1.0 General
1.1 As of October
1, 2013, new TRICARE Prime enrollments will no longer be available
to beneficiaries who reside outside of a TRICARE Third Generation
(T-3) Prime Service Area (PSA), unless they waive their access to
care standards. PSAs are geographic areas where TRICARE Prime is
offered. PSAs were created to ensure medical readiness of the active
duty force by augmenting the capability and capacity of Military
Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs).
Policy also allowed establishment of PSAs around the Base Realignment
and Closure (BRAC) sites. The PSAs being eliminated (referred to
as Transitional PSAs or TPSAs) were not built around MTFs/eMSMs
or BRAC sites, but in other geographic locations under the prior
TRICARE Next Generation (TNEX) contract. Some PSAs are also being
reduced. The TPSAs were allowed to continue until all three regions
were operating under the T-3 contracts.
1.2 TRICARE Prime enrollment for
beneficiaries enrolled outside of a TRICARE T-3 PSA will be automatically
terminated effective October 1, 2013 by the Defense Enrollment Eligibility
Reporting System (DEERS), unless they meet exception criteria contained
in the policy section below. Two notification letters will be mailed
to beneficiaries potentially impacted during the February to July
2013 period fully explaining the PSA changes and their TRICARE health
plan options as stated in
paragraph 2.9. The majority of the disenrolled
beneficiaries will retain TRICARE Standard and TRICARE Extra coverage.
Some of the disenrolled beneficiaries may be eligible to continue
their Prime enrollment in a T-3 PSA or with one of the six Uniformed
Services Family Health Plans (USFHPs). See
paragraph 2.4 for the impact
on TRICARE Young Adult (TYA) Prime enrollees.
1.3 The National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2014, Section
701, signed into law on December 26, 2013, gave certain beneficiaries
a “one-time” election to continue their TRICARE Prime enrollment.
The eligible beneficiaries included those who: (1) were involuntarily
dis-enrolled from TRICARE Prime on September 30, 2013, due to the
PSA reduction, and (2) lived within 100 miles of an MTF/eMSM. Enrollment
processes for these beneficiaries are outlined below.
1.4 The NDAA
for FY 2016, Section 701 signed into law on November 25, 2015, gave
certain beneficiaries a “one-time” election to continue their TRICARE
Prime enrollment. These eligible beneficiaries included those who:
(1) were involuntarily disenrolled from TRICARE Prime on September 30,
2013, due to the PSA reduction, (2) resided more than 100 miles
from an MTF/eMSM, and (3) were an eligible beneficiary by reason
of service in the Army, Navy, Air Force, or Marine Corps. Special enrollment
processes for these particular beneficiaries are outlined below.
2.0 Policy
2.1 Active Duty
Services Members (ADSMs)
TRICARE Prime enrollments
for ADSMs, including activated National Guard and Reserve members
(for more than 30 days), will not be affected by the PSA reductions.
All ADSMs shall remain enrolled in TRICARE Prime or TRICARE Prime
Remote (TPR), as appropriate.
2.2 Active Duty Family Members
(ADFMs) (including ADFM TYA Prime Enrollees)
ADFMs
(including ADFM TYA Prime enrollees) enrolled in TRICARE Prime and
who resided outside of a T-3 PSA on September 30, 2013, were 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 contractor shall continue to have a Primary Care Manager
(PCM) available for these beneficiaries and ensure all claims and
benefits are administered as TRICARE Prime. ADFMs shall remain enrolled
in TPR for Active Duty Family Members (TPRADFM), as appropriate.
The contractor shall manage the grandfathered ADFMs as stated in
this chapter.
2.2.1 Terms of Grandfathered 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.
2.2.2 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.
2.2.3 All previously grandfathered
beneficiaries (those grandfathered prior to the T-3 contracts) lost
their grandfathered status effective October 1, 2013. They will
be managed like all other beneficiaries.
2.3 Retirees
And Their Family Members
2.3.1 Retirees and their family
members enrolled in TRICARE Prime (including dependents of retirees
enrolled in TYA Prime), who reside outside of a T-3 PSA, were disenrolled
effective midnight on September 30, 2013. Impacted retirees and
their family members may re-enroll in TRICARE Prime at an MTF or
with a network civilian PCM inside a T-3 PSA if they live within
100 miles of an available PCM in a T-3 PSA, submit a new request
for enrollment, and waive both primary and specialty care travel
time standards. They may also enroll in one of the six USFHPs, if
available.
2.3.2 Retired beneficiaries who reside within a T-3
PSA, but are enrolled with a PCM located outside of a T-3 PSA will
remain enrolled in TRICARE Prime. DEERS will not automatically disenroll
these beneficiaries. The contractor notified those beneficiaries
and assisted them with selecting a PCM inside the T-3 PSA.
2.3.3 No retired
beneficiary will be given grandfathered status.
2.3.4 Retired
beneficiaries who were eligible and elected to re-enroll under Section
701 of the NDAA for FY 2014 must be re-enrolled effective October
1, 2013, paid retroactive enrollment fees, and waived both primary
and specialty care drive time standards. The contractor must have
available, and assign, a PCM for these beneficiaries within an existing
PSA. Once enrolled and fees are paid, any TRICARE Standard claim
processed with a date of service on or after October 1, 2013, for
the beneficiary shall be reprocessed under the TRICARE Prime option.
TRICARE Prime policies for these claims are waived as necessary
to reprocess the claims, i.e., PCM referrals.
2.3.5 Retired
beneficiaries who are eligible and elect to re-enroll under Section
701 of the NDAA for FY2016 must be re-enrolled by August 30, 2016,
pay required enrollment fees, and waive both primary and specialty
care travel drive time access to care (ATC) standards. Within an
existing PSA, the contractor shall have available and assign a PCM
for these beneficiaries residing greater than 100 miles from an
MTF. Once enrolled and fees are paid, TRICARE claims for these beneficiaries
with a date of service on or after the date of this enrollment shall
be processed under the TRICARE Prime option.
2.4 TYA
Enrollees
2.4.1 TYA Prime enrollments for those beneficiaries
who reside outside of a T-3 PSA will be processed according to their
sponsor’s status.
2.4.2 ADFM TYA Prime beneficiaries
enrolled outside of a T-3 PSA were grandfathered in TYA Prime effective
October 1, 2013, and will be able to retain grandfathered status
as long as they meet the following conditions:
• They reside within
40 miles of the residence where they or their sponsor was originally granted
grandfathered status (see
paragraphs 2.2.1 and
2.2.2),
• They remain eligible
to purchase coverage, and
• Their sponsor’s status
does not change.
2.4.3 Retired TYA Prime enrollees
who resided outside of a T-3 PSA were disenrolled effective midnight
September 30, 2013, with no lockout applied (Chapter 25, Section
1), unless they are enrolled to a PCM within a T-3 PSA. All TYA
eligible enrollees whose Prime enrollments are terminated must re-apply
for coverage by completing a new TYA Application (DD Form 2947)
to either enroll in TYA Standard or re-enroll in TYA Prime if they
meet the requirements for retiree enrollment in TRICARE Prime contained
in
paragraph 2.3.
2.4.4 Retired TYA Prime enrollees
who were eligible and elected to re-enroll under Section 701 of the
NDAA for FY 2014 must have re-enrolled effective October 1, 2013,
paid retroactive premiums, and waived both primary and specialty
care drive time standards. The contractor shall have available,
and assign, a PCM for these young adults within an existing PSA.
Once enrolled and premiums are paid, any TRICARE Standard claim
processed with a date of service on or after October 1, 2013, for
the young adults shall be reprocessed under the TRICARE Prime option.
TRICARE Prime policies for these claims are waived as necessary
to reprocess the claims, i.e., PCM referrals.
2.4.5 Retired
TYA Prime beneficiaries who are eligible and elect to re-enroll
under Section 701 of the NDAA for FY 2016 must be re-enrolled by
August 30, 2016, pay required premiums, and waive both primary and
specialty care travel drive time ATC standards. Within an existing
PSA, the contractor shall have available and assign a PCM for these
young adults residing greater than 100 miles from an MTF. Once enrolled
and premiums are paid, TRICARE claims for these beneficiaries with
a date of service on or after the date of this enrollment shall
be processed under the TRICARE Prime option.
2.5 Transitional
Assistance Management Program (TAMP)
TAMP
beneficiaries enrolled in Prime who reside outside of a T-3 PSA
will be grandfathered and managed like all other ADFMs. Additionally,
grandfathered Prime enrollees will continue to be grandfathered
if they become TAMP eligible and enroll in TAMP, as long as they
reside within 40 miles of the residence where they were originally
granted grandfathered status. Grandfathered status will not be given
to TAMP beneficiaries who move into an area that is not a T-3 PSA
on/after October 1, 2013.
2.6 Transitional Survivors
Transitional Survivors are grandfathered like
any other ADFM. However, when a surviving spouse’s status changes
from Transitional Survivor to Survivor, they will be disenrolled
from TRICARE Prime and have to apply for re-enrollment as a Survivor,
if TRICARE Prime is available within 100 miles of their residence.
The current survivors are managed like any other retired beneficiary
as described in
paragraph 2.3; they are not grandfathered.
2.7 TPR and TRPADFMs
The current policy for TPR and TPRADFM does
not change.
2.8 New
Enrollments in TPSAs (all beneficiaries)
2.8.1 New TRICARE Prime enrollments
in the TPSAs on or after April 1, 2013 will be limited. Beneficiaries
who establish a residence in a TPSA prior to August 20, 2013 (20th
of the month rule) can enroll in TRICARE Prime. Beneficiaries who
do not establish residence in the TPSA cannot enroll with a TPSA
PCM after April 1, 2013, unless they are attached to a grandfathered
ADSM. Beneficiaries may “transfer” their TRICARE Prime enrollment
to the TPSA if they establish residence in a TPSA before September
30, 2013.
2.8.2 ADFMs moving into an area that is not a T-3
PSA on or after October 1, 2013 will not receive grandfathered status.
If eligible to do so, they may enroll in TPRADFM. No TRICARE Prime
enrollments to providers in the disestablished TPSAs shall be permitted
after September 30, 2013, either for ADFMs or retirees.
2.9 Notification
and Disenrollment Letters
2.9.1 The contractor shall print
and mail two notification letters between February and July 2013. Defense
Health Agency (DHA) Beneficiary Education & Support Division
(BE&SD) will provide the MCSCs and the Defense Manpower Data
Center (DMDC) the notification letter templates for each beneficiary
category. DMDC will provide a listing of the beneficiaries, to include
their name and the demographic data needed, to complete the mailings.
Copies of the letters and beneficiary listing will also be provided
to the TRICARE Regional Offices (TROs). In August 2013, DMDC mailed
disenrollment letters to the beneficiaries whose TRICARE Prime enrollment
will be terminated effective October 1, 2013.
Note: All affected beneficiaries noted in the above
paragraphs may also have the option to enroll in the USFHP, where
available.
2.9.2 The retired beneficiaries eligible to re-enroll
under Section 701 of the NDAA for FY 2014 received one notification
letter from the DHA in April or May 2014.
2.9.3 The retired beneficiaries
eligible to re-enroll under Section 701 of the NDAA for FY 2016
will receive one notification letter from DHA through the Defense
Manpower Data Center (DMDC) in April or May 2016 regarding their
“one-time” re-enrollment option.
Note: For beneficiaries requesting enrollment under
the provisions of the NDAA for FY 2016 Section 701, the MTF Commander
will not need to notify the TRO Director of their desire to enroll
a beneficiary who resides greater than 100 miles from the MTF (as
would otherwise be required under
Chapter 6, Section 1, paragraph 11.6.3).
3.0 Effective
Dates
3.1 New enrollments in the TPSA are not allowed
after August 20, 2013, for any beneficiary category (20th of the
month rule), unless they qualify for TPR or TPRADFM.
3.2 All TPSAs
terminate effective midnight September 30, 2013.
3.3 Effective
October 1, 2013, PSAs will be maintained only at MTFs and designated
BRAC sites.
3.4 The retired beneficiaries eligible to re-enroll
under Section 701 of the NDAA for FY 2014 must submit their enrollment
request (per
Chapter 6, Section 1, paragraph 1.2) and applicable
fees to their contractor prior to June 30, 2014. All forms postmarked
on or prior to June 30, 2014 are acceptable. Their effective date
of coverage will be October 1, 2013.
3.5 The retired beneficiaries
eligible to re-enroll under Section 701 of the NDAA for FY 2016
must submit their enrollment request (per
Chapter 6, Section 1, paragraph 1.2) and applicable
fees to their contractor prior to August 30, 2016. All enrollment
forms postmarked on or prior to August 30, 2016 shall be accepted.
The effective date of coverage will be based on the “20th of the
month rule” for receipt of an enrollment form (per
Chapter 6, Section 1, paragraph 5.3.2).