The term “contractor” applies
to the Managed Care Support (MCS) contractor, TRICARE Overseas Program
(TOP) contractor, and Uniformed Services Family Health Plan (USFHP)/Designated
Providers (DPs) for purposes of enrollment portability.
1.0 The contractor shall, for the
geographic area of responsibility in which the beneficiary is enrolled
on Defense Enrollment Eligibility Reporting System (DEERS), provide
continuing coverage and update catastrophic cap accumulations for
the enrollee while the enrollee is traveling or relocating, except
in the case of care provided overseas (i.e., care outside of the
50 United States and the District of Columbia).
1.1 The TOP
contractor, shall process Civilian Health Care (CHC) claims while
the beneficiary is traveling or visiting overseas, regardless of
where the beneficiary resides or is enrolled.
1.1.1 TRICARE
Prime and TRICARE Select enrollees retain coverage whenever they
move or travel.
1.1.2 Enrollment
portability provisions apply to TRICARE Prime and TRICARE Select
enrollees’ travel or relocation to or from all areas, where TRICARE
Prime and TRICARE Select is available.
1.2 An enrollee may transfer enrollment
before or after moving either temporarily or permanently to a new location
using any of the enrollment options in
Section 1.
1.2.1 The outgoing contractor shall
continue to provide health care coverage until:
• The enrollment is transferred
to the gaining contractor;
• The beneficiary is no longer
eligible for enrollment in TRICARE Prime or TRICARE Select;
• The beneficiary disenrolls;
or
• The beneficiary is disenrolled
due to failure to pay required enrollment fees, whichever occurs
first.
1.2.2 TRICARE
Prime referral and authorization rules continue to apply (see
Chapter 7, Section 5 and
Chapter 8, Section 5). Under no circumstances
will retroactive disenrollment be allowed in order to avoid Point
Of Service (POS) cost-sharing provisions.
1.2.3 The contractor
shall, on the day it receives either a beneficiary’s signed enrollment
form, telephone portability request, or a request from the Government
furnished web-based self-service enrollment system/application agreeing
to a transfer of enrollment to the new geographic area of responsibility,
consider the beneficiary enrolled at the new location, regardless
of whether the appropriate updates have been performed in the Government-provided
web-based application to DEERS.
1.2.4 TRICARE
Prime enrollees should contact the new Primary Care Manager (PCM),
the new geographical area of responsibility’s Health Care Finder
(HCF), or the DP for health care and health-related assistance.
1.2.5 The contractor shall modify
the effective date for enrollment requests received from the Government furnished
web-based self-service enrollment system/application to be the date
the enrollment was submitted.
1.2.6 The effective
date for transfer of enrollment may differ from the effective date
for initial enrollment. See
Section 1 for
information on initial enrollment in TRICARE Prime. For transfers,
the original enrollment period on DEERS will remain in effect.
1.2.7 The contractor shall, when
enrollment changes from one contractor to another prior to the annual renewal
for enrollees in beneficiary categories required to pay enrollment
fees, obtain information from the losing contractor on fees that
are being automatically paid and transition these payment types
in the least disruptive manner for the beneficiary.
1.2.8 Enrollment fees must be paid
current prior to transfer of enrollment. See
Section 1, for
refunds of unused enrollment fees.
1.3 USFHP Portability Guidelines
1.3.1 TRICARE Prime USFHP enrollees
who are not otherwise TRICARE-eligible (e.g., 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 MCS
Contractor (MCSC).
1.3.2 Beneficiaries
enrolled in TRICARE Prime coverage who reside in a ZIP code where
USFHP and MCSC Prime networks co-exist may elect to change their
PCM to the other network at any time by disenrolling from their current
contractor and re-enrolling with the other contractor.
1.3.3 This is to be viewed as a PCM
change.
1.4 Enrollment
portability and PCM changes are not limited to the annual open enrollment
period nor require a Qualifying Life Event (QLE) to occur.