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TRICARE Policy Manual 6010.60-M, April 1, 2015
Eligibility And Enrollment
Chapter 10
Section 3.1
TRICARE Prime/Select And Status Changes
Issue Date:  May 15, 1996
Authority:  32 CFR 199.17
Revision:  C-69, September 4, 2020
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.
1.10  For exceptions to enrollment fee refunds and prorated fees, see the TOM, Chapter 6, Section 1.
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 TOM, Chapter 22, Sections 1 and 2, for policy with processing newborn and adoptee claims under TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) coverage.
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.
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