Military Health System

2.1  The sponsor is enrolled in TPR and the ADFM resides with the sponsor in a TPR residence (i.e., TPR zip code).

2.2  The sponsor is enrolled to a small Government clinic, troop medical clinic, Coast Guard clinic or other Military Treatment Facilities/Enhanced Multi-Service Markets (MTFs/eMSMs) designated by the Services to allow Active Duty Service Member (ADSM) enrollment only and offer zero capacity to enroll non-ADSM beneficiaries. DHA will provide a list of Defense Medical Information System Identification Codes (DMIS-IDs) MTFs/eMSMs that only enroll ADSM. The DMIS-ID list will be an attachment in the Managed Care Support Contract (MCSC). The ADFM must reside with the sponsor who is enrolled in an MTF/eMSM that only enrolls ADSMs.

2.3  If an ADSM receives a subsequent unaccompanied assignment after the TPR assignment and the family members are not authorized to accompany the member to the next duty assignment, and they continue to reside in the same TPR address, the family members may remain in TPRADFM for the duration of the subsequent assignment.

2.4  If an RC member sponsor becomes eligible for TRICARE because of a call or order to active duty for a period of more than 30 days, their eligible family members become eligible to enroll into TPRADFM upon becoming TRICARE-eligible (i.e., beginning the date early eligibility TRICARE starts or date of activation, whichever is first) if they meet all of the following eligibility requirements:

2.5  ADFMs currently enrolled in TPRADFM, who transition to Transitional Survivor status, may remain enrolled in TPRADFM. See TPM, Chapter 10, Section 7.1 for further information.

4.1  TPRADFM offered outside of a PSA has no network development requirements, except where contractually required. ADFMs enrolled in TPRADFM shall be assigned, or be allowed to select, a Primary Care Manager (PCM) when in the provider network. If a network provider is not available to serve as a primary care provider, the TPRADFM enrollee may utilize any local TRICARE participating or authorized provider for primary care services.

4.2  TPRADFMs enrollees are required to use TRICARE network providers where available within contractual access standards. If a network provider cannot be identified within the access standards, the enrolled family member shall use a TRICARE authorized provider. Contractors shall assist TPRADFM enrollees in finding a network or non-network TRICARE authorized provider for specialty care. TPRADFM enrollees may be eligible for the Prime travel benefit when referred more than 100 miles for specialty care inside the 50 U.S. and DC. If the contractor has not established a network of PCMs in a remote area, a TPRADFM enrollee will be enrolled without a PCM assigned. A generic PCM code shall be used for TPRADFM enrollees without assigned PCMs. The ADFM without an assigned PCM will be able to use a local TRICARE authorized provider (participating or non-participating) for primary health care services without a PCM’s approval. If a TPRADFM questions whether a service is covered as primary care, they may contact the contractor for assistance.

6.1  Specialty care requires a referral through the contractor. If the TPRADFM enrollee is assigned to a PCM, the PCM shall follow the contractor’s referral and authorization procedures. In cases where the TPRADFM enrollee is not assigned to a PCM, the TPRADFM enrollee, or the TPRADFM enrollee’s parent or guardian, is responsible for directly contacting the contractor to obtain referrals and authorizations if required. The TPRADFM enrollee should obtain a referral request from their primary care provider and the TPRADFM enrollee should forward that request to the contractor.

6.2  TPRADFM enrollees are required to obtain a referral and use TRICARE network providers for specialty care where available within TRICARE access standards or pay the Point of Service (POS) deductible and cost-share unless an appropriate out-of-network referral is obtained as required under TRICARE Prime.

8.1  Beneficiary education will be a joint effort with the Government providing all beneficiary educational materials for the TPR program.

8.2  The contractor shall utilize leading industry best practices in its outreach and communication with all MHS customers consistent with that offered to its commercial customers. Customer services shall include multiple, contemporary avenues of access (for example, e-mail, World Wide Web (WWW), telephone, texting, and smart phone applications, and other social media) for the MHS beneficiary. If the contractor chooses to distribute the supplied educational materials, the contractor is responsible for postage, envelopes, and mailing costs.

8.3  The contractor shall give TPRADFM enrollees the option of participating in health promotion and wellness programs offered in the direct care system and network locations. The contractor shall design and conduct, with Director, THP approval, TPRADFM briefings. The contractor shall include TPRADFM information and updates as part of all TRICARE briefings. Ongoing briefings will be on an “as needed” basis and will be coordinated with the Director, THP.

8.4  Enrollment in TPRADFM is optional for ADFMs who qualify for the program; therefore, a contractor shall limit educational activities for TPRADFM enrollees to distributing the materials provided or approved by the Government.

9.1  When the contractor receives an enrollment request (enrollment form, the Government furnished web-based self-service enrollment system/application transaction, or telephonic request documented in the contractor’s call center notes) from an ADFM for TPRADFM, the contractor shall ensure the sponsor is qualified based on the requirements in paragraph 2.0. If a TPRADFM enrollment request is received and the family member does not qualify for TPRADFM, the request shall be returned to the sender with a notice that the family member is not eligible for TPRADFM and the reason(s) why TPRADFM enrollment was denied. Additionally, see paragraph 9.4 when a TPRADFM enrollment request is received for a family member of an RC sponsor on active service for more than 30 days.

9.2  Enrollment in TPRADFM is optional for qualified family members. However, qualified family members must enroll within 90 days of their move to a TPR location (a Qualifying Life Event (QLE)) or during the open enrollment season in TPRADFM to receive the TPRADFM benefit. Qualified family members who elect not to enroll in TPRADFM may enroll in TRICARE Prime (where available, with access standards waived) or TRICARE Select.

9.3  An enrollment request (enrollment form, the Government furnished web-based self-service enrollment system/application transaction, or telephonic request documented in the contractor’s call center notes) must be submitted to the contractor by either the qualified family members or the Service member’s sponsor for each family member enrolling in TPRADFM. See Chapter 6, Section 1, for effective date rules. An official enrollment request includes those with:

9.4  When the contractor receives an enrollment request (enrollment form, Government furnished web-based self-service enrollment system/application transaction, or telephonic request documented in the contractor’s call center notes) for TPRADFM from a family member of an RC sponsor called or ordered to active service for more than 30 days, the contractor shall validate the family members’ eligibility in DEERS.

9.5  The contractor shall follow enrollment portability and transfer procedures in Chapter 6, Section 2. Additionally, if at any point the contractor determines or is advised that a family member is no longer eligible for TPRADFM, the contractor shall notify (letter, telephone call, or e-mail) the sponsor of the discrepant enrollment immediately. If the discrepant enrollment is not corrected within 30 days of the notification date, the contractor shall disenroll the family member(s) from TPRADFM effective the first of the month after 30 days from the initial notification date. The contractor shall provide information on TRICARE Select, and that they have 90 days from the date of the disenrollment to enroll in a TRICARE plan or they only will be eligible for MTF/eMSM care on a space-available basis.

9.6  The contractor shall enroll the TPRADFM qualified family member in the Government furnished web-based system/application and enter the TPRADFM’s enrollment status into Government furnished web-based system/application. The contractor shall use the DMIS-ID code(s) designated by the Director, THP for that region to enroll ADFMs into TPRADFM (see the TRICARE Systems Manual (TSM)). See paragraph 10.0 for PCM assignment requirements.

13.1  The payment provisions applicable under TPR for Service members which allow for additional payment in excess of otherwise allowable amounts to providers who are not TRICARE-authorized or certified do not apply to TPRADFM. Such payments shall not be made unless such payments are otherwise allowed under the payment provisions for unauthorized providers contained in the TPM.

13.2  For network providers, the contractor shall pay TPRADFM claims at the negotiated rate. For participating providers the contractor shall pay up to the CHAMPUS Maximum Allowable Charge (CMAC), or billed charges, whichever is less. Contractors shall follow the requirements in Chapter 8, Section 5 and the TRICARE Reimbursement Manual (TRM), Chapter 5, Section 1, for claims for TPRADFM enrollees receiving care from non-participating providers.

13.3  If a non-participating provider requires a TPRADFM enrollee to make an “up front” payment for health care services, in order for the enrollee to be reimbursed, the enrollee must submit a claim to the contractor with proof of payment and an explanation of the circumstances.

13.4  If the contractor becomes aware that a civilian provider is “balance billing” a TPRADFM enrollee or has initiated collection action for emergency or authorized care, the contractor shall notify the provider that balance billing is prohibited (see TRM, Chapter 3, Section 1).

13.5  If CMAC rates have been waived for TPR Service member enrollees under Section 4, paragraph 3.5, the TPRADFM enrollee shall not be extended the same waived CMAC rates. If required services are not available from a network or participating provider within the medically appropriate time frame, the contractor shall arrange for care with a non-participating provider subject to the normal reimbursement rules. The contractor shall make every effort to obtain the provider’s agreement to accept, as payment in full, a rate within 100% of the CMAC limitation. If this is not feasible, the contractor shall make every effort to obtain the provider’s agreement to accept, as payment in full, a rate between 100% and 115% of CMAC. By law the contractor shall not negotiate a rate higher than 115% of CMAC for TPRADFM care rendered by a non-participating provider. The contractor shall ensure that the approved payment is annotated in the authorization/claims processing system.