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 TRICARE 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 shall 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 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, paragraph 1.1.4.2.1). Active
duty personnel who retire may enroll at the same time as the remaining
family members.
1.3.1 If
this is not done before or within 30 days following the member’s
retirement or separation, enrollment or reenrollment will be effective
according to the provisions of
Section 2.1, paragraph 1.1.4.
1.3.2 If the enrollee is receiving
ongoing care at the time of retirement or separation, he/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 When status changes from Active
Duty Family Member (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 Primary Care Manager (PCM), if possible. Market Directors/Military
Treatment Facility (MTF) Directors shall
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, paragraph 1.1.4.
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 (pro-rated 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, paragraph 8.0.
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 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 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 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
day calendar period, the newborn or adoptee will revert to a non-enrolled
beneficiary effective the 61st 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
cost-sharing does not apply through the 60th day or the effective
date of enrollment, whichever is earlier. All services shall be
processed with the
TRICARE Prime copayment
even in the absence of referrals or authorizations. The Director,
TRICARE Regional Offices (TROs) is granted the authority to extend
the deemed period up to 120-days, on a case-by-case or regional
basis.
Note: In the
case of a reservist who has been called to active duty for a period
of 30 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 For those newborns and adoptees
who are covered under the 60 day “deemed enrollment” benefit, process
these claims as civilian
TRICARE Prime
for this period. If the newborn or adoptee is formally enrolled
during this period, process using enrollment status. 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, the contractor
shall process all claims as a non-enrolled beneficiary, applying
the appropriate TRICARE cost-shares and deductibles. See the TOM,
Chapter 8, Section 1, paragraph 5.0 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, paragraph 8.0). 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,
etc.) 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, children
who lose TRICARE eligibility due to age, remarriage of former spouses,
etc.
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 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, they 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,
the
contractor shall offer TRICARE Prime enrollees
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.
The contractor
shall allow beneficiaries
to
keep their PCM, if possible.
Market Directors/MTF
Directors
will determine if retiring beneficiaries who enroll
in
TRICARE Prime
can keep
their
Market/MTF
PCMs,
given the
Market’s/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 The
contractor shall cost-share claims for newborns and
adoptees
for up to the first 90 days of
life as TRICARE Prime if one or more family members (including
Active
Duty Service Members (ADSMs
))
are enrolled in
TRICARE Prime. Otherwise,
the
contractor shall cost-share claims
as
TRICARE Select for up to the first 90 days of life.
The
contractor shall include the following alert note on Explanation
Of Benefits (EOBs) for claims processed during this deemed enrolled
period: “TWO ACTIONS are required within 90 days of birth or adoption
to ensure continued TRICARE private sector coverage: (1) register
the child into Defense Enrollment Eligibility Reporting System (DEERS)
at a Department of Defense (DoD) ID card office; AND (2) choose
a TRICARE health plan and enroll your child if necessary. How best
to enroll your new child depends on who you are (ADSM or retiree)
and your location. For more information, please visit https://www.tricare.mil/LifeEvents/Baby/GettingTRICAREforChild.
Claims will be denied if received after 90 days of life if the newborn
is not enrolled in TRICARE Prime or TRICARE Select coverage.” The
contractor shall deny claims
if
received after 90 days of life if the newborn is not enrolled in
TRICARE Prime or
TRICARE Select coverage.
Once the newborn or adoptee is enrolled in TRICARE coverage, contractors
shall only
re-process claims paid during the first 90 days of life when requested
by a responsible member of the family.
Exception: If overseas, the time
frame above for newborn claims is extended up
to the first 120 days of life or from the date of
adoption. The child shall also be registered
in DEERS within 120 days from the child’s birth date or the date
of adoption. Once registered in DEERS, newly eligible ADFMs residing
in an overseas area are automatically enrolled into TRICARE Overseas
Program (TOP) Select and have 90 days after the auto enrollment
to change their enrollment to TOP Prime/TOP Prime Remote if desired
and if command sponsored.
2.8.2 Once
a newborn or adoptee is shown as enrolled in a TRICARE plan in DEERS, the
TRICARE Prime or TRICARE Select “deemed status” for cost-sharing
of claims no longer applies and the contractor shall
process claims received after the date of enrollment according
to the cost-sharing provisions of their
enrolled plan.
2.8.3 See TOM,
Chapter 22, Sections 1 and
2, for policy with processing newborn and
adoptee claims under TRICARE Reserve Select (TRS) and TRICARE Retired
Reserve (TRR) coverage.
2.9 The
contractor shall allow TRICARE eligible beneficiaries
who have less than 12 months of eligibility remaining (for example,
retirees who are 64 years of age, TAMP beneficiaries, etc.)
to
enroll in
TRICARE Prime or
TRICARE Select;
however, these enrollees will be disenrolled when they lose their TRICARE
eligibility. The
contractor shall allow the beneficiary
the
choice of paying all of the enrollment fee or paying the fees on
a monthly or quarterly basis. Once the enrollment is terminated,
the contractor
shall apply the remaining enrollment fees
to
the enrollment fees of another family member, or at the request
of the beneficiary,
refund
the
remaining enrollment fees. 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
n RC member is activated and
is treated as any other active duty member, the member’s
family
member qualify as ADFMs. See
Section 2.1 for
how this status change affects the
family member’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.