1.0 POLICY (Before
January 1, 2018)
1.1 Generally,
when the TRICARE eligibility status changes, eligibility for TRICARE
Prime benefits also changes. The time frames for Prime eligibility
parallel TRICARE eligibility.
1.2 In all cases, when TRICARE eligibility
ends, eligibility for Prime ceases. This includes retirees, their
family members and survivors who turn age 65 and are entitled to
Medicare but are not eligible for TRICARE for Life (TFL), dependent
children who lose TRICARE eligibility due to age, remarriage of former
spouses, etc.
1.3 To have continuous Prime coverage,
the enrollee shall submit an enrollment form, or use the Government
furnished web-based self-service enrollment system/application transaction,
or make a telephonic request to the contractor before, or within
30 days following, their retirement date, and pay the appropriate
enrollment fees, calculated based on the effective date of enrollment,
within the required time frames (see
Section 2.1, paragraph 1.1.4.2.1). Active
duty personnel who retire may enroll at the same time as the remaining
family members.
1.3.1 If this is not done before or within
30 days following the member’s retirement or separation, enrollment
or reenrollment will be effective according to the provisions of
Section 2.1, paragraph 1.1.4.
1.3.2 If the enrollee
is receiving ongoing care at the time of retirement or separation,
he/she must comply with all of the care authorization requirements
of the enrollee’s new status including getting a new authorization
from the contractor.
1.4 When status changes from Active
Duty Family Member (ADFM) to retiree family member, Prime enrollees
shall be offered an opportunity to continue enrollment in Prime,
if available, but at the retiree cost-sharing rates. These enrollees
must pay the applicable enrollment fees. Beneficiaries shall be permitted
to keep their Primary Care Manager (PCM), if possible. Military
Treatment Facility (MTF) Commanders/Enhanced Multi-Service Market
(eMSM) Managers shall determine if retiring beneficiaries who enroll
in Prime could keep their MTF/eMSM PCMs, given the MTF’s/eMSM’s enrollment
plan and MTF/eMSM capacity.
1.5 Prime Enrollment for Transitional Survivors.
Those in Transitional Survivor Status, are not distinguished from
other ADFMs for Prime eligibility. See the Transitional Survivor
Status policy in
Section 7.1.
1.6 When an active duty member retires other
than the first of the month or a member separates other than the
first of the month but continues to be eligible (e.g., is the spouse
of an active duty member; or is eligible for Transitional Assistance
Management Program (TAMP)), Prime enrollment may continue as of
the date of retirement or separation so long as all enrollment requirements
have been met as stated in
Section 2.1, paragraph 1.1.4.
1.7 When
TRICARE Prime enrollment changes from an individual to a family
enrollment status prior to annual renewal for beneficiary categories
required to pay an enrollment fee, the unused portion (pro-rated
on a monthly basis) of the fee will be applied toward a new enrollment
period or refunded in accordance with the TRICARE Operations Manual
(TOM),
Chapter 6, Section 1, paragraph 8.0.
1.7.1 For ADFMs,
single enrollment can be changed to family at any time during the
enrollment period. A new enrollment period shall be established
for the family.
1.7.2 A newborn or adoptee will be deemed
to be enrolled in Prime as of the day of birth or adoption if one
family member is already enrolled in Prime. A responsible representative
has 60 days to officially enroll the child to the Prime option.
If the newborn or adoptee is formally enrolled in Prime within the
60 day period, the effective date of enrollment will be the first
of the month following the date of birth or adoption. (The 20th
of the month enrollment rule is waived, if necessary.) If the newborn
or adoptee is not formally enrolled during the 60 day calendar period,
the newborn or adoptee will revert to a non-enrolled beneficiary
effective the 61st day. If the decision is made to continue Prime
coverage, an official enrollment request (enrollment form, Government
furnished web-based self-service enrollment system/application transaction,
or telephonic request) must be completed on behalf of the child.
For retirees or their family members or survivors who decide to continue
enrollment for the child, the unused portion (pro-rated on a monthly
basis) of the single enrollment fee they paid will be applied toward
a new family enrollment period. For newborns and newly adopted children
enrolled under this provision, Point of Service cost-sharing does
not apply through the 60th day or the effective date of enrollment,
whichever is earlier. All services shall be processed with the Prime
copayment even in the absence of referrals or authorizations. The
Director, TRICARE Regional Offices (TROs) is granted the authority
to extend the deemed period up to 120-days, on a case-by-case or
regional basis.
Note: In the case of a reservist who has been
called to active duty for a period of 30 days or less, a new family
member is not considered enrolled in Prime, since the family members
of the reservist are not eligible to enroll in Prime.
1.7.3 For those
newborns and adoptees who are covered under the 60 day “deemed enrollment” benefit,
process these claims as civilian Prime for this period. If the newborn
or adoptee is formally enrolled during this period, process using
enrollment status. If the newborn or adoptee is not formally enrolled
during the 60 day calendar day period, at the end of the 60th calendar
day period, the contractor shall process all claims as a non-enrolled
beneficiary, applying the appropriate TRICARE cost-shares and deductibles.
See the TOM,
Chapter 8, Section 1, paragraph 5.0 for claims
processing procedures.
1.8 When
a family enrollment status changes to single, there is no refund
of the paid enrollment fee, unless the family enrollment becomes
an individual enrollment due to death of one or more family members
or a retired TRICARE Prime enrollee becomes dual eligible (see the
TOM,
Chapter 6, Section 1, paragraph 8.0). The
remaining single enrollee continues to have Prime coverage until
the enrollee takes action to disenroll, the enrollee is no longer
eligible for TRICARE Prime, or the enrollee fails to pay a required
enrollment fee.
1.9 TRICARE eligible beneficiaries who
have less than 12 months of eligibility remaining (for example,
retirees who are 64 years of age, TAMP beneficiaries, etc.) are
allowed to enroll in Prime, however, these enrollees will be disenrolled
from Prime when they lose their TRICARE eligibility. The beneficiary
has the choice of paying all of the enrollment fee or paying the
fees on a monthly or quarterly basis. If paid on a monthly or quarterly
basis, the beneficiary will be required to pay the installments
that would cover the period of their eligibility only. See
paragraph 1.8 for
those who pay in full at the beginning of the enrollment period.
1.11 Enrollees may
disenroll from TRICARE Prime according to the requirements of
Section 2.1.
2.0 Policy (On
Or After January 1, 2018)
2.1 Generally, when the TRICARE eligibility
status changes, eligibility for TRICARE Prime or Select benefits
also changes.
2.2 In all cases, when TRICARE eligibility
ends, eligibility for TRICARE Prime or Select ceases. This includes
retirees, their family members and survivors who turn age 65 and
are entitled to Medicare but are not eligible for TFL if they don’t
elect Medicare Part B, for example, dependent children who lose TRICARE
eligibility due to age, remarriage of former spouses, etc.
2.3 A
change in status that results in a change in TRICARE coverage is
considered a Qualifying Life Event (QLE). Eligible beneficiaries
may elect to enroll in TRICARE Prime or Select within 90 days of
a QLE. See
Section 2.1.
2.4 Active
duty personnel who retire may enroll at the same time as the remaining
family members.
2.5 If a Prime enrollee is receiving ongoing
care at the time of retirement or separation, he/she must comply
with all of the care authorization requirements of the enrollee’s
new status including getting a new authorization from the contractor.
2.6 When status changes from ADFM to
retiree family member, Prime enrollees shall be offered an opportunity
to continue enrollment in Prime, if available, but at the retiree
cost-sharing rates. These enrollees must pay the applicable enrollment
fees. Beneficiaries shall be permitted to keep their PCM, if possible.
MTF Commanders/eMSM Managers shall determine if retiring beneficiaries
who enroll in Prime could keep their MTF/eMSM PCMs, given the MTF’s/eMSM’s
enrollment plan and MTF/eMSM capacity. Alternatively, they may elect
to enroll in TRICARE Select. See
Section 2.1,
for QLE information.
2.7 Prime Enrollment for Transitional Survivors.
Those in Transitional Survivor Status, are not distinguished from
other ADFMs for Prime eligibility. See the Transitional Survivor
Status policy in
Section 7.1.
2.8 Claims For
Newborns and Adoptees
2.8.1 Claims for newborns and adoptees will
be cost-shared for up to the first 90 days of life as TRICARE Prime
if one or more family members (including ADSMs) are enrolled in
Prime. Otherwise, the claims will be cost-shared as TRICARE Select
for up to the first 90 days of life. Claims will be denied if received
after 90 days of life if the newborn is not enrolled in TRICARE
Prime or Select coverage. Once the newborn or adoptee is enrolled
in TRICARE coverage, contractors will only re-process claims paid during
the first 90 days of life when requested by a responsible member
of the family.
Exception: If overseas, time frame is up
to the first 120 days of life.
2.8.2 Once a newborn or adoptee is shown
as enrolled in a TRICARE plan in Defense Enrollment Eligibility
Reporting System (DEERS), the TRICARE Prime or TRICARE Select “deemed
status” for cost sharing of claims no longer applies and claims
received after the date of enrollment shall be processed according
to the cost sharing provisions of their enrolled plan.
2.8.3 See
TOM,
Chapter 22, Sections 1 and
2, for policy
with processing newborn
and adoptee claims
under TRICARE Reserve
Select (TRS) and TRICARE Retired Reserve (TRR) coverage
.
2.9 TRICARE eligible beneficiaries who
have less than 12 months of eligibility remaining (for example,
retirees who are 64 years of age, TAMP beneficiaries, etc.) are
allowed to enroll in Prime or Select; however, these enrollees will
be disenrolled when they lose their TRICARE eligibility. The beneficiary
has the choice of paying all of the enrollment fee or paying the
fees on a monthly or quarterly basis. Once the enrollment is terminated,
remaining enrollment fees may be applied to the enrollment fees
of another family member, or at the request of the beneficiary,
may be refunded. See the TOM,
Chapter 6, Section 1.
2.10 Reserve Component beneficiaries that move
between a TRICARE Premium Plan (TRS, TRR, TRICARE Young Adult (TYA),
or Continued Health Care Benefit Plan (CHCBP) and a non-premium
plan. See
Section 2.1 for how these status changes affect
the beneficiaries’ cost-share, deductible and catastrophic cap.
When a Reserve Component member is activated and is treated as any
other active duty member, the member’s dependents qualify as ADFMs.
See
Section 2.1 for how this status change affects
the dependent’s cost-shares, deductibles and catastrophic cap.
2.11 Enrollees
may disenroll from TRICARE Prime or Select according to the requirements
of
Section 2.1.