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TRICARE Operations Manual 6010.62-M, April 2021
Enrollment
Chapter 6
Section 1
TRICARE Enrollment Processing
Revision:  
For purposes of this Chapter, the word “contractor” refers to the Managed Care Support Contractors (MCSCs), Uniformed Services Family Health Plan (USFHP)/Designated Provider (DP), and TRICARE Overseas Program (TOP) contractors unless otherwise noted.
1.0  ENROLLMENT PROCESSING
1.1  The contractor shall process enrollments, disenrollments, or Primary Care Manager (PCM) change requests for beneficiaries by mail using DD Form 2876 (for TRICARE Prime) or DD Form 3043 (for TRICARE Select), or by fax, telephone, or Beneficiary Web Enrollment (BWE).
1.2  The contractor shall ensure the aforementioned form(s) is readily available to potential enrollees.
1.3  The TOP contractor shall also collect applications and requests as defined above at TRICARE Service Centers (TSCs).
1.4  The contractor shall process enrollment requests within the following standards:
1.4.1  The contractor shall ensure that only eligible beneficiaries are enrolled as shown in Defense Enrollment and Eligibility Reporting System (DEERS).
1.4.2  The contractor shall update the residential, mailing, and email addresses and any other fields that can be updated in DEERS.
1.4.3  The contractor shall, upon receipt of a Policy Notification Transaction (PNT), re-enroll beneficiaries when their eligibility is updated in DEERS by the Uniformed Services.
1.4.4  The contractor shall reject the enrollment application if the requestor is not eligible for TRICARE.The contractor shall notify the requestor within 10 business days if the application is rejected.
1.4.6  The contractor shall complete each enrollment action within three business days of receiving all required information from the Market Directors/Military Medical Treatment Facility (MTF) Directors for those enrolled in Direct Care (DC).
1.4.7  The contractor shall process enrollments to a civilian network PCM with the exception of BWE requests, within three business days of receipt. BWE requests are processed automatically.
1.5  The contractor shall modify the effective date to be no later than the third business day, or the date requested by the beneficiary up to 90 calendar days in the future.The contractor shall ensure that enrollment requests are initiated by the proper person (for TRICARE Young Adult (TYA) must be the beneficiary themselves) sponsor, spouse, other legal guardian of the beneficiary, or an eligible beneficiary age 18 or older. An official enrollment request includes those with:
•  An original signature;
•  An electronic signature offered by and collected by the contractor;
•  A verbal consent provided via 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.
Note:  A signature from an Active Duty Service Member (ADSM) is never required to complete an ADSM Prime enrollment as enrollment in TRICARE Prime is mandatory per the TRICARE Policy Manual (TPM), Chapter 10, Section 2.1.
1.7  The contractor shall educate beneficiaries regarding their entitlement to enroll in a TRICARE Health Plan (THP). Education shall include health coverage options (to include DC and private sector care), enrollment options, timelines and limitation to space available MTF DC only if the beneficiary elects not to enroll in a plan.
1.8  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 for failure to pay enrollment fees on time, choosing to not enroll, or disenrolling from either TRICARE Prime or TRICARE Select.
1.9  The contractor shall follow the specifications defined and outlined in each Market/MTF Memorandum of Understanding (MOU)/Statement of Responsibility (SOR) for TRICARE Prime and TYA Prime enrollments.
1.10  The contractor shall record all enrollments using the Government furnished web-based enrollment system/application (DEERS), within 10 business days of receipt.
1.10.1  The contractor shall resend TRICARE Prime or TRICARE Plus PCM Information Transfers (PITs) to Markets/MTFs when requested.
1.10.2  The contractor shall request DEERS Support Office (DSO) assistance when DEERS will not accept an enrollment transition for an eligible beneficiary.
1.10.3  The contractor shall pend the application until the issue is resolved by DSO.
1.10.4  The contractor shall process or reject the application within three business days, upon response from DSO.
1.10.5  The contractor shall develop a residential or mailing address if the enrollment request contains neither a residential address nor a mailing address.
1.10.5.1  The contractor shall not input temporary addresses (e.g., Post Office (PO) Box, Unit address) unless provided by the enrollee or the Government.
1.10.5.2  The contractor shall update temporary addresses with the permanent address when provided by the enrollee in accordance with the TRICARE System Manual (TSM), Chapter 3, Section 4.2.
1.10.5.3  The contractor shall contact the beneficiary by telephone within five business days if the DEERS record does not contain an address or if the enrollment request contains information different from that contained in DEERS in fields for which the contractor does not have update capability. The telephone call should outline the discrepant information and request the beneficiary contact their military personnel office.
1.10.5.3.1  DMDC/DEERS will send a notification to the beneficiary that the TRICARE wallet card is available through MilConnect
1.10.5.3.2  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.)
1.10.5.3.3  The return address on any correspondence mailed by DMDC will be that of the appropriate contractor.
1.10.6  The contractor shall develop a process to fulfill the delivery if the correspondence is returned to the contractor by the United States Postal Service (USPS).
2.0  AUTOMATIC ENROLLMENT MANAGEMENT
2.1  Automatic Enrollment of ADSMs
DMDC/DEERS will automatically enroll all new ADSM accessions, to include Reserve Component (RC) members on active duty for more than 30 calendar days, into Health Care Delivery Program (HCDP) Plan 001 (TRICARE Prime for Active Duty Sponsors, No PCM Assigned).
2.2  Automatic Enrollment of Newly Eligible ADFMs
Note:  Automatic enrollment of ADFMs does not apply to USFHP contractors.
2.2.1  The contractor shall adjust any claims in question to apply TRICARE Prime plan benefits and waive POS cost-sharing provisions upon request from a beneficiary or sponsor who was auto-enrolled.
2.2.2  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.
2.2.3  The contractor shall document conversations if received over the telephone.
3.0  DUAL ELIGIBLES (ENTITLEMENT UNDER BOTH MEDICARE AND TRICARE)
3.1  The contractor shall ensure that only eligible dual eligible beneficiaries may qualify to enroll in a private sector plan.
3.1.1  Retirees and retired family members, under age 65 are eligible to enroll in TRICARE Prime provided the beneficiary maintains Medicare Part A and Part B.
3.1.2  Dual eligible ADFMs, regardless of age, are eligible to enroll in TRICARE Prime or TRICARE Select.
3.1.3  Dual eligible retirees and family members age 65 and over are not eligible to enroll in TRICARE Prime or TRICARE Select.
3.1.3.1  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.
3.1.3.2  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, TRICARE Prime-enrolled dual eligibles are not subject to POS cost-sharing.
3.3  The contractor shall ensure enrollment fees are waived for dual eligibles. (See paragraph 5.0.)
4.0  ASSIGNMENT OF PCM FOR TRICARE PRIME PLANS ENROLLEES
4.1  The contractor shall assign all TRICARE Prime enrollees to 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 DC and civilian network PCMs.
4.2  The contractor shall comply with the Market Director’s/MTF Director’s specifications as outlined in the Market/MTF MOU/SOR for which enrollees, or categories of enrollees, be assigned a DC PCM or offered a choice of civilian network PCMs.
4.2.1  The contractor shall provide beneficiaries with information about all available PCMs, consistent with Government Designated Authority (GDA) guidance, including available outcomes data for private sector care and DC PCMs in the market, to allow the beneficiary the greatest possible choice of providers.
4.2.2  The contractor shall enroll all ADSMs who do not meet the requirements for TRICARE Prime Remote (TPR) to an MTF PCM.
4.2.3  The contractor shall request the Market/MTF to shift capacity in the Government-furnished web-based enrollment system/application from another category to the ADFM beneficiary category if necessary to accommodate an E-1 through E-4 ADFM beneficiary’s PCM assignment request.
4.2.4  The contractor shall assign the beneficiary to a Market/MTF PCM unless capacity has been reached 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 ADSM.
4.3  The contractor shall provide guidance to the enrollee in selecting a primary care location or PCM using the specifications provided in the Market/MTF MOU.
4.4  The contractor shall refer the beneficiary to the Market/MTF where the beneficiary is enrolled upon receipt of an inquiry from a DC enrollee in regards to the person’s assigned PCM.
4.5  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.
4.5.1  The contractor shall determine the appropriate enrollment Defense Medical Information System Identification (DMIS-ID) based on the geographical area of responsibility and Market/MTF MOUs, access standards and other specific Government guidance at the time of enrollment.
4.5.2  The contractor shall assign the beneficiary to the PCM requested by the beneficiary (see paragraph 1.2) if capacity is available.
4.5.3  The contractor shall use the default PCM for that DMIS if the preferred PCM is not available.
4.5.4  The contractor shall assign an appropriate PCM if the enrollment request (see paragraph 1.2) identifies a gender or specialty preference.
4.5.5  The contractor shall enroll the beneficiary to the default PCM for that DMIS if the gender or specialty is not available.
4.5.6  The contractor shall use the default PCM for that DMIS if no PCM preference is stated on the enrollment application (see paragraph 1.2).
4.5.7  If there is no DC PCM available in the appropriate DMIS/Market/MTF, non-active duty beneficiaries may be enrolled to a civilian PCM by following the procedures specified in the Market/MTF MOU.
4.5.8  The contractor shall contact the Market/MTF for instructions if there is no PCM capacity in the Market/MTF for an ADSM.
4.6  The contractor shall not add, delete, or modify DC PCMs on the Government repository. The Government furnished web-based enrollment system/application reflects only those DC PCMs that the Market/MTF has loaded onto the DEERS PCM Repository.
4.7  The Government-furnished web-based enrollment system/application will only display PCMs with available capacity for the specific beneficiary’s category and age.
4.8  The contractor shall complete all panel PCM reassignments (batch) using the Government-provided systems application, PCM Reassignment System (PCMRS).
4.9  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 should 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
•  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
4.9.1  The contractor shall complete each DC PCM reassignment, both individual and panel reassignment, within three business days. The Market/MTF may request PCM reassignment, including panel reassignments, in several ways, including telephone, email 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 must provide sufficient information identifying both the PCMs and beneficiaries involved in a move to allow the contractor to reasonably accomplish the move.
4.9.2  The contractor shall process PCM change requests submitted by beneficiaries enrolled to a civilian network PCM by any means other than the Government-furnished, web-based self-service enrollment system/application within three business days of receipt, with an effective date no later than the third business day.
4.9.3  The contractor shall modify the effective date to be the date the contractor receives a PCM change request from the Government furnished web-based self-service enrollment system/application and be processed within six calendar days of receiving the request.
5.0  ENROLLMENT PERIOD
5.1  The contractor shall support one annual open enrollment period per calendar year for all Non-Active Duty Service Member (NADSM) beneficiaries.
5.1.1  Enrollments, with the appropriate application and any required enrollment fee, will be effective on January 1 of the following year.
5.1.2  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  Effective Date of Enrollment (On or After January 1, 2018)
5.2.1  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).
5.2.2  Requests for enrollment based on a QLE may be received up to 90 calendar days before and no later than 90 calendar days after the date of the QLE.
5.2.2.1  For online requests for an enrollment period of less than 90 calendar days, or an online request more than 90 calendar days from the date of the QLE, the web-based self-service enrollment system/application will display a message to contact the contractor.
5.2.2.2  For TRICARE Prime and TRICARE Select enrollments initiated or updated by DEERS per paragraph 2.0, see TPM, Chapter 10, Section 2.1 for effective enrollment dates.
5.3  Enrollment Transactions with an Effective Date before January 01, 2018
The contractor shall process any retroactive enrollment transactions with an effective date prior to January 01, 2018, in accordance with guidance provided by the GDA for the contract.
5.4  Enrollment Expiration
5.4.1  The contractor shall not send renewal notices to enrollees.
5.4.1.1  Exception: The contractor shall send the appropriate individual (e.g., 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 30 calendar days before the expiration date of enrollment for beneficiaries paying enrollment fees quarterly or annually.
5.4.1.2  The notification shall alert the beneficiary that he or she will only be eligible for MTF space-available care only should payment not be received.
5.4.1.3  If appropriate, the notification shall include any rate change information. The bill shall offer all available payment options and methods.
5.4.2  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.
5.4.3  The contractor shall send the appropriate individual (e.g., 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 calendar days prior to the implementation of any fee changes for beneficiaries that pay enrollment fees or premium payments on a monthly basis.
5.4.4  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.
5.4.5  See TPM, Chapter 10, Section 2.1 for actions required if a beneficiary is identified as being ineligible for continued enrollment.
5.4.6  The contractor shall reinstate coverage if the request is received with appropriate payment of fees within 90 calendar days from the last paid-through date.
5.4.7  DMDC will notify the beneficiary of the disenrollment within five business days of the disenrollment transaction.
5.4.8  ADSMs may not decline reenrollment nor request disenrollment.
5.5  Disenrollment
5.5.1  The contractor shall provide a mechanism for voluntary disenrollment.
5.5.1.1  Disenrollment requests must be initiated by the sponsor, spouse, other legal guardian of the beneficiary, or an eligible beneficiary 18 or older.
5.5.1.2  An ADSM cannot request disenrollment. An official disenrollment request includes those with:
•  An original signature;
•  An electronic signature offered by and collected by the contractor;
•  A verbal consent provided via 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.
5.5.2  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.
5.5.2.1  The contractor shall set the disenrollment effective date retroactive to the last paid-through date.
5.5.2.2  An enrollment fee payment includes the correct premium amount for the period the fee is intended to cover (i.e., monthly, quarterly, or annually).
5.5.3  The contractor shall reconcile their fee payment system against the fee totals in DEERS prior to processing a disenrollment for “non-payment of fees.”
5.5.4  The contractor may, once the contractor confirms that the payment amounts match, enter the disenrollment in the Government furnished web-based enrollment system/application.
5.5.5  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.
5.6  Enrollment Lockout
5.6.1  The contractor shall reinstate (restore) the enrollment if the beneficiary requests reinstatement within 90 calendar days of their disenrollment date (last paid-through date) and pays all past due fees, if applicable.
5.6.2  The contractor shall deny requests for reinstatement due to failure to pay fees and premiums received after 90 calendar days past the last paid-through date.
5.6.3  Exception
5.6.3.1  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 by the contractor, the GDAs may direct reinstatement of the coverage greater than 90 calendar days past the last paid-through date if all past fees are paid if applicable.
5.6.3.2  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
6.1.1  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.
6.1.1.1  The contractor shall report all enrollment fee refunds to DEERS in accordance with paragraph 8.0.
6.1.1.2  TRICARE Prime and TRICARE Select enrollees may choose one of the following three payment fee options (e.g., monthly, quarterly, or annually).
6.1.1.3  Beginning January 1, 2021: The contractor shall collect enrollment fees for new TRICARE Select policies, including TRICARE Select Group A enrollees that begin paying enrollment fees effective January 1, 2021, by monthly allotment only from military retired/retainer pay, where feasible, as mandated by law (National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2020, Section 702). Lack of feasibility includes instances where this is no retired/retainer pay (e.g., 100% disabled veterans, certain Unremarried Former Spouses (URFSs), survivors, etc.) available to cover monthly enrollment fees; or instances where the beneficiary adamantly refuses to authorize payment of fees via allotment. If not feasible, the contractor shall allow payment of monthly TRICARE Select enrollment fees via a monthly recurring electronic payment in the form of Electronic Funds Transfer (EFT) (which may include recurring credit and debit charge (RCC)).
6.1.1.4  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 US banking institution or other US financial institution.
6.1.1.5  The contractor may assess the account holder a fee of up to $20 US dollars in the event that there are insufficient funds to process an enrollment fee or premium payment. Assessed fees are retained by the contractor.
6.1.1.6   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 6.7.
6.1.1.7  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.
6.1.1.8  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.
6.1.2  Fiduciary Responsibilities
6.1.2.1  The contractor shall act as a fiduciary for all funds acquired from TRICARE Prime and Select enrollment fees, which are Government property.
6.1.2.2  The contractor shall develop strict funds control processes for its collection, retention and transfer of enrollment fees to the Government.
6.1.2.3  The contractor shall maintain all enrollment fees in accordance with these procedures.
6.1.2.4  The contractor shall maintain a separate non-interest bearing account for the collection and disbursement of enrollment fees.
6.1.2.5  The contractor shall deposit enrollment fees into the established account within one business day of receipt.
6.1.2.6  The contractor shall wire transfer the enrollment fees, minus any refund payments, twice monthly, on the 1st business day and the 15th business day to a specified Government account as directed by the DHA, Contract Resource Management (CRM) Office (Section J of the contract).
6.1.2.7  The contractor shall notify DHA CRM, by email, within one business day of the deposit stating the date and amount of the deposit.
6.1.2.8  The contractor shall maintain a clear, auditable record of all enrollment fees received, the date received and the date transferred to the Government, as well as all refunds issued, to whom the refund was issued, the amount of the refund, and the date reported to the Government.
6.1.3  Annual Payment Fee Option
6.1.3.1  The contractor shall collect all annual payment fee-option fees in one lump sum.
6.1.3.2  The contractor shall prorate the fee from the enrollment date to December 31 for initial enrollments.
6.1.3.3  The contractor shall accept payment of the annual enrollment fee only by debit or credit card (i.e., Visa or MasterCard) refer to paragraph 5.6 for disenrollment information if the appropriate enrollment fee payment is not received.
6.1.4  Monthly Payment Fee Option
6.1.4.1  The contractor shall collect monthly installment fee-options each month. Monthly installment fee options are equal to one-twelfth (1/12) of the total annual fee amount, rounded down if not divisible by 12 to the nearest dollar. Monthly enrollment fees must be paid-through an automated, recurring electronic payment in the form of an allotment from retirement pay or through EFT from the enrollee’s designated financial institution (which may include an RCC. These are the only acceptable payment methods for the monthly payment option.
6.1.4.2  The contractor shall collect up to three months of fees for enrollees who elect a monthly fee payment option contingent on the method and date the request is submitted to allow time for an allotment, or EFT, or RCC to be established.
6.1.4.3  The contractor shall explain the deposit amount required and accept payment by personal check, cashier’s check, traveler’s check, money order, debit, or credit card (e.g., Visa or MasterCard) for initial enrollment requests. For continuous coverage requests, contractors shall accept payment by allotment, EFT, or RCC.
6.1.4.4  The contractor shall obtain and verify the information needed to initiate monthly allotments and EFTs.
6.1.4.5  The contractor shall direct bill the beneficiary only when a problem occurs.
6.1.4.5.1  The contractor shall grant the enrollee 30 calendar days from the paid-through date to provide information for a new automated monthly payment when an administrative issue arises that stops or prevents an automated monthly payment from being received by the contractor (e.g., incorrect or transposed number provided by the beneficiary, credit card expired, bank account closed).
6.1.4.5.2  The contractor shall provide the beneficiary with the option to pay quarterly or annually.
6.1.4.5.3  The contractor may accept payment by check during this 30 calendar day period in order to preserve the beneficiary’s TRICARE Prime or TRICARE Select enrollment status.
6.1.4.6  The contractor shall coordinate allotments from active duty and retired pay with the Uniformed Service(s) Pay Center(s) as appropriate (see the TSM, Chapter 1, Section 1.1 for Payroll Allotment Interface Requirements).
6.1.4.7  The contractor shall also research and resolve all requests that have been rejected or not processed by the Uniformed Service(s) Pay Center(s) and resubmit the allotment request if the contractor’s research results in the positive application of the allotment action.
6.1.4.8  The contractor shall notify the beneficiary within five business days of rejected allotment requests and issue an invoice to the beneficiary for any outstanding enrollment fees due.
6.1.4.9  The contractor shall respond to all beneficiary inquiries regarding allotments in the method the inquiry is received (e.g., over the telephone, email, letter).
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, will determine the requirement for an enrollment fee.
6.3  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 SSN and pay an individual enrollment fee. URFSs may not “sponsor” other family members and their fees may not be factored into any family fees associated with the former spouse or sponsor.
6.3.2  Children residing with URFS, whose eligibility for benefits is based on the ex-spouse or former sponsor, are identified and enrolled under the ex-spouse or former sponsor’s SSN on DEERS, and fees for these children shall be combined with other fees paid under the ex-spouse or former sponsor.
6.3.3  The contractor shall collect the individual enrollment fee for an URFS’ enrollment under the URFS’ own SSN.
6.3.4  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 or 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.
6.4.2  Individual enrollments for such beneficiaries will have the enrollment fee waived.
6.4.3  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.
6.4.4  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.
6.4.5  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
6.6.1.1  Effective FY 2012, TRICARE Prime beneficiaries who are:
6.6.1.1.1  Survivors of active duty deceased sponsors, or
6.6.1.1.2  Medically retired Uniformed Services members and their dependents, had their TRICARE Prime enrollment fees frozen at the rate in effect when classified and enrolled in a fee paying TRICARE Prime plan. (This does not include TRICARE TYA plans).
6.6.1.2  Beneficiaries in these two categories who were enrolled in FY 2011 pay the FY 2011 rate.
6.6.1.3  Beneficiaries who became or become eligible in either category and enrolled during FY 2012 or after, shall have their fee frozen at the rate in effect at the time of enrollment in TRICARE Prime. The fees for these beneficiaries shall remain frozen as long as at least one family member remains enrolled in TRICARE Prime.
6.6.1.4  The fee for the dependent(s) of a medically retired Uniformed Services member shall not change if the dependent(s) is later re-classified a survivor.
6.6.1.5  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
6.6.2.1  There is no TRICARE Prime enrollment fee freeze for these retirees and family members; they pay the established annual TRICARE Prime enrollment fee amount.
6.6.2.2  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
The contractor shall collect pro-rated fee amounts for enrollees who do not enroll on the first of a month 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
6.8.1  The contractor shall update DEERS with the enrollment fee amount collected for any overpayment of enrollment fees. 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).
6.8.1.1  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. Funds applied that would move the paid-through date beyond the policy end date are stored as a credit. (The exception is when TRICARE Prime policies, prior to January 1, 2018, end mid-month; DEERS will set a paid-through date to the end of that month.)
6.8.1.2  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.
6.8.1.3  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).
6.8.1.4  The contractor shall update DEERS with any fee amount refunded within 30 calendar days.
6.8.1.5  The contractor shall notify the beneficiaries by letter of the credit, how the credit was applied, and how a refund can be requested for the 2018 and 2019 enrollment fees credited to the catastrophic cap.
6.8.1.6  The contractor shall include an explanation for the premium refund. See also paragraph 8.0.
6.8.2  The contractor shall resolve any over or under payments for enrolled beneficiaries.
6.8.2.1  The following reports shall be provided to the contractor by DEERS on a monthly basis to assist with identifying and correcting enrollment fee discrepancies. For split enrollments, the reports shall use the billing hierarchy to determine the responsible contractor.
6.8.2.2  Current policies that are two months past due (paid period end date more than two months in the past).
6.8.2.3  Any policies where the paid period end date exceeds the policy end date.
6.8.2.4  Policies where the paid period end date meets the policy end date but a credit exists.
6.8.2.5  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 calendar days of the report’s availability.
6.8.4  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.
6.8.5  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).
7.1.1  Upon enrollment, they will choose or be assigned a PCM located in the Market/MTF.
7.1.2  The choice of whether to enroll or to decline enrollment in TRICARE Prime is completely voluntary.
7.1.3  Family members of E-1 through E-4 who decline enrollment or who enroll in TRICARE Prime and subsequently disenroll may not re-enroll until the next open period or when a QLE occurs.
7.2  The contractor shall reinforce that enrollment in TRICARE Prime 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.
7.3  The contractor shall process enrollments and allowance of civilian PCM assignments in accordance with the MOU between the contractor and the Market/MTF.
7.4  The primary means of identification and subsequent referral for enrollment shall occur during in-processing to the installation.
7.4.1  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.
7.4.2  Beneficiaries at overseas locations may also be referred to their local TRICARE Service Center (TSC).
7.5  The contractor shall provide call center representatives and beneficiary education briefings which 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 (e.g., guaranteed access, the support of a PCM).
7.6  The contractor shall discuss the potential effective date of the enrollment.
7.7  Enrollment may be terminated at any time upon request of the enrollee, sponsor or other party as appropriate under existing enrollment and disenrollment procedures.
7.8  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.
7.9  The contractor shall not screen TRICARE claims to determine whether the claims may be for treatment of a non-enrolled ADFM of E-1 through E-4 living in a Prime Service Area (PSA).
7.10  The contractor shall promptly inform such individuals of their benefits and enroll them to the appropriate plan when they have been identified by DoD in the course of such a person’s interaction with the military health care system or personnel community and have been referred to the contractor for enrollment.
7.11  DMDC automatically enrolls newly eligible ADFMs into TRICARE Prime or TRICARE Select, if overseas into TOP Select. See paragraph 2.2.
8.0  TRICARE ELIGIBILITY CHANGES OR REFUNDS OF FEES
8.1  Refer to the TPM, Chapter 10, Section 3.1, for information on changes in eligibility.
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 or her TRICARE eligibility.
8.2.1  The beneficiary will have the choice of paying the entire enrollment fee or paying the fees on a more frequent basis (e.g., monthly).
8.2.2  The contractor shall collect only those installments required to cover the period of eligibility if the enrollee chooses to pay by installments. 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.
8.2.3  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).
8.2.4  The contractor shall include an explanation to the beneficiary for the fee refund.
8.2.5  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.
8.3.1  The contractor shall include an explanation to the beneficiary for the fee refund.
8.3.2  The contractor shall calculate the refund using monthly prorating, and report such refunds to DEERS within 30 calendar days.
8.3.3  Upon activation of the member, the family members will be automatically enrolled as ADFMs (see TPM, Chapter 10, Section 2.1).
8.3.4  If the reactivated member’s family chooses continued enrollment in TRICARE Prime or TRICARE Select, the family will begin a new enrollment period and shall be offered the opportunity to keep their PCM (TRICARE Prime only), if possible.
8.4  The contractor shall apply any catastrophic cap accumulation 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.
8.5.1  The contractor shall include an explanation for the fee refund to the beneficiary.
8.5.2  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.
8.5.3  The contractor shall refund remaining enrollment fees to the executor of the estate for individual enrollments.
8.5.4  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, for family enrollments that convert to individual plans.
8.5.5  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.
8.5.6  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:
•  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
•  Upon receipt of an unsolicited Government furnished policy notification noting a beneficiary’s fee waiver update based on the Part B enrollment.
8.6.1.1  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.
8.6.1.2  Refunds are required for all payments that extend beyond the date the enrollee has Medicare Part B coverage, as calculated by DEERS.
8.6.1.3  The contractor shall update DEERS with any amount refunded within 30 calendar days.
8.6.1.4  The contractor shall include an explanation to the beneficiary for the fee refund.
8.6.1.5  The contractor shall send a refund to the beneficiary if the fee waiver is a 100% waiver of the TRICARE Prime enrollment fee.
8.6.1.5.1  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.
8.6.1.5.2  A refund may not be required unless a credit remains when the policy is paid in full.
8.6.2   The contractor shall utilize the Government-furnished policy notifications received indicating a fee waiver based on Medicare to substantiate any claim of overpayment.
8.6.3  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).
8.6.4  The contractor shall update DEERS with any amount refunded within 30 calendar days and include an explanation to the beneficiary for the fee refund.
8.6.5  Medicare eligible ADFMs age 65 and over are not required to have Medicare Part B to remain enrolled in TRICARE Prime or TRICARE Select.
8.6.6  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.
Note:  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.
8.6.7  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  The contractor shall draw refunds from the contractor’s enrollment fee account and report said refunds 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.
8.9  The contractor shall, pursuant to criteria and documentation required for the specific TRICARE eligibility changes as listed in paragraph 7.0, refund overpaid fees in the following manner:
8.9.1  The contractor shall apply overpaid fees to another enrolled family member under the same Uniformed Service sponsor if within the maximum two calendar years.
8.9.2  Overpaid fees for URFS can only be applied to their enrollment records.
8.9.3  The contractor shall automatically refund prorated enrollment fees in excess of two calendar years.
8.9.4  The contractor shall, upon request from sponsor or responsible individual, apply overpaid fees as directed up to the maximum two calendar years and refund overpaid fees as requested.
8.9.5  The contractor shall not refund amounts of less than $1.00.
8.9.6  The contractor shall issue refunds within 30 calendar days to a Uniformed Service sponsor, eligible spouse, and then oldest child in that order.
8.9.7  Refunds for URFS enrollment fees shall only be refunded to the URFS.
8.9.8  The contractor shall update DEERS within 30 calendar days with any refund amount.
9.0  WOUNDED, ILL, AND INJURED (WII) ENROLLMENT CLASSIFICATION
9.1  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 RC Service members who have been activated for more than 30 calendar days.
9.1.1  These AC or 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.
9.1.2  WII Programs vary in name according to Service.
9.1.3  The Service determines member eligibility for enrollment into a WII Program, as well as whether or not to utilize these enrollments.
9.2  To better manage this population, a secondary enrollment classification of HCDP Plan Coverage Codes, WII 415 and WII 416 were developed. These 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 shall 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 shall process and pay under Supplemental Health Care Program (SHCP) rules. DEERS will not produce specific enrollment cards or letters for WII 415/416 enrollment.
9.3  The contractor shall code WII 415/416 TRICARE Encounter Data (TED) records 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).
9.4  WII 415 - WWI (e.g., Warrior Transition/MEDHOLD Unit (WTU))
9.4.1  The contractor shall enroll Service-defined eligible Service members assigned to a WII 415 Program such as a MEDHOLD or WTU to TRICARE Prime or TOP Prime prior to, or at the same time, as being enrolled into the WII 415.
9.4.1.1  Members cannot be enrolled to the WII 415 without a concurrent TRICARE Prime or TOP Prime enrollment.
9.4.1.2  Service appointed WII case managers will coordinate with the Market/MTF to facilitate TRICARE Prime PCM assignments for WII 415 members.
9.4.2  The contractor shall assign a PCM in accordance with the Market/MTF MOU and in coordination with the WII case manager.
9.4.3  WII 415 enrollment will not run in conjunction with Transitional Assistance Management Program (TAMP) and members enrolled in TPR or TOP Prime Remote are not eligible to enroll in the WII 415.
9.4.4  The contractor shall, upon receipt of the Government-provided DD Form 2876, the enrollment application form with WII 415, perform the enrollment in the Government furnished web-based enrollment system/application and include the following information:
9.4.4.1  WII 415 HCDP Plan Coverage Code.WII 415 Enrollment Start Date.
9.4.4.2.1  Contractors 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.
9.4.4.2.2  The start date may be changed up to 289 calendar days in the past or 90 calendar days into the future.)
9.4.5  WII 415 enrollments shall be in conjunction with a Market/MTF enrollment only, not to civilian network PCMs under TPR enrollment rules.
9.4.5.1  DEERS ends WII 415 enrollments upon loss of member’s active duty eligibility.
9.4.5.2  WII 415 Program enrollments are not portable across programs or geographical area of responsibility.
9.4.6  The TOP contractor shall enter WII 415 enrollments through the Government furnished web-based enrollment system/application for outside the 50 US and the District of Columbia.
9.4.7  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
•  Contractors can request unsolicited Government furnished policy notifications resend
•  Modify begin date
•  Modify end date
9.5  WII 416 - WII - Community Care Units (CCUs)
9.5.1  The contractor shall assign a PCM based on the Market/MTF MOU and in coordination with the WII entity (e.g., CCU).
9.5.1.1  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.
9.5.1.2  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.
9.5.1.3  Members cannot be enrolled to the WII 416 program without a concurrent Prime, TPR, TOP Prime, or TOP Prime Remote enrollment.
9.5.1.4  Service appointed case managers will coordinate with the contractor or Market/MTF to facilitate TRICARE Prime or TPR PCM assignments for eligible beneficiaries.
9.5.1.5   WII 416 enrollments will not run in conjunction with TAMP.
9.5.2  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.
9.5.2.1  The begin date will be the date the contractor receives the signed enrollment form.
9.5.2.2  A signed enrollment application includes those with an original signature, or an electronic signature offered by and collected by the contractor.
9.5.3  The contractor shall perform the enrollment in the Government furnished web-based enrollment system/application and include the following information:
9.5.3.1  WII 416 HCDP Plan Coverage Code.
9.5.3.2  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 calendar days in the past, or 90 calendar days in the future.)
9.5.4  WII 416 enrollments must be in conjunction with a Market/MTF, TPR, TOP Prime, or TOP Prime Remote enrollment.
9.5.4.1  DEERS will end WII 416 enrollments upon loss of member’s active duty eligibility.
9.5.4.2  WII 416 program enrollments are not portable across programs or geographical area of responsibility.
9.5.5  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
•  Contractors can request unsolicited Government furnished policy notification resend
•  Modify begin date
•  Modify end date
10.0  TRICARE POLICY FOR ACCESS TO CARE (ATC) AND PSA STANDARDS
10.1  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 HCD challenges in Alaska, the requirement to request a waiver for the drive time access standard does not apply to beneficiaries in Alaska.)
10.1.1  The contractor shall, before effecting an enrollment or portability transfer request, 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).
10.1.2  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.
10.2  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.
10.2.1  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.
10.2.2  The time or distance shall be computed between the enrollee’s residence and the physical location of the PCM (including Markets/MTFs).
10.2.3  It is not acceptable to use a geographic substitute, such as a geographic centroid.
10.3  The contractor shall, in conjunction with Markets/MTFs for Market/MTF enrollees, 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.
10.4  This includes educating beneficiaries, who waive their ATC travel standards, of the following:
10.4.1   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.
10.4.2  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).
10.4.3  They should consider whether any delay in accessing their enrollment site might aggravate their health status or delay receiving timely medical treatment.
10.5  Cross-Geographical Area Of Responsibility TRICARE Prime Enrollment
10.5.1  The enrolling contractor shall ensure a beneficiary is not approved for cross-geographical area of responsibility enrollment if they live within 30 minutes of a Market/MTF, unless the Market’s/MTF’s servicing contractor approves the enrollment. Otherwise, the beneficiary will be enrolled to the Market/MTF if a PCM is available.
10.5.2  The contractor shall enroll beneficiaries to the geographic area of responsibility 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).
10.5.2.1  An access to care drive time waiver is required (see paragraph 10.1).
10.5.2.2  All claims are processed by the geographic area of responsibility of enrollment.
10.5.2.3  Cross-geographical area of responsibility enrollment must be requested by either submitting an enrollment form (DD Form 2876) or by calling the regional contractor servicing the desired PCM.
10.6  Discrepant Addresses
10.6.1  The contractor shall inform the beneficiary at any point during the enrollment period where the contractor determines or is advised that a beneficiary is no longer eligible for continued TRICARE Prime enrollment due to an address discrepancy (e.g., claims filed with a home address listed which does not match their DEERS record). 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.
10.6.1.1  This notification (letter, telephone call, or email) shall occur when the discrepant information is first known by the contractor.
10.6.1.2  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.
10.6.2  The contractor shall notify the beneficiary of any apparent ineligibility for TRICARE Prime if the contractor confirms the beneficiary is ineligible for enrollment due to their address.
10.6.3  The contractor shall transfer the plan enrollment to TRICARE Select if the beneficiary fails to respond within 90 calendar days to a notification. If the beneficiary does respond and wishes to remain in TRICARE Prime, the contractor shall follow the relevant drive time waiver process outlined in this section.
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.
10.7  Market/MTF TRICARE Prime Enrollees
10.7.1  Non-active duty beneficiaries must reside within 30 minutes travel time from a Market/MTF to which they desire to enroll.
10.7.1.1  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.
10.7.1.2  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.
10.7.1.3  The contractor shall submit each request not addressed in the MOU to the Market Director/MTF Director, or designee, in a method that is outlined in the MOU.
10.7.1.4  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 be agreeable to the enrollment and have sufficient capacity and capability.
10.7.2  The contractor shall determine if the beneficiary resides 100 miles or more from the Market/MTF to which they are enrolled, and, if there is no 100 mile waiver on file, inform the beneficiary that he or she is no longer eligible for Prime enrollment to the Market/MTF. This notice advises the beneficiary that he or she is being automatically enrolled in TRICARE Select, and their option to enroll with a USFHP where available.
10.7.3  The contractor shall inform a beneficiary choosing not to enroll in TRICARE Select, or USFHP where available, about his or her military medical benefits limitation to direct care access to Markets/MTFs on a space available basis only.
10.7.4  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 10.5 regarding cross-geographical area of responsibility enrollments. Enrollment guidelines in MOUs may include:
10.7.4.1  ZIP codes and 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.
10.7.4.2  There may be ZIP codes and 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.
10.7.4.3  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 or she will consider requests or will not consider requests.
10.7.5  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 geographical area of responsibility, 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.
10.7.6  The contractor shall make this notification by any mutually agreeable method specified in the MOU.
10.7.7  The contractor shall not make the Market/MTF enrollment effective unless notified by the Market/MTF to do so.
10.7.7.1  The Market Director/MTF Director will notify the government designated authority 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 government designated authority (GDA) will make a determination on whether or not to approve or deny the request and notify the Market Director/MTF Director of his or her 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.
10.7.7.2  The contractor shall notify the beneficiary of the final decision regarding an enrollment request for TRICARE Prime enrollment where the beneficiary resides more than 100 miles from a Market/MTF.
10.7.7.3  Approved waivers for beneficiaries residing 100 miles or more from the Market/MTF remain in effect until the beneficiary changes residence or unless the Market Director/MTF Director determines that they will no longer allow these enrollments.
10.7.7.4  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.
10.7.7.5  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.
10.7.7.5.1  The contractor shall, prior to notification, obtain the rationale for the change from the Market/MTF to include in the notice to the beneficiary.
10.7.7.5.2  The proposed notice shall be reviewed and concurred by the GDA prior to being sent to the impacted beneficiaries (the GDA will coordinate notices with the DHA Communications prior to approval).
10.7.8  The contractor shall, at any time during the enrollment period 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 Market/MTF, 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).
10.7.8.1  The contractor shall notify the beneficiary of this waiver requirement within 30 calendar days of determining a need for waiver. 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 the DHA Communications prior to approval.)
10.7.8.2  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.
10.7.9  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 for each approved enrollment to a Market/MTF where the beneficiary has waived access standards.
10.7.10  The contractor shall provide the retained file to a successor contractor at the end of the final option period.
10.7.11  When an enrollment request requires Market Director/MTF Director or 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 GDA regarding waiver approval or disapproval.
10.8  Civilian TRICARE Prime PCMs
10.8.1  The contractor shall provide the capability and capacity to allow beneficiaries who reside in a PSA to enroll to a non-MTF civilian PCM within access standards.
10.8.2  The contractor may allow enrollment 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 and the beneficiary waives travel time access standards. (Also, see Chapter 5, Section 1.)
10.8.3  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.
10.8.3.1  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.
10.8.3.2  Beneficiaries who reside outside the PSA and enroll in TRICARE Prime must waive their primary and specialty care travel time access standards.
10.8.4  ADFMs (Including ADFM TYA Prime Enrollees) Residing Outside a PSA
The contractor shall manage grandfathered ADFMs as stated in this Chapter.
10.8.4.1  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.
10.8.4.2  ADFMs 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.
10.8.4.3  The contractor shall 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.
10.8.5  Terms of Grandfathered Prime for Prior PSAs - Status
10.8.5.1  The National Defense Authorization Act (NDAA) for FY 2014, Section 701, signed into law on December 26, 2013, gave certain beneficiaries a “one-time” election to continue their TRICARE Prime enrollment. The eligible beneficiaries included those who:
•  Were involuntarily disenrolled from TRICARE Prime on September 30, 2013, due to the PSA reduction; and
•  Lived within 100 miles of an Market/MTF.
10.8.5.2  The NDAA for FY 2016, Section 701 signed into law on November 25, 2015, gave certain beneficiaries a “one-time” election to continue their TRICARE Prime enrollment.
10.8.5.2.1  These eligible beneficiaries included those who:
•  Were involuntarily disenrolled from TRICARE Prime on September 30, 2013, due to the PSA reduction;
•  Resided more than 100 miles from an MTF/Enhanced Multi-Service Market (eMSM); and
•  Were an eligible beneficiary by reason of service in the Army, Navy, Air Force, or Marine Corps.
10.8.5.2.2  Special enrollment processes for these particular beneficiaries are outlined below.
10.8.5.3  An Interim Final Rule (IFR) was published in the Federal Register on September 29, 2017 (82 FR 45438–45461) that established TRICARE Select and other TRICARE reforms.
10.8.5.3.1  As noted in the IFR, the locations where TRICARE Prime will be offered will be determined by the Director, Defense Health Agency (DHA) and announced prior to the annual open season enrollment period.
10.8.5.3.2  The Final Rule, published February 15, 2019, continues the principle that the purpose of TRICARE Prime is to support the medical readiness of the armed forces and the readiness of medical personnel in areas of one or more MTFs.
10.8.5.3.3  The rule preserves the Department’s discretion with respect to the locations where TRICARE Prime is offered.
10.8.5.4  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.
10.8.5.4.1  Grandfathered ADFMs must be assigned a PCM.
10.8.5.4.2  Grandfathered ADFMs may add or terminate enrollment of dependents like any other ADFM (e.g., marriage, birth, adoption, divorce).
10.8.5.4.3  Dependents may live in a separate residence outside a T-3 PSA and still be grandfathered.
10.8.5.5  Grandfathered ADFMs lose their grandfathered status when they are:
10.8.5.5.1  No longer TRICARE eligible;
10.8.5.5.2  No longer residing within 40 miles of the residence where they were originally granted grandfathered status; or
10.8.5.5.3  Change to retired status.
10.8.5.6  No retired beneficiary will be given grandfathered status.
10.8.5.7  The contractor shall grandfather TAMP beneficiaries enrolled in TRICARE Prime who reside outside of a PSA similar to other ADFMs.
10.8.5.8  Grandfathered TRICARE Prime enrollees will continue to be grandfathered if they become TAMP eligible and enroll in TAMP, as long as they reside within 40 miles of the residence where they were originally granted grandfathered status.
10.8.6  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.
11.0  REPORTS
The contractor shall provide monthly ADSM enrollment and beneficiary services reports. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
12.0  Implementation Of TRICARE Select Group A Enrollment Fees
12.1  The contractor may collect and process enrollment requests to include processing of allotment requests prior to Open Season. If the beneficiary arranges a monthly fee option (allotment, where feasible) by November 20, 2020, the contractor shall not collect up to three months of enrollment fees to initialize a monthly fee option. If the beneficiary provides fee payment arrangements after November 20, 2020 the contractor shall follow the monthly payment fee option in paragraph 6.1.4.
12.2  In addition to the contractor’s existing best business practices regarding “failure to pay fees” notifications, if not already being done, the contractor shall:
•  Use Health Insurance Portability and Accountability Act (HIPAA) compliant “robo calls,” text messages, and emails to notify adult members of each household (sponsor, spouse, or adult child) that haven’t indicated whether they wish to continue their coverage and of the opportunity to reinstate their coverage.
•  Make and document at least three phone calls to home, mobile, or work phone numbers of an adult member of the household.
12.3  The contractor shall extend the TRICARE reinstatement policy for TRICARE Select Group A from 90 calendar days (see paragraph 5.6.1) until 180 days after termination of such coverage for failure to pay fees on January 1, 2021. Unless otherwise notified, this exception expires on June 30, 2021.
12.4  The contractor shall include information on the reinstatement option in claims denial correspondence when TRICARE Select Group A claims with a date of service after January 1, 2021 through June 30, 2021 are denied due to non-enrollment.
12.5  The contractor shall provide weekly TRICARE Select Group A reports (not applicable to those beneficiaries whose enrollment fees are waived by law) according to DD Form 1423, CDRL, located in Section J of the applicable contract. Unless otherwise directed, the contractor shall discontinue reports on June 30, 2021.
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