2.5.2 Enrollment
will be done during an open season enrollment period prior to the
beginning of each plan year, which operates with the calendar year
for TRICARE Prime and TRICARE Select. TRICARE Retired Reserve (TRR), TRICARE
Reserve Select (TRS) and TRICARE Young Adult (TYA) have open enrollment
(see
Chapter 1, Section 1.1). An enrollment choice
will be effective for the plan year. Beneficiaries may choose to
enroll, change, or terminate TRICARE Prime or TRICARE 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. See TOM,
Chapter 6, Section 1.
2.5.2.1 If a beneficiary elects 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.
2.5.2.2 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.
2.5.3 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 of 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 Market/MTF requires a TRICARE Prime enrollee to move from a
network PCM to a Market/MTF/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.
2.5.3.1 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 calendar 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.
2.5.3.1.1 EXCEPTION: The
contractor shall, upon request, 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 enrollment fees (if applicable) are paid back
to the retirement date for Uniformed Services retirements that occur
on or after January 1, 2018. The effective start date of coverage
must be the member’s retirement date.
2.5.3.1.2 The contractor shall apply
open season and QLE rules for requests for a retroactive enrollment
date greater than 12 months in the past or request a start of coverage
date other than the date of retirement, unless directed otherwise
by the GDA.
2.5.3.1.3 EXCEPTION: The
contractor shall enroll, upon request, Unremarried Former Spouses
(URFS) who become eligible for TRICARE as their own sponsor on or
after January 1, 2018, 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.
2.5.3.1.4 The contractor shall apply
open season and QLE rules for a retroactive enrollment date greater
than 12 months in the past or request a start of coverage date other
than the date of eligibility as an URFS, unless directed otherwise
by the GDA.
2.5.3.2 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.
2.5.3.3 Overlapping QLEs. If the beneficiary
has more than one QLE that have overlapping 90 calendar 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 calendar 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 calendar 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.
2.5.3.4 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.
2.5.3.5 The GDA reserves the right
to direct the contractors to change an enrollment regardless of
the QLE rules.
2.5.3.6 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 calendar 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.
2.5.3.7 A reinstatement of eligibility
is not a QLE. Extending the previous eligibility is not a QLE.
2.5.3.8 Enrollment portability and
PCM changes are not limited to the open enrollment period and do
not require a QLE.
2.5.3.8.1 A PCM change within a geographic
area of responsibility can occur at any time even if address does not
change.
2.5.3.8.2 The contractor shall verify
that PCM assignment complies with Market/MTF MOU.
2.5.3.8.3 The TRICARE overseas contractor
shall treat in-country moves as PCM changes. This will be enforced
when the TRICARE Overseas contractor receives the Policy Notification
Transaction (PNT).
2.5.3.8.4 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).
2.5.5 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.