1.0 POLICY (Before January 1, 2018)
1.1 Generally, when the TRICARE
eligibility status changes, eligibility for TRICARE Prime benefits
also changes. The time frames for Prime eligibility parallel TRICARE
eligibility.
1.2 In all cases, when TRICARE
eligibility ends, eligibility for TRICARE Prime ceases. This includes
retirees, their family members and survivors who turn age 65 and
are entitled to Medicare but are not eligible for TRICARE for Life (TFL),
dependent children who lose TRICARE eligibility due to age, remarriage
of former spouses, etc.
1.3 To have
continuous TRICARE Prime coverage, the enrollee will submit an enrollment
form, or use the Government furnished web-based self-service enrollment
system/application transaction, or make a telephonic request to
the contractor before, or within 30 calendar days following, their
retirement date, and pay the appropriate enrollment fees, calculated
based on the effective date of enrollment, within the required time
frames (see
Section 2.1). Active duty personnel who retire
may enroll at the same time as the remaining family members.
1.3.1 The contractor shall apply
an effective date according to the provisions of
Section 2.1 if
this is not done before or within 30 calendar days following the
member’s retirement or separation.
1.3.2 If the
enrollee is receiving ongoing care at the time of retirement or
separation, he or she must comply with all of the care authorization
requirements of the enrollee’s new status including getting a new
authorization from the contractor.
1.4 The contractor shall offer
TRICARE Prime enrollees an opportunity to continue enrollment in
TRICARE Prime, if available, but at the retiree cost-sharing rates
when status changes from Active Duty Family Member (ADFM) to retiree
family member. These enrollees must pay the applicable enrollment
fees. Beneficiaries shall be permitted to keep their Primary Care
Manager (PCM), if possible. Market Directors/Military Medical Treatment Facility
(MTF) Directors will determine if retiring beneficiaries who enroll
in TRICARE Prime could keep their Market/MTF PCMs, given the Market’s/MTF’s
enrollment plan and Market/MTF capacity.
1.5 TRICARE
Prime Enrollment for Transitional Survivors. Those in Transitional
Survivor Status, are not distinguished from other ADFMs for TRICARE
Prime eligibility. See the Transitional Survivor Status policy in
Section 7.1.
1.6 When an
active duty member retires other than the first of the month or
a member separates other than the first of the month but continues
to be eligible (e.g., is the spouse of an active duty member; or
is eligible for Transitional Assistance Management Program (TAMP)),
TRICARE Prime enrollment may continue as of the date of retirement
or separation so long as all enrollment requirements have been met
as stated in
Section 2.1.
1.7 When TRICARE
Prime enrollment changes from an individual to a family enrollment
status prior to annual renewal for beneficiary categories required
to pay an enrollment fee, the unused portion (prorated on a monthly basis)
of the fee will be applied toward a new enrollment period or refunded
in accordance with the TRICARE Operations Manual (TOM),
Chapter 6, Section 1.
1.7.1 For ADFMs,
single enrollment can be changed to family at any time during the
enrollment period. A new enrollment period shall be established
for the family.
1.7.2 The contractor
shall process claims with the TRICARE Prime copayment even in the
absence of referrals or authorizations for newborns or adoptees
as described in this paragraph. A newborn or adoptee will be deemed to
be enrolled in TRICARE Prime as of the day of birth or adoption
if one family member is already enrolled in TRICARE Prime. A responsible
representative has 60 calendar days to officially enroll the child
to the TRICARE Prime option. If the newborn or adoptee is formally
enrolled in TRICARE Prime within the 60 calendar day period, the effective
date of enrollment will be the first of the month following the
date of birth or adoption. (The 20th of the month enrollment rule
is waived, if necessary.) If the newborn or adoptee is not formally
enrolled during the 60 calendar day period, the newborn or adoptee
will revert to a non-enrolled beneficiary effective the 61st calendar day.
If the decision is made to continue TRICARE Prime coverage, an official
enrollment request (enrollment form, Government furnished web-based
self-service enrollment system/application transaction, or telephonic
request) must be completed on behalf of the child. For retirees
or their family members or survivors who decide to continue enrollment
for the child, the unused portion (pro-rated on a monthly basis)
of the single enrollment fee they paid will be applied toward a
new family enrollment period. For newborns and newly adopted children
enrolled under this provision, Point of Service (POS) cost-sharing
does not apply through the 60th calendar day or the effective date
of enrollment, whichever is earlier. The Government Designated Authority
(GDA) is granted the authority to extend the deemed period up to
120 calendar days, on a case-by-case or a geographical area basis.
Note: In the case of a reservist
who has been called to active duty for a period of 30 calendar days
or less, a new family member is not considered enrolled in TRICARE
Prime, since the family members of the reservist are not eligible
to enroll in TRICARE Prime.
1.7.3 The contractor
shall process claims as civilian TRICARE Prime for this period for
those newborns and adoptees who are covered under the 60 calendar
day “deemed enrollment” benefit.
1.7.4 The contractor
shall process claims using enrollment status if the newborn or adoptee
is formally enrolled during this period.
1.7.5 The contractor
shall process all claims as a non-enrolled beneficiary if the newborn
or adoptee is not formally enrolled during the 60 day calendar day
period, at the end of the 60th calendar day period applying the appropriate
TRICARE cost-shares and deductibles. See the TOM,
Chapter 8, Section 1, for claims processing procedures.
1.8 When
a family enrollment status changes to single, there is no refund
of the paid enrollment fee, unless the family enrollment becomes
an individual enrollment due to death of one or more family members
or a retired TRICARE Prime enrollee becomes dual eligible (see the
TOM,
Chapter 6, Section 1). The remaining single
enrollee continues to have TRICARE Prime coverage until the enrollee
takes action to disenroll, the enrollee is no longer eligible for
TRICARE Prime, or the enrollee fails to pay a required enrollment
fee.
1.9 TRICARE eligible beneficiaries
who have less than 12 months of eligibility remaining (for example,
retirees who are 64 years of age, TAMP beneficiaries) are allowed
to enroll in TRICARE Prime, however, these enrollees will be disenrolled
from TRICARE Prime when they lose their TRICARE eligibility. The
beneficiary has the choice of paying all of the enrollment fee or
paying the fees on a monthly or quarterly basis. If paid on a monthly
or quarterly basis, the beneficiary will be required to pay the
installments that would cover the period of their eligibility only. See
paragraph 1.8 for
those who pay in full at the beginning of the enrollment period.
1.11 Enrollees may disenroll from
TRICARE Prime according to the requirements of
Section 2.1.
2.0 Policy (On Or After January
1, 2018)
2.1 Generally, when the TRICARE
eligibility status changes, eligibility for TRICARE Prime or TRICARE
Select benefits also changes.
2.2 In all
cases, when TRICARE eligibility ends, eligibility for TRICARE Prime
or TRICARE Select ceases. This includes retirees, their family members
and survivors who turn age 65 and are entitled to Medicare but are
not eligible for TFL if they don’t elect Medicare Part B, for example,
dependent children who lose TRICARE eligibility due to age, remarriage
of former spouses.
2.3 A change
in status that results in a change in TRICARE coverage is considered
a Qualifying Life Event (QLE). Eligible beneficiaries may elect
to enroll in TRICARE Prime or TRICARE Select within 90 calendar
days of a QLE. See
Section 2.1.
2.4 Active duty personnel who retire
may enroll at the same time as the remaining family members.
2.5 If a TRICARE Prime enrollee
is receiving ongoing care at the time of retirement or separation,
he or she must comply with all of the care authorization requirements
of the enrollee’s new status including getting a new authorization
from the contractor.
2.6 When status
changes from ADFM to retiree family member, TRICARE Prime enrollees
shall be offered an opportunity to continue enrollment in TRICARE
Prime, if available, but at the retiree cost-sharing rates. These enrollees
must pay the applicable enrollment fees. Beneficiaries shall be
permitted to keep their PCM, if possible. Market Directors/MTF Directors
will determine if retiring beneficiaries who enroll in TRICARE Prime
could keep their Market/MTF PCMs, given the Market/MTF’s enrollment
plan and Market/MTF capacity. Alternatively, they may elect to enroll
in TRICARE Select. See
Section 2.1,
for QLE information.
2.7 TRICARE
Prime Enrollment for Transitional Survivors. Those in Transitional
Survivor Status, are not distinguished from other ADFMs for TRICARE
Prime eligibility. See the Transitional Survivor Status policy in
Section 7.1.
2.8 Claims For Newborns and Adoptees
2.8.1 Claims for newborns and adoptees
will be cost-shared for up to the first 90 calendar days of life
as TRICARE Prime if one or more family members (including ADSMs)
are enrolled in TRICARE Prime. Otherwise, the claims will be cost-shared
as TRICARE Select for up to the first 90 calendar days of life.
Claims will be denied if received after 90 calendar days of life
if the newborn is not enrolled in TRICARE Prime or TRICARE Select
coverage.
2.8.2 The contractor
shall only reprocess claims paid during the first 90 calendar days
of life when requested by a responsible member of the family once
the newborn or adoptee is enrolled in TRICARE coverage.
EXCEPTION: If
overseas, time frame is up to the first 120 calendar days of life.
2.8.3 Once a
newborn or adoptee is shown as enrolled in a TRICARE plan in Defense
Enrollment Eligibility Reporting System (DEERS), the TRICARE Prime
or TRICARE Select “deemed status” for cost sharing of claims no longer
applies and claims received after the date of enrollment shall be
processed according to the cost sharing provisions of their enrolled
plan.
2.8.4 See the
TOM,
Chapter 22, Section 1, for policy with processing
newborn and adoptee claims under TRICARE Reserve Select (TRS) and
TRICARE Retired Reserve (TRR) coverage.
2.9 TRICARE eligible beneficiaries
who have less than 12 months of eligibility remaining (for example,
retirees who are 64 years of age, TAMP beneficiaries) are allowed
to enroll in TRICARE Prime or TRICARE Select; however, these enrollees
will be disenrolled when they lose their TRICARE eligibility. The
beneficiary has the choice of paying all of the enrollment fee or
paying the fees on a monthly or quarterly basis. Once the enrollment
is terminated, remaining enrollment fees may be applied to the enrollment
fees of another family member, or at the request of the beneficiary,
may be refunded. See the TOM,
Chapter 6, Section 1.
2.10 Reserve
Component (RC) beneficiaries that move between a TRICARE Premium
Plan (TRS, TRR, TRICARE Young Adult (TYA), or Continued Health Care
Benefit Plan (CHCBP) and a non-premium plan. See
Section 2.1 for how
these status changes affect the beneficiaries’ cost-share, deductible
and catastrophic cap. When a RC member is activated and is treated
as any other active duty member, the member’s dependents qualify
as ADFMs. See
Section 2.1 for how this status change affects
the dependent’s cost-shares, deductibles, and catastrophic cap.
2.11 Enrollees may disenroll from
TRICARE Prime or TRICARE Select according to the requirements of
Section 2.1.