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);
• Gain
or loss of Other Health Insurance (OHI) (self-attestation);
• Gain
or loss or Medicaid entitlement;
• Gain
or loss of Medicare entitlement (not applicable for loss of Medicare
coverage for failing to sign up on time for Medicare coverage or
failing to pay Medicare premiums);
• 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.
2.3.3.1.1 EXCEPTION:
For Uniformed Services retirements that occur on or after January
1, 2018, upon request, contractors shall enroll retired service
members and their family members into TRICARE Prime (if qualified)
or TRICARE Select coverage retroactive to the date of retirement
if the enrollment request is received within 12 calendar months
of the retirement date and as long as all enrollment fees (if applicable)
back to the retirement date are paid. The effective start date of
coverage must be the member’s retirement date. However, if the effective
retirement date occurred between January 1, 2018 and May 1, 2018,
the contractor shall accept and process retroactive enrollment requests
if received by May 1, 2019, and charge appropriate enrollment fees
retroactive to the effective retirement date. The effective coverage
date remains the date of retirement. Otherwise, for retroactive
enrollment requests received after May 1, 2019 that request a retroactive
enrollment date greater than 12 months in the past or request a
start of coverage date other than the date of retirement, then open
season and QLE rules apply.
2.3.3.1.2 EXCEPTION:
For Unremarried Former Spouses (URFS) who become eligible for TRICARE as
their own sponsor on or after January 1, 2018, upon request, contractors
shall enroll them into TRICARE Prime (if qualified) or TRICARE Select
coverage retroactive to the date of eligibility as an URFS if the
enrollment request is received within 12 calendar months of the
initial eligibility date as an URFS and as long as all enrollment
fees (if applicable) back to the initial URFS eligibility date are
paid. The effective start date of coverage must be initial URFS
eligibility date. However, if the effective date of their eligibility
as an URFS occurred between January 1, 2018 and May 1, 2018, the
contractor shall accept and process retroactive enrollment requests
if received by May 1, 2019. The effective coverage date remains
the date of eligibility as an URFS. Otherwise, for retroactive enrollment
requests received after May 1, 2019 that request a retroactive enrollment
date greater than 12 months in the past or request start of coverage
date other than the date of eligibility as an URFS,
then open season and QLE rules apply.
Note: The
one year limitation on submittal of claims in the TOM, Chapter 8, Section 3, paragraph 2.1.1, is
waived for those retroactively enrolled with an effective coverage
date between January 1, 2018 and May 1, 2019. The contractor does
not need to identify these claims; however, the contractor shall
adjust claims when beneficiaries bring them to the contractor’s
attention.
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).
2.3.5 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.