2.3.2 Enrollment will be done during an
open season enrollment period prior to the beginning of each plan
year, which operates with the calendar year. An enrollment choice
will be effective for the plan year. Beneficiaries may choose to
enroll, change, or terminate TRICARE Prime or Select coverage from
the Monday of the second full week in November to the Monday of
the second full week in December of each calendar year. There is
a limited grace period exception to this enrollment requirement
for calendar year 2018, as provided in National Defense Authorization
Act (NDAA) FY 2017, Section 701(d)(3), to give TRICARE Prime or
TRICARE Select eligible beneficiaries another chance to adjust to
this new requirement for annual enrollment ending on December 31,
2018. See TOM,
Chapter 6, Section 1.
2.3.2.1 If electing to change their TRICARE
coverage during the open season, the newly elected coverage will
begin on January 1 of the following year and will continue in effect
until they lose eligibility or request to change their coverage
when authorized.
2.3.2.2 If a beneficiary
chooses to not elect to change their TRICARE coverage during the
open enrollment period, the coverage will be continued until the
end of the next calendar year unless otherwise terminated.
2.3.3 Qualifying
Life Events (QLEs)
As an exception to the open enrollment
period rule, enrollment changes can be made during the plan year
for certain QLEs, including:
• Marriage, divorce,
or annulment;
• Birth or adoption of a child;
• Placement of
a child by a court in a member’s home;
• Change in sponsor
status that results in ineligibility to continue existing TRICARE coverage);
• Gain or loss
of command sponsorship (overseas only);
• Loss of sponsor
or family member eligibility (age, Medicare, etc.);
• Relocation to
a new country, and/or city (OCONUS), region or zip +4 code (date received
or date specified by the beneficiary in the future) (self-attestation);
• Gain or loss
of Other Health Insurance (OHI) (self-attestation);
• Gain
or loss or Medicaid entitlement;
• Gain
or loss of Medicare entitlement (not applicable for loss of Medicare
coverage for failing to sign up on time for Medicare coverage or
failing to pay Medicare premiums);
• Death of a sponsor,
spouse or child;
• Change in eligibility status of any single
family member in another family (e.g., joint service member);
• Change in family
composition (gaining family only): Beneficiaries with multiple sponsors
whose eligibility to enroll is established from one sponsor to another
in DEERS without evidence of any other QLE. However, this QLE cannot
be used in the Government furnished web-based self-service enrollment
system/application. Beneficiaries must contact the contractor to
use this QLE.
• Government Directed PCM Changes: If a MTF/eMSM
requires a TRICARE Prime enrollee to move from a network PCM to
a MTF/eMSM PCM or vice versa, the enrollee may choose to agree with
the PCM change or may enroll in TRICARE Select.
• Government Directed
Plan change: If the Government no longer offers a TRICARE enrolled
health plan in one or more areas, affected beneficiaries may elect
to enroll in another qualified TRICARE plan.
2.3.3.1 Enrollment must be within 90 calendar
days of the date of the QLE. Coverage starts as of the date of the
QLE. Applicable enrollment fees must be paid for that period. For
QLEs resulting from address changes, the effective date will be
the address effective date on DEERS. Whenever DEERS supports entry
of a future effective date for a QLE event, DEERS will allow a QLE
enrollment action up to 90 days prior to that date. The enrollment
action will be effective the date of the QLE. This includes self-attest
QLEs with a future effective date.
2.3.3.1.1 EXCEPTION:
For Uniformed Services retirements that occur on or after January
1, 2018, upon request, contractors shall enroll retired service
members and their family members into TRICARE Prime (if qualified)
or TRICARE Select coverage retroactive to the date of retirement
if the enrollment request is received within 12 calendar months
of the retirement date and as long as all enrollment fees (if applicable)
back to the retirement date are paid. The effective start date of
coverage must be the member’s retirement date. However, if the effective
retirement date occurred between January 1, 2018 and May 1, 2018,
the contractor shall accept and process retroactive enrollment requests
if received by May 1, 2019, and charge appropriate enrollment fees
retroactive to the effective retirement date. The effective coverage
date remains the date of retirement. Otherwise, for retroactive
enrollment requests received after May 1, 2019 that request a retroactive
enrollment date greater than 12 months in the past or request a
start of coverage date other than the date of retirement, then open
season and QLE rules apply.
2.3.3.1.2 EXCEPTION:
For Unremarried Former Spouses (URFS) who become eligible for TRICARE as
their own sponsor on or after January 1, 2018, upon request, contractors
shall enroll them into TRICARE Prime (if qualified) or TRICARE Select
coverage retroactive to the date of eligibility as an URFS if the
enrollment request is received within 12 calendar months of the
initial eligibility date as an URFS and as long as all enrollment
fees (if applicable) back to the initial URFS eligibility date are
paid. The effective start date of coverage must be initial URFS
eligibility date. However, if the effective date of their eligibility
as an URFS occurred between January 1, 2018 and May 1, 2018, the
contractor shall accept and process retroactive enrollment requests
if received by May 1, 2019. The effective coverage date remains
the date of eligibility as an URFS. Otherwise, for retroactive enrollment
requests received after May 1, 2019 that request a retroactive enrollment
date greater than 12 months in the past or request start of coverage
date other than the date of eligibility as an URFS,
then open season and QLE rules apply.
Note: The
one year limitation on submittal of claims in the TOM, Chapter 8, Section 3, paragraph 2.1.1, is
waived for those retroactively enrolled with an effective coverage
date between January 1, 2018 and May 1, 2019. The contractor does
not need to identify these claims; however, the contractor shall
adjust claims when beneficiaries bring them to the contractor’s
attention.
2.3.3.2 A
QLE for one beneficiary in a sponsor’s family permits a change in
the sponsor’s enrollment or other family member’s enrollment status
during the QLE period. A specific QLE may only be used once to make
a change in enrollment status.
2.3.3.3 Overlapping QLEs. If the beneficiary
has more than one QLE that have overlapping 90-day periods, the
beneficiary will be allowed to pick which QLE to use. If the beneficiary
chooses a later QLE, the previous QLEs will no longer be available
to use. For example: A beneficiary loses OHI on January 1st and
has a child on February 1st. Within 90 days for either QLE, the
beneficiary may change their enrollment status based on the loss
of OHI or for the birth of a child, whichever QLE they decide to
use. If the beneficiary chooses to use the latter QLE to make an
enrollment change, they may no longer use the earlier QLE (loss
of OHI in this example). If the beneficiary makes a QLE enrollment
status change but then changes their mind, they must contact the
contractor to make the change if they are within the 90-day period
of a valid QLE. The beneficiary will be unable to take this action
in the Government furnished web-based self-service enrollment system/application.
2.3.3.4 Enrollment
choices made during open season can be changed if there is a QLE
that happens between that choice and December 31st of that year.
2.3.3.5 The
Director, DHA or designee, reserves the right to direct the contractors
to change an enrollment regardless of the QLE rules.
2.3.3.6 Canceling
a QLE event invalidates the QLE. If a projected QLE does not happen,
the beneficiary can request the previous coverage to be reinstated
as long as they are within 90 days of the projected QLE. In the
Government furnished self-service web-based enrollment system/application, once
a QLE is selected (or declined) no more actions may be made based
on that QLE. This includes future QLEs.
2.3.3.7 A
reinstatement of eligibility is not a QLE. Extending the previous
eligibility is not a QLE.
2.3.3.8 Enrollment
portability and PCM changes are not limited to the open enrollment
period and do not require a QLE.
2.3.3.8.1 A PCM change
within region can occur at any time even if address does not change. The
regional contractor will verify that PCM assignment complies with
MTF MOU.
2.3.3.8.2 For overseas,
in country moves shall be treated as PCM changes. This will be enforced when
the TRICARE Overseas contractor receives the Policy Notification
Transaction (PNT).
2.3.3.8.3 TRICARE Prime
Uniformed Services Family Health Plan (USFHP) enrollees who are
not otherwise TRICARE-eligible (i.e., 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 Managed Care
Support Contractor (MCSC).
2.3.5 Payment
of enrollment fees may be made on an annual or quarterly basis by
credit card and for monthly enrollment fee payments, by EFTs or
an allotment from retirement pay. No administrative fees are charged
to enrollees who choose to pay monthly or quarterly.
Note: Effective March
26, 1998, the TRICARE Prime enrollment fee is waived for those enrollees who
have Medicare Part B, regardless of age. Dual eligibles age 65 and
older, who have an active duty sponsor or who are not entitled to
premium-free Medicare Part A on their own record, or the record
of their current, former, or deceased spouse, may enroll in TRICARE
Prime. See TOM,
Chapter 6, Section 1.