2.1 Health
Care Delivery Program (HCDP) Eligibility and Enrollment
2.1.2 The contractor
shall contact the DHA Dental Service Point of Contact (DSPOC) when
they do not have proper documentation, such as military orders,
to verify eligibility for those individuals who are indicated on
DEERS as not eligible (e.g., not on active duty but who may have
a Line of Duty (LOD) condition or a Foreign Force Member (FFM)).
2.1.3 DSPOCs
are the final decision authority for eligible Active Duty Service
Members (ADSMs).
2.2 ADDP
Eligibility
2.2.1 All ADSMs of the Uniformed
Services (excluding Public Health Service (PHS), who are on continuous active
duty orders for more than 30 calendar days are eligible to receive
ADDP dental coverage, subject to the requirements and limitations
provided in the ADDP.
2.2.2 Who have
a duty location and residence greater than 50 miles from a Military
Medical Treatment Facility (MTF) dental center are automatically
eligible for RADDP benefits.
2.2.3 National
Guard (NG)/Reserve members that serve on continuous active duty
for more than 30 calendar days are considered ADSMs. NG members
are only TRICARE eligible if on federally funded orders for more
than 30 calendar days. If the NG member is on state orders, they
are not eligible for TRICARE. The NG will determine if the orders
qualify for TRICARE.
2.2.4 Reserve
Component (RC) members (which includes NG) who are issued delayed-effective-date
active duty orders for more than 30 calendar days in support of
a contingency operation are eligible for ADDP as defined in Department
of Defense Instruction (DoDI) 7730.54.
2.2.5 A Line
of Duty (LOD) investigation is for RC members who incur or aggravate
an injury, illness or disease while serving on active duty for 30
calendar days or less as defined in DoDI 1241.2.
2.2.6 Foreign Force Members (FFMs)
who are on temporary or permanent assignment in the ADDP geographic
area of responsibilities may be eligible to participate in the ADDP
pursuant to an approved agreement (e.g., reciprocal health care
agreement, North Atlantic Treaty Organization (NATO) Status of Forces
Agreement (SOFA), Partnership for Peace (PfP) SOFA).
2.2.7 Enrollment Requirements (Unique)
2.2.7.1 ADSMs whose permanent duty
location and/or residence is less than 50 miles from an MTF dental center
are automatically eligible for ADDP benefits and do not require
enrollment.
2.2.7.2 Within the ADDP there are three
types of Dental Coverage Plans that require enrollment. The RADDP plans
are:
2.2.7.2.1 RADDP for ADSMs Enrolled in
TRICARE Prime Remote (TPR)
Eligibility to enroll in medical
TPR requires that the ADSM’s permanent duty location and residence
be more than 50 miles from a Market/MTF or designated clinic. DEERS
will systematically enroll, disenroll, and maintain enrollments
into the RADDP for ADSMs enrolled in TPR coverage plan based on
the ADSM’s medical TPR enrollment. ADSMs living in a TPR location
must enroll in a medical TPR coverage plan to be enrolled in RADDP.
2.2.7.2.2 RADDP for ADSMs Not Eligible
for TPR
2.2.7.2.2.1 ADSMs whose permanent duty
location and/or residence is less than 50 miles from a Market/MTF or
designated clinic are not eligible to enroll in TPR. If the ADSM’s
permanent duty location and residence is within 50 miles of a Market/MTF,
but more than 50 miles from an MTF dental center, he or she will
not be automatically enrolled into RADDP. The ADDP contractor will
be able to manually enroll the ADSM into the RADDP.
2.2.7.2.2.2 The ADDP contractor shall verify
the coverage plan, and correct the enrollment begin date if it is different
than the Government furnished web-based enrollment system/application
default.
2.2.7.2.3 Automatic
Enrollment in RADDP for National Oceanic and Atmospheric Administration (NOAA)
2.2.7.2.3.1 All NOAA ADSMs will be eligible
for RADDP. DEERS will systematically enroll, disenroll, and maintain
enrollments into the RADDP for NOAA ADSMs.
2.2.7.2.3.2 When enrolling an ADSM into
RADDP, the Government furnished web-based enrollment system/application
will require the effective dates of the enrollment. Enrollments
may be established with past effective dates, the current date,
or future effective dates. The enrollment period cannot exceed the
end of eligibility, nor precede the eligibility begin date. DEERS
will ensure that the coverage plan sent with an enrollment is valid
based upon the assigned eligibility.
2.3 Disenrollment Activities
2.3.2 Disenrollment actions are used
to terminate an enrollment. Disenrollments will occur when there
is a loss of eligibility, or when the ADSM reports he or she no
longer lives and/or works within a MTF non-catchment area. Upon
disenrollment, DEERS will notify the ADSM of the change in or loss
of coverage.
2.3.3 Disenrollment - Loss of Eligibility
A loss of eligibility refers
to any loss or change in eligibility for:
• DoD health care benefits according
to the current DoDI 1000.13; or
• A medical TPR coverage plan.
Under these circumstances, DEERS will terminate any current enrollment
or enrollment effective at the end of the month in which eligibility
ends.
Example: When the eligibility of a ADSM
enrolled in TPR and RADDP terminates due to separation from service, the
eligibility for RADDP will be terminated, resulting in a disenrollment
by DEERS. The termination of coverage will affect the insured’s
current and/or future enrollment in a HCDP.
2.3.4 Disenrollment Due to No Longer
Living or Working within RADDP Eligible Location
2.3.4.1 When an ADSM enrolled in a
RADDP coverage plan for ADSMs living and working within 50 miles
of a Market/MTF without dental capability, moves within 50 miles
of a Market/MTF with dental capability, the work or home address
will be updated.
2.3.4.2 The ADDP contractor shall perform
a disenrollment from the RADDP coverage plan if applicable.
Note: Changing an ADSM’s residence
address will not cause an automatic disenrollment. DEERS will not disenroll
an ADSM from RADDP based on an address update.
2.4 Claims Processing [Unique to
ADDP/RADDP]
2.4.2 The DEERS Claims Service (DCS)
is used to determine benefit coverage for a given period. Contractors must
use the DCS for all claims processing.
2.4.3 DCS
Inquiry for Claims
The contractor
shall install a prepayment eligibility verification system into
its TRICARE operation that results in a query against DEERS for
TRICARE claims and adjustments. The query should be conducted early
in the claims processing cycle to assure extensive development/claims
review is not done on claims for ineligible beneficiaries. The DCS
Inquiry for Claims supports business events associated with data
for processing dental claims. This inquiry may also be used for
general customer service requests, beneficiary self-service purposes,
or for predeterminations as long as there is prior coordination
with Defense Health Agency (DHA) and DMDC.
2.5 Key Support POCs
2.5.1 A list
of key DMDC Support Office (DSO) personnel and the Joint Uniformed
Services Personnel Advisory Committee (JUSPAC) and the Joint Uniformed
Services Medical Advisory Committee (JUSMAC) Members is provided
by the DHA. These individuals are designated by the DHA to assist
DoD beneficiaries on issues regarding claims payments.
2.5.2 In extreme
cases, the DSO may direct the claims processor to override the DEERS
information; however, in most cases the DSO is able to correct the
database to allow the claim to be reprocessed appropriately.
2.5.3 The contractor
shall request data corrections using procedures in
Section 4.3.