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TRICARE Operations Manual 6010.59-M, April 1, 2015
Enrollment
Chapter 6
Section 1
TRICARE Prime And TRICARE Select Enrollment Processing
Revision:  C-86, March 26, 2021
The Managed Care Support Contractor, Uniformed Services Family Health Plan (USFHP) Designated Provider (DP), and TRICARE Overseas Program (TOP) contractor shall record all enrollments on Defense Enrollment Eligibility Reporting System (DEERS), as specified in the TRICARE Systems Manual (TSM), Chapter 3. The word “contractor” refers to all three contractors (listed above) for this section unless otherwise noted.
1.0  Enrollment Processing
1.1  For paper enrollment requests, the contractor shall use the TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form (one combined form), Department of Defense (DD) Form 2876. For TRICARE Select enrollments, the contractor shall use the TRICARE Select Enrollment, Disenrollment, and Change Form, DD Form 3043. The contractor shall ensure the aforementioned form is readily available to potential enrollees. The contractor shall implement enrollment processes (which do not duplicate Government systems) that ensure success and assistance to all beneficiaries. The contractor shall collect enrollment forms at a site(s) mutually agreed to by the contractor, Government Designated Authority (GDA), and Market Director/Military Treatment Facility (MTF) Director, by mail, fax, or by other methods proposed by the contractor and accepted by the Government. The contractor shall encourage the beneficiaries to use the Government furnished web-based self-service enrollment system/application to enroll. The overseas contractor shall also collect applications at TRICARE Service Centers (TSCs).
1.2  Enrollment requests must be initiated by the sponsor, spouse, other legal guardian of the beneficiary, or an eligible beneficiary age 18 or older. An official enrollment request includes those with (1) an original signature, (2) an electronic signature offered by and collected by the contractor, (3) a verbal consent provided via telephone and documented in the contractor’s call notes, or (4) a self-attestation by the beneficiary when using the Government furnished web-based self-service enrollment system/application. A signature from a Service member is never required to complete Prime enrollment as enrollment in Prime is mandatory per the TRICARE Policy Manual (TPM), Chapter 10, Section 2.1.
1.3  The contractor shall provide beneficiaries who enroll full and fair disclosure of any restrictions on freedom of choice that apply to enrollees, including the Point of Service (POS) option for TRICARE Prime enrollees and the consequences of possibly having direct care only coverage on a space available basis for failure to pay enrollment fees on time, choosing to not enroll, or disenroll from either TRICARE Prime or TRICARE Select.
1.4  Enrollment shall be on an individual or family basis. For newborns and adoptees, see the TPM, Chapter 10, Section 3.1.
1.5  For TRICARE Prime enrollments, the contractor shall follow the specifications recorded in each Market/MTF’s Memorandum of Understanding (MOU)/Statement of Responsibility (SOR).
1.6  The contractor shall record all enrollments using the Government furnished web-based enrollment system/application, within 10 working days of receipt. The equipment needed to run the DEERS desktop enrollment application shall be furnished by the contractor and shall meet technical specifications in the TSM, Chapter 3.
1.6.1  The contractor shall resend TRICARE Prime/TRICARE Plus PCM Information Transfers (PITs) to Market/MTFs when requested.
1.6.2  The contractor shall submit required changes to the DEERS Support Office (DSO) as required.
1.7  At the time of enrollment processing, the contractor shall access DEERS to verify beneficiary eligibility and shall update the residential, mailing, and e-mail addresses and any other fields that it can update on DEERS.
1.7.1  If the enrollment request (see paragraph 1.2) contains neither a residential address nor a mailing address, the contractor shall develop for a residential or mailing address.
1.7.2  Enrollees or the Government may provide the contractor a temporary address (i.e., Post Office Box, Unit address), until a permanent address is established. Temporary addresses shall be updated with the permanent address when provided to the contractor by the enrollee in accordance with the TSM, Chapter 3, Section 4.2. The contractor shall not input temporary addresses unless provided by the enrollee or the Government.
1.7.3  If the DEERS record does not contain an address, or if the enrollment request contains information different from that contained on DEERS in fields for which the contractor does not have update capability, the contractor shall contact the beneficiary by telephone within five calendar days, outline the discrepant information and request the beneficiary contact their military personnel office.
1.8  DMDC/DEERS shall notify the beneficiary of the TRICARE wallet card at MilConnect. DMDC will also provide notification of PCM assignments for new TRICARE Prime enrollments, disenrollments, enrollment transfers, and PCM changes. (See TSM, Chapter 3, Section 4.2.) The return address on any correspondence mailed by DMDC will be that of the appropriate contractor. In the case of receiving returned mail, the contractor shall develop a process to fulfill the delivery if the correspondence is returned to the contractor by the United States Post Office (USPS).
2.0  Automatic Enrollment Management
2.1  Automatic Eligibility Updates
DEERS will automatically update start and/or end dates of coverage when a beneficiary’s eligibility is updated by the Uniformed Services. The contractor will receive a Policy Notification Transaction (PNT) advising them of all changes, and will take action accordingly.
2.2  Automatic Enrollment of Active Duty Service Members (ADSMs)
DEERS will automatically enroll all new active duty service member accessions, to include Reserve Component members on active duty for more than 30 days, into Health Care Delivery Plan 001 (TRICARE Prime for Active Duty Sponsors, No PCM Assigned).
2.3  Automatic Enrollment of Newly Eligible Active Duty Family Members (ADFMs)
Note:  Automatic enrollment of ADFMs does not apply to USFHP contractors.
The contractor shall upon request from a beneficiary or sponsor, who was auto-enrolled, adjust any claims in question to apply Prime plan benefits, and waive POS cost-sharing provisions. The contractor shall educate the beneficiary or sponsor of this one-time correction and provide instruction to the beneficiary regarding their PCM assignment and the requirement to have referrals for all future specialty care. If received over the phone, the conversation shall be documented in the contractor’s call notes. The contractor need not identify these claims; however, the claims shall be adjusted as they are brought to their attention by beneficiaries.
3.0  Dual Eligibles (Entitlement Under Both Medicare And TRICARE)
3.1  Dual eligibles, (retired and retired family members, under age 65) are eligible to enroll in TRICARE Prime provided they maintain Medicare Part A and Part B. Dual eligible ADFMs, regardless of age, are eligible to enroll in TRICARE Prime or TRICARE Select. Dual eligible retirees and family members age 65 and over are not eligible to enroll in TRICARE Prime or TRICARE Select. Exception: Those not entitled to premium free Medicare part A on their own or the record of their current, former, deceased spouse may enroll in TRICARE Prime or TRICARE Select. Medicare is primary payor for all dual eligibles regardless of their sponsor’s status. (See the TPM, Chapter 10, Section 2.1 for additional dual eligible information.)
3.2  TRICARE Prime-enrolled dual eligibles, to the extent practicable, should follow all TRICARE Prime requirements for PCM assignment, referrals and authorizations. However, they are not subject to POS cost-sharing. Enrollment fees are waived for dual eligibles. (See paragraph 5.0.)
4.0  Assignment Of PCM For TRICARE Prime Enrollees
The contractor shall assign all TRICARE Prime enrollees a PCM by name (PCMBN) on the Government furnished web-based enrollment system/application at the time of TRICARE Prime enrollment. This applies to beneficiaries assigned to the Direct Care (DC) system as well as civilian network PCMs.
4.1  The contractor shall comply with the Market Director’s/MTF Director’s specifications in the Market/MTF MOU/SOR for which enrollees or categories of enrollees shall be assigned a DC PCM or offered a choice of civilian network PCMs.
4.1.1  The contractor shall enroll TRICARE Prime beneficiaries to the Market/MTF until the capacity is optimized in accordance with the Market Director’s/MTF Director’s determinations. TRICARE Prime beneficiaries who cannot be enrolled to the Market/MTF will be enrolled to the contractor’s network.
4.1.2  All active duty personnel not meeting the requirements for TRICARE Prime Remote (TPR) shall be enrolled to a Market/MTF, not the contractor’s network, regardless of capacities.
4.1.3  When a family member of an active duty E-1 through E-4 sponsor requests a PCM in a Market/MTF that offers TRICARE Prime for any beneficiary category other than active duty, that beneficiary shall be assigned a Market/MTF PCM unless capacity has been reached. If overall Market/MTF capacity has not been reached, the contractor shall request the Market/MTF to shift capacity in the Government furnished web-based enrollment system/application to the ADFM beneficiary category from another category if necessary to accommodate an E-1 through E-4 ADFM beneficiary’s PCM assignment request.
4.2  The contractor shall provide guidance to the enrollee in selecting a primary care location or PCM, as appropriate given Market/MTF guidance in the MOU. Upon receipt of an inquiry from a DC enrollee in regards to the person’s assigned PCM, the contractor shall refer the beneficiary to the Market/MTF where the beneficiary is enrolled.
4.3  At the time of enrollment, the contractor shall determine the appropriate enrollment Defense Medical Information System Identification (DMIS-ID) based on the regional and Market/MTF MOUs, access standards and/or other specific Government guidance. The contractor shall assign each enrollee a PCMBN at the time of enrollment based on those PCMs available within the Government furnished web-based enrollment system/application.
4.3.1  The contractor shall attempt to assign the beneficiary to the PCM requested by the beneficiary (see paragraph 1.2) if capacity is available. If the preferred PCM is not available, the contractor shall use the default PCM for that DMIS.
4.3.2  If the enrollment request (see paragraph 1.2) identifies a gender or specialty preference, the contractor shall assign an appropriate PCM. If the gender or specialty is not available, the beneficiary will be enrolled to the default PCM for that DMIS.
4.3.3  If no PCM preference is stated on the enrollment request (see paragraph 1.2), the contractor shall use the default PCM for that DMIS.
4.3.4  If there is no DC PCM available in the appropriate DMIS/Market/MTF, nonactive duty beneficiaries may be enrolled to a civilian PCM, by following the procedures specified in the Market/MTF MOU.
4.3.5  If there is no PCM capacity in the Market/MTF for a Service member, then the contractor shall contact the Market/MTF for instructions.
4.4  The Government furnished web-based enrollment system/application reflects only those DC PCMs that the Market/MTF has loaded onto the DEERS PCM Repository. Further, the Government furnished web-based enrollment system/application will only display PCMs with available capacity for the specific beneficiary’s category and age. The contractor shall not add, delete, or modify DC PCMs on the repository.
4.5  The contractor shall complete all panel PCM reassignments (batch) using a Government-provided systems application, PCM Reassignment System (PCMRS). Panel reassignments may be specified by the appropriate Market Director/MTF Director for a variety of reasons, including the rotation or deployment of DC PCMs. The contractor shall expect at least one-half of DC PCM assignments to change each year. These moves may be based on various factors of either the enrollment or the individual beneficiary, including:
•  DMIS ID to DMIS ID
•  PCM ID to PCM ID
•  Health Care Delivery Program (HCDP)
•  Sex of beneficiary
•  Unit Identification Code (UIC) (active duty only)
•  Age of beneficiary
•  Sponsor Social Security Number (SSN) and DoD Benefits Number (DBN)
•  Name of beneficiary
4.6  Markets/MTFs will request PCM reassignment, including panel reassignments, in several ways, including telephone, e-mail or other electronic submissions. The preferred method for panel reassignments is the batch staging application within PCMRS. Regardless of the submission method, the Market/MTF will provide sufficient information identifying both the PCMs and beneficiaries involved in a move to allow the contractor to reasonably accomplish the move. Thereafter, the contractor shall complete each DC PCM reassignment, both individual and panel reassignment, within three working days of receiving all necessary information from the Market/MTF.
4.7  PCM change requests submitted by beneficiaries enrolled to a civilian network PCM via any means other than the Government furnished web-based self-service enrollment system/application shall be processed by the contractor within three working days of receipt, with an effective date no later than the third working day.
4.8  PCM change requests submitted to the contractor via the Government furnished web-based self-service enrollment system/application shall be processed within six calendar days of receiving the request. The contractor shall modify the effective date to be no later than the third working day, or the date requested by the beneficiary up to 90 days in the future. Effective January 1, 2018, the contractor shall modify the effective date to be the date the contractor received the request.
5.0  Enrollment Period
5.1  Through December 31, 2017, the contractor shall support continuous open enrollment for all beneficiaries. Enrollment may occur any time during the contract period; however, all new enrollment periods will be aligned with the fiscal year. Therefore, the initial enrollment period may be shorter than a 12 month period.
Note:  The enrollment period for fiscal year 2017 includes the period between October 1, 2017 and December 31, 2017.
5.2  Starting January 1, 2018
5.2.1  The contractor shall support one annual open enrollment period per calendar year for all Non-Active Duty Service Member (NADSM) beneficiaries. Enrollments, with the appropriate application and any required enrollment fee, will be effective on January 1 of the following year. Beneficiaries will be automatically re-enrolled each year unless they elect a different option or disenroll during the open enrollment period. See TPM, Chapter 10, Section 2.1.
5.2.2  A one-time transition period will be in effect for the enrollment period beginning January 1, 2018 and ending December 31, 2018. Beneficiaries may elect to enroll in or change their TRICARE Prime or Select coverage at any time during the calendar year 2018 enrollment period.
5.3  Effective Date of Enrollment (Prior to January 1, 2018)
The contractor shall support continuous open enrollment for all beneficiaries. Enrollment may occur any time during the contract period; however, all new enrollment periods will be aligned with the fiscal year. Therefore, the initial enrollment period may be shorter than a 12 month period.
5.3.1  The effective date of enrollment for Service members shall be the date the contractor receives the enrollment application. For enrollment requests received via the Government furnished web-based self-service enrollment system/application, the contractor shall modify the effective date to be the date the enrollment was submitted.
5.3.2  For all other beneficiary categories, enrollment periods shall begin on the first day of the month following the month in which the enrollment application and any required enrollment fee payment is received by the contractor. If an application and fee are received after the 20th day of the month, enrollment will be on the first day of the second month after the month in which the contractor received the application. (This recurring principle is referred to as the “20th of the month” rule.)
5.3.3  Enrollees who transfer enrollment continue with the same enrollment period. The enrollment transfer, however, is effective the date the gaining contractor receives a signed enrollment application or transfer application. For enrollment transfers received via the Government furnished web-based self-service enrollment system/application, the contractor shall modify the effective date to be the date the enrollment was submitted. See TPM, Chapter 10, Sections 2.1 and 5.1 for information on Transitional Assistance Management Program (TAMP) and other changes in status.
5.3.4  Effective Date of Enrollment (On or After January 1, 2018)
5.3.4.1  TRICARE Prime and TRICARE Select enrollments will be effective the date of the Qualifying Life Event (QLE) or on January 1 of the following year for open enrollment period enrollments (see TPM, Chapter 10, Section 2.1). Enrollment requests will no longer be pended for six days.
5.3.4.2  Requests for enrollment based on a QLE may be received up to 90 days before and no later than 90 days after the date of the QLE. For online requests for an enrollment date less than 90 days or more than 90 days from the date of the QLE, the web- based self-service enrollment system/application will display a message to contact the contractor.
5.3.4.3  For TRICARE Prime and TRICARE Select enrollments initiated/updated by DEERS per paragraph 2.0, see TPM, Chapter 10, Section 2.1 for effective enrollment dates.
5.4  Enrollment Expiration (Before January 1, 2018)
5.4.1  Due to the extended enrollment period in 2017, the contractor shall not send renewal notices to TRICARE Prime enrollees on October 1, 2017 as in previous years. See paragraph 5.5.1.
5.4.2  The contractor shall automatically renew enrollments, including those for Service members, upon expiration unless the enrollee declines renewal, is no longer eligible for Prime enrollment, or fails to pay any required re-enrollment fee on a timely basis, including a 30 calendar day grace period beginning the first day following the last day of the enrollment period. See paragraph 11.5.1, for actions required if a beneficiary is identified as being ineligible for continued Prime, TPR or TPRADFM enrollment.
5.4.3  If the enrollee requests disenrollment during this grace period, the contractor shall disenroll the beneficiary effective retroactive to the enrollment period expiration date (last paid-through date).
5.4.4  If an enrollee does not respond to the notification and fails to make an enrollment fee payment by the end of the grace period, the contractor shall assume that the enrollee has declined continued enrollment. The contractor shall disenroll the beneficiary retroactive to the enrollment expiration date (last paid-through date).
5.4.5  Service members may not decline continued enrollment nor request disenrollment.
5.4.6  DMDC sends written notification to the beneficiary of the disenrollment and the reason for the disenrollment within five business days of the disenrollment transaction.
5.5  Enrollment Expiration (Starting January 1, 2018)
5.5.1  The contractor shall not send renewal notices to enrollees. Exception: Thirty (30) days before the expiration date of enrollment for beneficiaries paying enrollment fees quarterly or annually, the contractor shall send the appropriate individual (i.e., sponsor, custodial parent, retiree, retiree family member, survivor or eligible former spouse) a written notification of the pending enrollment expiration that includes a bill for the re-enrollment fee. The notification will alert the beneficiary that he/she will only be eligible for MTF space-available care only should payment not be received. If appropriate, the notification will include any rate change information. The bill shall offer all available payment options and methods. The contractor shall issue a delinquency notice to the appropriate individual 15 calendar days after the expiration date of the enrollment if a renewal payment is not received.
5.5.2  For beneficiaries that pay enrollment fees on a monthly basis: the contractor shall send the appropriate individual (i.e., sponsor, custodial parent, retiree, retiree family member, survivor or eligible former spouse) a written notification alerting the beneficiary of any fee changes at least 30 days prior to the implementation of any fee changes.
5.5.3  The contractor shall automatically renew enrollments, including those for Service members, each calendar year unless the enrollee declines renewal, is no longer eligible for enrollment, or fails to pay any required enrollment fee on a timely basis. See TPM, Chapter 10, Section 2.1 for actions required if a beneficiary is identified as being ineligible for continued enrollment. The contractor may reinstate coverage if the request is received with appropriate payment of fees within 90 days from the last paid-through date.
5.5.4  Active Duty Service Members (ADSMs) may not decline reenrollment nor request disenrollment.
5.5.5  DMDC shall notify the beneficiary of the disenrollment within five business days of the disenrollment transaction.
5.6  Disenrollment
5.6.1  Disenrollment requests must be initiated by the sponsor, spouse, other legal guardian of the beneficiary, or an eligible beneficiary 18 or older. An official disenrollment request includes those with:
•  An original signature;
•  An electronic signature offered by and collected by the contractor;
•  A verbal consent provided vial telephone and documented in the contractor’s call notes; or
•  A self-attestation by the beneficiary when using the Government furnished web-based self-service enrollment system/application. (A Service member cannot request disenrollment.)
5.6.2  The contractor shall automatically disenroll beneficiaries when the appropriate enrollment fee payment is not received by the 30th calendar day following the last paid-through date. The contractor shall set the disenrollment effective date retroactive to the last paid-through date. An enrollment fee payment includes the correct amount for the period the fee is intended to cover (i.e., monthly, quarterly, or annually).
5.6.3  Prior to processing a disenrollment for “non-payment of fees,” the contractor shall reconcile their fee payment system against the fee totals in DEERS. Once the contractor confirms that the payment amounts match, the disenrollment may be entered in the Government furnished web-based enrollment system/application.
5.6.4  Prior to January 1, 2018
5.6.4.1  The disenrolled beneficiary is responsible for the deductible and cost-shares applicable under TRICARE Extra or Standard for any health care received during the 30 day grace period. In addition, the beneficiary is responsible for the cost of any services received during the 30 day grace period that may have been covered under TRICARE Prime but are not a benefit under TRICARE Extra or Standard.
5.6.4.2  The contractor may suspend claims processing during the grace period to avoid the need to recoup overpayments.
5.6.5  Effective January 1, 2018
The contractor shall pend claims received during the grace period to avoid the need to recoup overpayments. See the TPM, Chapter 10, Sections 2.1 and 3.1 for additional information on disenrollment.
5.7  Enrollment Lockout (Prior to January 1, 2018)
5.7.1  The contractor shall “lockout” or deny re-enrollment effective the date of disenrollment for the following beneficiaries:
•  Retirees and/or their family members who voluntarily disenroll prior to their annual enrollment renewal date;
•  ADFMs (E-5 and above) who change their enrollment status (i.e., from enrolled to disenrolled twice in a given year) for any reason during the enrollment year (October 1 to September 30) (refer to this chapter and TPM, Chapter 10, Sections 2.1 and 3.1; and
•  Any beneficiary disenrolled for failure to pay required enrollment fees during a period of enrollment.
Note:  The 12 month lockout provision is not applicable to ADFMs whose sponsor’s pay grade is E-1 through E-4.
5.7.2  Beneficiaries who are disenrolled for the above reasons prior to December 31, 2018 are eligible to re-enroll any time during calendar year 2018. Beginning January 1, 2019, the 2018 enrollment grace period ends and only the annual open enrollment season and QLE rules fully apply. See TPM, Chapter 10, Section 2.1.
5.8  Enrollment Lockout (Starting January 1, 2018)
5.8.1  Enrollment lockouts are no longer necessary for TRICARE Prime and TRICARE Select as enrollments are only allowed during the annual open enrollment period or due to a QLE.
5.8.2  The contractor shall reinstate (restore) the enrollment if the beneficiary requests reinstatement within 90 days of their disenrollment date (last paid-through date) and pays all past due fees if applicable. Otherwise, requests for reinstatement due to failure to pay fees received after 90 days past the last paid-through date shall be denied by the contractor.
5.8.3  Exception
In the event the “failure to pay” disenrollment was directly caused by contractor or Government error, for example, the contractor failed to submit the correct allotment amount to the Defense Finance and Account Service (DFAS), upon request of the beneficiary via the contractor, the GDA, TRICARE Area Offices (TAOs), or USFHP program office may direct reinstatement of the coverage greater than 90 days past the last paid-through date if all past fees are paid if applicable. In no instance shall a new enrollment period be started in lieu of reinstatement from the last paid-through date.
6.0  Enrollment Fees
6.1  General
The contractor shall collect enrollment fee payments from TRICARE Prime and TRICARE Select enrollees as appropriate and report those fees, including any overpayments that are not refunded to the enrollee, to DEERS.
•  The contractor shall report refunds to DEERS: (1) all refunds of any enrollment fees collected, and (2) fee amounts forfeited by enrollees prior to January 1, 2018 who voluntarily disenroll and are not due a refund. The forfeited fee amounts, unless they can be credited to the enrollment of another family member(s), shall not be retained as a credit. For forfeited fees, the contractor shall adjust the fees paid on the enrollment policy to match with the voluntary termination date (“zero” the fees paid). (See the TSM, Chapter 3.) For enrollment fee refund policies as of January 1, 2018, see paragraph 9.0.
•  The contractor shall report a credit to DEERS to offset outstanding enrollment fees anytime a retirement date is retroactively changed by the Services as recorded in DEERS that results in a situation where past prorated enrollment fees are now due based on the changed date for a retiree who was previously paid to date in their enrollment fees that occurred before January, 1, 2018. The contractor shall credit the retiree’s enrollment fee and report as an offset to the collected enrollments deposited to the Defense Health Agency’s (DHA’s) account. This shall occur as long as the retiree’s enrollment fees are otherwise current.
•  To permit the transition from a fiscal to a calendar enrollment year, fiscal year 2017 is defined as the period from October 1, 2016 through December 31, 2017. For FY 2017, prorated TRICARE Prime enrollment fees are required for the additional period of October 1, 2017 through December 31, 2017.
•  TRICARE Prime and TRICARE Select enrollees may choose one of the following three payment fee options (i.e., annual, quarterly, or monthly).
•  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, 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).
•  When enrollment fee or premium payments are permitted by credit or debit cards, beneficiaries in overseas locations must utilize a credit or debit card issued by a U.S. banking institution or other U.S. financial institution.
•  In the event that there are insufficient funds to process an enrollment fee or premium payment, the contractor may assess the account holder a fee of up to 20 U.S. dollars ($20.00), which is retained by the contractor. The contractor shall provide commercial payment methods for enrollment fees and premiums that best meet the needs of beneficiaries while conforming to paragraphs 6.1.2 through 6.8.
6.1.1  Fiduciary Responsibilities
6.1.1.1  The contractor shall act as a fiduciary for all funds acquired from TRICARE Prime and Select enrollment fees, which are Government property. The contractor shall develop strict funds control processes for its collection, retention and transfer of enrollment fees to the Government. All enrollment fees received by the contractor shall be maintained in accordance with these procedures.
6.1.1.2  A separate non-interest bearing account shall be established for the collection and disbursement of enrollment fees. The contractor shall deposit enrollment fees into the established account within one business day of receipt.
6.1.1.3  The contractor shall wire-transfer the enrollment fees minus any refund payments twice monthly, on the first (business day) and the 15th to a specified Government account as directed by DHA Contract Resource Management (CRM) Office, refer to Section G of the contract. The Government will provide the contractor with information for this Government account. The contractor shall notify the DHA CRM, by e-mail, within one business day of the deposit stating the date and amount of the deposit.
6.1.1.4  The contractor shall maintain a clear, auditable record of all enrollment fees received, the date received and the date transferred to the Government. The contractor’s record shall also document all refunds issued, to whom the refund was issued, the amount of the refund, and the date reported to the Government.
6.1.2  Annual Payment Fee Option
An annual installment is collected in one lump sum. For initial enrollments, the contractor shall prorate the fee from the enrollment date to December 31. The contractor shall accept payment of the annual enrollment fee only by debit/credit card (e.g., Visa/MasterCard). See paragraph 5.6 for disenrollment information if the appropriate enrollment fee payment is not received.
6.1.3  Quarterly Payment Fee Option
Quarterly installments are equal to one-fourth (1/4) of the total annual fee amount. For initial enrollments, the contractor shall prorate the quarterly fee to cover the period until the next quarter. Quarters begin on January 1, April 1, July 1, and October 1. The contractor shall collect quarterly fees thereafter. The contractor shall accept payment of the quarterly enrollment fee by debit/credit card (e.g., Visa/MasterCard) and optionally may elect to receive quarterly payments via recurring debit/credit card or EFT transactions. See paragraph 5.6 for disenrollment information if the appropriate enrollment fee payment is not received.
6.1.4  Monthly Payment Fee Option
Monthly installments are equal to one-twelfth (1/12) of the total annual fee amount rounded down if not divisible by 12. Monthly enrollment fees must be paid-through an automated, recurring electronic payment either in the form of an allotment from retirement pay or through EFTs from the enrollee’s designated financial institution (which may include a recurring credit or debit card charge). These are the only acceptable payment methods for the monthly payment option.
6.1.4.1  Enrollees who elect a monthly fee payment option must pay up to three months of fees (contractor determined), at the time the enrollment request is submitted; contingent on the method and date the request is submitted to allow time for an allotment, EFT or RCC to be established. The contractor shall explain the amount required and accept payment by personal check, cashier’s check, traveler’s check, money order, or debit/credit card (e.g., Visa/MasterCard) for initial enrollment requests. For continuous coverage requests, contractors shall accept payment by allotment, EFT or RCC.
6.1.4.2  The contractor shall obtain and verify the information needed to initiate monthly allotments and EFTs.
6.1.4.3  The contractor shall direct bill the beneficiary only when a problem occurs.
6.1.4.4  When an administrative issue arises that stops or prevents an automated monthly payment from being received by the contractor (i.e., incorrect or transposed number provided by the beneficiary, credit card expired, bank account closed), the contractor shall grant the enrollee 30 days from the paid-through date to provide information for a new automated monthly payment method or the option to pay quarterly or annually. The contractor may accept payment by check during this 30 day period in order to preserve the beneficiary’s TRICARE Prime or Select enrollment status.
6.1.4.5  Allotments from retired pay will be coordinated by the contractor with the DFAS, U.S. Coast Guard (USCG), or Public Health Service (PHS), as appropriate (see the TSM, Chapter 1, Section 1.1, paragraph 7.10 for Payroll Allotment Interface Requirements).
6.1.4.6  The contractor shall also research and resolve all requests that have been rejected or not processed by DFAS, USCG, or PHS. If the contractor’s research results in the positive application of the allotment action, the contractor shall resubmit the allotment request.
6.1.4.7  Within five business days, the contractor shall notify the beneficiary of rejected allotment requests and issue an invoice to the beneficiary for any outstanding enrollment fees due. The contractor shall respond to all beneficiary inquiries regarding allotments.
6.2  Member Category
The sponsor’s member category on the effective date of the initial enrollment, as displayed in the Government furnished web-based enrollment system/application, shall determine the requirement for an enrollment fee.
6.3  Unremarried Former Spouses (URFSs) and Children Residing with Them
6.3.1  URFSs became sponsors in their own right as of October 1, 2003. As such, they are enrolled under their own SSNs and pay an individual enrollment fee. URFS may not “sponsor” other family members and their fees may not be factored into any family fees associated with the former spouse/sponsor.
6.3.2  Children residing with URFS, whose eligibility for benefits is based on the ex-spouse/former sponsor, are identified and enrolled under the ex- spouse/former sponsor’s SSN on DEERS, and fees for these children shall be combined with other fees paid under the ex-spouse/former sponsor.
Example:  The contractor shall collect the individual enrollment fee for an URFS’s enrollment under the URFS’s own SSN. The contractor shall also collect a family enrollment fee for any two or more eligible family members enrolled under the SSN of the ex-spouse/former sponsor. These enrollees might include the sponsor, any current spouse, and all eligible children, including those living with the URFS.
6.4  TRICARE Prime Fee Waiver
6.4.1  Each TRICARE Prime enrolled beneficiary, who is required to pay enrollment fees, regardless of age, who maintains enrollment in Medicare Part B, is entitled to a waiver of an amount equivalent to the individual TRICARE Prime enrollment fee. Hence, individual enrollments for such beneficiaries will have the enrollment fee waived. A family enrollment in TRICARE Prime, where one family member maintains enrollment in Medicare Part B, shall have one-half of the family enrollment fee waived; the remaining half must be paid. For a family enrollment where two or more family members maintain enrollment in Medicare Part B, the family enrollment fee is waived regardless of the number of family members who are enrolled in addition to those entitled to Medicare Part B.
6.4.2  A family enrollment in TRICARE Plus with Active Duty Select or TRICARE Plus with Retired Select or TRICARE Prime enrollment, is entitled to a waiver of an amount equivalent to the individual TRICARE Prime or TRICARE Select enrollment fee as appropriate (not to exceed two individual fee payments).
6.5  TRICARE Select Enrollment Fees
Families enrolled in TRICARE Select plans requiring enrollment fees (any combination of TRICARE Select or TRICARE Plus with Select plans) do not pay more than the TRICARE Select family enrollment fee. A fee waiver code will be applied to any policy that does not require fees to be paid.
6.6  Survivors of Active Duty Deceased Sponsors and Medically Retired Uniformed Services Members and their Dependents
6.6.1  Beneficiaries Whose Sponsor Has An Initial Service Date Before January 1, 2018
Effective Fiscal Year (FY) 2012, TRICARE Prime beneficiaries who are (1) survivors of active duty deceased sponsors, or (2) medically retired Uniformed Services members and their dependents, shall have their Prime enrollment fees frozen at the rate in effect when classified and enrolled in a fee paying Prime plan. (This does not include TRICARE Young Adult (TYA) plans). Beneficiaries in these two categories who were enrolled in FY 2011 will continue paying the FY 2011 rate. The beneficiaries who become eligible in either category and enrolled during FY 2012, or in any future fiscal year, shall have their fee frozen at the rate in effect at the time of enrollment in Prime. The fees for these beneficiaries shall remain frozen as long as at least one family member remains enrolled in Prime. The fee for the dependent(s) of a medically retired Uniformed Services member will not change if the dependent(s) is later re-classified a survivor. These two categories of beneficiaries who choose to enroll in TRICARE Select do not pay enrollment fees.
6.6.2  Beneficiaries Whose Sponsor Has An Initial Service Date On Or After January 1, 2018
There is no TRICARE Prime enrollment fee freeze for these retirees and family members; they pay the established annual TRICARE Prime enrollment fee amount. Medically retired members and their family members who choose to enroll in TRICARE Select pay the established annual TRICARE Select enrollment fee.
6.7  Mid-Month Enrollees
6.7.1  The contractor shall collect any applicable enrollment fee from mid-month enrollees at the time of enrollment. However, there will be no enrollment fee collected for the days between the effective enrollment date and the determined enrollment date.
6.7.2  The determined enrollment date shall be established using the “20th of the month rule,” as it is for initial enrollments.
Example:  If the retirement date is May 27, the effective enrollment date will be May 27 and the determined enrollment date will be July 1. Fees will be charged for the period from July 1 forward; no fees will be assessed for the period from May 27 through June 30. DEERS will calculate the paid-through dates based on DEERS data and the enrollment fee amount collected and entered into DEERS by the contractor.
6.7.3  Effective January 1, 2018, paragraphs 6.7.1 through 6.7.2 no longer apply. Fee amounts shall be pro-rated based on 1/30th of the TRICARE Prime or TRICARE Select fee, as applicable, calculated from the date of enrollment (initial eligibility or QLE date) to the end of the month.
6.8  Overpayment Of Enrollment Fees
The contractor shall update DEERS with the enrollment fee amount collected and DEERS will calculate the paid-through date and notify the contractor. DEERS will only extend the paid-through date to cover the current enrollment year, plus two future fiscal years (prior to January 1, 2018) or calendar years (starting January 1, 2018). DEERS will store amounts that cannot cover one month’s fees or amounts that extend the paid-through date beyond two years in the future as a credit.
6.8.1  Funds applied that would move the paid-through date beyond the policy end date are stored as a credit. (The exception is when Prime policies, prior to January 1, 2018, end mid-month; DEERS will set a paid-through date to the end of that month.) Also, if there is a 100% fee waiver with an end date that exceeds more than two fiscal years beyond the current enrollment year, the paid period can extend beyond the two fiscal years and any fee amounts sent to DEERS will be applied as a credit. The contractor shall refund any credit of $1 or more on a current enrollment that extends beyond two fiscal years (prior to January 1, 2018) or two future calendar years (starting January 1, 2018). The contractor shall update DEERS with any fee amount refunded within 30 calendar days. The contractor shall include an explanation for the premium refund. For the 2018 and 2019 enrollment fees credited to the catastrophic cap, the contractor shall notify the beneficiaries by letter of the credit, how the credit was applied, and how a refund can be requested. See also paragraph 8.0.
6.8.2  The following reports will be provided to the contractor by DEERS on a monthly basis to assist with identifying and correcting enrollment fee discrepancies. The contractor responsible for a beneficiary’s current enrollment shall resolve any over/under payments. For split enrollments, the reports will use the billing hierarchy to determine the responsible contractor.
•  Current policies that are two months past due (paid period end date more than two months in the past).
•  Any policies where the paid period end date exceeds the policy end date.
•  Policies where the paid period end date meets the policy end date but a credit exists.
•  Terminated policies where the paid period end date does not meet the policy end date.
6.8.3  The contractor shall analyze and correct all report accounts within 30 days of the report’s availability. The contractor shall correct any data inaccuracies in the enrollment fee reporting system to include the refunding of enrollment fees in excess of what is due, if necessary. The contractor shall update DEERS with any enrollment fee amounts refunded within 30 calendar days and notify DHA as specified above.
7.0  Enrollment Of Family Members Of E-1 Through E-4
7.1  When family members of E-1 through E-4 reside within a 30 minute drive time of a Market/MTF offering TRICARE Prime, the family members will be encouraged to enroll in TRICARE Prime by the enrolling entity (Government or contractor). Upon enrollment, they will choose or be assigned a PCM located in the Market/MTF. The choice of whether to enroll or to decline enrollment in TRICARE Prime is completely voluntary. Family members of E-1 through E-4 who decline enrollment or who enroll in Prime and subsequently disenroll may not re-enroll until the next open period or they experience a QLE.
7.2  Enrollment processing and allowance of civilian PCM assignments shall be in accordance with the Memorandum of Understanding between the contractor and the Market/MTF.
7.3  The primary means of identification and subsequent referral for enrollment shall occur during in-processing to the installation. Non-enrolled E-4 and below families may also be referred to the contractor’s call center, by Commanders, First Sergeants/Sergeants Major, Supervisors, Family Support Centers, and others. Beneficiaries at overseas locations may also be referred to their local TRICARE Service Center (TSC).
7.4  The contractor call center representatives and those giving beneficiary education briefings shall provide enrollment information and support the family member in managing their enrollment options. The education of such potential enrollees shall specifically address the advantages of TRICARE Prime enrollment, including guaranteed access, the support of a PCM, etc. The contractor shall reinforce that enrollment is at no cost for family members of E-1 through E-4 and will give them the opportunity to select or be assigned a Market/MTF PCM, to select a civilian PCM if permitted by applicable MOU or with USFHP, if available, or to decline enrollment in TRICARE Prime.
7.5  The contractor shall discuss the potential effective date of the enrollment.
7.6  Enrollment may be terminated at any time upon request of the enrollee, sponsor or other party as appropriate under existing enrollment/disenrollment procedures. Prior to January 1, 2018, beneficiaries may re-enroll at any time without restriction or penalty. See paragraph 5.2 for enrollment rules as of January 1, 2018.
7.7  The contractor shall not screen TRICARE claims to determine whether it may be for treatment of a non-enrolled ADFM of E-1 through E-4 living in a PSA. Rather, they are to support the prompt and informed enrollment of such individuals when they have been identified by DoD in the course of such a person’s interaction with the Military Healthcare System (MHS) or personnel community and have been referred to the contractor for enrollment.
7.8  Effective January 1, 2018, DMDC will automate the enrollment of newly eligible ADFMs into TRICARE Prime or TRICARE Select, if overseas into TOP Select. See paragraph 2.3.
8.0  TRICARE Eligibility Changes/Refunds Of Fees
See paragraph 9.0 for additional requirement starting January 1, 2018.
8.1  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/her TRICARE eligibility. The beneficiary shall have the choice of paying the entire enrollment fee or paying the fees on a more frequent basis (e.g., monthly or quarterly). If the enrollee chooses to pay by installments, the contractor shall collect only those installments required to cover the period of eligibility. DEERS will calculate the paid-through date based on the enrollment fee amount collected and entered into DEERS by the contractor, which in this circumstance, should cover the period of the beneficiary’s eligibility. The contractor shall refund any overpayment of $1 or more that DEERS does not use to extend the paid-through date to the policy end date (or the last day of the month in which a TRICARE Prime or TRICARE Select policy ends). The contractor shall include an explanation to the beneficiary for the fee refund. The contractor shall update DEERS with any fee amount refunded within 30 calendar days.
8.3  The contractor shall refund the unused portion of TRICARE Prime or TRICARE Select enrollment fees to retired enrollees whose sponsor is recalled to active duty. The contractor shall include an explanation to the beneficiary for the fee refund. The contractor shall calculate the refund using monthly prorating, and shall report such refunds to DEERS within 30 calendar days. Upon activation of the member, the family members will be automatically enrolled as ADFMs (see TPM, Chapter 10, Section 2.1). If the reactivated member’s family chooses continued enrollment in TRICARE Prime or TRICARE Select, the family shall begin a new enrollment period and shall be offered the opportunity to keep their PCM (TRICARE Prime only), if possible.
8.4  Any catastrophic cap accumulations shall be applied to the new enrollment period.
8.5  The contractor shall refund enrollment fees for deceased enrollees upon receiving a written request, along with a copy of the death certificate, from the remaining enrollee or the executor of the decedent’s estate. The contractor shall include an explanation for the fee refund to the beneficiary. Refunds shall be prorated on a monthly basis and apply both to individual plans where the sole enrollee is deceased and to the conversion of a family enrollment to an individual plan upon the death of one or more family members. For individual enrollments, the contractor shall refund remaining enrollment fees to the executor of the estate. For family enrollments that convert to individual plans, the contractor shall either credit the excess fees to the individual plan or refund them either to the remaining enrollee or to the executor of the decedent’s estate, as appropriate. Enrollment fees for family enrollments of three or more members are not affected by the death of only one enrollee and no refunds shall be issued. The contractor shall update DEERS with any amount refunded within 30 calendar days.
8.6  The contractor shall refund the unused portion of TRICARE Prime or TRICARE Select enrollment fees to enrollees who become eligible for Medicare Part A based upon disability, End Stage Renal Disease (ESRD) or upon attaining age 65, provided the beneficiary has Medicare Part B coverage.
8.6.1  The contractor shall issue refunds to these beneficiaries upon receiving (1) a written request from the beneficiary (that includes a copy of their Medicare card) and either confirming their Part B enrollment in DEERS or in a previous Government furnished policy notification, or (2) upon receipt of an unsolicited Government furnished policy notification noting a beneficiary’s fee waiver update based on the Part B enrollment. DEERS generates a Government furnished policy notification when the Centers for Medicare and Medicaid Services (CMS) sends DEERS data indicating a Part B enrollment or disenrollment. Refunds are required for all payments that extend beyond the date the enrollee has Medicare Part B coverage, as calculated by DEERS. The contractor shall update DEERS with any amount refunded within 30 calendar days. The contractor shall include an explanation to the beneficiary for the fee refund. If the fee waiver is a 100% waiver of the TRICARE Prime enrollment fee, the contractor shall send a refund to the beneficiary. If the fee waiver is a 50% waiver of the TRICARE Prime enrollment fee, DEERS will automatically calculate the overpayment and extend the paid-through date for the policy. A refund may not be required unless a credit remains when the policy is paid in full.
8.6.2  For TRICARE Prime enrollees who become Medicare eligible and who maintain Medicare Part B coverage and TRICARE Select enrollees who become Medicare eligible, refunds are required for overpayments occurring on and after the Start of Health Care Delivery (SHCD). The contractor shall utilize the Government furnished policy notifications received indicating a fee waiver based on Medicare to substantiate any claim of overpayment. The contractor shall update DEERS with any amount refunded within 30 calendar days and include an explanation to the beneficiary for the fee refund.
8.6.3  Medicare eligible ADFMs age 65 and over are not required to have Medicare Part B to remain enrolled in TRICARE Prime or TRICARE Select. To maintain TRICARE coverage upon the sponsor’s retirement, they must enroll in Medicare Part B during Medicare’s Special Enrollment Period prior to their sponsor’s retirement date. (The Special Enrollment Period is available anytime the sponsor is on active duty or within the first eight months of the sponsor’s retirement. If they enroll in Part B after their sponsor’s retirement date, they will have a break in TRICARE coverage.)
8.6.4  Medicare eligibles age 65 and over who are not entitled to premium-free Medicare Part A are not required to have Medicare Part B to remain enrolled in TRICARE Prime and TRICARE Select. Because they may become eligible for premium-free Medicare Part A at a later date, under their or their spouse’s SSN, they should enroll in Medicare Part B when first eligible at age 65 to avoid the Medicare surcharge for late enrollment.
8.7  Refunds shall be drawn from the contractor’s enrollment fee account and reported to the Government in accordance with the requirements specified above.
8.8  The contractor shall include full and complete information about the effects of changes in eligibility and rank in beneficiary education materials and briefings.
9.0  TRICARE Eligibility Changes/Refund of Fees
See TSM, Chapter 3.
9.1  Criteria and documentation required for the specific TRICARE eligibility changes as listed in paragraph 8.0 still apply; however, whenever any overpaid fee situation is identified, the contractor will:
9.1.1  Apply overpaid fees to another enrolled family member under the same Uniformed Service sponsor if within the maximum two calendar years. Overpaid fees for URFSs can only be applied to their enrollment records.
9.1.2  Automatically refund prorated enrollment fees in excess of two calendar years.
9.1.3  Upon request from sponsor or responsible individual, apply overpaid fees as directed up to the maximum two calendar years and/or refund overpaid fees as requested.
9.1.4  Refunds must be $1 or more.
9.1.5  Refunds will be issued within 30 days to a Uniformed Service sponsor, eligible spouse, and then oldest child in that order. Refunds for URFS enrollment fees shall only be refunded to the URFS.
9.1.6  Update DEERS within 30 calendar days with any refund amount.
10.0  Wounded, Ill, And Injured (WII) Enrollment Classification
The WII Program provides a continuum of integrated care from the point of injury to the return to duty or transition to active citizenship for the Active Component (AC) or the Reserve Component (RC) Service members who have been activated for more than 30 days. These AC/RC Service members, referred to as Service members, have been injured or became ill while on active duty and will remain in an active duty status while receiving medical care or undergoing physical disability processing. WII Programs vary in name according to Service. The Service shall determine member eligibility for enrollment into a WII Program, as well as whether or not to utilize these enrollments.
To better manage this population, a secondary enrollment classification of HCDP Plan Coverage Codes, WII 415 and WII 416 were developed. The primary rules apply to the WII HCDP codes:
•  Service members must be enrolled to TRICARE Prime prior to, or at the same time, as being enrolled into a WII 415 or WII 416 Program.
•  A member cannot be enrolled in WII 415 and WII 416 Programs at the same time.
•  WII 415 and WII 416 enrollments will terminate at the end of the member’s active duty eligibility, when members transfer enrollment to another Market/MTF, change of a plan code, or at the direction of the Service-specific WII entity.
•  Any claims processed for WII 415/416 enrollees shall follow the rules associated with the primary HCDP Plan Coverage Code, such as TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote. All claims will process and pay under Supplemental Health Care Program (SHCP) rules. DEERS will not produce specific enrollment cards or letters for WII 415/416 enrollment.
WII 415/416 TRICARE Encounter Data (TED) record(s) shall be coded with the WII 415/416 HCDP Plan Coverage Code; however, the Enrollment/Health Plan Code data element on the TED record shall reflect the appropriate value for the primary HCDP Plan Coverage Code. For example, a TED record for a WII 416 enrollee with primary enrollment to TPR would reflect the HCDP Plan Coverage Code of “416” but the Enrollment/Health Plan Code would be coded “W TPR Active Duty Service Member”.
10.1  WII 415 - Wounded, Ill, And Injured (e.g., Warrior Transition/MEDHOLD Unit (WTU))
10.1.1  Service defined eligible Service members assigned to a WII 415 Program such as a MEDHOLD or WTU shall be enrolled to TRICARE Prime or TOP Prime prior to, or at the same time, as being enrolled into the WII 415. Members cannot be enrolled to the WII 415 without a concurrent TRICARE Prime or TOP Prime enrollment. Service appointed WII case managers will coordinate with the Market/MTF to facilitate TRICARE Prime PCM assignments for WII 415 members. The contractor shall assign a PCM in accordance with the Market/MTF MOU and in coordination with the WII case manager. WII 415 enrollment will not run in conjunction with TAMP and members enrolled in TPR, or TOP Prime Remote are not eligible to enroll in the WII 415.
10.1.2  The Service-specific WII entity will stamp the front page of the DD Form 2876, enrollment application form, with WII 415. The enrollment form will then be sent to the appropriate contractor who shall perform the enrollment in the Government furnished web-based enrollment system/application and include the following information:
•  WII 415 HCDP Plan Coverage Code
•  WII 415 Enrollment Start Date (The contractor may change the Government furnished web-based enrollment system/application defaulted start date, which may or may not coincide with the Prime Enrollment Start Date. The start date may be changed up to 289 days in the past or 90 days into the future.)
10.1.3  WII 415 enrollments shall be in conjunction with a Market/MTF enrollment only, not to civilian network PCMs under TPR enrollment rules. DEERS shall end WII 415 enrollments upon loss of member’s active duty eligibility. WII 415 program enrollments shall not be portable across programs or regions. The TOP contractor shall enter WII 415 enrollments through the Government furnished web-based enrollment system/application for outside the 50 United States (U.S.) and the District of Columbia.
10.1.4  The contractor shall accomplish the following functions based on receipt of notification from the Service-specific WII Program entities:
•  Enrollment.
•  Disenrollment.
•  Cancel enrollment.
•  Cancel disenrollment.
•  Address update.
•  The contractor can request unsolicited Government furnished policy notifications resend.
•  Modify begin date.
•  Modify end date.
10.2  WII 416 - Wounded, Ill, And Injured - Community Care Units (CCUs)
10.2.1  Service defined eligible Service members may be assigned to a WII 416 Program such as the Army’s CCU and receive required medical care near the member’s home. The Service member shall be enrolled to TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote prior to or at the same time as being enrolled into WII 416. Members cannot be enrolled to the WII 416 program without a concurrent Prime, TPR, TOP Prime, or TOP Prime Remote enrollment. Service appointed case managers will coordinate with the contractor or Market/MTF to facilitate TRICARE Prime or TPR PCM assignments for eligible beneficiaries. The contractor shall assign a PCM based on the Market/MTF MOU and in coordination with the WII entity (e.g., CCU). WII 416 enrollments will not run in conjunction with TAMP.
10.2.2  The Service-specific WII Program will stamp the front page of the DD Form 2876, enrollment application form, with WII 416 for all new enrollments. The begin date will be the date the contractor receives the signed enrollment form. A signed enrollment application includes those with an original signature, or an electronic signature offered by and collected by the contractor. The enrollment form will then be sent to the appropriate contractor who shall perform the enrollment in the Government furnished web-based enrollment system/application and include the following information:
•  WII 416 HCDP Plan Coverage Code.
•  WII 416 Enrollment Start Date. (Date received by the contractor or the date indicated by the Service-specific WII Program which may be up to 289 days in the past, or 90 days in the future.)
10.2.3  WII 416 enrollments must be in conjunction with a Market/MTF, TPR, TOP Prime, or TOP Prime Remote enrollment. DEERS will end WII 416 enrollments upon loss of member’s active duty eligibility. WII 416 program enrollments are not portable across programs or regions.
10.2.4  The contractor shall accomplish the following functions based on receipt of notification from Service-specific WII program entities:
•  Enrollment.
•  Disenrollment.
•  Cancel enrollment.
•  Cancel disenrollment.
•  Address update.
•  The contractor can request Government furnished policy notification resend.
•  Modify begin date.
•  Modify end date.
11.0  TRICARE POLICY For Access To Care (ATC) And Prime Service Area (PSA) Standards
11.1  Non-active duty beneficiaries in the Continental United States (CONUS) and Hawaii who reside more than 30 minutes travel time from their desired PCM but less than 100 miles must waive primary and specialty drive-time ATC standards if they wish to enroll in TRICARE Prime. (Due to the unique health care delivery challenges in Alaska, the requirement to request a waiver for the drive-time access standard does not apply to beneficiaries in Alaska.) Before effecting an enrollment or portability transfer request, the contractor shall ensure that a beneficiary has waived travel time ATC standards either by checking the Drive Time Waiver box in Section V of the DD Form 2876 enrollment application (this includes an electronic signature offered by and collected by the contractor), by providing verbal consent via telephone communication (which shall be documented in the contractor call notes), or by requesting enrollment through the Government furnished web-based self-service enrollment system/application (for both civilian and Market/MTF PCMs). An approved waiver for a beneficiary residing less than 100 miles but more than 30 minutes from their PCM will remain in effect until the beneficiary changes residence.
11.2  The contractor shall estimate the travel time or distance between a beneficiary’s residence to a PCM (either a civilian PCM or a Market/MTF) using at least one web-based mapping program. The choice of the mapping program(s) is at the discretion of the contractor, but the contractor must use a consistent process to determine the driving distance for each enrollee applicant who may reside more than 30 minutes travel time from their PCM. The time or distance shall be computed between the enrollee’s residence and the physical location of the PCM (including Markets/MTFs). It is not acceptable to use a geographic substitute, such as a geographic centroid.
11.3  The contractor (in conjunction with Markets/MTFs for Market/MTF enrollees) shall provide beneficiary drive-time waiver education and ensure that beneficiaries who choose to waive these standards have a complete understanding of the rules associated with their enrollment and the travel time standards they are forfeiting. This includes educating beneficiaries, who waive their ATC travel standards, of the following:
•  They should expect to travel more than 30 minutes for access to primary care (including urgent care) and possibly more than one hour for access to specialty care services.
•  They will be held responsible for POS charges for care they seek that has not been referred by their PCM (or for Market/MTF enrollees, by another Market/MTF provider).
•  They should consider whether any delay in accessing their enrollment site might aggravate their health status or delay receiving timely medical treatment.
11.4  Cross-Region TRICARE Prime Enrollment
Beneficiaries shall enroll to the Region where the desired PCM is located; however, all TRICARE Prime enrollment policies still apply, i.e., PCM selection and utilization, referrals, drive times and distance standards to the desired PCM. An access to care drive-time waiver is required (see paragraph 11.1). All claims are processed by the Region of enrollment. Cross-region enrollment must be requested by either submitting an enrollment form (DD Form 2876) or by calling the regional contractor servicing the desired PCM. The enrolling contractor shall ensure a beneficiary is not approved for cross-region enrollment if they live within 30-minutes of a Market/MTF, unless the Market’s/MTF’s servicing contractor approves the enrollment. The beneficiary shall be enrolled to the Market/MTF if a PCM is available.
11.5  Discrepant Addresses
11.5.1  If at any point during the enrollment period the contractor determines or is advised that a beneficiary is no longer eligible for continued TRICARE Prime enrollment due to their address, the contractor shall inform the beneficiary of the discrepant address situation. For example, their residential address is 100 miles or more from the PCM or Market/MTF (with no 100 mile waiver) to which they are enrolled or their residential address is 100 miles or more from their assigned network PCM. This notification (letter, telephone call, or e-mail) shall occur when the discrepant information is first known by the contractor. If the beneficiary confirms the DEERS-recorded address is incorrect, and the beneficiary updates DEERS with correct information (contractor to assist as appropriate), the beneficiary will remain enrolled in TRICARE Prime if all enrollment requirements are met.
11.5.2  For the 50 United States and the District of Columbia Only: Once a month, when the contractor confirms the beneficiary is ineligible for enrollment due to their address, the contractor shall notify the beneficiary that they will be charged POS for all care received without a referral from their PCM. The contractor shall provide the beneficiary information about TRICARE Standard and Extra, prior to January 1, 2018, or TRICARE Select, starting January 1, 2018, and continue to process all claims until the enrollment is changed. If the beneficiary chooses to not enroll in TRICARE Select or USFHP, where available, within 90 days of notification, the contractor shall transfer the beneficiary enrollment to TRICARE Select.
Note:  The contractor, upon beneficiary request, will process retroactive enrollment requests from a beneficiary whose TRICARE Prime coverage was terminated on or after January 1, 2019 due to a discrepant address that resulted in no TRICARE private sector coverage. Affected beneficiaries may retroactively enroll in either TRICARE Prime (if qualified) or TRICARE Select. The contractor must collect all applicable retroactive TRICARE enrollment fees before processing an enrollment request. Alternatively, they may elect to restart their TRICARE coverage following QLE or annual open enrollment season rules and costs.
11.6  MARKET/MTF TRICARE Prime Enrollees
11.6.1  Non-active duty beneficiaries must reside within 30 minutes travel time from a Market/MTF to which they desire to enroll. If a beneficiary desiring enrollment resides more than 30 minutes (but less than 100 miles) from the Market/MTF, they may be enrolled so long as they waive primary and specialty ATC standards and the Market Director/MTF Director, or designee, approves the enrollment. (If the MOU includes zip codes or drive-time distances for which the Market/MTF is willing to accept enrollments that are beyond a 30 minute drive, this constitutes approval. See 32 CFR 199.17 for information on access standards. If not addressed in the MOU, the contractor shall submit each request to the Market Director/MTF Director, or designee, in a method that is outlined in the MOU.) The GDA may approve waiver requests from beneficiaries who desire to enroll to a Market/MTF and who reside 100 miles or more from the Market/MTF. In these cases, the Market Director/MTF Director must also agree to the enrollment and have sufficient capacity and capability.
11.6.2  If the contractor determines that the beneficiary resides 100 miles or more from the Market/MTF to which they are enrolled, and there is no 100 mile waiver on file, the contractor shall inform the beneficiary that they are no longer eligible for Prime enrollment to the Market/MTF. Any notice shall include information on any alternative options for enrollment. The notice shall also advise the beneficiary of the option to use TRICARE Standard/Extra (before January 1, 2018), enroll in TRICARE Select (on or after January 1, 2018) as a QLE, or enroll with a USFHP where available, within 90 calendar days of notification, the contractor shall transfer the beneficiary enrollment to TRICARE Select.
11.6.3  The contractor shall process all requests for enrollment to a Market/MTF in accordance with the MOU between the Market/MTF and the contractor. See paragraph 11.4 regarding cross-region enrollments. Enrollment guidelines in MOUs may include:
11.6.3.1  Zip codes and/or distances for which the Market Director/MTF Director is mandating enrollment to the Market/MTF. These mandatory Market/MTF enrollment areas must be within access standards (i.e., a 30 minute drive-time of the Market/MTF) and may apply to all eligible beneficiaries or may be based on beneficiary category priorities for Market/MTF access.
Note:  Non-active duty TRICARE Prime applicants who reside more than 30 minutes travel time from a Market/MTF must be afforded the opportunity to enroll with a civilian PCM.
11.6.3.2  There may be zip codes and/or distances for which the Market Director/MTF Director is willing to accept enrollment. This can include both areas within a 30 minute or less drive-time and over a 30 minute drive but within 100 miles. Any enrollment for a beneficiary with a drive of more than 30 minutes requires a signed waiver of access standards. If an enrollee applicant resides within a zip code previously determined to lie entirely within 30 minutes travel time from the Market/MTF, the contractor need not compute the travel time for that applicant.
11.6.3.3  In determining whether or not the Market Director/MTF Director will consider a request for TRICARE Prime enrollment beyond 100 miles, the Market Director/MTF Director may use zip codes to designate those areas where he/she will consider requests or will not consider requests.
11.6.4  The contractor shall notify the Market Director/MTF Director (or designee) when a beneficiary residing 100 miles or more from the Market/MTF, but in the same Region, requests a new enrollment or portability transfer to the Market/MTF. Such notification is not necessary if the MOU has already established that the Market Director/MTF Director will not accept enrollment of beneficiaries who reside 100 miles or more from the Market/MTF. The contractor shall make this notification by any mutually agreeable method specified in the MOU. The contractor shall not make the Market/MTF enrollment effective unless notified by the Market/MTF to do so.
11.6.4.1  The Market Director/MTF Director will notify the Director, GDA of their desire to enroll a beneficiary who resides 100 miles or greater from the Market/MTF and request approval for the TRICARE Prime enrollment. The Director, GDA will make a determination on whether or not to approve or deny the request and notify the Market Director/MTF Director of his decision by a mutually agreeable method. The Market Director/MTF Director is responsible for notifying the contractor of all approved enrollment requests for beneficiaries who reside 100 miles or greater from the Market/MTF. The contractor shall notify the beneficiary of the final decision.
11.6.4.2  Approved waivers for beneficiaries residing 100 miles or more from the Market/MTF shall remain in effect until the beneficiary changes residence or unless the Market Director/MTF Director determines that they will no longer allow these enrollments. Even if a beneficiary has previously waived travel time standards, any Market Director/MTF Director may revise the MOU (following the MOU revision process) to state that enrollment of some or all current enrollees who reside 100 or more miles from the Market/MTF are not to be renewed at the end of the enrollment period. The contractor shall inform such beneficiaries no later than two months prior to expiration of the current enrollment period that they are no longer qualified for renewal of enrollment to the Market/MTF. Prior to notification, the contractor shall obtain the rationale for the change from the Market/MTF to include in the notice to the beneficiary. The proposed notice shall be reviewed and concurred on by the Director, GDA prior to being sent to the impacted beneficiaries. (The GDA will coordinate notices with DHA Communications prior to approval.)
11.6.5  At any time during the enrollment period, if the contractor determines there is no signed travel time waiver on file for a current Market/MTF enrollee who resides more than 30 minutes from the MTF, the contractor shall, require the beneficiary to waive the primary and specialty care travel standards to continue their TRICARE Prime enrolled status. (This includes monitoring address changes received by the contractor from all sources.) The contractor shall notify the beneficiary of this waiver requirement within 30 days of determining a need for waiver. If the beneficiary chooses to not enroll in TRICARE Select, or USFHP, where available, within 90 calendar days. of notification, the contractor shall transfer the beneficiary enrollment to TRICARE Select. The language for all beneficiary notices shall be reviewed and concurred on by the GDA prior to being sent to beneficiaries. (The GDA will coordinate notices with DHA Communications prior to approval.)
•  Any notice to a beneficiary that is requesting they sign a waiver of access standards, denying their enrollment, or advising them they are not eligible for re-enrollment to a Market/MTF, shall include information on any available TRICARE plan options.
11.6.6  For each approved enrollment to a Market/MTF where the beneficiary has waived access standards, the contractor shall retain the enrollment request in a searchable electronic file until 24 months after the beneficiary is no longer enrolled to the Market/MTF. The contractor shall provide the retained file to a successor contractor at the end of the final option period.
11.6.7  When an enrollment request requires Market Director/MTF Director or Director, GDA approval, any contractual requirements relating to processing timeliness for enrollment requests will begin when the contractor has obtained direction from the Market Director/MTF Director or Director, GDA regarding waiver approval or disapproval.
11.7  Civilian TRICARE Prime PCMs
11.7.1  Within a PSA, the contractors’ civilian network shall have the capability and capacity to allow beneficiaries who reside in the PSA to enroll to a PCM within access standards. If a beneficiary who resides in the PSA requests enrollment to a specific PCM who is located more than a 30 minute drive from the beneficiary’s residence, the contractor may allow the enrollment if beneficiary waives travel time access standards. (Also, see Chapter 5, Section 1.)
11.7.2  Outside a PSA, for new enrollments (including portability transfers), the contractor is not required to establish a network with the capability and capacity to grant TRICARE Prime enrollment to beneficiaries who reside outside a PSA. Requests for new enrollments to the civilian network from beneficiaries residing outside a PSA will be granted provided there is sufficient unused network capacity and capability to accommodate the enrollment and that the PSA civilian network PCM to be assigned is located less than 100 miles from the beneficiary’s residence. Beneficiaries who reside outside the PSA and enroll in TRICARE Prime must waive their primary and specialty care travel time access standards.
11.7.2.1  ADFMs (Including ADFM TYA Prime Enrollees) Residing Outside A PSA
ADFMs (including ADFM TYA Prime enrollees) enrolled in TRICARE Prime and who reside outside of a T-3 PSA on September 30, 2013, will be grandfathered in TRICARE Prime starting October 1, 2013. They will remain enrolled in TRICARE Prime as long as they reside within 40 miles of the residence where they were originally granted grandfathered status and maintain eligibility as ADFMs. The contractor must continue to have a PCM available for these beneficiaries and ensure all claims and benefits are administered as TRICARE Prime. ADFMs shall remain enrolled in TPRADFM, as appropriate. The contractor will manage the grandfathered ADFMs as stated in this chapter.
11.7.2.2  Terms Of Grandfathered Prime - Status
The ADFM must maintain a residence within 40 miles of the residence where they were originally granted grandfathered status in order to retain grandfathered status. Grandfathered ADFMs must be assigned a PCM. Grandfathered ADFMs may add or terminate enrollment of dependents like any other ADFM (e.g., marriage, birth, adoption, divorce). Dependents may live in a separate residence outside a T-3 PSA and still be grandfathered.
11.7.2.3  Grandfathered ADFMs lose their grandfathered status when they are:
•  No longer TRICARE eligible;
•  No longer residing within 40 miles of the residence where they were originally granted grandfathered status; or
•  Change to retired status.
11.7.3  Beneficiaries who reside outside the PSA and are 100 miles or greater from an available civilian network PCM in the PSA shall not be allowed to enroll in TRICARE Prime.
12.0  Reports
The contractor shall provide monthly Service member enrollment and beneficiary services reports according to the Contract Data Requirements List (CDRL).
13.0  Implementation Of TRICARE Select Group A Enrollment Fees
13.1  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.
13.2  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.
13.3  The contractor shall extend the TRICARE reinstatement policy for TRICARE Select Group A from 90 days (see paragraph 5.8.2) 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.
13.4  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.
13.5  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, Contract Data Requirements List (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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