor to another in DEERS without
evidence of any other QLE. However, this QLE cannot be used in the Government
furnished web-based self-service enrollment system/application. Beneficiaries
must contact the contractor to use this QLE.
• Government
Directed PCM Changes: If a MTF/eMSM requires a TRICARE Prime enrollee to
move from a network PCM to a MTF/eMSM PCM or vice versa, the enrollee
may choose to agree with the PCM change or may enroll in TRICARE
Select.
• Government
Directed Plan change: If the Government no longer offers a TRICARE enrolled
health plan in one or more areas, affected beneficiaries may elect
to enroll in another qualified TRICARE plan.
2.3.3.1 Enrollment must be within 90 calendar days
of the date of the QLE. Coverage starts as of the date of the QLE.
Applicable enrollment fees must be paid for that period. For
QLEs resulting from address changes, the effective date will be
the address effective date on DEERS. Whenever DEERS supports entry
of a future effective date for a QLE event, DEERS will allow a QLE
enrollment action up to 90 days prior to that date. The enrollment
action will be effective the date of the QLE. This includes self-attest
QLEs with a future effective date.
2.3.3.2 A QLE for one beneficiary in a sponsor’s family
permits a change in the sponsor’s enrollment or other family member’s
enrollment status during the QLE period. A specific QLE may only be
used once to make a change in enrollment status.
2.3.3.3 Overlapping QLEs. If the beneficiary has more
than one QLE that have overlapping 90-day periods, the beneficiary
will be allowed to pick which QLE to use. If the beneficiary chooses
a later QLE, the previous QLEs will no longer be available to use.
For example: A beneficiary loses OHI on January 1st and has a child
on February 1st. Within 90 days for either QLE, the beneficiary
may change their enrollment status based on the loss of OHI or for
the birth of a child, whichever QLE they decide to use. If the beneficiary
chooses to use the latter QLE to make an enrollment change, they
may no longer use the earlier QLE (loss of OHI in this example).
If the beneficiary makes a QLE enrollment status change but then
changes their mind, they must contact the contractor to make the
change if they are within the 90-day period of a valid QLE. The
beneficiary will be unable to take this action in the Government furnished
web-based self-service enrollment system/application.
2.3.3.4 Enrollment choices made during open season
can be changed if there is a QLE that happens between that choice
and December 31st of that year.
2.3.3.5 The Director, DHA or designee, reserves the
right to direct the contractors to change an enrollment regardless
of the QLE rules.
2.3.3.6 Canceling
a QLE event invalidates the QLE. If a projected QLE does not happen,
the beneficiary can request the previous coverage to be reinstated
as long as they are within 90 days of the projected QLE. In
the Government furnished self-service web-based enrollment system/application, once
a QLE is selected (or declined) no more actions may be made based
on that QLE. This includes future QLEs.
2.3.3.7 A reinstatement of eligibility
is not a QLE. Extending the previous eligibility is not a QLE.
2.3.3.8 Enrollment portability and PCM
changes are not limited to the open enrollment period and do not
require a QLE.2.3.3.8.1 A
PCM change within region can occur at any time even if address does
not change. The regional contractor will verify that PCM assignment
complies with MTF MOU.
2.3.3.8.2 For overseas, in country moves
shall be treated as PCM changes. This will be enforced when the
TRICARE Overseas contractor receives the Policy Notification Transaction
(PNT).
2.3.3.8.3 TRICARE
Prime Uniformed Services Family Health Plan (USFHP) enrollees who
are not otherwise TRICARE-eligible (i.e., grandfathered Medicare
eligible beneficiaries who only have Part A) may only transfer enrollment
from one USFHP to another USFHP; they may not transfer to a Managed Care
Support Contractor (MCSC).
2.3.4 The contractor is responsible for collecting
enrollment fees from TRICARE Prime
or TRICARE Select enrollees, as appropriate, and keeps
or forwards all such fees to the Government,
as required by the contract.
2.3.5 Payment of enrollment fees may be made on an
annual or quarterly basis by credit card and for monthly enrollment
fee payments, by EFTs or an allotment from retirement pay. No administrative
fees are charged to enrollees who choose to pay monthly or quarterly.
Note: Effective March
26, 1998, the
TRICARE Prime enrollment
fee is waived for those enrollees who have Medicare Part B, regardless
of age. Dual eligibles age 65 and older, who have an
active
duty sponsor or who are not entitled to premium-free
Medicare Part A on their own record, or the record of their current,
former, or deceased spouse
, may enroll
in TRICARE Prime. See TOM,
Chapter 6, Section 1.
2.3.6 TRICARE enrollments for eligible enrollees
shall be automatically renewed upon the expiration of the enrollment
unless the enrollee declines renewal, is no longer eligible for
enrollment or fails to pay the enrollment fee on a timely basis,
as applicable.
2.3.7 Family members of Activated
Members of RCs. Family members of RCs
who have been ordered to active duty for a period of 31 days or
more may enroll in a TRICARE Prime option as qualified or TRICARE
Select. RCs include both reservists and members of the National
Guard. Members of the National Guard are included only if ordered
to federal duty. All requirements of this and other services apply
to these beneficiaries, including automatic enrollment. Activated
members of RCs are treated the same as any other active duty member.
2.4 Enrollment
Protocols
2.4.1 Beneficiaries, enrolling in
TRICARE Prime or TPR, may apply to enroll in a Region other than their
home of residence Region. All TRICARE Prime and TPR enrollment,
PCM
selection and utilization, and referral policies apply. See TOM,
Chapter 6, Section 1 and
Chapter 16, Section 1. (Note: This paragraph
does not apply to TOP Prime or TOP Prime Remote beneficiaries.)
2.4.2 No eligible beneficiary who resides in a TRICARE
region shall be denied enrollment or re-enrollment in, or be required
to disenroll from a TRICARE health plan because of a prior or current medical
condition.
2.4.3 The contractor shall provide
beneficiaries who enroll full and fair disclosure of any restrictions
on freedom of choice that may be applicable to TRICARE Prime (including
the POS option) and TRICARE Select.
2.4.4 TFL beneficiaries (retirees and their family
members who are age 65 and older and are eligible for both Medicare
and TRICARE) cannot enroll in TRICARE Prime (exception for those
Medicare eligible retirees over age 65 who were enrolled in USFHP
Prime prior to October 1, 2012). Retirees and their family members
under age 65 who have Medicare coverage can enroll in TRICARE Prime
if they have Medicare Part B. TRICARE Prime enrollment fees may
be waived if the beneficiary has Medicare Part B. TRICARE Prime
is not available for retirees overseas.
2.4.5 Retirees, retiree family members, and survivors
with any Medicare coverage at any age are not eligible to enroll
in TRICARE Select per 10 United States Code (USC) 1075(b)(1)(B).
2.4.6 Dependents of Active Duty Service Members (ADSMs),
including those with Medicare coverage (any age), may elect to enroll
in TRICARE Select.
2.4.7 Dual eligibles under age 65
(retirees and their dependents who have Medicare Parts A and B)
and dual eligibles who are ADFMs (any age) are eligible to enroll
in TRICARE Prime. See TOM,
Chapter 6, Section 1.
2.4.8 MHS beneficiaries who are not eligible to enroll
in TRICARE Prime may elect to enroll
with an MTF/eMSM PCM through the TRICARE Plus program to the extent
capability and capacity exists as determined by the MTF/eMSM.
2.5 Automatic
Enrollment Management
2.5.1 Automatic Reinstatement of
Coverage
2.5.1.1 DEERS will
automatically enroll or change the enrollment of certain beneficiaries
when a beneficiary’s eligibility is updated by the Uniformed Services
as described in the TRICARE Systems Manual (TSM),
Chapter 3, Section 4.2. Contractors will receive
a
PNT advising them of all changes. DEERS
will not automatically approve these PNTs.
2.5.1.2 For beneficiaries with coverage that has ended,
DEERS will automatically update enrollment start and/or end dates
of coverage when a beneficiary’s eligibility is updated by the Uniformed
Services.
2.5.1.3 If fees
or premiums are due as a result of the reinstatement, the contractor
shall give the beneficiary up to 90 days from the date the coverage
was automatically reinstated to pay any required fees or premiums
for any TRICARE health care plan.
2.5.2
Automatic
Enrollment Of ADFMs (Effective January 1, 2018)
2.5.2.1 Upon a Service member activation, including
early activations or an ADFM is added while the sponsor is on active
duty/early activation, DEERS will create a pending TRICARE Prime
enrollment with no PCM assigned for all TRICARE Prime eligible ADFMs
whose residential address is within a Continental United States
(CONUS) Prime Service Area (PSA).
2.5.2.2 Any ADFM whose residential address is not within
a CONUS PSA will not be enrolled into Prime but will be auto-enrolled
in TRICARE Select. See TOM,
Chapter 24, Section 5 for details for overseas.
2.5.2.3 A family member may be eligible for TRICARE
Programs under multiple Social Security Numbers (SSNs); however,
they may only be enrolled in one TRICARE Program at a time. Any
family member that is already enrolled in another family will not
be auto-enrolled.
2.5.2.4 DEERS will
set the effective/begin date of enrollment to the eligibility begin
date.
2.5.2.5 Upon request
from a beneficiary or sponsor, contractors may adjust any claims
for beneficiaries auto-enrolled to apply Prime benefits, not POS
cost-sharing provisions. See TOM,
Chapter 6, Section 1.
2.6 Group A and
Group B Beneficiaries
2.6.1 For purposes of enrollment
fees, cost-sharing, deductibles, and catastrophic caps, TRICARE Prime
and TRICARE Select enrollees are classified in one of two groups:
Group A if the sponsor’s initial enlistment or appointment in a
Uniformed Service was before January 1, 2018 and Group B if the sponsor’s
initial enlistment or appointment was on or after January 1, 2018.
See TOM,
Appendix A. However, if they become eligible
for and elect to enroll in TRICARE Reserve Select (TRS), TRICARE Retired
Reserve (TRR), TRICARE Young Adult (TYA), or Continued Health Care
Benefit Plan (CHCBP), they will have Group B cost-shares, deductibles,
and catastrophic caps regardless of when the sponsor entered military
services for the first time.
2.6.2 When Retired Reserve members
become entitled to TRICARE at age 60 or are recalled to active duty
before regular retirement (before age 60), their original date of
enlistment or appointment determines whether they and their family
members have Group A or Group B cost-shares.