1.0 General
1.1 As of
October 1, 2013, new TRICARE Prime enrollments will no longer be
available to beneficiaries who reside outside of a TRICARE Third
Generation (T-3) Prime Service Area (PSA), unless they waive their
access to care standards. PSAs are geographic areas where TRICARE
Prime is offered. PSAs were created to ensure medical readiness
of the active duty force by augmenting the capability and capacity
of Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets
(eMSMs). Policy also allowed establishment of PSAs around the Base
Realignment and Closure (BRAC) sites. The PSAs being eliminated
(referred to as Transitional PSAs or TPSAs) were not built around
MTFs/eMSMs or BRAC sites, but in other geographic locations under
the prior TRICARE Next Generation (TNEX) contract. Some PSAs are
also being reduced. The TPSAs were allowed to continue until all
three regions were operating under the T-3 contracts.
1.2 TRICARE Prime enrollment for
beneficiaries enrolled outside of a TRICARE T-3 PSA will be automatically
terminated effective October 1, 2013 by the Defense Enrollment Eligibility
Reporting System (DEERS), unless they meet exception criteria contained
in the policy section below. Two notification letters will be mailed
to beneficiaries potentially impacted during the February to July
2013 period fully explaining the PSA changes and their TRICARE health
plan options as stated in
paragraph 2.9. The majority of the disenrolled
beneficiaries will retain TRICARE Standard and TRICARE Extra coverage.
Some of the disenrolled beneficiaries may be eligible to continue
their Prime enrollment in a T-3 PSA or with one of the six Uniformed
Services Family Health Plans (USFHPs). See
paragraph 2.4 for the impact
on TRICARE Young Adult (TYA) Prime enrollees.
1.3 The National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 2014, Section 701, signed into law
on December 26, 2013, gave certain beneficiaries a “one-time” election
to continue their TRICARE Prime enrollment. The eligible beneficiaries
included those who: (1) were involuntarily dis-enrolled from TRICARE
Prime on September 30, 2013, due to the PSA reduction, and (2) lived
within 100 miles of an MTF/eMSM. Enrollment processes for these
beneficiaries are outlined below.
1.4 The NDAA
for FY 2016, Section 701 signed into law on November 25, 2015, gave
certain beneficiaries a “one-time” election to continue their TRICARE
Prime enrollment. These eligible beneficiaries included those who:
(1) were involuntarily disenrolled from TRICARE Prime on September 30,
2013, due to the PSA reduction, (2) resided more than 100 miles
from an MTF/eMSM, and (3) were an eligible beneficiary by reason
of service in the Army, Navy, Air Force, or Marine Corps. Special enrollment
processes for these particular beneficiaries are outlined below.
2.0 Policy
2.1 Active
Duty Services Members (ADSMs)
TRICARE Prime enrollments for
ADSMs, including activated National Guard and Reserve members (for more
than 30 days), will not be affected by the PSA reductions. All ADSMs
shall remain enrolled in TRICARE Prime or TRICARE Prime Remote (TPR),
as appropriate.
2.2 Active
Duty Family Members (ADFMs) (including ADFM TYA Prime Enrollees)
ADFMs (including ADFM TYA Prime
enrollees) enrolled in TRICARE Prime and who resided outside of
a T-3 PSA on September 30, 2013, were grandfathered in TRICARE Prime
starting October 1, 2013. They will 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 Primary Care Manager
(PCM) available for these beneficiaries and ensure all claims and
benefits are administered as TRICARE Prime. ADFMs shall remain enrolled
in TPR for Active Duty Family Members (TPRADFM), as appropriate.
The contractor shall manage the grandfathered ADFMs as stated in
this chapter.
2.2.1 Terms
of Grandfathered Status. The ADFM must maintain a residence within
40 miles of the residence where they were originally granted grandfathered
status in order to retain grandfathered status. Grandfathered ADFMs
must be assigned a PCM. Grandfathered ADFMs may add or terminate enrollment
of dependents like any other ADFM (marriage, birth, adoption, divorce,
etc.). Dependents may live in a separate residence outside a T-3
PSA and still be grandfathered.
2.2.2 Grandfathered ADFMs lose their
grandfathered status when they are:
• No longer TRICARE eligible,
• No longer residing within 40
miles of the residence where they were originally granted grandfathered
status, or
• Change to retired status.
2.2.3 All previously grandfathered
beneficiaries (those grandfathered prior to the T-3 contracts) lost
their grandfathered status effective October 1, 2013. They will
be managed like all other beneficiaries.
2.3 Retirees And Their Family Members
2.3.1 Retirees and their family members
enrolled in TRICARE Prime (including dependents of retirees enrolled
in TYA Prime), who reside outside of a T-3 PSA, were disenrolled
effective midnight on September 30, 2013. Impacted retirees and
their family members may re-enroll in TRICARE Prime at an MTF or
with a network civilian PCM inside a T-3 PSA if they live within
100 miles of an available PCM in a T-3 PSA, submit a new request
for enrollment, and waive both primary and specialty care travel
time standards. They may also enroll in one of the six USFHPs, if
available.
2.3.2 Retired beneficiaries who reside
within a T-3 PSA, but are enrolled with a PCM located outside of
a T-3 PSA will remain enrolled in TRICARE Prime. DEERS will not
automatically disenroll these beneficiaries. The contractor notified
those beneficiaries and assisted them with selecting a PCM inside the
T-3 PSA.
2.3.3 No retired beneficiary will
be given grandfathered status.
2.3.4 Retired
beneficiaries who were eligible and elected to re-enroll under Section
701 of the NDAA for FY 2014 must be re-enrolled effective October
1, 2013, paid retroactive enrollment fees, and waived both primary
and specialty care drive time standards. The contractor must have
available, and assign, a PCM for these beneficiaries within an existing
PSA. Once enrolled and fees are paid, any TRICARE Standard claim
processed with a date of service on or after October 1, 2013, for
the beneficiary shall be reprocessed under the TRICARE Prime option.
TRICARE Prime policies for these claims are waived as necessary
to reprocess the claims, i.e., PCM referrals.
2.3.5 Retired beneficiaries who are
eligible and elect to re-enroll under Section 701 of the NDAA for
FY2016 must be re-enrolled by August 30, 2016, pay required enrollment
fees, and waive both primary and specialty care travel drive time
access to care (ATC) standards. Within an existing PSA, the contractor
shall have available and assign a PCM for these beneficiaries residing
greater than 100 miles from an MTF. Once enrolled and fees are paid,
TRICARE claims for these beneficiaries with a date of service on
or after the date of this enrollment shall be processed under the
TRICARE Prime option.
2.4 TYA Enrollees
2.4.1 TYA Prime
enrollments for those beneficiaries who reside outside of a T-3
PSA will be processed according to their sponsor’s status.
2.4.2 ADFM TYA Prime beneficiaries
enrolled outside of a T-3 PSA were grandfathered in TYA Prime effective
October 1, 2013, and will be able to retain grandfathered status
as long as they meet the following conditions:
• They reside within 40 miles
of the residence where they or their sponsor was originally granted grandfathered
status (see
paragraphs 2.2.1 and
2.2.2),
• They remain eligible to purchase
coverage, and
• Their sponsor’s status does
not change.
2.4.3 Retired
TYA Prime enrollees who resided outside of a T-3 PSA were disenrolled
effective midnight September 30, 2013, with no lockout applied (
Chapter 25, Section 1), unless they are enrolled to
a PCM within a T-3 PSA. All TYA eligible enrollees whose Prime enrollments
are terminated must re-apply for coverage by completing a new TYA
Application (DD Form 2947) to either enroll in TYA Standard or re-enroll
in TYA Prime if they meet the requirements for retiree enrollment
in TRICARE Prime contained in
paragraph 2.3.
2.4.4 Retired
TYA Prime enrollees who were eligible and elected to re-enroll under
Section 701 of the NDAA for FY 2014 must have re-enrolled effective
October 1, 2013, paid retroactive premiums, and waived both primary
and specialty care drive time standards. The contractor shall have
available, and assign, a PCM for these young adults within an existing
PSA. Once enrolled and premiums are paid, any TRICARE Standard claim
processed with a date of service on or after October 1, 2013, for
the young adults shall be reprocessed under the TRICARE Prime option.
TRICARE Prime policies for these claims are waived as necessary
to reprocess the claims, i.e., PCM referrals.
2.4.5 Retired TYA Prime beneficiaries
who are eligible and elect to re-enroll under Section 701 of the
NDAA for FY 2016 must be re-enrolled by August 30, 2016, pay required
premiums, and waive both primary and specialty care travel drive
time ATC standards. Within an existing PSA, the contractor shall have
available and assign a PCM for these young adults residing greater
than 100 miles from an MTF. Once enrolled and premiums are paid,
TRICARE claims for these beneficiaries with a date of service on or
after the date of this enrollment shall be processed under the TRICARE
Prime option.
2.5 Transitional
Assistance Management Program (TAMP)
TAMP beneficiaries enrolled
in Prime who reside outside of a T-3 PSA will be grandfathered and managed
like all other ADFMs. Additionally, grandfathered Prime enrollees
will continue to be grandfathered if they become TAMP eligible and
enroll in TAMP, as long as they reside within 40 miles of the residence
where they were originally granted grandfathered status. Grandfathered
status will not be given to TAMP beneficiaries who move into an
area that is not a T-3 PSA on/after October 1, 2013.
2.6 Transitional Survivors
Transitional Survivors are
grandfathered like any other ADFM. However, when a surviving spouse’s status
changes from Transitional Survivor to Survivor, they will be disenrolled
from TRICARE Prime and have to apply for re-enrollment as a Survivor,
if TRICARE Prime is available within 100 miles of their residence.
The current survivors are managed like any other retired beneficiary
as described in
paragraph 2.3; they are not grandfathered.
2.7 TPR and TRPADFMs
The current policy for TPR
and TPRADFM does not change.
2.8 New
Enrollments in TPSAs (all beneficiaries)
2.8.1 New TRICARE
Prime enrollments in the TPSAs on or after April 1, 2013 will be
limited. Beneficiaries who establish a residence in a TPSA prior
to August 20, 2013 (20th of the month rule) can enroll in TRICARE
Prime. Beneficiaries who do not establish residence in the TPSA
cannot enroll with a TPSA PCM after April 1, 2013, unless they are
attached to a grandfathered ADSM. Beneficiaries may “transfer” their
TRICARE Prime enrollment to the TPSA if they establish residence
in a TPSA before September 30, 2013.
2.8.2 ADFMs
moving into an area that is not a T-3 PSA on or after October 1,
2013 will not receive grandfathered status. If eligible to do so,
they may enroll in TPRADFM. No TRICARE Prime enrollments to providers
in the disestablished TPSAs shall be permitted after September 30,
2013, either for ADFMs or retirees.
2.9 Notification and Disenrollment
Letters
2.9.1 The contractor shall print
and mail two notification letters between February and July 2013. Defense
Health Agency (DHA) Beneficiary Education & Support Division
(BE&SD) will provide the MCSCs and the Defense Manpower Data
Center (DMDC) the notification letter templates for each beneficiary
category. DMDC will provide a listing of the beneficiaries, to include
their name and the demographic data needed, to complete the mailings.
Copies of the letters and beneficiary listing will also be provided
to the TRICARE Regional Offices (TROs). In August 2013, DMDC mailed
disenrollment letters to the beneficiaries whose TRICARE Prime enrollment
will be terminated effective October 1, 2013.
Note: All affected beneficiaries
noted in the above paragraphs may also have the option to enroll in
the USFHP, where available.
2.9.2 The retired
beneficiaries eligible to re-enroll under Section 701 of the NDAA
for FY 2014 received one notification letter from the DHA in April
or May 2014.
2.9.3 The retired beneficiaries eligible
to re-enroll under Section 701 of the NDAA for FY 2016 will receive
one notification letter from DHA through the Defense Manpower Data
Center (DMDC) in April or May 2016 regarding their “one-time” re-enrollment
option.
Note: For beneficiaries
requesting enrollment under the provisions of the NDAA for FY 2016 Section
701, the MTF
Director will not need
to notify the TRO Director of their desire to enroll a beneficiary
who resides greater than 100 miles from the MTF (as would otherwise
be required under
Chapter 6, Section 1, paragraph 11.6.3).
3.0 Effective Dates
3.1 New enrollments
in the TPSA are not allowed after August 20, 2013, for any beneficiary category
(20th of the month rule), unless they qualify for TPR or TPRADFM.
3.2 All TPSAs terminate effective
midnight September 30, 2013.
3.3 Effective
October 1, 2013, PSAs will be maintained only at MTFs and designated
BRAC sites.
3.4 The retired beneficiaries eligible
to re-enroll under Section 701 of the NDAA for FY 2014 must submit
their enrollment request (per
Chapter 6, Section 1, paragraph 1.2) and applicable
fees to their contractor prior to June 30, 2014. All forms postmarked
on or prior to June 30, 2014 are acceptable. Their effective date
of coverage will be October 1, 2013.
3.5 The retired
beneficiaries eligible to re-enroll under Section 701 of the NDAA
for FY 2016 must submit their enrollment request (per
Chapter 6, Section 1, paragraph 1.2) and applicable
fees to their contractor prior to August 30, 2016. All enrollment
forms postmarked on or prior to August 30, 2016 shall be accepted.
The effective date of coverage will be based on the “20th of the
month rule” for receipt of an enrollment form (per
Chapter 6, Section 1, paragraph 5.3.2).