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
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, Managed
Care Support Program Section (MCSPS), 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. A signature from a Service member
is never required to complete TRICARE Prime enrollment as enrollment
in TRICARE 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 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, within 10 business days of receipt.
The equipment needed to run the DEERS desktop enrollment application
is 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
email 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 are 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 days, outline the discrepant information
and request the beneficiary contact their military personnel office.
1.8 DMDC/DEERS
will 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 the contractor shall 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 business 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 business days
of receipt, with an effective date no later than the third business 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 days of receiving the request. The
contractor shall modify the effective date to be no later than the
third business 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 TRICARE 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.
5.4 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
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 they will
only be eligible for Market/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 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
required actions
if a beneficiary is identified as being ineligible for continued
enrollment. The contractor
shall 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 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 shall 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 MCSPS, 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
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
contractor
shall not retain forfeited fee amounts, unless they
can be credited to the enrollment of another family member(s),
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 Uniformed 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 TRICARE 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. The
contractor shall maintain all enrollment fees received
by the contractor in accordance with
these procedures.
6.1.1.2 The contractor
shall establish a separate non-interest bearing account 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 email,
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 shall accept
payment by check during this 30 day period in order to preserve
the beneficiary’s TRICARE Prime or TRICARE Select
enrollment status.
6.1.4.5 The
contractor shall coordinate allotments from
retired
pay
with the DFAS or the appropriate
Uniformed Services pay center, 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, or the appropriate Uniformed
Services pay center. 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
. The contractor
shall combine fees for these children
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 TRICARE Select
plans) do not pay more than the TRICARE Select family enrollment
fee. The contractor shall apply a fee
waiver code 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.
The contractor shall pro-rate fee
amounts
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
TRICARE 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
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 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 TRICARE Prime and
subsequently disenroll may not re-enroll until the next open period
or they experience a QLE.
7.2 The
contractor shall ensure enrollment processing and civilian
PCM assignments are in accordance with
the MOU 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 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, or
• Select
a civilian PCM if permitted by applicable MOU, or
• Select USFHP,
if available, or
• Decline
enrollment in TRICARE Prime.
7.5 The
contractor shall discuss the potential effective date of the enrollment with
the beneficiary.
7.6 The contractor
shall terminate enrollment
upon
request of the enrollee, sponsor or other party as appropriate under
existing enrollment/disenrollment procedures.
The
request may be made at any time. 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, the contractor shall 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.
8.2 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 contractor shall allow the beneficiary 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 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
days. Upon activation
of the member, the family members
shall 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 The
contractor shall apply catastrophic cap accumulations 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. The contractor shall prorate refunds 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 the
contractor shall not issue a refund. 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. The
contractor shall issue refunds 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 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, the contractor shall issue refunds for
overpayments occurring on and after the Start of Health Care Delivery
(SHCD). The contractor shall use 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 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 The
contractor shall draw refunds 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
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
shall:
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 Only process
refunds of $1 or more.
9.1.5 Issued refunds 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 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 Uniformed Service
shall determine member eligibility for enrollment into a WII Program,
as well as whether or not to use these
enrollments.
To better
manage this population, a secondary enrollment classification of
HCDP Plan Coverage Codes, WII 415 and WII 416 were developed.
These primary
rules apply to the WII HCDP codes:
• Service
members shall 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 Uniformed Service-specific
WII entity.
• The contractor shall
follow the rules associated with the primary HCDP Plan Coverage Code,
such as TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote for
any claims processed for WII 415/416 enrollees. The
contractor shall process and pay all claims under Supplemental
Health Care Program (SHCP) rules. DEERS will not produce specific enrollment
cards or letters for WII 415/416 enrollment.
The
contractor shall code WII 415/416 TRICARE Encounter
Data (TED) record(s) 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 The
contractor shall enroll Uniformed Service defined
eligible Service members assigned to a WII 415 Program such as a
MEDHOLD or WTU, to TRICARE Prime or
TOP Prime prior to, or at the same time, as being enrolled into
the WII 415. The contractor shall not enroll Members to
the WII 415 without a concurrent TRICARE Prime or TOP Prime enrollment. Uniformed 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
Uniformed 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
Uniformed 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 Uniformed 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 contractor shall enroll the Service
member to TRICARE Prime, TPR, TOP Prime,
or TOP Prime Remote prior to or at the same time as being enrolled
into WII 416. The contractor shall not enroll Members to
the WII 416 program without a concurrent TRICARE Prime,
TPR, TOP Prime, or TOP Prime Remote enrollment. Uniformed 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
Uniformed 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 shall 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
Uniformed 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 shall 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 contractor
shall compute time or distance between the
enrollee’s residence and the physical location of the PCM (including
Markets/MTFs). The contractor shall not 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. The contractor shall make notification
(letter, telephone call, or email) 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 shall collect all applicable
retroactive TRICARE enrollment fees before processing an enrollment
request. Alternatively, the beneficiary 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
MCSPS 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 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: The contractor
shall afford the opportunity to non-active duty TRICARE
Prime applicants who reside more than 30 minutes travel time from
a Market/MTF 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 Chief, MCSPS 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 Chief, MCSPS 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 Chief, MCSPS prior
to being sent to the impacted beneficiaries. (The MCSPS 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
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
MCSPS prior
to being sent to beneficiaries.
• 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 Chief, approval,
any MCSPS contractual requirements
relating to processing timeliness for enrollment requests will begin when
the contractor has obtained direction from the Market Director/MTF
Director or Chief, MCSPS 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.
The contractor shall grant
requests for new enrollments to the civilian network
from beneficiaries residing outside a PSA
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 shall 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. The
contractor shall assign a PCM for grandfathered ADFMs. Grandfathered
ADFMs may add or terminate enrollment of family members like
any other ADFM (e.g., marriage, birth, adoption, divorce). Family
members 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;
• Are
no longer residing within 40 miles of the residence
where they were originally granted grandfathered status; or
• Change
to retired status.
11.7.3 The
contractor shall not enroll beneficiaries who reside
outside the PSA and are 100 miles or greater from an available civilian
network PCM in the PSA in TRICARE Prime.
12.0 Reports
The
contractor shall provide monthly Service member enrollment and beneficiary
services reports. Details for reporting are identified
in DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract.
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.