1.0 Enrollment
1.1 The contractor
shall develop an enrollment plan to support contractor enrollment
of beneficiaries and report on the implementation of the plan according
to contract requirements. The contractor shall consult with the
Director, TRICARE Regional Offices (TROs) and all Market/Military Medical Treatment
Facility (MTF) Directors where Prime
is offered in developing the enrollment plan.
1.2 The contractor shall have an
enrollment system that supports all enrollment related activities, i.e.,
Defense Enrollment Eligibility Reporting System (DEERS) enrollment
applications, and Market/MTF enrollment
guidelines.
1.3 The enrollment system shall
meet all the TRICARE Systems Manual (TSM) requirements, including
at a minimum, the following:
• Meet all system access requirements.
• Ensure installation of all
hardware.
• Ensure loading of all software.
• Ensure completion of all required
forms.
• Interface with Government systems.
1.4 The enrollment system shall
be fully operational 60 days prior to the start of health care delivery
(SHCD).
2.0 Enrollment Processing
At SHCD, all enrollment actions
will be accomplished by the incoming contractor. If the outgoing contractor
requires a retroactive change, they shall submit their request to
the incoming contractor who will perform the change and notify the
outgoing contractor, when it is complete.
2.1 Enrollment
Processing After The SHCD
Once health
care delivery begins, all enrollment actions will be accomplished
by the incoming contractor.
2.2 Phase-In
of TRICARE Prime Enrollment
The contractor shall begin
the enrollment process for the TRICARE Prime Program no later than
60 calendar days prior to the scheduled SHCD, with new enrollment
processing to begin 40 days prior to the SHCD, subject to the Defense
Health Agency (DHA) approval of systems under the contract.
2.2.1 Enrollment Actions During Enrollment
Dual Processing
2.2.1.1 When the Defense Manpower Data
Center (DMDC) creates the Enrollment Gold File for the incoming
contractor, enrollment dual processing begins (between 45-60 days
prior to SHCD). This process creates a future enrollment to the
incoming contractor. The following must be followed until SHCD.
2.2.1.2 For enrollments in the region
with an effective date prior to the SHCD (e.g., active duty enrollment,
mid-month enrollment; transfer-in), the incoming contractor must
effect an enrollment to begin on the SHCD once notified by the outgoing
contractor of the new enrollment. DMDC may run a report at the end
of the transition period that reflects new additions.)
2.2.1.2.1 The outgoing contractor has
until SHCD to send updated fee information to DEERS. Beginning at
the SHCD, the outgoing contractor will work with the incoming contractor
to resolve any discrepancies of cumulative enrollment fees and paid-through
dates on policies.
2.2.1.2.2 Beginning at the SHCD, the
incoming contractor shall send the corrected fee information to
DEERS using Fee/Catastrophic Cap and Deductible (CCD) Web Research
application or the batch fee interface outline in the TSM,
Chapter
3.
2.2.1.3 When a current enrollment in
the region requires deletion with an effective date prior to the
SHCD (e.g., transfers out; disenrollments for failure to pay fees;
cancellations, etc.), when requested by another enrolling contractor,
the incoming contractor must cancel the future enrollment segment and
notify the outgoing contractor when this action has been completed.
2.2.1.4 For all other enrollment actions
with an effective date prior to SHCD (e.g., Primary Care Manager
(PCM) changes; Defense Medical Information System Identification
Code (DMIS-ID) changes; enrollment begin date changes; etc.), when
requested by the outgoing contractor, the incoming contractor must
cancel the future enrollment segment and notify the outgoing contractor
when this action has been completed. When notified by the outgoing
contractor that their change has been effected, the incoming contractor
must verify/reinstate the future enrollment segment.
2.2.2 In addition to other contractually
required enrollment reports, the contractor, shall provide progress
updates on enrollment activities in accordance with the Integrated
Master Plan /Integrated Master Schedule (IMP/IMS).
2.3 Transfer Of Enrollment Files
2.3.1 The incoming contractor shall
obtain enrollment policy information from DEERS through an initial
enrollment load file. DMDC will provide the incoming contractor
with an enrollment load file for each contract transition. The outgoing
contractor shall provide: (1) the additional enrollment information
required for those Active Duty Family Members (ADFMs) enrolled in
TRICARE Prime residing outside of a Prime Service Area (PSA) who
were granted grandfathered status and who maintained their eligibility
for TRICARE Prime and (2) a list of those beneficiaries living greater
than 100 miles from a Primary Care Manager (PCM) and granted re-enrollment
per National Defense Authorization Act (NDAA) FY 2016, Section 701.
The additional enrollment information shall include, but is not
limited to, the original address of the beneficiary when they were
initially grandfathered or allowed to re-enroll. (See
Chapter 27 for more information on these beneficiaries.) The
incoming contractor shall process each enrollment load file within
24 hours or less from receipt of the file.
2.3.2 No later
than the date specified at the Transition Specifications Meeting,
the outgoing South Region contractor shall provide to the incoming
East Region contractor, the additional enrollment information required
for Continued Health Care Benefits Program (CHCBP) enrollees.
Note: Each contract transition shall
require a global freeze of enrollment. This freeze will occur beginning
the first weekend that precedes the 60 day window prior to the SHCD.
The actual calendar dates will be determined during the transition
meeting.
2.3.3 The incoming
contractor shall send enrollment renewal notices for all enrollees
whose current enrollment period expires on or after the SHCD. The
incoming contractor shall send billing statements where the enrollment
fee payment would be due on or after the SHCD. The incoming contractor
shall start sending billing notices and process renewals 45 days
prior to the SHCD.
2.3.4 Outstanding
enrollment record discrepancies and issues reported to the DEERS
Support Office (DSO) by the outgoing contractor will be transferred
to the incoming contractor for reconciliation. Records will be reconciled
in accordance with the TSM,
Chapter 3.
2.4 Enrollment Fees
2.4.1 The incoming
contractor shall obtain the cumulative total of enrollment fees
and paid- through dates for the policies from DEERS. The contractor
who collects the enrollment fee shall forward the fees to the Government
in accordance with
Chapter 6, Section 1.
The outgoing contractor shall work with the incoming contractor
to resolve any discrepancies of cumulative enrollment fees and paid-through
dates within 90 days of start of the SHCD on policies inherited
during the transition. The incoming contractor shall send the corrected
fee information to DEERS using the Fee CCD Web Research application
or the batch fee interface outlined in the TSM,
Chapter
3.
2.4.2 The incoming contractor shall
obtain information from the outgoing contractor on fees that are
being paid monthly (i.e., by allotment, recurring credit card, or
Electronic Funds Transfer (EFT) and transition these monthly payment
types in the least disruptive manner for the beneficiary.
2.4.3 The incoming contractor shall
coordinate the transition of allotment data, through the Performance,
Analysis, Transitions, and Integration Section (PAT&IS) and/or
the applicable DHA Program office, with the Defense Finance and
Accounting Service (DFAS), Public Health System (PHS), and U.S.
Coast Guard (USCG) during the transition-in period of the contract
(see the TSM,
Chapter 1, Section 1.1).
2.5 Phase-Out Of Enrollment Activities
2.5.1 Prior to the SHCD under the
successor contract, for all enrollment renewals or payments in which
the new enrollment period or period covered by the premium payment
will begin under the new contract, the outgoing contractor shall
amend renewal notices and billing statements (or include a stuffer/insert)
to advise the enrollee to direct any enrollment- related correspondence
and enrollment fee payments to the successor contractor.
2.5.2 The outgoing contractor shall
complete all pending enrollment actions prior to the DEERS global
enrollment freeze to transition enrollment. Any enrollment action
not completed by the outgoing contractor prior to the freeze (and
after the Gold File is created) will have to be accomplished following
the above procedures.
2.5.3 Any enrollment-related
correspondence and/or enrollment fee payments subsequently received
by the outgoing contractor shall be forwarded to the incoming contractor
within three working days of receipt. The incoming contractor shall
answer all correspondence in accordance with applicable standards
(see
Chapter 1, Section 3), update DEERS, as appropriate,
and forward the fees to the Government in accordance with
Chapter 6, Section 1.
2.5.4 No later
than the date specified at the Transition Specifications Meeting,
the outgoing contractor shall provide to the incoming contractor,
the additional enrollment information required for those ADFMs enrolled
in TRICARE Prime who reside outside of a PSA who were granted grandfathered status
and maintain their eligibility for TRICARE Prime. The additional
enrollment information shall include, but is not limited to, the
original address of the beneficiary when they were initially grandfathered.
2.5.5 No later
than the date specified at the Transition Specifications Meeting,
the outgoing South Region contractor shall provide to the incoming
East Region contractor, all billing and enrollment information required
to administer the Continued Health Care Benefit Program (CHCBP)
for its enrollees.
2.5.6 The outgoing contractor shall
terminate marketing and enrollment activity 40 calendar days prior
to the start of the incoming contractor’s SHCD. Any enrollment requests
or applications received after the 40th calendar day shall be transferred
to the incoming contractor by overnight delivery at the outgoing
contractor’s expense.
2.5.7 Throughout the transition period,
the outgoing and incoming contractors shall coordinate enrollment
files no less than weekly to ensure that new enrollments and enrollment
renewals are accurately and timely reflected in the incoming contractor’s
enrollment files and in DEERS.
3.0 Performance Readiness Validation
(PRV)/Performance Readiness Assessment and Verification (PRAV)
During transition, the incoming
contractor’s performance readiness status regarding enrollment activities
will be subject to PRV/PRAV reviews as described below.
3.1 Enrollment PRV
3.1.1 Sixty
days prior to SHCD, the contractor shall validate their enrollment
system is fully operational and meets all contract requirements.
The contractor shall demonstrate the ability to perform all required
billing, enrollment, and collection transactions. Validation shall
include demonstrating all hardware/software is operational, meets
system access requirements, and correctly interfaces with Government
systems including the required MTF/eMSM systems. The contractor
shall validate that all enrollment rules are loaded and that accessible
and sufficient staff is hired/trained to perform at historical levels
of enrollment transactions.
3.1.2 Sixty
days prior to SHCD, the contractor shall validate it has begun the
enrollment process for the TRICARE Prime Program and demonstrate
it can perform enrollment transactions with at a 97% accuracy rate
(to be considered accurate, all data elements within an enrollment
must be correct).
3.1.3 Forty-five
days prior to SHCD, the contractor shall validate their billing
system is fully operational and that it has started sending billing
notices and processing renewals. The contractor will validate they
have obtained information from the outgoing contractor on fees that
are being paid monthly (i.e., by allotment or EFT) and they are
transitioning these monthly payment types in the least disruptive
manner for the beneficiary.
3.2 Enrollment
PRAV
3.2.1 The contractor shall comply
with the Government’s approach for assessment and verification of
the contractor’s performance readiness regarding enrollment activities
as described above. If, after review, the Government finds the contractor’s
performance readiness for enrollment processing to be deficient,
the contractor must submit a detailed mitigation plan no later than
10 days business days following the Government’s findings.
3.2.2 Specific PRAV activities, assessment
techniques, and performance readiness thresholds will be identified
by the Government during the Transition Specification Meeting.