The term “contractor” applies
to the Managed Care Support (MCS) contractor, TRICARE Overseas Program
(TOP) contractor, and Uniformed Services Family Health Plan (USFHP)/Designated
Providers (DPs) for purposes of enrollment portability.
1.0 The contractor shall, for the
geographic area of responsibility in which the beneficiary is enrolled
on Defense Enrollment Eligibility Reporting System (DEERS), provide
continuing coverage and update catastrophic cap accumulations for
the enrollee while the enrollee is traveling or relocating, except
in the case of care provided overseas (i.e., care outside of the
50 United States and the District of Columbia).
1.1 The
TOP contractor, shall process Civilian Health Care (CHC) claims
while the beneficiary is traveling or visiting overseas, regardless
of where the beneficiary resides or is enrolled.
1.1.1 TRICARE
Prime and TRICARE Select enrollees retain coverage whenever they
move or travel.
1.1.2 Enrollment
portability provisions apply to TRICARE Prime and TRICARE Select
enrollees’ travel or relocation to or from all areas, where TRICARE
Prime and TRICARE Select is available.
1.2 An enrollee may transfer enrollment
before or after moving either temporarily or permanently to a new location
using any of the enrollment options in
Section 1.
1.2.1 The outgoing contractor shall
continue to provide health care coverage until:
• The enrollment is transferred
to the gaining contractor;
• The beneficiary is no longer
eligible for enrollment in TRICARE Prime or TRICARE Select;
• The beneficiary disenrolls;
or
• The beneficiary is disenrolled
due to failure to pay required enrollment fees, whichever occurs
first.
1.2.2 TRICARE
Prime referral and authorization rules continue to apply (see
Chapter 7, Section 5 and
Chapter 8, Section 5). Under no circumstances
will retroactive disenrollment be allowed in order to avoid Point
Of Service (POS) cost-sharing provisions.
1.2.3 The
contractor shall, on the day it receives either a beneficiary’s
signed enrollment form, telephone portability request, or a request
from the Government furnished web-based self-service enrollment
system/application agreeing to a transfer of enrollment to the new
geographic area of responsibility, consider the beneficiary enrolled
at the new location, regardless of whether the appropriate updates
have been performed in the Government-provided web-based application
to DEERS.
1.2.4 TRICARE Prime enrollees should
contact the new Primary Care Manager (PCM), the new geographical area
of responsibility’s Health Care Finder (HCF), or the DP for health
care and health-related assistance.
1.2.5 The
contractor shall modify the effective date for enrollment requests
received from the Government furnished web-based self-service enrollment
system/application to be the date the enrollment was submitted.
1.2.6 The effective date for transfer
of enrollment may differ from the effective date for initial enrollment.
See
Section 1 for information on initial enrollment
in TRICARE Prime. For transfers, the original enrollment period
on DEERS will remain in effect.
1.2.7 The
contractor shall, when enrollment changes from one contractor to
another prior to the annual renewal for enrollees in beneficiary
categories required to pay enrollment fees, obtain information from
the losing contractor on fees that are being automatically paid
and transition these payment types in the least disruptive manner
for the beneficiary.
1.2.8 Enrollment
fees must be paid current prior to transfer of enrollment. See
Section 1, for refunds of unused enrollment
fees.
1.3 USFHP
Portability Guidelines
1.3.1 TRICARE Prime USFHP enrollees
who are not otherwise TRICARE-eligible (e.g., grandfathered Medicare eligible
beneficiaries who only have Part A) may only transfer enrollment
from one USFHP to another USFHP; they may not transfer to a MCS
Contractor (MCSC).
1.3.2 Beneficiaries
enrolled in TRICARE Prime coverage who reside in a ZIP code where
USFHP and MCSC Prime networks co-exist may elect to change their
PCM to the other network at any time by disenrolling from their current
contractor and re-enrolling with the other contractor.
1.3.3 This is to be viewed as a PCM
change.
1.4 Enrollment
portability and PCM changes are not limited to the annual open enrollment
period nor require a Qualifying Life Event (QLE) to occur.