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