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TRICARE Policy Manual 6010.60-M, April 1, 2015
Eligibility And Enrollment
Chapter 10
Section 2.1
TRICARE Prime And TRICARE Select Enrollment
Issue Date:  May 15, 1996
Authority:  32 CFR 199.17
Revision:  C-51, September 11, 2019
1.0  POLICY (Through December 31, 2017)
1.1  In order to receive the expanded benefits and special cost-sharing of Prime, all beneficiaries must take specific action to enroll. For active duty members located in areas where the TRICARE program is implemented, enrollment in Prime is mandatory. An enrollment action must be completed and officially documented (enrollment form, the Government furnished web-based self-service enrollment system/application transaction or telephonic request documented in the contractor’s call notes) to ensure Defense Enrollment Eligibility Reporting System (DEERS) enrollment data is current and claims are processed expeditiously.
1.1.1  Enrollment Procedures
1.1.1.1  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.
1.1.1.2  Enrollment may occur at any time; however, the enrollment period shall coincide with the fiscal year (i.e., the beneficiary’s initial enrollment expires on October 1; all future enrollment periods will be October 1 to September 30). Enrollment may be on an individual or family basis.
1.1.1.3  The contractor is responsible for collecting enrollment fees from Prime enrollees, as appropriate, and forwards all such fees to the Government.
1.1.1.4  Payment of enrollment fees may be made on an annual or quarterly basis by credit card and for monthly enrollment fee payments, by Electronic Fund Transfers (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 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 (AD) 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 the TRICARE Operations Manual (TOM), Chapter 6, Section 1.
1.1.1.5  TRICARE Prime enrollments for eligible enrollees shall be automatically renewed upon the expiration of the enrollment unless the enrollee declines renewal, is no longer eligible for Prime enrollment or fails to pay the enrollment fee on a timely basis.
1.1.1.6  Family members of Activated Members of Reserve Components (RCs). Dependents of members of RCs who have been ordered to active duty for a period of 31 days or more may enroll in TRICARE Prime. 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. Activated members of RCs are treated the same as any other active duty member.
1.1.2  Enrollment Protocols
1.1.2.1  Beneficiaries, enrolling in TRICARE Prime or TRICARE Prime Remote (TPR), may apply to enroll in a Region other than their home of residence Region. All TRICARE Prime and TPR enrollment, Primary Care Manager (PCM) selection and utilization, and referral policies apply. See the TOM, Chapter 6, Section 1 and Chapter 16, Section 1. (Note: This paragraph does not apply to TOP Prime or TOP Prime Remote beneficiaries.)
1.1.2.2  No eligible beneficiary who resides in the TRICARE region shall be denied enrollment or re-enrollment in, or be required to disenroll from, the TRICARE Prime program because of a prior or current medical condition.
1.1.2.3  The contractor shall provide beneficiaries who enroll full and fair disclosure of any restrictions on freedom of choice that may be applicable to enrollees including the Point of Service (POS) option.
1.1.2.4  TRICARE for Life (TFL) beneficiaries (retirees and their dependents who are age 65 and over and are eligible for both Medicare and TRICARE) cannot enroll in TRICARE Prime. However, any beneficiary who is enrolled in TRICARE Prime at the time they attain their Medicare entitlement based on age will be permitted to enroll with a Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) through TRICARE Plus, to the extent capability and capacity exists in the MTF/eMSM. There shall be no TRICARE Plus affiliation with network providers.
1.1.2.5  Dual eligibles under age 65 (retirees and their dependents who have Medicare Parts A and B) have TFL coverage but may elect to enroll in TRICARE Prime. Dual eligibles who are Active Duty Family Members (ADFMs) (any age) also have TFL but may elect to enroll in TRICARE Prime or TRICARE Select. See the TOM, Chapter 6, Section 1.
1.1.2.6  TRICARE and the Military Health System (MHS) beneficiaries who are not eligible to enroll in TRICARE Prime may register for the purpose of accessing space-available care in the MTF/eMSM and customer services. This registration is NOT enrollment in TRICARE Prime and no TRICARE Prime program benefits or services (other than access to customer services and network providers) applies to this beneficiary group.
1.1.3  Retroactive Enrollment
For emergency cases that should be placed under immediate case management, MTF Commanders/eMSM Managers may approve exceptions on a case-by-case basis for retroactive enrollment with an effective date not earlier than the first day of the month that the application is submitted. Director, TRICARE Regional Offices (TROs) may approve exceptions on a case-by-case basis for retroactive enrollment to a network provider with an effective date not earlier than the first day of the month that the application is submitted.
1.1.4  Effective Date of Enrollment
1.1.4.1  An initial enrollment period shall begin on the first day of the month following the month in which the enrollment request (enrollment form, Government furnished web-based self-service enrollment system/application transaction, or telephonic request received by the contractor) and enrollment fee payment, if applicable, are received by the contractor. If the request and fee are received after the 20th day of the month, enrollment will begin on the first day of the second month after the month in which they were received by the contractor.
1.1.4.2  Reenrollments for those who were enrolled in Prime immediately prior to a change in their status:
1.1.4.2.1  When an active duty member’s retirement date is established, a Prime enrollment request to reenroll (enrollment form, Government furnished web-based self-service enrollment system/application transaction, or telephonic request received by the contractor) must be completed within 90 days following the member’s retirement. The effective date of reenrollment shall be the date of retirement, which will result in seamless TRICARE Prime benefits with no break in coverage. Otherwise, the request shall be considered an initial enrollment in Prime and effective according to the provisions of paragraph 1.1.4.1.
1.1.4.2.2  When an active duty 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) they and any eligible family members shall be allowed to reenroll in TRICARE Prime with no break in coverage. TAMP eligibles must request enrollment in Prime (enrollment form, Government furnished web-based self-service enrollment system/application transaction, or telephonic request received by the contractor) prior to the expiration of their period of TAMP eligibility to reenroll in Prime. Non-TAMP eligibles separating but who remain eligible for TRICARE must request enrollment in Prime within 30 days of their change in status. Otherwise, the request shall be considered an initial enrollment in Prime. The effective date of reenrollment shall be the start date of TAMP eligibility or the date of the separation which will then result in seamless TRICARE Prime benefits with no break in coverage.
1.1.4.2.3  TAMP eligible family members who were enrolled in Prime immediately prior to their sponsor’s change in status to active duty may continue their enrollment in TRICARE Prime with no break in coverage if they request reenrollment in TRICARE Prime (enrollment form, Government furnished web-based self-service enrollment system/application transaction, or telephonic request received by the contractor) within 30 days of their sponsor’s return to active duty status. If they request reenrollment within 30 days of the sponsor’s return to active duty status, the reenrollment will be retroactive to the date of the change in status from TAMP to active duty. If reenrollment is not accomplished within 30 days of the sponsor’s return to active duty status, the twentieth of the month rule will apply. For information on the effective dates of enrollments for Service members, see the TOM, Chapter 6, Section 1.
1.1.5  Beneficiaries shall be disenrolled when they are no longer eligible for TRICARE or when they do not submit payment for prescribed enrollment fees by the required date.
1.2  Portability
Enrollees may transfer enrollment when they move (within a contract area or outside a contract area). The transfer request or disenrollment may be submitted using an enrollment form, the Government furnished web-based self-service enrollment system/application transaction or telephonic request received and documented by the contractor. The losing contractor shall provide continuing coverage until:
•  The enrollee requests enrollment in the new location;
•  The enrollee disenrolls;
•  The enrollee is no longer eligible for enrollment in TRICARE Prime; or
•  The contractor must disenroll the beneficiary for failure to pay required enrollment fees, whichever occurs first.
The authorization and referral rules of the losing contractor will continue to apply until enrollment is transferred or the beneficiary is disenrolled (see the TOM, Chapter 6, Section 2).
2.0  Policy (Starting January 1, 2018)
2.1  In order to receive the expanded benefits and special cost-sharing of TRICARE Prime and TRICARE Select, beneficiaries must take specific action to enroll in TRICARE. For active duty members located in areas where the TRICARE program is implemented, enrollment in Prime is mandatory. An enrollment action must be completed and officially documented (enrollment form, the Government furnished web-based self-service enrollment system/application transaction or telephonic request documented in the contractor’s call notes) to ensure DEERS enrollment data is current and claims are processed expeditiously. Enrolling contractors must accept enrollment actions via the methods described in this paragraph.
2.2  Beneficiaries eligible to enroll in TRICARE Prime or TRICARE Select who do not enroll no longer have coverage under the TRICARE Program (including the TRICARE retail pharmacy and mail order pharmacy programs), except that they do not lose any statutory eligibility for space-available care in MTFs/eMSMs.
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);
•  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).
2.3.4  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.
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