1.0 BACKGROUND
1.1 TRICARE
Plus is a Market/Military Medical Treatment Facility (MTF)-based
program designed to allow Military Health System (MHS) beneficiaries
not enrolled in a TRICARE Prime option an opportunity to obtain
a primary care coordinator within the Market/MTF and to be assured
access to Market/MTF primary care appointments meeting TRICARE Prime
primary care access standards.
1.2 Market
Directors/MTF Directors will determine the number of TRICARE Plus
enrollees at their Market/MTF.
2.0 ENROLLMENT
2.1 The
contractor shall return incomplete forms or any application for
which enrollment or disenrollment cannot be effected, for any reason
other than internal contractor systems or process problems, while
completed and approved enrollment or disenrollment forms for TRICARE
Plus will be sent to the regional contractor by the Markets/MTFs
no less frequently than weekly.
2.2 The Market/MTF
is responsible for ensuring that the enrollment form is complete
with validated eligibility through Defense Enrollment Eligibility
Reporting System (DEERS) before submitting the forms to the contractor.
2.3 The contractor shall not correct
or complete any TRICARE Plus enrollment or disenrollment application on
behalf of a beneficiary.
2.4 The
Market/MTF maintains responsibility for capacity for TRICARE Plus
enrollment and will ensure that the capacity is reflected on the
DEERS Primary Care Manager (PCM) Repository.
2.5 The contractor shall ensure
that all TRICARE Plus enrollments received are entered in the Government-furnished
web-based enrollment system/application.
2.6 TRICARE
Plus enrollments cannot be completed using the Government furnished
self-service web-based enrollment system/application.
2.7 The contractor shall ensure
that all initial enrollments for beneficiaries over the age of 64
begin on the date the contractor enters the TRICARE Plus application
or the first day the beneficiary loses eligibility for TRICARE Prime,
whichever is later.
2.8 The
contractor shall ensure that all initial enrollment periods for
beneficiaries under age 65 begin on the date after disenrollment
from TRICARE Prime or the date the contractor enters the TRICARE
Plus application, whichever is later. Enrollment in TRICARE Plus
requires disenrollment from TRICARE Prime.
2.9 Enrollment
in TRICARE Plus-With Direct Care (DC) Only and TRICARE Plus-With
TRICARE For Life (TFL) is not limited to the open enrollment period
and does not require a Qualifying Life Event (QLE).
3.0 DISENROLLMENT
3.1 The
contractor shall process TRICARE Plus disenrollments in accordance
with
paragraph 2.1.
3.2 Beneficiaries
may disenroll from TRICARE Plus at any time.
3.3 Disenrollment forms will be
sent to the contractors by the Markets/MTFs no less frequently than
weekly.
4.0 PORTABILITY
4.1 TRICARE
Plus enrollment is not portable between Markets/MTFs.
4.2 Beneficiaries who wish to change
their TRICARE Plus enrollment to a different Market/MTF will have
the same opportunity to enroll at the new Market/MTF as any other
beneficiary without an established relationship with a primary care
coordinator.
4.3 There is no priority stemming
from previous enrollment in TRICARE Plus.
5.0 REFERRALS TO CIVILIAN PROVIDERS
5.1 The contractor shall provide
the name, telephone number, and address of providers within the
enrollee’s geographic area when care is not available at a Market/MTF.
5.2 TRICARE Plus enrollees may
contact the contractor for assistance with locating network and
non-network providers.
5.3 The
contractor shall not make appointments with providers for TRICARE
Plus beneficiaries.
5.4 The
contractor shall advise TRICARE Plus-With DC Only enrollees, that
TRICARE will not cost-share on any care provided by civilian providers.