The Managed
Care Support Contracto
r, Uniformed
Services Family Health Plan (USFHP) Designated Provider (DP), and
TRICARE Overseas Program (TOP) contracto
r shall
record all enrollments on Defense Enrollment Eligibility Reporting
System (DEERS), as specified in the TRICARE Systems Manual (TSM),
Chapter 3. The word “contractor” refers to
all three contractors (listed above) for this section unless otherwise
noted.
1.0
Enrollment
Processing
1.1 For paper enrollment requests, the contractor shall
use the TRICARE Prime Enrollment, Disenrollment, and Primary Care
Manager (PCM) Change Form (one combined form), Department of Defense
(DD) Form 2876. For TRICARE Select enrollments, the contractor shall
use the TRICARE Select Enrollment, Disenrollment, and Change Form,
DD Form 3043. The contractor shall
ensure the aforementioned form is readily available to potential
enrollees. The contractor shall
implement enrollment processes (which do not duplicate Government
systems) that ensure success and assistance to all beneficiaries. The
contractor shall collect
enrollment forms at a site(s) mutually agreed to by the contractor, Government
Designated Authority (GDA), and Market
Director/Military Treatment Facility (MTF) Director,
by mail, fax, or by other methods proposed by the contractor and
accepted by the Government. The contractor shall
encourage the beneficiaries to use the Government furnished web-based
self-service enrollment system/application to enroll. The overseas
contractor shall also collect applications at TRICARE Service Centers
(TSCs).
1.2 Enrollment
requests must be initiated by the sponsor, spouse, other legal guardian
of the beneficiary, or an eligible beneficiary age 18 or older.
An official enrollment request includes those with (1) an original
signature, (2) an electronic signature offered by and collected
by the contractor, (3) a verbal consent provided via telephone and
documented in the contractor’s call notes, or (4) a self-attestation
by the beneficiary when using the Government furnished web-based
self-service enrollment system/application. A signature from a Service
member is never required to complete Prime enrollment as enrollment
in Prime is mandatory per the TRICARE Policy Manual (TPM),
Chapter 10, Section 2.1.
1.3 The contractor shall provide beneficiaries
who enroll full and fair disclosure of any restrictions on freedom
of choice that apply to enrollees, including the Point of Service
(POS) option for TRICARE Prime enrollees and the consequences of
possibly having direct care only coverage on a space available basis
for failure to pay enrollment fees on time, choosing to not enroll,
or disenroll from either TRICARE Prime or TRICARE Select.
1.4 Enrollment shall be on an individual
or family basis. For newborns and adoptees, see the TPM,
Chapter 10, Section 3.1.
1.5 For TRICARE Prime enrollments, the
contractor shall follow the specifications recorded in each Market/MTF’s
Memorandum of Understanding (MOU)/Statement of Responsibility (SOR).
1.6 The contracto
r shall
record all enrollments using the Government furnished web-based enrollment
system/application, within 10 working days of receipt. The equipment
needed to run the DEERS desktop enrollment application shall be
furnished by the contractor and shall meet technical specifications
in the TSM,
Chapter 3.
1.6.1 The contractor shall
resend TRICARE Prime/TRICARE Plus PCM Information Transfers (PITs) to Market/MTFs when
requested.
1.6.2 The contractor shall
submit required changes to the DEERS Support Office (DSO) as required.
1.7 At the time of enrollment processing,
the contractor shall access DEERS to verify beneficiary eligibility
and shall update the residential, mailing, and e-mail addresses
and any other fields that
it can update
on DEERS.
1.7.1 If the enrollment request (see
paragraph 1.2)
contains neither a residential address nor a mailing address, the
contractor shall develop for a residential or mailing address.
1.7.2 Enrollees or the Government may
provide the contractor a temporary address (i.e., Post Office Box,
Unit addres
s), until a permanent address
is established. Temporary addresses shall be updated with the permanent
address when provided to the contractor by the enrollee in accordance with
the TSM,
Chapter 3, Section 4.2. The contractor shall
not input temporary addresses unless provided by the enrollee or
the Government.
1.7.3 If the DEERS record does not contain
an address, or if the enrollment request contains information different
from that contained on DEERS in fields for which the contractor
does not have update capability, the contractor shall contact the
beneficiary by telephone within five calendar days, outline the
discrepant information and request the beneficiary contact their
military personnel office.
1.8 DMD
C/DEERS
shall notify the beneficiary of the TRICARE wallet card at MilConnect.
DMDC will also provide notification of PCM assignments for new TRICARE
Prime enrollments, disenrollments, enrollment transfers, and PCM
changes. (See TSM,
Chapter 3, Section 4.2.) The return address
on any correspondence mailed by DMDC will be that of the appropriate
contractor. In the case of receiving returned mail, the contracto
r shall
develop a process to fulfill the delivery if the correspondence
is returned to the contractor by the United States Post Office (USPS).
2.0
Automatic
Enrollment Management
2.1 Automatic
Eligibility Updates
DEERS will
automatically update start and/or end dates of coverage when a beneficiary’s eligibility
is updated by the Uniformed Services. The contractor will receive
a Policy Notification Transaction (PNT) advising them of all changes,
and will take action accordingly.
2.2 Automatic Enrollment of Active Duty
Service Members (ADSMs)
DEERS will
automatically enroll all new active duty service member accessions,
to include Reserve Component members on active duty for more than
30 days, into Health Care Delivery Plan 001 (TRICARE Prime for Active
Duty Sponsors, No PCM Assigned).
2.3
Automatic
Enrollment of Newly Eligible Active Duty Family Members (ADFMs)
Note: Automatic enrollment
of ADFMs does not apply to USFHP contractors.
The contractor shall
upon request from a beneficiary or sponsor, who was auto-enrolled,
adjust any claims in question to apply Prime plan benefits, and
waive POS cost-sharing provisions. The contractor shall
educate the beneficiary or sponsor of this one-time correction and
provide instruction to the beneficiary regarding their PCM assignment
and the requirement to have referrals for all future specialty care.
If received over the phone, the conversation shall be documented
in the contractor’s call notes. The
contractor need not identify these claims; however, the claims shall
be adjusted as they are brought to their attention by beneficiaries.
3.0
Dual
Eligibles (Entitlement Under Both Medicare And TRICARE)
3.1 Dual
eligibles, (retired and retired family members, under age 65) are
eligible to enroll in TRICARE Prime provided they maintain Medicare
Part A and Part B. Dual eligible ADFMs, regardless of age, are eligible
to enroll in TRICARE Prime or TRICARE Select. Dual eligible retirees
and family members age 65 and over are not eligible to enroll in
TRICARE Prime or TRICARE Select. Exception: Those not entitled to
premium free Medicare part A on their own or the record of their
current, former, deceased spouse may enroll in TRICARE Prime or
TRICARE Select. Medicare is primary payor for all dual eligibles regardless
of their sponsor’s status. (See the TPM,
Chapter 10, Section 2.1 for additional dual
eligible information.)
3.2 TRICARE
Prime-enrolled dual eligibles, to the extent practicable, should
follow all TRICARE Prime requirements for PCM assignment, referrals
and authorizations. However, they are not subject to POS cost-sharing.
Enrollment fees are waived for dual eligibles. (See
paragraph 5.0.)
4.0 Assignment
Of PCM For TRICARE Prime Enrollees
The contractor
shall assign all TRICARE Prime enrollees a PCM by name (PCMBN) on
the Government furnished web-based enrollment system/application
at the time of TRICARE Prime enrollment. This applies to beneficiaries
assigned to the Direct Care (DC) system as well as civilian network
PCMs.
4.1 The contractor shall comply with
the
Market Director’s/MTF
Director’s specifications
in the
Market/MTF
MOU/SOR
for which enrollees or categories of enrollees shall be assigned
a DC PCM or offered a choice of civilian network PCMs.
4.1.1 The contractor shall enroll TRICARE
Prime beneficiaries to the Market/MTF until
the capacity is optimized in accordance with the Market
Director’s/MTF Director’s determinations.
TRICARE Prime beneficiaries who cannot be enrolled to the Market/MTF will
be enrolled to the contractor’s network.
4.1.2 All active duty personnel not meeting
the requirements for TRICARE Prime Remote (TPR) shall be enrolled
to a Market/MTF,
not the contractor’s network, regardless of capacities.
4.1.3 When a family member of an active
duty E-1 through E-4 sponsor requests a PCM in a Market/MTF that
offers TRICARE Prime for any beneficiary category other than active
duty, that beneficiary shall be assigned
a Market/MTF PCM
unless capacity has been reached. If overall Market/MTF capacity
has not been reached, the contractor shall request the Market/MTF to
shift capacity in the Government furnished web-based enrollment
system/application to the ADFM beneficiary category from another
category if necessary to accommodate an E-1 through E-4 ADFM beneficiary’s
PCM assignment request.
4.2 The contractor shall provide guidance
to the enrollee in selecting a primary care location or PCM, as
appropriate given Market/MTF guidance
in the MOU. Upon receipt of an inquiry from a DC enrollee in regards
to the person’s assigned PCM, the contractor shall refer the beneficiary
to the Market/MTF where
the beneficiary is enrolled.
4.3 At the time of enrollment, the contractor
shall determine the appropriate enrollment Defense Medical Information
System Identification (DMIS-ID) based on the regional and
Market/MTF
MOUs, access
standards and/or other specific Government guidance. The contractor
shall assign each enrollee a PCMBN at the time of enrollment based
on those PCMs available within the Government furnished web-based
enrollment system/application.
4.3.1 The contractor shall attempt to
assign the beneficiary to the PCM requested by the beneficiary (see
paragraph 1.2)
if capacity is available. If the preferred PCM is not available,
the contractor shall use the default PCM for that DMIS.
4.3.2 If the enrollment request (see
paragraph 1.2)
identifies a gender or specialty preference, the contractor shall
assign an appropriate PCM. If the gender or specialty is not available,
the beneficiary will be enrolled to the default PCM for that DMIS.
4.3.3 If no PCM preference is stated on
the enrollment request (see
paragraph 1.2), the contractor shall use the
default PCM for that DMIS.
4.3.4 If
there is no DC PCM available in the appropriate DMIS/Market/MTF,
nonactive duty beneficiaries may be enrolled to a civilian PCM,
by following the procedures specified in the Market/MTF MOU.
4.3.5 If there is no PCM capacity in the Market/MTF for
a Service member, then the contractor shall contact the Market/MTF for
instructions.
4.4 The Government furnished web-based
enrollment system/application reflects only those DC PCMs that the Market/MTF has
loaded onto the DEERS PCM Repository. Further, the Government furnished
web-based enrollment system/application will only display PCMs with
available capacity for the specific beneficiary’s category and age.
The contractor shall not add, delete, or modify DC PCMs on the repository.
4.5 The contractor shall complete all
panel PCM reassignments (batch) using a Government-provided systems
application, PCM Reassignment System (PCMRS). Panel reassignments
may be specified by the appropriate
Market Director/MTF
Director for
a variety of reasons, including the rotation or deployment of DC
PCMs. The contractor
shall expect at
least one-half of DC PCM assignments to change each year. These
moves may be based on various factors of either the enrollment or
the individual beneficiary, including:
• DMIS ID to DMIS ID
• PCM ID to PCM
ID
• Health Care
Delivery Program (HCDP)
• Sex of beneficiary
• Unit Identification
Code (UIC) (active duty only)
• Age of beneficiary
• Sponsor Social
Security Number (SSN) and DoD Benefits Number (DBN)
• Name of beneficiary
4.6 Markets/MTFs will request
PCM reassignment, including panel reassignments, in several ways, including
telephone, e-mail or other electronic submissions. The preferred
method for panel reassignments is the batch staging application
within PCMRS. Regardless of the submission method, the Market/MTF will provide
sufficient information identifying both the PCMs and beneficiaries involved
in a move to allow the contractor to reasonably accomplish the move.
Thereafter, the contractor shall complete each DC PCM reassignment,
both individual and panel reassignment, within three working days
of receiving all necessary information from the Market/MTF.
4.7 PCM change requests submitted by
beneficiaries enrolled to a civilian network PCM via any means other
than the Government furnished web-based self-service enrollment
system/application shall be processed by the contractor within three
working days of receipt, with an effective date no later than the
third working day.
4.8 PCM change requests submitted to
the contractor via the Government furnished web-based self-service
enrollment system/application shall be processed within six calendar
days of receiving the request. The contractor shall modify the effective
date to be no later than the third working day, or the date requested
by the beneficiary up to 90 days in the future. Effective January
1, 2018, the contractor shall modify the effective date to be the
date the contractor received the request.
5.0
Enrollment
Period
5.1 Through December 31, 2017, the contractor
shall support continuous open enrollment for all beneficiaries.
Enrollment may occur any time during the contract period; however,
all new enrollment periods will be aligned with the fiscal year.
Therefore, the initial enrollment period may be shorter than a 12
month period.
Note: The
enrollment period for fiscal year 2017 includes the period between
October 1, 2017 and December 31, 2017.
5.2
Starting
January 1, 2018
5.2.1 The contractor shall support one
annual open enrollment period per calendar year for all Non-Active
Duty Service Member (NADSM) beneficiaries. Enrollments, with the
appropriate application and any required enrollment fee, will be
effective on January 1 of the following year. Beneficiaries will be
automatically re-enrolled each year unless they elect a different
option or disenroll during the open enrollment period. See TPM,
Chapter 10, Section 2.1.
5.2.2 A one-time transition period will
be in effect for the enrollment period beginning January 1, 2018
and ending December 31, 2018. Beneficiaries may elect to enroll
in or change their TRICARE Prime or Select coverage at any time
during the calendar year 2018 enrollment period.
5.3
Effective
Date of Enrollment (Prior to January 1, 2018)
The contractor
shall support continuous open enrollment for all beneficiaries.
Enrollment may occur any time during the contract period; however,
all new enrollment periods will be aligned with the fiscal year.
Therefore, the initial enrollment period may be shorter than a 12
month period.
5.3.1 The effective date of enrollment
for Service members shall be the date the contractor receives the
enrollment application. For enrollment requests received via the
Government furnished web-based self-service enrollment system/application,
the contractor shall modify the effective date to be the date the
enrollment was submitted.
5.3.2 For
all other beneficiary categories, enrollment periods shall begin
on the first day of the month following the month in which the enrollment
application and any required enrollment fee payment is received
by the contractor. If an application and fee are received after
the 20th day of the month, enrollment will be on the first day of
the second month after the month in which the contractor received
the application. (This recurring principle is referred to as the
“20th of the month” rule.)
5.3.3 Enrollees who transfer enrollment
continue with the same enrollment period. The enrollment transfer,
however, is effective the date the gaining contractor receives a
signed enrollment application or transfer application. For enrollment
transfers received via the Government furnished web-based self-service
enrollment system/application, the contractor shall modify the effective
date to be the date the enrollment was submitted. See TPM,
Chapter 10, Sections 2.1 and
5.1 for information on Transitional Assistance
Management Program (TAMP) and other changes in status.
5.3.4 Effective
Date of Enrollment (On or After January 1, 2018)
5.3.4.1 TRICARE Prime and TRICARE Select enrollments
will be effective the date of the Qualifying Life Event (QLE) or
on January 1 of the following year for open enrollment period enrollments
(see TPM,
Chapter 10, Section 2.1). Enrollment requests
will no longer be pended for six days.
5.3.4.2 Requests for enrollment based on a
QLE may be received up to 90 days before and no later than 90 days
after the date of the QLE. For online requests for an enrollment
date less than 90 days or more than 90 days from the date of the
QLE, the web- based self-service enrollment system/application will
display a message to contact the contractor.
5.4 Enrollment
Expiration (Before January 1, 2018)
5.4.1 Due to the extended enrollment period
in 2017, the contractor shall not send renewal notices to TRICARE
Prime enrollees on October 1, 2017 as in previous years. See
paragraph 5.5.1.
5.4.2 The contractor shall automatically
renew enrollments, including those for Service members, upon expiration
unless the enrollee declines renewal, is no longer eligible for
Prime enrollment, or fails to pay any required re-enrollment fee
on a timely basis, including a 30 calendar day grace period beginning
the first day following the last day of the enrollment period. See
paragraph 11.5.1,
for actions required if a beneficiary is identified as being ineligible
for continued Prime, TPR or TPRADFM enrollment.
5.4.3 If the enrollee requests disenrollment
during this grace period, the contractor shall disenroll the beneficiary
effective retroactive to the enrollment period expiration date (last
paid-through date).
5.4.4 If an enrollee does not respond
to the notification and fails to make an enrollment fee payment
by the end of the grace period, the contractor shall assume that
the enrollee has declined continued enrollment. The contractor shall
disenroll the beneficiary retroactive to the enrollment expiration
date (last paid-through date).
5.4.5 Service
members may not decline continued enrollment nor request disenrollment.
5.4.6 DMDC
sends written notification to the beneficiary of the disenrollment
and the reason for the disenrollment within five business days of
the disenrollment transaction.
5.5 Enrollment
Expiration (Starting January 1, 2018)
5.5.1 The
contractor shall not send renewal notices to enrollees. Exception:
Thirty (30) days before the expiration date of enrollment for beneficiaries
paying enrollment fees quarterly or annually, the contractor shall
send the appropriate individual (i.e., sponsor,
custodial parent, retiree, retiree family member, survivor or eligible
former spouse) a written notification
of the pending enrollment expiration that includes a bill for the
re-enrollment fee. The notification will alert the beneficiary that
he/she will only be eligible for MTF space-available care only should
payment not be received. If appropriate, the notification will
include any rate change information. The bill shall offer all available
payment options and methods. The contractor shall issue a delinquency
notice to the appropriate individual 15 calendar days after the
expiration date of the enrollment if a renewal payment is not received.
5.5.2 For beneficiaries that pay enrollment
fees on a monthly basis: the contractor shall
send the appropriate individual (i.e., sponsor,
custodial parent, retiree, retiree family member, survivor or eligible former
spouse) a written notification alerting
the beneficiary of any fee changes at least 30 days prior to the
implementation of any fee changes.
5.5.3 The contractor shall automatically
renew enrollments, including those for Service members, each calendar
year unless the enrollee declines renewal, is no longer eligible
for enrollment, or fails to pay any required enrollment fee on a
timely basis. See TPM,
Chapter 10, Section 2.1 for actions required
if a beneficiary is identified as being ineligible for continued
enrollment.
The contractor
may reinstate
coverage if the request is received with appropriate payment of
fees within 90 days from the last paid-through date.
5.5.4 Active
Duty Service Members (ADSMs) may not decline reenrollment nor request disenrollment.
5.5.5 DMDC shall notify the beneficiary
of the disenrollment within five business days of the disenrollment
transaction.
5.6
Disenrollment
5.6.1 Disenrollment
requests must be initiated by the sponsor, spouse, other legal guardian
of the beneficiary, or an eligible beneficiary 18 or older. An official
disenrollment request includes those with:
• An original signature;
• An electronic signature offered by and
collected by the contractor;
• A verbal consent provided vial telephone
and documented in the contractor’s call notes; or
• A self-attestation by the beneficiary when
using the Government furnished web-based self-service enrollment
system/application. (A Service member cannot request disenrollment.)
5.6.2 The
contractor shall automatically disenroll beneficiaries when the
appropriate enrollment fee payment is not received by the 30th calendar
day following the last paid-through date. The contractor shall set
the disenrollment effective date retroactive to the last paid-through
date. An enrollment fee payment includes the correct amount for
the period the fee is intended to cover (i.e., monthly, quarterly,
or annually).
5.6.3 Prior to processing a disenrollment
for “non-payment of fees,” the contractor shall reconcile their
fee payment system against the fee totals in DEERS. Once the contractor
confirms that the payment amounts match, the disenrollment may be
entered in the Government furnished web-based enrollment system/application.
5.6.4 Prior to
January 1, 2018
5.6.4.1 The disenrolled
beneficiary is responsible for the deductible and cost-shares applicable under
TRICARE Extra or Standard for any health care received during the
30 day grace period. In addition, the beneficiary is responsible
for the cost of any services received during the 30 day grace period
that may have been covered under TRICARE Prime but are not a benefit
under TRICARE Extra or Standard.
5.6.4.2 The
contractor may suspend claims processing during the grace period
to avoid the need to recoup overpayments.
5.6.5 Effective
January 1, 2018
The contractor shall pend claims
received during the grace period to avoid the need to recoup overpayments.
See the TPM,
Chapter 10, Sections 2.1 and
3.1 for additional information on disenrollment.
5.7 Enrollment
Lockout (Prior to January 1, 2018)
5.7.1 The contractor shall “lockout” or
deny re-enrollment effective the date of disenrollment for the following
beneficiaries:
• Retirees and/or
their family members who voluntarily disenroll prior to their annual enrollment
renewal date;
• ADFMs (E-5 and
above) who change their enrollment status (i.e., from enrolled to disenrolled
twice in a given year) for any reason during the enrollment year
(October 1 to September 30) (refer to this chapter and TPM,
Chapter 10, Sections 2.1 and
3.1; and
• Any beneficiary disenrolled for failure
to pay required enrollment fees during a period of enrollment.
Note: The
12 month lockout provision is not applicable to ADFMs whose sponsor’s
pay grade is E-1 through E-4.
5.7.2 Beneficiaries
who are disenrolled for the above reasons prior to December 31,
2018 are eligible to re-enroll any time during calendar year 2018.
Beginning January 1, 2019, the 2018 enrollment grace period ends
and only the annual open enrollment season and QLE rules fully apply. See
TPM,
Chapter 10, Section 2.1.
5.8 Enrollment
Lockout (Starting January 1, 2018)
5.8.1 Enrollment lockouts are no longer necessary
for TRICARE Prime and TRICARE Select as enrollments are only allowed
during the annual open enrollment period or due to a QLE.
5.8.2 The contractor shall reinstate (restore)
the enrollment if the beneficiary requests reinstatement within
90 days of their disenrollment date (last paid-through date) and
pays all past due fees if applicable. Otherwise, requests for reinstatement
due to failure to pay fees received after 90 days past the last
paid-through date shall be denied by the contractor.
5.8.3 Exception
In the event the “failure to pay”
disenrollment was directly caused by contractor or Government
error, for example, the contractor failed to submit the correct
allotment amount to the Defense Finance and Account Service (DFAS),
upon request of the beneficiary via the contractor, the GDA, TRICARE
Area Offices (TAOs), or USFHP program
office may direct reinstatement of the coverage greater than 90
days past the last paid-through date if all past fees are paid if
applicable. In no instance shall a new enrollment period be started
in lieu of reinstatement from the last paid-through date.
6.0 Enrollment Fees
6.1 General
The contractor shall collect enrollment
fee payments from TRICARE Prime and TRICARE Select enrollees as
appropriate and report those fees, including any overpayments that
are not refunded to the enrollee, to DEERS.
• The contractor
shall report refunds to DEERS: (1) all refunds of any enrollment
fees collected, and (2) fee amounts forfeited by enrollees prior
to January 1, 2018 who voluntarily disenroll and are not due a refund.
The forfeited fee amounts, unless they can be credited to the enrollment
of another family member(s), shall not be retained as a credit. For
forfeited fees, the contractor shall adjust the fees paid on the
enrollment policy to match with the voluntary termination date (“zero”
the fees paid). (See the TSM,
Chapter 3.) For
enrollment fee refund policies as of January 1, 2018, see
paragraph 9.0.
• The contractor
shall report a credit to DEERS to offset outstanding enrollment
fees anytime a retirement date is retroactively changed by the Services
as recorded in DEERS that results in a situation where past prorated
enrollment fees are now due based on the changed date for a retiree
who was previously paid to date in their enrollment fees that occurred
before January, 1, 2018. The contractor shall credit the retiree’s
enrollment fee and report as an offset to the collected enrollments
deposited to the Defense Health Agency’s (DHA’s) account. This shall
occur as long as the retiree’s enrollment fees are otherwise current.
• To permit the
transition from a fiscal to a calendar enrollment year, fiscal year
2017 is defined as the period from October 1, 2016 through December
31, 2017. For FY 2017, prorated TRICARE Prime enrollment fees are
required for the additional period of October 1, 2017 through December
31, 2017.
• TRICARE Prime and TRICARE Select enrollees
may select one of the following three payment fee options (i.e.,
annual, quarterly, or monthly).
• When enrollment
fee or premium payments are permitted by credit or debit cards, beneficiaries
in overseas locations must utilize a credit or debit card issued
by a U.S. banking institution or other U.S. financial institution.
• In the
event that there are insufficient funds to process an enrollment
fee or premium payment, the contractor may assess the account holder
a fee of up to 20 U.S. dollars ($20.00), which is retained by the
contractor. The contractor shall provide commercial payment methods
for enrollment fees and premiums that best meet the needs of beneficiaries
while conforming to
paragraphs 6.1.2 through
6.8.
6.1.1 Fiduciary
Responsibilities
6.1.1.1 The contractor
shall act as a fiduciary for all funds acquired from TRICARE Prime
and Select enrollment fees, which are Government property. The contractor
shall develop strict funds control processes for its collection,
retention and transfer of enrollment fees to the Government. All
enrollment fees received by the contractor shall be maintained in
accordance with these procedures.
6.1.1.2 A separate non-interest bearing
account shall be established for the collection and disbursement
of enrollment fees. The contractor shall deposit enrollment fees
into the established account within one business day of receipt.
6.1.1.3 The contractor shall wire-transfer
the enrollment fees minus any refund payments twice monthly, on
the first (business day) and the 15th to a specified Government
account as directed by DHA Contract Resource Management (CRM) Office,
refer to Section G of the contract. The Government will provide
the contractor with information for this Government account. The
contractor shall notify the DHA CRM, by e-mail, within one business
day of the deposit stating the date and amount of the deposit.
6.1.1.4 The contractor shall maintain a
clear, auditable record of all enrollment fees received, the date
received and the date transferred to the Government. The contractor’s
record shall also document all refunds issued, to whom the refund
was issued, the amount of the refund, and the date reported to the
Government.
6.1.2
Annual
Payment Fee Option
An annual installment is collected
in one lump sum. For initial enrollments, the contractor shall prorate
the fee from the enrollment date to December 31. The contractor
shall accept payment of the annual enrollment fee only by debit/credit
card (e.g., Visa/MasterCard). See
paragraph 5.6 for disenrollment information
if the appropriate enrollment fee payment is not received.
6.1.3 Quarterly
Payment Fee Option
Quarterly installments are equal
to one-fourth (1/4) of the total annual fee amount. For initial
enrollments, the contractor shall prorate the quarterly fee to cover
the period until the next quarter. Quarters begin on January 1,
April 1, July 1, and October 1. The contractor shall collect quarterly
fees thereafter. The contractor shall accept payment of the quarterly
enrollment fee by debit/credit card (e.g., Visa/MasterCard) and
optionally may elect to receive quarterly payments via recurring debit/credit
card or Electronic Funds Transfer (EFT) transactions. See
paragraph 5.6 for
disenrollment information if the appropriate enrollment fee payment
is not received.
6.1.4 Monthly Payment
Fee Option
Monthly installments are equal to one-twelfth
(1/12) of the total annual fee amount rounded down if not divisible
by 12. Monthly enrollment fees must be paid-through an automated, recurring
electronic payment either in the form of an allotment from retirement
pay or through EFTs from the enrollee’s designated financial institution
(which may include a recurring credit or debit card charge). These
are the only acceptable payment methods for the monthly payment
option.
6.1.4.1 Enrollees
who elect a monthly fee payment option must pay up to three months
of fees (contractor determined), at the time the enrollment request
is submitted; contingent on the method and date the request is submitted
to allow time for an allotment, EFT or RCC to be established. The contractor
shall explain the amount required and accept payment by personal
check, cashier’s check, traveler’s check, money order, or debit/credit
card (e.g., Visa/MasterCard) for initial enrollment requests. For
continuous coverage requests, contractors shall accept payment by
allotment, EFT or RCC.
6.1.4.2 The contractor shall
obtain and verify the information needed to initiate monthly allotments
and EFTs.
6.1.4.3 The
contractor shall direct
bill the beneficiary only when a problem occurs.
6.1.4.4 When an administrative issue arises
that stops or prevents an automated monthly payment from being received
by the contractor (i.e., incorrect
or transposed number provided by the beneficiary, credit card expired,
bank account closed), the contractor
shall grant the enrollee 30 days from the paid-through date to provide
information for a new automated monthly payment method or the option
to pay quarterly or annually. The contractor may
accept payment by check during this 30 day period in order to preserve
the beneficiary’s TRICARE Prime or Select enrollment status.
6.1.4.5 Allotments from retired pay will be
coordinated by the contractor with the DFAS, U.S. Coast Guard (USCG),
or Public Health Service (PHS), as appropriate (see the TSM,
Chapter 1, Section 1.1, paragraph 7.10 for
Payroll Allotment Interface Requirements).
6.1.4.6 The contractor shall
also research and resolve all requests that have been rejected or
not processed by DFAS, USCG, or PHS. If the contractor’s research
results in the positive application of the allotment action, the
contractor shall resubmit the allotment request.
6.1.4.7 Within
five business days, the contractor shall notify the beneficiary
of rejected allotment requests and issue an invoice to the beneficiary
for any outstanding enrollment fees due. The contractor shall
respond to all beneficiary inquiries regarding allotments.
6.2 Member Category
The sponsor’s member category on
the effective date of the initial enrollment, as displayed in the
Government furnished web-based enrollment system/application, shall
determine the requirement for an enrollment fee.
6.3 Unremarried
Former Spouses (URFSs) and Children Residing with Them
6.3.1 URFSs
became sponsors in their own right as of October 1, 2003. As such,
they are enrolled under their own SSNs and pay an individual enrollment
fee. URFS may not “sponsor” other family members and their fees
may not be factored into any family fees associated with the former
spouse/sponsor.
6.3.2 Children residing with URFS, whose
eligibility for benefits is based on the ex-spouse/former sponsor,
are identified and enrolled under the ex- spouse/former sponsor’s
SSN on DEERS, and fees for these children shall be combined with
other fees paid under the ex-spouse/former sponsor.
Example: The contractor
shall collect the individual enrollment fee for an URFS’s enrollment under
the URFS’s own SSN. The contractor shall also collect a family enrollment
fee for any two or more eligible family members enrolled under the
SSN of the ex-spouse/former sponsor. These enrollees might include
the sponsor, any current spouse, and all eligible children, including
those living with the URFS.
6.4 TRICARE Prime
Fee Waiver
6.4.1 Each TRICARE Prime enrolled beneficiary,
who is required to pay enrollment fees, regardless of age, who maintains
enrollment in Medicare Part B, is entitled to a waiver of an amount
equivalent to the individual TRICARE Prime enrollment fee. Hence,
individual enrollments for such beneficiaries will have the enrollment
fee waived. A family enrollment in TRICARE Prime, where one family
member maintains enrollment in Medicare Part B, shall have one-half
of the family enrollment fee waived; the remaining half must be
paid. For a family enrollment where two or more family members maintain enrollment
in Medicare Part B, the family enrollment fee is waived regardless
of the number of family members who are enrolled in addition to
those entitled to Medicare Part B.
6.4.2 A
family enrollment in TRICARE Plus with Active Duty Select or TRICARE
Plus with Retired Select or TRICARE Prime enrollment, is entitled
to a waiver of an amount equivalent to the individual TRICARE Prime
or TRICARE Select enrollment fee as appropriate (not to exceed two
individual fee payments).
6.5 TRICARE Select Enrollment Fees
Families enrolled in TRICARE Select
plans requiring enrollment fees (any combination of TRICARE Select
or TRICARE Plus with Select plans) do not pay more than the TRICARE
Select family enrollment fee. A fee waiver code will be applied
to any policy that does not require fees to be paid.
6.6 Survivors
of Active Duty Deceased Sponsors and Medically Retired Uniformed
Services Members and their Dependents
6.6.1 Beneficiaries Whose Sponsor Has An Initial
Service Date Before January 1, 2018
Effective
Fiscal Year (FY) 2012, TRICARE Prime beneficiaries who are (1) survivors
of active duty deceased sponsors, or (2) medically retired Uniformed
Services members and their dependents, shall have their Prime enrollment
fees frozen at the rate in effect when classified and enrolled in
a fee paying Prime plan. (This does not include TRICARE Young Adult
(TYA) plans). Beneficiaries in these two categories who were enrolled
in FY 2011 will continue paying the FY 2011 rate. The beneficiaries
who become eligible in either category and enrolled during FY 2012,
or in any future fiscal year, shall have their fee frozen at the
rate in effect at the time of enrollment in Prime. The fees for
these beneficiaries shall remain frozen as long as at least one
family member remains enrolled in Prime. The fee for the dependent(s)
of a medically retired Uniformed Services member will not change
if the dependent(s) is later re-classified a survivor. These two
categories of beneficiaries who choose to enroll in TRICARE Select
do not pay enrollment fees.
6.6.2 Beneficiaries
Whose Sponsor Has An Initial Service Date On Or After January 1,
2018
There is no TRICARE Prime enrollment fee
freeze for these retirees and family members; they pay the established
annual TRICARE Prime enrollment fee amount. Medically retired members
and their family members who choose to enroll in TRICARE Select
pay the established annual TRICARE Select enrollment fee.
6.7 Mid-Month
Enrollees
6.7.1 The
contractor shall collect any applicable enrollment fee from mid-month
enrollees at the time of enrollment. However, there will be no enrollment
fee collected for the days between the effective enrollment date
and the determined enrollment date.
6.7.2 The
determined enrollment date shall be established using the “20th
of the month rule,” as it is for initial enrollments.
Example: If the
retirement date is May 27, the effective enrollment date will be
May 27 and the determined enrollment date will be July 1. Fees will
be charged for the period from July 1 forward; no fees will be assessed
for the period from May 27 through June 30. DEERS will calculate
the paid-through dates based on DEERS data and the enrollment fee amount
collected and entered into DEERS by the contractor.
6.7.3 Effective January 1, 2018,
paragraphs 6.7.1 through
6.7.2 no
longer apply. Fee amounts shall be pro-rated based on 1/30th of
the TRICARE Prime or TRICARE Select fee, as applicable, calculated from
the date of enrollment (initial eligibility or QLE date) to the
end of the month.
6.8
Overpayment
Of Enrollment Fees
The contractor shall
update DEERS with the enrollment fee amount collected and DEERS
will calculate the paid-through date and notify the contractor.
DEERS will only extend the paid-through date to cover the current
enrollment year, plus two future fiscal years (prior to January
1, 2018) or calendar years (starting January 1, 2018). DEERS will
store amounts that cannot cover one month’s fees or amounts that
extend the paid-through date beyond two years in the future as a
credit.
6.8.1 Funds applied that would move the
paid-through date beyond the policy end date are stored as a credit.
(The exception is when Prime policies, prior to January 1, 2018,
end mid-month; DEERS will set a paid-through date to the end of
that month.) Also, if there is a 100% fee waiver with an end date
that exceeds more than two fiscal years beyond the current enrollment
year, the paid period can extend beyond the two fiscal years and
any fee amounts sent to DEERS will be applied as a credit. The contractor
shall refund any credit of $1 or more on a current enrollment that
extends beyond two fiscal years (prior to January 1, 2018) or two
future calendar years (starting January 1, 2018). The contractor
shall update DEERS with any fee amount refunded within 30 calendar
days. The contractor shall include an explanation for the premium
refund. For the 2018 and 2019 enrollment fees credited to the catastrophic
cap, the contractor shall notify the beneficiaries by letter of
the credit, how the credit was applied, and how a refund can be
requested. See also
paragraph 8.0.
6.8.2 The following reports will be provided
to the contractor by DEERS on a monthly basis to assist with identifying
and correcting enrollment fee discrepancies. The contractor responsible
for a beneficiary’s current enrollment shall resolve any over/under
payments. For split enrollments, the reports will use the billing
hierarchy to determine the responsible contractor.
• Current policies that are two months past
due (paid period end date more than two months in the past).
• Any policies where the paid period end
date exceeds the policy end date.
• Policies where the paid period end date
meets the policy end date but a credit exists.
• Terminated policies where the paid period
end date does not meet the policy end date.
6.8.3 The contractor shall
analyze and correct all report accounts within 30 days of the report’s availability. The
contractor shall correct
any data inaccuracies in the enrollment fee reporting system to include
the refunding of enrollment fees in excess of what is due, if necessary. The
contractor shall update
DEERS with any enrollment fee amounts refunded within 30 calendar
days and notify DHA as specified above.
7.0
Enrollment
Of Family Members Of E-1 Through E-4
7.1 When
family members of E-1 through E-4 reside within a 30 minute drive
time of a Market/MTF offering
TRICARE Prime, the family members will be encouraged to enroll in
TRICARE Prime by the enrolling entity (Government or contractor).
Upon enrollment, they will choose or be assigned a PCM located in
the Market/MTF.
The choice of whether to enroll or to decline enrollment in TRICARE
Prime is completely voluntary. Family members of E-1 through E-4
who decline enrollment or who enroll in Prime and subsequently disenroll
may not re-enroll until the next open period or they experience
a QLE.
7.2 Enrollment processing and allowance
of civilian PCM assignments shall be in accordance with the Memorandum
of Understanding between the contractor and the Market/MTF.
7.3 The primary means of identification
and subsequent referral for enrollment shall occur during in-processing
to the installation. Non-enrolled E-4 and below families may also
be referred to the contractor’s call center, by Commanders, First
Sergeants/Sergeants Major, Supervisors, Family Support Centers,
and others. Beneficiaries at overseas locations may also be referred
to their local TRICARE Service Center (TSC).
7.4 The contractor
call center representatives and those giving beneficiary education
briefings shall provide enrollment information and support the family
member in managing their enrollment options. The education of such
potential enrollees shall specifically address the advantages of
TRICARE Prime enrollment, including guaranteed access, the support
of a PCM, etc. The contractor shall reinforce that enrollment is
at no cost for family members of E-1 through E-4 and will give them
the opportunity to select or be assigned a Market/MTF PCM,
to select a civilian PCM if permitted by applicable MOU or with
USFHP, if available, or to decline enrollment in TRICARE Prime.
7.5 The contractor shall discuss the
potential effective date of the enrollment.
7.6 Enrollment
may be terminated at any time upon request of the enrollee, sponsor
or other party as appropriate under existing enrollment/disenrollment
procedures. Prior to January 1, 2018, beneficiaries may re-enroll
at any time without restriction or penalty. See
paragraph 5.2 for enrollment rules
as of January 1, 2018.
7.7 The contractor shall
not screen TRICARE claims to determine whether it may be for treatment
of a non-enrolled ADFM of E-1 through E-4 living in a PSA. Rather,
they are to support the prompt and informed enrollment of such individuals
when they have been identified by DoD in the course of such a person’s
interaction with the Military Healthcare System (MHS) or
personnel community and have been referred to the contractor for
enrollment.
7.8 Effective January 1, 2018, DMDC will
automate the enrollment of newly eligible ADFMs into TRICARE Prime
or TRICARE Select, if overseas into TOP Select. See
paragraph 2.3.
8.0
TRICARE
Eligibility Changes/Refunds Of Fees
See
paragraph 9.0 for
additional requirement starting January 1, 2018.
8.2 The contractor shall allow a TRICARE-eligible
beneficiary who has less than 12 months of eligibility remaining
to enroll in TRICARE Prime or TRICARE Select until such time as
the enrollee loses his/her TRICARE eligibility. The beneficiary
shall have the choice of paying the entire enrollment fee or paying
the fees on a more frequent basis (e.g., monthly or quarterly).
If the enrollee chooses to pay by installments, the contractor shall
collect only those installments required to cover the period of eligibility.
DEERS will calculate the paid-through date based on the enrollment
fee amount collected and entered into DEERS by the contractor, which
in this circumstance, should cover the period of the beneficiary’s
eligibility. The contractor shall refund any overpayment of $1 or
more that DEERS does not use to extend the paid-through date to
the policy end date (or the last day of the month in which a TRICARE
Prime or TRICARE Select policy ends). The contractor shall include
an explanation to the beneficiary for the fee refund. The contractor
shall update DEERS with any fee amount refunded within 30 calendar
days.
8.3 The contractor
shall
refund the unused portion of TRICARE Prime or TRICARE Select enrollment fees
to retired enrollees whose sponsor is recalled to active duty. The
contractor shall include an explanation to the beneficiary for the
fee refund.
The contractor
shall
calculate the refund using monthly prorating, and shall report such
refunds to DEERS within 30 calendar days. Upon activation of the
member, the family members will be automatically enrolled as ADFMs
(see TPM,
Chapter 10, Section 2.1). If the reactivated
member’s family chooses continued enrollment in TRICARE Prime or TRICARE
Select, the family shall begin a new enrollment period and shall
be offered the opportunity to keep their PCM (TRICARE Prime only),
if possible.
8.4 Any catastrophic cap accumulations
shall be applied to the new enrollment period.
8.5 The contractor shall
refund enrollment fees for deceased enrollees upon receiving a written request,
along with a copy of the death certificate, from the remaining enrollee
or the executor of the decedent’s estate. The contractor shall include
an explanation for the fee refund to the beneficiary. Refunds shall
be prorated on a monthly basis and apply both to individual plans
where the sole enrollee is deceased and to the conversion of a family
enrollment to an individual plan upon the death of one or more family
members. For individual enrollments, the contractor shall refund
remaining enrollment fees to the executor of the estate. For family
enrollments that convert to individual plans, the contractor shall
either credit the excess fees to the individual plan or refund them
either to the remaining enrollee or to the executor of the decedent’s
estate, as appropriate. Enrollment fees for family enrollments of
three or more members are not affected by the death of only one
enrollee and no refunds shall be issued. The contractor shall
update DEERS with any amount refunded within 30 calendar days.
8.6 The contractor
shall
refund the unused portion of TRICARE Prime or TRICARE Select enrollment fees
to enrollees who become eligible for Medicare Part A based upon
disability, End Stage Renal Disease (ESRD) or upon attaining age
65, provided the beneficiary has Medicare Part B coverage.
8.6.1 The contractor shall issue refunds
to these beneficiaries upon receiving (1) a written request from
the beneficiary (that includes a copy of their Medicare card) and
either confirming their Part B enrollment in DEERS or in a previous
Government furnished policy notification, or (2) upon receipt of
an unsolicited Government furnished policy notification noting a
beneficiary’s fee waiver update based on the Part B enrollment.
DEERS generates a Government furnished policy notification when
the Centers for Medicare and Medicaid Services (CMS) sends DEERS
data indicating a Part B enrollment or disenrollment. Refunds are
required for all payments that extend beyond the date the enrollee
has Medicare Part B coverage, as calculated by DEERS. The contractor
shall update DEERS with any amount refunded within 30 calendar days.
The contractor shall include an explanation to the beneficiary for
the fee refund. If the fee waiver is a 100% waiver of the TRICARE
Prime enrollment fee, the contractor shall send a refund to the
beneficiary. If the fee waiver is a 50% waiver of the TRICARE Prime
enrollment fee, DEERS will automatically calculate the overpayment
and extend the paid-through date for the policy. A refund may not
be required unless a credit remains when the policy is paid in full.
8.6.2 For TRICARE Prime enrollees who
become Medicare eligible and who maintain Medicare Part B coverage
and TRICARE Select enrollees who become Medicare eligible, refunds
are required for overpayments occurring on and after the Start
of Health Care Delivery (SHCD).
The contractor shall utilize the Government furnished policy notifications
received indicating a fee waiver based on Medicare to substantiate
any claim of overpayment. The contractor shall update DEERS with
any amount refunded within 30 calendar days and include an explanation
to the beneficiary for the fee refund.
8.6.3 Medicare eligible ADFMs age 65 and
over are not required to have Medicare Part B to remain enrolled
in TRICARE Prime or TRICARE Select. To maintain TRICARE coverage
upon the sponsor’s retirement, they must enroll in Medicare Part
B during Medicare’s Special Enrollment Period prior to their sponsor’s
retirement date. (The Special Enrollment Period is available anytime
the sponsor is on active duty or within the first eight months of
the sponsor’s retirement. If they enroll in Part B after their sponsor’s
retirement date, they will have a break in TRICARE coverage.)
8.6.4 Medicare
eligibles age 65 and over who are not entitled to premium-free Medicare
Part A are not required to have Medicare Part B to remain enrolled
in TRICARE Prime and TRICARE Select. Because they may become eligible
for premium-free Medicare Part A at a later date, under their or
their spouse’s SSN, they should enroll in Medicare Part B when first
eligible at age 65 to avoid the Medicare surcharge for late enrollment.
8.7 Refunds shall be drawn from the
contractor’s enrollment fee account and reported to the Government
in accordance with the requirements specified above.
8.8 The contractor shall include full
and complete information about the effects of changes in eligibility
and rank in beneficiary education materials and briefings.
9.0 TRICARE Eligibility Changes/Refund of
Fees
9.1 Criteria and documentation required
for the specific TRICARE eligibility changes as listed in
paragraph 8.0 still
apply; however, whenever any overpaid fee situation is identified,
the contractor will:
9.1.1 Apply overpaid fees to another enrolled
family member under the same Uniformed Service sponsor if within
the maximum two calendar years. Overpaid fees for URFSs can only
be applied to their enrollment records.
9.1.2 Automatically
refund prorated enrollment fees in excess of two calendar years.
9.1.3 Upon
request from sponsor or responsible individual, apply overpaid fees
as directed up to the maximum two calendar years and/or refund overpaid
fees as requested.
9.1.4 Refunds must be $1 or more.
9.1.5 Refunds will be issued within 30
days to a Uniformed Service sponsor, eligible spouse, and then oldest
child in that order. Refunds for URFS enrollment fees shall only
be refunded to the URFS.
9.1.6 Update DEERS within 30 calendar days with
any refund amount.
10.0
Wounded,
Ill, And Injured (WII) Enrollment Classification
The WII
Program provides a continuum of integrated care from the point of
injury to the return to duty or transition to active citizenship
for the Active Component (AC) or the Reserve Component (RC) Service
members who have been activated for more than 30 days. These AC/RC
Service members, referred to as Service members, have been injured
or became ill while on active duty and will remain in an active
duty status while receiving medical care or undergoing physical
disability processing. WII Programs vary in name according to Service.
The Service shall determine member eligibility for enrollment into
a WII Program, as well as whether or not to utilize these enrollments.
To
better manage this population, a secondary enrollment classification
of HCDP Plan Coverage Codes, WII 415 and WII 416 were developed.
The primary rules apply to the WII HCDP codes:
• Service members must be enrolled to TRICARE
Prime prior to, or at the same time, as being enrolled into a WII
415 or WII 416 Program.
• A member cannot be enrolled in WII 415
and WII 416 Programs at the same time.
• WII 415 and WII 416 enrollments will
terminate at the end of the member’s active duty eligibility, when
members transfer enrollment to another Market/MTF,
change of a plan code, or at the direction of the Service-specific
WII entity.
• Any claims
processed for WII 415/416 enrollees shall follow the rules associated
with the primary HCDP Plan Coverage Code, such as TRICARE Prime,
TPR, TOP Prime, or TOP Prime Remote. All claims will process and
pay under Supplemental Health Care Program (SHCP) rules. DEERS will
not produce specific enrollment cards or letters for WII 415/416 enrollment.
WII 415/416 TRICARE Encounter Data
(TED) record(s) shall
be coded with the WII 415/416 HCDP Plan Coverage Code; however,
the Enrollment/Health Plan Code data element on the TED record shall reflect
the appropriate value for the primary HCDP Plan Coverage Code. For
example, a TED record for a WII 416 enrollee with primary enrollment
to TPR would reflect the HCDP Plan Coverage Code of “416” but the
Enrollment/Health Plan Code would be coded “W TPR Active
Duty Service Member”.
10.1 WII 415 - Wounded, Ill, And Injured
(e.g., Warrior Transition/MEDHOLD Unit (WTU))
10.1.1 Service defined eligible Service
members assigned to a WII 415 Program such as a MEDHOLD or WTU shall
be enrolled to TRICARE Prime or TOP Prime prior to, or at the same
time, as being enrolled into the WII 415. Members cannot be enrolled
to the WII 415 without a concurrent TRICARE Prime or TOP Prime enrollment.
Service appointed WII case managers will coordinate with the Market/MTF to
facilitate TRICARE Prime PCM assignments for WII 415 members. The
contractor shall assign a PCM in accordance with the Market/MTF MOU
and in coordination with the WII case manager. WII 415 enrollment
will not run in conjunction with TAMP and members enrolled in TPR,
or TOP Prime Remote are not eligible to enroll in the WII 415.
10.1.2 The Service-specific WII entity
will stamp the front page of the DD Form 2876, enrollment application
form, with WII 415. The enrollment form will then be sent to the
appropriate contractor who shall perform the enrollment in the Government
furnished web-based enrollment system/application and include the
following information:
• WII 415 HCDP
Plan Coverage Code
• WII 415 Enrollment
Start Date (The contractor may
change the Government furnished web-based enrollment system/application
defaulted start date, which may or may not coincide with the Prime
Enrollment Start Date. The start date may be changed up to 289 days
in the past or 90 days into the future.)
10.1.3 WII 415 enrollments shall be in
conjunction with a Market/MTF enrollment
only, not to civilian network PCMs under TPR enrollment rules. DEERS
shall end WII 415 enrollments upon loss of member’s active duty
eligibility. WII 415 program enrollments shall not be portable across
programs or regions. The TOP contractor shall enter WII 415 enrollments
through the Government furnished web-based enrollment system/application
for outside the 50 United States (U.S.) and the District of Columbia.
10.1.4 The contractor shall accomplish
the following functions based on receipt of notification from the
Service-specific WII Program entities:
• Enrollment.
• Disenrollment.
• Cancel enrollment.
• Cancel disenrollment.
• Address update.
• The
contractor can request
unsolicited Government furnished policy notifications resend.
• Modify begin
date.
• Modify end date.
10.2 WII 416 -
Wounded, Ill, And Injured - Community Care Units (CCUs)
10.2.1 Service defined eligible Service
members may be assigned to a WII 416 Program such as the Army’s
CCU and receive required medical care near the member’s home. The
Service member shall be enrolled to TRICARE Prime, TPR, TOP Prime,
or TOP Prime Remote prior to or at the same time as being enrolled
into WII 416. Members cannot be enrolled to the WII 416 program
without a concurrent Prime, TPR, TOP Prime, or TOP Prime Remote
enrollment. Service appointed case managers will coordinate with
the contractor or Market/MTF to
facilitate TRICARE Prime or TPR PCM assignments for eligible beneficiaries.
The contractor shall assign a PCM based on the Market/MTF MOU
and in coordination with the WII entity (e.g., CCU). WII 416 enrollments
will not run in conjunction with TAMP.
10.2.2 The Service-specific WII Program
will stamp the front page of the DD Form 2876, enrollment application
form, with WII 416 for all new enrollments. The begin date will
be the date the contractor receives the signed enrollment form.
A signed enrollment application includes those with an original
signature, or an electronic signature offered by and collected by
the contractor. The enrollment form will then be sent to the appropriate
contractor who shall perform the enrollment in the Government furnished
web-based enrollment system/application and include the following information:
• WII 416 HCDP Plan Coverage Code.
• WII 416 Enrollment Start Date. (Date received
by the contractor or the date indicated by the Service-specific
WII Program which may be up to 289 days in the past, or 90 days
in the future.)
10.2.3 WII 416 enrollments must be in conjunction
with a Market/MTF,
TPR, TOP Prime, or TOP Prime Remote enrollment. DEERS will end WII
416 enrollments upon loss of member’s active duty eligibility. WII
416 program enrollments are not portable across programs or regions.
10.2.4 The contractor shall accomplish
the following functions based on receipt of notification from Service-specific
WII program entities:
• Enrollment.
• Disenrollment.
• Cancel enrollment.
• Cancel disenrollment.
• Address update.
• The
contractor can request
Government furnished policy notification resend.
• Modify begin
date.
• Modify end date.
11.0 TRICARE POLICY For Access To Care (ATC)
And Prime Service Area (PSA) Standards
11.1 Non-active
duty beneficiaries in the Continental United States (CONUS) and
Hawaii who reside more than 30 minutes travel time from their desired
PCM but less than 100 miles must waive primary and specialty drive-time
ATC standards if they wish to enroll in TRICARE Prime. (Due to the
unique health care delivery challenges in Alaska, the requirement
to request a waiver for the drive-time access standard does not
apply to beneficiaries in Alaska.) Before effecting an enrollment
or portability transfer request, the contractor shall
ensure that a beneficiary has waived travel time ATC standards either
by checking the Drive Time Waiver box in Section V of the DD Form
2876 enrollment application (this includes an electronic signature
offered by and collected by the contractor), by providing verbal consent
via telephone communication (which shall be documented in the contractor
call notes), or by requesting enrollment through the Government
furnished web-based self-service enrollment system/application (for
both civilian and Market/MTF PCMs).
An approved waiver for a beneficiary residing less than 100 miles
but more than 30 minutes from their PCM will remain in effect until
the beneficiary changes residence.
11.2 The contractor shall estimate
the travel time or distance between a beneficiary’s residence to
a PCM (either a civilian PCM or a Market/MTF)
using at least one web-based mapping program. The choice of the
mapping program(s) is at the discretion of the contractor, but the
contractor must use a consistent process to determine the driving
distance for each enrollee applicant who may reside more than 30
minutes travel time from their PCM. The time or distance shall be
computed between the enrollee’s residence and the physical location
of the PCM (including Markets/MTFs).
It is not acceptable to use a geographic substitute, such as a geographic
centroid.
11.3 The contractor (in conjunction with
Markets/MTFs
for
Market/MTF
enrollees)
shall provide beneficiary drive-time waiver education and ensure
that beneficiaries who choose to waive these standards have a complete
understanding of the rules associated with their enrollment and
the travel time standards they are forfeiting. This includes educating
beneficiaries, who waive their ATC travel standards, of the following:
• They should expect to travel more than
30 minutes for access to primary care (including urgent care) and
possibly more than one hour for access to specialty care services.
• They will be held responsible for
POS charges for care they seek that has not been referred by their
PCM (or for Market/MTF enrollees,
by another Market/MTF provider).
• They should consider whether any delay
in accessing their enrollment site might aggravate their health
status or delay receiving timely medical treatment.
11.4
Cross-Region
TRICARE Prime Enrollment
Beneficiaries
shall enroll to the Region where the desired PCM is located; however,
all TRICARE Prime enrollment policies still apply, i.e., PCM selection
and utilization, referrals, drive times and distance standards to
the desired PCM. An access to care drive-time waiver is required
(see
paragraph 11.1). All claims are processed
by the Region of enrollment. Cross-region enrollment must be requested by
either submitting an enrollment form (DD Form 2876) or by calling
the regional contractor servicing the desired PCM. The enrolling
contractor shall ensure a beneficiary is not approved for cross-region enrollment
if they live within 30-minutes of a
Market/MTF
,
unless the
Market’s/MTF’s
servicing contractor
approves the enrollment. The beneficiary shall be enrolled to the
Market/MTF
if
a PCM is available.
11.5 Discrepant Addresses
11.5.1 If
at any point during the enrollment period the contractor determines
or is advised that a beneficiary is no longer eligible for continued
TRICARE Prime enrollment due to their address, the contractor shall
inform the beneficiary of the discrepant address situation. For
example, their residential address is 100 miles or more from the
PCM or Market/MTF (with
no 100 mile waiver) to which they are enrolled or their residential
address is 100 miles or more from their assigned network PCM. This
notification (letter, telephone call, or e-mail) shall occur when
the discrepant information is first known by the contractor. If
the beneficiary confirms the DEERS-recorded address is incorrect,
and the beneficiary updates DEERS with correct information (contractor
to assist as appropriate), the beneficiary will remain enrolled
in TRICARE Prime if all enrollment requirements are met.
11.5.2 For the 50 United
States and the District of Columbia Only: Once a month, when the contractor
confirms the beneficiary is ineligible for enrollment due to their
address, the contractor shall notify the beneficiary
that they
will
be charged POS for all care received without a referral from their PCM.
The
contractor shall provide the beneficiary information about TRICARE
Standard and Extra, prior to January 1, 2018
, or
TRICARE Select
, starting January 1,
2018
, and continue to process all claims until the
enrollment is changed. If the beneficiary chooses
to not enroll in TRICARE Select
or
USFHP
, where available,
within
90 days of notification, the contractor shall
transfer
the beneficiary enrollment to TRICARE Select.
Note: The
contractor, upon beneficiary request, will process retroactive enrollment
requests from a beneficiary whose TRICARE Prime coverage was terminated
on or after January 1, 2019 due to a discrepant address that resulted
in no TRICARE private sector coverage. Affected beneficiaries may retroactively
enroll in either TRICARE Prime (if qualified) or TRICARE Select.
The contractor must collect all applicable retroactive TRICARE enrollment
fees before processing an enrollment request. Alternatively, they
may elect to restart their TRICARE coverage following QLE or annual
open enrollment season rules and costs.
11.6
MARKET/MTF
TRICARE
Prime Enrollees
11.6.1 Non-active
duty beneficiaries must reside within 30 minutes travel time from
a
Market/MTF
to
which they desire to enroll. If a beneficiary desiring enrollment
resides more than 30 minutes (but less than 100 miles) from the
Market/MTF
,
they may be enrolled so long as they waive primary and specialty
ATC standards and the
Market Director/MTF
Director,
or designee, approves the enrollment. (If the MOU includes zip codes
or drive-time distances for which the
Market/MTF
is
willing to accept enrollments that are beyond a 30 minute drive,
this constitutes approval. See
32 CFR 199.17 for information
on access standards. If not addressed in the MOU, the contractor
shall submit each request to the
Market Director/MTF
Director,
or designee, in a method that is outlined in the MOU.) The
GDA may
approve waiver requests from beneficiaries who desire to enroll
to a
Market/MTF
and
who reside 100 miles or more from the
Market/MTF
.
In these cases, the
Market Director/MTF
Director must
also
agree
to
the enrollment and have sufficient capacity and capability.
11.6.2 If the contractor determines that
the beneficiary resides 100 miles or more from the Market/MTF to
which they are enrolled, and there is no 100 mile waiver on file,
the contractor shall inform the beneficiary that they are no longer
eligible for Prime enrollment to the Market/MTF.
Any notice shall include information on any alternative options
for enrollment. The notice shall also advise the beneficiary of
the option to use TRICARE Standard/Extra (before January 1, 2018),
enroll in TRICARE Select (on or after January 1, 2018) as a QLE,
or enroll with a USFHP where available, within 90
calendar days of notification, the contractor shall transfer the
beneficiary enrollment to TRICARE Select.
11.6.3 The contractor
shall process all requests for enrollment to a
Market/MTF
in
accordance with the MOU between the
Market/MTF
and
the contractor. See
paragraph 11.4 regarding cross-region enrollments.
Enrollment guidelines in MOUs may include:
11.6.3.1 Zip
codes and/or distances for which the
Market Director/MTF
Director is
mandating enrollment to the
Market/MTF
.
These mandatory
Market/MTF
enrollment
areas must be within access standards (i.e., a 30 minute drive-time
of the
Market/MTF
)
and may apply to all eligible beneficiaries or may be based on beneficiary
category priorities for
Market/MTF
access.
Note: Non-active
duty TRICARE Prime applicants who reside more than 30 minutes travel
time from a Market/MTF must
be afforded the opportunity to enroll with a civilian PCM.
11.6.3.2 There may
be zip codes and/or distances for which the Market
Director/MTF Director is willing
to accept enrollment. This can include both areas within a 30 minute
or less drive-time and over a 30 minute drive but within 100 miles.
Any enrollment for a beneficiary with a drive of more than 30 minutes
requires a signed waiver of access standards. If an enrollee applicant
resides within a zip code previously determined to lie entirely
within 30 minutes travel time from the Market/MTF,
the contractor need not compute the travel time for that applicant.
11.6.3.3 In determining
whether or not the Market Director/MTF Director will
consider a request for TRICARE Prime enrollment beyond 100 miles,
the Market Director/MTF Director may
use zip codes to designate those areas where he/she will consider
requests or will not consider requests.
11.6.4 The contractor shall notify the
Market
Director/MTF
Director (or
designee) when a beneficiary residing 100 miles or more from the
Market/MTF,
but in the same Region, requests a new enrollment or portability
transfer to the
Market/MTF
.
Such notification is not necessary if the MOU has already established
that the
Market Director/MTF
Director will
not accept enrollment of beneficiaries who reside 100 miles or more
from the
Market/MTF
.
The contractor shall make this notification by any mutually agreeable
method specified in the MOU. The contractor shall not make the
Market/MTF
enrollment
effective unless notified by the
Market/MTF
to
do so.
11.6.4.1 The Market
Director/MTF Director will
notify the Director, GDA of their desire
to enroll a beneficiary who resides 100 miles or greater from the Market/MTF and
request approval for the TRICARE Prime enrollment. The Director, GDA will
make a determination on whether or not to approve or deny the request
and notify the Market Director/MTF Director of
his decision by a mutually agreeable method. The Market
Director/MTF Director is
responsible for notifying the contractor of all approved enrollment
requests for beneficiaries who reside 100 miles or greater from
the Market/MTF. The
contractor shall notify the beneficiary of the final decision.
11.6.4.2 Approved
waivers for beneficiaries residing 100 miles or more from the Market/MTF shall remain
in effect until the beneficiary changes residence or unless the Market
Director/MTF Director determines
that they will no longer allow these enrollments. Even if a beneficiary
has previously waived travel time standards, any Market
Director/MTF Director may
revise the MOU (following the MOU revision process) to state that
enrollment of some or all current enrollees who reside 100 or more
miles from the Market/MTF are
not to be renewed at the end of the enrollment period. The contractor
shall inform such beneficiaries no later than two months prior to
expiration of the current enrollment period that they are no longer
qualified for renewal of enrollment to the Market/MTF.
Prior to notification, the contractor shall obtain the rationale
for the change from the Market/MTF to
include in the notice to the beneficiary. The proposed notice shall
be reviewed and concurred on by the Director, GDA prior
to being sent to the impacted beneficiaries. (The GDA will
coordinate notices with DHA Communications prior to approval.)
11.6.5 At any time during the enrollment
period, if the contractor determines there is no signed travel time
waiver on file for a current
Market/MTF
enrollee
who resides more than 30 minutes from the MT
F,
the contractor shall, require the beneficiary to waive the primary
and specialty care travel standards to continue their TRICARE Prime
enrolled status. (This includes monitoring address changes received
by the contractor from all sources.) The contractor shall notify
the beneficiary of this waiver requirement within 30 days of determining
a need for waiver.
If the beneficiary chooses to not
enroll in TRICARE Select, or USFHP, where available, within 90 calendar
days. of notification, the contractor shall transfer the beneficiary
enrollment to TRICARE Select. The language for all
beneficiary notices shall be reviewed and concurred on by the
GDA prior
to being sent to beneficiaries. (The
GDA will
coordinate notices with DHA Communications prior to approval.)
• Any notice to a beneficiary that
is requesting they sign a waiver of access standards, denying their
enrollment, or advising them they are not eligible for re-enrollment
to a Market/MTF,
shall include information on any available TRICARE plan options.
11.6.6 For each approved enrollment to
a Market/MTF where
the beneficiary has waived access standards, the contractor shall
retain the enrollment request in a searchable electronic file until
24 months after the beneficiary is no longer enrolled to the Market/MTF.
The contractor shall provide the retained file to a successor contractor
at the end of the final option period.
11.6.7 When an enrollment request requires Market
Director/MTF Director or
Director, GDA approval, any contractual
requirements relating to processing timeliness for enrollment requests
will begin when the contractor has obtained direction from the Market
Director/MTF Director or
Director, GDA regarding waiver approval
or disapproval.
11.7 Civilian
TRICARE Prime PCMs
11.7.1 Within
a PSA, the contractors’ civilian network shall have the capability
and capacity to allow beneficiaries who reside in the PSA to enroll
to a PCM within access standards. If a beneficiary who resides in
the PSA requests enrollment to a specific PCM who is located more
than a 30 minute drive from the beneficiary’s residence, the contractor
may allow the enrollment if beneficiary waives travel time access
standards. (Also, see
Chapter 5, Section 1.)
11.7.2 Outside a PSA, for new enrollments
(including portability transfers), the contractor is not required
to establish a network with the capability and capacity to grant
TRICARE Prime enrollment to beneficiaries who reside outside a PSA.
Requests for new enrollments to the civilian network from beneficiaries
residing outside a PSA will be granted provided there is sufficient
unused network capacity and capability to accommodate the enrollment
and that the PSA civilian network PCM to be assigned is located
less than 100 miles from the beneficiary’s residence. Beneficiaries
who reside outside the PSA and enroll in TRICARE Prime must waive
their primary and specialty care travel time access standards.
11.7.2.1 ADFMs (Including ADFM TYA Prime Enrollees)
Residing Outside A PSA
ADFMs (including ADFM TYA Prime
enrollees) enrolled in TRICARE Prime and who reside outside of a
T-3 PSA on September 30, 2013, will be 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 must continue
to have a PCM available for these beneficiaries and ensure all claims
and benefits are administered as TRICARE Prime. ADFMs shall remain
enrolled in TPRADFM, as appropriate. The contractor will
manage the grandfathered ADFMs as stated in this chapter.
11.7.2.2 Terms Of Grandfathered Prime - 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 (e.g., marriage,
birth, adoption, divorce). Dependents
may live in a separate residence outside a T-3 PSA and still be
grandfathered.
11.7.2.3 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.
11.7.3 Beneficiaries who reside outside
the PSA and are 100 miles or greater from an available civilian
network PCM in the PSA shall not be allowed to enroll in TRICARE
Prime.
12.0 Reports
The contractor
shall provide monthly Service member enrollment and beneficiary
services reports according to the Contract Data Requirements List
(CDRL).