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TRICARE Policy Manual 6010.60-M, April 1, 2015
Eligibility And Enrollment
Chapter 10
Section 3.1
TRICARE Prime/TRICARE Select And Status Changes
Issue Date:  May 15, 1996
Authority:  32 CFR 199.17
Revision:  C-91, November 19, 2021
1.0  POLICY (Before January 1, 2018)
1.1  Generally, when the TRICARE eligibility status changes, eligibility for TRICARE Prime benefits also changes. The time frames for TRICARE Prime eligibility parallel TRICARE eligibility.
1.2  In all cases, when TRICARE eligibility ends, eligibility for TRICARE Prime ceases. This includes retirees, their family members and survivors who turn age 65 and are entitled to Medicare but are not eligible for TRICARE for Life (TFL), dependent children who lose TRICARE eligibility due to age, remarriage of former spouses, etc.
1.3  To have continuous TRICARE Prime coverage, the enrollee shall submit an enrollment form, or use the Government furnished web-based self-service enrollment system/application transaction, or make a telephonic request to the contractor before, or within 30 days following, their retirement date, and pay the appropriate enrollment fees, calculated based on the effective date of enrollment, within the required time frames (see Section 2.1, paragraph 1.1.4.2.1). Active duty personnel who retire may enroll at the same time as the remaining family members.
1.3.1  If this is not done before or within 30 days following the member’s retirement or separation, enrollment or reenrollment will be effective according to the provisions of Section 2.1, paragraph 1.1.4.
1.3.2  If the enrollee is receiving ongoing care at the time of retirement or separation, he/she must comply with all of the care authorization requirements of the enrollee’s new status including getting a new authorization from the contractor.
1.4  When status changes from Active Duty Family Member (ADFM) to retiree family member, TRICARE Prime enrollees shall be offered an opportunity to continue enrollment in TRICARE Prime, if available, but at the retiree cost-sharing rates. These enrollees must pay the applicable enrollment fees. Beneficiaries shall be permitted to keep their Primary Care Manager (PCM), if possible. Market Directors/Military Treatment Facility (MTF) Directors shall determine if retiring beneficiaries who enroll in TRICARE Prime could keep their Market/MTF PCMs, given the Market’s/MTF’s enrollment plan and Market/MTF capacity.
1.5  TRICARE Prime Enrollment for Transitional Survivors. Those in Transitional Survivor Status, are not distinguished from other ADFMs for TRICARE Prime eligibility. See the Transitional Survivor Status policy in Section 7.1.
1.6  When an active duty member retires other than the first of the month or a member separates other than the first of the month but continues to be eligible (e.g., is the spouse of an active duty member; or is eligible for Transitional Assistance Management Program (TAMP)), TRICARE Prime enrollment may continue as of the date of retirement or separation so long as all enrollment requirements have been met as stated in Section 2.1, paragraph 1.1.4.
1.7  When TRICARE Prime enrollment changes from an individual to a family enrollment status prior to annual renewal for beneficiary categories required to pay an enrollment fee, the unused portion (pro-rated on a monthly basis) of the fee will be applied toward a new enrollment period or refunded in accordance with the TRICARE Operations Manual (TOM), Chapter 6, Section 1, paragraph 8.0.
1.7.1  For ADFMs, single enrollment can be changed to family at any time during the enrollment period. A new enrollment period shall be established for the family.
1.7.2  A newborn or adoptee will be deemed to be enrolled in TRICARE Prime as of the day of birth or adoption if one family member is already enrolled in TRICARE Prime. A responsible representative has 60 days to officially enroll the child to the TRICARE Prime option. If the newborn or adoptee is formally enrolled in TRICARE Prime within the 60 day period, the effective date of enrollment will be the first of the month following the date of birth or adoption. (The 20th of the month enrollment rule is waived, if necessary.) If the newborn or adoptee is not formally enrolled during the 60 day calendar period, the newborn or adoptee will revert to a non-enrolled beneficiary effective the 61st day. If the decision is made to continue TRICARE Prime coverage, an official enrollment request (enrollment form, Government furnished web-based self-service enrollment system/application transaction, or telephonic request) must be completed on behalf of the child. For retirees or their family members or survivors who decide to continue enrollment for the child, the unused portion (pro-rated on a monthly basis) of the single enrollment fee they paid will be applied toward a new family enrollment period. For newborns and newly adopted children enrolled under this provision, Point of Service cost-sharing does not apply through the 60th day or the effective date of enrollment, whichever is earlier. All services shall be processed with the TRICARE Prime copayment even in the absence of referrals or authorizations. The Director, TRICARE Regional Offices (TROs) is granted the authority to extend the deemed period up to 120-days, on a case-by-case or regional basis.
Note:  In the case of a reservist who has been called to active duty for a period of 30 days or less, a new family member is not considered enrolled in TRICARE Prime, since the family members of the reservist are not eligible to enroll in TRICARE Prime.
1.7.3  For those newborns and adoptees who are covered under the 60 day “deemed enrollment” benefit, process these claims as civilian TRICARE Prime for this period. If the newborn or adoptee is formally enrolled during this period, process using enrollment status. If the newborn or adoptee is not formally enrolled during the 60 day calendar day period, at the end of the 60th calendar day period, the contractor shall process all claims as a non-enrolled beneficiary, applying the appropriate TRICARE cost-shares and deductibles. See the TOM, Chapter 8, Section 1, paragraph 5.0 for claims processing procedures.
1.8  When a family enrollment status changes to single, there is no refund of the paid enrollment fee, unless the family enrollment becomes an individual enrollment due to death of one or more family members or a retired TRICARE Prime enrollee becomes dual eligible (see the TOM, Chapter 6, Section 1, paragraph 8.0). The remaining single enrollee continues to have TRICARE Prime coverage until the enrollee takes action to disenroll, the enrollee is no longer eligible for TRICARE Prime, or the enrollee fails to pay a required enrollment fee.
1.9  TRICARE eligible beneficiaries who have less than 12 months of eligibility remaining (for example, retirees who are 64 years of age, TAMP beneficiaries, etc.) are allowed to enroll in TRICARE Prime, however, these enrollees will be disenrolled from TRICARE Prime when they lose their TRICARE eligibility. The beneficiary has the choice of paying all of the enrollment fee or paying the fees on a monthly or quarterly basis. If paid on a monthly or quarterly basis, the beneficiary will be required to pay the installments that would cover the period of their eligibility only. See paragraph 1.8 for those who pay in full at the beginning of the enrollment period.
1.10  For exceptions to enrollment fee refunds and prorated fees, see the TOM, Chapter 6, Section 1.
1.11  Enrollees may disenroll from TRICARE Prime according to the requirements of Section 2.1.
2.0  Policy (On Or After January 1, 2018)
2.1  Generally, when the TRICARE eligibility status changes, eligibility for TRICARE Prime or TRICARE Select benefits also changes.
2.2  In all cases, when TRICARE eligibility ends, eligibility for TRICARE Prime or TRICARE Select ceases. This includes retirees, their family members and survivors who turn age 65 and are entitled to Medicare but are not eligible for TFL if they don’t elect Medicare Part B, for example, children who lose TRICARE eligibility due to age, remarriage of former spouses, etc.
2.3  A change in status that results in a change in TRICARE coverage is considered a Qualifying Life Event (QLE). Eligible beneficiaries may elect to enroll in TRICARE Prime or TRICARE Select within 90 days of a QLE. See Section 2.1.
2.4  Active duty personnel who retire may enroll at the same time as the remaining family members.
2.5  If a TRICARE Prime enrollee is receiving ongoing care at the time of retirement or separation, they must comply with all of the care authorization requirements of the enrollee’s new status including getting a new authorization from the contractor.
2.6  When status changes from ADFM to retiree family member, the contractor shall offer TRICARE Prime enrollees an opportunity to continue enrollment in TRICARE Prime, if available, but at the retiree cost-sharing rates. These enrollees must pay the applicable enrollment fees. The contractor shall allow beneficiaries to keep their PCM, if possible. Market Directors/MTF Directors will determine if retiring beneficiaries who enroll in TRICARE Prime can keep their Market/MTF PCMs, given the Market’s/MTF’s enrollment plan and Market/MTF capacity. Alternatively, they may elect to enroll in TRICARE Select. See Section 2.1, for QLE information.
2.7  TRICARE Prime Enrollment for Transitional Survivors. Those in Transitional Survivor Status, are not distinguished from other ADFMs for TRICARE Prime eligibility. See the Transitional Survivor Status policy in Section 7.1.
2.8  Claims For Newborns and Adoptees
2.8.1  The contractor shall cost-share claims for newborns and adoptees for up to the first 90 days of life as TRICARE Prime if one or more family members (including Active Duty Service Members (ADSMs)) are enrolled in TRICARE Prime. Otherwise, the contractor shall cost-share claims as TRICARE Select for up to the first 90 days of life. The contractor shall include the following alert note on Explanation Of Benefits (EOBs) for claims processed during this deemed enrolled period: “TWO ACTIONS are required within 90 days of birth or adoption to ensure continued TRICARE private sector coverage: (1) register the child into Defense Enrollment Eligibility Reporting System (DEERS) at a Department of Defense (DoD) ID card office; AND (2) choose a TRICARE health plan and enroll your child if necessary. How best to enroll your new child depends on who you are (ADSM or retiree) and your location. For more information, please visit https://www.tricare.mil/LifeEvents/Baby/GettingTRICAREforChild. Claims will be denied if received after 90 days of life if the newborn is not enrolled in TRICARE Prime or TRICARE Select coverage.” The contractor shall deny claims if received after 90 days of life if the newborn is not enrolled in TRICARE Prime or TRICARE Select coverage. Once the newborn or adoptee is enrolled in TRICARE coverage, contractors shall only re-process claims paid during the first 90 days of life when requested by a responsible member of the family.
Exception: If overseas, the time frame above for newborn claims is extended up to the first 120 days of life or from the date of adoption. The child shall also be registered in DEERS within 120 days from the child’s birth date or the date of adoption. Once registered in DEERS, newly eligible ADFMs residing in an overseas area are automatically enrolled into TRICARE Overseas Program (TOP) Select and have 90 days after the auto enrollment to change their enrollment to TOP Prime/TOP Prime Remote if desired and if command sponsored.
2.8.2  Once a newborn or adoptee is shown as enrolled in a TRICARE plan in DEERS, the TRICARE Prime or TRICARE Select “deemed status” for cost-sharing of claims no longer applies and the contractor shall process claims received after the date of enrollment according to the cost-sharing provisions of their enrolled plan.
2.8.3  See TOM, Chapter 22, Sections 1 and 2, for policy with processing newborn and adoptee claims under TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) coverage.
2.9  The contractor shall allow TRICARE eligible beneficiaries who have less than 12 months of eligibility remaining (for example, retirees who are 64 years of age, TAMP beneficiaries, etc.) to enroll in TRICARE Prime or TRICARE Select; however, these enrollees will be disenrolled when they lose their TRICARE eligibility. The contractor shall allow the beneficiary the choice of paying all of the enrollment fee or paying the fees on a monthly or quarterly basis. Once the enrollment is terminated, the contractor shall apply the remaining enrollment fees to the enrollment fees of another family member, or at the request of the beneficiary, refund the remaining enrollment fees. See the TOM, Chapter 6, Section 1.
2.10  Reserve Component (RC) beneficiaries that move between a TRICARE Premium Plan (TRS, TRR, TRICARE Young Adult (TYA), or Continued Health Care Benefit Plan (CHCBP) and a non-premium plan. See Section 2.1 for how these status changes affect the beneficiaries’ cost-share, deductible and catastrophic cap. When an RC member is activated and is treated as any other active duty member, the member’s family member qualify as ADFMs. See Section 2.1 for how this status change affects the family member’s cost-shares, deductibles and catastrophic cap.
2.11  Enrollees may disenroll from TRICARE Prime or TRICARE Select according to the requirements of Section 2.1.
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