2.3.2 Enrollment
will
occur during
the
TRICARE 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 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. 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.
Note: In any given year, if the date
range detailed in
paragraph 2.3.2 for the open season enrollment
period amounts to less than 30 days as required in
32 CFR 199.17(o)(1)(i), the Defense Health
Agency (DHA) will add days to the end of the date range detailed
above in order for the open season enrollment period to total 30
days. The DHA will communicate the resulting final date range for the
open season enrollment period to the contractor for the years where
such added days are required.
2.3.2.1 If electing to change their
TRICARE coverage during the TRICARE open
season enrollment period, 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,
to include:
• 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 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);
• Upon reflection
of delayed gain or loss of retroactive eligibility in DEERS (see paragraph 2.3.3.1.3 for exception);
• 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 health plan.
2.3.3.1 Enrollment
must be within 90 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, the contractor 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, the
contractor 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.
2.3.3.1.3 EXCEPTION:
The contractor shall, upon request, in the case of retroactive eligibility determinations
that occur on or after January 1, 2018, enroll Service members and
their family members into TRICARE Prime (if qualified) or TRICARE
Select coverage retroactive to the date of eligibility as assigned
in the Uniformed Services personnel systems as long as all enrollment
fees (if applicable) back to the retroactive eligibility date are
paid. The effective start date of coverage must be the date reflected
in DEERS as adjusted by the Uniformed Service. Without a retroactive
eligibility date reflected in Uniformed Services personnel systems
and DEERS, Open Season and QLE rules apply for retroactive enrollment
requests received after January 1, 2018.
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 upon 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 contractor 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 upon 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 shall verify that PCM assignment complies with Market/MTF
Memorandum of Understanding/Statement of Understanding (MOU/SOU).
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.