1.0 Enrollment
1.1 The
contractor shall develop an enrollment plan to support contractor
enrollment of beneficiaries and report on the implementation of
the plan according to contract requirements. The contractor shall
consult with the Director, TRICARE Regional Offices (TROs) and all
Military Treatment Facility (MTF) Commanders/Enhanced Multi-Service
Market (eMSM) Managers where Prime is offered in developing the
enrollment plan.
1.2 The
contractor shall have an enrollment system that supports all enrollment
related activities, i.e., Defense Enrollment Eligibility Reporting
System (DEERS) enrollment applications, and MTF/eMSM enrollment
guidelines.
1.3 The
enrollment system shall meet all the TRICARE Systems Manual (TSM)
requirements, including at a minimum, the following:
• Meet all
system access requirements.
• Ensure installation of all
hardware.
• Ensure loading of all software.
• Ensure completion of all required
forms.
• Interface with Government systems.
1.4 The enrollment system shall
be fully operational 60 days prior to the start of health care delivery
(SHCD).
2.0 Enrollment Processing
At
SHCD, all enrollment actions will be accomplished by the incoming
contractor. If the outgoing contractor requires a retroactive change,
they shall submit their request to the incoming contractor who will
perform the change and notify the outgoing contractor, when it is
complete.
2.1 Enrollment Processing After
The SHCD
Once
health care delivery begins, all enrollment actions will be accomplished
by the incoming contractor.
2.2 Phase-In
of TRICARE Prime Enrollment
The contractor shall begin
the enrollment process for the TRICARE Prime Program no later than 60
calendar days prior to the scheduled SHCD, with new enrollment processing
to begin 40 days prior to the SHCD, subject to the Defense Health
Agency (DHA) approval of systems under the contract.
2.2.1 Enrollment Actions During Enrollment
Dual Processing
2.2.1.1 When the Defense Manpower Data
Center (DMDC) creates the Enrollment Gold File for the incoming
contractor, enrollment dual processing begins (between 45-60 days
prior to SHCD). This process creates a future enrollment to the
incoming contractor. The following must be followed until SHCD.
2.2.1.2 For enrollments in the region
with an effective date prior to the SHCD (e.g., active duty enrollment,
mid-month enrollment; transfer-in), the incoming contractor must
effect an enrollment to begin on the SHCD once notified by the outgoing
contractor of the new enrollment. DMDC may run a report at the end
of the transition period that reflects new additions.)
2.2.1.2.1 The outgoing contractor has
until SHCD to send updated fee information to DEERS. Beginning at
the SHCD, the outgoing contractor will work with the incoming contractor
to resolve any discrepancies of cumulative enrollment fees and paid-through
dates on policies.
2.2.1.2.2 Beginning at the SHCD, the
incoming contractor shall send the corrected fee information to
DEERS using Fee/Catastrophic Cap and Deductible (CCD) Web Research
application or the batch fee interface outline in the TSM,
Chapter 3.
2.2.1.3 When a current enrollment in
the region requires deletion with an effective date prior to the
SHCD (e.g., transfers out; disenrollments for failure to pay fees;
cancellations, etc.), when requested by another enrolling contractor,
the incoming contractor must cancel the future enrollment segment and
notify the outgoing contractor when this action has been completed.
2.2.1.4 For all other enrollment actions
with an effective date prior to SHCD (e.g., Primary Care Manager
(PCM) changes; Defense Medical Information System Identification
Code (DMIS-ID) changes; enrollment begin date changes; etc.), when
requested by the outgoing contractor, the incoming contractor must
cancel the future enrollment segment and notify the outgoing contractor
when this action has been completed. When notified by the outgoing
contractor that their change has been effected, the incoming contractor
must verify/reinstate the future enrollment segment.
2.2.2 In addition to other contractually
required enrollment reports, the contractor, shall provide progress
updates on enrollment activities in accordance with the Integrated
Master Plan /Integrated Master Schedule (IMP/IMS).
2.3 Transfer Of Enrollment Files
2.3.1 The incoming contractor shall
obtain enrollment policy information from DEERS through an initial
enrollment load file. DMDC will provide the incoming contractor
with an enrollment load file for each contract transition. The outgoing
contractor shall provide
: (1) the additional
enrollment information required for those Active Duty Family Members
(ADFMs) enrolled in TRICARE Prime
residing outside
of a Prime Service Area (PSA) who were granted grandfathered status
and
who maintain
ed their
eligibility for TRICARE Prime
and (2) a list of those
beneficiaries living greater than 100 miles from a Primary Care
Manager (PCM) and granted re-enrollment per National Defense Authorization
Act (NDAA) FY 2016, Section 701. The additional enrollment
information shall include, but is not limited to, the original address
of the beneficiary when they were initially grandfathered
or allowed
to re-enroll.
(See Chapter 27 for
more information on these beneficiaries.) The incoming contractor
shall process each enrollment load file within 24 hours or less
from receipt of the file.
2.3.2 No
later than the date specified at the Transition Specifications Meeting,
the outgoing South Region contractor shall provide to the incoming
East Region contractor, the additional enrollment information required
for Continued Health Care Benefits Program (CHCBP) enrollees.
Note: Each contract transition shall
require a global freeze of enrollment. This freeze will occur beginning
the first weekend that precedes the 60 day window prior to the SHCD.
The actual calendar dates will be determined during the transition
meeting.
2.3.3 The
incoming contractor shall send enrollment renewal notices for all
enrollees whose current enrollment period expires on or after the
SHCD. The incoming contractor shall send billing statements where
the enrollment fee payment would be due on or after the SHCD. The
incoming contractor shall start sending billing notices and process
renewals 45 days prior to the SHCD.
2.3.4 Outstanding
enrollment record discrepancies and issues reported to the DEERS
Support Office (DSO) by the outgoing contractor will be transferred
to the incoming contractor for reconciliation. Records will be reconciled
in accordance with the TSM,
Chapter 3.
2.4 Enrollment Fees
2.4.1 The
incoming contractor shall obtain the cumulative total of enrollment
fees and paid- through dates for the policies from DEERS. The contractor
who collects the enrollment fee shall forward the fees to the Government
in accordance with
Chapter 6, Section 1.
The outgoing contractor shall work with the incoming contractor
to resolve any discrepancies of cumulative enrollment fees and paid-through
dates within 90 days of start of the SHCD on policies inherited
during the transition. The incoming contractor shall send the corrected
fee information to DEERS using the Fee CCD Web Research application
or the batch fee interface outlined in the TSM,
Chapter 3.
2.4.2 The incoming contractor shall
obtain information from the outgoing contractor on fees that are
being paid monthly (i.e., by allotment, recurring
credit card, or Electronic Funds Transfer (EFT) and
transition these monthly payment types in the least
disruptive manner for the beneficiary.
2.4.3 The incoming contractor shall
coordinate the transition of allotment data, through the Performance,
Analysis, Transitions, and Integration Section (PAT&IS) and/or
the applicable DHA Program office, with the Defense Finance and
Accounting Service (DFAS), Public Health System (PHS), and U.S.
Coast Guard (USCG) during the transition-in period of the contract
(see the TSM,
Chapter 1, Section 1.1).
2.5 Phase-Out Of Enrollment Activities
2.5.1 Prior to the SHCD under the
successor contract, for all enrollment renewals or payments in which
the new enrollment period or period covered by the premium payment
will begin under the new contract, the outgoing contractor shall
amend renewal notices and billing statements (or include a stuffer/insert)
to advise the enrollee to direct any enrollment- related correspondence
and enrollment fee payments to the successor contractor.
2.5.2 The outgoing contractor shall
complete all pending enrollment actions prior to the DEERS global
enrollment freeze to transition enrollment. Any enrollment action
not completed by the outgoing contractor prior to the freeze (and
after the Gold File is created) will have to be accomplished following
the above procedures.
2.5.3 Any
enrollment-related correspondence and/or enrollment fee payments
subsequently received by the outgoing contractor shall be forwarded
to the incoming contractor within three working days of receipt.
The incoming contractor shall answer all correspondence in accordance
with applicable standards (see
Chapter 1, Section 3),
update DEERS, as appropriate, and forward the fees to the Government
in accordance with
Chapter 6, Section 1.
2.5.4 No
later than the date specified at the Transition Specifications Meeting,
the outgoing contractor shall provide to the incoming contractor,
the additional enrollment information required for those ADFMs enrolled
in TRICARE Prime who reside outside of a PSA who were granted grandfathered status
and maintain their eligibility for TRICARE Prime. The additional
enrollment information shall include, but is not limited to, the
original address of the beneficiary when they were initially grandfathered.
2.5.5 No
later than the date specified at the Transition Specifications Meeting,
the outgoing South Region contractor shall provide to the incoming
East Region contractor, all billing and enrollment information required
to administer the Continued Health Care Benefit Program (CHCBP)
for its enrollees.
2.5.6 The
outgoing contractor shall terminate marketing and enrollment activity
40 calendar days prior to the start of the incoming contractor’s
SHCD. Any enrollment requests or applications received after the
40th calendar day shall be transferred to the incoming contractor
by overnight delivery at the outgoing contractor’s expense.
2.5.7 Throughout
the transition period, the outgoing and incoming contractors shall
coordinate enrollment files no less than weekly to ensure that new
enrollments and enrollment renewals are accurately and timely reflected
in the incoming contractor’s enrollment files and in DEERS.
3.0 Performance Readiness Validation
(PRV)/Performance Readiness Assessment and Verification (PRAV)
During
transition, the incoming contractor’s performance readiness status
regarding enrollment activities will be subject to PRV/PRAV reviews
as described below.
3.1 Enrollment
PRV
3.1.1 Sixty
days prior to SHCD, the contractor shall validate their enrollment
system is fully operational and meets all contract requirements.
The contractor shall demonstrate the ability to perform all required
billing, enrollment, and collection transactions. Validation shall
include demonstrating all hardware/software is operational, meets
system access requirements, and correctly interfaces with Government
systems including the required MTF/eMSM systems. The contractor
shall validate that all enrollment rules are loaded and that accessible
and sufficient staff is hired/trained to perform at historical levels
of enrollment transactions.
3.1.2 Sixty
days prior to SHCD, the contractor shall validate it has begun the
enrollment process for the TRICARE Prime Program and demonstrate
it can perform enrollment transactions with at a 97% accuracy rate
(to be considered accurate, all data elements within an enrollment
must be correct).
3.1.3 Forty-five
days prior to SHCD, the contractor shall validate their billing
system is fully operational and that it has started sending billing
notices and processing renewals. The contractor will validate they
have obtained information from the outgoing contractor on fees that
are being paid monthly (i.e., by allotment or EFT) and they are
transitioning these monthly payment types in the least disruptive
manner for the beneficiary.
3.2 Enrollment
PRAV
3.2.1 The
contractor shall comply with the Government’s approach for assessment
and verification of the contractor’s performance readiness regarding
enrollment activities as described above. If, after review, the
Government finds the contractor’s performance readiness for enrollment processing
to be deficient, the contractor must submit a detailed mitigation
plan no later than 10 days business days following the Government’s
findings.
3.2.2 Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the Transition
Specification Meeting.