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
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.
5.5 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
s5.10.1 In the event the “failure to
pay” disenrollment was
directly caused by contractor
or Government
:
• Error:
• Delay;
• Other circumstances
outside the enrollee’s control (as determined by the Chief, TRICARE
Health Plan)
Then the
MCSPS, TRICARE Area Offices (TAOs), or USFHP program office may
direct reinstatement of the coverage beyond 90
days of the last paid-through date upon
beneficiary request via the contractor or notification from Defense
Health Agency (DHA). As an example,
the enrollee would not be held liable if the contractor failed to
submit the correct allotment amount for enrollment fees to the Defense Finance
and Account Service (DFAS).
5.10.1.1 The contractor
shall ensure all past fees are paid, if applicable, before reinstating
coverage.
5.10.1.2 The contractor shall not start
a new enrollment period in lieu of reinstatement from the last paid-through
date.
5.10.2 The contractor
shall reinstate (restore) enrollment at beneficiary request beyond
90 days of the last paid-through date if the disenrollment was caused
by a recalculation of the catastrophic cap. All past fees must be
paid if applicable.
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 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.
8.2 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
9.2 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.