1.0 POLICY (Before
January 1, 2018)
1.1 Generally, when the TRICARE eligibility status
changes, eligibility for TRICARE Prime benefits also changes. The
time frames for Prime eligibility parallel TRICARE eligibility.
1.2 In all
cases, when TRICARE eligibility ends, eligibility for Prime ceases.
This includes retirees, their family members and survivors who turn
age 65 and are entitled to Medicare but are not eligible for TRICARE
for Life (TFL), dependent children who lose TRICARE eligibility
due to age, remarriage of former spouses, etc.
1.3 To have
continuous Prime coverage, the enrollee shall submit an enrollment
form, or use the Government furnished web-based self-service enrollment
system/application transaction, or make a telephonic request to
the contractor before, or within 30 days following, their retirement
date, and pay the appropriate enrollment fees, calculated based
on the effective date of enrollment, within the required time frames
(see
Section 2.1, paragraph 1.1.4.2.1). Active
duty personnel who retire may enroll at the same time as the remaining
family members.
1.3.1 If this is not done before or within 30 days
following the member’s retirement or separation, enrollment or reenrollment
will be effective according to the provisions of
Section 2.1, paragraph 1.1.4.
1.3.2 If the
enrollee is receiving ongoing care at the time of retirement or
separation, he/she must comply with all of the care authorization
requirements of the enrollee’s new status including getting a new
authorization from the contractor.
1.4 When status
changes from Active Duty Family Member (ADFM) to retiree family
member, Prime enrollees shall be offered an opportunity to continue
enrollment in Prime, if available, but at the retiree cost-sharing
rates. These enrollees must pay the applicable enrollment fees.
Beneficiaries shall be permitted to keep their Primary Care Manager
(PCM), if possible. Military Treatment Facility (MTF) Commanders/Enhanced
Multi-Service Market (eMSM) Managers shall determine if retiring beneficiaries
who enroll in Prime could keep their MTF/eMSM PCMs, given the MTF’s/eMSM’s enrollment
plan and MTF/eMSM capacity.
1.5 Prime Enrollment for Transitional
Survivors. Those in Transitional Survivor Status, are not distinguished
from other ADFMs for Prime eligibility. See the Transitional Survivor
Status policy in
Section 7.1.
1.6 When an active duty member
retires other than the first of the month or a member separates other
than the first of the month but continues to be eligible (e.g.,
is the spouse of an active duty member; or is eligible for Transitional
Assistance Management Program (TAMP)), Prime enrollment may continue
as of the date of retirement or separation so long as all enrollment
requirements have been met as stated in
Section 2.1, paragraph 1.1.4.
1.7 When TRICARE
Prime enrollment changes from an individual to a family enrollment
status prior to annual renewal for beneficiary categories required
to pay an enrollment fee, the unused portion (pro-rated on a monthly
basis) of the fee will be applied toward a new enrollment period
or refunded in accordance with the TRICARE Operations Manual (TOM),
Chapter 6, Section 1, paragraph 8.0.
1.7.1 For ADFMs,
single enrollment can be changed to family at any time during the
enrollment period. A new enrollment period shall be established
for the family.
1.7.2 A newborn or adoptee will
be deemed to be enrolled in Prime as of the day of birth or adoption
if one family member is already enrolled in Prime. A responsible
representative has 60 days to officially enroll the child to the
Prime option. If the newborn or adoptee is formally enrolled in
Prime within the 60 day period, the effective date of enrollment
will be the first of the month following the date of birth or adoption.
(The 20th of the month enrollment rule is waived, if necessary.)
If the newborn or adoptee is not formally enrolled during the 60
day calendar period, the newborn or adoptee will revert to a non-enrolled
beneficiary effective the 61st day. If the decision is made to continue
Prime coverage, an official enrollment request (enrollment form,
Government furnished web-based self-service enrollment system/application
transaction, or telephonic request) must be completed on behalf
of the child. For retirees or their family members or survivors
who decide to continue enrollment for the child, the unused portion
(pro-rated on a monthly basis) of the single enrollment fee they
paid will be applied toward a new family enrollment period. For
newborns and newly adopted children enrolled under this provision,
Point of Service cost-sharing does not apply through the 60th day
or the effective date of enrollment, whichever is earlier. All services
shall be processed with the Prime copayment even in the absence
of referrals or authorizations. The Director, TRICARE Regional Offices
(TROs) is granted the authority to extend the deemed period up to
120-days, on a case-by-case or regional basis.
Note: In the case of a reservist who has been called
to active duty for a period of 30 days or less, a new family member
is not considered enrolled in Prime, since the family members of
the reservist are not eligible to enroll in Prime.
1.7.3 For those
newborns and adoptees who are covered under the 60 day “deemed enrollment” benefit,
process these claims as civilian Prime for this period. If the newborn
or adoptee is formally enrolled during this period, process using
enrollment status. If the newborn or adoptee is not formally enrolled
during the 60 day calendar day period, at the end of the 60th calendar
day period, the contractor shall process all claims as a non-enrolled
beneficiary, applying the appropriate TRICARE cost-shares and deductibles.
See the TOM,
Chapter 8, Section 1, paragraph 5.0 for claims
processing procedures.
1.8 When
a family enrollment status changes to single, there is no refund
of the paid enrollment fee, unless the family enrollment becomes
an individual enrollment due to death of one or more family members
or a retired TRICARE Prime enrollee becomes dual eligible (see the
TOM,
Chapter 6, Section 1, paragraph 8.0). The
remaining single enrollee continues to have Prime coverage until
the enrollee takes action to disenroll, the enrollee is no longer
eligible for TRICARE Prime, or the enrollee fails to pay a required
enrollment fee.
1.9 TRICARE eligible beneficiaries
who have less than 12 months of eligibility remaining (for example,
retirees who are 64 years of age, TAMP beneficiaries, etc.) are
allowed to enroll in Prime, however, these enrollees will be disenrolled
from Prime when they lose their TRICARE eligibility. The beneficiary
has the choice of paying all of the enrollment fee or paying the
fees on a monthly or quarterly basis. If paid on a monthly or quarterly
basis, the beneficiary will be required to pay the installments
that would cover the period of their eligibility only. See
paragraph 1.8 for
those who pay in full at the beginning of the enrollment period.
1.11 Enrollees
may disenroll from TRICARE Prime according to the requirements of
Section 2.1.
2.0 Policy
(On Or After January 1, 2018)
2.1 Generally, when the TRICARE
eligibility status changes, eligibility for TRICARE Prime or Select benefits
also changes.
2.2 In all cases, when TRICARE
eligibility ends, eligibility for TRICARE Prime or Select ceases.
This includes retirees, their family members and survivors who turn
age 65 and are entitled to Medicare but are not eligible for TFL
if they don’t elect Medicare Part B, for example, dependent children
who lose TRICARE eligibility due to age, remarriage of former spouses,
etc.
2.3 A change in status that results
in a change in TRICARE coverage is considered a Qualifying Life Event
(QLE). Eligible beneficiaries may elect to enroll in TRICARE Prime
or Select within 90 days of a QLE. See
Section 2.1.
2.4 Active duty personnel who retire may enroll
at the same time as the remaining family members.
2.5 If a Prime enrollee is receiving ongoing care
at the time of retirement or separation, he/she must comply with
all of the care authorization requirements of the enrollee’s new
status including getting a new authorization from the contractor.
2.6 When status changes from ADFM to retiree family
member, Prime enrollees shall be offered an opportunity to continue
enrollment in Prime, if available, but at the retiree cost-sharing
rates. These enrollees must pay the applicable enrollment fees.
Beneficiaries shall be permitted to keep their PCM, if possible.
MTF Commanders/eMSM Managers shall determine if retiring beneficiaries
who enroll in Prime could keep their MTF/eMSM PCMs, given the MTF’s/eMSM’s
enrollment plan and MTF/eMSM capacity. Alternatively, they may elect
to enroll in TRICARE Select. See
Section 2.1,
for QLE information.
2.7 Prime Enrollment for Transitional
Survivors. Those in Transitional Survivor Status, are not distinguished
from other ADFMs for Prime eligibility. See the Transitional Survivor
Status policy in
Section 7.1.
2.8 Claims For
Newborns and Adoptees
2.8.1 Claims for newborns and adoptees
will be cost-shared for up to the first 90 days of life as TRICARE
Prime if one or more family members (including ADSMs) are enrolled
in Prime. Otherwise, the claims will be cost-shared as TRICARE Select
for up to the first 90 days of life. Claims will be denied if received
after 90 days of life if the newborn is not enrolled in TRICARE
Prime or Select coverage. Once the newborn or adoptee is enrolled
in TRICARE coverage, contractors will only re-process claims paid during
the first 90 days of life when requested by a responsible member
of the family.
Exception: If overseas, time
frame is up to the first 120 days of life.
2.8.2 Once a newborn
or adoptee is shown as enrolled in a TRICARE plan in Defense Enrollment Eligibility
Reporting System (DEERS), the TRICARE Prime or TRICARE Select “deemed
status” for cost sharing of claims no longer applies and claims
received after the date of enrollment shall be processed according
to the cost sharing provisions of their enrolled plan.
2.8.3 See the TOM,
Chapter 22, Sections 1 and
2, for policy to suspend newborn and adoptee claims
with TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR)
coverage for up to the first 90 days (120 days if overseas) of life.
2.9 TRICARE eligible beneficiaries who have less
than 12 months of eligibility remaining (for example, retirees who
are 64 years of age, TAMP beneficiaries, etc.) are allowed to enroll
in Prime or Select; however, these enrollees will be disenrolled
when they lose their TRICARE eligibility. The beneficiary has the
choice of paying all of the enrollment fee or paying the fees on
a monthly or quarterly basis. Once the enrollment is terminated,
remaining enrollment fees may be applied to the enrollment fees
of another family member, or at the request of the beneficiary,
may be refunded. See the TOM,
Chapter 6, Section 1.
2.10 Reserve Component
beneficiaries that move between a TRICARE Premium Plan (TRS, TRR, TRICARE
Young Adult (TYA), or Continued Health Care Benefit Plan (CHCBP)
and a non-premium plan. See Section 2.1 for
how these status changes affect the beneficiaries’ cost-share, deductible
and catastrophic cap. When a Reserve Component member is activated
and is treated as any other active duty member, the member’s dependents
qualify as ADFMs. See Section 2.1 for
how this status change affects the dependent’s cost-shares, deductibles
and catastrophic cap.
2.11 Enrollees may disenroll from TRICARE Prime
or Select according to the requirements of
Section 2.1.