TRICARE Manuals - Display Chap 6 Sect 1 (Change 118, Apr 7, 2023)

Enrollment

Chapter 6

Section 1

TRICARE Prime And TRICARE Select Enrollment Processing

Revision: C-112, August 16, 2022

The Managed Care Support Contractor (MCSC), Uniformed Services Family Health Plan (USFHP) Designated Provider (DP), and TRICARE Overseas Program (TOP) contractor shall record all enrollments on Defense Enrollment Eligibility Reporting System (DEERS), as specified in the TRICARE Systems Manual (TSM), Chapter 3. The word “contractor” refers to all contractors listed above for this section unless otherwise noted.

1.0 Enrollment Processing

1.1 For paper enrollment requests, the contractor shall use the TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form (one combined form), Department of Defense (DD) Form 2876. For TRICARE Select enrollments, the contractor shall use the TRICARE Select Enrollment, Disenrollment, and Change Form, DD Form 3043. The contractor shall ensure the aforementioned form is readily available to potential enrollees. The contractor shall implement enrollment processes (which do not duplicate Government systems) that ensure success and assistance to all beneficiaries. The contractor shall collect enrollment forms at a site(s) mutually agreed to by the contractor, Managed Care Support Program Section (MCSPS), and Market Director/Military Treatment Facility (MTF) Director, by mail, fax, or by other methods proposed by the contractor and accepted by the Government. The contractor shall encourage the beneficiaries to use the Government-furnished web-based self-service enrollment system/application to enroll. The overseas contractor shall also collect applications at TRICARE Service Centers (TSCs).

1.2 Enrollment requests are initiated by the sponsor, spouse, other legal guardian of the beneficiary, or an eligible beneficiary age 18 or older. An official enrollment request includes those with (1) an original signature, (2) an electronic signature offered by and collected by the contractor, (3) a verbal consent provided via telephone and documented in the contractor’s call notes, or (4) a self-attestation by the beneficiary when using the Government-furnished web-based self-service enrollment system. A signature from an Active Duty Service Member (ADSM) is never required to complete TRICARE Prime enrollment as enrollment in TRICARE Prime is mandatory per the TRICARE Policy Manual (TPM), Chapter 10, Section 2.1.

1.3 The contractor shall provide beneficiaries who enroll full and fair disclosure of any restrictions on freedom of choice that apply to enrollees, including the Point of Service (POS) option for TRICARE Prime enrollees and the consequences for failure to pay enrollment fees on time, choosing to not enroll, or disenroll from either TRICARE Prime or TRICARE Select.

1.4 The contractor shall ensure enrollment is on an individual or family basis. For newborns and adoptees, see the TPM, Chapter 10, Section 3.1.

1.5 For TRICARE Prime enrollments, the contractor shall follow the specifications recorded in each Market/MTF’s Memorandum of Understanding (MOU)/Statement of Responsibility (SOR).

1.6 The contractor shall record all enrollments using the Government-furnished web-based enrollment system, within 10 business days of receipt. The contractor shall furnish the equipment required to run the DEERS desktop enrollment application and the contractor shall ensure the equipment meets the technical specifications in the TSM, Chapter 3.

1.6.1 The contractor shall resend TRICARE Prime/TRICARE Plus PCM Information Transfers (PITs) to Market/MTFs when requested.

1.6.2 The contractor shall submit required changes to the DEERS Support Office (DSO) as required.

1.7 At the time of enrollment processing, the contractor shall access DEERS to verify beneficiary eligibility and shall update the residential, mailing, and email addresses and any other fields that it can update on DEERS.

1.7.1 If the enrollment request (see paragraph 1.2) contains neither a residential address nor a mailing address, the contractor shall develop for a residential or mailing address.

1.7.2 Enrollees or the Government may provide the contractor a temporary address (i.e., Post Office Box, Unit address), until a permanent address is established. The contractor shall update temporary addresses with the permanent address when provided by the enrollee in accordance with the TSM, Chapter 3, Section 4.2. The contractor shall not input temporary addresses unless provided by the enrollee or the Government.

1.7.3 If the DEERS record does not contain an address, or if the enrollment request contains information different from that contained on DEERS in fields for which the contractor does not have update capability, the contractor shall contact the beneficiary by telephone within five days, outline the discrepant information and request the beneficiary contact their military personnel office.

1.8 Defense Manpower Data Center (DMDC)/DEERS will notify the beneficiary of the TRICARE wallet card at MilConnect. DMDC will also provide notification of PCM assignments for new TRICARE Prime enrollments, disenrollments, enrollment transfers, and PCM changes. (See TSM, Chapter 3, Section 4.2.) The return address on any correspondence mailed by DMDC will be that of the appropriate contractor. The contractor shall develop a process to fulfill the delivery if the correspondence is returned to the contractor by the United States Postal Service (USPS).

2.0 Automatic Enrollment Management

See TPM, Chapter 10, Section 2.1 and TSM, Chapter 3, Section 4.2.

2.1 Automatic Eligibility Updates

DEERS will automatically update start dates, end dates, or start and end dates of coverage when a beneficiary’s eligibility is updated by the Uniformed Services. The contractor shall receive a Policy Notification Transaction (PNT) advising them of all changes, and the contractor shall take action accordingly.

2.2 Automatic Enrollment of Active Duty Service Members (ADSMs)

DEERS will automatically enroll all new ADSM accessions, to include Reserve Component members on active duty for more than 30 days, into Health Care Delivery Plan 001 (TRICARE Prime for Active Duty Sponsors, No PCM Assigned).

2.3 Automatic Enrollment of Newly Eligible Active Duty Family Members (ADFMs)

Note: Automatic enrollment of ADFMs does not apply to USFHP contractors.

DMDC will automatically enroll newly eligible ADFMs in TRICARE Prime or TRICARE Select, and if overseas in TOP Select. See Chapter 24, Section 5 for Overseas guidance. The contractor shall upon request from a beneficiary or sponsor, who was auto-enrolled, adjust any claims in question to apply TRICARE Prime plan benefits, and waive POS cost-sharing provisions. The contractor shall educate the beneficiary or sponsor of this one-time correction and provide instruction to the beneficiary regarding their PCM assignment and the requirement to have referrals for all future specialty care. If received over the phone, the contractor shall document the conversation in the contractor’s call notes. The contractor need not identify these claims; however, the contractor shall adjust claims as they are brought to its attention by beneficiaries.

3.0 Dual Eligibles (Entitlement Under Both Medicare And TRICARE)

3.1 Dual eligibles (retired and retired family members, under age 65) are eligible to enroll in TRICARE Prime provided they maintain Medicare Part A and Part B.

3.2 Dual eligible ADFMs, regardless of age, are eligible to enroll in TRICARE Prime or TRICARE Select.

3.3 Dual eligible retirees and family members age 65 and over are not eligible to enroll in TRICARE Prime or TRICARE Select. They are automatically covered by TRICARE For Life (TFL), provided they have Medicare Part A and Part B. Exception: Those not entitled to premium free Medicare Part A on their own or the record of their current, former, or deceased spouse may enroll in TRICARE Prime or TRICARE Select. Medicare is primary payer for all dual eligibles regardless of their sponsor’s status. (See the TPM, Chapter 10, Section 2.1 for additional dual eligible information.)

3.4 TRICARE Prime-enrolled dual eligibles, to the extent practicable, must follow all TRICARE Prime requirements for PCM assignment, referrals and authorizations. However, dual eligibles are not subject to POS cost-sharing. DEERS waives enrollment fees for dual eligible enrollees who have Medicare Part B. (See paragraph 5.0.)

4.0 Assignment Of PCM For TRICARE Prime Enrollees

The contractor shall assign all TRICARE Prime enrollees a PCM by name (PCMBN) on the Government-furnished web-based enrollment system/application at the time of TRICARE Prime enrollment. This applies to beneficiaries assigned to the Direct Care (DC) system as well as civilian network PCMs.

4.1 The contractor shall comply with the Market Director’s/MTF Director’s specifications in the Market/MTF MOU/SOR for assigning enrollees or categories of enrollees to a DC PCM or offering a choice of civilian network PCMs.

4.1.1 The contractor shall enroll TRICARE Prime beneficiaries to the Market/MTF until the capacity is optimized in accordance with the Market Director’s/MTF Director’s determinations. The contractor shall enroll TRICARE Prime beneficiaries to the contractor’s network if they cannot be enrolled to the Market/MTF.

4.1.2 The contractor shall enroll all active duty personnel not meeting the requirements for TRICARE Prime Remote (TPR) to a Market/MTF, not the contractor’s network, regardless of capacities.

4.1.3 When a family member of an active duty E-1 through E-4 sponsor requests a PCM in a Market/MTF that offers TRICARE Prime for any beneficiary category other than active duty, the contractor shall assign that enrollee to a Market/MTF PCM unless capacity has been reached. If overall Market/MTF capacity has not been reached, the contractor shall request the Market/MTF to shift capacity in the Government-furnished web-based enrollment system/application to the ADFM beneficiary category from another category if necessary to accommodate an E-1 through E-4 ADFM enrollee’s PCM assignment request.

4.2 The contractor shall provide guidance to the enrollee in selecting a primary care location or PCM, as appropriate given Market/MTF guidance in the MOU. Upon receipt of an inquiry from a DC enrollee in regards to the person’s assigned PCM, the contractor shall refer the enrollee to the Market/MTF where they are enrolled.

4.3 At the time of enrollment, the contractor shall determine the appropriate enrollment Defense Medical Information System Identification (DMIS-ID) based upon the regional and Market/MTF MOUs, access standards, or other specific Government guidance. The contractor shall assign each enrollee a PCMBN at the time of enrollment based upon those PCMs available within the Government-furnished web-based enrollment system/application.

4.3.1 The contractor shall attempt to assign the enrollee to the requested PCM (see paragraph 1.2) if capacity is available. If the preferred PCM is not available, the contractor shall use the default PCM for that DMIS.

4.3.2 If the enrollment request (see paragraph 1.2) identifies a gender or specialty preference, the contractor shall assign an appropriate PCM. If the gender or specialty is not available, the contractor shall assign the enrollee to the default PCM for that DMIS.

4.3.3 If no PCM preference is stated on the enrollment request (see paragraph 1.2), the contractor shall use the default PCM for that DMIS.

4.3.4 If there is no DC PCM available in the appropriate DMIS/Market/MTF, the contractor shall assign non-active duty enrollees to a civilian PCM, by following the procedures specified in the Market/MTF MOU.

4.3.5 If there is no PCM capacity in the Market/MTF for an ADSM, then the contractor shall contact the Market/MTF for instructions.

4.4 The Government-furnished web-based enrollment system/application reflects only those DC PCMs that the Market/MTF has loaded onto the DEERS PCM Repository. Further, the Government-furnished web-based enrollment system/application will only display PCMs with available capacity for the specific beneficiary’s category and age. The contractor shall not add, delete, or modify DC PCMs on the repository.

4.5 The contractor shall complete all panel PCM reassignments (batch) using a Government-provided systems application, PCM Reassignment System (PCMRS). Panel reassignments are specified by the appropriate Market Director/MTF Director for a variety of reasons, including the rotation or deployment of DC PCMs. The contractor shall expect at least one-half of DC PCM assignments to change each year. These moves are based upon various factors of either the enrollment or the individual beneficiary, including:

• DMIS ID to DMIS ID

• PCM ID to PCM ID

• Health Care Delivery Program (HCDP)

• Sex of beneficiary

• Unit Identification Code (UIC) (active duty only)

• Age of beneficiary

• Sponsor Social Security Number (SSN) and Department of Defense (DoD) Benefits Number (DBN)

• Name of beneficiary

4.6 Markets/MTFs will request PCM reassignment, including panel reassignments, in several ways, including telephone, e-mail or other electronic submissions. The preferred method for panel reassignments is the batch staging application within PCMRS. Regardless of the submission method, the Market/MTF will provide sufficient information identifying both the PCMs and beneficiaries involved in a move to allow the contractor to reasonably accomplish the move. Thereafter, the contractor shall complete each DC PCM reassignment, both individual and panel reassignment, within three business days of receiving all necessary information from the Market/MTF.

4.7 The contractor shall process PCM change requests submitted by beneficiaries enrolled to a civilian network PCM via any means other than the Government-furnished web-based self-service enrollment system/application within three business days of receipt, with an effective date no later than the third business day.

4.8 The contractor shall process PCM change requests submitted to the contractor via the Government-furnished web-based self-service enrollment system/application within six business days of receiving the PNT advising them of all changes. The contractor shall modify the effective date to be the date the contractor received the request.

Note: Prior to January 1, 2018, direction was for the contractor to modify the effective date to be no later than the third business day, or the date requested by the beneficiary up to 90 days in the future.

5.0 Enrollment Period

5.1 Through December 31, 2017, the contractor shall support continuous open enrollment for all beneficiaries. Enrollment may occur any time during the contract period; however, all new enrollment periods will be aligned with the fiscal year. Therefore, the initial enrollment period may be shorter than a 12 month period.

Note: The enrollment period for fiscal year 2017 includes the period between October 1, 2017 and December 31, 2017.

5.2 Starting January 1, 2018

5.2.1 The contractor shall support one annual open enrollment period per Calendar Year (CY) for all Non-Active Duty Service Member (NADSM) beneficiaries. Enrollments, with the appropriate application and any required enrollment fee, are effective on January 1 of the following year. Beneficiaries are automatically re-enrolled each year unless they elect a different option or disenroll during the open enrollment period. See TPM, Chapter 10, Section 2.1.

5.2.2 A one-time transition period will be in effect for the enrollment period beginning January 1, 2018 and ending December 31, 2018. Beneficiaries may elect to enroll in or change their TRICARE Prime or TRICARE Select coverage at any time during the calendar year 2018 enrollment period.

5.3 Effective Date of Enrollment (Prior to January 1, 2018)

The contractor shall support continuous open enrollment for all beneficiaries. Enrollment may occur any time during the contract period; however, all new enrollment periods will be aligned with the fiscal year. Therefore, the initial enrollment period may be shorter than a 12 month period.

5.3.1 The effective date of enrollment for Service members shall be the date the contractor receives the enrollment application. For enrollment requests received via the Government-furnished web-based self-service enrollment system/application, the contractor shall modify the effective date to be the date the enrollment was submitted.

5.3.2 For all other beneficiary categories, enrollment periods shall begin on the first day of the month following the month in which the enrollment application and any required enrollment fee payment is received by the contractor. If an application and fee are received after the 20th day of the month, enrollment will be on the first day of the second month after the month in which the contractor received the application. (This recurring principle is referred to as the “20th of the month” rule.)

5.3.3 Enrollees who transfer enrollment continue with the same enrollment period. The enrollment transfer, however, is effective the date the gaining contractor receives a signed enrollment application or transfer application. For enrollment transfers received via the Government-furnished web-based self-service enrollment system/application, the contractor shall modify the effective date to be the date the enrollment was submitted. See TPM, Chapter 10, Sections 2.1 and 5.1 for information on Transitional Assistance Management Program (TAMP) and other changes in status.

5.4 Effective Date of Enrollment (On or After January 1, 2018)

5.4.1 The contractor shall ensure TRICARE Prime and TRICARE Select enrollments are effective the date of the Qualifying Life Event (QLE) or on January 1 of the following year for open enrollment period enrollments (see TPM, Chapter 10, Section 2.1).

5.4.2 The contractor shall accept requests for enrollment based upon a QLE up to 90 days before and no later than 90 days after the date of the QLE. For online requests for an enrollment date less than 90 days or more than 90 days from the date of the QLE, the Government-furnished web- based self-service enrollment system/application will display a message to contact the contractor.

5.4.3 For TRICARE Prime and TRICARE Select enrollments initiated/updated by DEERS per paragraph 2.0, see TPM, Chapter 10, Section 2.1 for effective enrollment dates.

5.5 Enrollment Expiration (Before January 1, 2018)

5.5.1 Due to the extended enrollment period in 2017, the contractor shall not send renewal notices to TRICARE Prime enrollees on October 1, 2017 as in previous years. See paragraph 5.6.1.

5.5.2 The contractor shall automatically renew enrollments, including those for Service members, upon expiration unless the enrollee declines renewal, is no longer eligible for Prime enrollment, or fails to pay any required re-enrollment fee on a timely basis, including a 30 day grace period beginning the first day following the last day of the enrollment period. See paragraph 11.5.1, for actions required if a beneficiary is identified as being ineligible for continued Prime, TPR or TPRADFM enrollment.

5.5.3 If the enrollee requests disenrollment during this grace period, the contractor shall disenroll the beneficiary effective retroactive to the enrollment period expiration date (last paid-through date).

5.5.4 If an enrollee does not respond to the notification and fails to make an enrollment fee payment by the end of the grace period, the contractor shall assume that the enrollee has declined continued enrollment. The contractor shall disenroll the beneficiary retroactive to the enrollment expiration date (last paid-through date).

5.5.5 Service members may not decline continued enrollment nor request disenrollment.

5.5.6 DMDC sends written notification to the beneficiary of the disenrollment and the reason for the disenrollment within five business days of the disenrollment transaction.

5.6 Enrollment Expiration (Starting January 1, 2018)

5.6.1 The contractor shall not send renewal notices to enrollees. Exception: Thirty (30) days before the expiration date of enrollment for beneficiaries paying enrollment fees quarterly or annually, the contractor shall send the appropriate individual (i.e., sponsor, custodial parent, retiree, retiree family member, survivor or eligible former spouse) a written notification of the pending enrollment expiration that includes a bill for the re-enrollment fee. The notification alerts the beneficiary they will only be eligible for Market/MTF space-available care should the beneficiary fail to pay the enrollment fee. If appropriate, the contractor shall ensure the notification includes rate change information. The contractor shall ensure the bill offers all available payment options and methods. The contractor shall issue a delinquency notice to the appropriate individual 15 days after the expiration date of the enrollment if a renewal payment is not received.

5.6.2 For beneficiaries that pay enrollment fees on a monthly basis: the contractor shall send the appropriate individual (i.e., sponsor, custodial parent, retiree, retiree family member, survivor or eligible former spouse) a written notification alerting the beneficiary of any fee changes at least 30 days prior to the implementation of any fee changes.

5.6.3 The contractor shall automatically renew enrollments, including those for ADSMs, each CY unless the enrollee declines renewal, is no longer eligible for enrollment, or fails to pay any required enrollment fee on a timely basis. See TPM, Chapter 10, Section 2.1 for required actions if a beneficiary is identified as being ineligible for continued enrollment. The contractor may reinstate coverage if the request is received with appropriate payment of fees within 90 days from the last paid-through date.

5.6.4 ADSMs may not decline reenrollment nor request disenrollment.

5.6.5 DMDC will notify the beneficiary of the disenrollment within five business days of the disenrollment transaction.

5.7 Disenrollment

5.7.1 Disenrollment requests are initiated by the sponsor, spouse, other legal guardian of the beneficiary, or an eligible beneficiary 18 or older. An official disenrollment request includes those with:

• An original signature;

• An electronic signature offered by and collected by the contractor;

• A verbal consent provided via telephone and documented in the contractor’s call notes; or

• A self-attestation by the beneficiary when using the Government-furnished web-based self-service enrollment system/application. (An ADSM cannot request disenrollment.)

5.7.2 The contractor shall automatically disenroll beneficiaries when the appropriate enrollment fee payment is not received by the 30th day following the last paid-through date. The contractor shall set the disenrollment effective date retroactive to the last paid-through date. An enrollment fee payment includes the correct amount for the period the fee is intended to cover (i.e., monthly, quarterly, or annually).

5.7.3 Prior to processing a disenrollment for “non-payment of fees,” the contractor shall reconcile its fee payment system against the fee totals in DEERS. Once the contractor confirms that the payment amounts match, the disenrollment is entered in the Government-furnished web-based enrollment system/application.

5.7.4 Prior to January 1, 2018

5.7.4.1 The disenrolled beneficiary is responsible for the deductible and cost-shares applicable under TRICARE Extra or Standard for any health care received during the 30 day grace period. In addition, the beneficiary is responsible for the cost of any services received during the 30 day grace period that may have been covered under TRICARE Prime but are not a benefit under TRICARE Extra or Standard.

5.7.4.2 The contractor may suspend claims processing during the grace period to avoid the need to recoup overpayments.

5.7.5 Effective January 1, 2018

The contractor shall pend claims received during the grace period to avoid having to recoup overpayments. See the TPM, Chapter 10, Sections 2.1 and 3.1 for additional information on disenrollment.

5.8 Enrollment Lockout (Prior to January 1, 2018)

5.8.1 The contractor shall “lockout” or deny re-enrollment effective the date of disenrollment for the following beneficiaries:

• Retirees and/or their family members who voluntarily disenroll prior to their annual enrollment renewal date;

• ADFMs (E-5 and above) who change their enrollment status (i.e., from enrolled to disenrolled twice in a given year) for any reason during the enrollment year (October 1 to September 30) (refer to this chapter and TPM, Chapter 10, Sections 2.1 and 3.1; and

• Any beneficiary disenrolled for failure to pay required enrollment fees during a period of enrollment.

Note: The 12 month lockout provision is not applicable to ADFMs whose sponsor’s pay grade is E-1 through E-4.

5.8.2 Beneficiaries who are disenrolled for the above reasons prior to December 31, 2018 are eligible to re-enroll any time during calendar year 2018. Beginning January 1, 2019, the 2018 enrollment grace period ends and only the annual open enrollment season and QLE rules fully apply. See TPM, Chapter 10, Section 2.1.

5.9 Enrollment Reinstatement (Starting January 1, 2018)

5.9.1 Enrollment lockouts are no longer necessary for TRICARE Prime and TRICARE Select as enrollments are only allowed during the annual open enrollment period or due to a QLE.

5.9.2 The contractor shall reinstate (restore) the enrollment if the beneficiary requests reinstatement within 90 days of their disenrollment date (last paid-through date) and pays all past due fees if applicable. Otherwise, the contractor shall deny requests for reinstatement due to failure to pay fees received after 90 days past the last paid-through date.

5.10 Exception

In the event the “failure to pay” disenrollment was directly caused by contractor or Government error, for example, the contractor failed to submit the correct allotment amount to the Defense Finance and Account Service (DFAS), upon request of the beneficiary via the contractor, the MCSPS, TRICARE Area Offices (TAOs), or USFHP program office may direct reinstatement of the coverage greater than 90 days past the last paid-through date if all past fees are paid if applicable. The contractor shall not start a new enrollment period in lieu of reinstatement from the last paid-through date.

6.0 Enrollment Fees

6.1 General

The contractor shall collect enrollment fee payments from TRICARE Prime and TRICARE Select enrollees and report those fees, including any overpayments that are not refunded to the enrollee, to DEERS.

• The contractor shall report refunds to DEERS: (1) all refunds of any enrollment fees collected, and (2) fee amounts forfeited by enrollees prior to January 1, 2018 who voluntarily disenroll and are not due a refund. The contractor shall not retain forfeited fee amounts, unless they can be credited to the enrollment of another family member(s), as a credit. For forfeited fees, the contractor shall adjust the fees paid on the enrollment policy to match with the voluntary termination date (“zero” the fees paid). (See the TSM, Chapter 3.) For enrollment fee refund policies as of January 1, 2018, see paragraph 9.0.

• The contractor shall report a credit to DEERS to offset outstanding enrollment fees anytime a retirement date is retroactively changed by the Uniformed Services as recorded in DEERS that results in a situation where past prorated enrollment fees are now due based upon the changed date for a retiree who was previously paid to date in their enrollment fees that occurred before January, 1, 2018. The contractor shall credit the retiree’s enrollment fee and report as an offset to the collected enrollments deposited to the Defense Health Agency’s (DHA’s) account. This shall occur as long as the retiree’s enrollment fees are otherwise current.

• To permit the transition from a fiscal to a calendar enrollment year, fiscal year 2017 is defined as the period from October 1, 2016 through December 31, 2017. For FY 2017, prorated TRICARE Prime enrollment fees are required for the additional period of October 1, 2017 through December 31, 2017.

• TRICARE Prime and TRICARE Select enrollees may choose one of the following three payment fee options: annual, quarterly, or monthly.

• Beginning January 1, 2021: The contractor shall collect enrollment fees for new TRICARE Select policies, including TRICARE Select Group A enrollees that begin paying enrollment fees effective January 1, 2021, by monthly allotment only from military retired/retainer pay, where feasible, as mandated by law (National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2020, Section 702). Lack of feasibility includes instances where this is no retired/retainer pay (e.g., 100% disabled veterans, certain unremarried former spouses, survivors) available to cover monthly enrollment fees; or instances where the beneficiary adamantly refuses to authorize payment of fees via allotment. If not feasible, the contractor shall allow payment of monthly TRICARE Select enrollment fees via a monthly recurring electronic payment in the form of Electronic Funds Transfer (EFT) (which may include recurring credit/debit charge (RCC)).

• When enrollment fee or premium payments are permitted by credit or debit cards, beneficiaries in overseas locations must use a credit or debit card issued by a United States (U.S.) banking institution or other U.S. financial institution.

• In the event that there are insufficient funds to process an enrollment fee or premium payment, the contractor may assess the account holder a fee of up to 20 U.S. dollars ($20.00), which is retained by the contractor. The contractor shall provide commercial payment methods for enrollment fees and premiums that best meet the needs of beneficiaries while conforming to paragraphs 6.1.2 through 6.8.

6.1.1 Fiduciary Responsibilities

6.1.1.1 The contractor shall act as a fiduciary for all funds acquired from TRICARE Prime and TRICARE Select enrollment fees, which are Government property. The contractor shall develop strict funds control processes for its collection, retention and transfer of enrollment fees to the Government. The contractor shall maintain all enrollment fees received by the contractor in accordance with these procedures.

6.1.1.2 The contractor shall establish a separate non-interest bearing account for the collection and disbursement of enrollment fees. The contractor shall deposit enrollment fees into the established account within one business day of receipt.

6.1.1.3 The contractor shall wire-transfer the enrollment fees minus any refund payments twice monthly, on the first and the 15th business day to a specified Government account as directed by DHA Contract Resource Management (CRM) Office, refer to Section G of the contract. The Government will provide the contractor with information for this Government account. The contractor shall notify the DHA CRM, by email, within one business day of the deposit stating the date and amount of the deposit.

6.1.1.4 The contractor shall maintain a clear, auditable record of all enrollment fees received, the date received and the date transferred to the Government. The contractor’s record shall also document all refunds issued, to whom the refund was issued, the amount of the refund, and the date reported to the Government.

6.1.2 Annual Payment Fee Option

The contractor shall collect the annual fee in one lump sum. For initial enrollments, the contractor shall prorate the fee from the enrollment date to December 31. The specified fee payment amount is established and communicated by the Government to the contractor. The contractor shall accept payment of the annual enrollment fee only by debit/credit card (e.g., Visa/MasterCard). See paragraph 5.7 for disenrollment information if the appropriate enrollment fee payment is not received.

6.1.3 Quarterly Payment Fee Option

Quarterly installments are equal to one-fourth (1/4) of the total annual fee amount. The specified fee payment amount for the quarterly payment option is established and communicated by the Government to the contractor. For initial enrollments, the contractor shall prorate the quarterly fee to cover the period until the next quarter. Quarters begin on January 1, April 1, July 1, and October 1. The contractor shall collect quarterly fees thereafter. The contractor shall accept payment of the quarterly enrollment fee by debit/credit card (e.g., Visa/MasterCard) and optionally may elect to receive quarterly payments via RCC or EFT transactions. See paragraph 5.7 for disenrollment information if the appropriate enrollment fee payment is not received.

6.1.4 Monthly Payment Fee Option

Monthly installments are equal to one-twelfth (1/12) of the total annual fee amount. The specified fee payment amount for the monthly payment option is established and communicated by the Government to the contractor. Beneficiaries shall pay monthly enrollment fees through an automated, recurring electronic payment either in the form of an allotment from retirement pay or through EFTs from the enrollee’s designated financial institution (which may include a RCC). These are the only acceptable payment methods for the monthly payment option.

6.1.4.1 Enrollees who elect a monthly fee payment option shall pay up to three months of fees (contractor determined), at the time the enrollment request is submitted; contingent on the method and date the request is submitted to allow time to establish an EFT, RCC, or allotment. The contractor shall explain the amount required and accept payment by personal check, cashier’s check, traveler’s check, money order, or debit/credit card (e.g., Visa/MasterCard) for initial enrollment requests. For continuous coverage requests, the contractor shall accept payment by allotment, EFT or RCC.

6.1.4.2 The contractor shall obtain and verify the information required to initiate monthly allotments and EFTs.

6.1.4.3 The contractor shall direct bill the beneficiary only when a problem occurs.

6.1.4.4 When an administrative issue arises that stops or prevents an automated monthly payment from being received by the contractor (e.g., incorrect or transposed number provided by the beneficiary, credit card expired, bank account closed), the contractor shall grant the enrollee 30 days from the paid-through date to provide information for a new automated monthly payment method or the option to pay quarterly or annually. The contractor shall accept payment by check during this 30 day period to preserve the beneficiary’s TRICARE Prime or TRICARE Select enrollment status.

6.1.4.5 The contractor shall coordinate allotments from retired pay with the DFAS or the appropriate Uniformed Services pay center, as appropriate (see the TSM, Chapter 1, Section 1.1, paragraph 7.10 for Payroll Allotment Interface Requirements).

6.1.4.6 The contractor shall also research and resolve all requests that have been rejected or not processed by DFAS, or the appropriate Uniformed Services pay center. If the contractor’s research results in the positive application of the allotment action, the contractor shall resubmit the allotment request.

6.1.4.7 The contractor shall notify the beneficiary within five business days of rejected allotment requests and issue an invoice to the beneficiary for any outstanding enrollment fees due. The contractor shall respond to all beneficiary inquiries regarding allotments.

6.2 Member Category

The contractor shall use the sponsor’s member category on the effective date of the initial enrollment, as displayed in the Government-furnished web-based enrollment system/application, to determine the requirement for an enrollment fee.

6.3 Unremarried Former Spouses (URFSs) and Children Residing with Them

6.3.1 URFSs became sponsors in their own right as of October 1, 2003. As such, they are enrolled under their own SSNs and must pay an individual enrollment fee. URFS may not “sponsor” other family members and their fees may not be factored into any family fees associated with the former spouse/sponsor.

6.3.2 The contractor shall identify and enroll children residing with URFS, whose eligibility for benefits is based upon the ex-spouse/former sponsor, under the ex- spouse/former sponsor’s SSN on DEERS. The contractor shall combine fees for these children with other fees paid under the ex-spouse/former sponsor.

Example: The contractor shall collect the individual enrollment fee for an URFS’s enrollment under the URFS’s own SSN. The contractor shall also collect a family enrollment fee for any two or more eligible family members enrolled under the SSN of the ex-spouse/former sponsor. These enrollees may include the sponsor, any current spouse, and all eligible children, including those living with the URFS.

6.4 TRICARE Prime Fee Waiver

6.4.1 Each TRICARE Prime enrolled beneficiary, who is required to pay enrollment fees, regardless of age, and who maintains enrollment in Medicare Part B, is entitled to a waiver of an amount equivalent to the individual TRICARE Prime enrollment fee. Hence, the contractor shall waive enrollment fees for individual enrollments for such beneficiaries. The amount equivalent to one-half of the fee for a family enrollment in TRICARE Prime will be waived when, one family member maintains enrollment in Medicare Part B; the remaining half is paid by the enrollee. The entire enrollment fee for a family enrollment is waived when two or more family members maintain enrollment in Medicare Part B regardless of the number of family members who are enrolled in addition to those entitled to Medicare Part B.

6.4.2 The amount equivalent to the individual TRICARE Prime or TRICARE Select enrollment fee shall be waived for a family enrollment in TRICARE Plus with Active Duty TRICARE Select or TRICARE Plus with Retired TRICARE Select, as appropriate (not to exceed two individual fee payments).

6.5 TRICARE Select Enrollment Fees

The contractor shall ensure families enrolled in TRICARE Select plans requiring enrollment fees (any combination of TRICARE Select or TRICARE Plus with TRICARE Select plans) do not pay more than the TRICARE Select family enrollment fee. The contractor shall apply a fee waiver code to any policy that does not require fees to be paid.

6.6 Survivors of Active Duty Deceased Sponsors and Medically Retired Uniformed Services Members and their Family Members

6.6.1 Beneficiaries Whose Sponsor Has An Initial Service Date Before January 1, 2018

Effective FY 2012, TRICARE Prime beneficiaries who are (1) survivors of active duty deceased sponsors, or (2) medically retired Uniformed Services members and their family members, shall have their TRICARE Prime enrollment fees frozen at the rate in effect when classified and enrolled in a fee paying TRICARE Prime plan. (This does not include TRICARE Young Adult (TYA) plans). Beneficiaries in these two categories who were enrolled in FY 2011 must continue paying the FY 2011 rate. The beneficiaries who become eligible in either category and enrolled during FY 2012, or in any future FY, shall have their fee frozen at the rate in effect at the time of enrollment in TRICARE Prime. The fees for these beneficiaries shall remain frozen as long as at least one family member remains enrolled in TRICARE Prime. The fee for the family member(s) of a medically retired Uniformed Services member will not change if the family member(s) is later re-classified a survivor. These two categories of beneficiaries who choose to enroll in TRICARE Select do not pay the established annual TRICARE Select enrollment fee beginning January 1, 2021.

6.6.2 Beneficiaries Whose Sponsor Has An Initial Service Date On Or After January 1, 2018

There is no TRICARE Prime enrollment fee freeze for retirees and family members in the two categories in paragraph 6.6.1. The contractor shall require they pay the established annual TRICARE Prime enrollment fee amount. The contractor shall require medically retired members and their family members who choose to enroll in TRICARE Select to pay the established annual TRICARE Select enrollment fee.

6.7 Pro-rated Enrollment Fees

6.7.1 For enrollments prior to January 1, 2018, the contractor shall collect any applicable enrollment fee from pro-rated enrollees at the time of enrollment. However, there will be no enrollment fee collected for the days between the effective enrollment date and the determined enrollment date.

6.7.2 For enrollments prior to January 1, 2018, the determined enrollment date shall be established using the “20th of the month rule,” as it is for initial enrollments.

Example: If the retirement date is May 27, the effective enrollment date will be May 27 and the determined enrollment date will be July 1. Fees will be charged for the period from July 1 forward; no fees will be assessed for the period from May 27 through June 30. DEERS will calculate the paid-through dates based on DEERS data and the enrollment fee amount collected and entered into DEERS by the contractor.

6.7.3 Effective January 1, 2018, paragraphs 6.7.1 through 6.7.2 no longer apply. The contractor shall pro-rate fee amounts based upon 1/30th of the TRICARE Prime or TRICARE Select fee, as applicable, calculated from the date of enrollment (initial eligibility or QLE date) to the end of the month.

6.8 Overpayment Of Enrollment Fees

The contractor shall update DEERS with the enrollment fee amount collected and DEERS will calculate the paid-through date and notify the contractor. DEERS will only extend the paid-through date to cover the current enrollment year, plus future FYs (prior to January 1, 2018) or CYs (starting January 1, 2018). DEERS will store amounts that do not cover one month’s fees or amounts that extend the paid-through date beyond two years in the future as a credit.

6.8.1 Funds applied that would move the paid-through date beyond the policy end date are stored as a credit. (The exception is when TRICARE Prime policies, prior to January 1, 2018, end mid-month; DEERS will set a paid-through date to the end of that month.)

6.8.1.1 If there is a 100% fee waiver with an end date that exceeds more than two CYs (FYs before January 1, 2018) beyond the current enrollment year, the paid period may extend beyond the two CYs (FYs before January 1, 2018) and any fee amounts sent to DEERS are applied as a credit.

6.8.1.2 The contractor shall refund any credit of $1 or more on a current enrollment that extends beyond two future CYs (FYs prior to January 1, 2018). The contractor shall update DEERS with any fee amount refunded within 30 days. The contractor shall include an explanation for the premium refund. For the 2018 and 2019 enrollment fees credited to the catastrophic cap, the contractor shall notify the beneficiaries by letter of the credit, how the credit was applied, and how a refund can be requested. See also paragraph 8.0.

6.8.2 DEERS will provide the following reports to the contractor on a monthly basis to assist with identifying and correcting enrollment fee discrepancies. The contractor responsible for a beneficiary’s current enrollment shall resolve any over/under payments. For split enrollments, the reports use the billing hierarchy to determine the responsible contractor.

• Current policies that are two months past due (paid period end date more than two months in the past).

• Any policies where the paid period end date exceeds the policy end date.

• Policies where the paid period end date meets the policy end date but a credit exists.

• Terminated policies where the paid period end date does not meet the policy end date.

6.8.3 The contractor shall analyze and correct all report accounts within 30 days of the report’s availability. The contractor shall correct any data inaccuracies in the enrollment fee reporting system to include the refunding of enrollment fees in excess of what is due, if necessary. The contractor shall update DEERS with any enrollment fee amounts refunded within 30 days and notify DHA as specified above.

7.0 Enrollment Of Family Members Of E-1 Through E-4

7.1 When family members of E-1 through E-4 reside within a 30 minute drive time of a Market/MTF offering TRICARE Prime, the enrolling entity (Government or contractor) will encourage the family members to enroll in TRICARE Prime. Upon enrollment, family members will choose or be assigned a PCM located in the Market/MTF. The choice of whether to enroll or to decline enrollment in TRICARE Prime is completely voluntary. Family members of E-1 through E-4 who decline enrollment or who enroll in TRICARE Prime and subsequently disenroll may not re-enroll until the next open period or they experience a QLE.

7.2 The contractor shall ensure enrollment processing and civilian PCM assignments are in accordance with the MOU between the contractor and the Market/MTF.

7.3 The primary means of identification and subsequent referral for enrollment occurs during in-processing to the installation. Non-enrolled E-4 and below families may also be referred to the contractor’s call center, by Commanders, First Sergeants/Sergeants Major, Supervisors, Family Support Centers, and others. Beneficiaries at overseas locations may also be referred to their local TSC.

7.4 The contractor call center representatives and those giving beneficiary education briefings shall provide enrollment information and support the family member in managing their enrollment options. The education of such potential enrollees shall specifically address the advantages of TRICARE Prime enrollment, (e.g., guaranteed access, the support of a PCM). The contractor shall reinforce that enrollment is at no cost for family members of E-1 through E-4 and shall give them the opportunity to:

• Select or be assigned a Market/MTF PCM, or

• Select a civilian PCM if permitted by applicable MOU, or

• Select USFHP, if available, or

• Decline enrollment in TRICARE Prime and enroll in TRICARE Select.

7.5 The contractor shall discuss the potential effective date of the enrollment with the beneficiary.

7.6 The contractor shall terminate enrollment upon request of the enrollee, sponsor or other party as appropriate under existing enrollment/disenrollment procedures. The request may be made at any time. Prior to January 1, 2018, beneficiaries may re-enroll at any time without restriction or penalty. See paragraph 5.2 for enrollment rules as of January 1, 2018.

7.7 The contractor shall not screen TRICARE claims to determine whether it may be for treatment of a non-enrolled ADFM of E-1 through E-4 living in a Prime Service Area (PSA). Rather, the contractor shall support the prompt and informed enrollment of such individuals when they have been identified by DoD in the course of such a person’s interaction with the Military Healthcare System (MHS) or personnel community and have been referred to the contractor for enrollment.

7.8 Effective January 1, 2018, DMDC will automate the enrollment of newly eligible ADFMs into TRICARE Prime or TRICARE Select, if overseas into TOP Select. See paragraph 2.3.

8.0 TRICARE Eligibility Changes/Refunds Of Fees

See paragraph 9.0 for additional requirement starting January 1, 2018.

8.1 Refer to the TPM, Chapter 10, Section 3.1, for information on changes in eligibility.

8.2 The contractor shall allow a TRICARE-eligible beneficiary who has less than 12 months of eligibility remaining to enroll in TRICARE Prime or TRICARE Select until such time as the enrollee loses TRICARE eligibility. The contractor shall allow the beneficiary the choice of paying the entire enrollment fee or paying the fees on a more frequent basis (e.g., monthly or quarterly). If the enrollee chooses to pay by installments, the contractor shall collect only those installments required to cover the period of eligibility. DEERS will calculate the paid-through date based upon the enrollment fee amount collected and entered into DEERS by the contractor, which in this circumstance, shall cover the period of the beneficiary’s eligibility. The contractor shall refund any overpayment of $1 or more that DEERS does not use to extend the paid-through date to the policy end date (or the last day of the month in which a TRICARE Prime or TRICARE Select policy ends). The contractor shall include an explanation to the beneficiary for the fee refund. The contractor shall update DEERS with any fee amount refunded within 30 days.

8.3 The contractor shall refund the unused portion of TRICARE Prime or TRICARE Select enrollment fees to retired enrollees whose sponsor is recalled to active duty. The contractor shall include an explanation to the beneficiary for the fee refund. The contractor shall calculate the refund using monthly prorating, and shall report such refunds to DEERS within 30 days. Upon activation of the member, the family members are automatically enrolled as ADFMs (see TPM, Chapter 10, Section 2.1). If the reactivated member’s family chooses continued enrollment in TRICARE Prime or TRICARE Select, the family shall begin a new enrollment period and the contractor shall offer them the opportunity to keep their PCM (TRICARE Prime only), if possible.

8.4 The contractor shall apply any catastrophic cap accumulations to the new enrollment period.

8.5 The contractor shall refund enrollment fees for deceased enrollees upon receiving a written request, along with a copy of the death certificate, from the remaining enrollee or the executor of the decedent’s estate. The contractor shall include an explanation for the fee refund to the beneficiary. The contractor shall prorate refunds on a monthly basis and apply both to individual plans where the sole enrollee is deceased and to the conversion of a family enrollment to an individual plan upon the death of one or more family members. For individual enrollments, the contractor shall refund remaining enrollment fees to the executor of the estate. For family enrollments that convert to individual plans, the contractor shall either credit the excess fees to the individual plan or refund them either to the remaining enrollee or to the executor of the decedent’s estate, as appropriate. Enrollment fees for family enrollments of three or more members are not affected by the death of only one enrollee and the contractor shall not issue a refund. The contractor shall update DEERS with any amount refunded within 30 days.

8.6 The contractor shall refund the unused portion of TRICARE Prime or TRICARE Select enrollment fees to enrollees who become entitled to Medicare Part A regardless of reason, or age, provided the beneficiary has Medicare Part B coverage.

8.6.1 The contractor shall issue refunds to these beneficiaries upon receiving (1) a written request from the beneficiary (that includes a copy of their Medicare card) and either confirming their Part B enrollment in DEERS or in a previous Government-furnished policy notification, or (2) upon receipt of an unsolicited Government-furnished policy notification noting a beneficiary’s fee waiver update based upon the Part B enrollment. DEERS generates a Government-furnished policy notification when the Centers for Medicare and Medicaid Services (CMS) sends DEERS data indicating a Part B enrollment or disenrollment. The contractor shall issue refunds for all payments that extend beyond the date the enrollee has Medicare Part B coverage, as calculated by DEERS. The contractor shall update DEERS with any amount refunded within 30 days. The contractor shall include an explanation to the beneficiary for the fee refund. If the fee waiver is a 100% waiver of the TRICARE Prime enrollment fee, the contractor shall send a refund to the beneficiary. If the fee waiver is a 50% waiver of the TRICARE Prime enrollment fee, DEERS will automatically calculate the overpayment and extend the paid-through date for the policy. A refund is not required unless a credit remains when the policy is paid in full.

8.6.2 For TRICARE Prime and TRICARE Select enrollees who become entitled to Medicare and who maintain Medicare Part B coverage, the contractor shall issue refunds for overpayments occurring on and after the Start of Health Care Delivery (SHCD). The contractor shall use the Government-furnished policy notifications received indicating a fee waiver based upon the Medicare Part B effective date to substantiate any claim of overpayment. The contractor shall update DEERS with any amount refunded within 30 days and include an explanation to the beneficiary for the fee refund.

8.6.3 Medicare eligible ADFMs age 65 and over are not required to have Medicare Part B to remain enrolled in TRICARE Prime or TRICARE Select. To maintain TRICARE coverage upon the sponsor’s retirement, ADFMs must enroll in Medicare Part B during their Special Enrollment Period. To avoid a break in TRICARE coverage, ADFMs should sign up for Medicare Part B the month before their sponsor retires and pay applicable Medicare Part B premiums. (The Special Enrollment Period is available anytime the sponsor is on active duty or within the first eight months of the sponsor’s retirement. If they enroll in Part B after their sponsor’s retirement date, they will have a break in TRICARE coverage.)

8.6.4 TRICARE beneficiaries age 65 and over who are not entitled to premium-free Medicare Part A are not required to have Medicare Part B to remain enrolled in TRICARE Prime or TRICARE Select. The contractor shall advise enrollees who are not eligible for Medicare Part A that they may be eligible for Medicare on a spouse’s record. If there is the possibility to be eligible for Medicare Part A on a spouse’s record, then the 65 year old TRICARE beneficiary should be advised to sign up for Medicare Part B in order to avoid the Medicare Part B late enrollment premium penalty. Everyone is eligible for Medicare Part B at age 65, even if not eligible for Part A. To be eligible for Medicare Part A on a spouse’s record, the following must be met:

• For those currently married: Need to be married for at least a year.

• For those currently divorced: Must be single, after being married for at least ten years, to a spouse eligible for Medicare. If remarried, and still TRICARE eligible, see above for those currently married.

• For those widowed: Must be single after at least nine months of marriage to a spouse eligible for Medicare. If remarried, and still TRICARE eligible, see above for those currently married.

Those not eligible for Medicare Part A must sign up for Medicare Part A on their spouse’s record 2 to 3 months before the spouse turns 62 years of age. Otherwise, sign up must occur at the time the 65 year old is denied Medicare on their own record.

8.7 The contractor shall draw refunds from the contractor’s enrollment fee account and reported to the Government in accordance with the requirements specified above.

8.8 The contractor shall include full and complete information about the effects of changes in eligibility and rank in beneficiary education materials and briefings.

9.0 TRICARE Eligibility Changes/Refund of Fees

9.1 See TSM, Chapter 3.

9.2 Criteria and documentation required for the specific TRICARE eligibility changes as listed in paragraph 8.0 still apply; however, whenever any overpaid fee situation is identified, the contractor shall:

• Apply overpaid fees to another enrolled family member under the same Uniformed Services sponsor if within the maximum two CYs. Overpaid fees for URFSs are only applied to the URFS.

• Automatically refund prorated enrollment fees in excess of two CYs.

• Upon request from sponsor or responsible individual, apply overpaid fees as directed up to the maximum two CYs and/or refund overpaid fees as requested.

• Issue refunds that are $1 or more.

• Issued refunds within 30 days to a Uniformed Services sponsor, eligible spouse, and then oldest child in that order. Refunds for URFS enrollment fees are only refunded to the URFS.

• Update DEERS within 30 days with any refund amount.

10.0 Wounded, Ill, And Injured (WII) Enrollment Classification

10.1 The WII Program provides a continuum of integrated care from the point of injury to the return to duty or transition to active citizenship for the Active Component (AC) or the Reserve Component (RC) Service members who have been activated for more than 30 days. These AC/RC Service members, referred to as Service members, have been injured or became ill while on active duty and will remain in an active duty status while receiving medical care or undergoing physical disability processing. WII Programs vary in name according to Uniformed Services. The Uniformed Services will determine member eligibility for enrollment into a WII Program, as well as whether or not to use these enrollments.

10.2 To better manage this population, a secondary enrollment classification of HCDP Plan Coverage Codes, WII 415 and WII 416 were developed. These primary rules apply to the WII HCDP codes:

• The contractor shall enroll Service members to TRICARE Prime prior to, or at the same time, as being enrolled into a WII 415 or WII 416 Program.

• The contractor shall not enroll a Service member in WII 415 and WII 416 Programs at the same time.

• The contractor shall terminate WII 415 and WII 416 enrollments at the end of the member’s active duty eligibility, when members transfer enrollment to another Market/MTF, change of a plan code, or at the direction of the Uniformed Services-specific WII entity.

• The contractor shall follow the rules associated with the primary HCDP Plan Coverage Code, such as TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote for any claims processed for WII 415/416 enrollees. The contractor shall process and pay all claims under Supplemental Health Care Program (SHCP) rules. DEERS will not produce specific enrollment cards or letters for WII 415/416 enrollment.

• The contractor shall code WII 415/416 TRICARE Encounter Data (TED) record(s) with the WII 415/416 HCDP Plan Coverage Code; however, the Enrollment/Health Plan Code data element on the TED record shall reflect the appropriate value for the primary HCDP Plan Coverage Code. For example, a TED record for a WII 416 enrollee with primary enrollment to TPR reflects the HCDP Plan Coverage Code of “416” but the Enrollment/Health Plan Code is coded “W TPR Active Duty Service Member”.

10.3 WII 415 - Wounded, Ill, And Injured (e.g., Warrior Transition Unit (WTU)/MEDHOLD)

10.3.1 The contractor shall enroll Uniformed Services-defined eligible Service members assigned to a WII 415 Program such as a MEDHOLD or WTU, to TRICARE Prime or TOP Prime prior to, or at the same time, as being enrolled into the WII 415. The contractor shall not enroll Service members to the WII 415 without a concurrent TRICARE Prime or TOP Prime enrollment. Uniformed Services-appointed WII case managers will coordinate with the Market/MTF to facilitate TRICARE Prime PCM assignments for WII 415 members. The contractor shall assign a PCM in accordance with the Market/MTF MOU and in coordination with the WII case manager. WII 415 enrollment will not run in conjunction with TAMP and Service members enrolled in TPR. TOP Prime Remote are not eligible to enroll in the WII 415.

10.3.2 The Uniformed Services-specific WII entity stamps the front page of the DD Form 2876, enrollment application form, with WII 415. The enrollment form is then sent to the appropriate contractor who shall perform the enrollment in the Government-furnished web-based enrollment system/application and include the following information:

• WII 415 HCDP Plan Coverage Code

• WII 415 Enrollment Start Date (The contractor may change the Government-furnished web-based enrollment system/application defaulted start date, which may or may not coincide with the TRICARE Prime Enrollment Start Date. The start date may be changed up to 289 days in the past or 90 days into the future.)

10.3.3 WII 415 enrollments shall be in conjunction with a Market/MTF enrollment only, not to civilian network PCMs under TPR enrollment rules. DEERS will end WII 415 enrollments upon loss of the Service member’s active duty eligibility. WII 415 program enrollments shall not be portable across programs or regions. The TOP contractor shall enter WII 415 enrollments through the Government-furnished web-based enrollment system/application for outside the 50 U.S. and the District of Columbia.

10.3.4 The contractor shall accomplish the following functions based upon receipt of notification from the Uniformed Services-specific WII Program entities:

• Enrollment.

• Disenrollment.

• Cancel enrollment.

• Cancel disenrollment.

• Address update.

• May request unsolicited Government-furnished policy notifications resend.

• Modify begin date.

• Modify end date.

10.4 WII 416 - Wounded, Ill, And Injured - Community Care Units (CCUs)

10.4.1 Uniformed Services-defined eligible Service members may be assigned to a WII 416 Program such as the Army’s CCU and receive required medical care near the Service member’s home. The contractor shall enroll the Service member to TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote prior to or at the same time as being enrolled into WII 416. The contractor shall not enroll Service members to the WII 416 program without a concurrent TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote enrollment. Uniformed Services-appointed case managers will coordinate with the contractor or Market/MTF to facilitate TRICARE Prime or TPR PCM assignments for eligible beneficiaries. The contractor shall assign a PCM based upon the Market/MTF MOU and in coordination with the WII entity (e.g., CCU). WII 416 enrollments will not run in conjunction with TAMP.

10.4.2 The Uniformed Services-specific WII Program stamps the front page of the DD Form 2876, enrollment application form, with WII 416 for all new enrollments. The begin date is the date the contractor receives the signed enrollment form. A signed enrollment application includes those with an original signature, or an electronic signature offered by and collected by the contractor. The enrollment form is then sent to the appropriate contractor who shall perform the enrollment in the Government-furnished web-based enrollment system/application and included the following information:

• WII 416 HCDP Plan Coverage Code.

• WII 416 Enrollment Start Date. (Date received by the contractor or the date indicated by the Uniformed Services-specific WII Program which may be up to 289 days in the past, or 90 days in the future.)

10.4.3 WII 416 enrollments are in conjunction with a Market/MTF, TPR, TOP Prime, or TOP Prime Remote enrollment. DEERS ends WII 416 enrollments upon loss of member’s active duty eligibility. WII 416 program enrollments are not portable across programs or regions.

10.4.4 The contractor shall accomplish the following functions based upon receipt of notification from Uniformed Services-specific WII program entities:

• Enrollment.

• Disenrollment.

• Cancel enrollment.

• Cancel disenrollment.

• Address update.

• May request Government-furnished policy notification resend.

• Modify begin date.

• Modify end date.

11.0 TRICARE POLICY For Access To Care (ATC) And PSA Standards

11.1 Non-active duty beneficiaries in the Continental United States (CONUS) and Hawaii who reside more than 30 minutes travel time from their desired PCM but less than 100 miles must waive primary and specialty drive-time ATC standards if they wish to enroll in TRICARE Prime. (Due to the unique health care delivery challenges in Alaska, the requirement to request a waiver for the drive-time access standard does not apply to beneficiaries in Alaska.) Before effecting an enrollment or portability transfer request, the contractor shall ensure that a beneficiary has waived travel time ATC standards either by checking the Drive Time Waiver box in Section V of the DD Form 2876 enrollment application (this includes an electronic signature offered by and collected by the contractor), by providing verbal consent via telephone communication (which is documented in the contractor call notes), or by requesting enrollment through the Government-furnished web-based self-service enrollment system/application (for both civilian and Market/MTF PCMs). An approved waiver for a beneficiary residing less than 100 miles but more than 30 minutes from their PCM remains in effect until the beneficiary changes residence.

11.2 The contractor shall estimate the travel time or distance between a beneficiary’s residence to a PCM (either a civilian PCM or a Market/MTF) using at least one web-based mapping program. The choice of the mapping program(s) is at the discretion of the contractor, but the contractor shall use a consistent process to determine the driving distance for each enrollee applicant who may reside more than 30 minutes travel time from their PCM. The contractor shall compute time or distance between the enrollee’s residence and the physical location of the PCM (including Markets/MTFs). The contractor shall not use a geographic substitute, such as a geographic centroid.

11.3 The contractor (in conjunction with Markets/MTFs for Market/MTF enrollees) shall provide beneficiary drive-time waiver education and ensure that beneficiaries who choose to waive these standards have a complete understanding of the rules associated with their enrollment and the travel time standards they are forfeiting. This includes educating beneficiaries, who waive their ATC travel standards, of the following:

• Travel may be more than 30 minutes for access to primary care (including urgent care) and possibly more than one hour for access to specialty care services.

• Beneficiaries are held responsible for POS charges for care they seek that has not been referred by their PCM (or for Market/MTF enrollees, by another Market/MTF provider).

• Beneficiaries should consider whether any delay in accessing their enrollment site may aggravate their health status or delay receiving timely medical treatment.

11.4 Cross-Region TRICARE Prime Enrollment

Beneficiaries must enroll to the Region where the desired PCM is located; however, all TRICARE Prime enrollment policies still apply, (i.e., PCM selection and utilization, referrals, drive times and distance standards to the desired PCM). An access to care drive-time waiver is required (see paragraph 11.1). All claims are processed by the Region of enrollment. Beneficiaries must request cross-region enrollment by either submitting an enrollment form (DD Form 2876) or by calling the regional contractor servicing the desired PCM. The enrolling contractor shall ensure a beneficiary is not approved for cross-region enrollment if they live within 30-minutes of a Market/MTF, unless the Market’s/MTF’s servicing contractor approves the enrollment. The beneficiary is enrolled to the Market/MTF if a PCM is available.

11.5 Discrepant Addresses

11.5.1 If at any point during the enrollment period the contractor determines or is advised that a beneficiary is no longer eligible for continued TRICARE Prime enrollment due to their address, the contractor shall inform the beneficiary of the discrepant address situation. For example, their residential address is 100 miles or more from the PCM or Market/MTF (with no 100 mile waiver) to which they are enrolled or their residential address is 100 miles or more from their assigned network PCM. The contractor shall make this notification (letter, telephone call, or email) when the discrepant information is first known by the contractor. If the beneficiary confirms the DEERS-recorded address is incorrect, and the beneficiary updates DEERS with correct information (contractor to assist as appropriate), the beneficiary remains enrolled in TRICARE Prime if all enrollment requirements are met.

11.5.2 For the Continental U.S., Hawaii, and the District of Columbia: When the contractor confirms the beneficiary is ineligible for TRICARE Prime/Prime Remote enrollment due to their residential address, the contractor shall notify the beneficiary within five business days that they have a discrepant address and will be disenrolled unless further action is taken within 90 days. Notification shall include information about TRICARE Standard and Extra, prior to January 1, 2018, or TRICARE Select, starting January 1, 2018. See paragraph 1.0 for notification processes for discrepant DEERS records. The contractor shall continue to process all claims until the enrollment is changed.

11.5.2.1 The beneficiary must take action to enroll in TRICARE Select or USFHP (where available) within 90 days of this notification. The contractor, upon beneficiary request, shall process a retroactive enrollment for TRICARE Prime coverage that was terminated due to a discrepant address. However, the contractor shall collect all applicable retroactive TRICARE enrollment fees before processing an enrollment request. Alternatively, the beneficiary may elect to restart TRICARE coverage following a QLE or annual open enrollment season rules and costs.

Note: The contractor may reprocess impacted claims upon request from the beneficiary once retro-active enrollment is completed.

11.5.2.2 If the beneficiary takes no action within the 90-day window, the contractor shall terminate the TRICARE Prime/Prime Remote enrollment, effective the 91st day. Once enrollment is terminated, any care received outside the direct care system is not covered.

11.5.3 TRICARE Select Jurisdiction

If at any point during the enrollment period the contractor determines or is advised that a TRICARE Select enrollee’s residential address does not match the region of enrollment, the contractor shall not disenroll the beneficiary. If the contractor is aware of a TRICARE Select beneficiary requesting enrollment with an out-of-region address in DEERS, the contractor shall advise the beneficiary of the necessity to enroll in the region of their address in DEERS and inform the beneficiary to contact their correct Regional contractor to enroll in TRICARE Select.

11.6 Market/MTF TRICARE Prime Enrollees - Continental U.S., Hawaii, and the District of Columbia

11.6.1 Non-active duty beneficiaries shall reside within 30 minutes travel time from a Market/MTF to which they desire to enroll. A beneficiary desiring enrollment who resides more than 30 minutes (but less than 100 miles) from the Market/MTF, may be enrolled as long as the beneficiary waives primary and specialty ATC standards and the Market Director/MTF Director, or designee, approves the enrollment. If the MOU includes ZIP codes or drive-time distances for which the Market/MTF is willing to accept enrollments that are beyond a 30 minute drive, this constitutes approval. See 32 CFR 199.17 for information on access standards. If not addressed in the MOU, the contractor shall submit each request to the Market Director/MTF Director, or designee, in a method outlined in the MOU. The MCSPS may approve waiver requests from beneficiaries who desire to enroll to a Market/MTF and who reside 100 miles or more from the Market/MTF. In these cases, the Market Director/MTF Director must also agree to the enrollment and have sufficient capacity and capability.

11.6.2 If the contractor determines that the beneficiary resides 100 miles or more from the Market/MTF to which they are enrolled, and there is no 100-mile waiver on file, the contractor shall inform the beneficiary that they are no longer eligible for TRICARE Prime enrollment to the Market/MTF. See paragraph 11.5.

11.6.3 The contractor shall process all requests for enrollment to a Market/MTF in accordance with the MOU between the Market/MTF and the contractor. See paragraph 11.4 regarding cross-region enrollments. The following enrollment guidelines may be included in MOUs.

11.6.3.1 ZIP codes or distances for which the Market Director/MTF Director is mandating enrollment to the Market/MTF. These mandatory Market/MTF enrollment areas are within access standards (i.e., a 30 minute drive-time of the Market/MTF) and may apply to all eligible beneficiaries or may be based upon beneficiary category priorities for Market/MTF access.

Note: The contractor shall afford the opportunity to non-active duty TRICARE Prime applicants who reside more than 30 minutes travel time from a Market/MTF to enroll with a civilian PCM.

11.6.3.2 ZIP codes or distances for which the Market Director/MTF Director is willing to accept enrollment may include both areas within a 30 minute or less drive-time or over a 30 minute drive but within 100 miles. Any enrollment for a beneficiary with a drive of more than 30 minutes requires a signed waiver of access standards. If an enrollee applicant resides within a ZIP code previously determined to lie entirely within 30 minutes travel time from the Market/MTF, the contractor need not compute the travel time for that applicant.

11.6.3.3 The Market Director/MTF Director may use ZIP codes to designate distances beyond 100 miles for which they will consider requests for enrollment.

11.6.4 The contractor shall notify the Market Director/MTF Director (or designee) when a beneficiary residing 100 miles or more from the Market/MTF, but in the same Region, requests a new enrollment or portability transfer to the Market/MTF. Such notification is not necessary if the MOU has already established that the Market Director/MTF Director will not accept enrollment of beneficiaries who reside 100 miles or more from the Market/MTF. The contractor shall make this notification by any mutually agreeable method specified in the MOU. The contractor shall not make the Market/MTF enrollment effective unless notified by the Market/MTF to do so.

11.6.4.1 The Market Director/MTF Director will notify the Chief, MCSPS of their desire to enroll a beneficiary who resides 100 miles or greater from the Market/MTF and request approval for the TRICARE Prime enrollment. The Chief, MCSPS will make a determination on whether or not to approve or deny the request and notify the Market Director/MTF Director of the decision by a mutually agreeable method. The Market Director/MTF Director will notify the contractor of all approved enrollment requests for beneficiaries who reside 100 miles or greater from the Market/MTF. The contractor shall notify the beneficiary of the final decision.

11.6.4.2 Approved waivers for beneficiaries residing 100 miles or more from the Market/MTF will remain in effect until the beneficiary changes residence or unless the Market Director/MTF Director determines that they will no longer allow these enrollments. Even if a beneficiary has previously waived travel time standards, any Market Director/MTF Director may revise the MOU (following the MOU revision process) to state that enrollment of some or all current enrollees who reside 100 or more miles from the Market/MTF will not be renewed at the end of the enrollment period. The contractor shall inform such beneficiaries no later than two months prior to expiration of the current enrollment period that they are no longer qualified for renewal of enrollment to the Market/MTF. Prior to notification, the contractor shall obtain the rationale for the change from the Market/MTF to include in the notice to the beneficiary. The Chief, MCSPS will review and concur on the proposed notice prior to sending to the impacted beneficiaries. (The MCSPS will coordinate notices with DHA Communications prior to approval.)

11.6.5 At any time during the enrollment period, if the contractor determines there is no signed travel time waiver on file for a current Market/MTF enrollee who resides more than 30 minutes from the MTF, the contractor shall require the beneficiary to waive the primary and specialty care travel standards to continue their TRICARE Prime enrolled status. (This includes monitoring address changes received by the contractor from all sources.) The contractor shall notify the beneficiary of this waiver requirement within 30 days of determining a need for waiver. If the beneficiary chooses to not enroll in TRICARE Select or USFHP (where available) within 90 days. of notification, the contractor shall terminate the TRICARE Prime enrollment. DMDC will send the disenrollment notice and inform the beneficiary that their military medical benefits are now limited to direct care access to MTFs on a space available basis only. The MCSPS will review and concur on the language for all beneficiary notices prior to their being sent to beneficiaries. (The MCSPS will coordinate notices with DHA Communications prior to approval.)

• The contractor shall ensure any notice to a beneficiary requesting they sign a waiver of access standards, denying their enrollment, or advising them they are not eligible for re-enrollment to a Market/MTF, includes information on any available TRICARE plan options.

11.6.6 For each approved enrollment to a Market/MTF where the beneficiary has waived access standards, the contractor shall retain the enrollment request in a searchable electronic file until 24 months after the beneficiary is no longer enrolled to the Market/MTF. The contractor shall provide the retained file to a successor contractor at the end of the final option period.

11.6.7 When an enrollment request requires Market Director/MTF Director or Chief, MCSPS approval, any contractual requirements relating to processing timeliness for enrollment requests will begin when the contractor has obtained direction from the Market Director/MTF Director or Chief, MCSPS regarding waiver approval or disapproval.

11.7 Civilian TRICARE Prime PCMs - Continental U.S., Hawaii, and the District of Columbia

11.7.1 Within a PSA, the contractor’s civilian network shall have the capability and capacity to allow beneficiaries who reside in the PSA to enroll to a PCM within access standards. If a beneficiary who resides in the PSA requests enrollment to a specific PCM located more than a 30 minute drive from the beneficiary’s residence, the contractor may allow the enrollment if the beneficiary waives travel time access standards. (Also, see Chapter 5, Section 1.)

11.7.2 For new enrollments (including portability transfers), the contractor is not required to establish a network with the capability and capacity to grant TRICARE Prime enrollment to beneficiaries who reside outside a PSA. The contractor shall grant requests for new enrollments to the civilian network from beneficiaries residing outside a PSA provided there is sufficient unused network capacity and capability to accommodate the enrollment and that the PSA civilian network PCM to be assigned is located less than 100 miles from the beneficiary’s residence. Beneficiaries who reside outside the PSA and enroll in TRICARE Prime must waive their primary and specialty care travel time access standards.

11.7.2.1 ADFMs (Including ADFM TYA Prime Enrollees) Residing Outside A PSA

ADFMs (including ADFM TYA Prime enrollees) enrolled in TRICARE Prime and who reside outside of a T-3 PSA on September 30, 2013, are grandfathered in TRICARE Prime starting October 1, 2013. They remain enrolled in TRICARE Prime as long as they reside within 40 miles of the residence where they were originally granted grandfathered status and maintain eligibility as ADFMs. The contractor shall continue to have a PCM available for these beneficiaries and ensure all claims and benefits are administered as TRICARE Prime. ADFMs shall remain enrolled in TPRADFM, as appropriate. The contractor shall manage the grandfathered ADFMs as stated in this chapter.

11.7.2.2 Terms Of Grandfathered TRICARE Prime - Status

The ADFM maintains a residence within 40 miles of the residence where they were originally granted grandfathered status to retain grandfathered status. Grandfathered ADFMs are assigned a PCM. Grandfathered ADFMs may add or terminate enrollment of family members like any other ADFM (e.g., marriage, birth, adoption, divorce). Family members may live in a separate residence outside a T-3 PSA and still be grandfathered.

11.7.2.3 Grandfathered ADFMs lose their grandfathered status when they:

• Are no longer TRICARE eligible;

• Are no longer residing within 40 miles of the residence where they were originally granted grandfathered status; or

• Change to retired status.

11.7.3 The contractor shall not enroll beneficiaries who reside outside the PSA and are 100 miles or greater from an available civilian network PCM in the PSA in TRICARE Prime.

12.0 Reports

The contractor shall provide monthly Service member enrollment and beneficiary services reports. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

13.0 Implementation Of TRICARE Select Group A Enrollment Fees

13.1 The contractor may collect and process enrollment requests to include processing of allotment requests prior to Open Season. If the beneficiary arranges a monthly fee option (allotment, where feasible) by November 20, 2020, the contractor shall not collect up to three months of enrollment fees to initialize a monthly fee option. If the beneficiary provides fee payment arrangements after November 20, 2020, the contractor shall follow the monthly payment fee option in paragraph 6.1.4.

13.2 In addition to the contractor’s existing best business practices regarding “failure to pay fees” notifications, if not already being done, the contractor shall:

• Use Health Insurance Portability and Accountability Act (HIPAA) compliant “robo calls,” text messages, and emails to notify adult members of each household (sponsor, spouse, or adult child) that haven’t indicated whether they wish to continue their coverage and of the opportunity to reinstate their coverage.

• Make and document at least three phone calls to home, mobile, or work phone numbers of an adult member of the household.

13.3 The contractor shall extend the TRICARE reinstatement policy for TRICARE Select Group A from 90 days (see paragraph 5.9) until 180 days after termination of such coverage for failure to pay fees on January 1, 2021. Unless otherwise notified, this exception expires on June 30, 2021.

13.4 The contractor shall include information on the reinstatement option in claims denial correspondence when TRICARE Select Group A claims with a date of service after January 1, 2021 through June 30, 2021 are denied due to non-enrollment.

13.5 The contractor shall provide weekly TRICARE Select Group A reports (not applicable to those beneficiaries whose enrollment fees are waived by law). Details for reporting are identified in DD Form 1423, CDRL, located in Section J of the applicable contract. Unless otherwise directed, the contractor shall discontinue reports on June 30, 2021.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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